Chapters Living Of Council Bluffs
Inspection history, citations, penalties and survey trends for this long-term care facility in Council Bluffs, Iowa.
- Location
- 3000 Risen Son Blvd, Council Bluffs, Iowa 51503
- CMS Provider Number
- 165466
- Inspections on file
- 28
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 59 (1 serious)
Citation history
Health deficiencies cited at Chapters Living Of Council Bluffs during CMS and state inspections, most recent first.
The deficiency involves multiple failures in pressure ulcer prevention, assessment, and treatment for several residents. A resident admitted without ulcers developed an in-house Stage 2 sacral pressure injury that was not consistently measured or fully assessed for several weeks, despite documented infection and worsening appearance. Staff did not reliably notify the NP or MD of deterioration, did not change treatment orders in a timely manner, and did not update the care plan with new interventions, while the resident reported not being repositioned every 2 hours and sometimes remaining in a saturated brief overnight. Another resident with incontinence-associated dermatitis and documented skin risk had wound assessments with missing or inconsistent measurements, photos showing apparent Stage 2 sacral/coccygeal ulcers that were not documented as such, and a care plan that did not reflect the specific skin issues or interventions identified on the MDS. Staff interviews and the DON’s statements confirmed gaps in CNA reporting, nurse assessment, physician notification, and overall wound care practices.
Surveyors found that the facility failed to consistently involve residents and their representatives in interdisciplinary care plan conferences and did not keep care plans current with residents’ changing clinical conditions. Several residents and families reported they had not been invited to care conferences since a change in ownership, and the social services director acknowledged many conferences were not completed or documented. Care plans for multiple residents were not revised to reflect new transfer requirements (e.g., need for a full-body mechanical lift), new or discontinued indwelling catheters, new diagnoses such as influenza requiring EBP and droplet precautions, and the development or progression of pressure injuries, including MASD, DTI, Stage 2 ulcers, and a surgically debrided Stage 4 sacral ulcer with a wound vac. Staff interviews showed that the MDS coordinator was largely responsible for care plan updates, floor nurses generally did not revise care plans, and IDT participation and documentation of care conferences were inconsistent, resulting in outdated or incomplete care plans that did not match current orders or resident needs.
The facility failed to provide ongoing, understandable education on Resident Rights to its residents and/or their representatives. During a Resident Council meeting, residents reported they were unaware of having rights, did not know what those rights were, and did not know if they were posted in the facility. Review of several months of Resident Council minutes showed that leadership attended but did not provide Resident Rights education. The Life Enrichment Director acknowledged that staff had not been reviewing or educating residents on their rights during these meetings, and the DON stated that Resident Rights were only given at admission and not reviewed on an ongoing basis. Neither could confirm that Resident Rights were posted and readily available, despite facility policy requiring that residents be informed of their rights and that these rights be posted throughout the facility.
Surveyors found that multiple residents who required staff assistance with oral hygiene, toileting, and repositioning did not consistently receive this care and that it was not documented as required. Several residents with cognitive impairment or physical limitations, including those with multiple sclerosis, had care plans specifying staff assistance with oral care, yet their records contained no oral care documentation, and one resident’s room lacked oral care supplies. Residents and family members reported that oral care was rarely provided, that a resident often had food on her face and mouth, and that one resident had to use an alarm to prompt staff to reposition her and reported not being changed overnight despite urinary incontinence. Staff interviews confirmed that oral care was expected twice daily per facility policy, but also revealed frequent findings of residents with unclean faces and hands after meals.
A facility failed to prevent accidents and injuries by allowing a resident with moderate cognitive deficit to be pushed a long distance in a manual w/c without footrests while observed by nursing staff, and another resident with severe cognitive impairment to be pushed with feet dragging on the floor. Two dependent residents who required full body mechanical lifts reported or were described as being transferred either with only one staff or without the lift at all, with multiple CNAs and nurses acknowledging that single-staff lift transfers occurred despite the expectation for two-person assistance. Additionally, monthly hot water temperature logs showed elevated readings in some areas and stopped being recorded, while the plant operations director, DON, and administrator each admitted they did not know the appropriate temperature parameters for resident use and had no policies in place for water temperature, mechanical lift use, or wheelchair transport safety.
Two residents did not receive appropriate assessment and care according to orders and clinical needs. One resident with intact cognition had a diabetic ulcer on a toe that was present on admission but was not identified on the admission skin assessment, and no wound assessment, physician notification, or treatment occurred for about a week until an RN documented and initiated ordered care. Another resident with near-intact cognition had a head injury first seen as a red mark on the forehead; the LPN obtained vitals but did not initiate neuro checks, fully assess for additional injuries, or promptly notify the DON, physician, or family. Neuro assessments and provider notification were delayed until the area became a hematoma later in the day, and additional bruising on the hip and shoulder was only discovered after transfer to the ED.
Surveyors found that the facility failed to follow physician orders for medication administration, including not administering prescribed medications, giving medications outside of ordered parameters, and not documenting required monitoring. In several cases, staff did not notify the primary care provider when a resident refused multiple medications over several days, and medications were administered or withheld without proper documentation or physician approval.
Three residents with indwelling catheters did not receive catheter care and monitoring as required, with multiple missed entries for catheter output and failure to report changes in eating patterns that could indicate UTI. One resident was hospitalized with severe sepsis due to UTI, and another was admitted for a complicated UTI. Nursing staff and leadership confirmed that missing documentation meant care was not completed, and facility policy required regular documentation and reporting of unusual findings.
Surveyors found that staff did not consistently follow Enhanced Barrier Precautions or perform required hand hygiene during high-contact care activities for two residents with indwelling catheters and wounds. Staff failed to wear gowns during transfers and grooming, and did not always perform hand hygiene between glove changes, despite facility policy and posted instructions.
The facility did not consistently update care plans with new fall prevention interventions after residents experienced multiple falls, and failed to complete or document required neurological assessments following unwitnessed falls. Several residents with cognitive impairment and fall risk were affected, and staff interviews revealed inconsistent practices and lack of access to current policies.
The facility did not update its Facility Assessment after a change in ownership, continuing to use an outdated document with the previous facility name. The current Administrator confirmed no updated assessment had been completed, and the ADON was unable to access or locate relevant policies. Corporate staff did not provide requested policy information after being contacted.
The facility did not employ a qualified Infection Preventionist (IP) as required, with the designated IP and DON both still in the process of completing necessary training. The antibiotic stewardship program was not current, and staff were unclear about the IP's qualifications. Corporate support was limited to remote assistance, and updated policies from new ownership were not provided when requested.
Surveyors found that the facility did not maintain a clean environment, with dead insects remaining in a hallway for several days and a resident's room and bathroom left uncleaned despite family concerns. Housekeeping was expected to clean daily, but debris and stains persisted, and staff denied receiving complaints about cleanliness.
A resident who required significant assistance and had multiple medical conditions reported that a CNA was rude, spilled a bedpan on her bed, and placed her call light out of reach. The DON investigated internally and educated the CNA, but did not report the allegation to the State Agency as required. The previous administrator and other staff were not fully informed, and the facility could not provide a relevant abuse reporting policy during the survey.
Two residents reported staff misconduct, including rudeness, removal of call lights, and rough handling, but the facility failed to conduct thorough investigations. Key staff and resident interviews were not completed, written statements were not collected, and there was no evidence of a standardized process for investigating abuse allegations.
Two residents admitted with existing pressure ulcers did not have comprehensive care plans specifying the type and location of their wounds, and one resident's care plan lacked interventions to prevent new pressure ulcers. Staff interviews confirmed reliance on care plans for pressure ulcer management, but the plans were incomplete and lacked individualized interventions. The facility also lacked clear policies on care plan development and updating.
Care plans were not updated for three residents after they experienced falls, and one resident's care plan was not revised when a new pressure ulcer developed. The care plans lacked specific details and interventions, and staff interviews revealed confusion about responsibilities and procedures for care plan updates. The facility could not provide a policy on care plan revision, and corporate staff did not supply requested policies.
Two residents with pressure ulcers did not have their treatment orders consistently signed out as completed, with multiple omissions in documentation of wound care, dressing changes, and evaluations. Staff confirmed that unsigned orders on the TAR indicated treatments were not done, and the facility lacked a clear policy for treatment order administration and documentation.
The facility did not provide enough nursing staff to meet resident needs, resulting in delayed assistance for residents, including one who waited up to 40 minutes for help while managing a UTI. Staff reported operating mechanical lifts alone due to low staffing, and the facility lacked clear policies on call light response and lift use.
The facility did not maintain complete and accurate medical records for three residents, including missing documentation of scheduled showers and absent incident reports for two falls. Staff interviews revealed problems with access to the electronic charting system and a lack of clear documentation policies following a change in facility ownership.
The facility failed to maintain proper infection control during food preparation. The Culinary Supervisor used gloves while preparing grilled cheese sandwiches but touched non-food contact surfaces before handling food, violating the facility's policy. The Dietary Manager noted that staff were advised to avoid using gloves unless necessary to prevent complacency.
The facility failed to ensure that a CNA completed the required Dependent Adult Mandatory Reporter (DAMR) Training, as their training certificate had expired. This was discovered during a personnel file review, revealing non-compliance with the facility's policy that mandates periodic training to recognize and prevent abuse, neglect, and misappropriation of resident property.
The facility failed to implement proper infection prevention practices for two residents under Enhanced Barrier Precautions. A resident with an indwelling catheter received care from a CNA who improperly wore a gown, while another resident with a lung infection was not provided with necessary droplet precaution signage and PPE. Staff did not adhere to required PPE protocols, leading to deficiencies in infection control.
A facility inaccurately assessed a resident's MDS by documenting insulin use, despite the resident receiving Trulicity, not insulin. Staff interviews revealed a misunderstanding of Trulicity as insulin. The DON and Administrator acknowledged the error and the lack of a specific policy on MDS accuracy.
Two residents reported feeling disrespected by a CNA during personal care, with one resident having moderate cognitive impairment and the other having no cognitive impairment. The incidents were not reported to management, indicating a breakdown in the reporting process. The facility's policy prohibits such behavior, but the incidents were not investigated as required.
The facility failed to meet professional standards of care for two residents, leading to deficiencies in documentation and medication management. A resident with diabetes had a low blood glucose reading that was not documented or followed up as per policy. Another resident with hypertension received medication despite consistently low blood pressure readings, due to a lack of established parameters. Staff interviews revealed inconsistencies in handling these situations, and the facility lacked specific policies to guide care.
A resident was discharged to a hotel without securing home health services or follow-up appointments, despite having a history of orthostatic hypotension, type 2 diabetes, and chronic kidney disease. The social worker faced challenges with insurance acceptance and communication, leading to a delay in home health services and lack of follow-up appointments. The facility's discharge plan lacked documentation of arranged follow-up care, resulting in a deficiency in discharge planning.
A resident with a fracture experienced severe pain that was not adequately assessed or managed by the facility staff. Despite a care plan directing the administration of pain medications and physician notification if interventions were unsuccessful, the resident did not receive PRN pain medication on a critical day, and there was a lack of pain assessments and vital signs documentation. The resident's pain was later documented at a level of 9, leading to a transfer to the emergency department due to uncontrolled pain. Staff interviews revealed inconsistencies in pain management practices.
Failure to Prevent, Assess, and Manage Pressure Ulcers and Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention, assessment, and treatment, and to prevent the development and worsening of pressure ulcers for multiple residents, most extensively documented for Resident #29. Resident #29 was admitted without pressure ulcers and initially assessed with a Braden score of 20 (not at risk), later decreasing to 16 (at risk) and then to 9 (very high risk). An in-house acquired Stage 2 sacral pressure ulcer was first documented on 11/28/25 with measurements, and again on 12/6/25 with increased size. On 12/16/25, the wound was documented as a Stage 2 ulcer but without any measurements. From 12/16/25 through 1/3/26, there were no complete wound assessments with measurements, descriptions, or photos, despite ongoing skin check entries that noted a pressure injury on the coccyx/sacrum without measurements or detailed description. During this period, the care plan did not reflect new or updated interventions in response to the in-house acquired Stage 2 ulcer or its deterioration. Resident #29’s wound worsened significantly without timely or adequately documented provider notification or changes in treatment. Infection documentation from 1/1/26 through 1/5/26 noted a sacral ulcer infection with odor but lacked measurements, wound description, and MD notification. On 1/3/26, an unstageable sacral pressure ulcer with slough/eschar, strong odor, and a much larger area was documented. A subsequent 1/5/26 skin and wound evaluation described an unstageable ulcer with slough/eschar and large dimensions, again without physician notification. The DON acknowledged that weekly wound assessments with measurements and descriptions were not completed between 12/16/25 and 1/3/26 and that the wound did not change from a Stage 2 to a large unstageable ulcer overnight. Interviews with nursing staff indicated that the wound had gotten larger and worse, that the NP was told it looked worse, and that treatment orders were not changed from 12/16/25 until the resident was seen at a wound clinic on 1/2/26. Hospital records later documented a sacral decubitus ulcer with foul odor, significant necrotic tissue, and debridement down to ligamentous structures and exposed bone. The deficiency also includes failures in basic preventive care such as repositioning and incontinence management for Resident #29. The resident, who had multiple sclerosis and could not reposition herself, reported that staff were not turning her every 2 hours as ordered and that she had to set an alarm on her phone to prompt staff. She stated that some overnight shifts only repositioned her once late in the night and that she had reported these concerns multiple times. Staff interviews corroborated concerns that the resident was not being repositioned appropriately and that CNAs had reported the wound was not improving but were told to apply cream without the nurse assessing the area. There were also reports that a CNA refused to change the resident’s saturated brief, allegedly stating there were no briefs and reapplying the same brief, while another CNA described only “freshening up” the resident and not returning later in the shift. The DON and nursing staff acknowledged that CNAs may not recognize or report early pressure injuries, that CNA reports to nurses were sometimes undocumented, and that “a lot of balls were dropped” regarding wound care. For Resident #2, the deficiency includes incomplete and inaccurate wound assessment and documentation, and failure to align the care plan with identified skin risks and conditions. Resident #2 was admitted with a Braden score of 17 and a documented need for repositioning at least every 2 hours, and had incontinence-associated dermatitis (IAD) on the buttocks present on admission. Wound evaluations showed large fluctuations in the documented size of the IAD over time, including a significant increase in area on 12/5/25 and later a marked decrease by 12/30/25, followed by another large increase on 1/6/26. The 12/12/25 wound evaluation lacked any measurements, and a photo from 1/6/26 showed two areas consistent with Stage 2 pressure ulcers on the sacrum/coccyx that were not documented as such in the record. The MDS identified that the resident was at risk for pressure ulcers and had MASD, and that interventions such as pressure-reducing devices and nutrition/hydration interventions were in place, but the care plan only reflected a generic potential for pressure injury and did not include the specific skin issues or interventions identified on the MDS. Interviews and record reviews further demonstrated systemic issues contributing to the deficiencies. The NP reported that she was shown a picture of Resident #29’s wound on 12/16/25 and then only heard again around Christmas via a text that the wound looked worse and needed a wound care visit; she did not receive updates on the wound clinic’s findings and was not informed when the wound became unstageable or significantly deteriorated. She stated she would have expected notification with such changes and that the wound appeared preventable and should not have progressed to its current state. Nursing staff acknowledged expectations to notify physicians of wound changes, lack of improvement, or deterioration, but also acknowledged that this did not occur consistently for Resident #29. The DON confirmed that physician notifications and wound assessments were missing or incomplete, that CNA reports were sometimes not documented, and that there were multiple failures in wound care practices across the facility. Overall, the documented actions and inactions include failure to perform consistent, measurable weekly wound assessments; failure to document and communicate wound deterioration and infection to providers; failure to update care plans and interventions in response to new or worsening pressure ulcers; failure to ensure regular repositioning and timely incontinence care; and failure to accurately identify and document pressure ulcers versus dermatitis. These failures affected multiple residents, with detailed evidence for Residents #29 and #2, and were acknowledged by the DON and nursing staff as significant lapses in wound care and skin integrity management.
Failure to Involve Residents/Representatives and Update Interdisciplinary Care Plans for Changing Clinical Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop, review, and revise comprehensive care plans with an interdisciplinary team that included residents and/or their representatives, and to update care plans when residents’ conditions changed. Multiple residents and family members reported that care plan conferences had not occurred since a change in facility ownership, despite prior practice of quarterly meetings. For example, one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and diabetes, had a baseline care plan and a signed POA document, but there were no care conference attendance sheets, and the family stated they had not been included in care plan meetings since the new company took over. Another cognitively intact resident and that resident’s son both reported they had never been invited to care conferences since admission, and the social services director acknowledged that many care conferences were not completed and that residents and families had not been part of quarterly assessments. The facility also failed to revise care plans to reflect significant changes in residents’ clinical status and treatment orders. One resident with intact cognition and a right femur fracture was being transferred with a whole body mechanical lift per therapy evaluation and documentation, but the care plan still listed stand-pivot transfers with one staff and a gait belt; staff reported they had not received updated transfer information and expected therapy to update the care plan. Another resident with moderate cognitive impairment and multiple diagnoses had a care plan with 19 focus areas whose interventions had largely not been updated since the prior year, despite the facility no longer offering restorative nursing services; there was no EMR documentation of care conferences or timely updates, and late entries were added to progress notes only after surveyor inquiry. A resident who experienced a fall, hospitalization, and diagnosis of Influenza A had a marked decline in transfer ability and required a full-body mechanical lift and transmission-based precautions, but the care plan was not updated to reflect the new transfer status or the need for PPE until after surveyor review. Additional failures involved skin integrity and catheter-related care planning. One resident admitted with a Stage 2 pressure ulcer and later placed on and then removed from an indwelling urinary catheter had care plan interventions that continued to reference catheter care and Enhanced Barrier Precautions for the catheter after the catheter was discontinued by physician order; the MDS showed the resident as incontinent without a catheter, but the care plan was not revised. Another resident at risk for pressure injuries developed in-house acquired moisture-associated skin damage on the buttocks and a deep tissue injury on the right heel, with multiple wound treatment orders and documentation of a scoop mattress and lack of repositioning aids; however, the care plan did not include MASD, the DTI, or related interventions such as pressure-reducing devices or nutrition/hydration measures. A different resident admitted without pressure injuries developed in-house Stage 2 pressure ulcers on the buttocks and a DTI on the right heel; the care plan contained no prevention focus, goals, or interventions until after the wounds occurred. Further, residents with existing or worsening pressure injuries did not have their care plans revised to reflect new or escalated needs. One cognitively intact resident with an in-house Stage 2 sacral pressure ulcer later required surgical debridement of a Stage 4 sacral ulcer with exposed bone and a wound vacuum; the care plan showed a generic focus on potential for pressure injury and an in-house Stage 2 sacral ulcer but no new interventions after the ulcer progressed and the resident returned from the hospital with a wound vac and more advanced wound status. Another cognitively intact resident at risk for pressure ulcers developed unstageable skin on 12/23, but there was no care plan update or added interventions for this finding. Interviews with the MDS coordinator, DON, RN staff, and social services indicated that the MDS coordinator was primarily responsible for building and updating care plans, floor nurses generally did not update care plans, and care conferences were not consistently scheduled or documented with IDT participation, residents, or families, resulting in multiple care plans that were outdated, incomplete, or not reflective of current clinical orders and conditions.
Failure to Provide Ongoing, Understandable Education on Resident Rights
Penalty
Summary
The facility failed to provide ongoing education to residents and/or their representatives on Resident Rights in a format that was understandable to them. During a Resident Council meeting, residents present reported they were unaware that they had rights, did not know what their Resident Rights were, and did not know if these rights were posted within the facility. Review of Resident Council minutes for three consecutive months showed that various facility leaders attended the meetings but did not provide education on Resident Rights. During the same Resident Council meeting, the Life Enrichment Director stated she typically led the council and that an Activity Coordinator filled in when she was unavailable, and she acknowledged that staff had not been reviewing or educating residents on Resident Rights during these meetings. The DON stated that Resident Rights were provided only as part of admission packets and agreed they needed to be reviewed with residents on an ongoing basis, and neither the Life Enrichment Director nor the DON could confirm that Resident Rights were posted and readily available for residents, despite the facility’s Resident Rights policy stating that residents were to be informed of their rights and that these rights were to be posted throughout the facility. No specific resident medical histories or clinical conditions were described in relation to this deficiency, and the census at the time was 28 residents.
Failure to Provide and Document Oral Care, Toileting, and Repositioning for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required assistance with oral care, toileting, and repositioning for multiple dependent residents. For Resident #22, the Quarterly MDS dated 10/31/2025 showed a BIMS score of 4, indicating severe cognitive impairment, and documented a need for substantial/maximal assistance with oral hygiene. Her care plan, revised 11/18/2020, identified an ADL self-care performance deficit related to multiple sclerosis and required one staff to assist with daily grooming, including personal hygiene and oral care. A handwritten sign in her room requested that staff brush her teeth every day, and her emergency contact reported that her teeth were sometimes not brushed much when she visited, stating the resident would allow staff to complete oral care. On interview, the resident stated staff had not brushed her teeth that morning. The DON later stated she was unaware of the sign and that oral care should be completed at least twice a day, ideally by CNAs but also by nurses or other clinical staff, and possibly during OT. Resident #2’s MDS documented a BIMS of 15, indicating no cognitive impairment, and a need for supervision or touching assistance for oral hygiene. Her care plan, initiated 12/5/2025, documented that she required assistance of one staff for oral care. Review of her EHR showed no documentation of oral care provided. In interview, she stated she had a toothbrush in her bathroom and that whether oral care was provided depended on the staff. She reported that her husband helped her brush her teeth in the evenings, OT used to help her when she was going to therapy, and that occasionally a CNA would assist her with oral care. Resident #3’s MDS showed a BIMS of 11, indicating moderate cognitive impairment, and a need for partial/moderate assistance with oral hygiene. Her care plan, initiated 4/12/2025, documented that she required assistance of one staff for oral care, yet her EHR contained no documentation of oral care. Observation revealed no toothbrush in her room, and the ADON confirmed there was no equipment available to provide oral care. A CNA stated she had completed oral care that morning, claimed she obtained a new toothbrush for the resident every day, and said the resident only required set-up according to the care plan, which conflicted with the documented need for assistance. Resident #29’s MDS documented a BIMS of 15 and a need for supervision or touching assistance for oral hygiene, and her care plan dated 11/19/2025 indicated she required assistance of one for oral care. Her EHR contained no documentation of oral care. She reported that she had to set an alarm on her phone to ensure staff came to reposition her every two hours as ordered by her doctor, and that prior to a hospital stay staff were not repositioning her every two hours, with some overnight shifts only repositioning her at 3:00 or 4:00 AM. She stated she had multiple sclerosis, could not reposition herself in bed, and required staff assistance. She also reported that staff rarely provided oral care, that she could not sit up in bed on her own, and that she would appreciate staff assistance with oral care. She further stated that on one night a CNA refused to change her brief, that she was out of briefs and remained incontinent of urine without being changed all night, and that this CNA only repositioned her but did not change her. She reported prior concerns about this CNA’s care and described feeling treated without appropriate dignity or respect when requesting to be cleaned and changed. Resident #30’s MDS documented a BIMS of 13, indicating no cognitive impairment, and a need for substantial/maximal assistance with oral hygiene. Her care plan, initiated 12/3/2025, documented that she required assistance of one for oral care, yet her EHR contained no documentation of oral care. Her daughter reported that when she visited at random times, she frequently found food on the resident’s face and mouth and that it appeared her mother’s teeth had not been brushed. Staff interviews confirmed expectations and practices related to oral care: the ADON stated it was an expectation that all residents receive oral care even if they do not have teeth, and that dentures should be cleaned or soaked overnight. The DON stated oral care should be completed or offered and documented if refused, and that the required assistance should be reflected on the care plan. A CNA described asking cognitively intact residents when they wanted their teeth brushed and providing oral care before breakfast for residents who were not cognitively aware, and reported frequently finding residents with food on their faces and hands not cleaned from dinner, which she had brought to management’s attention. Review of the facility’s undated oral care policy showed that the purpose of the procedure was to keep lips and oral tissues moist, cleanse and freshen the mouth, and prevent oral infection. The policy required review of the care plan for special needs, assembly of needed equipment and supplies, and documentation in the medical record of the date and time mouth care was provided, the name and title of the person providing care, assessment data about the mouth, complaints of pain or discomfort, refusals with reasons and interventions, and the signature and title of the person recording the data. The policy also required CNAs to report to the licensed nurse for documentation. Despite these policy requirements and the care plan directives, surveyors found no documentation of oral care for multiple residents who required assistance, observed lack of oral care supplies in at least one resident’s room, and obtained resident and family reports that oral care, toileting, and repositioning were not consistently provided as needed.
Failure to Ensure Wheelchair, Mechanical Lift, and Hot Water Safety
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and injuries related to wheelchair transport, mechanical lift use, and hot water temperature monitoring. For one resident with moderate cognitive deficit who used a manual wheelchair with staff assistance, a CNA pushed the resident approximately 240 feet through two hallways without wheelchair footrests in place. A nurse and another staff member observed and interacted with the CNA during this transport but did not stop the wheelchair movement despite facility expectations that residents must have footrests on before being pushed. Another resident with severe cognitive impairment, who was dependent on staff for manual wheelchair use, was observed being pushed by a CNA from the dining room to the living room with the resident’s feet dragging on the floor for about 75 feet, again without use of footrests. The facility also failed to ensure safe and consistent use of full body mechanical lifts for residents who required dependent transfers. One cognitively intact resident, fully dependent on staff for chair-to-bed transfers and care-planned for a full body mechanical lift with two staff, reported that some staff used only one person during lift transfers, while most used two. The resident, a nurse for 30 years, stated she knew two staff were required and that she had to ask staff to get a second person, expressing worry about ending up on the floor if the sling broke. Another resident with moderate cognitive impairment, also fully dependent for transfers, stated she did not like using the full body mechanical lift and instead grabbed staff around the neck while they placed her in the wheelchair, and that staff sometimes brought the lift into the room but then decided not to use it. Multiple staff interviews confirmed inconsistent and unsafe practices with mechanical lifts. One staff member stated he had been trained that lift use was based on manufacturer recommendations and that it could be used with only one person, and he reported concerns to an LPN without apparent follow-up. An RN reported seeing staff transfer residents requiring full body mechanical lifts with only one staff and stated that “all the staff do it all the time,” naming specific CNAs who frequently did so. Another RN acknowledged having to remind certain staff that two people were needed for full body lift transfers and that she had received reports of staff transferring residents alone. A CNA stated staff were not supposed to transfer residents alone with full body lifts but that when a nurse would not help, she transferred with only one staff. The facility further failed to protect residents from possible scalding injuries by not adequately monitoring and controlling hot water temperatures. Review of water temperature logs showed monthly readings in resident rooms and the laundry area, with some laundry temperatures documented above 140°F, and no temperatures recorded after mid-November. The Director of Plant Operations stated it was probably his job to review the temperatures monthly but admitted he did not do so and did not know what temperatures were too hot for resident rooms or showers, nor the appropriate high or low limits. The DON stated that 124°F for resident room water was “a little too hot” but was unsure of the correct temperature to prevent burns or the timeframe for burns to occur. The Administrator stated he was not a temperature expert, could not state the appropriate water temperature for showers or resident rooms, and was unsure whether the Director of Plant Operations had ever been trained on appropriate water temperatures. No policies were presented for appropriate water temperatures, full body mechanical lift use, or wheelchair transportation safety.
Failure to Assess and Treat Diabetic Ulcer and Head Injury for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assessment and treatment for a diabetic foot ulcer for one resident and failure to appropriately assess and monitor a head injury for another resident. For the first resident, the admission/readmission progress note dated 1/5/26 documented no impaired skin integrity, including no diabetic ulcer or open areas, despite the resident later being identified as having a diabetic ulcer on the second digit of the left foot. The resident, who had a BIMS score of 15 indicating no cognitive impairment, reported that she had informed the RN/ADON about the sore on her foot and that nothing was done until another RN intervened. The electronic health record showed that a wound evaluation entered on 1/15/26 documented a diabetic ulcer on the left second toe, present on admission, with specific measurements and description, and physician notification at that time. Further review of the records for this resident showed that the wound was again evaluated on 1/16/26 and 1/23/26 with documented measurements, but there was no documentation of any physician notification or treatment for the wound from the time of admission on 1/5/26 until 1/15/26, when the RN first addressed the area. A physician’s order to cleanse the second toe on the left foot and apply triple antibiotic ointment with a bandage daily had a start date of 1/15/26, indicating that treatment was not initiated until ten days after admission. The DON stated that the initial admission skin assessment was completed by one RN who left without documenting the assessment, and that the evening nurse then completed the assessment again. The DON also stated she did not think the initial nurse observed the resident’s foot or toe, acknowledged that the wound should have been noticed on admission, and confirmed that the resident was in the facility for a week without the wound being assessed or treated. For the second resident, who had a BIMS score of 13 indicating no cognitive impairment, the facility failed to appropriately assess and monitor a head injury and associated bruising. A skin check dated 12/22/25 documented no skin issues. On 1/4/26 in the morning, an LPN observed a scratch or red mark on the right side of the resident’s forehead and obtained an initial set of vital signs and an assessment as part of the daily assessment, but did not initiate neuro checks at that time and did not remove the resident’s clothing to assess hips or buttocks, only pulling pant legs up. The LPN reported conflicting accounts from the resident about how the injury occurred and stated she was not aware of any procedure for injury of unknown origin or for witnessed/unwitnessed head injury. Later that day, when the resident’s daughter arrived, the area on the forehead had progressed to a swollen “goose egg,” at which point neuro checks were started and the on-call provider was notified, with documentation showing neurological assessments beginning at 6:00 PM and a skilled note at 7:49 PM describing a hematoma to the right forehead and notifications made. The resident’s daughter reported finding her mother with a bruise on the knee and a wound on the right side of the head, and stated the resident told her she had fallen in the bathroom that morning. She also reported that additional large bruises on the right hip and right shoulder blade were only discovered and brought to attention when the resident was examined in the emergency department the following day. The DON acknowledged that there had been an injury of unknown origin and that staff had not notified the physician or family appropriately when the injury was first found in the morning, and that neuro assessments should have been initiated at that time but were not. The DON stated she would have expected staff to notify her, the physician, and the family when the head injury was first observed at approximately 7:30 AM, and confirmed that these actions were not completed as expected. The nurse practitioner stated she was notified of the forehead area and conflicting stories but was not made aware of the goose egg or any other bruising, and that she would have expected staff to call with any head injuries and start neuro assessments immediately.
Failure to Follow Physician Orders and Notify Providers Regarding Medication Administration
Penalty
Summary
The facility failed to provide needed services in accordance with professional standards by not following physician orders for multiple residents. For one resident with severe cognitive impairment and multiple diagnoses, including atrial fibrillation, heart failure, and respiratory failure, the facility did not administer three prescribed medications, failed to obtain daily weights as ordered, and administered a medication despite the resident's pulse being below the prescribed parameter. Documentation was missing for several medication administrations and required monitoring. Another resident with severe cognitive impairment and multiple chronic conditions, including coronary artery disease, hypertension, and neurogenic bladder, experienced repeated refusals of several scheduled medications and supplements over multiple days. The facility did not notify the primary care provider of these refusals, both for single instances and for continuous refusals over three days, despite facility policy requiring such notification. The resident subsequently refused all medications, nutrition, and hydration for a period, and was later taken to the hospital by family with a diagnosis of complicated urinary tract infection and altered mental status. Staff interviews confirmed that the primary care provider was not notified as required. A third resident with normal cognition and diagnoses including anemia, atrial fibrillation, and renal insufficiency received medication outside of prescribed parameters, specifically antihypertensive medication when blood pressure or pulse was below the hold parameters. There was also a lack of documentation for vital signs required before administration of these medications, and medications were held without physician orders when no parameters were specified. Staff and administration interviews confirmed that documentation was lacking and that medications were administered or withheld outside of physician orders and facility policy.
Failure to Provide and Document Catheter Care and UTI Monitoring
Penalty
Summary
The facility failed to provide catheter care and monitoring in accordance with professional standards for three residents with indwelling catheters. For each resident, there were multiple instances where catheter output was not documented as required by physician orders and facility policy. In addition, the facility did not consistently monitor or report changes in eating patterns, which were identified in care plans as potential signs or symptoms of urinary tract infection (UTI). One resident with severe cognitive impairment and a history of atrial fibrillation, heart failure, and recent UTI had an indwelling catheter. The resident's treatment records showed missing documentation of catheter output on several shifts, and there was no evidence that changes in eating patterns were reported as required. The resident was hospitalized with severe sepsis due to UTI, with hospital records noting overt purulence in the catheter and abnormal urinalysis results. Another resident with neurogenic bladder and a suprapubic catheter also had multiple missed entries for catheter output and decreased nutritional and fluid intake that was not reported to the primary care physician. This resident was subsequently hospitalized for a complicated UTI, and the physician confirmed that notification should have occurred for decreased intake. A third resident with normal cognition and a history of anemia, renal insufficiency, and recent UTI also had an indwelling catheter. Documentation of catheter output was missing for several shifts across multiple months, and there was no supporting documentation in the medical record for these omissions. Interviews with nursing staff and facility leadership confirmed that lack of documentation indicated the task was not completed, and that the expectation was for catheter output to be recorded each shift as ordered. Facility policy required catheter bags to be emptied and output documented at least every eight hours, with unusual findings reported to the physician.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Surveyors identified that the facility failed to implement appropriate infection prevention and control practices, specifically regarding hand hygiene and the use of Enhanced Barrier Precautions (EBP) during resident care for two out of three residents reviewed. Observations and record reviews revealed that staff did not consistently follow EBP protocols, such as wearing gowns and gloves during high-contact care activities, and did not always perform hand hygiene at required times, including between glove changes. The facility's own policies and posted signage required these precautions for residents with indwelling catheters, wounds, or pressure ulcers, but these were not always adhered to during care activities such as transferring, grooming, and catheter care. One resident with severe cognitive impairment, a suprapubic catheter, and a history of urinary tract infection was observed receiving care where staff initially followed infection control practices but failed to don gowns during subsequent high-contact activities like transferring and grooming. Another resident with an indwelling catheter, pressure ulcer, and multiple comorbidities was observed during care where staff changed gloves without performing hand hygiene, contrary to facility policy and CDC guidelines. Documentation also showed lapses in recording EBP implementation for this resident during certain shifts. Interviews with the Interim Director of Nursing and the Administrator confirmed that staff were expected to follow EBP protocols, including the use of gowns and gloves for high-contact care and hand hygiene between glove changes. However, direct observations and record reviews demonstrated that these expectations were not consistently met, resulting in a failure to fully implement the facility's infection prevention and control program as required.
Failure to Implement and Document Fall Prevention and Post-Fall Assessments
Penalty
Summary
The facility failed to provide appropriate interventions to prevent falls and did not complete required neurological assessments after unwitnessed falls for several residents. For one resident with severe cognitive impairment and a history of falls, the care plan was not updated with new interventions after multiple falls occurred on consecutive days. Progress notes documented repeated incidents of the resident being found on the floor, but no additional fall prevention strategies were added to the care plan following these events. Another resident experienced multiple unwitnessed falls, but the neurological assessment flow sheets showed that vital signs, level of consciousness, pupil response, motor functions, and pain response were not consistently documented as assessed after these incidents. This lack of documentation was also observed for another resident with severe cognitive impairment and a history of falls, where neurological checks were incomplete or missing after unwitnessed falls, despite facility policy requiring such assessments for a 72-hour period following an unwitnessed fall. Additionally, a resident with mild cognitive impairment and multiple medical diagnoses, including a history of falls, was observed with fall prevention equipment not consistently in use, such as a fall mat being folded and not placed by the bed. The care plan for this resident included general fall prevention measures, but after documented falls, there was no evidence of individualized interventions being added. Staff interviews revealed inconsistent knowledge and use of care plans and interventions, and the facility was unable to provide a current policy regarding fall interventions after a fall, relying instead on an outdated neurological assessment policy.
Failure to Update Facility Assessment Following Change in Ownership
Penalty
Summary
The facility failed to update its Facility Assessment to reflect current operations and resources necessary to care for its 26 residents. The most recent Facility Assessment provided was dated from July 2023 through June 2024 and still referenced the previous facility name, despite a change in ownership in February. The current CEO, acting as Administrator, confirmed that the assessment had not been updated since the new management took over. The Skilled Unit Manager/ADON reported being unable to access the previous owners' program to obtain policies and could not locate a relevant policy in the facility's binders. Additionally, corporate staff were asked to provide the policies they intended to implement, but as of several days after the request, no policies had been provided.
Failure to Employ Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified individual to serve as the Infection Preventionist (IP) responsible for the infection prevention and control program. According to document reviews and staff interviews, the designated IP, who is also the MDS Coordinator, had not completed the required specialized training in infection prevention and control, having only started the modules in April. The Director of Nursing (DON) was also undergoing the same training, and both relied on a corporate nurse for assistance, who was not regularly present at the facility. The facility's policy required the IP to be adequately qualified and to have completed accredited continuing education, which had not occurred at the time of the survey. Further review revealed that the antibiotic stewardship program, which falls under the IP's responsibilities, was not up to date, as evidenced by an incomplete binder for the current year. Staff interviews confirmed uncertainty regarding the IP's prior training and the lack of completion of required documentation. Additionally, the facility was unable to provide updated policies from the new ownership when requested by surveyors, indicating a lack of clear guidance and oversight for the infection prevention and control program.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and homelike environment for its residents. Over several days, multiple dead June bugs were seen on the floor between exit doors near a resident room, and these were not removed despite repeated observations. Additionally, a family member reported that housekeeping had not cleaned her relative's room since admission, leading her to personally pick up debris from the floor and bathroom. Direct observations confirmed the presence of white debris by the resident's recliner, a white spot under chairs, and a brown stain running from the toilet bowl to its base in the bathroom. These conditions persisted over multiple days, even after the concerns were brought to the attention of facility leadership. Interviews with staff revealed that housekeeping is expected to clean resident rooms and bathrooms daily, typically with two housekeepers on duty, though sometimes only one is available. Despite these expectations, the staff member interviewed denied receiving any complaints from residents about cleanliness. The ongoing presence of debris and unsanitary conditions in the resident's room and bathroom, as well as the accumulation of dead insects in common areas, demonstrate a failure to provide a clean and safe environment as required.
Failure to Report Alleged Staff Misconduct to State Agency
Penalty
Summary
The facility failed to report an allegation of staff misconduct to the State Agency as required. A resident with a history of stroke, atrial fibrillation, coronary artery disease, heart failure, thyroid disorder, and sleep apnea, who required substantial assistance with activities of daily living and was cognitively intact, reported that a night shift CNA was rude, spilled a bedpan on her bed, denied the incident, and placed her call light out of reach. The resident also reported that the CNA told her she was using her call light too much and requested that this staff member not be allowed back in her room. The incident was witnessed by the resident's son, who corroborated the resident's account and added that the CNA called his mother 'crazy' and dismissed her concerns. The Director of Nursing (DON) conducted an internal investigation, which included speaking with the resident, her son, and the staff member involved. The DON provided education to the CNA regarding resident rights, infection control, and communication, and instructed her to stay out of the resident's room. However, the DON did not report the allegation to the State Agency, as required by regulation. The previous administrator, who was the Abuse Coordinator at the time, stated she was not fully informed of the incident and would have reported it had she known the full details. Other facility staff, including the Assistant Director of Nursing, were unaware that the incident had not been reported and assumed proper procedures had been followed. The facility was unable to provide a policy regarding the reporting of such incidents during the survey, and corporate staff did not supply the requested policies in a timely manner. The failure to report the allegation of staff misconduct to the State Agency constituted a deficiency in the facility's abuse reporting procedures.
Failure to Thoroughly Investigate Allegations of Staff Misconduct and Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of staff misconduct and abuse involving two residents. In the first case, a resident with a history of stroke, atrial fibrillation, coronary artery disease, heart failure, thyroid disorder, and sleep apnea, who required significant assistance with activities of daily living, reported that a CNA was rude, removed her call light out of reach, and spilled a bedpan on her bed. The resident's son and other staff corroborated aspects of her account, including the removal of the call light and the resident being upset. However, the facility's investigation did not include interviews with other staff who cared for the resident after the incident, nor did it include a comprehensive follow-up interview with the resident. Statements from involved staff were not formally documented, and other staff who were aware of the incident were not asked to provide statements. In the second case, another resident, recently admitted for rehabilitation after a fall and with a UTI, reported that staff were mean to her and described an incident involving a male staff member, which was not corroborated by staffing records. The resident exhibited confusion, paranoia, and combative behavior, as documented in progress notes and staff interviews. Despite these concerns, the facility's investigation was limited to a conversation with the resident's family and a single staff member. There was no evidence of interviews with other residents or staff who cared for the resident after the alleged incident, nor was there a thorough follow-up interview with the resident herself. Both cases demonstrated a lack of comprehensive investigation into allegations of staff misconduct and abuse. The facility did not follow a systematic process for interviewing all relevant parties, collecting written statements, or ensuring that all aspects of the allegations were explored. Additionally, the facility was unable to provide a policy regarding the investigation of abuse allegations, and there was no evidence that a thorough or standardized investigative process was followed.
Incomplete Comprehensive Care Plans for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to complete comprehensive care plans for two residents following their admission, as identified through observations, record reviews, and interviews. One resident was admitted with multiple stage 4 pressure ulcers and was at risk for developing additional pressure injuries. The care plan for this resident did not specify the type and location of the pressure ulcers, despite documentation in the Minimum Data Set (MDS) and the resident's own report of pressure ulcers on her right heel and bottom. Another resident, admitted with a stage 2 pressure ulcer and at risk for further skin breakdown, also had a care plan lacking details on the type and location of the pressure ulcer. Additionally, the care plan for this resident did not include interventions to prevent new pressure ulcers from developing. Staff interviews revealed that CNAs and LPNs relied on care plans for guidance on pressure ulcer care, including repositioning and maintaining skin integrity. However, the care plans reviewed did not provide individualized or comprehensive interventions, and staff reported not having access to care sheets. The MDS Coordinator and Assistant Director of Nursing confirmed that care plans should include specific information about the presence, monitoring, and treatment of pressure ulcers, as well as preventive measures, but these elements were missing or incomplete in the reviewed care plans. Further review indicated that the facility lacked a clear policy regarding the development and updating of comprehensive care plans, as the current management could not locate relevant policies from previous ownership or provide new ones. This lack of policy guidance contributed to the incomplete documentation and planning for residents with pressure ulcers, as evidenced by the care plans and staff statements.
Failure to Update Care Plans After Falls and Pressure Ulcer Development
Penalty
Summary
The facility failed to update and revise care plans for three residents after significant changes in their conditions, specifically following falls and the development of new pressure ulcers. For one resident with severe cognitive impairment and a history of falls, multiple falls were documented within a short period, but the care plan was not updated to reflect these incidents or to add new interventions. Another resident, who had mild cognitive impairment and was at risk for pressure ulcers, developed new stage 2 pressure ulcers in-house, yet the care plan lacked specific details such as the type and location of the ulcers and did not include interventions to prevent new pressure ulcers from developing. Additionally, this resident experienced multiple falls, but the care plan was not revised to address these events or to implement new fall prevention strategies. A third resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease and a history of falls, experienced several falls, one of which resulted in injury and hospitalization. Despite these incidents, the care plan was not promptly updated to reflect the new falls or to add or revise interventions. Staff interviews revealed that care plans were not consistently updated immediately after significant events, and there was confusion among staff regarding who was responsible for updating care plans and what information should be included. Some staff relied on the charting system to check for interventions, but care sheets were not available, and there was a lack of clear policy guidance on care plan revision. The facility was unable to provide a policy regarding care plan revision, and corporate staff did not supply requested policies in a timely manner. The lack of timely and comprehensive updates to care plans after significant changes in residents' conditions, such as falls and the development of pressure ulcers, was identified through observations, record reviews, and staff and resident interviews. This deficiency affected at least three residents in a facility with a census of 26 residents.
Failure to Document Completion of Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that treatment orders for pressure ulcer care were consistently signed out as completed for two residents. For one resident with a history of stroke, renal insufficiency, depression, and obesity, documentation showed that multiple treatment orders—including dressing changes, skin prep applications, ointment applications, and wound evaluations—were not signed out as completed on several dates across multiple months. The resident was identified as being at risk for pressure ulcers and had documented unhealed stage 1 pressure injuries. The care plan directed staff to administer medications and treatments as ordered, but the Treatment Administration Records (TARs) revealed repeated omissions in documentation of completed care. Another resident, who had no cognitive impairment and was at risk for pressure ulcers with three unhealed stage 4 pressure ulcers, also had multiple treatment orders not signed out as completed. These included wound evaluations, dressing changes, and specific wound care procedures for sacral and buttocks ulcers, as well as a puncture wound. The TARs for this resident showed numerous instances where required treatments and evaluations were not documented as completed over several months. Interviews with the resident indicated that dressings and treatments were performed daily, but staff interviews confirmed that if an order was not signed out on the TAR, it was considered not done. Further investigation revealed that the facility lacked a clear policy regarding the administration and documentation of treatment orders. The Assistant Director of Nursing (ADON) was unable to locate a relevant policy in the facility’s records or obtain one from the previous owners. Corporate staff were also unable to provide the requested policies by the time of the survey. This lack of policy guidance contributed to inconsistent documentation practices and the observed deficiencies in pressure ulcer care.
Insufficient Staffing Leading to Delayed Resident Assistance and Unsafe Transfers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by resident council notes, facility assessment, and interviews with residents and staff. The facility assessment documented staffing ratios of 1 LPN/RN to 15 residents on the day shift, 1 LPN to 30 residents on the overnight shift, 1 CNA to 10 residents on day and evening shifts, and 1 CNA to 15 residents on the overnight shift. Residents and staff reported that these staffing levels were inadequate, particularly on the overnight shift, resulting in delayed assistance for residents. One resident reported waiting up to 40 minutes for help, which led to incontinence episodes and feelings of humiliation, especially while managing a urinary tract infection. Staff interviews confirmed that there were often only two CNAs on the morning and evening shifts and only one CNA on the overnight shift. Staff acknowledged that due to insufficient staffing, mechanical lifts were sometimes operated by a single staff member, contrary to safe transfer practices, and that call lights were not answered promptly. The facility was unable to provide policies regarding call light response times and the use of mechanical lifts, and corporate staff did not provide requested policies after a change in facility ownership.
Incomplete Medical Record Documentation and Missing Incident Reports
Penalty
Summary
The facility failed to ensure that medical records for three residents were complete and accurate, as required by professional standards. For two residents, documentation of showers was incomplete, with records showing only two showers documented in the past 30 days, despite care plans indicating the need for showers twice a week. Both residents reported receiving showers as scheduled and had no complaints, but the records did not reflect this care. Additionally, for one resident with severe cognitive impairment and a history of falls, incident reports for two separate falls were missing from the records, even though progress notes described the incidents and subsequent actions taken. Interviews with staff revealed issues with access to the electronic charting system, leading to lapses in documentation of both baths and incident reports. The Assistant Director of Nursing acknowledged that some staff could not access the charting system, and that incident reports were sometimes completed by hand and not entered into the system. Furthermore, the facility was unable to provide policies regarding documentation practices, as the transition to new ownership had left staff without access to previous policies or clear guidance on documentation requirements.
Infection Control Breach During Food Preparation
Penalty
Summary
The facility failed to ensure proper infection control measures during food service, as observed with Staff F, the Culinary Supervisor. While preparing grilled cheese sandwiches, Staff F donned disposable gloves and then touched several non-food contact surfaces, including a bag of bread and the counter, before handling food. He used the same gloved hand to grab bread and cheese slices, butter the bread, and place it on the grill. This practice was contrary to the facility's policy, which required gloves to be changed whenever they became contaminated by touching non-food contact surfaces. The Dietary Manager acknowledged that staff were instructed to avoid using gloves unless necessary, as they tended to become complacent and touch surfaces before handling food.
Failure to Ensure Timely Completion of Mandatory Reporter Training
Penalty
Summary
The facility failed to ensure that all staff completed the required Dependent Adult Mandatory Reporter (DAMR) Training, as evidenced by the personnel file review of a Certified Nurse Aide (CNA), referred to as Staff E. The review revealed that Staff E's DAMR training certificate had expired, as it was last completed over three years ago. This deficiency was identified when the survey team requested the personnel file, and it was discovered that the training had not been renewed as required. The facility's policy mandates that associates receive training during orientation and through periodic educational sessions, which includes recognizing signs of burnout, frustration, and stress that may lead to abuse, as well as understanding what constitutes abuse, neglect, and misappropriation of resident property.
Infection Control Deficiencies in PPE Usage and Precaution Signage
Penalty
Summary
The facility failed to adhere to proper infection prevention practices for two residents under Enhanced Barrier Precautions (EBP). Resident #2, who had severe cognitive impairment and an indwelling catheter, was observed receiving catheter care from a CNA who did not properly wear the gown as required. The CNA rolled up the sleeves of the gown, contrary to the facility's policy and the CDC guidelines, which state that the gown should cover the arms to the end of the wrists. This improper use of personal protective equipment (PPE) was acknowledged by both the Director of Nursing and the Administrator, who confirmed that the facility's expectation was for the gown sleeves to be down over the wrist during catheter care. Resident #180, with moderate cognitive impairment and a lung infection, was supposed to be under droplet and contact precautions due to a recent influenza A infection. However, observations revealed that there was no eye protection available outside the resident's room, and no signage indicating the need for droplet precautions. Staff members, including an RN and a CMA, admitted to not wearing the required eye protection when caring for the resident, despite being aware of the droplet precautions. The lack of proper signage and PPE availability led to staff not fully adhering to the necessary precautions. The facility's failure to ensure proper infection control measures were in place and followed for residents on EBP and droplet precautions highlights a significant deficiency in their infection prevention and control program. The absence of appropriate PPE and signage, along with staff not following established protocols, contributed to the lapses in infection control for these residents.
Inaccurate MDS Assessment for Insulin Use
Penalty
Summary
The facility failed to accurately assess a resident's status during the observation period of the Minimum Data Set (MDS) by incorrectly documenting the use of insulin for one resident. The MDS for the resident indicated severe cognitive impairment and inaccurately recorded insulin injections and changes in insulin orders, despite the Medication Administration Record (MAR) showing no insulin orders. Instead, the resident was prescribed Trulicity, a glucagon-like peptide, administered subcutaneously every Monday. Staff interviews revealed a misunderstanding, with a Registered Nurse/MDS coordinator incorrectly identifying Trulicity as insulin. The Director of Nursing (DON) and the Administrator acknowledged the error, confirming the MDS was inaccurately coded and that the facility lacked a specific policy on MDS accuracy, relying instead on the Resident Assessment Instrument (RAI).
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents during personal care interactions. Resident #8, who has moderate cognitive impairment, reported feeling disrespected by Staff H, a CNA, who made dismissive comments when the resident struggled to stand up from the toilet. This incident was overheard by another resident, but despite being reported to Staff I, an LPN, it was not escalated to management. Resident #8 expressed that some staff were occasionally short with her, particularly when she required assistance after using the bathroom, although she did not feel abused. Resident #175, who has no cognitive impairment, also reported feeling disrespected by Staff H. The resident recounted being rushed and spoken to in a demeaning manner by Staff H during bathroom visits, which made her feel sad and hurt. Despite these feelings, Resident #175 did not report the incidents to other staff members. The facility's management, including the Administrator, Nurse Manager, and DON, were unaware of these incidents until the survey, indicating a breakdown in the reporting process. The facility's policy prohibits abuse, neglect, and exploitation, and mandates investigation of such allegations, but the incidents were not reported or investigated as required.
Deficiencies in Documentation and Medication Management
Penalty
Summary
The facility failed to adhere to professional standards of quality care for two residents, leading to deficiencies in documentation and medication management. Resident #172, who had a history of diabetes mellitus and was dependent on staff for various activities, experienced a low blood glucose reading. The staff did not document the specific glucose level, nor did they perform a follow-up check as required by the facility's hypoglycemia policy. The policy mandates prompt treatment with fast-acting carbohydrates and repeated glucose checks every 15 minutes, which were not conducted. The lack of documentation and follow-up was confirmed by staff interviews and a review of the resident's chart. Resident #9, who had diagnoses including heart failure and hypertension, experienced consistently low blood pressure readings. Despite these readings, the staff continued to administer hypertension medication without established parameters to determine when to hold the medication. The facility lacked a specific policy on blood pressure parameters, relying instead on nursing judgment. Interviews with staff revealed inconsistencies in how low blood pressure readings were handled, with some nurses holding the medication and others administering it without clear guidelines. The Medical Director mentioned standard parameters for holding medication, but these were not documented in the resident's care plan or MAR. The Director of Nursing acknowledged the absence of established parameters for Resident #9's hypertension medication, which led to inconsistent practices among the nursing staff. The Administrator confirmed that the facility did not have a policy on blood pressure parameters, which contributed to the deficiency. The lack of documentation and clear guidelines for managing low blood glucose and blood pressure readings resulted in a failure to meet professional standards of quality care for the residents involved.
Deficiency in Discharge Planning for Resident
Penalty
Summary
The facility failed to ensure that follow-up services and appointments were established before discharging a resident, leading to a deficiency in discharge planning. Resident #173, who had intact cognitive ability and required partial assistance with daily activities, was discharged to a hotel without securing home health services or follow-up appointments with a doctor. The resident had a history of orthostatic hypotension, type 2 diabetes mellitus, and chronic kidney disease, and was admitted for physical and occupational therapy. Despite the discharge plan indicating that the resident's needs could be met in a lower health setting, the resident expressed feeling scared and nervous about the discharge. The social worker attempted to arrange home health services and follow-up appointments but faced challenges with insurance acceptance and communication. The resident was locked out of his previous residence and had no family support, leading the social worker to arrange for a hotel stay. The social worker contacted three home health agencies, but only one accepted the resident's insurance, and there was a delay in paperwork processing. Additionally, the primary care physician's office had not received the necessary discharge paperwork from the facility, and the resident struggled to manage his diabetes and edema without the required medical supplies and support. The facility's discharge plan lacked documentation of arranged follow-up appointments, and there was a misunderstanding regarding the acceptance of the resident's insurance by the primary care physician's office. The Director of Nursing was only involved in the medication list transfer, while the social worker was responsible for follow-up appointments and services. The facility's policy required appropriate discharge planning and communication of necessary information to the continuing care provider, which was not adequately fulfilled in this case.
Failure to Assess and Manage Resident's Pain
Penalty
Summary
The facility failed to adequately assess and manage the pain of Resident #171, who was experiencing severe pain related to a fracture. Despite having a care plan that included administering pain medications as ordered, monitoring their effectiveness, and notifying the physician if pain management interventions were unsuccessful, the staff did not follow these directives. On 11/17/24, the resident did not receive any PRN pain medication, and there was a lack of pain assessments and vital signs documentation. The resident was noted to be screaming in pain throughout the day, yet the staff did not administer the prescribed Oxycodone or notify the physician as required. On 11/18/24, the resident continued to experience significant pain, which was not adequately assessed or managed by the staff. The resident received Tylenol and Cyclobenzaprine, but the documentation lacked a pain rating or comprehensive assessment. The resident's pain was later documented at a level of 9, and she was transferred to the emergency department at the request of her family and physician due to uncontrolled pain. Interviews with staff revealed inconsistencies in pain assessment and management, with some staff members acknowledging the resident's pain while others questioned whether it was genuine or behavioral. The facility's policy on pain management, revised in 2019, emphasizes the importance of effective pain assessment and management, including notifying the physician of new or worsening pain. However, the staff failed to adhere to this policy, as evidenced by the lack of pain assessments and failure to administer PRN medications or notify the physician. The Director of Nursing acknowledged the deficiencies in pain assessment and management, indicating that an assessment should have been completed and PRN medication administered when the resident's pain was reported.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
