Cherokee Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Cherokee, Iowa.
- Location
- 1011 North Roosevelt, Cherokee, Iowa 51012
- CMS Provider Number
- 165330
- Inspections on file
- 25
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cherokee Specialty Care during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and mobility issues suffered a second-degree burn after spilling hot coffee in their lap. The facility failed to secure the coffee with a lid and did not adequately supervise the resident, who was known to drink coffee at all hours. Additionally, the prescribed treatment for the burns was not documented or followed, leading to significant pain and delayed care. Interviews with staff confirmed these oversights, and the resident required frequent morphine for pain management before passing away.
A facility failed to provide a resident or their representative with a written notice of rights, rules, services, and charges upon admission. The admission paperwork was not completed with the POA on the day of admission, and discrepancies in e-signature dates were found. Interviews confirmed the facility's admission process was flawed, and the Document Manager process failed to time-stamp e-signatures correctly. The Resident Council Meeting Minutes indicated a lack of transparency in the admission process.
A resident reported being verbally and physically abused by a CNA, who allegedly backed them into a wall. Despite the allegations, the facility allowed the CNA to continue working with other residents, although not with the complainant. The facility's investigation did not substantiate the claims, and police involvement did not confirm the allegations. The resident expressed ongoing discomfort and dissatisfaction with the situation.
A facility failed to report alleged abuse and missing Fentanyl patches to the Department of Inspection and Appeals and Licensing (DIAL) within the required time frames. An incident involving a resident and a CNA was not reported within 2 hours, and missing Fentanyl patches for two residents were not reported within 24 hours. The facility did not adhere to its policies requiring immediate reporting of such incidents.
The facility failed to investigate missing Fentanyl patches for two residents, one with no impaired decision-making abilities and another with moderate impairment. Despite the discovery of missing patches during routine checks, no investigations were conducted, as confirmed by the DON. This oversight contravenes the facility's policy to protect residents from neglect and misappropriation of property.
A facility failed to follow a resident's plan of care by not checking the colostomy bag every 3 hours as required. The resident, dependent on staff for daily activities, reported discomfort due to the bag being full of air. Clinical records and staff interviews confirmed the deficiency, with a CNA admitting the bag was not burped as needed due to staffing issues. The DON acknowledged the absence of a specific policy for colostomy care.
The facility failed to provide sufficient nursing staff, resulting in delayed call light responses for residents. Interviews and records showed that call lights were not answered within the expected 15 minutes, with some residents waiting over 30 to 45 minutes. Staffing levels were below the recommended daily pattern, particularly during the second and third shifts, as confirmed by staff and the Director of Nursing.
The facility failed to serve food at appetizing temperatures to several residents with intact cognition, as meals were often cold when they should have been hot. Observations showed a significant drop in food temperature from the steam table to room service delivery. The Dietary Service Manager and Administrator expected food to be served at appropriate temperatures, consistent with the facility's policy.
The facility did not have the certified Infection Preventionist present at quarterly QAA meetings, as required by their QAPI policy. Instead, the DON attended these meetings without having completed the necessary certification test to serve in this role. This was confirmed through interviews with a certified RN and the DON.
A facility failed to update a care plan for a resident with moderate cognitive impairment and frequent bladder incontinence. Despite the resident's frequent incontinence since early 2023, no urinary toileting program was attempted, and the care plan inaccurately described the incontinence as occasional. The ADON confirmed the care plan should have reflected frequent incontinence.
A resident with moderate cognitive impairment and frequent bladder incontinence did not receive appropriate treatment to restore continence, as a urinary toileting program was not attempted. The care plan inaccurately reflected occasional incontinence, and staff acknowledged the need for a toileting plan. Observations showed the resident required assistance with toileting and had difficulty expressing needs.
A dietary cook in the facility was observed handling food without gloves or performing hand hygiene, violating professional standards. The cook repeatedly handled frozen hamburger patties and touched various kitchen items without washing hands. Interviews with the Dietary Service Manager and Administrator confirmed that staff were expected to wash hands appropriately, as outlined in the facility's policy on preventing foodborne illness.
A resident receiving antibiotic treatment via a PICC line was not provided with proper Enhanced Barrier Precautions (EBP) by an LPN, who failed to wear a gown during the procedure. The facility's policy and CDC guidelines require PPE during high-contact care activities, which was not followed in this instance.
A resident with no cognitive impairment experienced a fall while out with family, resulting in a fracture. Despite the resident's complaints of pain and visible swelling, the facility delayed notifying the physician and resident representative. The facility's policy required prompt notification, but staff were unaware of the need to report incidents occurring outside the facility.
A resident with no cognitive impairment and a history of diabetes and hypoglycemia reported a fall while out with family, resulting in pain and swelling in her right ankle. Despite the resident's complaints and visible swelling, the facility delayed notifying the physician and conducting a thorough assessment. This led to a missed diagnosis of an acute spiral fracture, which was only identified after an x-ray was performed days later.
The facility failed to ensure food was stored and prepared under sanitary conditions, with various items found without proper labeling and visible cleanliness issues in the kitchen. The Dietary Manager confirmed that staff are expected to label everything and keep the area clean, but the observed conditions indicated a failure to follow these expectations.
Failure to Secure Hot Coffee Leads to Resident Burn
Penalty
Summary
The facility failed to secure a hot cup of coffee and adequately supervise a resident known to drink hot coffee at all hours, resulting in a second-degree burn to the resident's groin area. The resident, who had moderate impaired decision-making abilities due to non-Alzheimer dementia, was frequently incontinent and used a wheelchair for mobility. Despite these conditions, the resident was allowed to have a hot cup of coffee without a lid, leading to an accidental spill that caused significant injury. The resident's care plan included interventions such as using sippy cups to prevent skin injuries and placing the resident in an area where frequent observation was possible. However, these interventions were not effectively implemented, as evidenced by the incident. The facility also failed to follow physician orders for wound treatment, as the prescribed Silvadene cream was not noted on the September Medication Administration Record (MAR) or Treatment Administration Record (TAR), delaying appropriate care for the burns. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Practical Nurse (LPN), confirmed the lack of directives to use a lid on the coffee mug and the failure to document and follow through with the prescribed treatment. The Dietary Manager also noted that coffee temperatures were not consistently recorded, which could have contributed to the severity of the burn. The resident experienced substantial pain from the burns, requiring frequent administration of morphine for pain management, and ultimately passed away later in the month.
Failure to Provide Written Notice of Rights and Charges
Penalty
Summary
The facility failed to provide a resident or their representative with a written notice of rights, rules, services, and charges upon admission. This deficiency was identified for one of the three residents reviewed, specifically Resident #4, who was admitted to the facility via family vehicle with their daughter. Despite the presence of the Durable Power of Attorney (DPOA) during the admission process, the facility did not provide the necessary written documentation to the resident or their representative. The admission paperwork was not completed with the Power of Attorney (POA) on the day of admission, and the POA later discovered discrepancies in the e-signature dates, indicating that they were not present when the documents were signed. Interviews with the Social Service Director and the Regional Director of Human Resources confirmed that the facility's admission process was flawed, as the admission paperwork was not properly provided to the resident or their representative. The facility's Document Manager process, which allows for electronic signatures, failed to automatically time-stamp the e-signatures as per normal routine. Additionally, the Resident Council Meeting Minutes revealed a request from a resident or representative to review the admission packet, indicating a lack of transparency in the admission process. The facility has since revised its admission process, but the deficiency highlights a failure to ensure that residents and their representatives are fully informed of their rights and responsibilities upon admission.
Resident Alleges Abuse by CNA, Facility Investigation Inconclusive
Penalty
Summary
The facility failed to provide a supportive and safe environment for a resident, identified as Resident #3, who reported an incident involving a Certified Nurse Aide (CNA). The resident alleged that the CNA backed them into a wall and verbally abused them. Despite the allegation, the facility allowed the CNA to continue working with other residents, although they were instructed not to assist Resident #3. The resident's Minimum Data Set (MDS) assessment indicated no impaired decision-making abilities and documented the need for partial assistance with certain activities of daily living. The facility's internal investigation did not substantiate the resident's claims, and the CNA was allowed to continue working. The resident's grievance was documented, and the police were involved, but the allegations were not confirmed. The resident expressed ongoing discomfort and reported physical pain related to the incident, although the facility's staff did not observe any functional impairments. The resident's behavior and interactions with the staff were monitored, and the resident was offered alternative living arrangements, which they considered but did not immediately accept. The facility's policies emphasize the right of residents to be free from abuse and neglect, and the resident's rights include being treated with dignity and respect. Despite these policies, the facility's response to the incident did not fully align with the resident's reported experience, as the CNA continued to work in the facility. The resident's ongoing dissatisfaction with the situation was noted in subsequent documentation, indicating unresolved concerns about the incident.
Failure to Report Alleged Abuse and Missing Fentanyl Patches
Penalty
Summary
The facility failed to report alleged violations involving mistreatment, neglect, or abuse of a resident to the Department of Inspection and Appeals and Licensing (DIAL) within the required time frame. Specifically, an incident involving a resident who accused a CNA of backing them against a wall was not reported within the mandated 2-hour window. The facility conducted an internal investigation and determined that the CNA was not capable of the alleged action, but did not notify DIAL as required. Additionally, the facility did not report missing Fentanyl patches for two residents to DIAL within the required 24-hour period. One resident, who was on a Fentanyl patch for chronic pain, was found without the patch during a scheduled check, and no investigation was initiated to determine the cause of the missing patch. Similarly, another resident's Fentanyl patch was not found during a scheduled change, and the facility again failed to report this to DIAL. The facility's policies require immediate reporting of all allegations of abuse, neglect, and misappropriation of resident property to DIAL. However, in these instances, the facility did not adhere to its own policies or regulatory requirements, resulting in a failure to report potential abuse and missing controlled substances in a timely manner.
Failure to Investigate Missing Fentanyl Patches
Penalty
Summary
The facility staff failed to investigate the missing Fentanyl patches for two residents, leading to a deficiency in handling opioid medications. Resident #3, who had no impaired decision-making abilities, was on a pain management plan involving Fentanyl patches due to chronic pain. On a scheduled medication administration, the nurse discovered that the Fentanyl patch was missing from the resident's body, and despite a thorough search and inquiry, the patch was not found. The Director of Nursing confirmed that no investigation was initiated regarding the missing patch, which is against the facility's expectations. Similarly, Resident #1, who had moderate impaired decision-making abilities, was also prescribed Fentanyl patches for pain management. During a routine check, the patch was found missing, and again, no investigation was conducted to determine the cause or whereabouts of the missing patch. The Director of Nursing acknowledged the failure to investigate the missing patch for this resident as well. The facility's policy mandates that all residents have the right to be free from abuse, neglect, and misappropriation of property, which includes ensuring the safe administration and monitoring of medications. The failure to investigate the missing Fentanyl patches for both residents indicates a lapse in adhering to these policies, potentially compromising the residents' safety and well-being.
Failure to Adhere to Colostomy Care Plan
Penalty
Summary
The facility failed to adhere to professional standards and the resident's plan of care by not checking a resident's colostomy bag every 3 hours as required. The resident, who has a colostomy and is dependent on staff for all activities of daily living, reported that the staff did not check the colostomy bag every 3 hours, leading to discomfort due to the bag being full of air. The clinical records corroborated the resident's statement, showing that the colostomy bag was not checked at the prescribed intervals. Observations and staff interviews confirmed the deficiency. A Certified Nursing Assistant admitted that the colostomy bag was not burped every 3 hours due to staffing issues, despite the plan of care's requirements. The Director of Nursing acknowledged the lack of a specific policy or procedure for colostomy care, stating that the facility follows state and federal guidelines. This lack of adherence to the plan of care and professional standards resulted in the identified deficiency.
Inadequate Staffing Leads to Delayed Call Light Response
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in delayed response times to call lights. Interviews with residents and staff, as well as resident council minutes, revealed that call lights were not being answered within the expected 15-minute timeframe. Specifically, two residents reported waiting over 30 to 45 minutes for assistance. The facility's Director of Nursing confirmed the staffing shortages and acknowledged that the facility's guidelines for call light response times were not being met. The facility's assessment outlined a daily staffing pattern that was not adhered to, as evidenced by the two-week work schedule. On several days, the number of Certified Nursing Assistants (CNAs) scheduled was below the recommended levels, particularly during the second and third shifts. This staffing inadequacy was corroborated by staff interviews, where CNAs reported difficulties in responding to call lights promptly due to insufficient staffing, especially when assisting residents with mechanical lifts.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to four residents, all of whom had intact cognition as indicated by their BIMS scores of 15. These residents reported that their meals were often served cold when they should have been hot. Specifically, Resident #1 mentioned that room trays were not delivered until after everyone in the dining room had been fed, resulting in cold food. Resident #5 and Resident #35 also reported that their meals were frequently cold, with Resident #35 noting that the food quality had been poor for the four years he had been at the facility. Resident #39 added that the food was often burnt and then served cold. Observations on a specific day revealed that the dining service was completed in the dining room before room trays were sent out, leading to a significant drop in food temperature. For instance, chicken and dumplings initially measured at 156 degrees dropped to 113.9 degrees by the time they were served to residents in their rooms. Similarly, green beans went from 146 degrees to 86.4 degrees. Interviews with the Dietary Service Manager and the Administrator confirmed that their expectations were for food to be served at appropriate temperatures, aligning with the facility's policy on food preparation and service, which mandates maintaining proper hot and cold temperatures during food service.
Infection Preventionist Absence at QAA Meetings
Penalty
Summary
The facility failed to have the Infection Preventionist present at the quarterly Quality Assessment and Assurance (QAA) meetings, as required by their Quality Assurance and Performance Improvement (QAPI) Program policy. The Director of Nursing (DON) attended the meetings on behalf of the Infection Preventionist on three specific dates. However, the DON had not completed the necessary certification test to officially serve as the Infection Preventionist. This oversight was confirmed during interviews with both a Registered Nurse, who had obtained certification as an Infection Preventionist but did not attend the meetings, and the DON, who acknowledged the incomplete certification process.
Failure to Revise Care Plan for Frequent Incontinence
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for one resident, who was identified as having moderate cognitive impairment and frequent bladder incontinence. The Minimum Data Set (MDS) assessment indicated that the resident had been frequently incontinent since February 2023, yet no urinary toileting program had been attempted. The care plan, last revised in June 2022, inaccurately described the resident's incontinence as occasional and included interventions such as assisting the resident to the bathroom or commode as needed. The Assistant Director of Nursing acknowledged that the care plan should have reflected the resident's frequent incontinence, not occasional incontinence.
Failure to Implement Urinary Toileting Program for Incontinent Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with bladder incontinence, as required to restore continence to the extent possible. The resident, who had a moderate cognitive impairment, was frequently incontinent of bladder, yet a urinary toileting program had not been attempted. The resident's care plan, which was revised over a year prior, inaccurately identified the resident as having occasional bladder incontinence, and interventions included assisting the resident to the bathroom or commode as needed. Observations and staff interviews revealed that the resident had been frequently incontinent, and the care plan did not reflect this accurately. The Assistant Director of Nursing acknowledged that the resident's care plan should have indicated frequent incontinence and that a toileting plan had not been tried. Additionally, a Certified Nursing Assistant noted that the resident sometimes took herself to the bathroom but required assistance, and had difficulty verbally expressing her needs. The facility's policy on urinary continence and incontinence management required staff to screen and manage individuals with urinary incontinence, and to initiate a toileting plan if the resident remained incontinent despite treating transient causes.
Failure to Maintain Hand Hygiene in Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards in the preparation, serving, and distribution of food, as observed during a survey. A dietary cook, identified as Staff B, was seen handling food without wearing gloves or performing hand hygiene. Specifically, Staff B opened a freezer, retrieved a box of frozen hamburger patties, and used a spatula to cook them, all without washing hands. This process was repeated three times, and Staff B also touched various kitchen items, such as lids, cabinet handles, spatulas, and freezer door handles, without completing hand hygiene. Interviews with the Dietary Service Manager and the Administrator confirmed that the expectation was for staff to wash hands at appropriate times while in the kitchen. The facility's policy on preventing foodborne illness, dated October 2017, requires employees to wash their hands before contacting food surfaces, after handling raw meat, and after handling soiled equipment or utensils.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to universal infection control measures and Enhanced Barrier Precautions (EBP) during the care of a resident with a peripherally inserted central catheter (PICC) line. The resident, identified as having intact cognition, was receiving antibiotic treatment for a urinary tract infection and had a history of methicillin-resistant Staphylococcus aureus (MRSA). During an observation, a Licensed Practical Nurse (LPN) performed hand hygiene and donned gloves before cleansing the PICC line port and administering medication. However, the LPN did not wear a gown, which is required under EBP for residents with indwelling medical devices. Interviews with the LPN and the Director of Nursing (DON) confirmed the expectation that staff should wear gloves, gowns, and appropriate personal protective equipment (PPE) for residents on EBP. The facility's policy on Enhanced Barrier Precautions, as well as guidelines from the Centers for Disease Control and Prevention, emphasize the necessity of PPE during high-contact care activities, such as device care. The failure to wear a gown during the procedure was a deviation from these established protocols, contributing to the deficiency noted in the report.
Failure to Notify Physician and Representative of Resident's Fall
Penalty
Summary
The facility failed to immediately notify the physician and resident representative of a fall with an injury for a resident. The resident, who had no cognitive impairment and was diagnosed with diabetes and hypoglycemia, experienced an unwitnessed fall in the dining room and later reported a fall while out with family. Despite the resident's complaints of pain and visible swelling and bruising on the right ankle, the facility did not notify the physician until two days after the resident reported the fall, and the resident representative was not informed until the following day. The resident was administered pain medication multiple times due to increasing pain in the right ankle, which was later diagnosed as an acute spiral fracture of the distal fibula. The facility's policy required prompt notification of the physician and resident representative in the event of an accident or incident, but this was not adhered to in this case. The Assistant Director of Nursing acknowledged that staff were unaware of the need to report incidents occurring outside the facility, leading to a delay in completing the incident report and notifying the necessary parties.
Failure to Timely Assess and Notify Physician of Resident's Injury
Penalty
Summary
The facility failed to provide adequate assessment and timely intervention for a resident who experienced a change in condition. The resident, who had no cognitive impairment and was diagnosed with diabetes and hypoglycemia, reported a fall while out with family, which resulted in pain and swelling in her right ankle. Despite the resident's complaints of pain and the visible swelling and bruising, the facility did not notify the physician or conduct a thorough assessment until two days later. The resident initially reported pain in her right leg and ankle, receiving Hydrocodone and Acetaminophen for relief. However, the pain persisted, and the resident's condition worsened, with increased swelling and bruising noted by staff. Despite these observations, the facility delayed notifying the physician and failed to conduct an x-ray until several days after the resident first reported the fall and pain. The delay in assessment and notification resulted in a missed diagnosis of an acute spiral fracture of the distal fibula, which was only identified after the resident was sent for an x-ray. The facility's policy required prompt notification of the physician in the event of a change in a resident's condition, but this protocol was not followed, leading to inadequate care for the resident.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to ensure food was stored and prepared under sanitary conditions, as observed during an initial kitchen tour. Various items in the kitchen fridge, freezer, drink refrigerator, and dry storage area were found without proper labeling, including open containers of chicken, cottage cheese, deli ham, tuna salad, smoked chicken salad, potato salad, coleslaw, and various beverages. Additionally, several items in the freezer and dry storage lacked received dates, and some items were past their use-by dates. The kitchen also had visible cleanliness issues, such as dried food and white streaked areas on the front of refrigerators, freezers, ovens, and cabinets, as well as food crumbs, dried food items, and other debris on the floor. The facility's policies on food receiving, storage, and sanitation were not adhered to, as evidenced by the observations made during the tour. Further observations revealed unsanitary conditions, such as a red substance on a cabinet shelf, excess peanut butter around a container with an uncovered knife, and a knife with margarine left on top of a margarine container. The Dietary Manager confirmed that staff are expected to label everything in the kitchen, keep the area clean, and discard expired items. However, the observed conditions indicated a failure to follow these expectations, leading to the identified deficiencies in food storage and preparation practices.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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