Clarion Wellness And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clarion, Iowa.
- Location
- 110 13th Avenue Sw, Clarion, Iowa 50525
- CMS Provider Number
- 165362
- Inspections on file
- 27
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Clarion Wellness And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents experienced repeated delays in call light response, with documented waits of 15 minutes or more, including several instances exceeding 30 minutes. Both residents had cognitive impairments and reported or were observed waiting extended periods for assistance, contrary to facility policy requiring call lights to be answered within 10-15 minutes. The administrator acknowledged staff shortages during the period in question.
Three residents in an LTC facility experienced verbal abuse and disrespect from CNAs. One resident, with no memory impairments, was verbally abused when requesting assistance with bed-making. Another resident, dependent on staff for personal care, was rudely questioned by a CNA when feeling unwell. A third resident, requiring substantial assistance, was rudely treated and physically poked by an agency CNA. Despite these incidents, the residents generally felt safe and satisfied with the care from other staff members.
The facility failed to report two separate abuse allegations to the Department of Inspections, Appeals, and Licensing (DIAL) within the required 24-hour timeframe. In one case, a resident reported alleged physical abuse to a CNA, but it was not reported to the DON until days later. In another case, a CNA witnessed alleged verbal abuse but delayed reporting it to the DON. Both incidents involved residents with specific medical conditions and cognitive assessments.
The facility failed to promptly separate staff accused of abuse from residents. In one case, a resident reported physical abuse to a CNA, who did not report it, allowing the alleged abuser to continue working. In another case, a CNA witnessed verbal abuse but delayed reporting, allowing the alleged abuser to work multiple shifts. The facility's policy on immediate reporting and separation was not followed.
Two residents in a LTC facility were not protected from abuse, leading to a deficiency. One resident reported physical abuse by a staff member, who continued to work and enter her room alone, causing fear and discomfort. Another resident experienced verbal abuse, which was not reported promptly, allowing the staff member to continue working with vulnerable residents. The facility failed to adhere to its abuse prevention and reporting policies.
Two residents in a long-term care facility experienced significant medication errors. One resident did not receive their prescribed Revlimid medication for over a month, while another resident received medications not prescribed to her due to a mix-up by a CMA. The facility failed to follow its policies on medication administration and physician orders, leading to these errors.
The facility failed to ensure proper food handling procedures during lunch service, as uncovered food items were delivered to residents in multiple hallways. A cook admitted to not covering desserts, chips, and crackers, despite the expectation to do so for infection control. The Administrator confirmed this expectation, although the facility lacked a specific policy on food service safety.
A resident with an indwelling urinary catheter experienced improper handling of their catheter drainage bag, which was observed lying on the floor and hanging on a trash can. This was against the facility's policy, which required the bag to be covered and properly positioned to prevent infection. Staff actions did not align with these guidelines, leading to a deficiency in maintaining a sanitary environment.
A CNA failed to report an alleged abuse incident involving a resident due to lacking a valid Dependent Adult Abuse Mandatory Reporter Certificate at the time of the incident. The facility's policies require immediate reporting of abuse, but the CNA did not comply, and the necessary certification was only obtained after the incident.
A facility failed to maintain consistent code status documentation for a resident, resulting in a mismatch between the IPOST, Care Plan, and EHR. The Care Plan and physician orders indicated CPR/Full Code, while the IPOST reflected a DNR status. The facility's policy required written submissions for changes, which were not properly communicated, leading to this discrepancy. The DON acknowledged the inconsistency.
The dietary staff at a facility failed to properly prepare pureed food for three residents, as observed during a survey. A cook, lacking formal training, prepared a turkey and wild rice casserole without measuring ingredients or using a puree graph to determine portion sizes. The administrator acknowledged the absence of a specific puree policy but expected staff to follow therapeutic diets and use the graph for portion control.
Failure to Provide Timely Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by prolonged call light response times for two residents. One resident, with moderately impaired cognition, was observed waiting 27 minutes for a response to his call light and reported frequent waits of half an hour or more. Facility records confirmed multiple instances over several days where this resident's call light remained unanswered for 15 minutes or longer, with some instances exceeding 25 minutes. The resident reported having to plan ahead for bathroom needs due to the long wait times and stated that these delays occurred throughout various shifts. Another resident, with severe cognitive impairment, was observed waiting 32 minutes for a response to their call light. Call light reports for this resident also documented numerous occasions where the call light was on for 15 minutes or more, including several instances exceeding 30 minutes and one instance lasting 50 minutes. The facility's policy required staff to answer call lights within 10-15 minutes, and the administrator confirmed the expectation for a 15-minute response time. The administrator also noted that two staff members had called in on one of the days in question.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat three residents with respect and dignity, leading to deficiencies in their care. Resident #1, who had no memory impairments and required supervision for activities of daily living, experienced verbal abuse from a CNA. The resident had requested assistance with making her bed, but the CNA responded rudely and did not fulfill the request. The resident felt scared and upset due to the CNA's behavior, which included yelling and slamming the door shut. Resident #2, with intact cognition and dependent on staff for personal care, also reported verbal abuse from a CNA. The resident, who was not feeling well, requested to go to bed, but the CNA responded rudely and questioned why the resident had not informed the first shift about her condition. This interaction left the resident feeling upset, although she later reported feeling safe at the facility. Resident #4, who required substantial assistance with daily activities and had intact cognition, reported an incident with an agency CNA who was rude and physically poked him in the chest. Although the poking did not cause pain, it was described as annoying. The resident expressed a desire not to be cared for by that particular CNA again, although he generally felt safe and satisfied with the care provided by other staff members.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) within the required 24-hour timeframe for two separate allegations of abuse. In the first incident, a resident reported alleged physical abuse to a CNA, but the allegation was not reported to the Director of Nursing (DON) until several days later. The facility began its investigation and reported the incident to DIAL on the same day the DON was informed, but this was beyond the 24-hour requirement. In the second incident, a CNA documented witnessing alleged verbal abuse towards another resident but did not report it to the DON until four days later. The DON then reported the incident to DIAL, but the facility failed to provide the completed investigation findings and results within the required five days. The facility eventually filed their Self-Report with DIAL, but this was also delayed. Both residents involved had specific medical conditions and cognitive assessments that were documented in their Minimum Data Set (MDS) assessments. The first resident had moderately impaired cognition and was receiving hospice services, while the second resident had intact cognition but was diagnosed with a neurocognitive disorder and other related conditions. The facility's failure to report these allegations in a timely manner and to complete the investigation within the required timeframe constituted a deficiency.
Removal Plan
- The facility educated all staff regarding the abuse policy and reporting of alleged abuse to their supervisor immediately. The facility would notify the as needed (PRN) staff prior to them working their next shift.
- The facility terminated the employment of the 2 alleged perpetrators.
Failure to Timely Separate Alleged Abusers from Residents
Penalty
Summary
The facility failed to promptly separate staff members accused of alleged physical and verbal abuse from dependent residents. In the first case, a resident reported an allegation of physical abuse to a CNA, who did not report the incident to the administration, allowing the alleged abuser to continue working for several days. Additionally, a dietary staff member learned of the allegation but delayed reporting it until later in the day, further allowing the staff member to work their entire shift. In the second case, a CNA witnessed another CNA using profanity towards a behavioral resident but did not report the incident until their next scheduled workday. This delay in reporting allowed the alleged abuser to continue working multiple shifts before the administration was informed. The facility's investigation revealed that the alleged abuser continued to work with access to vulnerable residents during this period. The facility's policy on abuse prevention and prohibition was not adhered to, as staff failed to immediately report and separate the alleged abusers from residents. The policy mandates that any suspected abuse should be reported immediately, and the alleged perpetrator should be removed from resident care pending investigation. However, in both cases, the staff did not follow these procedures, resulting in continued exposure of residents to potential harm.
Removal Plan
- The facility educated all staff regarding the abuse policy and reporting of alleged abuse to their supervisor immediately. The facility would notify the as needed (PRN) staff prior to them working their next shift.
- The facility terminated the employment of the 2 alleged perpetrators.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a deficiency. Resident #47 reported alleged physical abuse by a staff member on multiple occasions, but the facility did not take immediate action. The alleged abuser continued to work and enter Resident #47's room alone, despite the resident expressing fear and discomfort. The facility's investigation revealed that the staff member had inappropriate interactions with the resident, including kissing her on the neck and cheek, which made her uncomfortable and increased her feelings of depression. In another incident, Resident #316 was subjected to verbal abuse by a staff member, which was not reported to the Director of Nursing until several days later. The staff member continued to work with vulnerable residents during this time, creating an immediate jeopardy situation. The facility's lack of timely action and failure to separate the alleged abuser from the resident contributed to the deficiency. Both incidents highlight the facility's failure to adhere to its abuse prevention and reporting policies. The facility did not promptly investigate or address the allegations, allowing the alleged perpetrators to continue working with residents. This inaction compromised the safety and well-being of the residents involved.
Removal Plan
- The facility educated all staff regarding the abuse policy and reporting of alleged abuse to their supervisor immediately.
- The facility would notify the as needed (PRN) staff prior to them working their next shift.
- The facility terminated the employment of the 2 alleged perpetrators.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications per physician orders for two residents, leading to significant medication errors. Resident #25, who has a history of cancer, anemia, hypertension, and renal disease, did not receive their prescribed Revlimid medication from April 25, 2024, to June 5, 2024. Despite having a complete cycle of Revlimid available, the facility staff did not administer the medication as ordered, and there was no documentation of notifying the resident's primary care physician or family about the omission. The facility also failed to complete an investigation or medication error form regarding this omission. Resident #2, who has a history of coronary artery disease, hypertension, hyperlipidemia, thyroid disorder, anxiety disorder, depression, schizophrenia, and cognitive communication deficit, received medications not prescribed to her. Instead, she was given her roommate's medications, which included Oxycodone, Baclofen, Gabapentin, Lexapro, Melatonin, and Topamax. This error occurred when a certified medication aide (CMA) mixed up the medication cups for Resident #2 and her roommate, Resident #10, and left the medications unattended in the room. The facility's policies on physician orders and medication administration were not followed, contributing to these errors. The charge nurse or DON is responsible for placing orders for prescribed medications, and medication errors should be reported to the resident's attending physician. Additionally, the policy requires staff to accurately prepare, administer, and document oral medications, ensuring the correct resident receives the correct medication by verifying their identity before administration.
Removal Plan
- The facility educated all nurses and certified medication aides (CMAs) on following the physician orders policy. As needed (PRN) staff members will complete education prior to working the next shift.
- The DNS (Director Nursing Services)/designee will audit all missing/omitted MAR (Medication Administration Records) and TAR (Treatment Administration Record) entries. They will educate nursing when needed on following physician orders, correct order entry, and the process for medication errors.
- Two nurses will double note all orders. This is a permanent systemic change.
- The DNS/designee will run missing entries report in the electronic medical record (EMR) for omissions on the MAR/TAR.
Improper Food Handling Procedures
Penalty
Summary
The facility failed to ensure proper food handling procedures during lunch service, leading to potential contamination of food. Observations revealed that room trays delivered to residents in multiple hallways contained uncovered food items, including desserts, a bowl of chips, and a bowl of crackers. During an interview, a cook acknowledged that food should be covered when transported down hallways but admitted to not covering the desserts, chips, and crackers. The Administrator confirmed the expectation for staff to cover all food during transport for infection control purposes, although the facility lacked a specific policy on food service safety and infection control.
Improper Handling of Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections for a resident with an indwelling urinary catheter. The resident, who was recently admitted and lacked a completed Minimum Data Set (MDS) assessment, had a care plan that directed staff to position the catheter bag and tubing below the bladder level and away from the entrance room door. However, observations revealed that the catheter drainage bag was repeatedly mishandled. On multiple occasions, the bag was found lying on the floor without a privacy cover and hanging on the side of a trash can containing garbage, which is contrary to the facility's policy. Staff actions were inconsistent with the facility's policy, which required daily and as-needed catheter care to promote hygiene, comfort, and reduce infection risk. The policy also instructed staff to cover the drainage bag with a privacy bag to maintain dignity. Despite these guidelines, the catheter bag was observed uncovered and improperly positioned, and the Assistant Director of Nursing was seen discarding garbage in the trash can while the catheter bag was hanging on it. The Nurse Consultant later verified that the catheter drainage bag should not hang on the side of a dirty trash can.
Failure to Ensure Mandatory Reporter Certification for CNA
Penalty
Summary
The facility failed to provide a valid Dependent Adult Abuse Mandatory Reporter Certificate for Staff C, a Certified Nursing Assistant (CNA), at the time of an alleged abuse incident. Resident #47 reported an alleged abuse incident to Staff C, who did not report it to the administrative staff as required. The review of Staff C's employee file revealed that the certificate was completed only after the incident, dated 3/27/24, while the alleged abuse occurred on 3/20/24. The facility's policy mandates immediate reporting of abuse allegations, but Staff C did not comply with this requirement. The facility's policies on abuse prevention and reporting require staff to be trained on recognizing and reporting abuse, neglect, and exploitation. However, the facility could not provide evidence of Staff C's certification prior to the incident. The Director of Nursing stated that Staff C was in the process of obtaining the certification, but it was not provided before the survey exit. The facility's failure to ensure that Staff C had the necessary certification and training contributed to the deficiency in handling the abuse allegation appropriately.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure consistency in the code status documentation for a resident, leading to a discrepancy between the Iowa Physician's for Scope of Treatment (IPOST), the Care Plan, and the Electronic Health Record (EHR). The Care Plan indicated that the resident desired cardiopulmonary resuscitation (CPR) as per the IPOST, and the clinical physician orders also reflected a CPR/Full Code status. However, the resident's IPOST document indicated a do not resuscitate (DNR) status. The facility's Advanced Directives policy required any changes or revocations to be submitted in writing and communicated to the Care Plan team for updates. During an interview, the Director of Nursing acknowledged the inconsistency between the IPOST, Care Plan, and EHR orders for the resident.
Deficiency in Pureed Food Preparation for Residents
Penalty
Summary
The facility's dietary staff failed to properly execute the food and nutrition services for residents requiring a pureed diet. During an observation, a cook was seen preparing a pureed turkey and wild rice casserole for three residents without measuring the ingredients or using the puree graph to determine the appropriate portion size. The cook added unmeasured amounts of thickener and chicken broth to the mixture, altering the original volume, and used a scoop to plate the food without verifying the consistency or portion size. Interviews revealed that the cook had been pureeing food for about a year without receiving any formal training on the process or the required texture for pureed servings. The cook relied on information from the dietitian and online searches, and was unaware of how to use the puree graph in the kitchen. The facility's administrator acknowledged the lack of a specific puree policy but expected staff to follow therapeutic diets and use the graph to ensure appropriate portion sizes. The deficiency affected three residents on a pureed diet in a facility with a census of 61 residents.
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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