Colonial Manors Of Columbus Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus Junction, Iowa.
- Location
- 814 Springer Avenue, Columbus Junction, Iowa 52738
- CMS Provider Number
- 165476
- Inspections on file
- 17
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Colonial Manors Of Columbus Community during CMS and state inspections, most recent first.
A resident with a history of stroke and dementia had conflicting code status documentation, with a CPR label on the chart exterior and a DNR order in the chart. The DON was unaware the label had not been updated after the resident started hospice, and staff relied on the chart label in emergencies, leading to inaccurate representation of the resident's wishes.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found gaps in staff training and a lack of clear protocols, which left residents vulnerable to mistreatment without timely detection or intervention.
The facility failed to complete MDS assessments on time for four residents, with delays acknowledged by an LPN and attributed to new staff by the DON. The facility's policy requires timely MDS completion, but this was not effectively implemented, resulting in deficiencies.
The facility failed to update care plans for residents following significant changes in their medical conditions. A resident's care plan lacked documentation for anticoagulant medication, another resident's plan was not updated with new fall interventions despite multiple falls, and two residents' plans did not address a pressure ulcer and a C. diff infection, respectively. The DON acknowledged these omissions.
A facility failed to accurately code the MDS assessment for a resident's medications, incorrectly indicating the use of a hypnotic medication not documented in the EHR. The resident, with intact cognition, was documented to take an antidepressant and an anti-convulsant for specific disorders. Interviews with an LPN and the DON confirmed the expectation for accurate MDS coding, with the LPN suggesting a possible error by the previous DON.
The facility failed to update the PASRR for two residents with new mental health diagnoses and psychotropic medications. One resident had moderate cognitive impairment with multiple diagnoses and medications not reflected in the PASRR. Another resident, with intact cognition, had additional diagnoses and medications not updated in the PASRR. The Administrator believed the updates were made by the previous DON, but they were not completed.
A facility failed to include diuretic medication in the care plan for a resident with severe cognitive impairment. The resident was taking Furosemide daily for bilateral lower extremity edema, as per a physician's order. The Director of Nursing acknowledged the omission, which was contrary to the facility's policy on comprehensive care plans.
A resident with hypertension and heart failure did not receive prescribed PRN Furosemide despite significant weight gains. The facility's staff failed to administer the medication as per physician orders, with the Certified Medication Aide acknowledging that it had been a while since the PRN Lasix was given. This deficiency was identified through a review of the Medication Administration Record and staff interviews.
A resident with advanced Parkinson's disease and moderately impaired cognition did not receive the required twice-weekly showers due to staffing shortages. The resident expressed dissatisfaction with the missed showers, and staff confirmed that low staffing levels sometimes prevented them from providing showers on scheduled days. The facility's documentation did not consistently reflect the expected shower schedule.
The facility failed to ensure daily weights for two residents on diuretics, consistent follow-up on bowel management for a resident, and thorough assessments for a resident's heel wound. Staff interviews revealed discrepancies in documentation and monitoring, with missing weight records, inconsistent bowel management interventions, and incomplete wound assessments.
A facility failed to ensure a timely response from a physician to a pharmacist's GDR recommendation for a resident on psychotropic medications. The resident, with cognitive impairment and multiple diagnoses, was on a regimen including escitalopram, Seroquel, and trazodone. Despite the pharmacist's recommendation, the provider delayed responding, citing potential impairment of the resident's function as a reason for declining dose reduction. The facility's policy required monthly drug regimen reviews and timely action on irregularities, which was not adhered to in this case.
The facility failed to maintain an effective QAPI process, resulting in repeat deficiencies in care plan revision, assessment/intervention, and drug regimen review. Despite having a plan of correction, the facility struggled with follow-through due to staff changes, including the retirement of the previous DON. The facility's QAPI policy outlined systems for monitoring care, but these were not effectively implemented, leading to the recurrence of deficiencies.
Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to ensure that accurate code status information was recorded and readily available for a resident. Specifically, a resident with a history of cerebral vascular accident and dementia, who had a moderate level of mental impairment, had conflicting documentation regarding their code status. The outside cover of the resident's hard clinical chart displayed a label indicating CPR should be performed in the event of cardiac or respiratory arrest, and a form inside the chart also included an order for CPR. However, a separate section of the chart contained an Iowa Physician Order for Scope of Treatment (IPOST) form, signed by the resident's durable power of attorney for healthcare and a healthcare practitioner, which indicated a DNR (Do Not Resuscitate) order. During staff interviews, it was revealed that the DON was unaware that the CPR identification label on the chart had not been updated when the resident began hospice care. Staff reported that in an emergency, they would refer to the label on the outside of the chart to determine whether to perform CPR. The facility's policy stated that residents have the right to make decisions regarding their healthcare, including CPR/DNR status, but the failure to update the chart label resulted in inconsistent and potentially misleading information about the resident's wishes.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these types of mistreatment. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and preventing such incidents. The absence of robust preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.
Delayed MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure timely completion of Minimum Data Set (MDS) assessments for four residents, as required by regulations. Resident #26 was admitted on 12/27/23, but their admission MDS assessment, with an Assessment Reference Date (ARD) of 1/9/24, was not completed until 1/19/24. Similarly, Resident #29's admission MDS assessment, with an ARD of 5/20/24, was completed on 5/30/24. Additionally, the annual MDS assessments for Resident #13 and Resident #5 were also delayed. Resident #13's assessment, with an ARD of 5/14/24, was completed on 6/4/24, and Resident #5's assessment, with an ARD of 2/26/24, was completed on 3/18/24. During interviews, staff acknowledged the delays in completing the MDS assessments. Staff C, an LPN, confirmed that the assessments for Residents #29, #13, and #5 were submitted after the 14-day deadline. The Director of Nursing (DON) admitted that the facility struggled to complete assessments on time, attributing the delays to new staff members who were not fully familiar with the process. The facility's policy requires a schedule for MDS completion, but it appears this was not effectively implemented, leading to the deficiencies noted.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to update the care plans for several residents following significant changes in their medical conditions and treatments. For Resident #15, the care plan did not include a focus area for anticoagulant medication, despite the resident being prescribed Eliquis for nonrheumatic aortic valve stenosis. This oversight occurred even though the medication was initiated shortly after the resident's admission. The Director of Nursing acknowledged that anticoagulants should be included in the care plan. Resident #9, who had severely impaired cognition, experienced multiple falls without injury, yet the care plan had not been updated with new fall interventions since April 2023. The resident had fallen on several occasions in 2024, but the care plan remained unchanged. The Director of Nursing confirmed that fall interventions should be part of the care plan. For Resident #20, the care plan lacked documentation of a pressure ulcer on the left heel, despite the resident having a history of Methicillin Susceptible Staphylococcus Aureus infection and receiving treatment for the ulcer. Similarly, Resident #6's care plan did not address an infection of Clostridium Difficile, even though the resident had been diagnosed and treated for this condition. The Director of Nursing acknowledged that these issues needed to be addressed in the care plans.
Inaccurate MDS Coding for Resident's Medications
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident's medications. Specifically, the MDS assessment indicated that a resident took a hypnotic medication, which was not documented in the Electronic Health Record (EHR). The resident, who scored a perfect 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam indicating intact cognition, was documented to have taken an antidepressant and an anti-convulsant for mixed obsessional thoughts, hoarding disorder, and major depressive disorder. However, there was no evidence in the EHR that the resident took a hypnotic medication. During interviews, a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) both acknowledged the expectation for accurate MDS coding, with the LPN suggesting the error may have been a mistake by the previous DON.
Failure to Update PASRR for Residents with New Diagnoses
Penalty
Summary
The facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) for two residents, despite new mental health diagnoses and psychotropic medications being added to their care plans. Resident #19, who was moderately cognitively impaired, had diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, and a psychotic disorder. The resident was on antipsychotic and antidepressant medications, which were not reflected in the PASRR Level 1 Screen Outcome. The care plan and electronic medical record (EMR) indicated the use of psychotropic medications for behavioral disturbances, but the PASRR was not updated to reflect these changes. Resident #20, with intact cognition, had medical diagnoses of a psychotic disorder, anxiety disorder, and depression, and was taking antipsychotics and antidepressants. The PASRR Level 1 Screen Outcome did not require a Level 2 review and only noted depression and the use of Escitalopram. However, the care plan and EMR showed additional diagnoses and medications, including major depressive disorder and delusional disorders, which were not updated in the PASRR. During an interview, the Administrator acknowledged that the PASRRs for both residents should have been resubmitted. The Administrator believed that the previous Director of Nursing (DON) had updated the PASRRs after discussing the changes with psychiatric staff. The facility's PASRR policy indicated that updates were necessary for new diagnoses of certain mental health disorders, but the updates were not completed in these cases.
Failure to Include Diuretic Medication in Care Plan
Penalty
Summary
The facility failed to include diuretic medication in the comprehensive care plan for a resident with severe cognitive impairment. The resident, who scored 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam, was taking diuretic medication as per the Minimum Data Set (MDS) assessment. The care plan did not address the diuretic medication, despite a physician's order for Furosemide, a diuretic, to be administered daily for bilateral lower extremity edema. This order was noted on the resident's admission date and remained current at the time of review. The Director of Nursing acknowledged that diuretics should have been included in the care plan, as per the facility's policy on comprehensive care plans, which aims to develop quantifiable objectives and care directives for maintaining the resident's optimum health status.
Failure to Administer Diuretic Medication as Ordered
Penalty
Summary
The facility failed to administer diuretic medication as per physician orders for a resident with a diagnosis of hypertension and unspecified heart failure. The resident, who had intact cognition, was prescribed Furosemide to be taken daily and as needed for weight gain of 3 or more pounds. However, the Medication Administration Record for March, May, and July 2024 showed that the resident did not receive any doses of PRN Furosemide, despite documented weight gains exceeding 3 pounds on multiple occasions. Interviews with facility staff revealed a lack of adherence to the physician's orders regarding the administration of diuretic medication. Certified Nursing Assistants were responsible for taking daily weights and reporting them to the charge nurse or medication aide, who would then document them in the Medication Administration Record. However, the Certified Medication Aide acknowledged that it had been a while since the PRN Lasix was given, indicating a failure to act on significant weight changes as required by the physician's orders.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to provide a shower twice a week for a resident with moderately impaired cognition and advanced Parkinson's disease. The resident, identified as Resident #13, was dependent on staff for bathing and required a mechanical lift for transfers. The resident's care plan indicated a need for extra time to complete activities of daily living (ADLs) due to deteriorating abilities. However, the Plan of Care (POC) Response History Report showed that the resident only received a bath on four specific dates, indicating a failure to meet the twice-weekly shower requirement. Interviews with the resident and staff revealed that the resident did not always receive the scheduled showers due to low staffing levels. The resident expressed dissatisfaction with missing showers, stating it bothered her and that there was insufficient staff to reschedule missed showers. Staff members confirmed that there were instances when the resident did not receive a bath on the scheduled day, and attempts were made to make up for it the following day. The Director of Nursing (DON) stated that showers were expected to be given twice a week and documented in the POC, but the documentation did not reflect this expectation consistently.
Deficiencies in Weight Monitoring, Bowel Management, and Wound Assessment
Penalty
Summary
The facility failed to ensure daily weights were obtained per physician orders for two residents who were on diuretic medication due to conditions such as hypertension and heart failure. For one resident, the care plan and physician orders specified daily weight monitoring, yet multiple dates in July and August lacked documentation of the resident's weight. Similarly, another resident's care plan and physician orders required daily weight checks, but several dates in July were missing weight documentation. Interviews with staff revealed that certified nursing assistants were responsible for obtaining weights, which were then supposed to be recorded by the charge nurse or medication aide. However, discrepancies were noted between paper and electronic health records, and the Director of Nursing was unsure why orders were not consistently documented electronically. The facility also failed to follow up consistently on a resident's bowel management, despite documentation of no bowel movement for over three days. The resident, who was on morphine for dyspnea related to congestive heart failure, had physician orders for bowel management interventions, including the use of magnesium hydroxide, bisacodyl suppositories, and Fleet's enema. However, the medication administration record showed inconsistent administration of these interventions, with significant gaps in the administration of prescribed medications. Interviews with staff indicated a lack of consistent monitoring and follow-up on bowel movements, despite facility policies outlining specific protocols for bowel management. Additionally, the facility did not complete thorough assessments for a resident's heel wound. The resident had a history of a pressure ulcer on the left heel, and the care plan lacked documentation of this condition. The electronic medical record and physician orders detailed various treatments and dressing changes, but there were instances where wound assessments were not completed as required. Staff interviews revealed that wound measurements were not consistently documented, and there were occasions when the resident's wound dressing was not changed due to the resident's participation in activities. The Director of Nursing acknowledged the need for regular wound assessments but noted that sometimes doctors preferred to leave dressings in place, leading to incomplete documentation.
Failure to Ensure Timely Physician Response to Pharmacist's GDR Recommendation
Penalty
Summary
The facility failed to ensure timely response from the physician to the pharmacist's Gradual Dosage Reduction (GDR) recommendation for a resident identified as having unnecessary medications. The resident, who had a moderately impaired cognitive status, was diagnosed with non-Alzheimer's dementia, anxiety disorder, depression, and a psychotic disorder. The resident was on a regimen of psychotropic medications including escitalopram, Seroquel, and trazodone. Despite the pharmacist's GDR recommendation letter being sent on February 25, 2024, the provider only responded on February 27, 2024, declining the dose reduction due to potential impairment of the resident's function. The facility's policy required that the drug regimen of each resident be reviewed monthly by a licensed pharmacist, with any irregularities reported to the attending physician, medical director, and Director of Nursing (DON). These reports were expected to be acted upon, with the attending physician documenting any actions taken or rationale for no changes in the resident's medical record. However, the facility's administrator noted issues with receiving timely responses from the provider, leading to the pharmacist sending letters to both the provider and the DON to track them. This deficiency was identified during a survey, highlighting the facility's failure to ensure the physician's timely response to the pharmacist's recommendations.
Repeat Deficiencies in QAPI Process
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) process, resulting in repeat deficiencies identified during the current recertification and complaint survey. These deficiencies were previously noted in surveys conducted over the past ten months. The specific areas of deficiency included care plan revision, assessment/intervention, and drug regimen review, all of which were cited at a no actual harm level. The facility had a census of 28 residents at the time of the survey. During an interview, the Administrator acknowledged the repeat citations and attributed the challenges to the retirement of the previous Director of Nursing (DON) and the onboarding of new staff. Despite having a plan of correction in place, the Administrator admitted that there was a lack of effective follow-through. The facility's QAPI policy for 2024 outlined systems for monitoring care and services, incorporating feedback from various stakeholders, and using performance indicators to track care processes and outcomes. However, the facility's failure to effectively implement these systems led to the recurrence of deficiencies.
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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