Cottage Grove Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Cedar Rapids, Iowa.
- Location
- 2115 First Avenue Se, Cedar Rapids, Iowa 52402
- CMS Provider Number
- 165322
- Inspections on file
- 23
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Cottage Grove Place during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, prior fall‑related fracture, and identified fall and wandering risks was care‑planned for mechanical‑lift transfers, wheelchair use, and close supervision. During a noon meal in the dining room, a CNA and a medication aide left the room with another resident to lay that resident down, leaving multiple residents still eating without staff present after an LPN had instructed them regarding the other resident. While the dining room was unsupervised for several minutes, the cognitively impaired, fall‑risk resident fell from the wheelchair; another resident witnessed the fall but could not intervene. Staff returned to find the resident on the floor with a right forehead hematoma and right shoulder pain, and later ED imaging confirmed an acute fracture of the right scapula. Interviews and records showed that facility expectations called for continuous supervision in the dining room when residents were present, but no written policy for dining room supervision existed at the time.
The facility failed to ensure sufficient staffing to respond to door alarms, resulting in alarms sounding multiple times without staff intervention. A family member silenced the alarms using a code, which was the same as the entry code for the building. The facility had 58 residents, 34 with moderate to severely impaired cognition. Staff interviews revealed that the alarms could not be heard from key areas, contributing to the lack of response.
A facility failed to ensure that a resident's psychotropic medications for anxiety and depression had corresponding diagnoses in their electronic health record. The resident's MAR showed prescriptions for Trazodone, Duloxetine, and Lorazepam, but the necessary diagnoses were missing. Interviews revealed the resident's anxiety and depression, and the DON acknowledged the oversight. The facility's policy lacked procedures to align medication with diagnoses.
A resident experienced significant weight loss due to the facility's failure to provide appropriate vegetarian dietary options and effective interventions. Despite being involved in menu planning, the resident frequently did not order enough food and primarily consumed milk. The resident refused the prescribed nutritional supplement, citing a dislike for the taste and an allergy to strawberries. Interviews with the DON and dietician confirmed the facility's lack of a specific weight loss policy and failure to meet the resident's dietary needs.
The facility failed to provide timely toileting assistance and proper hygiene practices for two residents, leading to potential infection risks. A resident was left without toileting for over four hours, and staff did not change gloves during incontinence care. Another resident was changed without proper barriers and glove changes. Additionally, a resident with wandering behavior urinated in inappropriate locations without interventions, and another resident did not receive baths as frequently as desired.
The facility failed to respond to call lights promptly for five residents, leading to a deficiency in staffing adequacy. Residents reported and observations confirmed delays ranging from 18 minutes to over an hour. The DON and Administrator acknowledged the lack of call light audits and tracking systems, contributing to the issue.
A resident with severe cognitive impairment experienced medication refusals, a fall, and significant weight loss without family notification. The facility's policy required notifying the family of such changes, but documentation of these notifications was absent.
The facility failed to administer medications correctly for three residents, leading to inconsistent dosing times, missed insulin administration, and a delay in Prednisone delivery. A resident with intact cognition received medications at incorrect times due to unclear scheduling instructions. Another resident with diabetes did not receive insulin as ordered, and the physician was not notified of low blood sugar. A third resident did not receive a Prednisone taper due to pharmacy delays, resulting in hospitalization. The facility's policies for medication administration and physician order transcription were not followed.
The facility failed to obtain timely treatment orders and assessments for residents with skin conditions, including a resident with a new skin area, another with moisture-associated skin damage, and a third with a surgical wound infection. Delays in treatment and assessment led to hospital transfers and inadequate care, contrary to facility policies.
A resident developed a Stage 3 pressure injury on the left foot due to inadequate monitoring of a wander guard device. The resident, at risk for pressure injuries, had the device initially placed on the ankle, which caused skin breakdown. Despite care plan interventions, the facility failed to document regular checks on the device's placement, leading to the injury's progression. The facility's policy required regular skin assessments, but these were not effectively implemented, contributing to the injury's development.
A resident with severe cognitive impairment and a history of wandering was left unsupervised, leading to unsafe actions and inappropriate voiding. Despite a care plan requiring supervision, the resident was observed wandering unsupervised and engaging in hazardous behaviors. Staff interviews indicated insufficient staffing levels to adequately supervise residents with behavioral issues, contributing to the facility's failure to prevent accidents and hazards.
A resident with moderate cognitive impairment and a gastrostomy tube did not receive proper enteral feeding care. An LPN failed to prime the feeding tube, and the resident's head of bed was not elevated to the required 30 to 45 degrees during feeding, contrary to facility policy. The DON confirmed these expectations, highlighting a deficiency in care.
A resident with diabetes and other conditions did not receive their prescribed Rybelsus medication upon arrival at the facility. The pharmacy filled the prescription, but the facility delayed signing for it due to cost approval issues, resulting in the resident using their own supply initially.
A resident with severely impaired cognition did not receive the required Speech Therapy services as per their certification periods. The resident was scheduled for 12 therapy sessions from late November to late December but only received six. During a subsequent period, the resident was scheduled for eight sessions but was discharged to the hospital without receiving any. Staffing challenges were cited as a reason for the missed sessions.
Unsupervised Dining Room Leads to Unwitnessed Fall and Shoulder Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an accident‑hazard‑free environment in the dining room, resulting in an unwitnessed fall and fracture for one resident. The resident had severe cognitive impairment, a history of falls with fracture within the prior six months, and multiple diagnoses including fractures, hypertension, diabetes, and dementia. Care plans identified the resident as at risk for wandering and falls, required substantial/maximal assistance for transfers with a mechanical lift, use of a wheelchair for mobility, and continuous use of a left upper extremity immobilizer. The care plans also documented a prior facility fall on 11/3/2025 when the resident slid out of bed, and fall risk evaluations on 10/22/2025 and 11/28/2025 confirmed the resident was a fall risk. On the day of the incident, the resident was in the dining room in a wheelchair during the noon meal. Two staff members, a CNA and a medication aide, were present in the dining room assisting residents with eating and passing medications. Another resident in the dining room was reportedly refusing to eat and “not acting right,” prompting staff to call an LPN from upstairs to assess that resident. The LPN came to the dining room, observed the two staff assisting residents, and told them to lay the other resident down. Accounts differ on timing and interpretation: the CNA and medication aide reported they understood this as an immediate directive and left the dining room with the other resident, while the LPN stated she meant for the lay‑down to occur when staff did their regular lay‑downs and that the residents in the dining room should have been removed or one staff member should have remained. When the CNA and medication aide left the dining room, residents were still eating and no other staff remained in the room. The two staff took the other resident to her room, transferred her to bed using a stand‑up lift, and provided cares, which took approximately 8–15 minutes. During this period, the dining room was unsupervised. While they were away, a male resident witnessed the cognitively impaired, fall‑risk resident fall but was unable to intervene. Upon returning, staff found the resident on the floor on her right side with the wheelchair nearby; she had been seated at a table in her wheelchair when they left. The resident had a hematoma to the right forehead, right shoulder pain, and later imaging in the ED showed an acute fracture of the distal tip of the right acromion of the right scapula. The facility administrator and ADON later confirmed that residents in the dining room were expected to be under supervision while eating and that there was no specific written policy for dining room supervision at the time of the incident. The facility’s self‑report and subsequent interviews confirmed that the fall was unwitnessed and occurred in the dining room shortly after lunch, during a period when no staff were present. The resident, who was unable to provide a reliable history due to dementia, was found seated upright on the floor with legs extended and guarding her right shoulder. The ED documentation noted the unwitnessed fall, right forehead hematoma, right shoulder pain, and contusion to the right side of the face, with imaging confirming the right scapular fracture and no acute intracranial or spinal injury. Staff interviews consistently indicated that facility expectations had been communicated verbally or in meetings that at least one staff member should remain in the dining room when residents were present and eating, but on the day of the incident, both staff assigned to the dining room left simultaneously, leaving the resident and others unsupervised. The report also describes the sequence of clinical assessment and diagnostic imaging following the fall. After the incident, the LPN obtained orders for cervical spine and right shoulder X‑rays and contacted the portable X‑ray company, which initially indicated same‑day availability. When the company later could not come until several days later, the resident was sent to the ED for urgent evaluation due to increased pain. The ED confirmed the right scapular fracture and the resident returned with a right arm sling. Nursing staff on subsequent shifts were aware that the resident was awaiting imaging and reported that the resident was sleeping and did not recall complaints of pain during their checks, but the documentation and ED findings confirmed that the resident had sustained a significant injury as a result of the unwitnessed fall in the unsupervised dining room.
Failure to Respond to Door Alarms
Penalty
Summary
The facility failed to ensure sufficient staffing to respond to door alarms, which resulted in alarms sounding multiple times without staff intervention. On the day of the incident, two door alarms sounded four times within a 14-minute period, and no staff were present to respond. A family member was observed silencing the alarms using a code, which was the same as the entry code for the building. The facility had 58 residents, 34 of whom had moderate to severely impaired cognition as indicated by their Brief Interview for Mental Status (BIMS) scores. Five residents used wander guards for safety, and 14 residents lived in proximity to the alarmed doors, with 9 of them having a BIMS score of 12 or lower. Interviews with staff revealed that the door alarms could not be heard from key areas such as the dining room and the nurse's desk, which contributed to the lack of response. Staff members were unaware of any recent incidents of residents leaving the building unassisted, but acknowledged that if an alarm was heard, they were expected to check the grounds. The Director of Nursing and the Administrator confirmed the issues with the alarm system, including the inability to run reports on alarm frequency and the inappropriate deactivation of alarms by family members.
Lack of Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications administered to a resident for anxiety and depression had corresponding diagnoses in the resident's electronic health record. This deficiency was identified for one of the three residents reviewed, specifically Resident #6. The resident's Medication Administration Record (MAR) indicated prescriptions for Trazodone, Duloxetine, and Lorazepam, intended for depression and anxiety. However, the electronic health record lacked documented diagnoses of depression and anxiety, despite the resident's care plan including focus areas for these conditions. During interviews, Resident #6 expressed feelings of anxiety and depression following a stroke, and staff confirmed the resident's confusion and anxiety. The Director of Nursing acknowledged the absence of the necessary diagnoses in the electronic health record and recognized the need for further investigation. Additionally, the facility's medication administration policy did not include procedures to ensure that medication diagnoses aligned with resident diagnoses, contributing to the oversight.
Failure to Prevent Weight Loss in Vegetarian Resident
Penalty
Summary
The facility failed to implement effective interventions to prevent weight loss for a resident who was identified as a vegetarian and had specific dietary preferences and allergies. The resident, who had no cognitive impairments, required set-up assistance with eating and had a history of anemia, hypertension, chronic pain, and malaise. Despite being involved in menu planning, the resident frequently did not order enough food and primarily consumed milk during meals. The care plan included monitoring weights, providing a regular diet, and offering vegetarian food choices, but these interventions were not effectively implemented. The resident experienced significant weight loss over several months, with a noted decrease of 10 pounds in one month and a total loss of 16.8 pounds since January. The facility's records indicated that the resident refused the prescribed nutritional supplement, Boost Plus, multiple times, citing a dislike for the taste and an allergy to strawberries, which was the flavor provided. The resident expressed a preference for tofu and other vegetarian protein sources, which were not accommodated by the facility's general diet offerings. Interviews with the facility's DON and dietician confirmed that the facility did not have a specific weight loss policy and only provided a general diet, failing to meet the resident's vegetarian dietary needs. The facility acknowledged the responsibility to furnish appropriate foods for the resident's diet and recognized the need to develop a diet plan that aligns with the resident's preferences and nutritional requirements.
Deficiencies in Resident Care and Hygiene Practices
Penalty
Summary
The facility failed to provide timely toileting assistance and adhere to proper hand hygiene and personal protective equipment guidelines during incontinence care for two residents. Resident #21, who was always incontinent of bowel and bladder and dependent on staff for toileting, was observed sitting in a wheelchair for over four hours without being offered toileting. During incontinence care, staff failed to change gloves between clean and dirty tasks and did not follow proper wiping techniques, increasing the risk of infection. The Director of Nursing (DON) acknowledged the staff's failure to change gloves and the absence of a peri care or toileting policy. Resident #27, also incontinent and dependent on staff for toileting, was observed being changed without proper use of barriers and glove changes. Staff placed dirty wipes and briefs directly on the bed without a barrier and touched clean items with dirty gloves. The DON confirmed that the staff should have changed gloves and used barriers during the process. The facility also failed to implement interventions to prevent inappropriate voiding for Resident #34, who exhibited wandering behavior and severe cognitive impairment. Despite frequent incidents of urination in inappropriate locations, the facility did not have a toileting program in place for the resident. Additionally, Resident #48 did not receive baths according to their desired frequency, with documentation showing fewer baths than the facility's policy required. The DON confirmed the expectation for residents to receive showers at least twice a week, which was not met for Resident #48.
Delayed Call Light Responses in LTC Facility
Penalty
Summary
The facility failed to respond to call lights in a timely manner for five residents, leading to a deficiency in providing adequate nursing staff to meet residents' needs. Resident #44, with intact cognition and requiring substantial assistance for daily activities, had a call light unanswered for 18 minutes. Resident #42, with moderate cognitive impairment and dependent on staff for activities, reported waiting 20-45 minutes for call light responses, and an observation confirmed a delay of 18 minutes. Resident #251, who required assistance from two people for mobility and toileting, reported long wait times due to staff shortages, and the Director of Nursing admitted to a lack of call light audits. Resident #48's representative reported that call lights were not answered promptly, with waits of 35 minutes to an hour, particularly when the resident was in a basement room. Resident #203, with intact cognition, experienced a 20-minute wait for assistance to use the bathroom. The facility's Director of Nursing and Administrator acknowledged that call lights should be answered within 15 minutes but admitted to not having conducted audits or having a system to track response times, contributing to the deficiency.
Failure to Notify Family of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's representative of several significant changes in the resident's condition. The resident, who had diagnoses including skin changes, diabetes, and non-Alzheimer's dementia, with a severely impaired cognition score, refused multiple medications on two separate occasions. These medications included donepezil, carbidopa-levodopa, metformin, and vinpocetine. Additionally, the resident refused a Med Pass supplement. There was no documentation indicating that the family was notified of these medication refusals. Furthermore, the resident experienced a fall, as noted in health status notes, but the facility could not locate a fall incident report. The family was not informed of the fall. The resident also experienced a significant weight loss from 172 lbs to 161 lbs, as noted in a physician fax, but again, there was no documentation of family notification. The facility's policy required staff to report changes in a resident's condition to both the physician and the family, which was not adhered to in these instances.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications in accordance with professional standards for three residents. Resident #203, who had intact cognition, received her medications at incorrect times over several days. The facility's medication administration schedule lacked clear instructions for administering medications ordered twice daily, leading to inconsistent dosing times. The Director of Nursing (DON) and an Advanced Registered Nurse Practitioner (ARNP) acknowledged the inappropriate practice of administering medications within broad time frames, which was not aligned with professional standards. Resident #33, with moderate cognitive impairment and insulin-dependent diabetes, did not receive her prescribed insulin dose on one occasion, and the nurse failed to notify the physician when the resident's blood sugar was low. The nurse misinterpreted the order, believing insulin should be held if blood sugar was below a certain level, which was incorrect. The DON confirmed that the nurse should have contacted the physician for further instructions, highlighting a lapse in following the facility's policy for physician order transcription and medication administration. Resident #204, who required continuous oxygen therapy and had multiple diagnoses, did not receive a prescribed Prednisone taper due to a delay in medication delivery from the pharmacy. The facility failed to notify the physician about the missing medication, and the resident experienced respiratory issues, leading to hospitalization. The facility had an emergency medication kit that included Prednisone, but it was not utilized. The DON and Facility Administrator acknowledged the failure to document physician notification and the transcription of orders into the electronic medical record, as required by facility policy.
Deficiencies in Timely Treatment and Assessment of Skin Conditions
Penalty
Summary
The facility failed to obtain a timely treatment order for a new skin area for a resident with diabetes and hip fracture, who required assistance for mobility and had intact cognition. The resident complained of soreness at the coccyx, and a new area was identified, but the treatment order was not documented until several days later, delaying the initiation of treatment. Another resident with severely impaired cognition and a history of skin changes and diabetes was not assessed or treated for moisture-associated skin damage (MASD) in a timely manner. The facility lacked documentation of skin assessments and treatments for MASD, and the resident was later transferred to the hospital with a Stage 2 pressure injury. Additionally, the facility did not assess or intervene when the resident showed signs of altered mental status, leading to a hospital transfer with symptoms of fever, confusion, and purulent drainage from a Foley catheter. A third resident, dependent on staff for mobility and with a history of joint replacement surgery, showed signs of infection at the surgical wound site. Despite the presence of redness, inflammation, and purulent drainage, the facility delayed notifying the provider and obtaining appropriate wound care orders. The facility's policy required immediate notification of the provider for signs of infection, but this was not adhered to, resulting in a delay in addressing the resident's wound infection.
Failure to Monitor Wander Guard Leads to Stage 3 Pressure Injury
Penalty
Summary
The facility failed to adequately monitor and assess the skin condition of a resident wearing a wander guard device, resulting in the development of a Stage 3 pressure injury on the resident's left inner foot. The resident, who had intact cognition and was at risk for pressure injuries due to limited mobility and other health conditions, was initially noted to have a new pressure area on the foot attributed to the wander guard. Despite the removal of the device from the ankle and its relocation to the wrist, the injury progressed from a scab to an unstageable pressure injury with slough and drainage. The resident's care plan included interventions for skin integrity and pressure injury prevention, such as wearing a heel boot and weekly skin evaluations. However, the care plan did not specifically address the pressure injury that developed. The facility's records lacked documentation of regular checks on the wander guard's placement and function, which was expected to be recorded in the Electronic Health Record. The resident's wound assessments over several months showed deterioration, with the injury eventually classified as a Stage 3 pressure injury. The facility's policy required regular skin assessments and immediate reporting of any changes, but these protocols were not effectively implemented. The Director of Nursing acknowledged that the wander guard had caused the initial skin breakdown due to the resident's side sleeping and contracted legs. Despite the facility's policy and the resident's care plan, the lack of consistent monitoring and documentation contributed to the progression of the pressure injury.
Inadequate Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident with severe cognitive impairment, resulting in unsafe actions and inappropriate voiding. The resident, who had a history of wandering and was at high risk for falls, was observed multiple times engaging in unsafe behaviors without staff intervention. These behaviors included urinating in inappropriate locations, wandering unsupervised, and interacting with potentially hazardous objects. The resident's care plan indicated a need for supervision and redirection due to their wandering behavior and potential for aggression. Despite this, the resident was frequently left unsupervised, as evidenced by multiple observations where the resident wandered into other residents' rooms, attempted to pick up non-existent objects, and urinated on the floor in the dining room. Staff interviews revealed that the lower level of the facility, where the resident resided, was often understaffed, with only one nurse or medication aide available to supervise multiple residents with behavioral issues. Staff members reported that the current staffing levels were insufficient to provide the necessary supervision for residents with wandering behaviors. The Director of Nursing expected staff to remain in common areas to monitor residents like the one in question, but observations showed that this expectation was not consistently met. The lack of adequate supervision and staffing contributed to the resident's unsafe actions and the facility's failure to prevent accidents and hazards.
Improper Administration of Enteral Tube Feeding
Penalty
Summary
The facility failed to properly administer enteral tube feeding to a resident with a gastrostomy tube, leading to a deficiency in care. The resident, who had moderate cognitive impairment and diagnoses including cancer and malnutrition, required tube feeding for a significant portion of their nutritional intake. During an observation, a Licensed Practical Nurse (LPN) prepared the tube feeding without priming the tubing, which is necessary to prevent air from entering the abdomen. Additionally, the resident's head of bed was not elevated to the required 30 to 45 degrees during the feeding process, as it remained at approximately 15 degrees. The facility's Director of Nursing (DON) confirmed the expectation that tubing should be primed before feeding and that the head of bed should be elevated appropriately during and after feeding. The facility's policy also instructed staff to maintain the head of bed elevation at least 30 degrees during feeding and for a period afterward. Despite these guidelines, the staff did not adhere to the proper procedures, resulting in a failure to provide appropriate care for the resident with a feeding tube.
Failure to Provide Routine Medications
Penalty
Summary
The facility failed to ensure the provision of routine medications for a resident diagnosed with diabetes, hip fracture, and pain, who had an intact cognitive status. The resident's Minimum Data Set (MDS) assessment indicated a need for Rybelsus, a medication used to improve blood sugar levels, with an order dated 12/7/23. However, the resident reported having to use her own supply of Rybelsus upon arrival at the facility because the medication was not available. The pharmacy had filled the prescription on 12/6/23, but the facility did not sign for it until 12/8/23. The delay was due to the pharmacy needing approval from the facility because of the medication's cost. The pharmacy contacted the facility on 12/6/23 and 12/7/23, receiving approval on 12/7/23. The Director of Nursing confirmed that for skilled residents, the facility was responsible for medication costs, and the admission packet indicated a contract with a pharmacy for pharmaceutical services.
Failure to Provide Required Speech Therapy Services
Penalty
Summary
The facility failed to provide the required Speech Therapy services for a resident with severely impaired cognition, as indicated by a BIMS score of 4 out of 15. The resident had a certification period for Speech Therapy from 11/24/23 to 12/21/23, during which they were supposed to receive therapy 12 times. However, documentation shows that the resident only received therapy on six occasions within this period. Additionally, during a subsequent certification period from 2/13/24 to 3/13/24, the resident was scheduled for eight therapy sessions but was discharged to the hospital on 2/25/24, with no documentation of any therapy sessions conducted between 2/13/24 and 2/25/24. The Director of Therapy acknowledged staffing challenges with speech therapists and was unable to explain why the resident did not receive the scheduled therapy sessions. The Director of Nursing confirmed that therapy should adhere to the number of visits ordered. The facility's policy, although undated and untitled, stated that therapists should provide rehabilitation services according to physician orders, which was not followed in this case.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
