Creston Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Creston, Iowa.
- Location
- 1001 Cottonwood Drive, Creston, Iowa 50801
- CMS Provider Number
- 165199
- Inspections on file
- 25
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Creston Specialty Care during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was not administered medications according to physician orders, resulting in possible double dosing of Apixaban due to improper handling of short stock medication cards and the administration of an incorrect dosage of cranberry concentrate. The resident experienced gross hematuria and mouth swelling, prompting medical evaluation. Staff interviews and record reviews confirmed deviations from medication administration protocols, including failure to verify correct dosages and improper use of medication cards.
Multiple residents experienced prolonged wait times for toileting and transfer assistance due to insufficient nursing staff, with call lights often left unanswered for over 15 minutes. Residents reported episodes of incontinence and emotional distress, and staff interviews confirmed that short staffing, especially on afternoon and evening shifts, contributed to these delays. Facility leadership acknowledged the issue, and observations documented staff and administrators walking past active call lights without responding.
Five residents who experienced a significant change in condition by enrolling in hospice care did not have their Comprehensive MDS Assessments completed and transmitted within the required 14-day period, with delays ranging from 18 to 25 days. The facility lacked a specific policy for MDS timing and relied on the RAI manual.
A resident with multiple chronic conditions and intact cognition was not properly offered the COVID-19 vaccine, as evidenced by a lack of signatures on the declination form and the resident's statement that she would have accepted the vaccine if offered. The DON confirmed the absence of required documentation, and facility policy mandates both education and documentation for vaccine offers.
A resident with severe cognitive impairment and full dependence on staff for wheelchair mobility was repeatedly denied assistance to leave her room, despite multiple requests. Staff locked her wheelchair brakes and did not attempt alternative interventions as outlined in her care plan, resulting in the resident being left calling for help until meal service. Interviews with staff and family confirmed awareness of the need to support resident choice and try various interventions, but these were not consistently implemented.
A resident with moderate cognitive impairment and multiple diagnoses experienced frequent pain that interfered with therapy. Despite having physician orders for Oxycodone based on a pain scale, the resident received only one tablet on eight occasions when their pain was rated between 6 and 10, instead of the prescribed two tablets. The facility's medication administration policy required adherence to prescriber orders, but the resident's pain management was not aligned with these orders.
A resident with moderate cognitive impairment and a history of falls experienced three falls over three months due to staff not following safety precautions during transfers. The staff failed to consistently use a gait belt, leading to increased pain and the need for more intensive pain management and assistance. The resident's mobility was significantly affected, requiring a two-person assist for transfers and increased reliance on a wheelchair.
A cook at the facility was observed handling ready-to-eat food with gloved hands instead of using tongs during breakfast service, contrary to FDA guidelines and facility policy. The Certified Dietary Manager intervened, noting the improper practice, which was due to a misunderstanding by the cook regarding sanitary food handling procedures.
The facility failed to protect resident information from unauthorized access, affecting five residents. A document with personal health information was observed on a medication cart, and an LPN confirmed it was a communication sheet. The facility's confidentiality policy requires safeguarding resident privacy, but the DON acknowledged that such sheets should not be left visible.
The facility failed to manage Legionella risk and ensure proper hand hygiene. The Maintenance Supervisor did not document the flushing of secondary showers, contrary to the Legionella Water Management Policy. An LPN did not perform hand hygiene while treating a resident with MASD, risking cross-contamination. A CNA also failed to perform hand hygiene while managing a resident's catheter bag. The DON confirmed that hand hygiene should be performed at specific times, as per policy.
A resident with stage II pressure ulcers was left with a trash bag on their bed and uncovered legs after a dressing change by an LPN. The resident, who was cognitively intact, expressed dissatisfaction with the care, stating that staff often left him uncovered. A CMA later addressed the issue by removing the trash and covering the resident. The DON confirmed that facility policy requires staff to ensure residents' comfort after care procedures.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 8%. An LPN administered the wrong medication to a resident due to not checking the medication bottle properly and the prescribed medication not being stocked. The facility's policy requires three checks to ensure correct administration, which were not followed.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to provide services that met professional standards for one resident by not following physician orders for medication administration. The resident, who had diagnoses including atrial fibrillation, anemia, heart failure, hypertension, and respiratory failure, was prescribed Apixaban (an anticoagulant) and cranberry concentrate for UTI prevention. The Medication Administration Record (MAR) and facility documentation revealed discrepancies in the administration of Apixaban, with evidence suggesting the resident may have received double doses on two separate days due to improper handling of short stock medication cards. Staff did not consistently use the calendar date system for dispensing medications, resulting in the potential for duplicate dosing, which could not be definitively confirmed or ruled out by the facility. The resident experienced gross hematuria (blood in the urine) and was subsequently evaluated by a provider, who suspected the bleeding was caused by extra doses of Apixaban. The medication was held as a result, and the bleeding stopped. The resident later developed mouth swelling and pain, prompting a transfer to the emergency department, where no further significant findings were reported except for mouth pain. Interviews with staff confirmed the presence of two medication cards for Apixaban and missing doses from both, as well as a lack of adherence to the prescribed method for dispensing short stock medications. Additionally, the facility failed to provide the correct dosage of cranberry concentrate as ordered by the physician. The resident was given 450 mg instead of the prescribed 500 mg, and this discrepancy was acknowledged by both the administering nurse and the DON. The facility's policy required medications to be administered in accordance with prescriber orders, including verifying the right medication and dosage, but this was not followed in the cases of both Apixaban and cranberry concentrate for this resident.
Delayed Call Light Response and Inadequate Staffing
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in delayed responses to call lights and unmet toileting needs for multiple residents. Observations and interviews revealed that residents experienced significant wait times, sometimes exceeding 15 minutes, for assistance with toileting and transfers. One resident, who required partial assistance for transfers and toileting, reported waiting longer than 15 minutes for help, leading to episodes of incontinence and emotional distress. Another resident, dependent on staff for all transfers and toilet hygiene, described waiting over 1.5 hours to be changed, resulting in attending activities in soiled clothing and feeling upset about personal hygiene. Continuous observations documented instances where call lights remained on for extended periods, such as a 22-minute wait, with staff and even the administrator walking past without responding. In one case, a resident had to call out for help and ultimately relied on a family member for assistance after staff failed to respond, resulting in an incontinence episode. Staff interviews confirmed that short staffing, particularly on the afternoon and evening shifts, made it difficult to answer call lights promptly, especially for residents requiring more intensive assistance. The facility's own policies emphasized the importance of timely responses to call lights and maintaining resident dignity by avoiding demeaning practices such as delayed toileting assistance. Despite these policies, both nursing and administrative staff acknowledged that call lights were often not answered within the expected timeframe, and that staffing shortages contributed to these delays. The Director of Nursing, Assistant Director of Nursing, and Administrator all recognized that residents were left waiting for assistance, sometimes resulting in incontinence and residents turning off call lights themselves after prolonged waits.
Failure to Timely Complete MDS Assessments After Significant Change
Penalty
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within the federally required timeframe following a significant change in condition for five residents who enrolled in hospice care. For each resident, the Electronic Health Record and Medicare Hospice Election forms documented the date hospice services began, but the corresponding Significant Change MDS assessments were completed and dated well beyond the 14-day requirement outlined in the 2024 Resident Assessment Instrument (RAI) Manual. The delays ranged from 18 to 25 days after hospice election, exceeding the federal guidelines for timely assessment. This deficiency was identified through clinical record review and staff interviews, which confirmed that the facility did not have a policy regarding MDS Assessments and relied solely on the RAI manual. The residents involved were all documented as having a significant change in condition due to enrollment in hospice care, which should have triggered a timely comprehensive assessment. The lack of timely MDS completion was observed for all five residents reviewed for MDS Assessments.
Failure to Properly Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to properly offer and document the COVID-19 vaccination for one resident who was eligible for the vaccine. The resident's vaccine record indicated a refusal of the COVID-19 vaccine, but the declination form lacked both the resident's and staff member's signatures. The resident had a BIMS score of 15, indicating intact cognition, and had multiple diagnoses including heart failure, chronic kidney disease, diabetes mellitus, seizure disorder, anxiety, depression, and asthma. The resident's medical record and progress notes documented a refusal of the vaccine, but there was no evidence that the resident was provided with education or that a proper consent or declination process was followed as required by facility policy. During an interview, the resident stated she was not offered the COVID-19 vaccine and confirmed she would have accepted it if offered, despite previously declining influenza and pneumococcal vaccines. The DON acknowledged the lack of signatures on the declination form and stated that staff use these forms to determine if a resident was asked about vaccination. Facility policy requires that residents be provided with education about vaccines and that this education be documented in the medical record, but there was no documentation that this occurred for the resident in question.
Failure to Support Resident Choice and Prevent Involuntary Seclusion
Penalty
Summary
Staff failed to support a resident's right to self-determination and choice by not assisting her in leaving her room despite multiple requests. The resident, who had severely impaired cognition and was fully dependent on staff for wheelchair mobility, was observed repeatedly calling for help to leave her room. Staff locked her wheelchair brakes, preventing her from leaving, and did not attempt other interventions as outlined in her care plan, such as providing one-on-one support or moving her to a quieter area. The resident remained in her room calling for help until she was eventually removed for lunch service. On another occasion, staff again failed to assist her, and when she managed to leave her room independently, she was returned and her wheelchair was locked again. Interviews with staff and the resident's family confirmed that staff were aware of the need to assist dependent residents in leaving their rooms upon request and to try a variety of interventions if one failed. The family member reported previous concerns about the resident being left in her room with her wheelchair locked, describing it as being treated like a prison. Staff interviews revealed inconsistent application of interventions and an acknowledgment that the resident should have been assisted. Facility policy and the Director of Nursing confirmed that residents should be supported in exercising their rights and not subjected to involuntary seclusion.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication according to physician orders for a resident with moderate cognitive impairment and multiple diagnoses, including arthritis and fractures. The resident's Minimum Data Set (MDS) indicated frequent pain that interfered with therapy, and the care plan directed staff to anticipate and respond immediately to pain complaints. The Medication Administration Record (MAR) documented orders for both scheduled and as-needed pain medications, including Oxycodone for pain rated on a scale of 1-10. However, the resident received only one tablet of Oxycodone on eight occasions when their pain was rated between 6 and 10, contrary to the physician's order to administer two tablets for pain rated in this range. The Director of Nursing confirmed that the expectation was to follow the physician's orders based on the pain scale, and any pain rated higher than five should have been treated with two tablets of Oxycodone. The facility's medication administration policy required medications to be administered according to prescriber orders and for staff to verify the right dosage before administration. Despite these policies, the resident's pain management was not aligned with the prescribed orders, leading to inadequate pain relief on multiple occasions.
Failure to Ensure Safe Transfers Leads to Multiple Falls
Penalty
Summary
The facility failed to maintain a safe environment for Resident #21, who experienced three falls over a three-month period due to staff not adhering to safety precautions during transfers. The resident, who had moderate cognitive impairment and a history of falls, required partial assistance for transfers and was supposed to be assisted with a gait belt. However, staff failed to consistently use the gait belt, leading to falls that resulted in increased pain and the need for more intensive pain management and assistance. The first incident occurred when the resident fell after using the restroom, and it was documented that the staff did not use a gait belt during the transfer. The second fall happened during a transfer to bed when a CNA momentarily let go of the gait belt to adjust the bed, causing the resident to lose balance and fall. The third fall occurred again during a transfer to bed, with staff failing to use a gait belt, resulting in further pain and discomfort for the resident. Following these incidents, the resident experienced increased pain, particularly in the left knee and hip, requiring frequent administration of pain medication and topical treatments. The resident's mobility was significantly affected, necessitating a two-person assist for transfers and increased reliance on a wheelchair. Despite the facility's policy on managing falls and fall risks, the staff did not consistently implement the required interventions to prevent falls and minimize complications.
Improper Food Handling During Breakfast Service
Penalty
Summary
During a breakfast meal service, a deficiency was observed in the facility's food handling practices. Staff A, a cook, was seen preparing breakfast trays while wearing disposable, single-use gloves. Initially, she used tongs to place biscuits on plates, but soon after, she began using her gloved hands to handle the biscuits directly. She continued to use her hands to slice biscuits, spoon gravy, and touch multiple serving utensils, steam tray covers, and bowls. This practice was repeated for several trays, indicating a failure to maintain sanitary conditions as per the FDA Food Code 2022 guidelines. The Certified Dietary Manager (CDM) noticed Staff A's actions and questioned her about the use of tongs. Staff A responded that she believed it was acceptable to touch the food with her gloved hands since she had set up the steam table while wearing gloves. This misunderstanding led to the improper handling of ready-to-eat food, which is against the facility's policy on preventing foodborne illness. The facility's policy requires that food be stored, prepared, handled, and served in a manner that minimizes the risk of foodborne illness, which was not adhered to in this instance.
Unauthorized Access to Resident Information
Penalty
Summary
The facility failed to protect resident information from unauthorized access, affecting five residents. On June 17, 2024, a document titled 'Hall 2 Hot Chart' was observed on a medication cart, displaying personal health information for these residents. Staff H, an LPN, confirmed that the sheet on the medication cart was a communication sheet containing resident information. The facility's policy on confidentiality, revised in October 2017, mandates safeguarding personal privacy and limiting access to resident records to authorized personnel. However, the Director of Nursing acknowledged that communication sheets should not be left facing up with resident information visible.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to identify and manage areas or devices that could reduce the risk of Legionella or other waterborne pathogens. The Maintenance Supervisor admitted that while the secondary showers' water supply lines were routinely flushed, this was not documented. The facility's Legionella Water Management Policy, revised in 2017, was not followed, as evidenced by the lack of documentation for the flushing of plumbing fixtures in unused rooms. The Administrator confirmed that one of the four resident showers was not routinely used, and staff were expected to adhere to the facility's policy. In another incident, a Licensed Practical Nurse (LPN) failed to perform proper hand hygiene while administering treatment to a resident with Moisture Associated Skin Damage (MASD). The LPN used stock ointments not dedicated for single-patient use and did not wash hands before donning gloves or after removing them. The ointment containers were exposed during treatment, leading to potential cross-contamination. The Director of Nursing (DON) stated that staff should place ointments in a medication cup and perform hand hygiene before and after treatment, as per the facility's hand hygiene policy. Additionally, a Certified Nursing Assistant (CNA) did not perform hand hygiene at the appropriate times while managing a resident's catheter bag. The CNA donned gown and gloves before entering the resident's room but did not perform hand hygiene before applying gloves. After emptying the catheter bag, the CNA removed gloves and gown without performing hand hygiene immediately. The DON confirmed that hand hygiene should be completed at the start of treatment, when gloves are visibly soiled, when removing dirty gloves, and when leaving a resident's room, as outlined in the facility's hand hygiene policy.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to uphold the dignity of a resident by leaving a trash bag with bandage wrappers on the resident's bed and not covering the resident's legs after a dressing change. The resident, who was cognitively intact with a BIMS score of 14/15, had two stage II pressure ulcers upon admission. During an observation, a Licensed Practical Nurse (LPN) placed a trash bag on the resident's bed while changing dressings on the resident's feet. After completing the procedure, the LPN left the room without removing the trash bag, replacing the resident's socks, or covering the resident's legs. The resident activated the call light shortly after the LPN left, and a Certified Medication Aide (CMA) responded. The resident requested the CMA to bring the LPN back to remove the trash and cover him properly. The CMA returned alone, removed the trash, replaced the resident's socks, and covered the resident's legs. The resident expressed dissatisfaction with the care, stating that staff often left him uncovered after personal care. The Director of Nursing (DON) confirmed that the facility's policy required staff to dispose of trash and ensure residents' comfort after care procedures.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 8%. During a medication administration observation, two errors were identified out of 25 opportunities. Specifically, a Licensed Practical Nurse (LPN) administered Fexofenadine Hydrochloride instead of the prescribed Fiber 500 mg to a resident. The error occurred because the LPN did not check the medication bottle properly and the Fiber medication was not stocked in the medication cart. The facility's policy on administering medications, revised in April 2019, requires that medications be administered safely, timely, and as prescribed, with the individual administering the medication checking the label three times to ensure the right resident, medication, dosage, time, and method of administration. The Director of Nursing confirmed that these checks should be performed during medication administration. However, the LPN failed to adhere to this policy, leading to the medication error.
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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