Crestview Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in West Branch, Iowa.
- Location
- 451 West Orange Street, West Branch, Iowa 52358
- CMS Provider Number
- 165287
- Inspections on file
- 22
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Crestview Specialty Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple risk factors developed a Stage 3 pressure ulcer after admission. Staff failed to follow physician orders for wound care, did not use infection control techniques, omitted required wound treatments, and did not implement pressure-relieving interventions such as an air mattress or regular repositioning. The resident was left in a wheelchair for hours without assistance, and staff were unaware of the resident's skin breakdown, resulting in the development of a new unstageable pressure ulcer.
Two residents did not receive wound care as ordered, with missed or undocumented treatments, improper dressing application, and lack of provider notification when care was refused. Staff interviews and record reviews confirmed that wound assessments and documentation were incomplete, and facility policy for wound care and communication was not consistently followed.
Several residents with severe cognitive impairment and mobility limitations experienced unsafe transfers and incomplete post-fall assessments. One resident fell from a mechanical lift due to improper sling attachment, resulting in fractures and a head injury. Another resident was assisted without a gait belt and fell, while a third was found on the floor without appropriate neurological evaluation. Additionally, a resident requiring two-person assistance was transferred by one CNA without a gait belt. Staff did not consistently follow care plans, manufacturer instructions, or facility policies, leading to injuries and inadequate supervision.
Surveyors found that mechanical lifts and a wheelchair remained visibly soiled over multiple days, and a soiled incontinence pad was left on a bed. CNAs confirmed responsibility for cleaning and stated that soiled items should be removed immediately, but these tasks were not completed as required by facility policy.
A resident with moderate cognitive impairment who required assistance with bathing and personal hygiene did not receive a bath or shower for 17 days due to insufficient staffing. Multiple staff members, including CNAs, RNs, and LPNs, reported being unable to complete required care tasks, such as wound care and scheduled baths, because of routine understaffing. Staff also described situations where residents received meals in their rooms and feeding assistance was delayed, highlighting ongoing staffing shortages despite facility policies intended to address such issues.
Three residents experienced a lack of dignity and respect in their care, including not being offered meal choices, being left in soiled bedding and rooms with persistent odors, and being left undressed and exposed in bed. Staff failed to maintain a clean environment and did not consistently uphold residents' rights to a dignified existence.
A resident with moderate cognitive impairment and diagnoses of dementia and depression was administered risperidone, an antipsychotic medication, without documented informed consent from the responsible party. Staff interviews and record reviews confirmed that the required consent process was not followed, and the care plan did not reflect the use of the medication, contrary to facility policy.
Several residents, including those with cognitive impairments and incontinence, did not receive required assistance with bathing and personal hygiene, with some going extended periods without baths and one resident not receiving needed incontinence care. Staff interviews indicated that missed care was due in part to short staffing, and documentation did not reflect resident refusals or consistent attempts to provide care.
A resident with severe cognitive impairment and a history of pressure ulcers developed a new Stage 2 ulcer on the left heel due to inconsistent use of prescribed protective boots. Despite a care plan requiring bilateral Prafo boots, the resident was observed wearing tennis shoes, leading to the ulcer's recurrence. Staff confusion and inconsistency regarding footwear contributed to the deficiency.
The facility failed to respond to call lights within 15 minutes for several residents, as observed during the survey. A resident with intact cognition and requiring assistance activated the call light, but personal care was delayed. Another resident with medical conditions also experienced delays in receiving assistance. Staffing levels did not meet the Facility Assessment requirements, contributing to the delays, particularly on weekends. The facility's outdated call light system further complicated the issue.
The facility failed to maintain proper hand hygiene during a meal service, as observed with staff not washing hands after handling food and touching various surfaces. Despite training and policy requirements, staff did not adhere to handwashing protocols, leading to potential cross-contamination.
The facility did not have a certified Infection Preventionist (IP) as required by their policy. The Assistant DON was still completing the necessary training. The DON, who is new and not certified, suggested regional personnel for the IP interview. The Regional Director of Operations, not being a nurse, stated that collaboration with the Regional Nurse Consultant and the DON was needed to decide on the interview process, as no IP was on staff.
A facility failed to notify the OSLTO of two hospital transfers for a resident with intact cognition and multiple diagnoses, including cancer and schizophrenia. The resident was transferred to the hospital four times, but the facility did not report two of these transfers. Staff interviews revealed that the social worker was responsible for notifications, and the decision to report was based on whether the transfer was overnight.
A resident with a history of heart and lung conditions returned from the hospital with new medication orders, which were not entered into the eMAR by the facility staff. This oversight led to the resident not receiving critical medications, resulting in worsening respiratory distress and rehospitalization. The error was discovered by a regional nurse, highlighting a breakdown in communication and procedure within the facility.
A resident with no cognitive impairment reported that staff searched her room without consent while she was away, leaving her belongings unorganized. The search was conducted to find a missing remote belonging to her roommate. The ADON and DON were aware of the incident, which violated the facility's Resident Rights policy emphasizing respect and dignity.
The facility failed to accurately assess and respond to the worsening conditions of two residents, leading to severe outcomes. One resident experienced worsening gastrointestinal symptoms over four days, resulting in death after emergent hospital treatment. Another resident experienced worsening edema and inability to urinate, leading to hospitalization. Additionally, a resident with diabetes missed insulin doses due to incorrect transcription of a physician's order, resulting in hospitalization for Diabetic Ketoacidosis.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, left femur fracture, and malnutrition was admitted to the facility without any pressure ulcers and was assessed as being at risk for developing them. The resident was dependent on staff for all transfers, bed mobility, dressing, and toilet hygiene, and had an indwelling urinary catheter with frequent bowel incontinence. Despite being identified as at risk, the care plan did not address the development of a Stage 3 pressure ulcer that was identified on the resident's sacrum. Physician orders were issued for wound treatments, an air mattress, and repositioning every two hours, but these interventions were not consistently implemented. Observations revealed multiple failures in following physician orders and standard care practices. The resident was found without a dressing on the pressure ulcer, and infection control techniques were not utilized during wound care. The air mattress, which was ordered to reduce pressure, was not in place on several occasions. Staff omitted key components of the wound care treatment, such as the application of calcium alginate, and failed to perform hand hygiene or change gloves during wound care. The resident was also left in a wheelchair for extended periods without repositioning or toileting assistance, and staff were unaware of the resident's skin impairments. Further observations documented that the resident's sacral wound was left without a dressing, and a new open area developed on the coccyx. The air mattress intervention continued to be unimplemented, and the resident was found with incontinent stool on the buttocks. Nursing staff admitted to being behind on treatments and not completing wound care as ordered. The care plan and Braden scale assessments were not updated to reflect the resident's changing condition, and the facility failed to ensure timely and appropriate interventions to prevent further skin breakdown.
Failure to Follow Physician Orders and Document Wound Care
Penalty
Summary
The facility failed to assess and follow physician treatment orders for non-pressure wound care for two residents. For one resident with peripheral vascular disease, traumatic compartment syndrome, diabetes, and atrial fibrillation, there was a lack of documentation regarding wound measurements or assessments for vascular wounds on both heels. The treatment administration record showed missed or undocumented wound care on scheduled days, and there was no evidence that the provider was notified when the resident refused wound care. Additionally, a vascular surgery clinic note indicated that the resident had not received proper wound care at the facility, and the family expressed distress over the lack of care during a medical appointment. For another resident with moderate cognitive impairment, esophageal obstruction, dysphagia, heart failure, and chronic kidney disease, the care plan required regular skin evaluations and specific wound care for a skin tear on the left calf. The treatment administration record revealed missed documentation of scheduled wound care, and during an observation, the dressing applied was not consistent with the physician's order. Staff interviews confirmed that the correct dressing was not used and that wound care was not always performed as ordered. Facility policy required verification of physician orders, adherence to care plans, and notification of supervisors if wound care was refused. However, staff interviews and record reviews demonstrated that these procedures were not consistently followed, resulting in missed or improper wound care and lack of appropriate documentation and communication regarding resident refusals and wound status.
Failure to Use Safe Transfer Techniques and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure safe transfer techniques and adequate supervision to prevent accidents for multiple residents, resulting in significant injuries and incomplete post-fall assessments. One resident with severe cognitive impairment and a history of fractures was transferred using a mechanical lift by a CNA who did not follow manufacturer instructions for sling attachment. The resident fell from the lift, sustaining a sacral fracture, tibial plateau fracture, and head injury. The CNA operated the lift alone, did not cross the sling straps as required, and the incident was not immediately reported to the state agency. The facility's own policy and the lift manufacturer's instructions were not followed during this transfer. Another resident with severe cognitive impairment and a history of falls was assisted from a dining room chair without the use of a gait belt, contrary to care plan requirements. The resident fell, complained of dizziness and back pain, and developed a chin bruise. Staff failed to check the resident's range of motion before moving her from the floor, and neurological assessments were not completed as required by facility protocol. Similarly, a third resident with severe cognitive impairment and a history of crawling on the floor was found on the floor by staff, but the event was not treated as an unwitnessed fall, and a neurological assessment was not initiated as required by policy. Additionally, another resident dependent on two staff for transfers was observed being transferred by a single CNA without a gait belt, in violation of the care plan and facility policy. Staff interviews confirmed that transfers were not performed according to established protocols, and staff were not consistently using required safety equipment. Facility policies on safe lifting, neurological assessment, and fall protocols were not followed, leading to preventable injuries and incomplete post-incident assessments for multiple residents.
Failure to Maintain Clean Resident Equipment and Environment
Penalty
Summary
Surveyors observed multiple instances of unclean resident equipment and environmental surfaces within the facility. A full body mechanical lift in one hallway had a brown smear on its leg that remained uncleaned over two consecutive days. Similarly, a mechanical sit-to-stand lift in another hallway had a heavily soiled foot plate with debris that was not addressed over the same period. Additionally, a high back wheelchair was found in the hallway with a yellow-stained towel on its seat, which was not removed or cleaned throughout the day. In a resident room, brown spots and smears were noted on the bathroom floor near the toilet, and a soiled incontinence pad was left on the bed. Interviews with CNAs confirmed that staff were responsible for cleaning mechanical lifts, changing bed linens, and removing soiled incontinence pads. Both interviewed CNAs stated that soiled incontinence pads should not be left on beds and that cleaning of equipment and surfaces was part of their duties. Review of the facility's cleaning and disinfection policy indicated that environmental surfaces and equipment should be cleaned and disinfected regularly and when visibly soiled, in accordance with CDC and OSHA standards. The observations and staff interviews demonstrated a failure to maintain a clean and safe environment as required by facility policy.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the individualized needs of residents, as evidenced by clinical record review, staff interviews, and facility policy review. One resident with moderate cognitive impairment, requiring moderate assistance for bathing and partial assistance for personal hygiene, did not receive a bath or shower for a period of 17 days. Staff interviews revealed that certified nursing assistants (CNAs) and registered nurses (RNs) were unable to complete all required personal care tasks due to routine understaffing. Staff reported that these concerns had been brought to management multiple times without any observed improvement. Additional interviews with licensed practical nurses (LPNs), RNs, and CNAs indicated that wound care treatments and scheduled baths were often delayed or missed when medication aides were not available or when only one CNA was assigned to a hallway with approximately 25 residents, many of whom required two staff members for mechanical lift transfers. Staff also reported that, due to insufficient staffing, residents sometimes received meals in their rooms instead of the dining room, and feeding assistance was provided one at a time. The facility's assessment stated that staffing was based on resident acuity and that contingency plans existed for staff call-outs, but staff consistently reported that these measures were insufficient to address ongoing staffing shortages.
Failure to Ensure Resident Dignity and Respect in Care and Environment
Penalty
Summary
The facility failed to provide a respectful and dignified environment for three residents, as evidenced by multiple observations and interviews. One resident, who was cognitively intact and dependent on staff for toileting and mobility, was not offered meal choices according to her preferences. Staff delivered an incorrect meal and, without asking the resident for her preference, substituted it with a food item not listed on the menu or alternative menu. The resident reported that she is never asked what she would like to eat and is typically given whatever is available, rather than being provided with options. Another resident with bowel incontinence and frequent diarrhea was observed multiple times in a room with a strong odor of feces and urine, and with visibly soiled sheets and floors. The resident confirmed that his sheets had been soiled since the previous night. Observations over several days revealed persistent dried feces on the bed sheets, floor, and bathroom surfaces. Staff interviews confirmed awareness of the soiled conditions, and the CNA job description included maintaining a clean and pleasant environment, which was not upheld in this case. A third resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was found lying in bed without an incontinence product and with pants pulled down around her ankles. This condition persisted during subsequent observations until the DON intervened to provide care and clothing. The resident expressed feeling cold during this time. Facility policy requires residents to be treated with dignity and respect, which was not observed in these instances.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of an antipsychotic medication, risperidone, for one resident diagnosed with non-Alzheimer's dementia and depression. Clinical record review showed that the resident had moderate cognitive impairment, as indicated by BIMS scores of 9 and 11 on separate assessments. The resident began receiving risperidone on a routine basis, as documented in progress notes and the Minimum Data Set (MDS) assessments. However, there was no documentation of informed consent from the resident's responsible party for the use of this psychotropic medication during the period from when the medication was initiated through the time of the survey. Staff interviews confirmed that the process for obtaining consent was not followed, with the Licensed Practical Nurse stating that the nurse who received the order should have contacted the family or resident to obtain and document consent in the chart. The facility's policy on antipsychotic medication use, dated 12/2016, requires that informed consent be obtained, but review of the resident's evaluations and care plan revealed no such documentation. The care plan also failed to include the use of the antipsychotic medication.
Failure to Provide Required Bathing and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically in the areas of bathing and incontinence care, for several residents. One resident with severe cognitive impairment, non-Alzheimer's dementia, schizophrenia, and congestive heart failure was observed with visibly wet clothing and was not assisted by staff with changing or incontinence care, despite care plan interventions indicating the need for staff assistance. Staff acknowledged the resident's inability to perform self-care after incontinence and confirmed that staff should have reapproached and assisted the resident. Multiple residents did not receive the required twice-weekly bathing. One resident with intact cognition and no documented refusals had no baths recorded during their stay. Another resident with severe cognitive impairment and no history of care refusal went up to 14 days without a bath, with documentation showing missed or unattempted baths and only one recorded refusal. A third resident with intact cognition and no refusal behavior had no documented baths for 27 days, with only one recorded refusal, and staff interviews indicated that the resident rarely refused bathing and liked to be clean. Additionally, a resident with moderate cognitive impairment and frequent incontinence was observed to be unshaven, with greasy hair and dirty clothing on consecutive days, and staff reported that the resident did not refuse bathing. Bathing records for this resident showed missed or unattempted baths due to environmental limitations or lack of staff. Staff interviews revealed that short staffing contributed to missed baths, and the facility's policy required assistance with ADLs to maintain hygiene, which was not consistently provided.
Failure to Prevent Recurrence of Pressure Ulcer
Penalty
Summary
The facility failed to prevent the recurrence of a pressure ulcer for a resident, identified as Resident #27, who had a history of severe cognitive impairment and was dependent on staff for dressing and footwear. The resident had previously healed from a Stage 4 pressure ulcer on the left heel, which was resolved in September. However, a new Stage 2 pressure ulcer developed in the same area by October. The resident was assessed as being at moderate to high risk for pressure injuries, as indicated by the Braden Scale scores. The care plan for the resident included the use of bilateral Protective Relief Ankle Foot Orthosis (Prafo) boots to prevent pressure ulcers. Despite this, observations and interviews revealed that the resident was not consistently wearing the prescribed protective boots. Instead, the resident was found wearing tennis shoes, which were not recommended by the wound care provider. Staff interviews indicated confusion and inconsistency regarding the resident's footwear, with some staff members unsure about when the resident should wear the protective boots. The Family Nurse Practitioner and the Director of Nursing both acknowledged that the recurrence of the pressure ulcer could have been prevented if the resident had consistently worn the protective boots. The facility's policy on wound care emphasized the importance of following physician orders and care plans, but this was not adhered to in the case of Resident #27. The lack of consistent application of the prescribed protective measures contributed to the recurrence of the pressure ulcer on the resident's left heel.
Staffing Shortages Lead to Delayed Call Light Responses
Penalty
Summary
The facility failed to respond to call lights within 15 minutes for four residents, as observed during the survey. Resident #12, who had intact cognition and required assistance for various activities, activated the call light at 12:50 PM. Although an LPN turned off the call light and administered insulin, personal care was not provided, and the resident had to wait until 1:08 PM for a CNA to assist with toileting. Similarly, Resident #204, with intact cognition and medical conditions that required assistance, activated the call light at 9:12 AM. An LPN turned off the light at 9:25 AM, promising to send help, but the resident continued to wait until 9:45 AM for assistance from CNAs. Resident #6, with a history of falls and intact cognition, reported that call lights often took 20-30 minutes to be answered, occurring every other day across all shifts. Resident #50, also with intact cognition and dependent on staff for transfers and personal hygiene, confirmed that call lights took 20 minutes or more to be answered. The facility's policy on answering call lights did not specify a time frame, contributing to the delay in response times. The facility's staffing levels did not meet the requirements outlined in the Facility Assessment for several days. The Daily Staffing Plan required two licensed nurses, two medication aides, and six CNAs on the day shift, but records showed that staffing levels were often below these requirements. Interviews with staff and the Director of Nursing revealed that staffing shortages, particularly on weekends, contributed to the delays in responding to call lights. The facility's call light system was also outdated, preventing the production of call light records or logs, further complicating the issue.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
During a noon meal service, the facility failed to adhere to proper hand hygiene practices, leading to potential cross-contamination of food. Observations revealed that Staff H wiped his hand on his shirt after handling a pan of food from the oven. Staff G, after touching various surfaces and handling food, did not wash her hands before returning to the serving line. She caught a spilled mixture of lettuce and cheese with her bare hand and returned it to the preparation pan. Additionally, Staff G handled meal request slips, disposed of them, and continued plating food without washing her hands. Both Staff G and Staff H were observed leaving and returning to the serving area without washing their hands. The Certified Dietary Manager (CDM) confirmed that handwashing was covered in both orientation and ongoing training, and expressed that staff should wash their hands before serving and after any contamination. The facility's handwashing policy, revised in 2020, mandates handwashing after contact with unclean surfaces and when moving between different areas, which was not followed during the observed meal service.
Lack of Certified Infection Preventionist in Facility
Penalty
Summary
The facility failed to have a qualified Infection Preventionist (IP) who completed specialized training in infection prevention and control, as required by their policy. During an interview, the Director of Nursing (DON) and Regional Nurse Consultant confirmed that the facility did not have a certified IP. The Assistant DON was in the process of completing the necessary training but had not yet finished. The DON, being new to the position and not certified, suggested that the IP interview should be conducted with regional personnel. The Regional Director of Operations, who is not a nurse, indicated that collaboration with the Regional Nurse Consultant and the DON would be necessary to determine the appropriate person to conduct the interview, as no IP was currently on staff. The facility's policy, revised in September 2017, requires the IP to conduct ongoing surveillance for Healthcare-Acquired Infections (HAIs) and other significant infections that may impact resident outcomes and require preventative interventions.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Ombudsman (OSLTO) of two separate hospital transfers for a resident. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status score of 13 out of 15, was diagnosed with cancer, schizophrenia, and an excoriation disorder. The resident's care plan included focus areas for impaired cognitive function, risk for skin and soft tissue infection, mental health support, and diabetic ulcers on eight fingers. The resident was transferred to the hospital on four occasions, but the facility did not include the May and June transfers in the notifications to the OSLTO. Interviews with facility staff revealed that the social worker was responsible for submitting discharge information to the OSLTO. The Administrator stated that the decision to report a transfer depended on whether it was an overnight stay. The Social Services Director confirmed that she did not include transfers if the resident returned the same day. This oversight resulted in the omission of a same-day return transfer and a five-day hospital visit from the required notifications.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medication as ordered by the physician for a resident who had recently returned from the hospital. The resident, who had a history of acute congestive heart failure, chronic kidney disease, atrial fibrillation, and pneumonia, was admitted to the emergency department with acute hypoxic respiratory failure. Upon discharge back to the facility, the resident received new physician orders for medications including albuterol, prednisone, Spiriva, and an increased dose of furosemide. However, these new orders were not entered into the electronic Medication Administration Record (eMAR) by the staff nurse, resulting in the resident not receiving the prescribed medications. The resident's condition worsened due to the lack of medication administration, leading to increased shortness of breath, lethargy, and low oxygen saturation levels. The resident was readmitted to the hospital, where it was discovered that the new medication orders had not been implemented since the resident's return to the facility. The failure to administer the medications as ordered was identified by the corporate regional nurse, prompting a self-report to the state and a subsequent investigation. Interviews with facility staff revealed that the new orders were not entered into the system due to a series of miscommunications and oversights. The agency nurse who assisted with the resident's readmission handed the paperwork to the Director of Nursing (DON), who then left the facility due to illness without ensuring the orders were processed. The Assistant Director of Nursing (ADON) later discovered the oversight but was unable to retrieve the orders in a timely manner, as they were locked in the DON's office. This chain of events led to a significant medication error, contributing to the resident's deterioration and eventual rehospitalization.
Removal Plan
- Education provided to nursing staff
- Charge nurse responsible to complete on any admission or transfer in from the hospital followed by double noting by two nurses
Unauthorized Search of Resident's Belongings
Penalty
Summary
The facility failed to respect the personal property and possessions of a resident when staff searched the resident's room without consent. The incident involved a resident who had no cognitive impairment and used a wheelchair for mobility, with diagnoses including post-polio syndrome, rheumatoid arthritis, and paraplegia. The resident reported that while she was away for a physician's appointment, staff searched her belongings without her knowledge, leaving them unorganized. The search was conducted in an attempt to locate a missing television remote belonging to the resident's roommate. Staff interviews revealed that the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were aware of the incident. The ADON confirmed that the resident reported the unauthorized search, and the DON acknowledged instructing staff not to search residents' belongings without their knowledge. The facility's Resident Rights policy, revised in December 2016, emphasizes treating residents with respect and dignity, and ensuring they are free from misappropriation of property. Despite this policy, the staff's actions violated the resident's rights, as they conducted the search without obtaining the resident's consent.
Failure to Assess and Respond to Resident Conditions
Penalty
Summary
The facility failed to accurately assess and respond to the worsening conditions of two residents, leading to severe outcomes. One resident, with a history of traumatic brain injury, diabetes, and other conditions, experienced worsening gastrointestinal symptoms over four days, including stomach ache, abdominal tenderness, and emesis. Despite these symptoms, the facility staff did not notify the medical provider or seek treatment orders in a timely manner. The resident's condition deteriorated, requiring emergent medical treatment in the hospital emergency room, where they died within six hours of admission due to complications including acute respiratory distress syndrome, small bowel obstruction, and acute pancreatitis. Another resident, admitted with diagnoses including congestive heart failure and diabetes, experienced worsening edema and an inability to urinate over two days. The facility failed to document and assess these symptoms adequately, resulting in the resident's hospitalization for urinary retention, suspected bladder malignancy, and acute kidney injury. The facility also failed to administer the resident's prescribed medications promptly due to a delay in completing the admission assessment and entering medication orders into the system. Additionally, the facility failed to correctly transcribe a physician's order for insulin for a resident with diabetes, leading to missed insulin doses and the resident's hospitalization for Diabetic Ketoacidosis. The resident's care plan lacked focus on insulin administration and blood sugar monitoring, contributing to the oversight. The facility's failure to ensure accurate medication administration and timely medical intervention resulted in significant adverse outcomes for the residents involved.
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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