Crown Pointe Estates Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sioux Center, Iowa.
- Location
- 1400 7th Avenue Se, Sioux Center, Iowa 51250
- CMS Provider Number
- 165157
- Inspections on file
- 19
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Crown Pointe Estates Care Center during CMS and state inspections, most recent first.
A resident with impaired balance and CHF suffered an unwitnessed fall during the night, resulting in leg pain and later diagnosis of a hip fracture. The overnight RN assessed the resident, administered Tylenol, and sent a fax to the physician, but did not make a phone call or notify the family. The physician did not acknowledge the fax until days later, and the family was not informed at the time of the incident, contrary to facility policy requiring prompt notification after significant changes in condition.
A resident with severe cognitive impairment was transferred to a hospital, and although verbal consent for a bed hold was obtained from the representative, the facility did not secure the required signature or specify the daily bed hold rate as mandated by policy.
A resident with a negative initial PASRR result was not referred for a Level II PASRR evaluation after developing new or possible serious mental health conditions, despite having diagnoses such as anxiety disorder, hallucinations, and dementia with Parkinsonism, and receiving behavioral health services and related medications. The DON confirmed that PASRR updates were expected with such changes, but the facility lacked a related policy.
Staff did not use required Enhanced Barrier Precautions, such as gown and gloves, while providing wound care and personal care to a resident with an open wound. Despite facility policy and available supplies, both a CNA and an RN performed dressing changes and toileting assistance without following EBP protocols.
A resident with a history of heart failure and impaired balance experienced an unwitnessed fall overnight. Staff did not promptly notify the physician or family, and failed to reassess the resident or document vital signs in a timely manner despite ongoing pain and inability to bear weight. The resident was not sent to the hospital until the morning shift, where a hip fracture, hypotension, and sepsis were diagnosed, leading to rapid decline and death. Facility policy for post-fall assessment and notification was not followed.
A resident with recent increased confusion and weakness, identified as high risk for falls, experienced two falls in one day. Despite facility policy requiring gait belt use for assisted ambulation and transfers, staff failed to use a gait belt while helping the resident, resulting in a second fall when the staff member let go to adjust a chair cushion.
The facility failed to store food properly for all residents. Surveyors found cooked ground beef dated a week prior and undated, open bags of chicken and pork in the freezer. The kitchen supervisor confirmed that opened food should be dated and leftovers are only good for 3 to 5 days. The facility's policy required food to be covered, labeled, and dated, but no policy on leftover storage duration was provided.
The facility failed to provide bed hold notices to two residents or their representatives during hospital transfers. One resident with severe cognitive impairment and another with no cognitive impairment were transferred to the hospital without receiving the required bed hold documentation. The facility's policy mandates informing residents and their representatives about bed hold policies at admission and transfer, which was not adhered to in these cases.
A resident with severe cognitive impairment did not receive wound care as per physician orders, which required a silver foam dressing to be changed three times a week. During an observation, it was found that the dressing had not been changed for five days. Staff interviews confirmed the dressing schedule, but the facility lacked a policy to ensure compliance with physician orders.
Two residents with severe cognitive impairments were served incorrect meal portions due to the use of a soup spoon instead of the required measuring devices. The facility's dietary guidelines specified portion sizes for an IDDSI level 6 diet, but Staff E estimated the portions due to a lack of measuring tools. The facility lacked a policy to ensure adherence to dietary guidelines.
A facility failed to adhere to infection prevention practices during wound and catheter care for a resident with severe cognitive impairment and an indwelling catheter. Staff did not maintain proper gown usage, as sleeves were pushed up during care, contrary to Enhanced Barrier Precautions (EBP) policy. Observations showed lapses in maintaining gown sleeve coverage and hand hygiene, which are crucial for residents with indwelling medical devices.
Failure to Notify Physician and Family After Resident Fall with Injury
Penalty
Summary
The facility failed to notify both the physician and the family after a resident experienced a fall with injury. The resident, who had a moderate cognitive deficit and was at risk for falls due to impaired balance and congestive heart failure, was found on the floor in his room after an unwitnessed fall around midnight. He complained of pain in his left leg and was given Tylenol before being transferred to a recliner. Although a fax was sent to the physician, there was no immediate phone contact, and the fax was not acknowledged by the physician until several days later. The family was also not notified at the time of the incident. Staff interviews revealed that the overnight nurse did not call the physician or the family, believing that unless it was an emergency, the morning nurse would handle family notification. The resident continued to experience pain and was unable to bear weight on his leg during subsequent checks. He was eventually sent to the hospital in the morning, where a fractured hip was diagnosed. Facility policy required notification of the physician and family in the event of a significant change in status, but this was not followed in this case.
Failure to Obtain Signed Bed Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to ensure that the required bed hold notice was properly signed by either the resident or the resident's responsible person when a resident was transferred out of the facility. Clinical record review showed that a resident with severe cognitive impairment, as indicated by a BIMS score of 01 and diagnoses including hypertension, anemia, and hyponatremia, was transferred to a hospital due to high potassium levels. Documentation revealed that while verbal consent for the bed hold was obtained from the resident's representative, the bed hold notice lacked both the required signature and the amount per day that the resident or representative agreed to pay. Facility policy requires written and verbal notice at admission and at the time of transfer, but this was not followed in this instance.
Failure to Refer for Level II PASRR Evaluation After Change in Mental Health Status
Penalty
Summary
The facility failed to refer a resident, who initially had a negative Level I Preadmission Screening and Resident Review (PASRR) result, for a Level II PASRR evaluation after new or possible serious mental disorder, intellectual disability, or other related conditions became evident. Clinical record review showed that the resident had diagnoses including anxiety disorder, hallucinations, and dementia with Parkinsonism, and was prescribed medications such as Depakote, Remeron, and Seroquel for behavioral and mental health conditions. The resident also received behavioral health services, as documented in visit notes. Despite these changes in diagnosis, medication, and behavioral health interventions, the facility did not update or submit a new PASRR referral as required. During staff interview, the DON acknowledged the expectation to update PASRR with such changes and reported the absence of a facility policy related to PASRR.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) during wound care and personal care activities for a resident with an open wound. During an observation, a CNA and an RN assisted the resident with toileting and performed a dressing change on a coccyx wound without wearing the required gown and gloves, despite the facility's policy mandating EBP for any wound requiring a dressing. The open wound had been identified several days prior and was being treated per physician orders. The facility's policy clearly states that EBP, including gown and gloves, must be used during high-contact care activities such as dressing changes, toileting, and hygiene for residents with wounds requiring dressings, regardless of MDRO status. Staff interviews confirmed that EBP supplies were available, but the precautions were not followed during the observed care.
Failure to Provide Timely Assessment and Intervention After Resident Fall
Penalty
Summary
Staff failed to provide adequate and timely assessment and intervention following a resident's unwitnessed fall during the overnight shift. The resident, who had a history of congestive heart failure, impaired balance, and moderate cognitive deficit, was found on the floor after attempting to go to the bathroom. Initial assessment noted pain in the left leg, and Tylenol was administered. However, the nurse did not contact the on-call physician or the family, and the resident was transferred back to a recliner without further immediate medical evaluation. Subsequent monitoring throughout the night revealed ongoing pain and an inability to bear weight on the left leg, but no additional vital signs were documented during a follow-up assessment, and the physician was not notified until the morning shift. The nurse reported attempting to contact the DON but did not reach them and instead sent a fax to the physician. The resident's condition deteriorated, with a significant drop in blood pressure recorded in the early morning. It was only after the morning nurse assessed the resident and found severe pain with range of motion that the physician was contacted and the resident was sent to the hospital. At the hospital, the resident was diagnosed with a closed intertrochanteric fracture of the left hip, hypotension, and sepsis. The resident's condition rapidly declined, leading to admission to the ICU and subsequent death. Facility policy required immediate and ongoing neuro checks and vital signs after unwitnessed falls, as well as prompt physician notification for suspected fractures or significant pain, but these procedures were not followed in this case.
Failure to Use Gait Belt During Resident Transfer and Ambulation
Penalty
Summary
A resident with a history of ovarian cancer and a recent fracture, who was independent with transfers and ambulation using a walker, experienced a change in status with increased confusion and weakness. On the morning in question, the resident had an unwitnessed fall in the bathroom and was subsequently identified as high risk for falls. Despite this change in condition and the facility's policy requiring the use of gait belts for residents needing assistance with ambulation or transfers, staff failed to use a gait belt when assisting the resident later that morning. During this assistance, the staff member momentarily let go of the resident to adjust a chair cushion, resulting in the resident falling backwards. Interviews with staff confirmed that the resident was more confused and weak than usual, and that the need for close monitoring and use of a gait belt had been communicated. However, the staff member assisting the resident did not use a gait belt and instead held onto the back of the resident's pants. The facility's policy, last reviewed in September 2024, clearly stated that gait belts should be used for any resident requiring assistance with ambulation or transfers, but this protocol was not followed, directly contributing to the resident's second fall.
Failure to Store Food Properly
Penalty
Summary
The facility failed to store food in accordance with professional standards for all 91 residents. During a kitchen tour, surveyors observed cooked ground beef in a metal steam table container dated a week prior, which should have been discarded according to the kitchen supervisor. Additionally, the small fried food freezer contained undated and open bags of chicken strips, chicken patties, and breaded pork. The kitchen supervisor acknowledged that all opened food bags should be dated and that leftover food is only good for 3 to 5 days after preparation. The facility's policy on nutrition services required food to be covered, labeled, and dated when stored, but no specific policy on the acceptable number of days for storing leftovers was provided by the facility management or administration.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to residents or their representatives when residents were transferred out of the facility for hospital admissions. This deficiency was identified for two residents. Resident #29, who had severe cognitive impairment with diagnoses of renal failure and heart failure, was transferred to the emergency department due to increased swelling in the left lower calf. The resident was absent from the facility from September 10, 2023, to September 12, 2023. However, the clinical record lacked documentation of a bed hold notice for this hospital admission. Similarly, Resident #45, who had no cognitive impairment and was diagnosed with heart failure, renal failure, and Diabetes Mellitus, was transferred to the hospital on November 29, 2023, and returned on December 4, 2023. The facility also failed to provide a bed hold notice for this resident's hospital admission. The facility's bed hold policy, last reviewed in July 2024, requires that residents and their representatives be informed in writing and verbally about the bed hold policy at the time of admission and transfer. The Administrator acknowledged the expectation for staff to complete bed hold forms and mentioned ongoing audits to address the issue.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following physician orders for a resident with severe cognitive impairment. The resident had a physician's order for a silver foam dressing to be applied to a wound on the coccyx three times a week and as needed. The dressing was to be changed every Sunday, Wednesday, and Friday at 7 am. However, during an observation, it was found that the dressing had not been changed as per the schedule, as it was dated five days prior to the observation. Staff interviews revealed that the dressing was intended to cover a pressure area and should have been changed according to the physician's order. Despite this, the facility lacked a policy on following or completing physician orders, relying instead on the expectation that professional standards would be followed. This oversight resulted in the dressing not being changed as required, indicating a failure to meet the professional standards of care for the resident.
Failure to Provide Correct Meal Portions for Residents
Penalty
Summary
The facility failed to provide a well-balanced diet that meets the nutritional and special dietary needs of two residents, as observed during a survey. Resident #22 and Resident #41, both with severe cognitive impairments as indicated by their Brief Interview for Mental Status (BIMS) scores, were served incorrect portion sizes for their meals. Specifically, Staff E used a soup spoon to serve three spoonfuls of noodles and beef to each resident, instead of using the appropriate measuring devices as per the dietary requirements. The physician's orders for both residents specified an International Dysphagia Diet Standardisation Initiative (IDDSI) level 6 soft and bite-sized diet, which required specific portion sizes of 3 oz of beef tips and 4 oz of noodles. Staff E admitted to running out of measuring devices and resorted to estimating the portion sizes by eye, which led to the incorrect serving sizes. The facility's menu documentation confirmed the required portion sizes for the IDDSI level 6 diet, and the Certified Dietary Manager (CDM) stated that the expectation was to use the appropriate scoop sizes. However, the facility was unable to provide a policy regarding the adherence to menu guidelines and the use of proper measuring tools, indicating a lack of procedural guidance in ensuring dietary compliance.
Infection Control Deficiency in Wound and Catheter Care
Penalty
Summary
The facility failed to provide appropriate infection prevention practices during wound care and catheter care for a resident with severe cognitive impairment and an indwelling catheter. During an observation, a staff member was seen changing the resident's right knee dressing. The staff member performed hand hygiene and donned a gown and gloves before removing the old dressing. However, the staff member did not maintain proper gown usage, as the sleeves were pushed up and not returned to cover the wrists during care. This was contrary to the facility's policy on Enhanced Barrier Precautions (EBP), which requires gown sleeves to remain in place during resident contact. Another observation revealed a staff member performing catheter and peri care on the same resident. The staff member initially followed proper hand hygiene and PPE protocols but failed to maintain gown sleeve coverage after washing hands. The facility's policy and CDC guidelines emphasize the importance of maintaining gown coverage and performing hand hygiene when changing gloves, especially for residents with indwelling medical devices. The staff member admitted to forgetting to adjust the gown sleeves, which was not in compliance with the expected infection prevention practices.
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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