Davenport Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Davenport, Iowa.
- Location
- 1130 W 53rd Street, Davenport, Iowa 52806
- CMS Provider Number
- 165510
- Inspections on file
- 22
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Davenport Lutheran Home during CMS and state inspections, most recent first.
The facility failed to maintain a sanitary and orderly dining environment, with a damaged ceiling beam wrapped in plastic above the dining area. The plastic, containing clumps of material, was partially detached, and beverage carts were placed underneath. Staff and residents were observed in close proximity to the compromised area. The damage was attributed to a storm, and the facility was awaiting an insurance appeal.
The facility failed to maintain proper food temperatures during a noon meal service. Initial food temperatures were recorded between 177 and 200 degrees Fahrenheit, but the turkey tetrazzini temperature dropped to 130 degrees Fahrenheit during service, below the required 140 degrees. The Dining Services Director acknowledged the issue, indicating a need for improvement.
A facility failed to maintain accurate Advance Directive records for a resident, resulting in a discrepancy between the care plan and electronic health record regarding the resident's code status. Despite the resident's clear preferences, staff were unaware of the inconsistency, highlighting a failure to adhere to the facility's policy on documenting CPR wishes.
The facility failed to follow infection control protocols for two residents with indwelling medical devices. A resident with a feeding tube did not receive care with the required gown and gloves, despite the facility's Enhanced Barrier Precautions policy. Another resident's urinary catheter bag was observed dragging on the floor, contrary to facility policy. Multiple staff members did not correct the bag's position, indicating a lapse in adherence to infection prevention measures.
A resident with impaired cognition reported aggressive care during a shower by a CNA. The incident was communicated to an LPN, who informed the DON and ADON, but it was not documented or reported to the state agency as required by facility policy. The DON, after consulting with the CEO, chose not to report the incident, believing it was not intentional harm. The Administrator was informed but unsure of the reporting requirements.
A resident with Alzheimer's disease reported aggressive care during a shower by a CNA, but the facility failed to investigate the allegation. Despite being informed, the DON did not conduct an investigation or interview the resident, and there was no documentation of the incident. The facility's policy requires thorough investigations, but no evidence of such an investigation or incident report was found.
The facility failed to routinely monitor INR levels for two residents on warfarin, leading to a critical condition for one resident who was hospitalized with a dangerously high INR and subdural hematomas. Despite multiple evaluations, there was no documentation of INR monitoring or warfarin dosage adjustments. Another resident also lacked consistent INR checks, contrary to facility policy requiring prompt notification of lab values to physicians.
The facility failed to include warfarin monitoring in the care plans for two residents, despite the medication's need for regular assessment due to bleeding risks. Both residents received warfarin consistently over several months, but their care plans lacked focus areas and interventions for monitoring the anticoagulant. The Director of Nursing confirmed that care plans did not have specifics related to warfarin, highlighting a systemic issue.
A resident with a history of urinary catheter use experienced discomfort and was transferred to a hospital due to the facility's failure to timely assess catheter function and lack of replacement supplies. The resident's catheter was blocked, causing pain and a distended abdomen. Staff did not monitor urine output adequately, and the facility lacked the necessary Coude catheter for replacement, leading to the resident's transfer for further evaluation.
Facility Fails to Maintain Sanitary Dining Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in the dining room, as observed during four separate dining observations. A significant issue was noted with a ceiling beam on the east side of the dining room, which was wrapped in plastic and secured with tan tape. The plastic contained clumps of white, dark brown, and black material, and the tape was partially detached, leaving a portion of the plastic hanging. This area was located above the floor, wall, and door connecting the kitchen to the dining area, where staff frequently passed to set up the dining area and serve meals. A beverage cart with various drinks was positioned directly under the compromised beam, and residents were observed standing and sitting near this area during meal times. Interviews with staff revealed that the damage was believed to be caused by a roof leak from a storm the previous year, and the facility was awaiting the outcome of an insurance appeal. Despite the ongoing issue, the plastic remained as a temporary fix, and the Dining Services Director was unaware of when repairs would be completed. Observations showed that food service carts, including those with exposed food items, were placed under the damaged beam, posing potential contamination risks. The Administrator acknowledged the damage and the temporary nature of the plastic covering, indicating that the facility was in a holding pattern while awaiting insurance resolution.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain proper safe and appetizing food temperatures during a noon meal service. Observations revealed that the temperatures of various food items, such as turkey tetrazzini, peas, mashed potatoes, mixed vegetables, Swedish meatballs, green beans, and pureed items, were initially recorded at high temperatures ranging from 177 to 200 degrees Fahrenheit. However, during the meal service, the temperature of the turkey tetrazzini dropped to 130 degrees Fahrenheit, which was below the facility's policy requirement of maintaining hot foods at 140 degrees Fahrenheit or higher. The Dining Services Director acknowledged the issue, noting that the turkey tetrazzini did not meet the required temperature and stated that it was an area needing improvement. The facility's policy, reviewed earlier in the year, outlined procedures for maintaining food temperatures, including reheating food if it falls below 140 degrees Fahrenheit and monitoring food temperatures. Despite these procedures, the facility did not ensure that the food served to residents met the required temperature standards, leading to the deficiency.
Discrepancy in Advance Directive Records
Penalty
Summary
The facility failed to maintain accurate Advance Directive records for one resident, leading to a discrepancy in the resident's code status documentation. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status exam, had a care plan that specified a preference for Full Code with certain limitations, such as not wanting intubation or mechanical ventilation. However, the electronic health record and physician orders documented the resident as Full Code without these specific limitations. Interviews with staff revealed a lack of awareness regarding the discrepancy in the resident's code status records. A Licensed Practical Nurse and the Assistant Director of Nursing both stated that they would refer to either the paper chart or the computer for code status information, but neither was aware of the inconsistency in the records. The facility's policy on CPR Emergency Treatment/Life Support Measures requires that the resident's wishes regarding CPR be verified and documented, which was not accurately reflected in the resident's records.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to utilize Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device. Resident #52, who is cognitively impaired and requires substantial assistance with daily activities, was observed receiving a feeding tube formula without the attending Licensed Practical Nurse (LPN) donning a gown, as required by the facility's EBP policy. The policy mandates the use of gowns and gloves during high-contact care activities to prevent the transmission of multidrug-resistant organisms. Despite the presence of an EBP sign on the resident's door and the nurse's acknowledgment of the requirement, the gown was not worn during the procedure. Another deficiency was noted in the care of Resident #125, who has an indwelling urinary catheter and is cognitively intact. The resident was observed in the dining room with the catheter collection bag dragging on the floor, outside of its dignity cover. Multiple staff members, including Certified Nursing Assistants (CNAs) and an LPN, failed to reposition the bag during their interactions with the resident. The facility's policy clearly states that catheter tubing and drainage bags should not touch the floor, yet this protocol was not followed, leading to a potential risk of contamination. These observations highlight lapses in adherence to infection prevention protocols, specifically regarding the use of personal protective equipment and the proper handling of medical devices. The facility's policies were not followed, as evidenced by the staff's actions and inactions during routine care activities for residents with indwelling medical devices.
Failure to Report Alleged Abuse in LTC Facility
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with impaired cognition, who required moderate assistance for daily activities. The resident, diagnosed with conditions such as anemia, hypertension, renal insufficiency, osteoporosis, and Alzheimer's disease, reported to a CNA that another CNA had performed care aggressively during a shower. The incident was communicated to a Licensed Practical Nurse (LPN), who then informed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). However, the LPN did not document the incident due to the timing of her shift change, and the CNA involved was sent home by another nurse. The DON acknowledged awareness of the incident and stated that the facility's policy required immediate reporting of abuse allegations to the state agency. Despite this, the DON, after consulting with the CEO, decided not to report the incident, believing it was not intentional harm. The Administrator was also informed but was unsure of the reporting requirements and did not refer to the facility's policy. The facility's policy mandates that all allegations of resident abuse be reported to the state agency within two hours, which was not adhered to in this case.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with multiple diagnoses, including Alzheimer's disease, who required moderate assistance for daily activities. The resident, who had impaired cognition, reportedly experienced aggressive care during a shower by a CNA. Despite being informed of the incident, the Director of Nursing did not conduct an investigation or interview the resident, and there was no documentation of the incident in the resident's medical record. The facility's policy mandates prompt and thorough investigations of abuse allegations, including interviews with residents and staff, and documentation of findings. However, the Administrator assumed an investigation had been completed, but there was no evidence of such an investigation or an incident report. The lack of adherence to the facility's policy resulted in a failure to properly address and document the alleged abuse incident.
Failure to Monitor INR Levels for Residents on Warfarin
Penalty
Summary
The facility failed to obtain routine laboratory orders for INR tests to monitor the use of the anticoagulant warfarin for two residents. Resident #1 was admitted to the hospital with a critical INR result of greater than 9, which is significantly higher than the desired range of 2-3 for residents on warfarin. This resident was later diagnosed with subdural hematomas with a midline shift, a serious medical condition. The last INR check for Resident #1 was conducted on 5/14/24, and there was no follow-up INR test until the resident's condition worsened, leading to hospitalization. Resident #1's clinical records showed multiple evaluations by nurse practitioners and doctors, but none addressed the resident's warfarin order or INR lab orders/results. Despite several health status notes and evaluations for various complaints, including hand swelling, hematuria, and pain, there was no documentation of INR monitoring or adjustments to the warfarin dosage. The lack of routine INR monitoring and follow-up on abnormal lab values contributed to the resident's critical condition. Similarly, Resident #4's records indicated a lack of consistent INR monitoring. Although there was an order for monthly INR checks, the clinical record lacked documentation of INR checks from 5/8/24 onwards. The facility's policy required prompt notification of lab values to physicians, but this was not adhered to, resulting in a failure to ensure appropriate medical treatment for residents on anticoagulation therapy.
Removal Plan
- INR levels obtained on all current residents receiving Warfarin to ensure therapeutic INR ranges and appropriate Coumadin dosages.
- Obtained Collaborative Drug Therapy Management Protocol Warfarin and INR Management Draft for review from Main at Pharmacy to manage the facility's Anticoagulation Program.
- Created Pro-Time/ INR Tracking Flow Sheet with draw dates, results, dose adjustment/order, and next lab date. Flow Sheet binders were placed.
- Educated staff on floor.
- Educational material uploaded on online education and assigned to all facility Nurses/CMAs titled: Long-Term Care (LTC) Anticoagulation Regulation and Education Review.
- Initiated Point Click Care prompt for noting INR results prior to administering Coumadin medication.
Failure to Include Warfarin Monitoring in Care Plans
Penalty
Summary
The facility failed to include the use of the anticoagulant medication warfarin in the care plans for two residents, despite the medication's requirement for regular monitoring, assessment, and routine labs due to an increased risk of bleeding. Resident #1, diagnosed with coronary artery disease, heart failure, hypertension, and orthostatic hypertension, was administered warfarin consistently from January to August 2024. However, their care plan lacked a focus area and related interventions for monitoring and assessing warfarin use and the associated risk of bleeding. The care plan did address potential falls, noting incidents in May 2024, but did not incorporate the anticoagulant's risks. Similarly, Resident #4, with diagnoses including heart failure, hypertension, and hemiplegia, received warfarin regularly from April to August 2024. Like Resident #1, their care plan did not include a focus area or interventions for warfarin monitoring and bleeding risk assessment. The care plan did address potential falls due to decreased mobility and weakness from a previous stroke. During an interview, the Director of Nursing acknowledged that the care plans lacked specifics related to warfarin, indicating a systemic issue in care plan development for residents on anticoagulants.
Failure to Timely Assess and Replace Urinary Catheter
Penalty
Summary
The facility failed to complete appropriate assessments of urinary catheter function in a timely manner and did not have the necessary catheter replacement supplies available, leading to a resident's discomfort and subsequent transfer to a hospital. The resident, who had a history of benign prostatic hyperplasia and cerebrovascular accident with hemiplegia, required assistance with transfers, dressing, and toileting, and used a urinary catheter for elimination. The care plan directed staff to change the Foley catheter monthly and monitor urinary output every shift, but there was no physician order for routine catheter replacement or flushing in case of obstruction. On the night of the incident, a nurse was informed that the resident's catheter was not draining. Upon assessment, the nurse found the resident in discomfort with a firm and distended abdomen, and the catheter was blocked. Attempts to flush the catheter were unsuccessful, and upon removal, a large blood clot was found. The facility lacked the necessary Coude catheter for replacement, and the resident's responsible party had to retrieve one from home. Due to the resident's continued pain and bloody drainage, the nurse decided to send the resident to the hospital for further evaluation and catheter reinsertion. Interviews with staff revealed that the resident's urine output was not adequately monitored, and the issue was not addressed until the resident's responsible party raised concerns. The Director of Nursing stated that low urine output should have been reported and assessed for catheter complications, and the facility should have had a replacement catheter available. The resident's responsible party believed the catheter had been pulled, causing trauma and obstruction, leading to the hospital transfer.
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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