Dubuque Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Dubuque, Iowa.
- Location
- 2935 Kaufmann Avenue, Dubuque, Iowa 52001
- CMS Provider Number
- 165228
- Inspections on file
- 22
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Dubuque Specialty Care during CMS and state inspections, most recent first.
The facility experienced repeat deficiencies in care plan management, nursing staffing, food sanitation, and infection control due to an ineffective QAPI program. Despite having a policy and committee in place, the same issues were cited in consecutive surveys, indicating that the QAPI process did not prevent recurrence of these problems.
Surveyors found that the facility did not include required PASRR Level II recommendations in the care plans for two residents with complex mental health and medical diagnoses. Both residents were missing multiple care plan components related to specialized services, rehabilitative services, and community placement supports, as identified in PASRR compliance reports.
A resident's care plan was not updated to address a new diagnosis of PTSD, despite documentation in the clinical record and PASRR. Staff interviews revealed a lack of information on the resident's PTSD triggers and no clear facility policy on care plan content, even though facility policy required care plan updates after significant changes in condition.
Two residents who were dependent on staff for transfers and toileting experienced significant delays in call light response, with wait times reported up to an hour during busy periods. Both residents had complex medical needs, and one reported incontinence due to the delay. Staff and leadership interviews confirmed awareness of the issue, and facility policy required timely responses, but these standards were not consistently met.
An LPN failed to prime insulin pens before administering insulin to a resident with diabetes and other medical conditions, resulting in a significant medication error. The facility's policy lacked clear instructions for insulin pen use, and both the DON and LPN confirmed the expected procedure was not followed.
A staff member preparing pureed foods did not sanitize prep surfaces or equipment between food items, used the same dry cloth for cleaning, and failed to wash hands throughout the process. Cross-contamination occurred as food residues were smeared across surfaces, and proper procedures for pureeing menu items were not followed, as confirmed by dietary management.
Staff did not consistently use Enhanced Barrier Precautions or keep catheter tubing off the floor for a resident with a urostomy and neurogenic bladder. The resident's tubing was observed dragging on the floor, and a CNA failed to wear a gown during high-contact care, contrary to facility policy and infection control standards.
The facility did not provide necessary behavioral health care and services to residents who required them, resulting in unmet behavioral health needs.
A resident with multiple diagnoses developed pressure ulcers due to inadequate preventive measures and inconsistent treatment documentation. The care plan did not address the new ulcers, and staff interviews revealed uncertainty about the cause and preventive actions. An LPN failed to follow proper infection control during wound care, and there was no evidence of a root-cause analysis or physician notification, indicating a lack of adherence to facility policy.
The facility failed to maintain proper hygiene during dining service when a Dietary Aide was observed passing glasses to residents with fingers touching the drinking surfaces. The Dietary Service Manager confirmed that staff are instructed to avoid such practices, but the facility's sanitation policy lacked specific guidance on hand placement.
The facility failed to follow physician's orders for insulin administration, resulting in missed and delayed doses for four residents with diabetes. A resident reported missing an Ozempic dose due to a pharmacy error, and the Location Administration Report showed insulin was often given late. Observations confirmed delays, and interviews revealed no valid reasons for the timing issues, indicating a deficiency in care standards.
A facility failed to provide adequate nursing staff, resulting in delayed call light responses and medication errors. Residents experienced significant delays in receiving assistance, leading to accidents and missed medications. Staffing shortages and unfamiliarity with the facility layout by agency staff contributed to these issues.
A facility failed to maintain a homelike environment due to musty urine odors and stained carpets in common areas. A resident with intact cognition reported the odor, which was confirmed by observations of multiple stains on the carpet. Interviews revealed staff were unaware of the cleaning schedule and overdue deep cleaning, leading to insufficient cleaning efforts.
The facility failed to update care plans for two residents after significant changes in their conditions. One resident, with moderate cognitive impairment, suffered a fractured ankle during a transfer, but their care plan was not updated to reflect new medical interventions. Another resident, cognitively intact, developed pressure ulcers, yet their care plan did not include these new conditions or required interventions. The ADON acknowledged the need for immediate updates but could not explain the oversight.
A facility failed to follow proper infection control techniques during wound care for a resident with pressure ulcers. An LPN did not disinfect scissors between uses and failed to change gloves appropriately, despite the facility's expectations. The resident had a history of neuropathy and chronic edema, with new wounds developing from blisters caused by wheelchair footrest bars. Interviews with the DON, ADON, and an RN confirmed the expected procedures were not followed.
Two residents experienced delays in receiving assistance with toileting, leading to incontinence and feelings of embarrassment. Despite policies requiring prompt response to call lights, staff did not consistently adhere to these guidelines, resulting in prolonged wait times and discomfort for the residents. Interviews revealed a lack of awareness and documentation of complaints, and issues with the call light system were acknowledged but not effectively addressed.
A resident with moderate cognitive impairment and dependency on staff for transfers experienced an ankle injury, potentially due to a mechanical lift. The facility failed to notify the family of the x-ray results and orthopedic consultation, despite policy requiring notification within 24 hours. Staff interviews confirmed the expectation of prompt family notification, but documentation showed gaps in communication.
A resident with moderate cognitive impairment and multiple medical conditions experienced a fractured ankle after an incident involving her wheelchair. Despite complaints of pain and visible bruising, the facility failed to document an assessment of the injury before sending her to the hospital, violating their policy on acute condition changes.
A resident with moderate cognitive impairment and multiple diagnoses suffered an ankle injury due to inadequate supervision during a transfer and wheelchair transport. The resident's foot slipped off the EZ stand during a transfer, and later got caught under the wheelchair pedal while being pushed, despite reminders to keep feet on the pedals. The facility's policy required evaluation and documentation of falls, but there was confusion about the cause of the injury, highlighting a failure in supervision and equipment use.
Two residents experienced significant delays in receiving assistance due to malfunctioning call lights. One resident, dependent on staff for toileting, reported waiting up to three hours for help, while another had an accident after a similar delay. The maintenance supervisor, visiting the facility once a week, was unaware of the issues, and the facility lacked a systematic approach to documenting and addressing call light problems.
A facility failed to notify the ombudsman of hospital transfers for a resident with heart failure and other conditions, leading to a deficiency. The resident was transferred to the hospital twice for shortness of breath and evaluation, but the facility did not inform the ombudsman as required. The Business Office Manager was unaware of the notification requirement, and the facility lacked a policy on ombudsman notification.
A facility failed to document the review of the Bed Hold policy with a resident's family when the resident was transferred to the hospital. The resident, who was cognitively intact and had multiple diagnoses, was found unresponsive and transferred with a diagnosis of Urosepsis. The facility's policy required the nurse to review and document the Bed Hold policy, but an RN was unaware of this process, leading to the deficiency.
Repeat Deficiencies Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in repeat deficiencies across multiple survey cycles. Specifically, deficiencies were identified in care plan timing and revision (F657), sufficient nursing staff (F725), food procurement, storage, preparation, and service sanitation (F812), and infection control (F880) during a recertification and complaint survey. These same deficiencies were cited again in a subsequent survey, indicating that the facility did not adequately address or prevent recurrence of these issues through its QAPI processes. Interviews and policy reviews revealed that, although the facility had a QAPI policy outlining the responsibilities of the QAPI Committee—including data collection, root cause analysis, and communication with leadership—the program was not effective in resolving or preventing the repeat deficiencies. The administrator reported that the facility worked on the previously cited deficiencies through QAPI, but the recurrence of the same issues suggests that the actions taken were insufficient to achieve sustained improvement.
Failure to Incorporate PASRR Level II Recommendations into Care Plans
Penalty
Summary
The facility failed to incorporate recommendations from the Pre-admission Screening and Resident Review (PASRR) Level II Determinations into the care plans for two residents. For one resident with diagnoses including seizure disorder, depression, bipolar disorder, and schizophrenia, the PASRR compliance report indicated noncompliance with disability-specific specialized services, rehabilitative services, and community placement supports. The care plan for this resident lacked multiple required components as identified by the clinical reviewer, despite the resident being observed as well-groomed and not displaying behaviors requiring staff intervention during the survey period. Another resident, diagnosed with diabetes mellitus, anxiety disorder, depression, and post-traumatic stress disorder, was observed to be tearful and upset over recent events, including changes to her care plan and being sent to the emergency department for evaluation. The PASRR compliance report for this resident also found the facility noncompliant with providing disability-specific specialized services, rehabilitative services, and community placement supports, with multiple required care plan components missing. These findings were based on observation, record review, and interviews with residents and staff.
Failure to Update Care Plan After New PTSD Diagnosis
Penalty
Summary
The facility failed to update the care plan for one resident after a new mental health diagnosis was identified. Clinical record review showed that the resident had a diagnosis of Post Traumatic Stress Disorder (PTSD) and anxiety, as documented in the Minimum Data Set (MDS) assessment and the Pre-admission Screening & Resident Review (PASRR). The electronic health record listed PTSD as a diagnosis, but the care plan, last revised on 6/20/25, did not reflect this updated diagnosis or address PTSD as required. The Trauma Informed Intake assessment indicated that the trauma care plan should be reviewed or updated, but this was not done. During staff interviews, the MDS Coordinator stated that the resident did not know her PTSD triggers and that there was no facility policy guiding what to include in the care plan, though she followed the Resident Assessment Instrument (RAI). The DON stated that she expected PTSD to be addressed in the care plan. Facility policy required care plans to be reviewed and revised after significant changes in a resident's condition, but this was not followed in this case.
Delayed Call Light Response for Dependent Residents
Penalty
Summary
The facility failed to respond to call lights in a timely manner for two residents who were dependent on staff for transfers, toileting, and personal hygiene. Clinical record reviews showed that both residents had significant medical conditions, including heart failure, anxiety disorder, cancer, and high blood pressure, and were non-ambulatory or required substantial assistance. Interviews with the residents revealed that call light response times could take up to 30 minutes before and after meals, and sometimes up to 40 minutes to an hour after lunch, particularly during busy periods such as between 11 AM and 2 PM and on weekends. One resident reported experiencing incontinence due to the long wait for assistance, leading to frustration and upset feelings. Staff interviews confirmed that the expectation was to answer call lights within 15 minutes, but acknowledged that response times sometimes exceeded this standard. The Director of Nursing and the Administrator were aware of the complaints, with the Administrator noting that grievances had been filed and audits conducted regarding call light response times. Resident Council meeting notes also documented concerns about delays in call light responses. Facility policy emphasized the importance of timely responses to residents' requests and needs, but the observed and reported delays indicated a failure to meet these standards for the residents involved.
Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to prime insulin pens prior to administering insulin to a resident on two separate occasions. The resident had a medical history that included diabetes mellitus, renal insufficiency, and osteomyelitis of the right ankle and foot, and was cognitively intact. The resident's orders included daily administration of two types of insulin via pen injectors. During direct observation, the LPN attached new needles to both insulin pens, dialed the prescribed doses, but did not prime the pens before administering the medication. Interviews with the Director of Nursing and the LPN confirmed that the expected procedure was to prime the insulin pen with 2 units and waste those units before administration, which was not done in these instances. Review of the facility's insulin administration policy did not provide specific instructions for insulin pen use, only for syringe administration. The failure to prime the insulin pens as required resulted in a significant medication error for the resident.
Failure to Maintain Sanitary Conditions During Pureed Food Preparation
Penalty
Summary
During a kitchen observation, a staff member responsible for preparing pureed foods failed to follow safe and sanitary food handling practices. The staff member did not sanitize the food preparation surfaces or equipment between different food items, instead using the same dry cloth to wipe surfaces and the puree machine multiple times, which resulted in cross-contamination of turkey, peas, and gravy. Additionally, the staff member did not wash her hands at any point during the puree process, even after handling different foods, wiping her hands on her clothing, and donning and removing gloves. There was no sanitizer bucket or spray available near the preparation area, and the staff member was observed smearing food residues back onto the prep surfaces. The staff member also failed to follow the correct procedure for pureeing bread as required by the menu, initially forgetting to include it and expressing uncertainty about the process. When prompted, she did not wash her hands before handling the bread and continued to use the same unsanitized cloth and surfaces. The pureed foods were left in holding containers on the counter, and food residues remained on the prep surfaces and equipment. Interviews with dietary management confirmed that the staff member did not adhere to required hand hygiene or sanitization protocols during the food preparation process.
Failure to Implement Enhanced Barrier Precautions and Maintain Catheter Hygiene
Penalty
Summary
Facility staff failed to consistently implement Enhanced Barrier Precautions (EBP) and maintain proper infection control practices for a resident with a urostomy and neurogenic bladder. Observations revealed that the resident's urostomy tubing was allowed to drag on the floor while she moved through the facility in her wheelchair. Staff interviews confirmed that catheter tubing is expected to be kept off the floor, but this was not adhered to during the observed incident. The resident was dependent on staff for transfers and toileting hygiene, and her care plan included the use of EBP to prevent infection. Additionally, during a high-contact care activity involving emptying the resident's urinary drainage bag, a Certified Nurse Aide (CNA) failed to wear a gown as required by EBP protocols, although gloves were used. The facility's policy mandates the use of gowns and gloves for high-contact activities involving residents with indwelling medical devices such as urinary catheters. Staff interviews and policy reviews confirmed the expectation for EBP use and proper handling of catheter tubing, but these standards were not consistently followed for this resident.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. As a result, residents with behavioral health needs did not receive the appropriate care and services as required by regulations.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in a resident identified as cognitively intact with a BIMS score of 15, and diagnosed with heart failure, renal insufficiency, and COPD. The resident was dependent on staff assistance for certain activities and was at risk for pressure ulcers, as noted in the care plan. However, the care plan did not address the development of pressure ulcers on both outer calves. The resident developed new wounds, which were attributed to the rubbing of the wheelchair footrest bars against her legs, exacerbated by chronic edema and neuropathy. The treatment records showed inconsistencies in the application of prescribed treatments, with several dates lacking documentation of treatment administration. During a wound care observation, an LPN failed to follow proper infection control procedures by not disinfecting scissors used to cut dressings, potentially compromising wound care. Interviews with staff revealed uncertainty about the cause of the wounds and whether preventive measures were in place, indicating a lack of communication and understanding among the care team. The facility's policy on ulcers and skin breakdown required staff to assess and document risk factors for pressure ulcers, examine new residents for existing conditions, and involve physicians in identifying ulcer types and complications. However, there was no evidence of a root-cause analysis being conducted to determine the cause of the wounds, and the Director of Nursing was unsure if the primary care physician had been notified. This lack of adherence to policy and communication contributed to the deficiency in pressure ulcer prevention and care.
Improper Hygiene Practices During Dining Service
Penalty
Summary
The facility failed to maintain proper hygiene standards during dining service, as observed on July 8, 2024. A Dietary Aide, identified as Staff A, was seen passing 20 glasses to 14 residents with her fingers over the top or touching the drinking surface on the side of the glasses. Additionally, she served 7 glasses to 2 residents with her fingers on the inside surface of the glasses. This practice was contrary to the facility's hygiene expectations, as explained by the Dietary Service Manager during an interview on July 10, 2024. The manager stated that staff are instructed to avoid touching the plates with their fingers, wear hair nets, and not wear gloves unless cleaning. Drinks can be poured ahead of time but must be covered, dated, and refrigerated. The manager emphasized that no hands should be over the top of tumblers, and staff must use handles on mugs. However, the facility's sanitation policy, last updated in October 2008, lacked specific guidance on hand placement during dining service.
Insulin Administration Delays and Errors
Penalty
Summary
The facility failed to adhere to physician's orders for administering insulin to four residents with diabetes mellitus, leading to missed and delayed medication doses. Resident #36, who has intact cognition and requires assistance with personal care, reported that his medications were often late, and he missed his Ozempic dose on 7/6/24 due to a pharmacy error. The Medication Administration Record confirmed the missed dose, and the Location Administration Report showed that insulin was administered outside the allowed time window 33 out of 43 times, with some doses being over two hours late. Resident #4, who is cognitively intact and independent in most activities, was observed receiving insulin after breakfast instead of with meals as ordered. The Location Administration Report indicated that insulin was consistently administered late on multiple occasions. Similarly, Resident #56, who is also cognitively intact and independent, received insulin doses late, as documented in the Location Administration Report. Observations confirmed that insulin was administered after the resident was out of the bathroom, further delaying the medication. Resident #60, who requires supervision or partial assistance, also experienced delays in insulin administration. The Location Administration Report showed that insulin was given late on several dates. Interviews with the ADON and a nurse practitioner revealed that insulin should be administered before or with meals, and there was no identified reason for the delays. The facility's failure to administer insulin as prescribed and within the appropriate time frame constitutes a deficiency in meeting professional standards of quality care.
Staffing Shortages Lead to Delayed Call Light Responses and Medication Errors
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in delayed responses to call lights and missed medication administration. Observations and interviews revealed that call lights for four residents were not answered in a timely manner, with delays ranging from 15 to 17 minutes. Residents expressed frustration and embarrassment due to the delays, particularly when needing assistance with toileting, which sometimes resulted in accidents. The facility's care plans did not adequately address the need for timely response to call lights, despite residents' dependence on staff for assistance with daily activities. Resident #14, who is cognitively intact and requires assistance with transfers, experienced a 17-minute delay in having her call light answered. Similarly, Resident #28, who is completely dependent on staff for assistance with toileting and other activities, reported that his call light sometimes did not work properly, leading to waits of up to three hours. Resident #214, with moderate cognitive impairment, also experienced delays, resulting in accidents while waiting for assistance to the bathroom. Staff interviews indicated that call lights were not being answered promptly due to staff shortages and unfamiliarity with the facility layout by agency staff. Additionally, Resident #36, who requires assistance with personal care and has diabetes, experienced issues with medication administration. His medications were frequently administered outside the allowed time window, and he missed a dose of semaglutide due to it being unavailable. The facility's medication administration policy requires timely administration, but staffing shortages and call-offs contributed to the delays. The Director of Nursing was unaware of the missed medication, highlighting a lack of communication and oversight in medication management.
Failure to Maintain a Homelike Environment Due to Odors and Stains
Penalty
Summary
The facility failed to maintain a homelike environment due to musty urine odors in common areas and stains on hallway carpets. Resident #27, who has intact cognition as indicated by a BIMS score of 15 out of 15, reported a musty smell, possibly urine, in the B wing, which was more noticeable during humid days. Observations confirmed the presence of multiple stains on the carpet in the B hallway, ranging from golf ball-sized to larger stains, with unknown substances ground into the fibers. Additional observations noted a milky white stain and a reddish-brown stain that clumped the carpet fibers together. Interviews with facility staff revealed a lack of awareness and action regarding the carpet cleaning schedule and odor concerns. The Administrator was unaware of the carpet cleaning schedule, and the Maintenance Supervisor acknowledged that the carpets were overdue for a deep cleaning. The facility's housekeeping staff was responsible for shampooing carpets until a full-time maintenance person could be hired, but the current cleaning efforts were insufficient to address the odors and stains effectively.
Failure to Update Care Plans After Changes in Resident Conditions
Penalty
Summary
The facility failed to update the care plans for two residents after significant changes in their care needs. Resident #5, who has moderate cognitive impairment and is dependent on staff for transfers and toileting, suffered a fractured ankle during a transfer. Despite the incident occurring on 6/28/24 and subsequent medical interventions, including a non-weight-bearing status and the application of a CAM boot, the resident's care plan was not updated to reflect these changes. The care plan, last reviewed on 6/30/23, did not include any new interventions following the incident. Similarly, Resident #14, who is cognitively intact and dependent on staff for certain activities, developed pressure ulcers on both lower legs, as noted on 3/22/24. Despite multiple treatment orders and changes in wound care over several months, the resident's care plan, last updated on 7/30/20, did not reflect the new pressure ulcers or the interventions required for their management. The Assistant Director of Nursing (ADON) acknowledged that care plans should be updated immediately when such changes occur, but could not explain why the updates were not made.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to utilize proper infection control techniques during wound care for a resident identified as cognitively intact with a BIMS of 15, and diagnosed with heart failure, renal insufficiency, and COPD. The resident was dependent on staff for assistance with footwear, transfers, and standing. The care plan identified the resident as being at risk for pressure ulcers, with open areas on the right shin, but did not account for pressure ulcers on both outer calves. During an observation of wound care, an LPN donned an isolation gown and gloves, removed a soiled dressing, and cleansed the wound correctly. However, the LPN then used the same gloves to handle scissors, which were not disinfected before cutting a new dressing, and placed it on the wound. This process was repeated for another wound on the resident's right calf without disinfecting the scissors. Interviews with the DON, ADON, and an RN revealed that the facility's expectation was for staff to change gloves when moving from dirty to clean tasks and to disinfect scissors between uses. The progress notes indicated that the resident had new wounds that developed from blisters caused by wheelchair footrest bars, with a history of neuropathy and chronic edema. The wounds were measured, and while the left leg wound showed no signs of infection, the right leg wound had surrounding erythema, warmth, and mild yellow drainage. The failure to disinfect scissors and change gloves appropriately during wound care was identified as a deficiency in infection control practices.
Failure to Respond to Call Lights Promptly
Penalty
Summary
The facility failed to treat residents with dignity and respect, as evidenced by the experiences of two residents. Resident #36, who had intact cognition and required assistance with personal care, reported long wait times for assistance with toileting. Despite being able to use a urinal independently, Resident #36 experienced discomfort and embarrassment due to delayed staff response to call lights, resulting in incontinence and prolonged periods in soiled conditions. The resident's care plan did not document the use of a urinal as an intervention, and staff were aware of the resident's complaints but did not document them. Resident #214, with moderate cognitive impairment and a history of hip fracture, also experienced delays in receiving assistance, leading to incontinence episodes. Observations confirmed that the resident's call light was not answered promptly, and the resident reported feeling embarrassed and degraded by the situation. The facility's policy required staff to respond to call lights within 15 minutes, but this was not consistently adhered to, as evidenced by the 16-minute delay observed by surveyors. Interviews with facility staff, including the Administrator, Director of Nursing, and Assistant Director of Nursing, revealed a lack of awareness of documented complaints regarding call light response times. The Maintenance Supervisor acknowledged issues with the call light system but was unable to generate reports to track response times. The facility's policies on answering call lights and resident rights emphasized the importance of timely assistance and treating residents with dignity, but these were not effectively implemented, contributing to the deficiencies observed.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the family of a resident's change in condition, specifically regarding an incident involving a fractured ankle. The resident, who had moderate cognitive impairment and was dependent on staff for transfers and toileting, experienced an ankle injury potentially caused by a mechanical lift transfer. Despite the resident's family being informed of the initial pain and new medical orders, they were not notified of the x-ray results or the subsequent orthopedic consultation. This lack of communication was a chronic issue, as reported by the resident's family member. The facility's policy required family notification within 24 hours of any significant change in the resident's condition, but this was not adhered to in this case. Interviews with staff, including the ADON and RNs, confirmed that family notification should occur promptly and be documented in the resident's records. However, the documentation review revealed gaps, with the last family notification form completed over a month prior to the incident. This deficiency highlights a failure in the facility's communication and documentation processes regarding changes in resident conditions.
Failure to Document Assessment Before Hospital Transfer
Penalty
Summary
The facility failed to document an assessment for a resident who was sent to the hospital, which constitutes a deficiency in care. The resident, identified as having moderate cognitive impairment and several medical conditions including renal insufficiency, diabetes mellitus, and a urinary tract infection, was totally dependent on staff for transfers and toileting. An incident occurred where the resident's right foot slipped off the foot pedal of her wheelchair, resulting in a fractured ankle. Despite the resident's complaints of significant pain and visible bruising, the facility did not document an assessment of the injury before sending the resident to the hospital for further evaluation. The facility's policy on acute condition changes requires nursing staff to collect pertinent details and document assessments before contacting a physician or deciding on a transfer. However, in this case, the necessary assessment was not documented, as confirmed by a staff interview. This lack of documentation and assessment before the resident's transfer to the hospital represents a failure to adhere to the facility's policy and ensure appropriate care for the resident.
Failure to Prevent Injury During Transfer and Wheelchair Transport
Penalty
Summary
The facility failed to prevent an incident resulting in injury for a resident with moderate cognitive impairment and multiple diagnoses, including renal insufficiency, diabetes mellitus, and a urinary tract infection. The resident was totally dependent on staff for assistance with transfers and toileting. The incident occurred when the resident's ankle slipped off the EZ stand during a transfer, leading to complaints of pain and swelling in the right ankle. The resident's care plan had identified a risk for falls and directed staff to encourage the use of a call light for assistance and refer the resident to physical therapy as needed. Interviews with staff revealed inconsistencies in the account of the incident. A family member reported being informed by the facility that the resident fractured her ankle, possibly due to the mechanical lift of the wheelchair. However, staff interviews indicated that the resident's foot got caught under the wheelchair pedal while being pushed down the hall, despite reminders to keep feet on the pedals. The nurse's progress notes and incident report documented the resident's complaints of pain and the presence of bruising and swelling, but there was confusion about the exact cause of the injury. The facility's policy on falls required staff to evaluate and document falls, including observations of the events. Despite this, there was a lack of clarity and documentation regarding the cause of the resident's injury. The emergency room physician's notes indicated severe osteopenia in the resident's right foot but no evident fracture. The facility's failure to provide adequate supervision and ensure proper use of equipment during transfers and transport in a wheelchair contributed to the resident's injury.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to maintain a functioning call light system for two residents, leading to significant delays in receiving assistance. Resident #28, who is cognitively intact and completely dependent on staff for toileting and personal hygiene, reported that his call light frequently malfunctioned, sometimes leaving him waiting for up to three hours. Despite informing CNAs about the issue, it was not effectively communicated to the maintenance supervisor, who was unaware of the problem until it was brought to his attention during the survey. Resident #36, also cognitively intact and dependent on staff for toileting and transfers, experienced similar issues with the call light system. He reported an incident where he had to wait three hours for assistance after urinating on himself because the call light was not functioning. Staff interviews confirmed that the resident had reported long wait times and that the call light system was not always reliable. The maintenance supervisor, who only visited the facility once a week, acknowledged issues with the call lights but lacked the knowledge to generate a report on the system's functionality. The facility's policy on answering call lights, revised in March 2021, requires staff to ensure that call lights are plugged in and functioning at all times. However, the maintenance supervisor's limited presence and the lack of a systematic approach to documenting and addressing call light issues contributed to the deficiency. The administrator and director of nursing were unaware of any documented complaints, indicating a gap in communication and oversight regarding the call light system's reliability.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the ombudsman of hospital transfers for a resident, leading to a deficiency. The resident, who had a Brief Interview for Mental Status score indicating no cognitive impairment, was diagnosed with heart failure, urinary tract infection, and acute and subacute infective endocarditis. The resident was transferred to the hospital twice in May for shortness of breath and evaluation and treatment. However, the facility did not notify the ombudsman of these transfers, as required. The Business Office Manager was unaware of the need to notify the ombudsman for hospital admissions when residents were not discharged from the facility. Additionally, the facility lacked a policy regarding ombudsman notification.
Failure to Document Bed Hold Policy Review
Penalty
Summary
The facility failed to document that the Bed Hold policy had been reviewed with a resident who was transferred to the hospital. The resident, identified as cognitively intact with a BIMS score of 15, had diagnoses including Heart Failure, Renal Insufficiency, and COPD. The resident was dependent on staff assistance for certain activities. On the morning of the incident, the resident was found unresponsive and was transferred to the emergency department with a diagnosis of Urosepsis. However, there was no documentation indicating that the Bed Hold policy had been reviewed with the resident's family. The facility's policy required the nurse responsible for sending the resident to the hospital to review the Bed Hold policy with the resident or their family and document it in the electronic medical record. This documentation should include the name of the family member or resident and be completed before the transfer. An interview with the ADON confirmed this procedure, but an RN reported she had never completed or reviewed the Bed Hold policy with any residents and was unaware of the process. This lack of documentation and adherence to policy led to the deficiency.
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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