Dunlap Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Dunlap, Iowa.
- Location
- 1403 Harrison Road, Dunlap, Iowa 51529
- CMS Provider Number
- 165193
- Inspections on file
- 21
- Latest survey
- May 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Dunlap Specialty Care during CMS and state inspections, most recent first.
Surveyors identified multiple instances of improper food storage and handling, including undated and expired food items in refrigerators and dry storage, as well as staff using bare hands and tongs interchangeably during meal service. The Certified Dietary Manager and Registered Dietitian confirmed that these practices did not meet facility expectations or policy requirements.
Multiple residents and family members reported that rooms and common areas were not cleaned regularly, with dead insects observed in several locations. Housekeeping staff and supervisors confirmed significant understaffing, lack of proper orientation, and inability to complete required cleaning tasks, resulting in missed areas and unaddressed grievances about cleanliness. Facility policy required regular cleaning, but these standards were not consistently met.
Two residents did not receive ordered medications as prescribed, with staff documenting administration on the MAR despite the medications not being given. One resident missed a scheduled nebulizer treatment for pneumonia, and another did not receive a prescribed dose of Lasix, as confirmed by both staff and medication packaging. Staff interviews revealed a lack of clarity on procedures for missed medications and failure to notify supervisors, resulting in noncompliance with professional standards for medication administration.
A resident who was fully dependent on staff developed a new deep tissue injury on the heel, which was not identified by staff until discovered by a provider. Despite care plan instructions to use a pressure-relieving boot, staff did not consistently implement this intervention, and the resident was repeatedly observed without the required device in place. Documentation failed to reflect the presence of the skin issue, and staff interviews revealed gaps in awareness and follow-through with prescribed care.
A resident with significant cognitive and physical impairments, including a PEG tube and Foley catheter, did not receive scheduled morning medications until the afternoon, contrary to facility policy. Documentation also lacked evidence that a physician was notified of the late administration.
Three residents with complex medical needs, including those on dialysis and with indwelling catheters, had incomplete or delayed documentation in their medical records. Nursing notes and assessments were entered days after care was provided, and some referenced vital signs or procedures that were not actually completed or recorded at the indicated times. Staff confirmed that documentation was sometimes based on assumptions rather than direct observation, in violation of facility policy requiring accurate and timely recordkeeping.
Staff failed to follow Enhanced Barrier Precautions (EBP) for two residents with indwelling devices and wounds, including not wearing gowns or gloves during wound care and feeding tube procedures, despite facility policy requiring EBP for such conditions.
A resident with an indwelling catheter did not have documented orders for regular catheter changes, leading to a deficiency in care. Despite a care plan and a standard order for monthly changes, the facility failed to document or perform consistent catheter changes, resulting in the resident's hospitalization for sepsis. Staff interviews revealed confusion about the frequency of catheter changes, and the Director of Nursing admitted the policy had not been updated in the QAPI meeting.
The facility failed to maintain sanitary conditions in the kitchen and during meal service. Observations revealed unsanitary conditions such as grease and food debris on the stove, scattered food debris on a dish cart, and accumulated debris on the floor. The Dietary Manager and another staff member failed to perform hand hygiene during meal service, and food was placed on unsanitized surfaces. The facility's sanitation policy required clean and sanitary conditions, which were not met.
The facility failed to treat residents with dignity and respect, as evidenced by incidents involving disrespectful remarks by staff. An LPN made derogatory comments towards residents, including telling a CNA to let a resident sit in waste to 'teach him a lesson.' Another resident experiencing chest pain was dismissed by the same LPN as attention-seeking. An RN was reported for rude behavior towards a resident with paraplegia, who filed a grievance. These incidents highlight a failure to uphold residents' rights to dignity and respect.
A resident with heart failure, COPD, and respiratory failure did not have their oxygen tubing changed weekly as ordered by the physician. The tubing, last changed on 6/12/24, was observed unchanged until 7/1/24, when the Activity Coordinator, not typically responsible for this task, replaced it. The care plan lacked specific instructions for tubing changes, and the facility's policy required weekly changes, which were not adhered to.
A facility failed to accurately document the changing of oxygen tubing for a resident with heart failure, COPD, and respiratory failure. Despite physician orders to change the tubing weekly and as needed, observations showed the tubing had not been changed as documented. The care plan lacked specific instructions for tubing changes, and the facility's policy required detailed documentation of respiratory therapy, which was not followed.
A facility failed to implement Enhanced Barrier Precautions during catheter care for a resident with an indwelling catheter and a history of MRSA. A CNA did not wear a gown as required, despite the facility's policy and CDC guidelines emphasizing the need for PPE during high-contact care activities. The DON confirmed the expectation for proper PPE use.
A resident was unable to access personal funds after business hours due to the facility's lack of a policy and availability of funds. Staff confirmed that funds were only accessible when the business office was open, and the DON was initially mistaken about the availability of funds at the nurse's station.
Improper Food Storage and Handling Practices Identified
Penalty
Summary
Surveyors observed multiple instances where food was not stored in accordance with professional standards. During a kitchen tour, open bags of lettuce with expired dates, undated open bags of hard-boiled eggs, and expired yogurt containers were found in refrigerators. Additionally, cheese was found in a container with an outdated open date. In dry storage, several open bags of food items, including gravy mix, lemonade mix, gluten free flour, egg noodles, tri-colored noodles, and cake mix, were found undated. Staff interviews confirmed that the facility's expectation was for all open food items to be dated and expired food to be discarded, which was not followed in these instances. Further observations during meal service revealed improper food handling practices. A Certified Dietary Manager (CDM) was seen using metal tongs to serve bread and then using bare hands to replace the lid, touching both the tongs and the lid handle throughout the service. Another CDM was observed handling sandwiches with bare hands after performing hand hygiene, removing them from the refrigerator, and placing them on a plate for a resident. The Registered Dietitian (RD) acknowledged witnessing bare hand contact with food and expressed concerns about cross-contamination due to improper use of tongs and bare hands. Facility policy required all foods to be covered, labeled, and dated, which was not consistently followed.
Failure to Maintain Clean and Homelike Environment Due to Inadequate Housekeeping
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. Several residents and family members reported that rooms and common areas, such as the chapel and hallways, were not cleaned in a timely manner. Dead insects, including spiders, were observed in resident rooms, the chapel, and around the nurses' station. One resident's family member reported seeing a spider in the dining room for about a week and noted that her mother's room also had spiders at times. Another resident stated that housekeeping rarely cleaned her room, less than twice a month, and that she had reported this to nursing staff. A third resident reported having to clean his own room due to lack of housekeeping and had filed grievances about the cleanliness of his room and bathroom, which he felt were not addressed adequately. Staff interviews revealed significant understaffing in the housekeeping department, with only one housekeeping aide responsible for cleaning all resident rooms and common areas. The aide reported being unable to complete all required cleaning tasks due to time constraints and lack of support, missing areas such as the chapel, hallways, and nurses' station. The aide also stated that he had not received proper orientation for his role and that requests for additional staff or overtime were not fulfilled until surveyors arrived. The temporary housekeeping supervisor and maintenance supervisor confirmed that the facility was short-staffed, with two full-time housekeeping positions and laundry staff unfilled, and that cleaning schedules were not being followed due to limited hours and competing priorities. Documentation review showed that grievances regarding unclean rooms and bathrooms had been submitted over the past three months, with residents expressing dissatisfaction with the cleanliness and the lack of timely response from housekeeping. The facility's policy required regular cleaning and disinfection of resident rooms and personal use items, but observations and staff statements indicated that these standards were not consistently met. The administrator acknowledged that additional housekeeping staff were only brought in from other facilities during the survey, and that insects should have been cleaned up promptly.
Failure to Follow Physician Orders and Accurate Medication Administration Documentation
Penalty
Summary
The facility failed to follow physician orders and ensure proper medication administration for two residents. For one resident with severe cognitive impairment and a recent diagnosis of pneumonia, there was a physician's order for a sodium chloride inhalation nebulization solution to be administered in the morning. On the specified date, the Medication Administration Record (MAR) was signed by a registered nurse indicating the treatment was given, but both the Director of Nursing (DON) and the resident's daughter confirmed that the treatment was not administered. The nurse admitted to not providing the treatment and acknowledged signing the MAR in error, with the medication still in her possession at the time. The resident's daughter discovered the omission later in the day and reported it to staff. For another resident with lymphedema and no cognitive impairment, there was a physician's order for a daily mid-morning dose of Lasix. The MAR indicated the medication was administered, but the resident reported not receiving it, and observation of the medication bubble pack confirmed the dose was still present. The certified medication aide and the DON both acknowledged the missed dose, and the nurse responsible stated that it was not uncommon for medications to be missed without explanation. The nurse also admitted to not notifying anyone about the missed dose and was unclear about the process for handling such situations. Policy review revealed that medication administration must be documented immediately after it is given, and not before, with proper signatures. In both cases, staff documented administration of medications that were not actually given, and there was a lack of communication and follow-up regarding the missed doses. These actions and inactions resulted in the facility failing to meet professional standards of quality in medication administration for the residents involved.
Failure to Prevent and Manage Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer and did not ensure that appropriate interventions were consistently in place for a resident at risk. A resident, who was totally dependent on staff for mobility and care, developed a new deep tissue injury on the right heel that was discovered by the primary care provider during rounds. Prior to this, staff documentation indicated no new skin issues, and the resident had reported heel pain to the provider but not to other staff. The resident had multiple diagnoses, including anemia, heart failure, renal insufficiency, malnutrition, and asthma, and was identified as being at risk for skin impairment and pressure ulcers. The care plan was updated to include the use of a pressure-relieving boot for the resident's right heel after the ulcer was discovered. However, observations showed that staff did not consistently implement this intervention. On several occasions, the resident was observed in bed with his heels resting directly on the bed surface and the protective boot not in use, despite care plan instructions. Staff interviews revealed a lack of awareness regarding the resident's pain and the development of the sore, and there was uncertainty about whether staff should have identified the issue sooner. Documentation and policy review indicated that while the facility had protocols for assessing risk and providing wound care, there was a lack of clear guidance on staff responsibility for following through with prescribed interventions. The resident's electronic chart showed no documentation of skin issues in the period leading up to the discovery of the ulcer, and staff were not consistently monitoring or documenting the use of pressure-relieving devices as required by the care plan.
Failure to Administer Medications Timely for Dependent Resident
Penalty
Summary
The facility failed to ensure that medications were administered in a timely manner for one resident. Specifically, a resident with moderate cognitive deficits, total dependence on staff for care, a terminal diagnosis of progressive multifocal leukoencephalopathy, a Foley catheter, and a PEG tube for feeding did not receive her scheduled morning medications until the afternoon. The Medication Administration Audit Report showed that ten morning medications, scheduled between 7 am and 9 am, were not given until 12:20 PM, and two additional medications scheduled for 11:00 AM were administered at 3:37 PM. There was no documentation in the clinical record that the physician had been notified of these late administrations. Facility policy required that morning medications be administered between 7 am and 9 am, and later morning medications between 11 am and 1 pm, with immediate documentation after administration. The failure to follow these policies was confirmed by staff interviews and record review. The resident was observed to be in bed, receiving continuous tube feeding, and unable to respond to questions at the time of observation. The lack of timely medication administration and absence of physician notification constituted the deficiency identified during the survey.
Failure to Maintain Accurate and Timely Medical Records for Residents
Penalty
Summary
The facility failed to maintain accurate and timely medical records for three residents, resulting in incomplete or delayed documentation of care and assessments. For one resident with moderate cognitive deficits, an indwelling urinary catheter, and a feeding tube, the care plan required catheter care every shift. However, the Medication Administration Record indicated that a catheter flush was not completed as scheduled, and a late nursing note was entered stating the flush was done with normal saline after the fact, based on an assumption rather than direct observation or confirmation. The Director of Nursing confirmed that the documentation was entered the next day without certainty that the procedure had been performed. Two other residents receiving dialysis also had deficiencies in their medical records. For both, Dialysis Evaluation forms were completed and entered into the system up to 12 days after the actual assessment dates. Additionally, the documentation referenced vital signs that were either missing or not recorded at the times indicated. For example, one resident's evaluation referenced vital signs that were not present in the record for the specified date and time, and another had only partial vital sign documentation that did not match the times noted in the assessment. Staff interviews and record reviews confirmed that the facility's documentation practices did not align with its own policy, which requires objective, complete, and accurate records of care, including the date and time procedures and treatments are provided. The lack of timely and accurate documentation for these residents, particularly those with complex medical needs such as dialysis and indwelling catheters, constituted a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of indwelling medical devices and wounds. For one resident with a stage 2 pressure ulcer not present on admission, staff were observed performing transfers and wound care without donning gowns, despite completing hand hygiene and glove use. Both the RN/ADON and DON provided conflicting statements regarding the necessity of EBP for this resident, with the DON stating EBP should be used for residents with draining wounds or external devices, but ultimately EBP was not applied during care. Another resident with a Foley catheter and a feeding tube, who was totally dependent on staff for care, also did not receive EBP during high-contact activities. During a procedure involving the disconnection and flushing of the feeding tube, the RN failed to wear gloves or a gown, and interacted directly with the resident. Facility policy required EBP for residents with wounds or indwelling medical devices, regardless of known infection or colonization with multidrug-resistant organisms, but this was not followed during the observed care activities.
Failure to Ensure Regular Catheter Changes for Resident
Penalty
Summary
The facility failed to ensure that a resident had orders to change his catheter, which led to a deficiency in the care provided. The resident, who had no cognitive impairment, was admitted with an indwelling catheter and various diagnoses, including renal failure and depression. Despite having a care plan that included monitoring for urinary tract infection symptoms and catheter care, the facility did not have documented orders for regular catheter changes in the resident's Medication Administration Records (MARs) and Treatment Administration Records (TARs). The resident's catheter was reportedly not changed since his admission until he was hospitalized in December for acute encephalopathy and sepsis, which was believed to be due to the catheter not being changed. Although there was a standard order dated December to change the catheter monthly, there were no other catheter orders completed or documented in the electronic health record. Staff interviews revealed inconsistencies in the understanding of catheter change frequency, with some staff believing it should be every 30 days and others every 60 days. The Director of Nursing acknowledged that the catheter change policy had not been updated in the Quality Assurance and Performance Improvement (QAPI) meeting, and there were no progress notes indicating catheter changes. The lack of documentation and clear orders led to the deficiency, as the facility did not ensure the catheter was changed according to any consistent schedule, resulting in potential harm to the resident.
Sanitation and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and during meal service, as observed during a survey. The initial kitchen walk-through revealed several unsanitary conditions, including a stove top with a thick layer of grease and food debris, a clean dish cart with scattered food debris, and a floor with accumulated food debris and dried liquid. Additionally, all refrigerator and freezer systems had dried liquid and debris at the bottom, and there was ice build-up in the freezers and milk cooler. The microwave was splattered with food and dried liquid, the toaster was covered in grime, and dead gnats were found along the window sills. The Dietary Manager acknowledged these issues and indicated a problem with a staff member who worked over the weekend. During lunch service, further deficiencies were noted. The Dietary Manager failed to perform hand hygiene after serving a resident and handling food items. The manager also placed a slice of bread directly on the bread bag and a spatula on the counter before using it to make a grilled cheese sandwich. Another staff member, identified as Staff B, also failed to perform hand hygiene while entering and exiting the kitchen and accessing the refrigerator multiple times. The Dietician observed these failures and reported that staff did not use hand hygiene appropriately and expected food and utensils to be placed on sanitized surfaces. The facility's sanitation policy, last revised in October 2008, required the food service area to be maintained in a clean and sanitary manner, with all equipment and surfaces washed and sanitized properly.
Disrespectful Treatment of Residents by Staff
Penalty
Summary
The facility failed to treat all residents with dignity and respect, as evidenced by multiple incidents involving disrespectful remarks made by staff members. Staff G, an LPN, was reported to have made derogatory comments towards several residents, including telling a CNA to let a resident sit in their own waste to 'teach him a lesson.' This resident, who had an intact cognitive ability and required substantial assistance for toileting due to multiple health conditions, was subjected to disrespectful treatment. Other staff members corroborated these incidents, noting that Staff G often spoke loudly and disrespectfully to residents. Another incident involved Resident #25, who had a moderate cognitive deficit and was experiencing chest pain. Staff G dismissed the resident's concerns, loudly accusing him of seeking attention and medication. This resident had a history of serious health issues, including hypertension and respiratory failure, and was later taken to the hospital for treatment. Staff members reported that Staff G made similar dismissive comments to emergency personnel, further demonstrating a lack of respect and dignity towards the resident. Additionally, Resident #81, who had intact cognitive ability and required assistance due to paraplegia and pressure ulcers, reported being treated rudely by Staff J, an RN. The resident filed a grievance after being embarrassed and blamed for her medical condition in front of others. A family member and other staff confirmed the RN's rude behavior. The facility's policy emphasizes the residents' right to be free from abuse and neglect, yet these incidents highlight a failure to uphold these standards, as acknowledged by the DON.
Failure to Change and Label Oxygen Tubing
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not adhering to the physician's order to change and label oxygen tubing weekly and as needed. Resident #15, who had diagnoses of heart failure, COPD, and respiratory failure, was observed with oxygen tubing that had not been changed since 6/12/24, despite the physician's order dated 4/7/24 requiring weekly changes. The care plan for Resident #15 did not specify when the oxygen tubing should be changed, contributing to the oversight. On 7/1/24, the tubing was observed to be changed and labeled with a new date, but this was done by the Activity Coordinator, who stated it was not typically her responsibility. The Director of Nursing confirmed that the expectation was for oxygen tubing to be changed every Sunday, which was not followed in this case. The facility's policy, last revised in November 2011, also required weekly changes of oxygen tubing, indicating a lapse in following established protocols.
Inaccurate Documentation of Oxygen Tubing Changes
Penalty
Summary
The facility failed to accurately document the changing of oxygen tubing for a resident diagnosed with heart failure, COPD, and respiratory failure. The resident, who had no cognitive impairment, was prescribed oxygen therapy with specific instructions to change the tubing every Sunday night and as needed, with the new tubing dated accordingly. However, the care plan did not specify when the tubing should be changed, leading to discrepancies in documentation. Observations revealed that the oxygen tubing for the resident had not been changed since a specific date, despite records inaccurately indicating changes on subsequent dates. The facility's policy required weekly changes and detailed documentation of respiratory therapy, including the date, time, type of therapy, and the name and title of the individual performing it. The Director of Nursing confirmed the expectation for accurate documentation, highlighting the deficiency in maintaining proper records for the resident's oxygen therapy.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to universal infection control measures and Enhanced Barrier Precautions (EBP) during catheter care for a resident with renal insufficiency, neurogenic bladder, and multiple sclerosis, who utilized an indwelling catheter. The resident had a history of MRSA, and the physician's orders required enhanced barrier precautions every shift. During an observation, a Certified Nursing Assistant (CNA) performed catheter care without wearing a gown, which is required under EBP for high-contact care activities involving urinary catheters. The CNA acknowledged the oversight in an interview, confirming that a gown should have been worn. The Director of Nursing (DON) also stated that the expectation was for gowns and proper personal protective equipment (PPE) to be used during such procedures. The facility's policy on Enhanced Barrier Precautions, as well as guidelines from the Centers for Disease Control and Prevention, emphasize the necessity of PPE during high-contact activities to prevent the spread of multidrug-resistant organisms (MDROs).
Deficiency in Resident Access to Personal Funds
Penalty
Summary
The facility failed to provide ready and reasonable access to personal funds for a resident, as required by regulations. A resident reported that they could only access their personal funds when the business office person was present. Staff interviews confirmed that no personal funds were available to residents after normal business hours. The Business Office Manager acknowledged the lack of a policy related to personal funds and confirmed that funds were not accessible after hours without prior notice. The Director of Nursing initially stated that a small amount of money was kept at the nurse's station for resident requests, but later admitted to being mistaken about the availability of funds after hours.
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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