Elm Crest Retirement Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Harlan, Iowa.
- Location
- 2104 12th Street, Harlan, Iowa 51537
- CMS Provider Number
- 165372
- Inspections on file
- 21
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Elm Crest Retirement Community during CMS and state inspections, most recent first.
Staff did not consistently follow the care plan and therapy recommendations requiring two-person assistance for transfers of a resident with significant physical and cognitive impairments, resulting in a fall during a transfer when only one staff member assisted. Interviews indicated confusion among staff about the required level of assistance, and previous incidents of falls had already been documented for this resident.
A resident with a history of falls and requiring substantial assistance was not provided with safe transfer techniques, resulting in multiple falls and injuries. The resident fell in the bathroom without a gait belt or proper footwear, leading to a C3 fracture and skin tears. Staff interviews revealed inadequate orientation and lack of access to resident information for a CNA, who assisted the resident alone despite needing two-person assistance. The facility's policy required gait belts, but they were not used during the incident.
The facility failed to maintain proper dish sanitization standards, with the dish machine operating below required temperatures for both wash and rinse cycles. Staff continued to use dishes washed at inadequate temperatures, and temperature checks were not effectively conducted. The issue persisted despite maintenance visits, and the facility's policy for verifying dish machine temperatures was not consistently followed.
The facility failed to implement proper infection control measures and Enhanced Barrier Precautions (EBP) for three residents. A resident with an indwelling catheter did not receive care with appropriate hand hygiene or gown use. Another resident with a G-tube did not have gown precautions followed during care. Additionally, an LPN did not change gloves between administering nasal and ocular medications. The DON confirmed that staff were expected to follow hand hygiene and PPE protocols.
A facility failed to complete a comprehensive MDS assessment for a resident, missing data in Section GG on functional abilities. The DON and MDS Coordinator could not explain the oversight, despite the expectation for full completion. The PTA provided input for the section, but it remained incomplete, contrary to the facility's policy.
A facility failed to create a comprehensive care plan for a resident diagnosed with MRSA. Despite the diagnosis and treatment order, the care plan lacked focus, goals, or interventions for MRSA, and enhanced barrier precautions were not implemented. Staff acknowledged the oversight, and the facility's policy for comprehensive care planning was not followed.
A facility failed to consistently implement a restorative ambulation program for a resident with neuropathy and diabetes, as outlined in their care plan. Despite the resident's intact cognition and a goal to ambulate 500 feet daily, documentation showed inconsistencies in the program's execution. The resident reported not walking to meals as intended, and the DON confirmed the program was not followed as written.
A resident with COPD did not receive proper respiratory care as the facility failed to maintain nebulizer equipment according to protocol. The nebulizer tubing and mask were not regularly cleaned or dated, and staff interviews revealed a lack of adherence to the facility's policy for nebulizer management.
A resident with severe cognitive deficits was treated with a lack of dignity and respect by a staff member in an LTC facility. The resident, who was restless and attempted to stand unassisted, was subjected to a harsh tone and physical contact by an untrained staff member, leading to an escalation where the resident bit the staff member. The staff member reacted by pushing the resident's forehead, contrary to the facility's dignity policy.
The facility failed to update care plans for four residents, leading to discrepancies between documented care needs and actual resident abilities. A resident was observed self-propelling a wheelchair despite the care plan requiring two staff for transfers. Another resident's care plan did not reflect their independence with a walker. A third resident's care plan required maximum assistance for transfers, but observations showed they needed less help. Lastly, a resident's care plan included outdated hospice interventions and fall checks that were not documented.
The facility failed to complete necessary assessments and follow protocol for two residents who sustained falls with major injuries. One resident with severe cognitive impairment experienced a delayed post-fall evaluation, while another resident with intact cognition had an incomplete assessment. Staff interviews revealed inconsistencies in following the facility's protocol for using mechanical lifts and completing documentation promptly, leading to deficiencies in care.
Failure to Use Safe Transfer Techniques for High-Risk Resident
Penalty
Summary
Staff failed to use safe transferring techniques for a resident with a history of multiple falls and significant physical and cognitive impairments. The resident, who had diagnoses including renal insufficiency, neurogenic bladder, diabetes mellitus, cerebrovascular accident, and chronic pain, required substantial assistance for transfers and was care planned for two-person assistance. Despite this, on one occasion, only one staff member assisted the resident in transferring from the toilet to a wheelchair, resulting in the resident sliding to the floor. The care plan had been updated to specify two-person assistance for transfers, especially when no grab bar was available, and therapy recommendations also indicated the need for two staff during transfers. Interviews with staff revealed inconsistent understanding and implementation of the required level of assistance, with some staff unsure whether one or two people were needed for transfers. Documentation showed previous incidents where the resident was found on the floor or lowered to the floor during transfers, and interventions were put in place to address these risks. However, the failure to consistently follow the care plan and therapy recommendations led to another fall event. The facility's policy required individualized fall risk assessment and care planning, but these were not effectively implemented for this resident.
Failure to Use Safe Transfer Techniques Leads to Resident Falls
Penalty
Summary
The facility failed to use safe transfer techniques for a resident, leading to multiple falls and injuries. Resident #37, who had a minimal cognitive deficit and required substantial assistance for transfers, fell in the bathroom and sustained bruising and a skin tear after staff assisted him without a gait belt or proper footwear. The resident had a history of falls and was at high risk for falling due to previous falls at home. Despite this, the care plan did not include adequate interventions to prevent further falls. On one occasion, the resident fell in his room while attempting to go to the bathroom, resulting in a C3 fracture and a skin tear. The resident was sent to the emergency room for evaluation and was later admitted to the hospital. Upon returning to the facility, the resident was placed on 15-minute visual checks, and new gripper socks were provided. However, the care plan lacked updates or new interventions following another fall on November 6, 2024, when the resident fell in the bathroom while being assisted by staff without a gait belt or proper footwear. Staff interviews revealed that a Certified Nurse Aide (CNA) had limited orientation and was not able to access the electronic chart for resident information. The CNA was informed that the resident required two-person assistance, but another aide left the room, leaving the CNA to assist the resident alone. The facility's policy required the use of gait belts for residents needing assistance with transfers, but the CNA did not use one, believing it was unnecessary because the resident had a walker. The facility's Director of Nursing confirmed that gait belts were supposed to be used and were kept in residents' rooms, but the CNA reported that there were no gait belts available in the resident's room at the time of the incident.
Improper Dish Sanitization in LTC Facility
Penalty
Summary
The facility failed to adhere to proper sanitation standards by serving residents on dishes that were not rinsed at the appropriate temperature in the dish machine, potentially spreading illness. Observations on November 12 revealed that the high-temperature dish machine was operating with a wash cycle temperature of 140 degrees and a rinse cycle temperature of 170 degrees, both below the required standards. The facility's Temperature Monitoring Form for October documented several instances where the wash and rinse temperatures were below the required 150 degrees and 180 degrees, respectively. Staff M, a Dietary Aide, admitted to continuing to wash and store dishes even when the dish machine temperatures were below the required levels, believing that a rinse temperature above 150 degrees was sufficient. Staff M used temperature strips to check the rinse temperature, but these strips did not change color, indicating that the required temperature was not reached. Staff N, the Certified Dietary Manager, acknowledged the issue and stated that the dish machine had not been reaching the necessary rinse temperature of 180 degrees. Despite a maintenance visit on November 6, there was no service request for low temperatures, and the technician confirmed that the machine did not reach the required rinse temperature during his tests. The facility's policy required staff to verify proper temperatures and machine function before use, but this was not consistently followed. The Administrator confirmed the facility's expectations for dish machine temperatures and the protocol for notifying management if temperatures were not met. However, the staff did not consistently follow these procedures, leading to the use of inadequately sanitized dishes.
Infection Control and EBP Deficiencies
Penalty
Summary
The facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection prevention and control. Resident #33, diagnosed with renal insufficiency, neurogenic bladder, and septicemia, and a carrier of MRSA, was observed during a catheter care procedure where the CNA did not perform hand hygiene or wear a gown, contrary to the care plan's special instructions for enhanced precautions. The CNA admitted to being unaware of the enhanced barrier precautions required for residents with catheters. Resident #9, with a history of hemiplegia, seizure disorder, traumatic brain injury, and gastrostomy status, was also a carrier of MRSA. During a procedure involving the resident's G-tube, the RN performed hand hygiene but did not don a gown, as required by the care plan's special instructions for enhanced precautions. The RN was unaware that gowns should be worn during G-tube care. Both the DON and the Administrator confirmed that their expectations were for hand hygiene and PPE to be used appropriately, and for EBP to be followed during catheter care. Resident #21, with a moderate cognitive deficit and a history of visual and swallowing deficits, was observed during a medication pass where the LPN failed to change gloves between administering nasal and ocular medications. The DON stated that nurses were taught to change gloves between different medication routes and perform hand hygiene before donning a new pair of gloves. The facility's policy on handwashing and glove use was not adhered to, as gloves were not changed between different routes of medication administration.
Incomplete MDS Assessment for Resident
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required timeline for one resident. Specifically, the MDS Quarterly assessment for the resident lacked data or a reason for non-assessment in Section GG, which pertains to functional abilities. The previous Quarterly MDS for the same resident had been completed in its entirety, indicating a lapse in the current assessment process. The Director of Nursing (DON) and the MDS Coordinator were unable to provide an explanation for the incomplete section, despite the expectation that the document should be fully completed. Interviews with facility staff revealed that the MDS is typically completed through coordination between the facility's MDS Coordinator and a Corporate MDS Consultant. However, the current MDS Coordinator was not in the position at the time of the incomplete assessment and could not provide details on the oversight. The Physical Therapist Assistant (PTA) mentioned providing input for Section GG, but the section remained incomplete. The facility's policy on comprehensive assessments, revised in October 2023, mandates that MDS assessments be completed according to the criteria outlined in the RAI User Manual, which was not adhered to in this instance.
Failure to Develop Comprehensive Care Plan for MRSA Diagnosis
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). Despite the electronic health record indicating a new order for Bactrim DS and a diagnosis of MRSA, the resident's care plan lacked any focus, goals, or interventions related to this diagnosis. The Minimum Data Set (MDS) assessment did not document an active diagnosis of a multidrug-resistant organism (MDRO), and the care plan did not address the necessary enhanced barrier precautions (EBP) for the resident. Interviews with staff revealed that the care plan for the resident was not updated to include the MRSA diagnosis. Staff G, responsible for writing care plans, acknowledged the absence of a care plan for MRSA. The Director of Nursing (DON) also confirmed that there was no sign outside the resident's door indicating the need for enhanced barrier precautions, which should have been in place. The facility's policy requires comprehensive, person-centered care plans developed by an interdisciplinary team, but this was not adhered to in the case of the resident with MRSA.
Failure to Implement Restorative Ambulation Program
Penalty
Summary
The facility failed to provide adequate services to maintain or improve the mobility of a resident, identified as Resident #12, who was part of a review involving two residents. Resident #12 had a documented history of hypertension, diabetes mellitus, neuropathy, and severe visual impairment, with intact cognition as indicated by a BIMS score of 15. The resident's care plan included a focus on an ambulation restorative nursing program due to neuropathy and diabetes, with a goal of ambulating 500 feet daily. However, the restorative program documentation for the last 30 days showed inconsistencies in the resident's ambulation records, with multiple entries on certain days and numerous entries marked as not applicable, indicating a lack of consistent implementation of the program. Interviews and observations revealed that Resident #12 was not consistently walked to meals as per the restorative program. The resident expressed that she was supposed to walk to the dining room for every meal but was no longer doing so. The Director of Nursing acknowledged that the resident was not being walked to meals as the program was written, and the facility's policy on Restorative Nursing Services emphasized individualized, resident-centered goals. The failure to adhere to the restorative program as outlined in the care plan led to the deficiency identified in the report.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring the use of a nebulizer. The resident, who had a history of heart failure, hypertension, and asthma/COPD, was prescribed Ipratropium-Albuterol Solution to be inhaled three times a day. The care plan included interventions such as administering prescribed respiratory treatments and monitoring lung sounds and oxygen saturations. However, observations revealed that the nebulizer equipment was not properly maintained, with tubing and mask left undated and not regularly cleaned as per the facility's policy. Staff interviews indicated a lack of adherence to the facility's protocol for nebulizer management. The Registered Nurse stated that nebulizer tubing should be changed weekly, with the date and initials marked on the tubing, but this was not done. The Health Unit Coordinator noted that the Treatment Administration Record should reflect the order to change the tubing/mask, which was missing. The Director of Nursing acknowledged the difficulty in tracking changes without proper documentation. The facility's policy required disconnection, rinsing, disinfecting, and air drying of nebulizer equipment, with changes every seven days, which was not followed in this case.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by an incident involving Resident #96. The resident, who had a severe cognitive deficit and was at high risk for falls, was subjected to demeaning and forceful behavior by a staff member, Staff D. The resident was restless and attempted to stand up unassisted, prompting Staff D to use a harsh tone and physical contact to keep her seated. This interaction escalated when the resident bit Staff D, who then reacted by pushing the resident's forehead. Staff interviews revealed that Staff D was not trained to monitor residents and was not equipped to handle such situations. Despite being instructed to use non-medical interventions for the resident's anxiety, Staff D used a firm voice and physical restraint, which was not in line with the facility's dignity policy. Other staff members, including Staff F and Staff H, witnessed the incident and reported that Staff D's actions were aggressive and not appropriate for the resident's condition. The facility's policy on dignity, which emphasizes respectful communication and sensitivity towards cognitively impaired residents, was not adhered to in this case. Staff D, who was new to the position, admitted to being unprepared and using a harsh tone with the resident. The facility's administration acknowledged that Staff D was not trained for such interactions, yet they justified her actions as an attempt to prevent the resident from falling, despite the presence of other staff in the dining room who could have assisted.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the care plans to reflect the current status of four residents. For Resident #1, the care plan did not accurately reflect the resident's ability to self-propel a wheelchair and the need for assistance with transfers. Despite observations of the resident independently moving in a wheelchair and requiring only limited assistance for transfers, the care plan still indicated the need for two staff members for all transfers and did not include a toileting program. Resident #2's care plan was not updated to reflect the resident's current level of independence. Although the resident was observed walking independently with a four-wheeled walker and was planning to discharge home, the care plan still included interventions for assistance with edema wear and toileting, which were not being followed as the resident was not wearing edema garments during observations. For Resident #3, the care plan required maximum assistance from two staff members for transfers, but observations and staff interviews indicated the resident could complete transfers with assistance from one to two staff members and actively participated in transfers. Resident #4's care plan included outdated interventions related to hospice services, which had been discontinued, and fall interventions that were not being documented or followed, as staff were unsure if visual checks were still occurring.
Failure to Complete Post-Fall Assessments and Follow Protocol
Penalty
Summary
The facility failed to provide necessary services in accordance with professional standards by not completing assessments on residents who sustained ground-level falls with major injuries. Resident #1, who had severe cognitive impairment and multiple fractures, experienced a fall on 3/25/24. However, the post-fall evaluation was not completed until 3/29/24, and the assessment was conducted by a different staff member, indicating a delay in the evaluation process. Additionally, the facility did not follow its protocol of using a full body lift to transfer Resident #1 after the fall. Resident #3, who had intact cognition and required substantial assistance for transfers, also experienced a fall. The post-fall evaluation for Resident #3 was incomplete, lacking documentation on contributing factors, medication changes, vitals, and clinical suggestions. Despite the resident being moved to a bed and then transferred to a hospital, the necessary assessments and documentation were not completed promptly. Staff interviews revealed inconsistencies in the post-fall assessment process, with staff failing to follow the facility's protocol for using a mechanical lift and completing documentation immediately. The facility's policy on fall risk prevention emphasized the need for thorough documentation after a fall to prevent further incidents. However, the facility did not adhere to its own guidelines, as evidenced by the incomplete and delayed assessments for both residents. The Director of Nursing and the Administrator expressed expectations for immediate and complete documentation, but these expectations were not met, leading to deficiencies in the care provided to the residents.
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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