Emmetsburg Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Emmetsburg, Iowa.
- Location
- 2405 21st Street, Emmetsburg, Iowa 50536
- CMS Provider Number
- 165352
- Inspections on file
- 17
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Emmetsburg Care Center during CMS and state inspections, most recent first.
A resident with intact cognition, multiple comorbidities, and documented moisture-related skin breakdown on the buttocks had a physician order for barrier cream to be applied with cares each shift. On a morning when the resident reported staff were rushed, she stated no cream was applied and that not all staff had been using her ointment, even though the Treatment Administration Record showed the treatment as completed. A CMA reported being told CNAs had applied the cream, but one CNA only "thought" another applied an unidentified cream from a white tube, and the other CNA denied providing incontinence care or applying any barrier cream. Later that day, an LPN measured an enlarged buttocks wound with additional open areas and applied Desitin, while the resident again confirmed she had not received cream that morning, demonstrating that the ordered treatment was neither consistently provided nor accurately documented.
The facility failed to provide and document scheduled bathing assistance for three residents who required varying levels of help with ADLs, despite care plans and standard twice-weekly bath schedules. One cognitively intact resident with multiple diagnoses went 11 and 7 days between baths, with no record of additional bathing offers, and a family member reported very infrequent bathing. Another cognitively intact resident with cancer, HTN, recent UTI, and CKD experienced 5- and 7-day gaps between baths and reported not having a shower or bath for about two and a half weeks, stating staff only used wipes for perineal care. A third resident with moderately impaired cognition and chronic conditions went 15 days without a bath, despite a preference for whirlpool baths and scheduled twice-weekly bathing, and reported receiving baths only about once a week. The DON and Administrator stated that baths are automatically scheduled twice weekly and documented in the EMR, and facility policy required point-of-care documentation of bathing, but records lacked documentation of missed baths and re-approach attempts.
The facility did not provide food prepared in a form tailored to meet the individual needs of residents, resulting in meals that were not consistently modified for specific dietary or physical requirements.
The facility failed to prevent accidents and provide adequate supervision for three residents, resulting in falls both during off-site transport and while using mechanical lifts. One resident fell during a medical transport without required staff assistance or mobility aids, while two others experienced falls from sit-to-stand lifts due to improper sling use, lack of staff education, and failure to follow manufacturer instructions.
Staff did not follow the established portion size guidelines for serving pureed food, using the wrong scoop size and resulting in incorrect portions for four residents on pureed diets. The error was confirmed by the cook and dietary manager, and there was no formal policy in place for the puree process.
Surveyors identified multiple food safety and sanitation deficiencies, including expired and improperly labeled food in storage, unsanitary freezer conditions, and improper food handling during meal service. Staff were observed using bare hands to retrieve utensils and holding plates against dirty uniforms, contrary to facility policy.
Staff did not follow required hand hygiene and infection control protocols while assisting a resident with transfers and toileting. A CNA failed to perform hand hygiene after removing gloves, handled soiled items with bare hands, and placed dirty clothing on the floor, only washing hands at the end of care. These actions did not comply with the facility's infection prevention policy.
A resident with a history of falls and no cognitive impairment experienced multiple falls in the facility. The required neurological assessments following each fall were not completed as per protocol, with several evaluations missed and documented as 'sleeping.' The Regional Nurse Consultant confirmed the assessments should have been completed.
The facility failed to develop comprehensive care plans for two residents, neglecting to address risk factors and interventions for medical conditions and high-risk medications. One resident with multiple diagnoses, including recurrent UTIs, did not have a care plan addressing UTI risks or medication side effects. Another resident on anticoagulant medication lacked a care plan for monitoring potential side effects. The MDS Coordinator acknowledged these omissions, and the facility lacked a policy on comprehensive care planning.
A resident with a history of serious health conditions experienced symptoms of a potential cardiopulmonary issue, including headache, chest pain, and elevated vital signs. Despite these symptoms, the facility failed to conduct a timely follow-up assessment or notify the physician and family. The resident's condition worsened overnight, leading to a delayed transfer to the emergency room the following morning.
A resident with severe cognitive impairment was found with a pillow placed under the fitted sheet, restricting their movement. Staff used the pillow to prevent the resident from rolling out of bed, but it was not documented in the care plan. The MDS Coordinator and DON confirmed this placement constituted a restraint, contrary to facility policy.
A resident requiring substantial assistance for daily baths did not receive consistent bathing due to staffing shortages. The resident, who was cognitively intact and had multiple diagnoses, had baths documented only on select dates over a month. CNAs reported difficulties in providing regular baths due to insufficient staff, and the facility lacked a specific bathing policy.
A resident with moderate cognitive impairment and dental issues was served a regular pork chop instead of the prescribed mechanical soft ground meat diet. The cook served the regular pork chop based on the resident's preference, despite the dietary order. The facility's policy on ground meat diet orders was not followed, and the staff failed to notify the dietician or update the care plan.
Failure to Provide and Accurately Document Ordered Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services according to accepted standards of clinical practice for a resident with intact cognition who was dependent for transfers and required assistance with bed mobility. The resident had diagnoses including cancer, hypertension, recent UTI, and chronic kidney disease, and was care planned as being at risk for altered skin integrity due to frequent urinary incontinence and need for bed mobility assistance. A health status note documented moisture breakdown on the left inner buttocks with specific measurements, and a physician order directed staff to apply barrier cream with cares every shift to promote healing; however, the order did not specify the location for application or the type of barrier cream to be used. The facility’s policy required active physician orders to be followed and carried out as written. On the morning in question, the resident reported that staff were in a hurry, that her bottom was hurting, and that no cream had been applied that morning, despite having ointment available in her bedside table and a treatment order in place. She stated not all staff had been using the cream. The Treatment Administration Record showed the barrier cream treatment as signed off as completed for that morning shift. A CMA reported he was told the barrier cream was applied with morning cares by two CNAs. One CNA stated she thought the other CNA applied a cream from a white tube but did not know what it was or where it came from, while the other CNA reported she did not assist with changing the resident’s brief that morning and did not apply any barrier cream. Later that day, an LPN measured the wound on the left buttocks and found it had increased in size with two small open areas, and applied Desitin ointment. The resident again verified she had not received any cream or treatment for the wound during the morning shift, indicating the ordered treatment was not provided as documented.
Failure to Provide and Document Scheduled Bathing for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance according to residents’ assessed needs, care plans, and scheduled bathing routines for three residents. One resident with intact cognition and diagnoses including cancer, hypertension, non-Alzheimer’s dementia, anxiety disorder, and schizophrenia was care planned to receive staff assistance with showers/bathing per schedule. Task forms showed this resident received only four baths/showers over a 30-day period, with gaps of 11 days and 7 days between baths. The clinical record did not contain documentation of other attempts to offer or encourage bathing, and the resident’s sister reported that bathing was very infrequent and seemed to occur about every two weeks, often when she was present. A second cognitively intact resident with diagnoses including cancer, hypertension, recent UTI, and chronic kidney disease required setup or cleanup assistance for bathing and was also care planned for scheduled showers/bathing. Task forms showed this resident received four baths/showers over 30 days, with gaps of 5 days and 7 days between baths, and no documentation of additional offers or encouragement for bathing. This resident reported believing she had not had a shower or bath for about two and a half weeks and stated that staff only used wipes to clean her bottom. A third resident with moderately impaired cognition and diagnoses including hypertension, diabetes mellitus, depression, and overactive bladder required substantial/maximal assistance for bathing, preferred showers, and was scheduled for twice-weekly bathing. Task forms showed this resident had a 15-day gap without a bath, and the clinical record lacked documentation of other bathing attempts. This resident reported liking whirlpool baths, described the shower as gross, and stated he received a bath about once a week but would like more frequent baths. The DON and Administrator reported that baths are scheduled twice weekly and documented in the electronic record, and the DON acknowledged concerns with bathing documentation and lack of insight into why baths were not done, while facility policy required documentation of completed showers/baths in point-of-care charting.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures. The report does not provide further details about the residents involved or their medical conditions at the time of the deficiency.
Failure to Prevent Accidents and Ensure Safe Transfers
Penalty
Summary
The facility failed to provide adequate supervision and accident prevention for three residents reviewed for falls. One resident, who had a history of falls, generalized weakness, and required substantial assistance for mobility and toileting, experienced a fall outside the facility during transport to a medical appointment. The resident, who was known to have diarrhea and was on a blood thinner, was not accompanied by facility staff as required by his care plan, and did not use his prescribed mobility aids. The fall occurred when the resident attempted to use a restroom at a gas station with only the transport driver assisting, resulting in a head injury and hospitalization. Two other residents experienced falls during transfers using a mechanical sit-to-stand lift. One resident, with moderate cognitive impairment and significant physical limitations, slipped out of the sling during a transfer when the safety features were not properly utilized. Staff interviews revealed a lack of education and awareness regarding the use of a hip sling as a preventive measure, and there was no evidence of follow-up training after the incident. Observations showed that staff did not consistently use the correct sling or ensure that safety straps were properly tightened during transfers. Another resident, who was non-ambulatory and required maximal assistance, was involved in a fall when the sling used with the sit-to-stand lift was not manufactured for use with that specific lift, contrary to the operator's instructions. Staff failed to double-check the straps and did not use all required safety features, resulting in the resident being lowered to the floor after the sling became detached. Observations confirmed that mismatched slings were in use and that staff did not always adjust or tighten safety belts as required. The facility lacked consistent adherence to manufacturer instructions and did not provide adequate staff education or supervision to prevent these incidents.
Failure to Follow Pureed Diet Portion Sizes for Residents
Penalty
Summary
Staff failed to prepare and serve pureed food in accordance with the facility's established portion sizes and procedures for four residents on pureed diets. During meal preparation, the cook used a #10 scoop to serve pureed pork tenderloin instead of the required #12 and #16 scoops as indicated on the Pureed Diet Portion Sizes/Scoop Chart. This resulted in incorrect portion sizes being served, with leftover pureed meat remaining after meal service, despite only four servings being prepared for four residents. The cook acknowledged the error in scoop size and portioning, and the Certified Dietary Manager confirmed that the correct scoop sizes should have been used. The Administrator stated there was no formal policy on the puree process, and the facility relied on the portion size chart.
Food Safety and Sanitation Deficiencies in Kitchen and Meal Service
Penalty
Summary
The facility failed to adhere to food safety and sanitation standards as evidenced by multiple observations during a kitchen tour and meal service. Expired food items, including two large containers of cream cheese past their expiration date and an undated open container, were found stored in the refrigerator. Additionally, a container of chicken broth was dated but not properly labeled with a use-by date. Freezers were found to be in unsanitary condition, with food debris present in all units, a broken plastic container with dried/frozen residue, ice build-up, and a damaged freezer door seal. These conditions were not in compliance with the facility's own policies regarding food storage, labeling, and sanitation. During meal service, improper food handling practices were observed. A staff member was seen holding plates of food against a dirty uniform while cutting pork tenderloin for multiple residents, and handled a serving utensil with bare hands after it fell into a pan of potatoes, then continued to use the same utensil to serve food. The Certified Dietary Manager confirmed that these actions were inappropriate and not in line with facility policy, which requires the use of gloves or utensils when handling ready-to-eat foods and mandates proper sanitation procedures. These deficiencies were identified during a survey with a facility census of 43 residents.
Failure to Follow Hand Hygiene and Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during the care of a resident with multiple diagnoses, including hypertension, diabetes mellitus, cerebral palsy, and anxiety disorder. The resident required substantial to maximal assistance for transfers and toileting. During an observed transfer to the commode using a sit-to-stand lift, a CNA applied compression socks and braces to the resident's lower legs while wearing gloves, then removed the gloves without performing hand hygiene. The CNA and another staff member continued with the transfer process, including removing the resident's incontinence brief and placing it in the commode with bare hands, again without performing hand hygiene afterward. Further, the CNA handled the resident's clothing and placed soiled garments directly on the floor, donned new gloves without prior hand hygiene, and continued to assist the resident without following proper infection control protocols. Hand hygiene was only performed at the end of the care episode, after multiple opportunities were missed. The facility's policy required hand hygiene before and after direct resident contact, after glove removal, and after contact with soiled items, but these procedures were not followed during the observed care.
Inadequate Post-Fall Assessments for Resident
Penalty
Summary
The facility failed to perform adequate assessments following falls for a resident, identified as Resident #2, who was at risk for falls due to generalized weakness and difficulty in walking. The resident, who had no cognitive impairment and a history of falls, experienced multiple falls within the facility. After each fall, the facility was required to follow a specific neurological assessment protocol, which included frequent evaluations and documentation over a 72-hour period. However, the facility did not complete the required neurological assessments as per the protocol, with several instances of missed evaluations documented as the resident was 'sleeping.' The first incident on 1/9/25 involved the resident attempting to transfer to the bathroom without assistance, resulting in a fall. The neurological assessments were not completed at several required intervals. A subsequent fall on 1/12/25 was similarly followed by incomplete assessments, with multiple time slots marked as 'sleeping.' Another fall on 1/31/25 also showed a lack of completed assessments, with only two out of nine required evaluations documented. The Regional Nurse Consultant confirmed that the facility should have been completing the neurological assessments as per the protocol.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. Resident #35, with a BIMS score indicating intact cognition, had multiple diagnoses including anemia, atrial fibrillation, congestive heart failure, and recurrent urinary tract infections (UTIs). Despite receiving diuretic and opioid medications, the care plan did not address the risk factors for UTIs or the side effects of the high-risk medications. The MDS Coordinator acknowledged the oversight, noting that the care plan did not include interventions for UTIs or monitoring for medication side effects. Similarly, Resident #6, also with intact cognition, had diagnoses of atrial fibrillation, hypertension, and renal disease, and was receiving anticoagulant medication. The care plan failed to address the anticoagulant medication, its potential side effects, and necessary monitoring. The MDS Coordinator confirmed the omission, stating that high-risk medications should have been included in the care plan. The facility lacked a policy on comprehensive care planning, contributing to these deficiencies.
Failure to Timely Assess and Notify in Cardiopulmonary Event
Penalty
Summary
The facility failed to provide necessary assessment and interventions for a resident experiencing symptoms indicative of a potential cardiopulmonary issue. The resident, who had a history of cancer, anemia, heart failure, hypertension, and non-Alzheimer's dementia, reported symptoms including headache, chest pain, and jaw pain, along with elevated blood pressure and pulse. Despite these symptoms, the facility did not conduct a follow-up assessment or notify the physician and family in a timely manner. On the evening of the incident, the resident's vital signs indicated elevated blood pressure and pulse, and the resident reported a pain level of 7 out of 10. The LPN on duty asked the resident if they wanted to go to the emergency room, but the resident declined. The following morning, the resident's condition had worsened, with increased pain and discomfort, elevated pulse, and decreased oxygen saturation. It was only then that the facility contacted the emergency room and sent the resident for further evaluation. The clinical record lacked documentation of any follow-up assessments or notifications to the resident's family or physician on the evening of the initial symptoms. The MDS Coordinator and DON both acknowledged the delay in sending the resident to the emergency room and the lack of timely notification to the physician and family. The facility's policy required immediate notification of the resident's responsible party and physician in the event of a change in medical condition, which was not adhered to in this case.
Improper Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to protect a resident from the use of a physical restraint that the resident could not remove on their own. The resident, who had diagnoses of Alzheimer's Disease, anxiety disorder, and a history of falling, was observed with a pillow placed under the fitted sheet on their right side. This method of placement restricted the resident's movement, as confirmed by staff interviews and the facility's policy on physical restraint usage. Staff members, including CNAs, reported using the body pillow to prevent the resident from rolling out of bed, but it was not documented in the care plan or ordered for use. The MDS Coordinator acknowledged that the pillow was not on the care plan and confirmed that its placement under the fitted sheet constituted a restraint. The Director of Nursing also confirmed that the pillow should not be placed under the fitted sheet, as it restricts movement, and stated that staff had been educated on the correct placement of the body pillow.
Failure to Provide Bathing Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide bathing assistance according to the preferences of a resident who required substantial assistance. The resident, who was cognitively intact and had diagnoses of diabetes, major depressive disorder, and anxiety disorder, was documented to need extensive assistance for daily baths. However, the electronic health record showed that baths were only completed on specific dates over a month-long period, with no documentation of attempts to encourage bathing or records of refusals. Interviews with multiple Certified Nursing Assistants (CNAs) revealed that staffing shortages were a significant barrier to providing regular bathing assistance. CNAs reported that they often had to reschedule baths due to insufficient staff, leading to residents not receiving baths as needed. The facility lacked a specific policy on bathing, and the Director of Nursing confirmed that all bath records were maintained electronically without additional documentation forms.
Failure to Provide Prescribed Diet Texture
Penalty
Summary
The facility failed to ensure that a resident received the proper diet texture as prescribed. Resident #31, who has moderate cognitive impairment and is on a mechanically altered diet due to having very few teeth, was observed being served a regular pork chop instead of the prescribed mechanical soft ground meat. The cook, Staff C, acknowledged serving the regular pork chop because the resident preferred it this way, despite the dietary order. The resident confirmed that she liked her pork chop cut up and reported that she is on a ground meat diet due to her dental condition. The facility's policy on ground meat diet orders aims to provide appropriate texture meat products for residents with chewing or swallowing problems. However, the staff did not adhere to this policy, as they did not notify the dietician or update the care plan to reflect the resident's preference. The Director of Nursing (DON) reported that the Certified Dietary Manager (CDM) was educated on the need to notify the physician if a resident disagrees with the diet order, but this was not done in this instance.
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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