Estherville Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Estherville, Iowa.
- Location
- 2001 First Avenue North, Estherville, Iowa 51334
- CMS Provider Number
- 165523
- Inspections on file
- 23
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Estherville Community Care Center during CMS and state inspections, most recent first.
A cognitively intact but physically dependent resident, identified as at risk for falls and requiring assistance with toileting and transfers, was found on the floor after attempting to obtain help when needing the bathroom. The resident’s care plan required a call light within reach, but the call light cord had become caught in a bed rail hinge, preventing activation despite appearing to be within reach from the recliner. Unable to trigger the call light, the resident walked without a walker to retrieve a cell phone that was not within reach, resulting in a fall. Facility leadership and policy acknowledged that call lights were expected to be accessible, functional, and not wrapped around bed rails, but this was not achieved at the time of the event.
A cognitively intact, largely independent resident with multiple diagnoses, including CVA and hemiplegia, had an established goal and ongoing discussions about returning home, culminating in a provider order for discharge home. On the day of discharge, the family reported that no written discharge instructions or orders were reviewed or provided when they arrived and took the resident home. The DON later stated she had reviewed discharge instructions with the resident but acknowledged they were not signed and were instead mailed after discharge, and an RN confirmed that no discharge paperwork was given to the resident or family at the time of discharge. This occurred despite facility policy requiring residents to receive proper written notice and documented discharge planning.
The facility failed to submit accurate staffing reports for the CMS PBJ Staffing Data Report, indicating a lack of 24-hour licensed nursing coverage on seven dates. However, a review showed that nursing services were provided around the clock by the DON, LPNs, and RNs. The issue arose from staff hours not being transferred correctly for submission, which the Corporation was aware of and investigating.
The facility failed to complete comprehensive assessments within required time frames for seven residents, with delays ranging from 22 to 54 days. Despite a policy mandating timely assessments, the MDS for these residents were not completed within the 14-day requirement from the ARD. The deficiency was identified through record reviews, staff interviews, and policy review.
The facility failed to notify the LTC Ombudsman of a resident's transfer to a hospital, as required by policy. The resident's hospitalization was not included in the Discharge Report or the Notice of Transfer to the Ombudsman Report. The Administrator acknowledged the oversight, noting the resident was missed in the transfer notification process.
The facility failed to implement proper infection control practices during mealtimes, catheter management, and laundry delivery. A CNA did not perform hand hygiene after picking a fork off the floor before feeding a resident. A resident with an indwelling catheter was seen with the catheter bag and tubing dragging on the floor. Additionally, a Laundry Aide transported both clean and dirty laundry in uncovered carts, contrary to facility policy.
Two residents were unable to access their funds promptly due to the facility's lack of petty cash and reliance on corporate checks, which contradicted the policy of 24/7 access. One resident, with no cognitive impairment, experienced delays on weekends, while another, with moderate cognitive impairment, waited weeks for a $50 request. The administrator confirmed the issue, citing a two-day processing delay for corporate checks.
A resident with severe cognitive impairment fell and fractured her hip after slipping on water near an ice machine in the hallway. Staff interviews confirmed the presence of a small puddle of water, and the resident was wearing shoes without tread. The facility's policy emphasizes the importance of addressing environmental hazards like wet floors to prevent falls.
Failure to Ensure Accessible and Functional Call Light for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident had a functional call light system within reach, as required by the resident’s care plan and facility policy. The resident had an MDS BIMS score of 14, indicating intact cognition, and was dependent on staff for toileting, hygiene, bathing, lower body dressing, and transfers. The care plan identified the resident as at risk for falls related to a recent hospitalization and specified that the call light must be within reach. On the morning of the incident, staff heard someone calling for help and found the resident sitting on the floor with her back against her room door and feet extended. The resident reported she had attempted to use her call light for assistance to the bathroom, but the call light cord was caught in the hinge of the bed rail and could not be triggered when pulled. The incident documentation and subsequent interviews confirmed that, although the call light appeared to be within reach from the resident’s recliner, the cord had fallen and become entrapped under the bed grab bar, preventing activation. The resident then attempted to walk without her walker to retrieve her cell phone, which was charging on the sink counter, in order to call the facility for help, and she fell. Later observation showed the resident’s cell phone on a table across the room under a window, with a long cord attached but not within reach. The DON acknowledged that staff were expected to ensure call lights were within reach and not wrapped around bed rails, and the facility’s policy stated that all resident call lights must be accessible, functional, and answered promptly to maintain resident safety, dignity, and well-being. Despite these expectations and care plan interventions, the resident’s call light was not effectively accessible at the time assistance was needed.
Failure to Provide and Document Written Discharge Instructions at Time of Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that discharge instructions were documented in the medical record and provided in written form to a resident and/or the resident’s representative at the time of discharge. The resident had an MDS showing intact cognition (BIMS 14), independence with ADLs using a walker, and diagnoses including cerebrovascular accident, hemiplegia, anxiety, depression, and schizophrenia. The care plan and multiple care conference notes documented an ongoing goal and discussions about the resident’s wish to return home, with family expressing that discharge home remained a possibility and later anticipating a return home in the spring. On 2/24, a provider order was received for discharge home on 2/28, and the resident was discharged that day. Following discharge, the resident’s family reported that no discharge instructions or orders were reviewed or given to the resident or family when they arrived to take the resident home, stating they simply packed belongings and left. The Administrator confirmed the family had called to arrange discharge home, and the DON stated she went over discharge instructions with the resident prior to discharge but acknowledged that the discharge instructions were not signed by the resident. The DON further confirmed that discharge instructions were mailed to the resident several days after discharge for signature and had not been returned. Staff A, an RN, stated that no discharge paperwork was given to the resident or family at the time of discharge. This sequence of events occurred despite a facility policy stating that residents will receive proper written notice consistent with federal regulations and that discharge planning must include documentation of all planning activities.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the quarter from July 1 to September 30. The PBJ report indicated that the facility did not provide licensed nursing coverage 24 hours a day on seven specific dates in August and September. However, a review of the nurse schedule and time cards for these dates showed that nursing services were indeed provided around the clock by the Director of Nursing (DON), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). The Business Office Manager (BOM) mentioned that missed punches were submitted to Weblock and then uploaded to a folder in Teams for the Corporation to handle. The Administrator acknowledged that during this period, the previous Corporation was responsible for submitting hours to PBJ, and there was an issue with staff hours not being transferred correctly for submission, which the Corporation was aware of and investigating.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments within the required time frames for seven residents. Record reviews revealed that the Minimum Data Sets (MDS) for these residents were past due, with delays ranging from 22 to 54 days. The assessments were in-progress but not completed within the 14-day requirement from the Assessment Reference Date (ARD). The residents affected included those with ARDs dating back to early October and November, indicating a significant backlog in completing these assessments. The facility's policy, revised in August 2022, mandates that comprehensive assessments be conducted within 14 days of admission, upon significant changes in condition, quarterly, and annually. Despite this policy, the assessments were not completed in a timely manner, as confirmed by the facility's administrator, who acknowledged the expectation for timely completion. The deficiency was identified through record reviews, staff interviews, and policy review, highlighting a systemic issue in adhering to the assessment schedule.
Failure to Notify Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman of a resident's transfer to a hospital. The deficiency was identified through a review of records, staff interviews, and policy review. Specifically, the facility did not notify the Ombudsman about a resident's hospitalization from October 30 to November 6, as required by their policy. The resident was not included in the Discharge Report or the Notice of Transfer to the Ombudsman Report. The Administrator acknowledged the oversight during an interview, stating that the resident had been missed in the transfer notification process. The facility's policy mandates that a copy of the transfer or discharge notice should be sent to the Ombudsman and noted in the record, which was not adhered to in this case.
Infection Control Deficiencies in Hand Hygiene, Catheter Management, and Laundry Handling
Penalty
Summary
The facility failed to implement appropriate hand hygiene and infection control practices during mealtimes, catheter management, and laundry delivery. During an observation, a Certified Nurse Aide (CNA) was seen picking a fork off the floor, repositioning a resident, and feeding the resident without performing hand hygiene or changing gloves, contrary to the facility's hand hygiene policy. The Director of Nursing (DON) confirmed that staff should not pick utensils off the floor and then assist a resident with eating. Additionally, a resident with moderate cognitive impairment and an indwelling catheter was observed self-propelling her wheelchair with the catheter bag and tubing dragging on the floor, which was against the facility's policy that required catheter equipment to be kept off the floor. The Infection Preventionist (IP)/DON and the Administrator both stated that catheter bags and tubing should be kept in dignity bags and not on the floor. Furthermore, a Laundry Aide was observed transporting both clean and dirty laundry in uncovered carts throughout the facility, which was against the facility's policy that required laundry carts to be covered during transportation to prevent microbial contamination. The IP/DON and the Administrator confirmed that laundry should be covered at all times when transported in the facility.
Failure to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to provide residents with access to their funds upon request, as evidenced by the experiences of two residents. Resident #2, who has no cognitive impairment, reported being unable to access her money on weekends due to the facility waiting for a check to arrive. This delay resulted in her having to wait several days to obtain her funds. Similarly, Resident #4, who has moderate cognitive impairment, requested $50 from the administration weeks prior and had not received it. He was informed that the facility needed to wait for a check to arrive, as there was no money available in the building. The facility's policy states that residents should have access to their funds 24/7, yet the administrator confirmed that the facility was out of petty cash and had to wait for a corporate check, which took two days to process. This situation led to residents being unable to access their funds promptly, contrary to the facility's policy. The administrator acknowledged the issue and mentioned working with the corporate office to find a solution, but the deficiency was evident in the delay experienced by the residents.
Resident Fall Due to Environmental Hazard
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent a fall for a resident, resulting in a health deficiency. The resident, who had diagnoses of anxiety disorder, abnormal weight loss, and adult failure to thrive, was found to have a Brief Interview for Mental Status (BIMS) score of 15, indicating severe cognitive impairment. The incident occurred when the resident slipped on water in front of an ice machine in the hallway, leading to a fall that resulted in a left hip fracture. The fall was not witnessed, and the resident was subsequently transported to the emergency department for evaluation and hospitalization for surgery. Interviews with staff members revealed that they heard the resident yelling for help and found her lying on the floor by the ice machine. The resident reported slipping on water, and staff confirmed the presence of a small puddle of water near the fall site. The resident was wearing shoes without tread at the time of the incident, which may have contributed to the fall. The facility's policy on fall management highlights the importance of addressing environmental hazards, such as wet floors, to reduce the risk of falls and injuries. The Director of Nursing (DON) confirmed that staff should clean up any spilled ice by the ice machine immediately and ensure the floor is dry. The facility's failure to address the environmental hazard of a wet floor in a timely manner contributed to the resident's fall and subsequent injury. The incident underscores the need for vigilant supervision and prompt attention to potential hazards to prevent accidents in the facility.
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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