Friendship Haven, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Dodge, Iowa.
- Location
- 420 South Kenyon Road, Fort Dodge, Iowa 50501
- CMS Provider Number
- 165291
- Inspections on file
- 29
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Friendship Haven, Inc during CMS and state inspections, most recent first.
A resident with moderately impaired cognition, multiple neurological diagnoses, and a high fall-risk score required staff assistance for all transfers. During one episode, a CNA responded to the resident’s call light, found the resident slouched in a recliner with wet clothing, and attempted to assist with a transfer to a motorized scooter without using a gait belt, despite an expectation that assisted transfers use one. The resident’s legs gave out and the CNA lowered the resident to the floor without a gait assistive device. The CNA reported not knowing a gait belt was required and had seen others transfer the resident without one, while facility leadership acknowledged there was no formal gait belt policy, only an orientation acknowledgement form.
A resident with severe cognitive impairment and high care needs was photographed by a CNA in a compromising position, and the image was shared on social media. Despite being informed of the incident, staff allowed the CNA to continue working with residents for an entire shift, and a nurse present did not report the event or remove the CNA from duty, violating facility policy and failing to ensure resident safety.
Staff failed to protect a vulnerable resident with cognitive and physical impairments after learning that a staff member had taken and shared an inappropriate photograph of the resident on social media. Despite being aware of the incident, staff allowed the alleged abuser to continue working and have contact with the resident and others, and did not notify administration or separate the staff member as required by policy.
The facility did not notify the LTC Ombudsman of hospital transfers for two residents with multiple chronic conditions and intact cognition. Review of records showed that these residents were not included on the required transfer notification forms for several months, due to a misunderstanding by the Social Worker about which cases required reporting, contrary to facility policy.
A resident with an indwelling catheter and a history of urinary issues did not have their catheter changed monthly as ordered by the physician. Staff did not update the treatment record after the last catheter change, leading to a missed scheduled change, and the facility's policy for catheter care was not followed.
A resident with multiple chronic conditions who required nightly CPAP with oxygen was found with undated and unchanged oxygen tubing and an empty, undated water humidifier. Staff interviews revealed a lack of documentation and awareness regarding the resident's oxygen therapy, and the facility lacked a policy for oxygen administration.
A resident with Alzheimer's and a pelvic fracture was involved in an alleged abuse incident that was not reported timely. The incident, where a CNA allegedly backhanded the resident, was reported to the DON weeks later. Interviews revealed lapses in following the facility's abuse policy, as immediate reporting to authorities was not done.
A resident with Alzheimer's and a pelvic fracture was involved in an alleged abuse incident where a CNA hit the resident after being bitten. The incident was reported to an RN, but the alleged abuser was not immediately separated from the resident, violating the facility's abuse policy. The facility's policy requires immediate reporting and separation of the alleged abuser, which was not followed, leading to a deficiency.
A resident with severe cognitive impairment reported being sexually assaulted, but the allegation was not reported immediately as required. A CNA informed an LPN, who did not escalate the report to the DON or authorities promptly, leading to a delay in addressing the situation. The facility's policy mandates immediate notification of suspected abuse, which was not adhered to in this instance.
The facility failed to ensure safe wheelchair transportation for two residents, leading to a deficiency in accident hazard prevention. One resident with Alzheimer's and an artificial hip was pushed without foot pedals, requiring her to lift her feet. Another resident with severe cognitive impairment was also pushed without pedals, despite staff acknowledging the safety risk. The facility lacked a policy on wheelchair pedal placement.
A facility failed to complete post dialysis assessments for a resident with stage 4 chronic kidney disease and toxic nephropathy. Despite physician orders and care plan interventions requiring assessments before and after dialysis sessions, the facility's progress notes showed multiple instances where post dialysis assessments were not conducted. The DON acknowledged the inconsistency in completing these assessments as per policy.
A facility failed to verify the placement of a gastrostomy tube before administering medications to a resident, as required by their treatment orders. A registered nurse administered medications without performing the necessary litmus paper test to check the tube's placement, which was confirmed by the DON. The facility's policy required such checks to be conducted per physician orders or standards of practice.
Failure to Use Gait Belt During Transfer for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and use of required safety equipment during transfers for a resident at high risk for falls. The resident had moderately impaired cognition with a BIMS score of 12, diagnoses including cerebrovascular accident, multiple sclerosis, disorientation, and a history of repeated falls. The MDS and care plan documented that the resident required partial to moderate assistance and assistance of one staff member for all transfers, and a Fall Risk Assessment score of 16 identified the resident as high risk for falls. On the date of the incident, an Incident Report documented that the resident fell in her room during a transfer, with no apparent injuries, and that a gait assistive device was not used at the time of the fall. According to staff interviews, the CNA responding to the resident’s call light found the resident slouched in a recliner, appearing different than usual, with very wet pants. The CNA attempted to assist the resident to stand and noted the resident felt uneasy and needed to sit back down. On a subsequent attempt, the CNA stood the resident and began turning her toward a motorized scooter while only lightly touching and guiding the resident’s hips, without applying a gait belt. The resident’s legs gave out and the CNA lowered her to the floor, using her arms under the resident’s arms and ensuring the resident’s legs did not twist and her head did not hit the bed’s footboard. The CNA later acknowledged that the resident was supposed to have a gait belt during transfers but stated she did not know this at the time and had observed other staff transferring the resident without a gait belt. The Administrator confirmed there was no formal gait belt policy, only a gait belt acknowledgement form signed during orientation, while staff leadership stated it was an expectation that any resident requiring assistance with transfers use a gait belt.
Failure to Protect Resident from Abuse Due to Inappropriate Photograph and Delayed Staff Action
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident with severely impaired decision-making abilities from abuse and neglect. The resident, who required substantial to maximal assistance with daily activities and had a history of behavioral symptoms, was photographed by a Certified Nurse Aide (CNA) while in a vulnerable state. The photograph, which included the resident in bed with an exposed peri area, was shared on social media. This act was in direct violation of the facility's policy prohibiting the taking and distribution of resident photographs. Despite being made aware of the allegation that a CNA had taken a photograph of the resident, facility staff allowed the CNA to continue working with the resident and other residents for an entire 8-hour shift. A Registered Nurse (RN) and CNA instructor, who was present at the facility, became aware of the incident but did not notify facility administration or remove the CNA from duty. The RN later acknowledged that she should have reported the incident and separated the CNA from residents but failed to do so at the time. The facility's own policy clearly prohibits staff from taking or distributing photographs of residents in any manner that could demean or humiliate them. The failure to immediately remove the CNA from resident care and notify appropriate facility leadership resulted in a lack of a supportive and safe environment for the resident involved, as well as for other residents in the facility.
Failure to Protect Resident from Alleged Abuse Following Inappropriate Photograph
Penalty
Summary
Facility staff failed to protect a vulnerable resident from an alleged abuser after becoming aware of a photograph taken of the resident by a staff member. The resident involved had moderately impaired decision-making abilities, required substantial to total assistance with activities of daily living, and had diagnoses including anemia, hypertension, traumatic brain injury, depression, and bipolar disorder. The photograph, which was shared on social media, depicted the resident in bed with an exposed peri area alongside a staff member. Despite being made aware of the photograph during the shift, staff allowed the alleged abuser to continue working their entire shift and to have contact with the resident and other vulnerable residents. The staff member who was informed of the incident, a Registered Nurse and CNA instructor, did not notify facility administration or take steps to separate the alleged abuser from residents. The staff member later acknowledged not following proper procedures, attributing the oversight to focusing on her role as an instructor rather than as a facility nurse. The facility's policy prohibits staff from taking or distributing photographs of residents in any manner that could demean or humiliate them, including sharing on social media. The failure to immediately report the incident and remove the alleged abuser from resident care resulted in a lapse in protecting residents from potential abuse, as required by facility policy and regulatory standards.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman regarding hospital transfers for two residents who were reviewed. Both residents had intact cognition as indicated by their Brief Interview for Mental Status (BIMS) scores of 14 and had multiple chronic medical conditions, including heart failure, hypertension, coronary artery disease, chronic kidney disease, respiratory failure, diabetes, anxiety, and depression. Documentation review showed that these residents experienced multiple hospital admissions and readmissions over several months. However, their names were not included on the facility's Notice of Transfer Form to the Ombudsman for the relevant months in which the transfers occurred. Interviews and policy review revealed that the Social Worker, who was responsible for Ombudsman notifications, misunderstood the reporting requirements. The Social Worker only reported residents who did not want a bed hold, omitting those who had or wanted a bed hold from the Ombudsman report. This practice was inconsistent with the facility's policy, which required all discharges and types of discharges to be reported to the Ombudsman office as requested.
Failure to Change Indwelling Catheter per Physician Orders
Penalty
Summary
Staff failed to follow physician orders to change an indwelling catheter monthly for a resident with a history of obstructive uropathy, recent urinary tract infection, and cerebral infarction. The resident required substantial to maximal assistance with toileting and transfers and had an indwelling catheter in place following a recent hospitalization. Physician orders and the treatment administration record directed that the catheter and drainage bag be changed monthly, but documentation showed the catheter was last changed on 5/19/25, with no evidence of a change during the month of June as required. Staff interviews confirmed that the indwelling catheter was not changed according to the schedule, and the treatment record was not updated to reflect when the next change was due. The charge nurse did not perform the scheduled change, resulting in the catheter being missed for the month. The facility's policy required appropriate catheter care to prevent infection and maintain resident comfort and dignity, but this was not followed in this instance.
Failure to Change and Document Oxygen Tubing and Humidifier for Resident on CPAP
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required a CPAP machine with supplemental oxygen at night. The resident, who had diagnoses including hypertension, heart failure, coronary artery disease, and chronic kidney disease, was observed with undated oxygen tubing and a water humidifier that was not dated and contained very little water. On subsequent observation, the water humidifier was found to be empty. The resident was unable to recall when the tubing or humidifier had last been changed. Review of the Treatment Administration Records (TAR) from December 2024 to July 2025 showed no documentation that the oxygen tubing or water humidifier had been changed or replaced for this resident. Staff interviews revealed that the expectation was for oxygen tubing to be changed weekly, dated, and documented on the TAR, and for the water humidifier to be dated and changed as needed. However, the resident's oxygen tubing change was not listed on the TAR, and one RN was unaware that the resident was on oxygen with the CPAP machine. The Director of Nursing confirmed that the facility did not have a policy regarding oxygen administration or services, but expected staff to change and date the oxygen tubing weekly.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner after it was made concerning a resident diagnosed with Alzheimer's disease and a left pelvic fracture. The resident required assistance with activities of daily living and used a wheelchair for primary locomotion. On a specific date, the Director of Nursing (DON) was informed by a charge nurse about an abuse allegation involving the resident. A head-to-toe assessment was conducted, and no physical marks were found. However, the incident was reported to have occurred three weeks prior, involving a CNA allegedly backhanding the resident after the resident bit another CNA. Interviews revealed that the incident was not reported immediately as required by the facility's abuse policy. Staff E, a CNA, witnessed the incident but did not ensure the abuse policy was followed. Staff B, an LPN, was informed about the incident weeks later and subsequently notified the DON. Staff C, an RN, stated she was not informed of the incident at the time it occurred. The facility's policy mandates immediate reporting of abuse to the appropriate authorities, which was not adhered to in this case, leading to a delay in addressing the alleged abuse.
Failure to Separate Alleged Abuser from Resident
Penalty
Summary
The facility failed to separate an alleged abuser from a resident following an incident of alleged abuse involving a resident diagnosed with Alzheimer's disease and a history of a left pelvic fracture. The resident required assistance with activities of daily living, including toileting, and primarily used a wheelchair for locomotion. On the date of the incident, two CNAs assisted the resident with toileting. During this process, the resident bit one of the CNAs, who then witnessed the other CNA hitting the resident across the back with her hand. The incident was reported to a registered nurse, but the alleged abuser was not immediately separated from the resident as required by the facility's abuse policy. The facility's policy mandates that any staff member aware of an abuse situation must ensure the resident's safety and report the incident immediately to their supervisor. The policy also requires the immediate notification of the Administrator or designee, Director of Nursing, and appropriate state entities upon receiving notice of suspected abuse. However, the CNA who witnessed the incident did not follow up to ensure the facility's abuse policy was fully implemented, resulting in a written warning. The failure to separate the alleged abuser from the resident and the delay in reporting the incident to the appropriate authorities contributed to the deficiency identified in the facility's handling of the abuse allegation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse immediately, as required, for a resident with severe cognitive impairment and dependency on assistance for activities of daily living. The resident, who had a fracture of the left humerus and used a wheelchair for mobility, reported being sexually assaulted by a man. The incident was initially reported by a Certified Nursing Assistant (CNA) to a Licensed Practical Nurse (LPN) on the day before the Director of Nursing (DON) was informed. The LPN, who was new, did not take immediate action upon receiving the report, which led to a delay in notifying the appropriate authorities. The facility's investigation revealed that the resident had informed a CNA about the assault, who then reported it to the LPN. However, the LPN did not escalate the report to a supervisor or the DON immediately. The resident exhibited behavioral issues, including aggressive language and accusations against staff, which may have contributed to the delay in addressing the allegation. The facility's policy required immediate notification of the Administrator or DON upon receiving notice of suspected abuse, which was not followed in this case. The LPN received a written warning for failing to report the incident promptly.
Deficiency in Safe Wheelchair Transportation
Penalty
Summary
The facility failed to ensure the safe transportation of two residents in their wheelchairs, leading to a deficiency in accident hazard prevention and supervision. Resident #56, with moderately impaired cognition and diagnoses including Alzheimer's disease and a right artificial hip, was observed being pushed by a CNA from the dining room to her room without foot pedals on her wheelchair. The resident had to lift her feet off the floor during the transport. The CNA acknowledged that it would be safer to use foot pedals, especially since the resident seemed tired that day. Similarly, Resident #71, with severely impaired cognition and diagnoses of non-traumatic brain dysfunction and schizophrenia, was pushed by an RN without foot pedals on his wheelchair. The RN stated that the resident refused the pedals and felt safe pushing him as he usually held his feet up. However, other staff members, including another RN and the Unit Coordinator, agreed that it was not safe to push residents without foot pedals. The Director of Nursing also acknowledged the safety issue, noting the absence of a facility policy on wheelchair pedal placement.
Failure to Complete Post Dialysis Assessments
Penalty
Summary
The facility failed to complete post dialysis assessments for a resident who required dialysis services. The resident, identified as having intact cognition, was diagnosed with stage 4 chronic kidney disease and toxic nephropathy. The resident's care plan and physician orders specified that vital signs and assessments should be conducted before and after dialysis sessions three times a week. However, the facility's progress notes indicated that post dialysis assessments were not completed on several occasions over a two-month period. The facility's dialysis policy required ongoing assessment and monitoring of the resident's condition for complications before and after dialysis treatment. This included documentation regarding vascular access and checking for potential complications. Despite these requirements, the Director of Nursing acknowledged that the post dialysis assessments were not consistently completed as expected, indicating a failure to adhere to the established policy and care plan interventions for the resident.
Failure to Verify Gastrostomy Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed for checking the placement of a gastrostomy tube before administering medications to a resident. Resident #49 had specific orders in their Treatment Administration Record to verify the gastrostomy tube placement using litmus paper to check the pH level of aspirated stomach contents before administering medications. On the observed date, a registered nurse, Staff E, administered crushed medications diluted in water through the resident's gastrostomy tube without performing the required placement check using litmus paper. During an interview, Staff E admitted to forgetting to check the tube placement and residual before administering the medications. The Director of Nursing confirmed that the orders required checking both the residual and performing a litmus test prior to medication administration. The facility's policy on Naso Gastric Tubes / Gastrostomy Feeding Tubes, dated June 2023, also directed nurses to check tube placement and residual according to physician orders or standards of practice.
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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