Garden View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shenandoah, Iowa.
- Location
- 1200 West Nishna Road, Shenandoah, Iowa 51601
- CMS Provider Number
- 165531
- Inspections on file
- 30
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 25 (2 serious)
Citation history
Health deficiencies cited at Garden View Care Center during CMS and state inspections, most recent first.
A resident dependent on staff for tracheostomy care experienced repeated delays and refusals of suctioning by an LPN, despite physician orders for as-needed suctioning. The resident reported severe anxiety and fear due to these delays, and multiple CNAs confirmed the LPN's pattern of not responding promptly to requests. The DON was informed of concerns but did not initially identify any issues with the LPN's performance, and documentation of suctioning was lacking.
A resident dependent on staff for tracheostomy care reported that an LPN frequently refused or delayed suctioning, causing distress and anxiety. Multiple CNAs confirmed the LPN's refusal to provide care and reported these concerns to the DON, but no thorough investigation or separation of the LPN from the resident occurred. The resident's medical records showed no documentation of the suctioning order being followed, and the facility did not adhere to its abuse prevention and investigation policy.
A facility failed to maintain required 24-hour licensed nurse coverage when an LPN left the premises during an overnight shift, leaving no licensed nurse on site for several hours. Staff reported frequent absences by the LPN during overnight shifts, and documentation of concerns was lacking despite facility policy requiring continuous licensed nurse presence.
Nursing staff were assigned to work independently without documented orientation or competency-based training, as required by facility policy. Two LPNs reported not receiving an orientation checklist or formal training before caring for residents alone, and their files lacked evidence of completed orientation. A former RN and the administrator confirmed the absence of a formal orientation program, despite policy requiring a 10-hour orientation with a checklist.
Three cognitively intact residents who regularly received room trays reported that their meals were often cold upon delivery, with one noting the absence of heated carts and delays in tray delivery. Observation confirmed that at least one food item on a sample tray was below the required 135°F, and both dietary staff and facility policy affirmed that food should be served at or above this temperature.
Three residents who required staff assistance for bathing did not consistently receive scheduled baths or showers as outlined in their care plans, with EHR reviews showing significant gaps in care and a lack of documented refusals. Staff and DON interviews confirmed that missed baths were not always made up or properly documented, and that the facility's policy for regular bathing was not consistently followed.
The facility failed to follow physician orders, resulting in medication administration errors for multiple residents. A resident did not receive diabetes medication as ordered, and another resident's insulin was not administered per the sliding scale. Additionally, a resident's Oxycodone was destroyed without a discontinuation order. The facility's medication administration policy was not followed, leading to discrepancies in documentation and adherence to medication parameters.
A facility failed to properly assess and respond to an unwitnessed fall involving a resident with severe cognitive impairment, as neurological checks were not initiated immediately and the first set of vitals was delayed. Additionally, the facility did not conduct consistent respiratory assessments for residents who tested positive for COVID-19 and Influenza A, as required by protocol. These deficiencies highlight significant lapses in care and documentation.
The facility failed to maintain the required RN coverage for 8 consecutive hours, 7 days a week, as revealed by nursing schedules and staff interviews. The DON's frequent absences and reliance on a part-time RN contributed to inconsistent coverage. Staff reported communication issues and unresponsive management, leading to difficulties in scheduling RNs. Despite the facility's assessment claiming adequate coverage, the reality was insufficient, as indicated by staff comments and laughter about the ongoing issue.
The facility did not consistently update nurse staffing information daily for residents and visitors. Observations showed outdated postings on multiple occasions, with the DON indicating that night nurses were responsible for this task. The facility had a census of 37 residents.
A facility experienced a significant staffing deficiency when no licensed nurse was present for three hours, leaving the Administrator, who is not currently licensed, to oversee care. During this time, a resident fell, and proper protocols were not followed. The report also highlights a toxic work environment, with staff expressing frustration over the lack of support from the DON and ADON.
The facility's QAPI program was ineffective, as evidenced by repeated deficiencies in areas such as nursing staff sufficiency, quality of care, resident records, and infection control. Despite a revised QAPI plan, the facility continued to exhibit non-compliance, with the administrator acknowledging inconsistent corrective actions.
During an outbreak, a facility failed to enforce mask-wearing and proper infection control measures. Staff, including the Administrator and DON, were observed without masks, and masks were not available at the entrance. Additionally, a staff member did not use alcohol wipes before blood sugar checks or insulin administration, contrary to facility procedures. Residents and staff reported these issues, highlighting deficiencies in infection control and resident care.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident's care plan did not reflect the presence of an indwelling catheter and ostomy, while another resident's care plan lacked instructions for using a fall mat, despite a history of falls. Staff observations and interviews confirmed these oversights, which were not aligned with the facility's policy requiring timely care plan revisions.
A facility failed to complete ordered treatments for a resident with pressure ulcers, as shown by incomplete treatment administration records and inconsistent skin assessments. The resident, who had no cognitive impairment, reported that treatments were sometimes skipped depending on the staff. The DON noted that measurements were not taken during weekly assessments, contrary to facility protocol, and mentioned that the resident often refused treatments, although this was not documented.
A resident with severe cognitive impairment and physical limitations fell out of bed and was assisted back into a wheelchair by staff without the use of a gait belt, contrary to facility policy. The incident occurred when no nurse was present, and the Administrator conducted an assessment without performing neurological checks. Staff interviews indicated confusion about the facility's lifting policy, and the DON confirmed that a gait belt should have been used.
A LTC facility experienced a lapse in nursing coverage when an LPN, who had been working extended hours, was advised by the Administrator to leave for rest and medication retrieval. This left the facility without a licensed nurse from 1:30 PM to 4:30 PM, despite the presence of high-risk residents. The Administrator, not currently licensed, attempted to fill the gap, but critical medical protocols were not followed, highlighting inadequate staffing contingency measures.
A resident with severe cognitive impairment fell out of bed when no licensed nurse was present. The Administrator, a former nurse without an active license, assessed the resident and assisted in transferring her without a gait belt. The facility lacked proper nursing coverage for three hours, and necessary neurological assessments were not conducted.
A resident with severe cognitive impairment and multiple health conditions was frequently administered a PRN narcotic pain medication without clear evidence of pain. Staff interviews revealed that the medication was often given to ensure a quieter night shift, despite the resident being on a sleeping pill. The facility's policy required re-evaluation of frequent PRN use, but no such re-evaluation was documented.
The facility failed to store medications properly after delivery, as observed when a bag containing various medications was left unattended on the nurse's station counter. Staff interviews confirmed that medications should be put away immediately, but the incident revealed a lapse in following the facility's storage policy.
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and assessment. A resident with severe cognitive impairment experienced an unwitnessed fall that was not properly documented or assessed. Additionally, two residents' positive test results for Influenza A and COVID-19 were not recorded in their medical records, contrary to facility policy.
A CNA at a long-term care facility was found to have physically and verbally abused two residents with severe cognitive impairments. The abuse included rough handling and derogatory language, leading to bruises on one resident. Despite staff awareness, the incidents were not reported to the state agency, and the CNA was not immediately removed from resident care, resulting in Immediate Jeopardy.
A facility failed to report abuse allegations to the state agency within the required timeframe. A CNA witnessed another CNA abusing two residents, but the incident was not reported to the administration or state agency. One resident had severe cognitive impairment and was found with bruises consistent with fingerprint marks. Staff interviews revealed a history of abuse by the same CNA, but fear of retaliation and a belief that nothing would be done prevented reporting. The facility's policy for immediate reporting was not followed.
A facility failed to separate an alleged CNA abuser, resulting in continued verbal and physical abuse of two residents. Despite reports of abuse, the CNA continued working with residents, leading to Immediate Jeopardy. The facility's delayed investigation and failure to follow abuse prevention policies exposed residents to further harm.
A resident with a history of exit-seeking behavior eloped from the facility without triggering alarms due to a known door code and malfunctioning Wanderguard System. The facility failed to update the resident's Elopement Risk Assessment and did not ensure alarms were audible throughout the building. Staff were aware of the resident's behavior but did not prevent the elopement, and the facility's policies were not effectively implemented.
The facility failed to properly store and safeguard resident medical records, as observed in a basement room with significant water intrusion and mold growth. The Maintenance Director and Administrator were aware of the issues, but the records remained improperly stored, contrary to the facility's policy.
The facility has repeatedly failed to systematically identify, report, and prevent adverse events, with deficiencies noted in reporting alleged violations, maintaining sufficient nursing staff, and infection prevention. The Administrator cited inconsistent nursing leadership and staffing challenges, including reliance on agency employees, as contributing factors. The facility's QAPI policy was not effectively implemented, and individual performance improvement plans were not available for review.
The facility failed to maintain a safe and comfortable environment by not providing sufficient linens and ensuring residents' beds were consistently made. Multiple residents reported issues with bed linens, including shortages of bed soakers and unmade beds. Staff confirmed the shortage of linens and improvised with available supplies. Despite suggestions to purchase more linens, administration delayed ordering until the beginning of the month.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with intact cognition and a history of falls was not provided with a timely care plan for wandering behavior. Another resident with severe cognitive impairment was not consistently transferred to a stationary chair during meals as per the care plan. Additionally, a resident with multiple diagnoses lacked a care plan focus on enhanced barrier precautions. The facility's administrator acknowledged potential gaps in care plans due to changes in nursing leadership.
The facility failed to provide adequate nursing staff, resulting in delayed care and unmet resident needs. Staffing schedules showed consistent understaffing, confirmed by staff and resident interviews. A CNA reported working alone with a nurse on overnight shifts, while an LPN noted that low staffing prevented completion of treatments. Residents experienced long wait times for call lights, with one resident soiling herself due to delays. The administrator acknowledged the issue, aiming for two staff on overnight shifts.
The facility failed to address water intrusion and a black substance in the basement, which may have contributed to respiratory issues in a resident with pre-existing conditions. Despite awareness of these issues, no structural assessment or root cause analysis was conducted, and the infection prevention staff did not investigate the potential link between the basement conditions and residents' symptoms.
The facility failed to protect residents from accidents, as evidenced by incidents involving two residents. One resident, who required a non-weight-bearing mechanical lift, was improperly transferred by a CNA without a gait belt, resulting in a fall and fractures. Another resident, with a moderate cognitive deficit, experienced multiple falls due to inadequate interventions and care planning. The facility's policies on fall risk reduction and clinical change management were not adequately followed.
The facility failed to provide adequate staffing, resulting in delayed call light responses and unmet resident needs. A resident with quadriplegia reported hour-long waits for assistance, especially at night. Staff confirmed insufficient staffing, particularly during night shifts, impacting care delivery. The DON expressed concerns about staffing cuts due to budget constraints, which were deemed unsafe given the high needs of residents.
The facility failed to provide the required 8-hour RN coverage daily, as revealed by a review of the nursing schedule for June and July 2024. During a transition with the DON, LPNs covered shifts, leading to gaps in RN coverage. Staff reported feeling overwhelmed due to insufficient staffing, particularly when residents required two-person assistance. The facility's assessment indicated that staffing should ensure professional guidance, but actual levels were inadequate.
The facility failed to update comprehensive care plans for four residents, resulting in discrepancies between care plans and current needs. A resident's care plan did not reflect the need for a non-weight-bearing mechanical lift, while another's fluid restriction was outdated. Additionally, wound care instructions and fluid intake monitoring were not accurately documented, leading to inconsistencies in care.
The facility failed to maintain proper hand hygiene and glove use during food preparation and service. Staff did not clean thermometers between food items, moved between tasks without washing hands, and handled food with improper glove use. Despite training, the facility lacked a specific kitchen hygiene policy.
Two residents with chronic skin ulcers did not receive timely and accurate assessments and interventions. One resident, with impaired cognitive skills and multiple health conditions, had missed treatments and incomplete skin assessments. Another resident, with normal cognition and a history of ulcers, also experienced lapses in wound care and incomplete assessments. The facility's policies on skin and wound care management were not followed, and care plans did not reflect the residents' current needs.
The facility failed to consistently perform pre and post dialysis assessments for two residents with chronic kidney disease and end-stage renal disease. Incomplete documentation and assessments were noted, with staff acknowledging the deficiency. The facility's policy required specific assessments, which were not consistently followed.
The facility failed to implement proper hand hygiene and infection control practices during wound care for two residents. A resident with cognitive impairments and venous stasis ulcers received treatment without hand hygiene by an RN, contrary to the facility's policy. Another resident, at risk for pressure ulcers, also experienced inadequate hand hygiene during wound care, with the RN failing to clean a tape measure between wounds and not separating cleaning from wound management. The DON acknowledged these deficiencies.
A resident with multiple medical conditions did not receive the influenza vaccine despite signing a consent form. The facility's immunization process failed due to a breakdown in communication between the social worker and nursing staff, leading to a lack of documentation and administration of the vaccine.
The facility failed to report a verbal abuse incident involving an LPN and a paralyzed resident in a timely manner. The incident occurred but was not reported until several days later due to the reporting staff member's uncertainty and concerns about favoritism. The facility's policy requires immediate reporting, which was not followed.
The facility failed to allow a resident to return after a transfer to an acute setting due to behavioral issues. Despite the resident's history of behaviors, there was no documentation of PRN medication administration or the transfer to the ER. The emergency discharge was issued without proper documentation and procedures.
The facility failed to complete a recapitulation of stay for two residents at the time of their discharge. Essential information such as the course of illness/treatment, lab results, medication reconciliation, and post-discharge care plans were missing from the discharge paperwork. The Director of Clinical Services acknowledged the deficiency and noted that the facility's policy did not specify a timeframe for completion.
The facility failed to complete discharge assessments for three residents who were discharged without following the required procedures, including documenting progress towards goals, verifying care plans, and conducting necessary reviews and education.
The facility failed to maintain complete and accurate medical records for a resident with multiple behavioral issues. Despite several documented incidents of disruptive behavior, there were gaps in the records, including the absence of PRN medication administration and documentation of the resident's transfer to the ER. Interviews revealed further discrepancies, with hospital staff noting a lack of communication from the facility and the administrator acknowledging the documentation lapses.
Failure to Provide Timely Tracheostomy Suctioning Results in Resident Neglect
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN), identified as Staff A, repeatedly refused or delayed providing suctioning care for a resident who was dependent on staff for tracheostomy management. The resident had physician orders for deep suctioning as needed, with specific instructions for frequency and technique. Despite these orders, documentation revealed that Staff A did not record performing suctioning during his shifts, and multiple staff and the resident reported that Staff A would not respond promptly to requests for suctioning, often requiring the resident to activate the call light multiple times and for certified nursing assistants (CNAs) to repeatedly notify Staff A before the care was provided. The resident, who had diagnoses including acute and chronic respiratory failure with hypoxia, functional quadriplegia, and a tracheostomy, reported experiencing severe anxiety and fear for his life when suctioning was not performed as needed. The resident stated that this neglect occurred nearly every night Staff A worked, and that all overnight CNAs were aware of Staff A's refusal to provide timely suctioning. Staff interviews corroborated the resident's account, with CNAs stating that Staff A would often refuse to suction the resident, sometimes claiming he had already done so or was busy, and that the resident appeared scared and anxious as a result. The director of nursing (DON) was made aware of concerns regarding the frequency and timeliness of suctioning, including receiving calls and text messages from staff about the issue. However, the DON did not identify or document any concerns with Staff A's performance at the time, and there was no evidence that the DON was aware of the ongoing pattern of neglect until later. Staff A denied refusing care and claimed to have provided suctioning as needed, but this was contradicted by multiple staff and the resident's statements, as well as the lack of documentation in the medical record.
Failure to Investigate and Respond to Alleged Neglect of Tracheostomy Care
Penalty
Summary
The facility failed to investigate an allegation of neglect involving a resident who was dependent on staff for tracheostomy care. The resident reported that an LPN frequently refused or delayed providing suctioning, despite having physician orders for deep suctioning as needed every 20 minutes. The resident described having to activate the call light multiple times and rely on CNAs to communicate his needs to the LPN, resulting in significant anxiety and feelings of neglect. Multiple CNAs corroborated the resident's account, stating that the LPN routinely refused to suction the resident's tracheostomy when requested, and that these concerns were reported to the DON both verbally and via text message. Despite these reports, there was no evidence that the facility conducted a thorough investigation into the allegations. Documentation and interviews revealed that the DON was made aware of the situation through staff communications, including text messages and phone calls, but did not initiate a formal investigation or separate the LPN from the resident during the period in question. The DON acknowledged receiving concerns about the frequency of suctioning and the LPN's response but did not document any follow-up actions or witness statements related to the alleged neglect. The clinical record lacked documentation of the suctioning order being utilized by the LPN, and there was no evidence of a comprehensive review of the resident's care or staff performance regarding the allegations. The resident involved had a history of acute and chronic respiratory failure with hypoxia, functional quadriplegia, and a tracheostomy, making timely and appropriate suctioning critical to his well-being. The failure to respond appropriately to the resident's needs and to staff reports of neglect constituted a deficiency in the facility's abuse prevention, identification, and investigation procedures. The facility's policy required immediate notification, investigation, and documentation of alleged abuse or neglect, but these steps were not followed in this case.
Failure to Maintain 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide a licensed nurse on the premises on a 24-hour basis, specifically during the overnight shift from 11/11/25 to 11/12/25, when the only scheduled LPN left the facility. Review of staffing records and timecards confirmed that the LPN clocked out at 1:15 AM, leaving the facility without a licensed nurse on site for several hours while 37 residents were present. Staff interviews revealed that the LPN had a pattern of leaving the building or being unaccounted for during overnight shifts, often leaving his phone at the nurses' station and instructing CNAs to call him if needed, though he was sometimes unreachable. On the night in question, the LPN left the facility to get gas and was subsequently detained by law enforcement after a traffic stop. CNAs reported being unaware that the LPN had left the premises and were unable to locate him when needed for resident care, including when a resident developed a fever. The DON was notified by staff and law enforcement after the LPN was taken into custody, and EMS was dispatched to the facility to provide medical coverage until the DON arrived. Staff interviews indicated that concerns about the LPN's absences had been previously reported to the DON, but there was no documentation of disciplinary action or ongoing concerns in the staff records. Facility policy and the facility assessment both required a licensed nurse to be present 24 hours a day to provide direct resident care. Despite this, the LPN was the only nurse scheduled for the overnight shift and left the premises, resulting in a period where no licensed nurse was available to meet residents' needs. Staff and resident interviews corroborated that the LPN was frequently absent from the building during his shifts, and the facility lacked documentation or monitoring to address these concerns.
Failure to Provide Adequate Orientation and Competency Training for Nursing Staff
Penalty
Summary
Nursing staff at the facility were scheduled to work independently with residents without adequate orientation or competency-based training. Two LPNs reported that they did not receive an orientation checklist or formal training before being assigned to care for residents on their own. One LPN stated he did not follow another nurse or complete any orientation checklist, and his personnel file lacked documentation of orientation or training. Another LPN reported receiving some instruction on medication times and paperwork but did not receive competency-based training on specific clinical skills such as catheter care, enteral tubes, or tracheostomy care, despite being expected to perform these tasks. His personnel file also lacked an orientation or training checklist. A former RN at the facility confirmed that there was no checklist for orienting new staff and expressed concerns about the competency and readiness of new hires, specifically noting that one LPN was allowed to work independently despite her concerns about his abilities. The facility administrator acknowledged the absence of a formal orientation or training program, and the DON stated that while a process was being developed, there was no formal orientation list in place. Facility policy required a 10-hour orientation program with a checklist for all new hires, but this was not followed or documented for the staff reviewed.
Failure to Serve Room Trays at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing and safe temperature to three residents who consistently received room trays. All three residents were cognitively intact and reported that their meals were often cold upon delivery to their rooms. One resident specifically noted that the facility did not use heated carts for room tray delivery and expressed concern that food sat too long before being brought to her room. Another resident stated that every meal delivered to her room was cold, while a third resident mentioned that food was sometimes served cold and she would request reheating if needed. Observation of the meal delivery process revealed that room trays were loaded onto a cart and delivered to resident rooms, with a sample tray temperature check showing that one of the food items, pepper steak, was below the facility's required minimum temperature of 135 degrees Fahrenheit. Both the kitchen manager and consulting dietitian confirmed that food should be delivered at or above 135 degrees. Facility policy also indicated that potentially hazardous foods must be maintained above 135 degrees to prevent the growth of harmful pathogens, and the administrator confirmed the expectation for food temperature compliance.
Failure to Provide Scheduled Baths or Showers to Multiple Residents
Penalty
Summary
The facility failed to provide scheduled baths or showers to three out of four residents reviewed, despite care plans and facility protocols indicating the required frequency. Electronic Health Record (EHR) reviews showed that one resident, who was cognitively intact and required substantial assistance, was scheduled for three baths per week but only received 30 out of 48 expected baths over a four-month period. Staff interviews confirmed that baths were sometimes missed due to staffing shortages, and there was no documentation of resident refusals for the missed baths in the EHR or on bath sheets, despite staff claims that refusals would be recorded. Another resident, also cognitively intact and dependent on staff for bathing, received only 8 out of 18 scheduled baths over a two-month period, with no refusals documented in the EHR. A third resident, similarly dependent, received 17 out of 33 scheduled baths over a four-month period, with only one refusal documented. The facility's policy required that residents be assisted with bathing according to their care plans and preferences, but the records and interviews indicated that this standard was not consistently met. The Director of Nursing (DON) and other staff acknowledged that baths were missed and that the facility had identified this as a concern. The DON confirmed that the expectation was for residents to receive at least two baths per week, and that the documentation did not reflect refusals for the missed baths. The administrator also acknowledged the issue, stating that resident preferences were considered in care planning, but that the scheduled baths were not consistently provided as required.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to medication administration errors. Resident #2, who had no cognitive impairment, did not receive her diabetes medication, Mounjaro, on a specified date, and her antihypertensive medication, Hydralazine, was administered outside the ordered parameters. Additionally, her weekly weight monitoring was not completed as ordered. There were no progress notes documenting the reasons for these discrepancies. Resident #2 reported that the Assistant Director of Nursing (ADON) did not administer medications to several residents, including herself, on a particular day, and there was a discrepancy in the administration of her insulin, Tresiba. Resident #3, also without cognitive impairment, did not receive his insulin as per the sliding scale order, and there were no notes explaining the deviation. On another occasion, the ADON documented that Resident #3 refused his morning medications, which he stated was due to the late administration time, advised by his doctor. Staff confirmed that Resident #3 had never refused his medications before, indicating a possible error in documentation or communication. Resident #6's medication, Oxycodone, was destroyed without obtaining a discontinuation order from the physician. The medication had not been used for several months, and there was no documentation explaining the destruction. The Director of Nursing was unsure why the medication was destroyed without an order. The facility's policy on medication administration was not followed, as medications were not signed out immediately after administration, and parameters for holding medications were not adhered to.
Deficiencies in Fall and Infection Assessment Protocols
Penalty
Summary
The facility failed to adequately assess and respond to an unwitnessed fall involving Resident #5, who had severe cognitive impairment and a history of falls. On 2/12/2025, Resident #5 was found on the floor next to her bed without her fall mat in place, and no call light was activated. The Interim Administrator, who was not a licensed nurse, conducted an initial assessment and assisted the resident into a wheelchair without using a gait belt. Neurological checks were not initiated immediately, and the first set of vitals was delayed by 30 minutes. The facility's protocol for neurological assessments following an unwitnessed fall was not followed, as confirmed by staff interviews and the Director of Nursing. Additionally, the facility failed to conduct appropriate assessments for residents who tested positive for COVID-19 and Influenza A. Residents #1, #8, #11, #12, #13, and #14, who tested positive for COVID-19, did not receive consistent respiratory assessments every shift as required. Their clinical records lacked documentation of regular COVID-19 Observation assessments and vital signs monitoring. Similarly, Resident #9, who tested positive for Influenza A, did not have consistent vital signs and respiratory assessments documented in their clinical record. The facility's failure to adhere to established protocols for post-fall assessments and monitoring of residents with infectious diseases highlights significant lapses in care. The lack of timely and thorough assessments, as well as the absence of consistent documentation, contributed to the deficiencies identified during the survey. These actions and inactions demonstrate a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage for 8 consecutive hours, 7 days a week, as evidenced by the review of nursing schedules, staffing sheets, and Payroll Based Journal (PBJ) reports. Specific dates in January and February 2025, as well as several dates in late 2024, were identified where the facility did not have the necessary RN coverage. Interviews with staff, including Licensed Practical Nurses (LPNs) and Certified Medication Aides (CMAs), revealed that the facility struggled with consistent RN coverage, often relying on the Director of Nursing (DON) and a part-time RN who worked weekends. However, the DON's frequent absences due to vacation, illness, or hospitalization further exacerbated the issue. Staff interviews highlighted a lack of communication and coordination in scheduling RNs, with some RNs expressing difficulty in picking up shifts due to unresponsive management. The facility's assessment claimed to maintain 24-hour licensed nurse coverage, but the reality, as reported by staff, was inconsistent and insufficient. The DON and Assistant Director of Nursing (ADON) were often unavailable, and agency staff were sometimes used to fill gaps, but this did not ensure the required coverage. The deficiency was further underscored by staff laughter and comments about the ongoing issue, indicating a lack of confidence in the facility's ability to meet regulatory requirements for RN coverage.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily with accurate and updated details for residents and visitors to see. Observations on multiple dates revealed that the daily staff postings were not updated consistently. On February 13, 2025, the postings were dated February 11, 2025, and on February 19, 2025, the postings were dated February 18, 2025. The Director of Nursing (DON) stated that night nurses were responsible for filling out the staff postings. The facility reported a census of 37 residents at the time of the survey.
Staffing and Management Deficiencies Lead to Unsafe Conditions
Penalty
Summary
The deficiency report highlights a significant lapse in staffing and management at the facility, which led to a period where no licensed nurse was present to care for the residents. On the day in question, the facility was left without a nurse for approximately three hours due to a combination of staff illness, weather conditions, and scheduling issues. During this time, the Administrator, who is not currently licensed to practice as a nurse, attempted to fill the gap by overseeing the medication cart and assessing a resident who had fallen. However, this was not sufficient to meet the facility's needs, as the absence of a licensed nurse left the staff feeling unsupported and concerned for resident safety. The report details an incident involving a resident who fell out of bed during the period without a nurse. The resident was assessed by the Administrator, who determined there were no injuries, but the assessment was not conducted by a licensed nurse, and proper protocols, such as using a gait belt for lifting, were not followed. Additionally, neurological assessments were not initiated despite the fall being unwitnessed. This incident underscores the facility's failure to ensure adequate staffing and appropriate care for residents, as the Administrator's actions, while well-intentioned, did not comply with standard nursing practices. The report also reveals a broader issue of poor management and a toxic work environment, as staff members expressed frustration with the lack of support from the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON and ADON were reported to have remained in their offices rather than assisting with resident care, contributing to a hostile work environment. Staff members reported feeling unsupported and retaliated against for raising concerns, further exacerbating the facility's challenges in maintaining a safe and effective care environment.
Repeated Deficiencies in QAPI Program
Penalty
Summary
The facility failed to ensure a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies identified in multiple surveys. The Department of Inspections, Appeals and Licensing (DIAL) website revealed that the facility had a history of deficiencies, including insufficient nursing staff, inadequate quality of care, issues with resident records, and infection control problems. These deficiencies were noted across several surveys, including complaint surveys and the annual recertification survey, indicating a pattern of non-compliance with regulatory standards. The facility's QAPI plan, revised in January 2025, aimed to foster a culture of proactive leadership and systematic improvement. However, the plan's implementation appeared ineffective, as evidenced by the recurrence of deficiencies. The administrator acknowledged that after surveys, results are shared with the management team to develop a plan of correction. However, the approach to preventing recurrence seemed inconsistent, relying on actions such as staff demotion, audits, and training, which may not have been sufficient to address the underlying issues. The repeated deficiencies suggest that the facility's QAPI efforts were not adequately addressing the root causes of the problems identified in the surveys.
Infection Control and Insulin Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures during an outbreak status, as observed by surveyors. Despite a sign on the front entrance indicating that masks were required, masks were not readily available at the entrance, and staff, including the Administrator and Director of Nursing (DON), were frequently observed without masks. This non-compliance with mask-wearing protocols was consistent across multiple days and involved various staff members, including the Activity Director and Transportation staff, who were seen with masks improperly worn or not worn at all. The facility was in outbreak status due to COVID-19, with several staff and residents testing positive, yet routine testing and mask enforcement were not adequately implemented. Additionally, the facility failed to adhere to proper procedures for obtaining blood sugar levels and administering insulin to residents. Multiple residents reported that Staff A did not use alcohol wipes before performing finger sticks for blood sugar checks or before administering insulin injections. This was corroborated by other staff members who were aware of the issue but did not take corrective action. Residents expressed concern over this practice, which was contrary to the facility's established procedures for blood sampling and insulin administration. The facility's COVID-19 policy guidelines and procedures for blood sampling and insulin administration were not followed, leading to deficiencies in infection control and resident care. Staff interviews revealed a lack of consistent testing and mask-wearing, with some staff unaware of the current protocols. The DON acknowledged the issues but did not ensure compliance with the facility's policies, contributing to the ongoing deficiencies during the outbreak status.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to update the care plans for two residents, leading to deficiencies in their care. Resident #4, who had no cognitive impairment, was documented to have an indwelling catheter, ostomy, and received tracheostomy care. However, the care plan, last revised in November 2024, did not reflect these medical devices or provide directives for their care. This oversight was confirmed by staff observations and record reviews, indicating a lack of necessary updates to the resident's care plan to address their current medical needs. Resident #5, with severe cognitive impairment, had a history of falls and required a fall mat when in bed. Despite this, the care plan did not instruct staff to use a fall mat, and staff interviews confirmed that the mat was not in place during a recent fall. The Director of Nursing acknowledged the oversight, noting that the care plan should have included the use of a fall mat. The facility's policy requires care plans to be revised with significant changes in a resident's condition, but this was not adhered to, resulting in inadequate care planning for the residents involved.
Failure to Complete Ordered Treatments for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to complete treatments as ordered for a resident with pressure ulcers, as observed through clinical record reviews, resident and staff interviews, and facility policy review. The resident, who had a BIMS score of 15 indicating no cognitive impairment, was at risk for developing pressure ulcers and had existing stage two pressure ulcers and venous and arterial ulcers. Despite having a care plan that directed staff to follow doctor's orders for treatment and to monitor and document the location, size, and treatment of skin injuries, the facility did not consistently complete these tasks. The resident's treatment administration records (TAR) for December 2024, January 2025, and February 2025 showed multiple instances where orders for wound care and skin assessments were not signed out as completed. This included the application of dressings, ointments, and other treatments, as well as weekly skin assessments and the elevation of the resident's legs. The resident reported that while treatments generally got done, there were times when nurses skipped them, sometimes for two days at a time, depending on which staff were working. The Director of Nursing (DON) stated that measurements were not obtained during weekly skin assessments because they were done monthly at the wound clinic. However, the facility's protocol required full assessment and documentation of pressure sores, including measurements. The DON also mentioned that the resident often refused treatments, although this was not documented as required by the facility's procedures. The facility's failure to consistently follow treatment orders and document assessments and refusals contributed to the deficiency.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the use of a gait belt for a resident with severe cognitive impairment and physical limitations during a transfer after a fall. The resident, who had a history of stroke, dementia, and other medical conditions, required extensive assistance for transfers. On the day of the incident, the resident fell out of bed, and the staff, including the Administrator, assisted the resident back into a wheelchair without using a gait belt, contrary to the facility's policy. The resident's fall was unwitnessed, and although the Administrator assessed the resident for pain and injuries, no neurological assessments were conducted. Staff interviews revealed confusion regarding the facility's policy on lifting residents, with some staff unsure if a mechanical lift was required. The Director of Nursing acknowledged that a gait belt should have been used during the transfer. The facility's policy on safe lifting and movement of residents emphasized the use of appropriate techniques and devices, including gait belts, to ensure resident safety and comfort. However, the staff did not adhere to this policy during the incident, leading to the deficiency.
Nursing Coverage Lapse in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing coverage on a specific date, resulting in a period from approximately 1:30 PM to 4:30 PM where no licensed nurse was present in the building. This occurred after an LPN, who had been working extended hours due to another staff member calling in sick, was advised by the Administrator to leave the facility to rest and retrieve her medications. The absence of a licensed nurse during this time left the facility without the necessary medical oversight, despite the presence of high-risk residents, including one with complex medical needs such as a tracheostomy, indwelling catheter, and a history of frequent hospitalizations. During the period without nursing coverage, the facility had several CNAs and CMAs on duty, but no licensed nurse to oversee care or respond to medical emergencies. The Administrator, who was not currently licensed as a nurse, assumed some responsibilities, including taking charge of the medication cart keys and assessing a resident who had fallen. However, the lack of a licensed nurse meant that certain medical protocols, such as neurological assessments following an unwitnessed fall, were not completed. Staff interviews revealed that this situation was unprecedented in the facility, causing concern and anxiety among the staff. The facility's staffing plan and contingency measures were insufficient to address the sudden shortage, despite having partnerships with staffing agencies. The Administrator's actions, including advising the LPN to leave and attempting to fill the gap himself, were inadequate to meet regulatory requirements for nursing coverage. The absence of a licensed nurse during this critical period posed a significant risk to resident safety, particularly for those with complex medical needs and those in isolation due to infectious diseases.
Inadequate Staffing and Competency in Resident Care
Penalty
Summary
The facility failed to ensure that licensed staff were competent to complete an assessment after a resident experienced an unwitnessed fall. The resident, who had severe cognitive impairment and required extensive assistance for transfers due to a history of stroke and other medical conditions, fell out of bed when there was no licensed nurse present in the building. The Administrator, who was a former nurse but did not have an active license, assessed the resident for pain and injuries and assisted in transferring her to a wheelchair without using a gait belt. During the time of the incident, the facility was without a licensed nurse for approximately three hours. Staff members, including a Certified Medication Aide, were present but were not licensed to perform the necessary assessments. The Administrator, who was aware of the situation, instructed a nurse to take a break due to exhaustion, leaving the facility without proper nursing coverage. The Director of Nursing eventually arrived later in the afternoon. The incident highlighted a lapse in staffing and competency, as the necessary neurological assessments were not conducted following the unwitnessed fall. Additionally, the transfer of the resident was performed without the use of a gait belt, which is against standard protocol for ensuring resident safety during transfers. The facility's failure to maintain adequate licensed nursing staff and ensure proper assessment and transfer procedures contributed to the deficiency.
Unnecessary Administration of PRN Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically the administration of a PRN narcotic pain medication, Oxycodone, without clear evidence of pain. The resident, who had severe cognitive impairment and a history of stroke, cancer, heart failure, and dementia, was documented to have received the narcotic on several occasions despite staff observations that he did not appear to be in pain. The resident's care plan included directives to administer analgesic medications as ordered and to anticipate and respond to his pain needs, but there was no consistent evidence of pain that justified the frequent administration of the narcotic. Staff interviews revealed discrepancies in the administration of the PRN narcotic. Several staff members, including LPNs and CNAs, reported that the resident often moaned and groaned but did not exhibit behaviors consistent with significant pain. Some staff indicated that the narcotic was given to help the resident sleep, despite the resident being on a sleeping pill, and one staff member admitted to administering the medication to ensure a quieter night shift. The resident's Medication Administration Record (MAR) showed frequent administration of the narcotic by a specific LPN, raising concerns about the necessity of the medication. The facility's policy on administering medications required re-evaluation of frequent PRN medication use by the attending physician and care team, with input from a consultant pharmacist. However, there was no documentation of such re-evaluation or clinical justification for the frequent use of the narcotic. The Director of Nursing and other staff members acknowledged the resident's behaviors were more related to agitation than pain, further questioning the appropriateness of the narcotic administration.
Failure to Properly Store Delivered Medications
Penalty
Summary
The facility failed to appropriately store medications after they were delivered from the pharmacy, as observed on two separate occasions. On February 13, 2025, a blue plastic bag containing medication cards for sertraline, oseltamivir, Lisinopril, pyridostigmine, Eliquis, and metoprolol was found opened and unattended on the counter at the nurse's station for 30 minutes. This was contrary to the facility's policy, which requires medications to be stored in locked compartments. Staff interviews revealed that medications are usually delivered in white or blue bags and should be put away immediately by the nurse or Certified Medication Aide (CMA) present at the time of delivery. The Director of Nursing (DON) confirmed the procedure for handling delivered medications, which involves checking the packing slip, signing forms, and storing the medications in the cart. However, the incident on February 13, 2025, indicated a lapse in this procedure, as the medications were left unattended on the counter. Staff members, including a Licensed Practical Nurse (LPN) and a CMA, acknowledged that medications should not be left on the counter unattended, highlighting a failure in adhering to the facility's medication storage policy.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and assessment. Resident #5, who had severe cognitive impairment and a history of falls, experienced an unwitnessed fall that was not properly documented or assessed. The incident report for the fall was delayed, and a post-fall assessment was not conducted immediately. The Administrator, who was present during the fall, did not perform a neurological assessment, and the Director of Nursing acknowledged the delay in completing the incident report due to her absence from the facility. Additionally, the facility did not document positive test results for Influenza A and COVID-19 for Residents #9 and #10, respectively, in their medical records. Both residents were placed in isolation due to their positive test results, but the documentation in their progress notes was incomplete. The Director of Nursing admitted that the staff failed to chart these test results, which was contrary to the facility's policy guidelines that required all test results to be recorded in the residents' permanent medical records.
Failure to Prevent Abuse of Residents by CNA
Penalty
Summary
The facility failed to prevent physical and verbal abuse of two residents, identified as Resident #2 and Resident #5, by a Certified Nursing Assistant (CNA) known as Staff U. The abuse was witnessed by another CNA and involved both physical and verbal aggression. Resident #2, who had a severe cognitive impairment with a BIMS score of 3, was found with bruises on her chest that resembled fingerprints. These bruises were discovered during a skin assessment conducted by a Licensed Practical Nurse (LPN). Staff interviews revealed that Staff U had a history of being rough with Resident #2, including pushing her down into a chair and using derogatory language. Resident #5, also with severe cognitive impairment and a BIMS score of 6, was similarly subjected to rough handling and verbal abuse by Staff U. Witnesses reported that Staff U aggressively moved Resident #5 by grabbing his feet and pulling him up by his arms. Staff U was also reported to have used offensive language towards Resident #5, threatening to hit him. Multiple staff members corroborated these incidents, indicating a pattern of abusive behavior by Staff U towards both residents. The facility's administration acknowledged that the abuse incidents were not reported to the state agency as required. The Administrator admitted that the facility's expectation was for all possible abuse to be reported, but this did not occur. The investigation revealed that Staff U's negative attitude and rough handling of residents were known issues, yet she was not immediately separated from resident care. This oversight allowed the abuse to continue, resulting in an Immediate Jeopardy situation for the residents involved.
Removal Plan
- Resident and staff interviews to determine any unreported incidence of abuse conducted.
- All Staff are educated on Abuse types, Reporting Requirements, and Requirement of immediate separation with all employees being educated on the abuse policy prior to working with residents.
- The Administrator has been identified as the Abuse Coordinator and signage for phone number/contact for reporting has been placed conspicuously in the facility.
Failure to Report Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. On August 26, 2024, between 5:00 pm and 5:30 pm, a CNA witnessed another CNA physically and verbally abusing two residents. Despite reporting the incident to a nurse, neither the CNA nor the nurse reported the abuse to the state agency or the administration. This failure resulted in residents being exposed to actual abuse and the potential for further abuse, creating an Immediate Jeopardy to their health, safety, and security. Resident #2, who had a severe cognitive impairment with a BIMS score of 3, was found to have three bruises on her chest, which were documented by a Licensed Practical Nurse (LPN) during a skin assessment on August 27, 2024. The bruises were consistent with fingerprint marks, suggesting physical abuse. Additionally, Resident #5, also severely cognitively impaired with a BIMS score of 6, was dependent on staff for dressing and toileting. Staff interviews revealed that the same CNA had a history of verbally and physically abusing these residents, but these allegations were not reported. The investigation uncovered that multiple staff members had witnessed or were aware of the abusive behavior by the CNA, identified as Staff U, but failed to report it due to fear of retaliation or a belief that nothing would be done. The facility's policy required immediate reporting of suspected abuse to the Administrator and Director of Nursing, but this protocol was not followed. The Administrator acknowledged that the allegations should have been reported to the state agency and that Staff U should have been immediately separated from resident care, which did not occur.
Removal Plan
- Resident and staff interviews to determine any unreported incidence of abuse.
- All Staff are educated on Abuse types, Reporting Requirements, and Requirement of immediate separation with all employees being educated on the abuse policy prior to working with residents.
- The Administrator has been identified as the Abuse Coordinator and signage for phone #/contact for 24/7 reporting has been placed conspicuously in the facility.
Failure to Separate Alleged Abuser Leads to Continued Resident Abuse
Penalty
Summary
The facility failed to separate an alleged CNA abuser, resulting in continued verbal and physical abuse of two residents. On August 26, 2024, a CNA witnessed another CNA physically and verbally abusing two residents. Despite reporting the incident to a nurse, the alleged abuser continued to work with the residents. The following day, staff identified a bruise on one resident's chest, shaped like fingers, indicating physical abuse. The investigation revealed that the same CNA had a history of abusing these residents, which was not immediately addressed, leading to an Immediate Jeopardy situation. The facility's investigation into the incidents was delayed and incomplete. The Administrator was informed of verbal abuse by the alleged CNA but did not immediately separate the CNA from resident care. Staff interviews revealed that the CNA had been verbally abusive and physically rough with residents, including pulling a resident's legs aggressively and using inappropriate language. Despite multiple staff members witnessing and reporting these behaviors, the facility did not take immediate action to protect the residents or report the incidents to the state agency. The facility's policy on abuse prevention and reporting was not followed, as staff failed to report the abuse immediately, and the alleged abuser was not separated from resident care. The facility's failure to act promptly and comprehensively investigate the allegations exposed residents to further abuse and created an Immediate Jeopardy to their health and safety. The facility's inaction and lack of adherence to its abuse prevention policy contributed to the deficiency.
Removal Plan
- Resident and staff interviews to determine any unreported incidence of abuse.
- All Staff are educated on Abuse types, Reporting Requirements, and Requirement of immediate separation with all employees being educated on the abuse policy prior to working with residents.
- The Administrator has been identified as the Abuse Coordinator and signage for phone #/contact for reporting has been placed conspicuously in the facility.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to protect residents from potential accidents and injuries, particularly for two residents identified as having wandering and elopement risks. One resident, with a history of exit-seeking behavior, was able to leave the facility without triggering the door alarm, as the door code had not been changed despite the resident knowing it. The resident was found at a nearby Walmart by police after being missing for over an hour. The facility's Wanderguard System (WGS) was not functioning properly, and the resident's bracelet had not been checked for functionality. The facility's failure to conduct an updated Elopement Risk Assessment after previous exit-seeking incidents contributed to the deficiency. The resident had been demonstrating exit-seeking behaviors earlier in the day and had a history of wandering and exit-seeking, yet the care plan did not include interventions for wandering until after the incident. Staff interviews revealed that the door alarm and WGS alarm were not audible from the back of the building, and the front door code was known by several residents, further compromising security. Additionally, observations showed that the facility was located near busy roads without sidewalks, increasing the risk for residents who eloped. Staff were aware of the resident's exit-seeking behavior but did not take adequate measures to prevent elopement. The facility's policies on elopement and missing resident protocols were not effectively implemented, as evidenced by the lack of an overhead announcement when the resident was discovered missing.
Removal Plan
- The code to the door was changed.
- All Residents had Elopement Risk Assessments reviewed and/or completed.
- Elopement Binders were updated with current at risk residents and care plans were added to the binders regarding the resident's individual supervision needs.
- Residents with WGS had Sensor Checks added to the Electronic Medication Administration Record (EMAR) for placement and function daily.
- The WGS door alarm checks were to be completed daily and audited by the Administrator.
- The facility provided education to the staff on Elopement Procedures/Protocols.
- Additional education was provided regarding supervision levels of residents per care plan and the removal plan. Employees will be educated prior to the start of their next shift.
- Code to the front door was changed and staff educated that only staff members were to have the code.
- No family members, residents, or visitors were to know the code for exiting the building.
- The resident smoking area moved to the back of the facility.
- Staff were re-educated on the elopement policy and not sharing the front door code.
Failure to Safeguard and Properly Store Resident Medical Records
Penalty
Summary
The facility failed to maintain and safeguard resident medical records in accordance with accepted professional standards. During an observation, it was noted that the basement of the facility had significant issues with water intrusion, particularly in a room where resident records were stored. The room had a window well with washed away soil, and the walls were covered with a black fuzzy substance, indicating mold growth. The paint on the walls was chipping, loose, and bubbled, and there were signs of water damage to the boxes and resident records stored in the basement. Staff interviews revealed that the Maintenance Director was aware of the water intrusion issues and had informed the Administrator. The Administrator acknowledged being aware of the conditions and the improper storage of medical records but had not yet taken action to address the situation. The facility's policy on the location and storage of medical records stated that records should be protected from fire, water damage, insects, and theft, and stored in a locked room, which was not adhered to in this case.
Repeated Deficiencies in Reporting, Staffing, and Infection Control
Penalty
Summary
The facility failed to demonstrate evidence of systematic identification, reporting, investigation, analysis, and prevention of adverse events, as well as the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility has a history of repeated deficiencies in several areas, including F609 (reporting alleged violations), F689 (free of accidents/hazards and supervision), F725 (sufficient nursing staff), and F880 (infection prevention and control). These deficiencies have been noted in multiple surveys over the years, with some resulting in harm level deficiencies. The Administrator acknowledged the lack of a performance improvement plan (PIP) for F609, citing inconsistent nursing leadership and challenges in developing a comprehensive plan due to the varied nature of the violations. The Administrator also highlighted staffing issues, including reliance on agency employees who sometimes cancel, leading to insufficient staffing levels. There was no current PIP related to staffing, and the facility's corporate office handled onboarding, which the Administrator believed could be more efficient if done in-house. Additionally, the facility had issues with infection prevention and control, particularly with hand hygiene and water intrusion concerns, which were not logged or analyzed due to the absence of consistent nursing leadership. The facility's QAPI policy outlined a process for identifying and prioritizing performance improvement plans, but the Administrator admitted that individual PIPs were not readily available for the survey team.
Facility Fails to Provide Sufficient Linens and Consistently Made Beds
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents by not providing sufficient linens and ensuring that residents' beds were consistently made. Observations and interviews revealed that multiple residents, including those with normal cognition, reported issues with bed linens. Resident #6 mentioned frequent shortages of bed soakers, while Resident #10 and Resident #11 reported returning to unmade beds after dialysis and finding dirty, stained sheets, respectively. Resident #7, who has moderate cognitive impairment, was observed with an unmade bed lacking a fitted sheet. Staff interviews corroborated these findings, with several CNAs and LPNs acknowledging the shortage of bed pads, sheets, and other linens. Staff members reported improvising with available linens or repositioning when supplies were insufficient. The housekeeping assistant and laundry aide confirmed the low supply of linens and stated that restocking typically occurred by mid to late morning. Despite suggestions to purchase more linens, the administration's response was that ordering would be done at the beginning of the month. The facility's policy on maintaining a homelike environment emphasized the need for clean bed and bath linens in good condition, which was not consistently met.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop, implement, and follow comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #1, with intact cognition and a history of falls, was identified as a high risk for wandering. Despite having a Wanderguard System in place since February, the care plan did not include a focus area or interventions for wandering behavior until late August. This delay in updating the care plan left staff without specific guidance on managing the resident's wandering risk. Resident #2, with severe cognitive impairment and requiring substantial assistance, had a care plan that included transferring to a stationary chair during meals to improve eating. However, observations revealed that the resident was consistently left in a wheelchair during meals, contrary to the care plan's interventions. Staff admitted to not consistently following the care plan. Resident #11, with intact cognition and multiple diagnoses, had a care plan that lacked focus areas or interventions for enhanced barrier precautions, despite having a treatment regime for lower extremity wounds. The facility's administrator acknowledged that care plans might be lacking due to changes in directors of nursing.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure the safety and well-being of its residents, as evidenced by the staffing schedules and interviews with staff and residents. The August and September 2024 schedules revealed consistent understaffing across various shifts, with fewer Certified Nursing Assistants (CNAs) than required. Staff interviews confirmed that the shortage led to missed breaks and delayed resident care. A CNA reported working overnight shifts alone with a nurse, while a Licensed Practical Nurse (LPN) noted that low staffing levels prevented the completion of resident treatments as ordered. A Certified Medication Aide (CMA) expressed concerns about managing medication carts alone and being unable to respond to door alarms due to insufficient staffing. Residents also reported negative impacts due to the staffing deficiencies. One resident, who was dependent on staff for all activities of daily living and used a power wheelchair, stated that call lights could take up to an hour to be answered during overnight shifts. Another resident, who required substantial assistance for transfers and had bowel incontinence, reported long wait times for call lights, resulting in soiling herself. The facility's administrator acknowledged the longer call light response times, particularly after supper and during overnight shifts, and stated that the goal was to have two staff members on overnight shifts. The facility's policy indicated that staffing should be sufficient to meet residents' needs based on their care plans, but this was not achieved.
Inadequate Infection Control Due to Basement Conditions
Penalty
Summary
The facility failed to implement appropriate infection prevention practices, particularly in addressing water intrusion and a black substance in the basement. The Administrator acknowledged awareness of these issues, which included water entering through a wall and window well during heavy rainfall, causing mud on the floor and a black fuzzy substance on the wall. Despite these conditions, no structural integrity assessment was conducted, and the infection prevention staff did not perform a root cause analysis to determine if these environmental factors contributed to respiratory issues in residents. Resident #7, who had a history of respiratory problems, was hospitalized for acute hypoxic respiratory failure and later required supplemental oxygen. The Administrator noted that several residents exhibited flu-like symptoms in August, but none tested positive for COVID-19. The facility's infection prevention and control policy emphasized the importance of surveillance and data analysis to identify potential infection issues, but the facility did not adequately investigate the potential link between the basement conditions and the exacerbation of respiratory symptoms in residents.
Failure to Prevent Resident Falls and Injuries
Penalty
Summary
The facility failed to protect residents from possible accidents and injuries, as evidenced by the incidents involving two residents. Resident #13, who was cognitively intact and had a history of falls, was involved in an incident where a CNA attempted to transfer her to a wheelchair without a gait belt, resulting in a fall and subsequent fractures. The resident had been previously assessed as requiring a non-weight-bearing dependent mechanical lift for transfers, but the CNA was unaware of this requirement. The resident's care plan was not up to date, and the CNA did not have access to the necessary equipment, leading to the improper transfer attempt. Additionally, Resident #39, who had a moderate cognitive deficit and was a fall risk, experienced multiple falls over a period of time. Despite being identified as a fall risk, the facility failed to implement and document effective interventions to prevent these falls. Observations showed that the resident was often found in precarious positions, such as reaching for items on the floor, which contributed to the falls. The care plan for Resident #39 included frequent checks and removal of potential fall hazards, but these measures were not effectively carried out. The facility's policies on fall risk reduction and clinical change in condition management were not adequately followed. The Director of Nursing acknowledged the lack of implemented interventions and care planning for Resident #39's falls. The facility's failure to update care plans, communicate changes in resident status, and ensure staff were informed of and equipped to follow proper procedures contributed to the deficiencies observed.
Inadequate Staffing Leads to Delayed Call Light Response
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in delayed response times to call lights. Resident #35, who has a C5 level spinal injury and quadriplegia, reported that call lights could take up to an hour to be answered, particularly at night. This issue was consistently raised in Resident Council meetings, with concerns about inadequate staffing during evenings and weekends. Resident #14 and Resident #2 also reported long wait times for call lights, with instances of waiting up to an hour or more. The Director of Nursing expressed concerns about staffing cuts due to budget constraints, which she deemed unrealistic and unsafe given the high needs of the residents, including those requiring two-person assistance and extensive wound care. Staff interviews corroborated the residents' experiences, with reports of insufficient staffing, particularly during night shifts. Licensed Practical Nurses and Certified Medication Aides described situations where they were unable to complete all necessary treatments and tasks due to being understaffed. The facility's assessment indicated a staffing plan that was not being met, with only one nurse and two Certified Medication Aides on day shifts, and even fewer staff during evening and night shifts. This staffing shortage led to delays in care and unmet resident needs, particularly for those requiring two-person assistance.
Deficiency in RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours each day, as required. This deficiency was identified through a review of the nursing schedule for June and July 2024, which revealed multiple days without the mandated RN coverage. The facility had a census of 40 residents during this period. The gap in RN coverage occurred during a transition phase with the Director of Nursing (DON), leading to Licensed Practical Nurses (LPNs) covering the shifts. Staff interviews confirmed the absence of RN coverage, with LPNs stepping in to fill the gap. Staff reported feeling overwhelmed due to the increased expectations and insufficient staffing, particularly when residents required assistance from two staff members. The facility's assessment indicated that the staffing ratio should ensure professional guidance and supervision, but the actual staffing levels fell short of this requirement.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to revise and update the Comprehensive Care Plan for four residents, leading to discrepancies between the care plans and the residents' current needs and physician orders. For Resident #13, the care plan was outdated and did not reflect the resident's current need for a non-weight-bearing dependent mechanical lift due to hip precautions and pain. Despite the resident's return from the hospital with a left lower extremity immobilizer and non-weight-bearing status, the care plan still indicated the need for two staff for transfers, which was not aligned with the facility's no-lift policy. Resident #2's care plan contained outdated fluid restriction information, specifying a limit of 1500cc per day, while the physician's orders had been updated to allow 2000cc per day. This discrepancy was not addressed in the care plan, leading to potential inconsistencies in the resident's care. Similarly, Resident #6's care plan did not reflect the current treatment orders for wound care, which included specific instructions for dressing changes and wound management that were not updated in the care plan. For Resident #27, the care plan did not accurately document the monitoring and recording of fluid intake, as the electronic health record did not provide a location for recording fluids consumed at meals. Additionally, the care plan did not align with the physician's orders for fluid restrictions and weight monitoring. These deficiencies highlight the facility's failure to ensure that care plans are consistently updated to reflect the residents' current medical needs and physician directives.
Deficiency in Hand Hygiene and Glove Use During Food Service
Penalty
Summary
The facility failed to adhere to professional standards for hand hygiene and glove use during food preparation, serving, and distribution. During an observation, it was noted that the cook and dietary aide did not clean the thermometer between checking different food items and placed the uncovered thermometer on a countertop among various items, including trash. The dietary aide moved between the kitchen and dining room without performing hand hygiene, and the cook handled dirty dishes and returned to food preparation without washing hands. Additionally, the cook donned gloves without prior hand hygiene and handled food items, placing used gloves on the counter next to food items without washing hands. Furthermore, during meal service, the dietary aide discarded plates and continued serving without hand hygiene. Another staff member delivered room trays but only performed hand hygiene on two out of eleven opportunities. The facility's administrator acknowledged the need for improved hygiene practices in the kitchen, and although hand hygiene training had been provided, the facility lacked a specific policy for kitchen hygiene.
Deficiencies in Skin Ulcer Care and Assessment
Penalty
Summary
The facility failed to ensure accurate and timely assessment and interventions for two residents with chronic skin ulcers. Resident #40, who had moderately impaired cognitive skills and multiple health conditions, including heart failure and peripheral vascular disease, was observed with swollen and blotchy red lower limbs with open areas. Despite having treatment orders for his skin ulcers, the Treatment Administration Record (TAR) showed missed treatments on several dates in June, with no explanation in the nursing notes. Weekly skin assessments were incomplete, lacking mention of the legs or toes on several occasions, and there was a lack of documentation regarding the condition of the toes on his right foot. Resident #6, with normal cognition and a history of venous and arterial ulcers, also experienced lapses in care. The Treatment Administration Record (TAR) indicated that wound care was not signed off as completed on three occasions in July. The care plan for Resident #6 included specific interventions for skin integrity, but weekly skin assessments were incomplete, lacking measurements and site information. The Director of Nursing (DON) acknowledged that weekly skin assessments should be thoroughly completed and that treatments should be done daily as ordered. The facility's policies on skin and wound care management and clinical change in condition were not adhered to, as evidenced by the lack of weekly skin reports and daily observations. The DON stated that care plans should reflect the current needs of the residents, but the care plans were being completed by an off-site staff member, and a new Unit Manager had been hired to oversee MDS, care plans, and higher-need skin assessments.
Inconsistent Dialysis Care and Assessment
Penalty
Summary
The facility failed to provide consistent pre and post dialysis assessments for two residents requiring dialysis care. Resident #2, with a diagnosis of chronic kidney disease stage 5 and morbid obesity, had incomplete documentation for dialysis sessions in July 2024, with missing post-dialysis assessments on several occasions. On one instance, the resident ended dialysis early due to back pain and was taken to the hospital, yet the post-dialysis assessment was only partially completed upon return to the facility. The resident reported that staff did not consistently perform assessments before and after dialysis. Similarly, Resident #27, diagnosed with renal insufficiency and end-stage renal disease, also experienced incomplete documentation of dialysis assessments. The resident's care plan required monitoring for specific symptoms and conditions related to dialysis, but the facility failed to consistently complete these assessments. The Director of Nursing and a Nurse Consultant acknowledged the deficiency, confirming that assessments were not being completed as required. The facility's policy required specific pre and post-dialysis assessments, which were not consistently followed.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to implement appropriate hand hygiene and infection control practices during wound care treatments for two residents. Resident #40, who had moderately impaired cognitive skills and multiple health conditions including heart failure and venous stasis ulcers, was observed receiving wound care without proper hand hygiene by Staff A, a Registered Nurse. During the treatment, Staff A did not perform hand hygiene after removing gloves and before leaving the room, which is against the facility's infection prevention policy. Resident #6, who had normal cognition and was at risk for pressure ulcers, also received wound care from Staff A in the presence of the Director of Nursing (DON). Staff A failed to perform hand hygiene multiple times during the procedure, including after glove removal and before donning new gloves. Additionally, the tape measure used for measuring wounds was not cleaned between uses on different wounds, and there was no separation between cleaning and wound management of each lower extremity. The DON acknowledged the lack of proper hand hygiene and the need for better separation during the wound care process. These observations indicate a deficiency in the facility's infection prevention and control practices, specifically in the area of hand hygiene during wound care procedures. The facility's policy emphasizes the importance of hand hygiene to prevent the spread of infections, yet these practices were not followed by the staff, leading to potential risks for the residents involved.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility failed to offer an influenza immunization to a resident, despite the resident having signed a consent form for the vaccine. The resident, who had intact cognitive ability with a BIMS score of 15, was totally dependent on staff for certain activities of daily living and had multiple medical diagnoses, including anemia, heart failure, renal insufficiency, pneumonia, septicemia, and chronic respiratory failure. The resident's care plan indicated the presence of a tracheostomy and cardiac devices, highlighting the importance of receiving the influenza vaccine. The deficiency occurred due to a breakdown in the facility's immunization process. The Infection Preventionist confirmed that there was no documentation of the resident receiving the influenza vaccine, despite the signed consent. The facility's policy required all residents to receive the influenza vaccine annually, barring any contraindications or refusals. The process involved the social worker handling paperwork and consents, which were then passed to nursing for follow-up with a doctor's order and administration of the vaccine. However, the communication and procedural steps failed, resulting in the resident not receiving the vaccine.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report a reportable event in a timely manner for one resident. The incident involved a Licensed Practical Nurse (LPN) verbally abusing a paralyzed resident by making derogatory comments about the resident's hygiene and mobility. The incident occurred on 3/23/24 but was not reported to the facility's compliance hotline until 3/27/24. The delay in reporting was due to the reporting staff member's uncertainty about the consequences and whether the incident constituted abuse. The staff member also expressed concerns about the Administrator's favoritism towards the offending LPN. The facility's policy requires immediate reporting of suspected abuse, but this protocol was not followed. The Regional Director of Clinical Services and the Administrator both confirmed that staff are expected to report abuse allegations immediately. The Administrator acknowledged that not all staff had been educated on the reporting procedures, particularly those who had not worked recently or were PRN staff members. The facility's Abuse Prevention Program and Reporting Policy mandates immediate notification to the shift supervisor, Administrator, and Director of Nursing (DON) for any suspected abuse, neglect, mistreatment, or misappropriation of property.
Failure to Allow Resident Return After Transfer
Penalty
Summary
The facility failed to allow a resident to return after a facility-initiated transfer to an acute setting. Resident #2, who had no cognitive impairment and was actively planning to discharge to the community, exhibited behaviors such as cursing, yelling, and throwing items. Despite these behaviors, there was no documentation of PRN medication administration to manage his anxiousness since 3/21/24. The facility's records lacked documentation of the behaviors and the transfer to the ER on 3/27/24. On 3/27/24, the Administrator presented Resident #2 with an emergency discharge letter at the hospital ER, citing aggressive and violent behaviors as the reason for discharge. The hospital staff reported that Resident #2 had no behavioral issues while admitted and noted the lack of PRN medication administration. The Administrator admitted that staff likely did not document the behaviors because they were accustomed to Resident #2's actions. The facility's Discharge Management policy requires documentation and written notice for transfers, which was not adequately followed in this case. The Administrator stated that Resident #2 was sent to the hospital due to increased behaviors and the inability to calm him down. The facility called 911, and the police and EMS were involved in transferring him to the hospital. The Administrator acknowledged that there was no documentation in the resident's EHR to reflect the behaviors leading to the transfer. The emergency discharge was issued for the safety of staff and residents, but the facility failed to provide sufficient documentation and follow proper procedures for the transfer and discharge.
Failure to Complete Recapitulation of Stay for Discharged Residents
Penalty
Summary
The facility failed to complete a recapitulation of stay for two residents at the time of their discharge. For the first resident, the discharge paperwork lacked essential information such as the course of illness/treatment, pertinent lab, radiology, and consultation results, and a reconciliation of pre-discharge and post-discharge medications. Additionally, there was no post-discharge plan of care developed with the resident and their representative to assist in adjusting to the new living environment. This deficiency was noted despite active discharge planning documented in the resident's care plan and progress notes indicating the resident's wish to return to the community. For the second resident, the discharge paperwork similarly lacked a recapitulation of the resident's stay. The resident's care plan documented their wish to discharge to the community, and progress notes indicated that the resident left with family to transfer to another facility. However, the necessary documentation summarizing the resident's stay and ensuring continuity of care was missing. The Director of Clinical Services acknowledged that the facility's policy did not specify a timeframe for completing the recapitulation of stay but stated it should be done within a couple of days of discharge.
Failure to Complete Discharge Assessments
Penalty
Summary
The facility failed to complete discharge assessments for three residents who were discharged from the facility. Resident #2, who had no cognitive impairment and wished to discharge to the community, was presented with an emergency discharge letter at the hospital emergency room without a discharge assessment being completed. Similarly, Resident #4, who had active discharge planning to return to the community, was discharged home with family without a discharge assessment. Resident #5, who also had discharge planning to return to the community, left with his family to transfer to another facility without a discharge assessment being completed. The facility's policy required nursing staff to document resident progress towards goals, verify care plans, review vital signs, weight records, MAR/TAR, progress notes, and conduct a skin sweep prior to discharge. Additionally, treatments and services arranged for discharge, resident/family education, and completion of the Interdisciplinary Discharge Summary/Recapitulation Form were required. However, these steps were not followed for the three residents, leading to the deficiency. The Administrator and Director of Clinical Services acknowledged that discharge assessments should have been part of the recapitulation of stay but were not completed in these cases.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to a deficiency. Resident #2, who had no cognitive impairment and several diagnoses including malignant neoplasm of the rectum and moderate intellectual disabilities, exhibited multiple behavioral issues that were not properly documented. The resident's care plan indicated a desire to discharge to the community, and staff were instructed to evaluate and discuss his prognosis for independent or assisted living. However, the facility's records lacked documentation of significant behavioral incidents and the administration of PRN medications to manage his anxiousness. Several incidents involving Resident #2 were noted in the progress notes, including conflicts with other residents, yelling, and physical aggression. Despite these documented behaviors, there were gaps in the medical records, such as the absence of PRN medication administration on specific dates when the resident exhibited disruptive behaviors. Additionally, the facility's records did not include documentation of the resident's transfer to the emergency room (ER) or the assessments leading up to the transfer. Interviews with hospital staff and the facility's administrator revealed further discrepancies. The hospital staff reported that Resident #2 had not received PRN medication since a specific date, and there was no communication from the facility regarding the resident's condition before his arrival at the ER. The facility's administrator acknowledged the lack of documentation and attributed it to staff possibly overlooking the need to document the resident's behaviors. The facility's policy on documentation emphasized the importance of maintaining accurate records, but this was not adhered to in the case of Resident #2.
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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