Glen Haven Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Glenwood, Iowa.
- Location
- 133 Indian Hills Drive, Glenwood, Iowa 51534
- CMS Provider Number
- 165530
- Inspections on file
- 24
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Glen Haven Village during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and chronic kidney disease experienced a delay of six days in obtaining a physician-ordered urinalysis (UA) with culture and sensitivity. Staff were aware of the outstanding order but did not notify the physician in a timely manner when unable to collect the specimen, and communication among staff regarding the order was inconsistent. The lack of a clear policy or procedure contributed to the delay in obtaining the necessary lab work.
Staff failed to consistently implement and document pressure ulcer prevention and care interventions for two residents, resulting in the development and worsening of pressure ulcers. Required devices such as heel protectors were not used as ordered, and changes in skin condition were not promptly communicated to the care team or physician, contrary to facility policy.
The facility did not consistently provide or communicate alternative meal options to residents who declined the food initially served, including residents with communication deficits and those with specific dietary needs. Staff were often unaware of available alternatives or did not offer them, and information about substitutes was not posted or accessible to residents. This resulted in residents not being able to exercise their food preferences as outlined in facility policy.
The facility did not timely update care plans for two residents after significant incidents—a pressure injury and a burn from hot coffee. Although interventions were implemented, the care plans did not reflect current treatments or changes in condition, and staff confirmed that updates were not made as required by facility policy.
A resident with cognitive impairment and physical care needs suffered burns after spilling hot coffee, and review showed that required Hot Liquids Risk Assessments were not completed as per facility policy. Staff were unaware of the incident and relevant procedures, and the facility's policy lacked clear assessment details.
Two residents reported that hot foods were frequently served cold or cool, and observations confirmed that food was not consistently held at safe temperatures during meal service. Staff failed to maintain proper food temperatures, did not report broken equipment, and did not always check food temperatures after reheating, resulting in meals being served below required standards.
A resident with an indwelling catheter and moderate cognitive impairment, who was on Enhanced Barrier Precautions (EBP), did not receive proper infection prevention measures during catheter care. A CNA/CMA performed catheter care using gloves but failed to don a gown as required by facility policy, a lapse confirmed by the DON. The facility's policy mandated both gown and gloves for such care to prevent MDRO transmission.
A resident with intact cognition and on anticoagulant medication fell and sustained a head injury due to the facility's failure to use a gait belt during a transfer. Despite the care plan requiring staff assistance and the use of a gait belt, these measures were not followed, leading to the resident's fall in the bathroom. Staff interviews confirmed the facility's policy on gait belt usage, but it was not adhered to at the time of the incident.
A significant medication error occurred when a resident with severe cognitive impairment was mistakenly given medications intended for her roommate. The error was discovered after the resident exhibited symptoms such as vomiting and lethargy, and lab tests confirmed the presence of unprescribed medications. The incident was attributed to a Registered Nurse's failure to adhere to the facility's medication administration policy, including proper resident identification and medication preparation procedures.
The facility failed to ensure privacy and dignity for residents during personal care and interactions. A resident felt undignified when a window was left open during care, and several residents reported disrespectful treatment by a CNA, including rough handling and unresponsiveness. Staff interviews corroborated these concerns, leading to the CNA's termination.
The facility failed to develop comprehensive care plans for two residents, omitting necessary details for anticoagulant and diuretic therapies. A resident with severe cognitive impairment and hypertension was prescribed a diuretic, but the care plan did not reflect this. Another resident with coronary artery disease and hypertension was prescribed an anticoagulant, yet the care plan lacked documentation for this medication. Staff acknowledged that these therapies should have been included in the care plans.
A facility failed to conduct regular care plan conferences for a resident with no cognitive impairment, as neither the resident nor their family were invited to participate. Staff confirmed that care conferences were not held quarterly as required, with the last documented meeting occurring months prior. The facility's policy encourages resident and family involvement in care planning, but this was not followed in this instance.
The facility failed to follow infection control measures during catheter care for two residents. In one case, staff did not wear a gown as required by Enhanced Barrier Precautions (EBP), and in another, a CNA did not perform hand hygiene between glove changes. The Director of Nursing confirmed the expectation for proper PPE use and hand hygiene.
Failure to Timely Obtain Urinalysis and Notify Physician
Penalty
Summary
The facility failed to provide needed services in accordance with professional standards by not obtaining a urinalysis (UA) in a timely manner and failing to notify the physician of the failed attempt for one resident. The resident, who had moderate cognitive impairment and chronic kidney disease, had a physician's order for a one-time UA with culture and sensitivity, which was to be completed within a specified timeframe. However, the UA was not obtained until six days after the order was placed, despite multiple staff being aware of the outstanding order and the resident's ongoing need for the test. Documentation and interviews revealed that staff were unclear about the procedures for timely notification of the physician when unable to obtain a UA. The nurse responsible stated she would wait up to 48 hours before notifying the physician or requesting a straight catheterization, but in this case, the delay extended to five days. Communication among staff was inconsistent, with some staff unaware of the order and others not taking steps to facilitate urine collection, such as placing a collection hat in the bathroom. The resident's family also questioned why the physician was not notified sooner about the inability to obtain the UA. The delay in obtaining the UA was further compounded by confusion regarding specimen collection and communication breakdowns between shifts. The order for the UA was acknowledged by staff, but there was no clear policy or procedure guiding how quickly the lab should be obtained or when to escalate to the physician. The Director of Nursing confirmed that the expectation was for the UA to be obtained before the six-day delay occurred, but acknowledged the absence of a formal policy on the matter.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
Staff failed to provide adequate pressure ulcer prevention and care for two residents, resulting in the development and worsening of pressure ulcers. One resident, who was at moderate risk for pressure injury and had significant cognitive and physical impairments, was not consistently provided with required heel protectors as ordered. Observations showed the resident without protective boots, with feet unsupported and dangling while seated in a wheelchair for extended periods. Multiple open wounds and unblanchable red areas were noted on the resident's feet and heels, with staff unaware of the status or treatment of these sores. Documentation was incomplete, lacking timely updates on new wounds and notification to the physician or hospice regarding changes in skin condition. Another resident, with a history of stroke, dementia, and other chronic conditions, experienced repeated episodes of redness and later blackened and scabbed areas on the toes. Despite ongoing skin assessments documenting these changes over several weeks, there was a delay in notifying the care coordinator and physician, and interventions were not implemented promptly. The care coordinator was not aware of the skin condition until several weeks after initial signs were documented, and the director of nursing confirmed that earlier intervention should have occurred. The facility's policy required immediate notification and documentation of impaired skin integrity, which was not followed in these cases. Both cases demonstrated a failure to monitor, document, and respond to changes in skin condition as required by facility policy and care plans. Staff did not ensure that prescribed interventions, such as heel protectors and pressure-reducing devices, were consistently used, nor did they update care plans or notify appropriate medical personnel in a timely manner when new or worsening wounds were identified. These lapses contributed to the development and progression of pressure ulcers in residents who were at risk.
Failure to Provide and Communicate Alternative Meal Options
Penalty
Summary
The facility failed to provide food that accommodated resident preferences and did not consistently offer or communicate appealing alternative meal options to residents who declined the food initially served. Several residents, including those with intact cognitive abilities and those with communication deficits, reported not being aware of available meal substitutes or how to request them. For example, one resident with dysphagia, anxiety, and deafness communicated via writing that he was unaware of meal options beyond what was served and did not know what vegetable substitutes were available. Another resident with diabetes, anxiety, and autism expressed uncertainty about what would happen if he did not eat the served meal and was also unaware of food substitute options. Staff interviews revealed inconsistent knowledge and practices regarding alternative meal options. Some staff members, including CNAs and cooks, were unsure of what alternatives were available or where such options were listed. The dietary manager confirmed that a list of alternatives existed but was not posted or provided to residents, being kept only in a kitchen binder. Staff generally relied on their knowledge of resident preferences or pocket care plans, but did not consistently offer alternatives unless specifically requested, and alternatives were not clearly communicated or visible to residents. Observations during meal service showed that when a resident refused a food item, such as corn, staff did not always offer an alternative, and in some cases, staff were unsure what alternatives could be provided. The menu board listed only the main meal, and there was no system in place for residents to select or be informed of alternative options. Documentation in the admission packet stated that food preferences would be considered, but in practice, residents were not consistently assisted in exercising choice regarding their meals.
Failure to Timely Update Care Plans After Resident Incidents
Penalty
Summary
The facility failed to review and revise care plans for two residents following significant changes in their conditions. For one resident with moderate cognitive impairment and multiple diagnoses, including stroke and dementia, a pressure area developed on the left great toe. Although interventions such as a blanket cradle and wound care were implemented, the resident's care plan and pocket care plan were not updated to reflect the removal of the air mattress or the new interventions for the toe wound. Observations and interviews confirmed that the care plan did not accurately reflect the resident's current needs or the interventions in place. Another resident, who had cognitive impairment and required setup for eating, sustained burns on the inner upper thighs after spilling hot coffee. The pocket care plan was updated to include the addition of ice cubes to coffee, but the main care plan was not revised to document the burn incident or the interventions trialed and refused by the resident. The care plan also did not include the family's responses to the incident. Staff interviews confirmed that the care plan should have been updated following the incident, and facility policy required individualized interventions for hot liquids to be noted in the care plan. Facility policies reviewed indicated that care plans should be updated after changes in condition and after each comprehensive review or quarterly assessment. Despite these policies, the care plans for both residents were not revised in a timely manner to reflect new interventions or changes in condition, as confirmed by staff and administrative interviews.
Failure to Complete Hot Liquids Risk Assessment for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary services in accordance with professional standards by not completing a Hot Liquids Risk Assessment for one resident with cognitive impairment and physical care needs. The resident, who had diagnoses including coronary artery disease, hypertension, and chronic pain, was noted to have short and long-term memory problems and required setup assistance for eating. Despite these needs, the resident was observed drinking coffee on multiple occasions, and a progress note documented that the resident spilled a cup of coffee, resulting in red blistering burns on both inner upper thighs. A review of assessments from January to June revealed that no Hot Liquids Risk Assessment had been completed for this resident, contrary to facility policy, which required such assessments upon admission and quarterly. Staff interviews confirmed a lack of awareness regarding the incident and the facility's policy on serving hot liquids. The Director of Nursing and Administrator both acknowledged that the required assessment was missing, and the facility's Hot Liquid Safety Policy was found to be incomplete regarding assessment procedures.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing and safe temperature to two residents who were cognitively intact, as evidenced by their BIMS scores. Both residents reported that hot foods were served cold or cool on multiple occasions, with one resident specifically stating that food had been served cold in the past week. During meal service observation, staff removed food from the oven and placed it on a stove top that was not turned on, and one of the burners was broken. Staff did not report the broken burner, and food was held on the stove without heat. Temperatures of the food at the start of service were within appropriate ranges, but by the end of service, some items had dropped below the expected holding temperature, with mashed potatoes at 121 degrees and beef stroganoff at 130 degrees. Staff reheated a plate in the microwave for one resident but failed to check the temperature before serving it. Staff interviews revealed inconsistent understanding of required holding and serving temperatures, with expectations ranging from 135 to 150 degrees for holding and 165 degrees for reheating. The facility's policy required hot foods to be served at a minimum of 120 degrees and held at 140 degrees or above, but these standards were not consistently met. Staff and dietary management acknowledged that residents had complained about cold food, and the issue was not communicated or addressed effectively.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency was identified when staff failed to follow appropriate infection prevention practices for a resident with an indwelling catheter who was on Enhanced Barrier Precautions (EBP). The resident, who had moderate cognitive impairment and required EBP due to the presence of an indwelling catheter, had care plans and physician orders specifying catheter care and the use of EBP supplies. During an observed catheter care procedure, a Certified Nursing Assistant/Certified Medication Assistant performed hand hygiene and wore gloves but did not don a gown as required by the facility's EBP policy. The staff member completed the catheter care without the gown, despite the policy stating that both gown and gloves must be worn during high-contact resident care activities for residents with indwelling medical devices. The Director of Nursing confirmed that the facility's expectation was for staff to wear a gown during any catheter care or contact with a catheter for residents on EBP. The facility's policy, implemented prior to the incident, clearly outlined the need for both gown and gloves during such care to prevent the transfer of multidrug-resistant organisms (MDROs). The failure to adhere to these established infection prevention protocols was observed and acknowledged by facility leadership.
Failure to Use Gait Belt Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in a fall and injury. The resident, who had intact cognition and required partial to moderate assistance for transfers, was on anticoagulant medication and had a history of heart failure and renal insufficiency. The care plan indicated the need for staff assistance during transfers and the use of a gait belt, but these measures were not followed at the time of the incident. On the day of the incident, the resident was found on the floor with a laceration to the back of the head after a fall in the bathroom. The resident was not wearing a gait belt or knee brace, which were required for safe transfers. Staff H, the CNA assisting the resident, admitted to not using a gait belt and being unprepared to prevent the fall. The resident was subsequently sent to the hospital due to the risk of complications from anticoagulant therapy. Interviews with staff revealed that the facility policy required the use of gait belts for all non-mechanical transfers, and staff were aware of this requirement. However, the policy was not adhered to during the incident, leading to the resident's fall and injury. The facility had provided gait belts and communicated the resident's assistance needs, but these protocols were not followed, resulting in the deficiency.
Significant Medication Error Due to Improper Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving Resident #24. Resident #24, who had severe cognitive impairment and a history of diabetes mellitus and hemiplegia, was mistakenly administered medications intended for her roommate, Resident #13. This error occurred during the 7 PM medication pass on June 9, 2024, when Staff D, a Registered Nurse, administered Risperdal and Depakote to Resident #24, medications that were not prescribed for her. The error was discovered after Resident #24 exhibited symptoms such as vomiting and lethargy, and lab tests confirmed the presence of these medications in her system. The incident was initially reported by Staff C, a Certified Nursing Assistant, who observed discrepancies in the medication administration process. Staff C noted that Resident #13 had not received her medications and reported the situation to Staff B, a Licensed Practical Nurse and Care Coordinator. Despite attempts to clarify the situation, it was not until the following day that the error was confirmed through lab results. The facility's medication administration policy, which includes verifying resident identity and ensuring medications are administered as prescribed, was not adhered to by Staff D, leading to the medication error. Camera footage from the evening of the incident showed Staff D administering medications to Resident #24 without proper verification and preparation procedures. The footage also captured Staff D's actions that were inconsistent with the facility's medication administration policy, such as crushing pills and mixing them with pudding without proper documentation or verification. The facility's failure to follow established procedures for medication administration resulted in a significant medication error, affecting Resident #24's health and well-being.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to provide privacy and dignity to residents during personal care, as evidenced by multiple observations and interviews. Resident #15, who had no cognitive impairment, expressed feeling undignified when the window was left open during a wound vacuum dressing change, allowing visibility from outside. Staff involved acknowledged the oversight, and the Director of Nursing confirmed that the facility's expectation was to ensure privacy by closing doors or curtains during care. Additionally, the facility's investigation revealed that Staff A, a Certified Nursing Assistant, was reported by several residents to have treated them disrespectfully. Resident #1, with no cognitive impairment, reported that Staff A was mean and uncommunicative. Resident #3, also cognitively intact, described Staff A as rough and expressed relief when she left. Resident #13, with moderately impaired cognition, reported that Staff A refused to provide ice water, called them a whiner, and ignored them. Resident #44, also with moderately impaired cognition, reported that Staff A did not respect their choices and was sometimes sassy. Interviews with other staff members corroborated these reports, with some describing Staff A as rude or snappy. Staff B, an LPN, noted that residents felt safer after Staff A was no longer present. The facility's administrator confirmed that an investigation was conducted, and Staff A was terminated following confirmation of a pattern of disrespectful behavior towards residents.
Failure to Include Anticoagulant and Diuretic Therapies in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which included necessary details for anticoagulant and diuretic therapies. Resident #43, who has severe cognitive impairment and diagnoses of essential hypertension and localized edema, was prescribed furosemide, a diuretic, but the care plan did not reflect this treatment. The diuretic was discontinued during a hospital stay and restarted about a month prior to the survey, yet the care plan remained incomplete. Staff F, an LPN, acknowledged that the facility's expectation was for the use of a diuretic to be included in the care plan. Similarly, Resident #38, with diagnoses of coronary artery disease, hypertension, and transient ischemic attack, was prescribed Xarelto, an anticoagulant, but the care plan lacked documentation for this medication. Staff F, responsible for completing care plans for Resident #38's unit, confirmed that anticoagulants should have been included in the care plans. The Director of Nursing also stated that the facility's expectation was for care plans to include the use of anticoagulants and diuretics for the respective residents.
Failure to Conduct Regular Care Plan Conferences
Penalty
Summary
The facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team, including the resident and their representative, for one of the residents reviewed. Resident #34, who entered the facility on April 1, 2021, and had no cognitive impairment as indicated by a BIMS score of 14, reported that neither she nor her family were invited to care plan conferences. This lack of involvement in care planning was confirmed by staff interviews and a review of the facility's electronic health records. Staff I, the Recreation Coordinator, and Staff J, the Resident Services Director, acknowledged that care conferences for Resident #34 were not held every three months as required. The last documented care conference was in January 2024, and there was no evidence of quarterly meetings being conducted. The Director of Nursing also confirmed the absence of documentation for quarterly care conferences. The facility's policy encourages resident and family participation in care planning, but this was not adhered to in the case of Resident #34.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to adhere to universal infection control measures and Enhanced Barrier Precautions (EBP) during catheter care for two residents. In the first instance, a Certified Nursing Assistant (CNA) and a Medication Aide performed catheter care for a resident without wearing a gown, as required by EBP. Although they completed hand hygiene and donned gloves, they neglected to wear the necessary gown while draining the urinary collection bag, which resulted in urine spilling onto the floor. The staff acknowledged forgetting to wear the gown, and the Director of Nursing (DON) confirmed that the expectation was for the correct personal protective equipment (PPE) to be worn during such procedures. In the second instance, a CNA performed catheter care for another resident but failed to perform hand hygiene consistently between glove changes. The CNA completed hand hygiene initially and donned gloves and a gown, but after removing gloves and performing various tasks, such as moving the resident and emptying the urine graduate, the CNA did not perform hand hygiene before donning new gloves. The DON stated that the facility's expectation was for hand hygiene to be completed with all glove changes and before and after all resident care. The facility's hand hygiene policy emphasized that gloves are not a substitute for hand hygiene and that hand hygiene should be performed before and after glove use.
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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