Golden Age Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Centerville, Iowa.
- Location
- 1915 South 18th Street, Centerville, Iowa 52544
- CMS Provider Number
- 165257
- Inspections on file
- 23
- Latest survey
- October 21, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Golden Age Care Center during CMS and state inspections, most recent first.
A controlled pain medication was removed from locked storage by an LPN and left unattended in a resident's room, resulting in the medication going missing. The resident had moderate cognitive impairment and multiple diagnoses. Facility policy and staff interviews confirmed that medications should not be left unsecured or unattended.
Several residents with chronic conditions were not offered the pneumococcal vaccine as required by CDC guidelines and facility policy. The DON confirmed that eligible residents had not been assessed or offered the vaccine, and documentation was lacking or inconsistent across records. Some residents had received earlier vaccines but were not offered updated versions, and staff interviews confirmed the deficiency.
A resident with diabetes, hypertension, and Parkinson's disease was allowed to self-administer insulin without thorough documentation of an assessment to determine clinical appropriateness. Despite staff facilitating the resident's self-administration and a note indicating he managed the task, the care plan and records lacked comprehensive assessment details as required by facility policy.
A resident with diabetes, hypertension, and Parkinson's disease, who was cognitively intact, reported being left in soiled briefs for hours and missing insulin administration. Multiple staff confirmed the resident voiced these concerns and some reported them to nursing leadership, but there was no documentation that the facility's grievance process was initiated or followed, in violation of policy.
Two residents with significant medical needs experienced delays in receiving assistance due to a malfunctioning call system that failed to alert staff at the nurse's station. Staff and administrator interviews confirmed the system was old, unreliable, and did not consistently provide sound or visual alerts, resulting in prolonged wait times for residents needing help.
A resident with a history of falls, diabetes, and a humerus fracture developed deep tissue injuries on both heels. Required wound care treatments, including application of skin prep, Santyl, and dressings, were not consistently documented or completed as ordered. Staff interviews revealed that missed treatments were due to staffing issues, and an order for PT positioning was not carried out. The DON confirmed that treatments and therapy orders should be completed as ordered.
A resident with diabetes did not receive prescribed insulin or blood sugar checks on two occasions, with medication records and progress notes lacking documentation of administration or refusal. Staff interviews confirmed the omission, and the DON acknowledged that refusals should be documented and the physician notified, but this was not done according to facility policy.
A facility failed to provide consistent restorative therapy for a resident, leading to a deficiency in maintaining the resident's ability to perform activities of daily living. Despite the resident's intact cognitive status and prioritization of improving ambulation, several planned restorative tasks were not completed over a three-month period. Interviews revealed that the restorative aide was often pulled to other duties, and there was a lack of a designated restorative nurse to ensure the program was followed.
A resident with cognitive intactness and requiring assistance with daily activities experienced prolonged discomfort due to a sore groin and peri area. Despite complaints and visible symptoms, staff failed to utilize available barrier creams and instead applied an antifungal powder without an order. The resident's discomfort persisted for eight days before appropriate treatment was ordered, highlighting a lapse in timely intervention and assessment by the facility staff.
A resident with multiple health issues developed a blister on their foot, which was not reported to the physician or family by the nursing staff. Despite the blister's growth and a noticeable odor, the facility failed to communicate the condition's severity, leading to a deficiency in notification protocol.
A resident with multiple comorbidities developed a new blister on the foot, which was treated by a nurse without obtaining physician orders or notifying the power of attorney. The blister worsened, and the treatment was changed without proper authorization. The Advanced Practice Nurse Practitioner was unaware of the issue until later, highlighting a deficiency in communication and protocol adherence.
Controlled Medication Left Unattended and Unsecured
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to keep a controlled medication, Hydrocodone-Acetaminophen, secured and properly administered to a resident with moderate cognitive impairment and diagnoses including non-Alzheimer's dementia, diabetes, and depression. The LPN removed the medication from a locked storage and left it unattended in the resident's room on the bedside table while stepping out to attend to another task, without observing the resident take the medication as required. Upon returning, the LPN discovered the medication was missing and could not be located after searching the room and trash bins. The Director of Nursing confirmed that the expectation was for the medication to be administered immediately after removal from storage and not left unattended. The facility's policy also required medications to be administered as ordered and not left unsecured. Staff interviews corroborated that the medication was left unattended and subsequently went missing.
Failure to Offer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to four out of five sampled residents reviewed for immunizations, despite CDC guidelines and facility policy requiring assessment and offering of the vaccine within 30 days of admission. The Director of Nursing (DON) acknowledged that some residents were eligible for the vaccine but had not been offered it, citing issues such as difficulty accessing the Iowa Immunization Registry Information (IRIS) account and discrepancies between hard chart, electronic records, and a separate file maintained by the DON. A recent pharmacy audit had also identified residents in need of vaccines, but the necessary follow-up had not occurred. Clinical record reviews revealed that several residents, including those with significant medical histories such as diabetes, dementia, coronary artery disease, COPD, and heart failure, either lacked documentation of being offered or receiving the appropriate pneumococcal vaccines per current CDC guidelines. In some cases, residents had received earlier versions of the vaccine but had not been offered the updated vaccines as recommended. Interviews with residents and staff confirmed that eligible residents had not been offered the vaccine, and the facility's policy, last updated in 2017, was not being followed as required.
Failure to Document Assessment for Self-Administration of Insulin
Penalty
Summary
The facility failed to ensure thorough documentation of an assessment regarding a resident's ability to self-administer insulin. Clinical record review, policy review, and staff interviews revealed that a resident with diagnoses including diabetes, hypertension, and Parkinson's disease was self-administering insulin without comprehensive documentation of an assessment to determine if this was clinically appropriate. Although the resident had an intact cognitive status as indicated by a perfect BIMS score, the care plan did not document the resident's ability to self-administer insulin, and the facility's policy required such an assessment. Staff interviews indicated that nursing staff either handed the insulin to the resident or left it on his table, and the resident administered it himself, particularly after refusing to have certain staff administer his insulin. The Director of Nursing was unaware if a formal assessment had been documented, and only a brief handwritten note was found stating the resident had self-administered insulin and "did fine." No further details or formal assessments were available, and it was unclear if staff observation was required during administration. The lack of detailed documentation and assessment constituted the deficiency.
Failure to Promptly Address Resident Grievances
Penalty
Summary
The facility failed to promptly address and resolve grievances raised by a resident with diagnoses including diabetes, hypertension, and Parkinson's disease, who was cognitively intact. The resident reported having to remain in soiled briefs for extended periods, specifically stating that on one occasion he sat in his own waste for 4-5 hours before being changed, and described this as humiliating. Additionally, the resident reported that staff failed to check his blood sugar or administer insulin on a previous occasion. Multiple staff members confirmed that the resident had voiced these concerns to them, and some reported relaying the complaints to nursing leadership or social services. Despite these reports, there was no documentation indicating that the facility's grievance process was initiated or followed in response to the resident's complaints. The facility's grievance policy required prompt efforts to resolve issues, but the administrator stated she was unaware of the concerns and would have expected the grievance process to be carried out if staff had reported them. The lack of documented follow-up or resolution demonstrates a failure to honor the resident's right to voice grievances without discrimination or reprisal, as required by facility policy.
Failure to Maintain Functioning Call System in Resident Areas
Penalty
Summary
The facility failed to provide a properly functioning call system in resident bathrooms and bathing areas for two residents. One resident, with diagnoses including traumatic brain injury, heart disease, renal insufficiency, neurogenic bladder, and reduced mobility, required substantial assistance for transfers and was instructed to use the call light for help. This resident reported waiting up to forty-five minutes for staff assistance, attributing the delay to the malfunctioning call system, which was not visible or audible at the nurse's station. Another resident, with diabetes, depression, vision deficits, and heart disease, used a walker and required prompt staff response. This resident confirmed awareness of the call system malfunction and described having to search for staff when assistance was needed, as the call light in their room was not detected at the nurse's station unless staff happened to walk by and see the overhead light. Staff interviews confirmed the call system was old, frequently malfunctioned, and did not consistently activate sound or light at the nurse's station for several halls. Staff reported that only one hall had a functioning sound system, while others relied solely on overhead lights, which could be missed if not directly observed. The administrator acknowledged ongoing issues with the system, frequent repairs, and the need for replacement. Facility policy required each resident room to have a functioning call light system, but observations and interviews demonstrated that this standard was not met for the affected residents.
Failure to Complete Ordered Pressure Ulcer Treatments and Interventions
Penalty
Summary
The facility failed to carry out ordered interventions and treatments for a resident with pressure ulcers. Clinical record review showed that the resident, who had a history of humerus fracture, falls, and diabetes, was at risk for pressure ulcers and developed deep purple, boggy blisters on both heels, later assessed as suspected deep tissue injuries. The Treatment Administration Records (TARs) indicated multiple instances where required wound care treatments, such as application of skin prep, Santyl ointment, and dressings, were not documented as completed on several dates. Additionally, an order for Physical Therapy for positioning related to heel wounds was not documented as carried out. Staff interviews confirmed that due to staffing issues, some dressing changes and treatments were not completed as ordered, with some shifts failing to follow up on missed treatments. Nursing staff acknowledged that there were times when wound care was not performed as scheduled, and the DON stated that staff are expected to carry out treatments and therapy orders in a timely manner. The lack of documentation and completion of ordered treatments and interventions led to the deficiency in pressure ulcer care for the resident.
Failure to Administer and Document Insulin for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with diabetes, hypertension, and Parkinson's disease did not receive prescribed insulin and blood sugar checks as ordered. The resident's Minimum Data Set indicated insulin dependence, and the Medication Administration Records (MARs) showed orders for blood sugar checks and Novolog insulin administration three times daily. On two separate occasions, the MARs lacked documentation and staff initials for both insulin administration and blood sugar checks during evening shifts. Progress notes also did not indicate whether the resident received or refused insulin on those dates. Interviews with staff revealed that the DON discussed documenting a refusal for insulin, although staff accounts and the resident indicated that the insulin was not administered and the resident was upset about missing a dose. The DON stated that refusals should be documented with reasons and the physician notified, but there was no documentation to support that this process was followed. The facility's policy required accurate recording of physician orders and avoidance of medication errors, which was not adhered to in this instance.
Failure to Provide Consistent Restorative Therapy
Penalty
Summary
The facility failed to provide restorative activity as planned for a resident, leading to a deficiency in maintaining the resident's ability to perform activities of daily living. The resident, who had an intact cognitive status and required moderate assistance with various activities, was supposed to receive restorative tasks 3-6 times per week as part of a Nursing Restorative Care Program. However, documentation indicated that several tasks were not completed in January, February, and March 2025. Interviews with staff and the resident revealed inconsistencies in the provision of restorative therapy, with the restorative aide being pulled to other duties and not consistently providing the planned therapy. The resident, who had a history of a broken hip and other medical conditions, expressed frustration over the lack of progress in his mobility goals, attributing it to the insufficient restorative therapy. The Assistant Director of Nursing acknowledged the lack of a designated restorative nurse and the need for better tracking of the restorative programs. Despite the resident's prioritization of improving ambulation, the facility's failure to consistently implement the restorative care plan contributed to the deficiency.
Failure to Provide Timely Treatment for Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed and provided with timely interventions to maintain their optimal health and well-being. A resident with an intact cognitive status and requiring moderate assistance with daily activities, including having a catheter and occasional bowel incontinence, complained of a sore groin and peri area. Despite the resident's complaints of discomfort and visible redness and tenderness, the staff did not produce a skin sheet or provide immediate appropriate treatment. The resident's discomfort was not addressed promptly, as the staff failed to utilize available barrier creams listed in the Treatment Administration Record (TAR) and instead applied an antifungal powder without an order. The delay in obtaining a physician's order for a barrier cream resulted in the resident experiencing discomfort for eight days before receiving the appropriate treatment. Staff interviews revealed that the nurse on duty was aware of the resident's complaints but did not thoroughly review the TAR, which contained orders for barrier creams that could have alleviated the resident's discomfort. The Director of Nursing indicated that the process for addressing resident complaints involves assessing the resident and contacting the physician for necessary orders, with the only difference on weekends being the need to contact the on-call physician.
Failure to Notify Physician and Family of Resident's Blister
Penalty
Summary
The facility failed to notify a physician and the family representative of a resident upon the discovery of a blistered area on the resident's left foot. The resident, who had an intact cognitive status and required significant assistance with daily activities, was diagnosed with lymphedema, congestive heart failure, renal insufficiency, diabetes mellitus, and morbid obesity. On a skin assessment, a new blister was identified on the resident's left foot, measuring 6 cm by 3.5 cm. Staff A, a registered nurse, noted the blister in a progress note and indicated that the physician was updated, but later admitted in interviews that neither the physician nor the resident's power of attorney (POA) was contacted about the blister. Further interviews revealed that the blister had grown in size by the next assessment, yet there was still no notification to the physician or the POA. The Advanced Practice Nurse Practitioner (ARNP) was unaware of the blister until her return from vacation. The resident's POA discovered the blister's severity during a visit, noting a strong odor in the room attributed to the resident's wounds. The lack of communication regarding the resident's condition and the progression of the blister represents a deficiency in the facility's protocol for notifying relevant parties of changes in a resident's condition.
Failure to Obtain Treatment Orders for New Wounds
Penalty
Summary
The facility failed to obtain treatment orders for a resident who developed new wounds. The resident, who had an intact cognitive status, required significant assistance with daily activities and had multiple diagnoses including lymphedema, congestive heart failure, renal insufficiency, diabetes mellitus, and morbid obesity. On a skin assessment, a new blister was identified on the resident's left foot, which was initially covered with Xeroform and cling wrap by a registered nurse. However, the nurse did not contact the physician to obtain an order for this treatment, nor did she notify the resident's power of attorney about the change in condition. The situation worsened when the blister increased in size, and the nurse changed the treatment to a non-stick telfa dressing without obtaining a physician's order. Again, the physician was not contacted, and the power of attorney was not informed of the condition's progression. The Advanced Practice Nurse Practitioner was unaware of the blister until after returning from vacation, despite the resident's multiple comorbidities that contributed to skin issues. This lack of communication and failure to obtain necessary treatment orders led to the deficiency identified in the report.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
