Good Samaritan - George
Inspection history, citations, penalties and survey trends for this long-term care facility in George, Iowa.
- Location
- 324 First Avenue North, George, Iowa 51237
- CMS Provider Number
- 165247
- Inspections on file
- 17
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Good Samaritan - George during CMS and state inspections, most recent first.
The facility did not meet staffing requirements due to inaccurate PBJ data submission, which showed excessively low weekend staffing despite reports that nurse and CNA schedules were consistent throughout the week. The Administrator was unaware of the data submission process and confirmed the absence of a PBJ policy, while the DON attributed the discrepancy to the use of corporate staffing pool personnel.
Staff failed to provide accurate meal portions to residents, with pureed meals being served in incorrect amounts and without proper measurement. Some residents received only half portions without care plan authorization, and staff relied on visual estimation rather than precise measurement, contrary to facility policy and dietary orders.
Surveyors found that food items in the kitchen and refrigerator were not labeled, dated, or stored according to facility policy and professional standards. Open containers of cereals, syrups, dairy products, juices, and dressings were observed without required labels or open dates, and some items were improperly stored, such as uncovered cake and a box of oranges on the floor. Interviews with the Dietary Manager and Administrator confirmed these practices did not meet expectations.
A resident with severe cognitive impairment was transferred to the hospital twice, and on both occasions, the facility failed to obtain the required signature from the resident's representative on the bed hold notice, relying only on verbal authorization and not following policy to mail the notice if the representative was not present.
A resident with multiple medical conditions who used a CPAP machine nightly did not have current CPAP orders or settings entered into the electronic chart, and the use of the CPAP was not included in the care plan. Staff interviews confirmed the omission occurred during a change in responsibility, and facility policy requiring documentation and care planning for respiratory devices was not followed.
A CNA allegedly slapped a cognitively impaired resident during care, but the incident was not reported immediately, allowing the CNA to continue working with residents. The facility's policy requires immediate reporting of abuse, but staff failed to follow this protocol, delaying the investigation and exposing residents to potential harm.
The facility failed to serve full food portions and did not consistently fill and empty scoop utensils during meal preparation. Meals were partially switched due to improperly thawed meat, and incorrect scoop sizes led to inconsistent food portions for residents. The facility lacked a policy on portion size and scoop usage, and the Administrator expected correct food servings as per the menu.
The facility failed to submit accurate staffing reports for the CMS PBJ Staffing Data Report, showing excessively low weekend staffing and insufficient licensed nursing coverage for four or more days. The issue arose from incorrect payroll data, as employees were not punched in for breaks, leading to inaccurate reporting.
A facility failed to ensure proper hand hygiene during urinary catheter care for a resident. A CNA was observed changing gloves multiple times without performing hand hygiene in between, contrary to the facility's policy. The Nurse Educator present acknowledged the oversight.
A resident with severe cognitive impairment was physically abused by a CNA during bedtime care, as the CNA became frustrated and swatted the resident's arm. The incident was witnessed by another CNA but was not reported immediately, delaying intervention. The facility's policy on abuse and neglect was not followed, as the incident was only reported to the DNS several days later, allowing the involved staff member to continue working with residents.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairment within the required 2-hour timeframe. The incident, where a CNA allegedly swatted the resident's arm during care, was reported to the DNS on June 27, but the facility delayed notifying the authorities until later that day, violating state regulations.
Failure to Accurately Report Staffing Data in PBJ Submission
Penalty
Summary
The facility failed to meet staffing requirements in all metrics as evidenced by the CMS Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Quarter 2, 2025, which showed excessively low weekend staffing data. The facility reported a census of 31 residents during this period. Staffing schedules for nurses and CNAs were reportedly similar for both weekdays and weekends, but the PBJ data submitted indicated otherwise. The Administrator stated he was unaware of how the corporate office submitted staffing data and confirmed there was no facility policy regarding PBJ. The Director of Nursing (DON) suggested the low weekend staffing data may have resulted from the use of corporate-supplied staffing pool personnel, but maintained that actual staffing levels did not differ between weekdays and weekends and that insufficient staffing did not occur during the quarter.
Failure to Serve Proper Meal Portions to Residents
Penalty
Summary
Facility staff failed to serve proper portion sizes to residents during meal service, as observed during a meal preparation and service. Staff A prepared pureed meals by combining multiple servings of meat, potatoes, roll, and gravy, as well as spinach, but did not accurately measure the portions according to the residents' dietary requirements. Instead of providing the prescribed two #8 scoops of the pureed mixture per resident, Staff A served only one scoop of each mixture to two residents, leaving extra food in the pan. When questioned, Staff A was unable to confirm the exact measurements used and admitted to estimating portion sizes based on visual cues rather than precise measurement. Additionally, approximately ten plates were served with smaller, unmeasured portions because residents reportedly requested half servings, but only one resident was care planned for half portions. Interviews with the Dietary Manager and review of facility policies confirmed that staff are expected to serve full portions unless otherwise ordered and documented in the care plan. The Dietary Manager acknowledged that Staff A should have served the correct portions and that only one resident was authorized for half portions. Facility policy also specifies that pureed foods should not be combined unless requested and documented, and that meals should be well-balanced and provide adequate nutrition. The Administrator confirmed that staff are required to serve proper amounts as ordered.
Failure to Store and Prepare Food Under Sanitary Conditions
Penalty
Summary
Surveyors observed multiple instances of improper food storage and preparation in the facility's kitchen. During an initial walkthrough, several open food items, including containers of Cheerios, rice cereal, raspberry syrup, oatmeal, and cornstarch, were found without labels or open dates. In the refrigerator, there were uncovered servings of cake, open cartons of liquid egg, heavy whipping cream, white milk, pitchers of orange and apple juice, thickened water, open containers of Greek yogurt past their expiration date, and various dressings and sauces, all lacking required labels or open dates. Additionally, a box of oranges was found sitting directly on the floor. These findings were in direct violation of the facility's policy, which requires opened or prepared foods to be placed in enclosed containers, labeled, dated, and stored properly. Interviews with the Dietary Manager and the Administrator confirmed that their expectations aligned with the facility's policy, specifically that dietary staff should date items when opened and ensure proper storage, including covering and labeling. The failure to follow these procedures was evident in the observed conditions, as numerous food items were not labeled, dated, or stored according to professional standards and facility policy. The facility had a census of 31 residents at the time of the survey.
Failure to Obtain Required Bed Hold Notice Signatures
Penalty
Summary
The facility failed to ensure that required bed hold notices were properly signed by the resident's representative when a resident with severe cognitive impairment was transferred out of the facility on two separate occasions. Clinical record review showed that the resident, who had diagnoses including hypertension, anemia, and arthritis, was hospitalized twice, and in both instances, the bed hold documentation only included verbal authorization from the resident's representative without obtaining the necessary signature. Facility policy requires that the Notice of Bed-Hold Policy be mailed if the family or representative does not come to the facility to receive a copy, but there was no evidence that this was done. Interviews confirmed that the signatures were missed and should have been obtained.
Failure to Document and Care Plan CPAP Use for Resident
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for a resident who required nightly use of a continuous positive airway pressure (CPAP) machine. The resident, who had diagnoses including renal insufficiency, diabetes, and anemia, reported using a CPAP nightly. Observations confirmed the presence of a CPAP machine at the bedside, and a faxed physician's order for the device was present. However, the facility did not enter the CPAP order or its settings into the electronic chart, and the resident's care plan did not reflect the use of the CPAP machine. The Minimum Data Set (MDS) assessment also failed to indicate the resident's use of a non-invasive mechanical ventilator. Interviews with facility staff revealed that the omission occurred during a transition of responsibility from the Director of Nursing (DON) to the MDS Coordinator. Both the MDS Coordinator and the DON confirmed that the CPAP order and care plan documentation were missing. The facility's policy required provider orders for respiratory devices to be recorded and included in the care plan, but these steps were not followed for this resident.
Failure to Report Abuse Allegation Promptly
Penalty
Summary
The facility staff failed to report an allegation of abuse involving a Certified Nurse Aide (CNA) who allegedly slapped a resident on the upper arm. This incident occurred during bedtime care when the resident, who has severe cognitive impairment due to a stroke, hypertension, and depression, yelled out. The CNA became frustrated and swatted the resident's arm. Despite witnessing the event, the staff did not report it immediately, allowing the alleged perpetrator to continue working with other residents. The incident was not reported to the Director of Nursing Services (DNS) until several days later, when a CNA confided in another staff member about witnessing the abuse. The staff member who was informed did not report the incident immediately, citing distrust in the charge nurse on duty. It was only after further discussion with another staff member that the incident was finally reported to the DNS. The facility's policy requires immediate reporting of any suspected abuse to a supervisor, and the charge nurse is responsible for assessing the situation and ensuring the safety of residents by removing the alleged perpetrator from direct care. However, this protocol was not followed, resulting in a delay in addressing the abuse allegation and exposing residents to potential harm.
Removal Plan
- The local police, resident's physician, and family/responsible party were notified of the allegation. An initial report was made to DIAL within the expected two-hour time frame.
- Staff members who failed to report immediately received immediate education and re-did the Iowa required Dependent Adult Abuse course online. Corrective action was completed as well with both staff members.
- The social services manager interviewed all residents to determine if there were any concerns by residents of care and treatment by staff members. None were identified.
- Education on abuse and neglect for all staff regarding the treatment of residents and the importance of immediately notifying leadership and/or supervisor of any allegation so steps can be immediately taken to remove/separate suspected staff from residents. A quiz for comprehension was completed by staff. Education was completed with all staff prior to any staff working another shift.
- Administrator or designee will audit through abuse and neglect questionnaires 5 team members randomly to include all shifts daily to ensure staff education on abuse and neglect investigation and reporting.
- Audits will be taken to QAPI for further review and recommendations.
- Center leadership has continued to provide daily reminders to staff on the need to report immediately any suspected abuse and/or neglect.
- Center leadership, including the Director of Nursing, Administrator, and Social Services, have ensured that their phone numbers have been made available for all staff to place in their phones to ensure the ability to call them at all times.
- A Skills Fair was completed where continuing reminders and education were again provided.
Failure to Serve Correct Food Portions
Penalty
Summary
The facility failed to serve the full portions of food to residents and did not consistently fill and empty scoop utensils when preparing meals. The Dietary Manager (DM) reported that meals were partially switched due to meat not being completely thawed, leading to a replacement meal being served. During meal service, the DM did not completely fill and empty the scoop when serving corn and minced pork, resulting in two residents receiving 1.5 ounces more pork, while the last two residents did not receive full scoops. Additionally, the incorrect scoop size used for broccoli resulted in a resident receiving 2.5 ounces less broccoli. The facility did not provide a policy specifically related to portion size and usage of food scoops when plating food. The Administrator expected staff to serve the correct amount of food as per the menu.
Inaccurate Staffing Reports Due to Payroll Errors
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the period of January 1 to March 31. The report indicated excessively low weekend staffing, with the facility failing to provide licensed nursing coverage 24 hours a day for four or more days within the quarter. Despite the staffing for nurses and Certified Nursing Assistants (CNAs) being scheduled similarly for weekdays and weekends, no issues were found for nursing coverage. The deficiency was attributed to incorrect payroll data, as employees were not punched in for breaks, leading to inaccurate reporting.
Failure in Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during urinary catheter care for a resident. During an observation, a Certified Nursing Assistant (CNA) donned personal protective equipment and retrieved a urine colander. The CNA placed the colander in the bathroom, removed and discarded gloves, but failed to perform hand hygiene before donning new gloves. The CNA then assisted the resident to sit in a recliner, again removed and discarded gloves without completing hand hygiene, and donned new gloves. The CNA continued to handle the resident's catheter drainage without performing hand hygiene between glove changes. The facility's policy, last revised in July 2024, instructed staff to perform hand hygiene after glove removal. The Nurse Educator present during the observation acknowledged the failure to perform hand hygiene after changing gloves.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who physically struck a resident. The resident, who had severe cognitive impairment due to a stroke, hypertension, and depression, was receiving bedtime care when the incident occurred. During the care, the resident yelled out due to discomfort from cold wipes, which led to the CNA becoming frustrated and swatting the resident's upper arm. This incident was witnessed by another CNA, who reported that the resident expressed pain by saying 'ouch' and questioned the action. Despite witnessing the event, the incident was not immediately reported to the Director of Nursing Services (DNS) or management, delaying appropriate intervention. The facility's policy on abuse and neglect, which emphasizes the residents' right to be free from abuse, was not adhered to in this case. The incident was only reported to the DNS several days later, on 6/27/24, after being confided to another staff member. Interviews with staff involved revealed that the incident was not immediately reported, and the resident's condition was not assessed for physical harm immediately following the event. The facility's failure to promptly report and address the incident allowed the staff member involved to continue working with residents, contrary to the facility's policy and the administrator's expectations.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 4, who had diagnoses of stroke, hypertension, and depression. On June 19, 2024, a Certified Nursing Assistant (CNA) allegedly swatted the resident's arm out of frustration during bedtime care. This incident was reported to the Director of Nursing Services (DNS) on June 27, 2024, at 10:20 p.m., but the facility did not submit a self-report to the authorities until 9:34 p.m. on the same day, which was beyond the 2-hour reporting requirement. The facility's policy mandates that any allegations of abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than two hours after the allegation is made. Despite this policy, the DNS acknowledged the delay in reporting the incident to the state. The failure to adhere to the reporting timeline constitutes a deficiency in the facility's compliance with state regulations regarding the timely reporting of abuse allegations.
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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