Good Samaritan - Holstein
Inspection history, citations, penalties and survey trends for this long-term care facility in Holstein, Iowa.
- Location
- 505 West Second Street, Holstein, Iowa 51025
- CMS Provider Number
- 165207
- Inspections on file
- 19
- Latest survey
- June 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Good Samaritan - Holstein during CMS and state inspections, most recent first.
The facility did not update care plans to reflect significant changes in the status and care needs of three residents, including a resident admitted to hospice, another who experienced a fall with a new intervention, and a third with notable weight loss and new diabetic management orders. These omissions were identified through clinical record review, staff interviews, and facility policy review.
A facility failed to document a resident's advanced directives upon admission. The resident's Care Plan lacked information on CPR preferences, and the EHR did not indicate a code status or advanced directive. The resident expressed a desire for CPR, but the DON was unaware of the missing documentation, stating staff should check the EHR for code status.
The facility failed to develop comprehensive care plans for three residents with severe cognitive impairments and various medical conditions. One resident's care plan lacked direction for diabetes management, another's did not address high-risk medication side effects, and a third's did not specify target behaviors or interventions for antidepressant use. The DON acknowledged these deficiencies, which contravened the facility's policy for individualized care plans.
The facility failed to provide adequate oral care for two residents with cognitive impairments, as required by their care plans. Despite needing assistance, there was insufficient documentation of oral hygiene in the EHR. Staff interviews confirmed that oral care was not consistently documented, and the DON acknowledged a mistake in task scheduling, leading to this deficiency.
A facility failed to provide adequate supervision and ensure the functionality of safety devices for two residents with severe cognitive impairments. One resident, at high risk for falls, was not provided with a gait belt during an incident where they were lowered to the floor after complaining of leg pain. Another resident, at risk for elopement, had a non-functional wander guard, with no documentation of daily checks as required. These deficiencies highlight lapses in adherence to care plans and safety protocols.
The facility failed to perform a gradual dose reduction (GDR) for a resident on Seroquel and did not document target behaviors or non-pharmacological interventions for another resident on psychotropic medications. The Director of Nursing confirmed the lack of GDR attempts, and staff interviews revealed missing documentation in care plans, contrary to facility policy.
The facility failed to ensure proper infection control during meal assistance. An RN was observed assisting two residents simultaneously without hand hygiene, and a CNA made direct contact with a fork's tines without replacing it. Staff interviews confirmed the facility's protocol requires hand hygiene between residents and utensil replacement if contact is made with eating surfaces.
A resident with severe cognitive deficits was subjected to abuse and restraint by two CNAs in a LTC facility. The resident, who required substantial assistance and exhibited behavior symptoms, was repeatedly pushed back into a chair and had her mouth covered by one CNA, while the other failed to intervene. The incident was initially witnessed but not reported immediately, highlighting a failure to adhere to the facility's abuse and neglect policy.
A resident with severe cognitive deficits was subjected to inappropriate handling by a CNA, who restrained her movements and covered her mouth, causing distress. Another CNA present did not intervene or report the incident. The facility failed to report the suspected abuse immediately and did not separate the alleged abuser from residents in a timely manner, violating their abuse prevention and reporting protocols.
A resident with severe cognitive deficits was subjected to inappropriate and punitive measures by CNAs in a LTC facility. The resident, who required substantial assistance and had a history of Alzheimer's disease, was restrained by being pushed into a chair and having her mouth covered to silence her. The incident was witnessed by the Activities Director and confirmed by video footage, revealing a lack of adequate training and competency testing in dementia care among staff.
The facility failed to accurately account for Schedule II medications for two residents, leading to discrepancies in administration records. A resident with severe cognitive deficits had discrepancies in Ativan administration, while another resident had leftover medications unaccounted for. Additionally, the facility did not secure medications properly, with a medication cart left unattended and a medication room door propped open. The Controlled Drug Count Record lacked proper documentation, indicating a lack of oversight in medication management.
Failure to Update Care Plans Following Changes in Resident Status and Interventions
Penalty
Summary
The facility failed to update and revise care plans to accurately reflect the current needs and interventions for three residents. For one resident with diagnoses including heart failure, renal insufficiency, diabetes mellitus, and hypertension, and who was admitted to hospice care, the care plan was not updated to reflect the hospice admission. Another resident with heart failure, renal insufficiency, peripheral vascular disease, and toxic liver disease experienced a fall, and although an intervention was documented in the progress notes, this intervention was not added to the care plan. A third resident with non-Alzheimer's dementia, diabetes mellitus, anxiety, and obesity experienced significant weight loss and had physician orders for daily blood sugar monitoring and diabetic medications with weight loss as a side effect, but the care plan was not updated to reflect these changes. Review of facility policy indicated that care plans are to be developed using an interdisciplinary team approach and must be updated to reflect the care currently required or provided for the resident, especially after significant changes in condition. Staff interviews confirmed that the expectation is for care plans to be updated when interventions or care needs change, but this was not done for the residents reviewed.
Failure to Document Advanced Directives for a Resident
Penalty
Summary
The facility failed to implement or follow through with advanced directives for a resident upon admission. The entry Minimum Data Set (MDS) indicated that the resident entered the facility on a specific date, but the Care Plan implemented did not document whether the resident wanted cardiopulmonary resuscitation (CPR) if needed. A review of clinical records showed a lack of documentation regarding the resident's code status or any advanced directive. The Electronic Health Record (EHR) did not indicate whether the resident required CPR or was designated as do not resuscitate (DNR). During an interview, the resident expressed a desire for CPR, but the Director of Nursing (DON) was unaware of the missing code status in the EHR, stating that staff are instructed to check the EHR for code status if CPR is required.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, each with severe cognitive impairments and various medical conditions. Resident #10, diagnosed with diabetes mellitus and other conditions, had a care plan that lacked direction for managing diabetes and insulin usage, including blood sugar monitoring and parameters for physician notification. Resident #16, who was on antidepressant and antipsychotic medications, had a care plan that did not address the potential side effects and monitoring requirements for these high-risk medications. The Director of Nursing acknowledged the expectation for these elements to be included in the care plan. Resident #31, with chronic kidney disease, diabetes, and other conditions, had a care plan that included antidepressant medication use but did not specify individualized target behaviors or non-pharmacological interventions. The resident's spouse confirmed the use of medication for behavior concerns, but the care plan lacked documentation of target behaviors and interventions. The Director of Nursing confirmed that target behaviors should be documented in the care plan and progress notes, but was unable to locate this information. The facility's policy requires individualized, comprehensive care plans with measurable goals, which was not adhered to in these cases.
Inadequate Oral Care Documentation for Residents
Penalty
Summary
The facility failed to provide adequate oral care for two residents, both of whom required assistance with oral hygiene due to cognitive impairments. Resident #22, with a BIMS score indicating they were rarely or never understood, required substantial assistance for oral hygiene. Despite the care plan instructing staff to assist with oral care every morning and evening, there was no documentation of oral care being performed in the last 30 days. Similarly, Resident #24, with severely impaired cognition and fully dependent on staff for oral care, had only three instances of oral hygiene documented in the same period, despite the care plan's directive for oral care twice daily or after each meal. Interviews with staff revealed a lack of consistent documentation practices, with oral care typically documented in the Electronic Health Record (EHR) once per shift. Staff members confirmed that if oral care was not documented, it was assumed not to have been done. The Director of Nursing acknowledged the absence of documentation and attributed it to a mistake in entering care tasks, which were set to be documented as needed rather than as a scheduled daily task. This oversight led to a deficiency in providing necessary oral care for the residents.
Inadequate Supervision and Safety Device Failures
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident with severe cognitive impairment and a high risk for falls. The resident, who required assistance with mobility and transfers, was not provided with a gait belt as directed in the care plan during an incident where they became unsteady and were lowered to the floor by a CNA. The resident had been complaining of right leg pain prior to the fall, which was not reported to the charge nurse until after the incident. The facility's investigation did not clarify whether a gait belt was used, and there was no follow-up on a request for physical therapy evaluation made a month prior to the incident. Another resident, also with severe cognitive impairment and at risk for elopement, was found to have a non-functional wander guard. The facility's records lacked documentation of daily checks for the placement and functionality of the wander guard, as required by the care plan and physician orders. The resident exhibited behaviors such as pacing, attempting to leave the facility, and hitting staff, indicating a need for close monitoring and functional safety devices. The facility's failure to ensure the proper use of safety devices and adequate supervision contributed to the deficiencies identified. The lack of documentation and follow-up on critical safety measures, such as the use of gait belts and the functionality of wander guards, highlights gaps in the facility's adherence to care plans and safety protocols.
Failure to Implement Gradual Dose Reductions and Document Target Behaviors
Penalty
Summary
The facility failed to complete a gradual dose reduction (GDR) for a resident who was taking Seroquel, an antipsychotic medication, for an adjustment disorder with mixed anxiety and depressed mood. The resident's clinical record lacked documentation of any GDR attempts in the past year, and there was no clinical rationale provided by a physician for continuing the medication without a GDR. The Director of Nursing (DON) confirmed that no GDR had been attempted since July 2023, despite the facility's policy requiring GDR attempts within the first year of initiating a psychotropic medication, unless clinically contraindicated. Another resident's care plan failed to include non-pharmacological interventions and targeted behaviors for monitoring and redirection, despite the resident receiving antipsychotic and antidepressant medications. The resident's electronic health record and progress notes did not identify specific target behaviors for the antidepressant medication, and staff interviews revealed that the care plan lacked documentation of these behaviors and interventions. The DON acknowledged that target behaviors and non-pharmacological interventions should be documented but were not found in the resident's records. The facility's policy on psychotropic medications emphasized the importance of gradual dose reductions and behavioral interventions unless clinically contraindicated. However, the facility did not adhere to these guidelines, as evidenced by the lack of GDR attempts and the absence of documented target behaviors and non-pharmacological interventions for the residents involved. This oversight indicates a failure to comply with federal regulations and facility policies regarding the management of psychotropic medications.
Inadequate Hand Hygiene During Meal Assistance
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during meal assistance, as observed on multiple occasions. On March 17, 2025, a Registered Nurse (RN), identified as Staff J, was seen assisting two residents with eating simultaneously without performing hand hygiene between assisting each resident. Additionally, Staff J was observed touching her face and continuing to assist the residents without sanitizing her hands. Similar observations were made on March 18, 2025, when Staff J again assisted two residents without hand hygiene between them. Furthermore, Staff K, a Certified Nurse Aide (CNA), was seen making direct contact with the tines of a fork while assisting a resident with eating, and continued to use the same utensil without replacing it. Interviews with various staff members, including a Certified Medication Aide (CMA), another CNA, and a Registered Nurse (RN), revealed that the facility's protocol prohibits assisting two residents at the same time without hand hygiene in between. They also confirmed that direct contact with the eating surface of utensils requires replacement of the utensil. The Director of Nursing (DON) reiterated these expectations, emphasizing the need for hand hygiene between residents and utensil replacement if contact is made with the eating surface. The facility's Infection Prevention and Control Program document, last revised in December 2024, mandates standard precautions, including proper hand hygiene for all residents.
Resident Abuse and Restraint by CNAs
Penalty
Summary
The facility failed to protect a resident from abuse, as observed in an incident involving two Certified Nurse Aides (CNAs), Staff E and Staff F. The resident, who had a severe cognitive deficit and required substantial assistance with daily activities, was subjected to punitive restrictions and restraints. Staff E was seen on video pushing the resident back into a chair multiple times, holding the resident's arms down, and placing a hand over the resident's mouth to silence her. Staff F, who was present during these actions, did not intervene or report the incident. The resident, who had a history of Alzheimer's disease and exhibited behavior symptoms such as verbal aggression and resistance to care, was described as restless, anxious, and confused during the incident. Despite the resident's attempts to stand and move, Staff E repeatedly restrained her by pushing her back into the chair and pinning her against the table. The resident's agitation increased as a result of these actions, leading to further attempts to stand and verbal outbursts. The incident was initially witnessed by Staff B, the Activities Director, who did not immediately report the abuse, believing it was not a significant concern. It was only after reviewing the video footage that the full extent of the abuse was recognized. The facility's policy on abuse and neglect emphasizes the right of residents to be free from abuse and the importance of immediate reporting of any suspected violations, which was not adhered to in this case.
Failure to Report and Address Suspected Abuse
Penalty
Summary
The facility failed to report suspected abuse immediately and did not separate an alleged abuser from residents in a timely manner. A staff member witnessed a CNA covering the mouth of an agitated resident but delayed reporting the incident for over two hours. The incident involved Resident #1, who had a severe cognitive deficit and required substantial assistance with daily activities. The resident was diagnosed with Alzheimer's disease and exhibited behavior symptoms such as verbal aggression and resistance to care. On the day of the incident, a video review revealed that Staff E, a CNA, repeatedly pushed Resident #1 back into a chair and restrained her movements by holding her arms and covering her mouth. Staff F, another CNA present during the incident, failed to intervene or report the actions. The resident appeared agitated and distressed, attempting to stand multiple times, only to be forced back into the chair by Staff E. The situation escalated to the point where the resident was crying and appeared to be in emotional distress. The facility's investigation showed that the Director of Nursing was informed of the incident later in the day, after Staff E had left the facility. Staff B, who initially witnessed the incident, did not report it immediately, believing it was not a significant concern. The facility's policy on abuse and neglect required immediate reporting of any suspected mistreatment, which was not adhered to in this case. The actions of Staff E and the inaction of Staff F and Staff B contributed to the deficiency, highlighting a failure in the facility's abuse prevention and reporting protocols.
Inadequate Dementia Care and Use of Restraints
Penalty
Summary
The facility failed to ensure that staff displayed competent dementia care and safe interventions for a resident with severe cognitive deficits. The resident, who had a BIMS score of 3 indicating a severe cognitive deficit, required substantial assistance with daily activities and had a history of Alzheimer's disease, cancer, anemia, and a hip fracture. The care plan for the resident indicated the need for 24/7 supervision and specific interventions to manage her behavior, which included verbal aggression and resistance to care. On the day of the incident, Staff E, a CNA, was observed using inappropriate and punitive measures to control the resident's movements. The CNA was seen pushing the resident down into a chair, holding her wrists, and placing a hand over her mouth to silence her. These actions were taken despite the resident's visible agitation and attempts to stand, which were met with further restraint by the CNA. Staff F, another CNA present during the incident, failed to intervene or report the inappropriate actions of Staff E. The incident was witnessed by Staff B, the Activities Director, who reported hearing the resident screaming and observed Staff E's hand over the resident's mouth. The facility's video footage confirmed the inappropriate handling of the resident, including the use of physical restraint by pushing the chair against the table to prevent the resident from standing. Interviews with staff revealed a lack of adequate training and competency testing in dementia care, contributing to the inappropriate handling of the resident.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to ensure accurate accounting of Schedule II medications for two residents, leading to discrepancies in medication administration records. Resident #3, who had severe cognitive deficits and was dependent on staff for daily activities, had discrepancies in the administration of Ativan, with the Individual Resident Narcotic Record (IRNR) showing more administrations than recorded on the Medication Administration Record (MAR). Similarly, Resident #4, who had intact cognitive ability and was independent in daily activities, had leftover medications that were not accounted for, and the facility's process involved destroying these without proper documentation. Additionally, the facility did not maintain secure storage of medications, as observed when a medication cart was left unattended with keys in the narcotic drawer, and the medication room door was propped open. The Controlled Drug Count Record also lacked proper documentation, with missing nurse initials on several dates, and a Licensed Practical Nurse pre-signed for shifts, indicating a lack of proper oversight and accountability in medication management.
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.
