Good Samaritan - Indianola
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianola, Iowa.
- Location
- 708 South Jefferson, Indianola, Iowa 50125
- CMS Provider Number
- 165186
- Inspections on file
- 27
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Good Samaritan - Indianola during CMS and state inspections, most recent first.
The facility failed to provide adequate nursing staff, particularly on night and weekend shifts, resulting in prolonged call light response times for multiple cognitively intact residents. With only three to four CNAs and two nurses caring for 82 residents across four halls, including an isolated rehab hall, residents reported routinely waiting 45 minutes to over an hour for assistance with toileting, hygiene, and going to bed, and some reduced their use of call lights because help did not arrive. Call light logs documented numerous delays ranging from about 18 minutes to more than two hours. Resident council minutes repeatedly noted concerns about insufficient staffing and delayed call light responses, while CNAs, an RN, and an LPN consistently described the facility as chronically short staffed at night and on weekends. The DON confirmed that the facility expected five CNAs on nights, a 15-minute call light response time, and acknowledged that current staffing and call light times were inadequate, with no clear chain-of-command process when the on-call manager was unavailable.
The facility was cited for repeatedly failing over several survey cycles to correct known staffing deficiencies despite an active QAPI focus on assuring appropriate staffing. Public state survey records showed multiple surveys over a multi-year period with cited staffing violations while the facility maintained a census of 82 residents. QAPI notes identified staffing as an ongoing action item, and the Administrator acknowledged that leadership had been aware of staffing needs prior to his tenure and that the issue represented a repeat failure, though earlier QAPI documentation was unavailable.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required. Surveyors found gaps in staffing and leadership coverage during their review.
Staff failed to maintain the dignity of two residents by not promptly changing a stained shirt and by responding abruptly to a request, leaving one resident feeling insignificant. Another resident with quadriplegia experienced repeated delays in receiving feeding assistance, often being the last to be served meals due to staff unavailability, despite her dependence on staff for eating. These deficiencies were confirmed through observations, resident and staff interviews, and review of facility policies.
A CMA left a cup containing a Senna tablet unattended on a locked medication cart while administering medications, with a resident in a wheelchair nearby. Facility policy requires all medications to be secured and not left accessible when staff are not present. The DON confirmed that medications should not be left unattended.
Staff did not disinfect a mechanical lift between uses for two residents, with CNAs transferring one resident and then another using the same lift without cleaning it in between. Disinfectant wipes were not available on the equipment or in resident rooms, and staff interviews revealed inconsistent disinfection practices and a lack of a specific written policy for cleaning reusable equipment.
A male resident with dementia and a history of hypersexual behaviors was able to enter a female resident's room and inappropriately touch her, despite known risks and prior incidents. The female resident, who had limited mobility and required assistance with ADLs, was asleep during the incident and did not recall it. Staff interventions, including monitoring and alarms, were not sufficient to prevent the abuse, and the care plan for the female resident did not address the risk of resident-to-resident incidents.
Staff did not have access to an accurate code status for a resident with multiple diagnoses and moderately impaired cognition. The binder at the nursing station contained an IPOST form directing CPR, while both the EHR and the IPOST indicated the resident wished to be DNR. The DON confirmed that IPOSTs in the binders were expected to be accurate.
A resident with impaired cognition and physical limitations experienced an incident where another resident entered her room and touched her inappropriately. The care plan was not updated to reflect the incident or to include interventions for her psychosocial and mental health needs, despite facility policy requiring such updates after changes in resident status.
Staff did not follow infection control protocols during incontinence care for a resident, allowing a clean brief to come into contact with urine-soiled bedding. In a separate case, staff failed to use required gowns during high-contact care activities for a resident with a suprapubic catheter and quadriplegia, despite facility policy and care plan directives for Enhanced Barrier Precautions (EBP).
A resident's bathroom floor remained persistently sticky over several days, with shoes sticking to the surface during multiple observations. Despite a policy requiring daily and routine thorough cleaning, the floor was not properly maintained, and staff were aware of issues with the cleaning solution concentration.
A resident with cognitive and physical impairments did not receive timely assistance with incontinence care or nail hygiene, as required by their care plan and facility policy. Staff failed to check or change the resident's incontinence brief for several hours, resulting in a saturated brief and urine odor, and the resident's nails remained untrimmed and dirty despite policy requiring regular care.
Staff failed to respond to call lights within the expected timeframe, with a resident waiting at least 10 minutes and staff repeatedly turning off the call light without providing assistance. Multiple residents reported long waits and inadequate responses. Additionally, a resident with cognitive and physical impairments did not receive timely incontinence care, remaining in a saturated brief for several hours despite care plan directives and facility policy. Staffing shortages contributed to these deficiencies.
The facility failed to provide sufficient staffing, leading to delays in resident care. Residents reported long wait times for assistance, and staff expressed being overworked and unable to take breaks. The facility was often short-staffed, contributing to increased falls and UTIs among residents.
The facility failed to maintain adequate nursing staff, resulting in the DON and ADON working the floor despite a census of 78 residents, exceeding the regulatory limit for a DON to serve as a charge nurse. Staffing files showed the DON worked the floor frequently, leading to her resignation due to burnout. The facility had a staffing contract with an agency but failed to utilize it, contributing to the staffing issues.
The facility failed to maintain appropriate food temperatures during meal service, as observed by surveyors. Residents reported receiving cold meals, linked to a malfunctioning steam table and non-operational plate warmer. The Dietary Cook and CDM confirmed these issues, which had been reported but not resolved. A sample tray showed food temperatures below required levels.
A resident with a high risk for falls experienced multiple falls due to inadequate supervision and care planning. The facility failed to perform a root cause analysis or update the care plan with fall interventions, resulting in repeated falls and a serious head injury. Staff interviews revealed issues with staffing levels and incident reporting, contributing to the deficiency.
A resident with severe cognitive impairment and multiple medical conditions did not receive prescribed lymphedema pump treatments due to the facility's failure to process and implement physician orders accurately. Despite the presence of the pump in the facility, the treatment was not administered, as confirmed by staff interviews and record reviews.
A LTC facility experienced significant medication errors involving two residents. One resident accidentally ingested another's medications, leading to a severe drop in blood pressure and emergency treatment. Another resident received incorrect doses of a pain medication over several instances. Additionally, a nurse was observed leaving a medication cart unattended, with insulin pens and supplies accessible. These incidents highlight failures in medication administration and supervision.
The facility failed to provide adequate staffing, resulting in residents being left unsupervised and experiencing neglect, such as missed baths and long call light response times. Staff reported being overburdened and unable to perform their duties effectively, particularly during the evening shift. Previous incidents of unsupervised residents led to a resident-to-resident encounter requiring investigation.
The facility failed to maintain complete and accurate medical records, delaying surveyor access to necessary documents. The DON manually entered data due to incomplete records, and a resident was left unobserved for 56 minutes despite being on 15-minute checks. Issues with the electronic health records system and incorrect instructions further complicated the survey process.
The facility failed to notify the Ombudsman of resident transfers to the hospital for five residents, as required by regulations. This deficiency was identified through record reviews and staff interviews, revealing that notifications had not been completed from December 2023 to March 2024. The facility's policy did not include the requirement for such notifications, contributing to the oversight.
The facility failed to investigate and document grievances regarding missing cigarettes for several residents. Despite reports to staff, including the DON, the facility's grievance documentation was incomplete, and residents feared losing smoking privileges if they continued to voice concerns. The facility's policy requires documentation and investigation of grievances, which was not followed, leading to a deficiency.
A resident with multiple pressure ulcers did not receive consistent wound care, as treatments were not documented in the TAR. The resident reported inconsistent dressing changes, leading to severe drainage. Staff acknowledged the resident's noncompliance and adjusted care times, but the DON confirmed that undocumented treatments were considered not done. Facility policies on systematic assessment and documentation were not followed.
A resident with Parkinson's Disease, dementia, and Tourette's syndrome was administered antipsychotic medications without documented non-pharmacological interventions, violating the facility's policy. Staff interviews revealed inconsistent documentation practices, and the Director of Nursing expected documentation of three non-pharmacological interventions prior to PRN medication administration.
A facility failed to accurately complete an MDS assessment for a resident with multiple mental health diagnoses. The MDS did not reflect the resident's status as determined by the state level II PASRR process, which recommended specific support services. The care plan lacked information about PASRR completion and recommended resources, despite facility policies requiring such documentation.
The facility failed to maintain an updated PASRR for a resident with schizophrenia and depression, and did not incorporate PASRR service recommendations into another resident's care plan. One resident's PASRR was outdated and lacked necessary diagnoses, while another's care plan did not reflect PASRR findings despite having multiple mental health diagnoses and using psychotropic medications.
Two residents in an LTC facility did not receive their scheduled baths and grooming. One resident with Parkinson's and dementia had unkempt fingernails and was unshaven, with inconsistent bath documentation. Another resident with a stroke and pressure ulcers reported not having a bath for ten days, despite a thrice-weekly schedule. Staff interviews revealed documentation gaps and potential staffing issues.
A resident with multiple wounds did not receive proper infection control during a dressing change. An LPN failed to change gloves and sanitize hands between handling soiled dressings and clean supplies, contrary to the facility's infection control policy. The DON confirmed the expectation for staff to perform hand hygiene when moving from dirty to clean areas.
Inadequate Night and Weekend Staffing Leading to Prolonged Call Light Response Times
Penalty
Summary
The deficiency involves the facility’s failure to maintain adequate nursing staff on the overnight and weekend shifts, resulting in prolonged call light response times for multiple residents. Surveyors observed that during an overnight shift there were only three CNAs and two nurses in the building until an additional CNA arrived, bringing the CNA count to four for a building with four halls, including an isolated rehab hall staffed by only one person. The facility census was 82 residents. The DON later confirmed that the facility’s expectation was to have five CNAs on the overnight shift, and acknowledged that recent resignations and staff on paternity and maternity leave had led to operating with fewer staff than typical. The facility assessment stated that staffing was to be based on resident acuity and needs, feedback, and use of pool and agency staff as needed. Multiple cognitively intact residents reported long waits for assistance via call lights, particularly at night and on weekends. One resident who could not get to the bathroom independently stated that while daytime staffing was often sufficient, nighttime staffing was inadequate and call lights were not answered in a timely manner, leading him to feel he had to advocate for other residents. Another resident who was dependent for care reported waiting at least 45 minutes, and possibly over an hour, for assistance after soiling herself, describing this as a daily and nightly occurrence and noting that she felt miserable and ashamed having to sit in urine and feces. A third resident reported that call light response times were usually 45 minutes or longer, especially on nights and weekends, and that she had reduced how often she used her call light because help did not come; she also reported not reliably receiving water at night. Another resident stated that staffing was usually bad at night and that she typically waited over an hour for assistance with going to bed, with night and weekend staff frequently reporting they were short staffed. Objective call light response logs for several residents over a three-day period showed numerous instances of call lights remaining unanswered for extended periods, including times ranging from approximately 18 minutes to over two hours. Resident council minutes from two separate months documented ongoing resident concerns about insufficient staffing and a desire for call lights to be answered within 15 minutes, showing the facility had been made aware of these issues over time. Staff interviews across multiple CNAs, an RN, and an LPN consistently described the facility as always or frequently short staffed, especially at night and on weekends, with reports of operating with only one CNA per hall and sometimes only two to three CNAs total. Staff stated that the low staffing levels caused slow call light response times and made it impossible to be everywhere they were needed, with one nurse reporting that it could take 45 minutes or more to answer other call lights when they were already responding to one. The DON confirmed the expectation of a 15-minute call light response time and acknowledged that the recent call light times were unacceptable, and also stated there was no chain-of-command protocol when the manager on call was unavailable.
Repeated Failure to Correct Ongoing Staffing Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to make a good faith effort to correct ongoing deficient practices related to sufficient staffing over a three-year period. Review of the state agency’s public website showed multiple surveys ending on 07/29/2025, 04/24/2025, 01/30/2025, and 06/18/2025, each resulting in a deficiency cited for staffing while the facility reported a census of 82 residents. Quality Assurance and Performance Improvement (QAPI) meeting notes dated 12/15/2025 identified assuring appropriate staffing as an active area of the QAPI action plan, indicating that staffing concerns were formally recognized within the facility’s quality program. In an interview on 01/14/2026, the Administrator stated the facility had been aware of the need for more staff since before he assumed the role in November and acknowledged that the staffing issues were a repeat facility failure, though he could not explain why the failure persisted due to his limited tenure. He also reported that QAPI meeting notes from before December were unavailable, but that facility leadership had known about staffing issues for some time. No specific residents, clinical conditions, or direct resident care events are described in the report; the deficiency centers on repeated staffing violations and the facility’s failure over multiple survey cycles to effectively address and correct these known staffing problems through its QAPI and QAA processes.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and the lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Maintain Resident Dignity and Timely Assistance with Meals
Penalty
Summary
Surveyors identified that staff failed to maintain resident dignity and timely care in several instances. One resident with intact cognition and a history of stroke, hemiplegia, and COPD was observed wearing a shirt stained with food after breakfast. The resident expressed discomfort about being in public with the stained shirt and stated she would have preferred to have it changed. Staff acknowledged the stain but did not change the shirt after transferring the resident to bed, and the resident remained in the stained shirt for an extended period. Additionally, when the resident requested to go outside to smoke, a staff member responded abruptly and dismissively, which made the resident feel insignificant. Another resident, also with intact cognition and diagnosed with multiple sclerosis and quadriplegia, required maximal assistance for eating. This resident routinely experienced delays in receiving assistance with meals, often being the last to be served because staff were not available to help her eat when she arrived in the dining room. The resident reported feeling neglected and believed staff prioritized other residents over her, particularly after the departure of a staff member who previously assisted her regularly. The issue was corroborated by interviews with dietary and clinical staff, who confirmed that the resident's meal was withheld until a staff member was available to assist, resulting in frequent delays. Facility records and staff interviews confirmed that both residents' concerns had been raised to management, and the issues persisted despite awareness among leadership. The facility's own policy emphasized the importance of maintaining resident dignity and providing necessary assistance, but observations and interviews demonstrated that these standards were not consistently upheld for the affected residents.
Unattended Medication Left Accessible on Medication Cart
Penalty
Summary
A Certified Medication Aide (CMA) was observed administering medications and left an opaque medication cup containing an orange, round pill (identified as Senna, a stool softener) unattended on top of a locked medication cart. During this time, the CMA walked away from the cart and into a resident's room, leaving the medication accessible. A resident in a wheelchair was observed nearby, three doors away from the unattended medication cart. The pill remained on the cart for several minutes while the CMA was away. Facility policy requires that all medications be secured in a locked medication cart, drawer, or cupboard, and not left accessible when staff are not present. The CMA confirmed that the medication should have been disposed of and not left unattended. The Director of Nursing (DON) also stated that medications should be secured in the medication cart or appropriately disposed of, and not left unattended.
Failure to Disinfect Mechanical Lift Between Resident Uses
Penalty
Summary
Staff failed to implement the facility's infection control policy by not disinfecting a mechanical lift between uses for two residents. On the observed date, Certified Nurse Aides (CNAs) transferred one resident from a wheelchair to a bed using a mechanical lift, then placed the lift outside the room without disinfecting it. Later, the same lift was used to transfer another resident without being disinfected beforehand. The lift was again placed in the hallway after use, still without being cleaned. Staff interviews revealed that disinfectant wipes (Saniwipes) were not available in resident rooms and were supposed to be stored either at the nurses' station or in storage pouches on the equipment, but none were found on the lift at the time of observation. Further interviews with staff indicated inconsistent practices regarding when and where reusable equipment was disinfected, with some staff stating that equipment was wiped down in the hallway after use or during the night, but not before being used for another resident. The Director of Nursing confirmed that staff were expected to disinfect the equipment between uses, but there was no specific written policy addressing the disinfection of reusable equipment such as mechanical lifts.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from abuse when a male resident with a history of dementia, impaired cognition, and documented hypersexual behaviors was able to enter the room of a female resident and inappropriately touch her. The male resident had a known pattern of sexually inappropriate behaviors, including previous incidents of touching other residents and staff inappropriately, making sexual remarks, and being noncompliant with medications prescribed for hypersexuality. Despite these behaviors, the care plan interventions, such as monitoring in hallways and use of alarms, were not sufficient to prevent the male resident from accessing other residents' rooms unsupervised. On the day of the incident, staff observed the male resident wandering the halls and entering female residents' rooms. Staff redirected him to his room, but he was later found in the female resident's room, sitting at the foot of her bed with her brief undone and his hand between her legs. The female resident, who had limited mobility due to a stroke and required assistance with ADLs, was asleep at the time and did not recall the incident upon waking. Staff immediately separated the residents and notified appropriate personnel, but the incident revealed that existing monitoring and supervision measures were inadequate to prevent resident-to-resident abuse. The care plan for the female resident did not include information about the risk of resident-to-resident incidents, despite her vulnerability due to physical limitations. Interviews with other residents indicated concerns about male residents entering female residents' rooms and a perception that staff response was not always timely. The report documents that the male resident's behaviors were known to staff, and interventions such as medication adjustments and increased monitoring had been attempted, but these measures did not prevent the incident of abuse.
Failure to Ensure Accurate Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that staff had access to an accurate code status for one resident reviewed for advance directives. Clinical record review showed that the resident had diagnoses including mild intellectual disabilities, heart failure, and depression, with a BIMS score indicating moderately impaired cognition. The facility's policy required advance directive orders to be kept in a binder accessible to nursing staff. During the survey, a registered nurse stated that code status would be checked first in the computer and then in the binder at the nursing station. However, the binder at the nursing station contained an IPOST form for the resident that directed staff to perform CPR, while both the electronic health record face sheet and the IPOST form itself indicated the resident wished to be DNR. The Director of Nursing confirmed that IPOSTs in the binders were expected to be accurate.
Failure to Update Care Plan After Resident-to-Resident Incident
Penalty
Summary
The facility failed to update and revise the care plan for a resident following a resident-to-resident incident involving inappropriate physical contact. The affected resident had a history of cerebrovascular accident (stroke), hemiplegia, muscle weakness, and impaired cognition, as indicated by a low BIMS score. The resident required significant assistance with activities of daily living and had documented symptoms of depression. Despite an incident in which another resident entered her room, undid her brief, and touched her inappropriately, the care plan was not updated to reflect this event or to include interventions addressing her psychosocial and mental health needs. Record review showed that the care plan, last revised after the incident, continued to focus on the resident's physical limitations and assistance needs but did not address the trauma or implement behavioral interventions related to the incident. Staff interviews confirmed that the care plan should have been updated to include the incident and related interventions. The facility's policy required care plans to be person-centered, updated as resident needs changed, and to include trauma-informed care, but these requirements were not met in this case.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow proper infection control practices during incontinence care for a resident with mild intellectual disabilities, heart failure, and depression. The resident, who required partial to moderate assistance with toileting hygiene and was incontinent of bowel and bladder, was observed lying on a soiled fitted sheet and bed pad. During care, staff changed the resident's incontinence brief before changing the soiled sheets, resulting in the clean brief coming into contact with urine-soiled bedding. Both the CNA and RN involved acknowledged that the clean brief was in contact with soiled sheets, which was contrary to facility policy and infection control standards. In a separate incident, staff did not implement Enhanced Barrier Precautions (EBP) for a resident with multiple sclerosis, neurogenic bladder, and a suprapubic catheter, who was also quadriplegic and dependent on staff for activities of daily living. Despite the care plan and facility policy requiring staff to wear gowns and gloves during high-contact care activities such as catheter care, changing briefs, dressing, and transfers, staff were observed performing these tasks without donning gowns. Specifically, staff emptied the resident's catheter bag, changed the resident's brief, assisted with dressing, and transferred the resident using a mechanical lift, all without wearing the required gown, though gloves were used. Interviews with staff and the Director of Nursing confirmed that the expectation was for gowns and gloves to be worn during high-contact care for residents requiring EBP, particularly those with indwelling catheters. Facility policies reviewed also supported these requirements, but observations showed that staff did not consistently adhere to them during the care of the resident with a catheter.
Failure to Maintain Clean and Non-Sticky Resident Bathroom Floor
Penalty
Summary
The facility failed to maintain a clean and non-sticky floor in the bathroom of one resident's room, as required by its housekeeping policy. Observations over three consecutive days revealed that the bathroom floor remained very sticky, with shoes noticeably sticking to the surface while walking. The facility's policy specified a daily cleaning schedule with routine thorough cleaning, but the persistent stickiness indicated that this was not effectively implemented for the resident's bathroom. The issue was identified through direct observation and confirmed by staff interviews, which acknowledged awareness of the problem and previous discussions about the cleaning solution concentration.
Failure to Provide Timely Incontinence and Nail Care
Penalty
Summary
A deficiency occurred when a resident with mild intellectual disabilities, heart failure, and depression, who required partial to moderate assistance with toileting hygiene, did not receive timely incontinence and nail care as directed by their care plan and facility policy. The resident was observed over a period of several hours without being offered assistance with toileting or incontinence care, despite care plan instructions to check and assist every two hours. The resident was later found with a heavily saturated incontinence brief and urine odor, and staff only provided care after being prompted by the surveyor. Staff interviews confirmed that the resident was not checked or changed as frequently as required, with one CNA stating she was the only one working on the hall and another indicating changes were attempted only before lunch and supper. Additionally, the resident's nails were observed to be untrimmed and had a black substance under several nails on multiple occasions, contrary to the facility's nail care policy requiring nails to be kept clean and trimmed. Despite these observations, no staff were seen addressing the resident's nail hygiene during the survey period. The DON confirmed that staff are expected to check and change residents every two hours and maintain clean, trimmed nails, but these standards were not met for this resident.
Delayed Call Light Response and Incontinence Care
Penalty
Summary
Facility staff failed to respond to resident call lights in a timely manner, with observations showing that a resident's call light remained unanswered for at least 10 minutes on multiple occasions. Staff entered the resident's room, turned off the call light, and left without providing the requested assistance, causing the resident to repeatedly activate the call light. Interviews with residents revealed consistent concerns about delayed responses, with some reporting waits of up to an hour and instances where staff turned off call lights without assisting them. The facility's call light system did not record response times, preventing the administrator from obtaining call light reports. Additionally, staff failed to provide timely incontinence care for a resident with mild intellectual disabilities, heart failure, and depression, who required partial to moderate assistance with toileting. Despite care plan instructions to check and assist the resident every two hours, staff did not offer toileting or incontinence care for nearly three hours, resulting in the resident being observed with a heavily saturated brief and visible incontinence products. Staff interviews confirmed that only one CNA was working on the hall at the time, and that care routines were not consistently followed as directed by facility policy.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple resident and staff interviews, as well as facility document reviews. Resident interviews revealed that residents felt the facility was understaffed, leading to delays in care. One resident, who is ambulatory, reported having to leave her room to find staff to assist her non-ambulatory roommate. Another resident reported that call lights at night could take over 30 minutes to be answered, and staff expressed feeling overworked. A third resident, who requires assistance with toileting and personal hygiene, reported that staff did not have time to help her apply barrier cream, which was left unused on her nightstand. Staff interviews corroborated the residents' concerns, with several staff members stating that the facility did not have enough staff to adequately care for all residents. Staff reported being unable to take breaks due to insufficient staffing, leading to burnout and high turnover rates. Some staff members were written up for failing to take breaks, despite the lack of coverage to allow for breaks. The facility's staffing coordinator confirmed that the facility often worked short-staffed, with staffing sheets showing that the facility was short-staffed on 13 out of 26 days reviewed. The lack of adequate staffing was linked to an increase in falls and urinary tract infections among residents, as reported by a registered nurse. The facility was on a performance improvement plan to address these issues. The Advanced Registered Nurse Practitioner noted that the facility's layout made it difficult for the limited number of nurses to cover all areas effectively. Overall, the facility's inability to maintain adequate staffing levels resulted in compromised care for residents, as evidenced by the documented delays and omissions in care.
Inadequate Staffing Leads to DON Working the Floor
Penalty
Summary
The facility failed to maintain adequate nursing staff, resulting in the Director of Nursing (DON) and Assistant Director of Nursing (ADON) working the nursing floor on multiple occasions. This occurred despite the facility having a census of 78 residents, which exceeds the regulatory threshold of 60 residents for a DON to serve as a charge nurse. The staffing files from December 2024 revealed that the DON and ADON were scheduled to work the floor on ten occasions. The former DON reported working the floor three times a week or more from November to December 2024, leading to her resignation due to burnout and concerns about her professional license. Interviews with the former DON and the Regional Director of Clinical Services highlighted administrative failures in staffing management. The facility had a staffing contract with an agency, Grapetree, which was not utilized to address the staffing shortages. The facility's job description for the DON allowed for resident care on an as-needed basis but did not specify limits on floor work. The failure to utilize available agency staffing and the lack of clear guidelines contributed to the DON's excessive workload, ultimately leading to her departure.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to serve food within appropriate temperature ranges during a meal service, as observed by surveyors. Multiple residents reported that their meals were often served cold, with one resident expressing concern for others who might not be able to reheat their food. The residents interviewed had intact cognition, as indicated by their BIMS scores. The issue was linked to a malfunctioning steam table and a non-operational plate warmer, which were unable to maintain the required food temperatures during service. The Dietary Cook and Certified Dietary Manager confirmed the problems with the steam table and plate warmer, which had been reported to maintenance but remained unresolved. The steam table was observed to lose significant heat over the course of service, and the plate warmer was not functioning at all. A sample tray prepared for surveyors showed food temperatures below the required levels, with the main dish and vegetables being lukewarm. The facility's policy on food temperature monitoring did not specify target temperatures for serving, contributing to the deficiency.
Inadequate Supervision and Care Planning for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate nursing supervision and care planning for a resident identified as having a high risk for falls. The resident, who had a history of repeated falls, anemia, atrial fibrillation, and severely impaired cognition, experienced multiple falls during their stay. Despite these incidents, the facility did not perform a root cause analysis to determine the reasons for the falls, nor did they update the resident's care plan with appropriate fall interventions. The resident's care plan, initiated upon admission, lacked specific interventions to prevent falls, even after the resident experienced several falls. The facility's documentation revealed that the resident had multiple falls, some resulting in injuries, including a head injury that led to a hospital admission for a brain bleed. The facility's incident reports and progress notes indicated that the resident was often found on the floor, attempting to transfer or move without assistance, and was not consistently using the call light system. Interviews with staff highlighted issues with staffing levels and the completion of incident reports. Some nurses failed to fill out incident reports for each fall, and there was a lack of timely documentation and follow-up on the resident's care plan. The Director of Clinical Services acknowledged the high number of falls and the need for improved incident reporting and care planning. Despite these acknowledgments, the facility did not adequately address the resident's fall risk, leading to repeated incidents and a serious injury.
Failure to Administer Lymphedema Treatment as Ordered
Penalty
Summary
The facility failed to provide treatments as ordered for a resident with severe cognitive impairment and multiple medical conditions, including non-Alzheimer's dementia, atrial fibrillation, congestive heart failure, and chronic lymphedema. The resident was admitted to the facility after a hospitalization for a pubic fracture, with discharge orders that included the use of lymphedema pumps. However, the facility did not implement these orders, as evidenced by the absence of the lymphedema pump in the resident's room and the lack of documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The Director of Nursing (DON) acknowledged that the lymphedema pump order was not processed accurately upon the resident's admission and subsequent hospital discharge. Despite the presence of the lymphedema pump in the facility, the treatment was not administered as ordered. This oversight was confirmed through staff interviews and record reviews, revealing a failure to accurately review, process, and implement the physician's orders for the resident's care.
Medication Errors and Unattended Medications in LTC Facility
Penalty
Summary
The facility failed to administer medications correctly, resulting in significant medication errors involving two residents. Resident #87, who had intact cognition and multiple medical conditions, accidentally ingested medications intended for another resident, Resident #188. This occurred after a registered nurse left the medication cup unattended on a bedside table. As a result, Resident #87 experienced a severe drop in blood pressure and pulse rate, necessitating emergency room treatment for a beta blocker overdose. The incident was documented in progress notes and a facility incident report, highlighting the nurse's error in leaving medications unsupervised. Additionally, the facility failed to administer the correct dose of a pain medication to Resident #3, who suffered from multiple sclerosis, malnutrition, and chronic pain. The resident's medication administration records revealed that the prescribed Fentanyl patch was not administered on the scheduled date, and subsequent doses were incorrect. The facility's records showed repeated administration of a lower dose than prescribed, without proper documentation or notification to the family and physician. This oversight was acknowledged by the facility administrator as a significant medication error. Observations during a medication administration round revealed further issues with medication management. A registered nurse was seen leaving a medication cart unattended while administering medications to residents, with insulin pens and diabetic supplies left accessible on the cart. Interviews with staff confirmed this practice, despite the facility's policy against leaving medications unattended. The Director of Nursing acknowledged that medications should not have been left unsupervised, indicating a systemic issue with medication administration practices.
Inadequate Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of its residents, as evidenced by multiple observations and interviews. A notable incident involved a resident who was left unsupervised for 56 minutes, despite being on 15-minute checks, which was acknowledged by the Director of Nursing (DON). The facility's documentation inaccurately reflected that the resident was checked every 30 minutes, contradicting the observed evidence. Interviews with residents revealed dissatisfaction with staffing levels, citing long call light response times, missed baths, and inadequate care, particularly during the second and overnight shifts. Staff interviews corroborated the residents' concerns, with several staff members expressing that the facility was understaffed, especially during the evening shift. Certified Medication Aides (CMAs) and Licensed Practical Nurses (LPNs) reported being forced to perform duties outside their roles due to insufficient staffing, which affected their ability to perform their primary responsibilities effectively. Staff also expressed fear of retribution for voicing concerns about staffing levels. The facility's internal documents and interviews with the administration indicated that staffing decisions were based on a facility assessment and feedback from staff, residents, and families. However, the facility had previously reported incidents of residents being left unsupervised, leading to a resident-to-resident sexual encounter that required investigation. The administration acknowledged the need to increase staffing during certain shifts but continued to rely on pool and agency staff as needed.
Deficiencies in Record-Keeping and Resident Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate medical records and did not provide timely access to electronic health records, which hindered the survey process. The Director of Nursing (DON) initially stated that the On-Base software system was used for storing resident documents and promised to set up facility computers for surveyors. However, there were delays in providing access to these records, as the Administrator struggled to make computers available due to security concerns and staff taking computers home. This resulted in surveyors not having access to necessary records, such as advanced directives and PASRR documentation, in a timely manner. During the survey, it was observed that the DON was manually entering information from skin monitoring forms because nurses did not have time to do so, indicating incomplete record-keeping. Additionally, the facility's electronic health records system lacked a PASRR document for a resident, which was later found to have been completed but not included in the resident's records. The facility's entrance conference worksheet also contained incorrect instructions for locating certain documents, further complicating the survey process. Furthermore, a resident was observed wandering the hallway unobserved for 56 minutes, despite their care plan indicating they were on 15-minute checks. The DON later provided resident check forms that inaccurately indicated the resident was checked every 30 minutes. The Health Information Management (HIM) Manager reported issues with indexing and uploading documents into the On-Base system, and a personnel change was made in the HIM department. The facility's policy required medical records to be complete, accurately documented, and readily accessible, but these standards were not met.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of resident transfers to the hospital for five residents, as required by regulations. The deficiency was identified through a review of facility records, staff interviews, and policy review. The residents involved were hospitalized and readmitted to the facility without the required notification to the Ombudsman. Specifically, Resident #29, #9, #57, #50, and #85 were transferred to the hospital, and the facility did not provide proof of notification to the Ombudsman for any of these cases. The facility's policy did not indicate that such notifications were required, contributing to the oversight. Interviews with the facility's Administrator and Social Services Director revealed that the lack of notifications was due to staff not following the ombudsman notification process. This issue was discovered during a mock survey, indicating that notifications had not been completed from at least December 2023 until the end of March 2024. The facility's policy, last reviewed in December 2023, did not include the requirement for ombudsman notifications upon resident discharge or transfer, which may have contributed to the deficiency.
Failure to Investigate and Document Grievances on Missing Cigarettes
Penalty
Summary
The facility failed to adequately investigate and follow up on residents' grievances regarding missing cigarettes. Multiple residents reported their cigarettes were missing, which were supposed to be stored securely at the nurse's station. Despite these reports, the facility's grievance documentation was incomplete, with only one grievance form filled out for a resident's missing cigarettes. This indicates a lack of proper documentation and follow-up on the residents' concerns. Interviews with residents revealed that they had reported their missing cigarettes to various staff members, including the social worker and the Director of Nursing (DON). However, the residents felt that their concerns were not being addressed, and there was a fear that their smoking privileges might be revoked if they continued to voice their grievances. The facility's staff, including CNAs and the social worker, acknowledged that they did not consistently fill out grievance forms when residents reported missing items, further contributing to the lack of resolution. The facility's policy on grievances requires that all grievances be documented and investigated, but this was not adhered to in the case of the missing cigarettes. The Administrator and DON were aware of some reports of missing cigarettes but did not have a comprehensive system in place to track and resolve these issues. The facility's failure to properly document and investigate the grievances led to a deficiency in honoring residents' rights to voice grievances without reprisal and ensuring their concerns were promptly addressed.
Failure to Document and Perform Consistent Wound Care
Penalty
Summary
The facility failed to document assessments, interventions, and treatments for a resident with skin management concerns, specifically pressure ulcers. Resident #64, who had diagnoses including sepsis, diabetes, and multiple pressure ulcers, was not consistently receiving documented wound care as per the treatment administration record (TAR). The TAR from April to June showed multiple instances where treatments were not documented for the resident's left toes, right plantar foot, and left heel. Additionally, there was a lack of documentation regarding the resident's refusal of wound care and the re-approach to offer dressing changes after a missed wound clinic appointment. Interviews with the resident and staff revealed inconsistencies in wound care practices. The resident reported that the dressing changes were not consistently performed, leading to severe drainage from the wounds. Staff A, a registered nurse, acknowledged the resident's noncompliance and stated that they adjusted care times to accommodate the resident's preferences. The Director of Nursing (DON) confirmed that if treatments were not documented, they were considered not done. The facility's policies required systematic assessment and accurate documentation of residents' skin conditions, which were not adhered to in this case.
Failure to Implement Non-Pharmacological Interventions Before Medication
Penalty
Summary
The facility failed to implement non-pharmacological and behavioral interventions before administering antipsychotic medications to a resident, leading to a deficiency in the resident's drug regimen. The resident, who had diagnoses of Parkinson's Disease, dementia, Tourette's syndrome, and repeated falls, was documented to have no hallucinations, delusions, or behaviors according to the Annual Minimum Data Set (MDS) assessment. Despite this, the resident was administered Hydroxyzine and Lorazepam without documented attempts of non-pharmacological interventions prior to medication administration on several occasions. Interviews with staff revealed that while they documented the administration of PRN medications on the Medication Administration Record (MAR), they did not consistently document non-pharmacological interventions in the progress notes. The Director of Nursing (DON) expected staff to document three non-pharmacological interventions in the resident's progress notes whenever a PRN medication was administered. The facility's Psychotropic Medication policy also required that alternative behavioral interventions be evaluated and documented before administering psychotropic medications.
Inaccurate MDS Assessment and PASRR Documentation
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, identified as Resident #64, who was part of a sample of eighteen residents reviewed. The resident had multiple diagnoses, including adjustment disorder with anxiety, mood disorder, bipolar disorder, and depression. The MDS assessment did not reflect the resident's status as determined by the state level II PASRR process, which identified the resident as having a serious mental illness and recommended specific support services. The care plan for the resident, revised on April 1, 2024, included various diagnoses and behaviors but lacked information about the PASRR completion and the recommended resources. The facility's PASRR policy, revised in November 2022, required that PASRR determinations and evaluation reports be included in the resident's assessment and care plans. However, this was not adhered to in the case of Resident #64. The MDS 3.0 / RAI policy indicated that social services were responsible for completing Section A of the MDS assessment, and the resident's electronic medical record should be reviewed to ensure documentation accuracy. An interview with the Administrator revealed that the social worker filled out Section A of the MDS, but the necessary PASRR information was not incorporated, leading to the deficiency.
Failure to Maintain and Implement PASRR for Residents
Penalty
Summary
The facility failed to maintain a valid Pre-admission Screening and Resident Review (PASRR) for one resident and did not incorporate PASRR service recommendations into another resident's comprehensive care plan. For Resident #37, the Minimum Data Set (MDS) dated 06/11/24 indicated that a Brief Interview for Mental Status (BIMS) could not be completed due to communication difficulties, and the resident had diagnoses including schizophrenia and depression. However, the PASRR dated 10/09/2019 did not include these diagnoses. The Social Services Director acknowledged that the PASRR had not been updated, which was a lapse from previous staff. For Resident #64, the MDS assessments revealed multiple mental health diagnoses and the use of psychotropic medications. Despite this, the care plan lacked documentation of a PASRR completion and the recommended resources. The facility's records did not initially contain a PASRR for this resident, but a PASRR notice dated 7/3/23 was later found, indicating a Level II determination with recommended services such as psychiatric evaluation and therapy. The facility's policy required PASRR findings to be included in the resident's care plan, which was not done in this case.
Failure to Provide Scheduled Baths and Grooming
Penalty
Summary
The facility failed to ensure that residents received their scheduled baths and grooming, as evidenced by the cases of two residents. Resident #50, who has Parkinson's Disease, diabetes, and dementia, required substantial assistance for bathing and personal hygiene. Observations revealed that the resident had uneven and jagged fingernails with brown debris and appeared unshaven. The facility's records showed inconsistencies in documenting the type of bath provided, and there was a lack of documentation for a period between May 21 and June 6. Interviews with staff confirmed that the paper skin sheets used did not indicate the type of bath given, and there was no section for fingernail care. Resident #64, diagnosed with a cerebrovascular accident, dementia, and pressure ulcers, reported not having a bath for ten days, despite being scheduled for baths three times a week. The facility's records showed a lack of documentation for the type of bath provided and missing skin measurements. Interviews with the resident and staff indicated that staffing issues might have contributed to the failure to provide scheduled baths. The facility's bathing policy required documentation of baths in the electronic health record, but the current system did not adequately capture the necessary details.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control techniques were followed during a dressing change for a resident with multiple wounds. The resident, who had diagnoses including sepsis, diabetes, and chronic ulcers, required Enhanced Barrier Precautions. During an observation, a Licensed Practical Nurse (LPN) did not change gloves or sanitize hands appropriately between handling soiled dressings and clean supplies. The LPN opened the resident's room door with a gloved hand, retrieved supplies, and continued the dressing change without performing hand hygiene as required by the facility's infection control policy. The Director of Nursing (DON) confirmed that staff are expected to change gloves and sanitize hands when moving from dirty to clean areas during treatments. The facility's infection control policy mandates glove removal and hand hygiene after handling soiled dressings and before proceeding with treatment. The observed actions of the LPN did not align with these procedures, leading to a deficiency in infection prevention and control practices.
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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