Good Samaritan - Ottumwa
Inspection history, citations, penalties and survey trends for this long-term care facility in Ottumwa, Iowa.
- Location
- 2035 Chester Avenue, Ottumwa, Iowa 52501
- CMS Provider Number
- 165211
- Inspections on file
- 32
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Good Samaritan - Ottumwa during CMS and state inspections, most recent first.
A resident with heart failure and intact cognition did not consistently receive ace wrap application to the lower extremities as ordered by a physician. Documentation in the Medication Administration Records was lacking, and staff interviews revealed confusion about the order's implementation and documentation, resulting in the resident not having the ace wrap applied as prescribed.
Two residents with orders for supplemental oxygen did not receive timely administration as required by their care plans and physician orders. One resident was observed with an empty oxygen tank on multiple occasions, while another was found without her nasal cannula and with an empty tank before it was replaced. Staff interviews revealed unclear responsibility for monitoring and changing oxygen tanks, leading to lapses in care.
A staff member failed to use both gown and gloves as required by Enhanced Barrier Precautions while providing peri care to a resident with an indwelling catheter. The staff member initially wore only gloves and not a gown during high-contact care activities, and had to interrupt care to obtain additional supplies and proper PPE before completing catheter care.
A resident with intellectual disabilities and impaired cognition fell from a wheelchair, sustaining major injuries, due to inadequate supervision and delayed assistance. Despite previous incidents of leaning forward, the care plan lacked timely interventions. Another resident with Parkinson's disease was observed being pushed in a wheelchair with a foot dragging on the floor, contrary to facility policy.
A facility failed to ensure consistent documentation of a resident's code status, resulting in a discrepancy between the IPOST form, which indicated CPR, and the electronic profile, which directed DNR. The resident, with a terminal prognosis and intact cognition, had their advance care planning choices misrepresented due to an RN's error in completing the IPOST form.
An LPN at a facility failed to follow proper infection control practices during medication administration for two residents. The LPN did not perform hand hygiene between medication passes and touched pills with bare fingers, contrary to the facility's policy. Interviews revealed a lack of clarity and adherence to the policy, which mandates hand hygiene before and after each medication pass and prohibits touching pills with bare hands.
A resident with severe cognitive impairment and requiring assistance with eating was observed in the dining room with a soiled shirt and food on their beard, compromising their dignity. Staff interviews revealed that clothing protectors were not available in the dining room, and the facility had a policy of not providing them unless requested by the family.
A resident with Parkinson's disease and respiratory issues experienced significant weight loss due to inadequate eating assistance. Despite a care plan requiring guidance and cueing, staff provided minimal help during meals, leading to the resident struggling to eat independently. The facility's policy on nutritional care was not followed, resulting in insufficient support for the resident's needs.
A resident with Alzheimer's and dementia, requiring substantial assistance, was not repositioned or toileted as per their care plan, leading to skin damage. Observations showed the resident left in a recliner for over two hours without assistance, resulting in reddened and excoriated skin. Staff acknowledged the lapse in care, and the DON confirmed the expectation for adherence to care plan interventions.
A resident with Alzheimer's and other health issues was not provided adequate hydration, as observed during multiple periods where no fluids were offered or accessible. Despite a care plan encouraging fluid intake, a family member reported concerns about the resident not receiving enough water. The DON and Administrator acknowledged the issue, which violated the facility's policy on hydration.
The facility failed to provide adequate personal hygiene services, specifically at least two bathing opportunities per week, for two residents with significant medical conditions. One resident missed five scheduled bathing opportunities, while another missed three in April and May 2024.
The facility failed to provide sufficient staff to meet resident needs, resulting in missed bathing opportunities for a resident who required maximal assistance. Staff interviews and Daily Assignment Records confirmed that the facility often operated with fewer aides than necessary, particularly on the 300 and 400/500 halls.
Failure to Follow Physician Orders for Ace Wrap Application
Penalty
Summary
The facility failed to implement and follow physician orders for the application of an ace wrap to a resident's lower extremities. The resident, who had a diagnosis of heart failure and demonstrated intact cognition, had a physician order for an ace wrap to be applied in the morning and removed in the evening. Review of the Medication Administration Records for three months showed no documentation that the ace wrap or compression stockings were applied as ordered. During observation, the resident was seen without the ace wrap or compression stockings, only wearing socks and shoes. When questioned, the resident reported that the ace wrap was applied once but caused significant discomfort, leading to its removal. Staff interviews revealed confusion regarding the documentation and implementation of the order. A registered nurse was unable to locate the task in the computer system, and the DON was uncertain where completion of the task would be documented, despite confirming the order existed. The ADON was eventually able to show where aides documented the application and removal of the ace wrap, indicating a lack of consistent process and oversight in ensuring physician orders were followed and properly documented.
Failure to Ensure Timely Administration of Supplemental Oxygen
Penalty
Summary
Facility staff failed to ensure that supplemental oxygen was administered in accordance with physician orders and individual care plans for two residents. For one resident with diagnoses including Parkinson's disease, coronary artery disease, and a right femur neck fracture, physician orders required oxygen at 2-3 liters per minute as needed to maintain oxygen saturation above 90%. Observations revealed that this resident was seated in a wheelchair with a nasal cannula attached to an oxygen tank that was empty or nearly empty, as indicated by the tank gauge in the red range, during both morning and afternoon checks. Staff interviews indicated that responsibility for changing oxygen tanks was shared among nurses and aides, but there was reliance on aides to notify nurses when tanks were low or empty. Another resident, with diagnoses including rheumatoid arthritis and requiring oxygen therapy for hypoxia, was observed in the dining room with an empty oxygen tank and not wearing her nasal cannula. Later, her tank was exchanged and she was observed wearing the nasal cannula with a half-full tank. The care plan for this resident included monitoring for respiratory distress and ensuring proper oxygen therapy. These observations demonstrate that staff did not promptly intervene to ensure oxygen was administered as ordered, resulting in residents not receiving prescribed oxygen therapy.
Failure to Use Enhanced Barrier Precautions During Peri Care
Penalty
Summary
A deficiency occurred when staff failed to follow Enhanced Barrier Precautions (EBP) during peri care for a resident with an indwelling catheter. The resident, who had a history of Parkinson's disease, coronary artery disease, malnutrition, and a right femur neck fracture, required moderate to dependent assistance with activities of daily living and was care planned for EBP due to the presence of a catheter. The care plan specified that staff should use both gown and gloves during high-contact care activities, including dressing, hygiene, and device care. During an observation, a certified nurse aide was seen providing care to the resident while only wearing gloves and not a gown, as required by EBP protocols. The aide was preparing to complete peri care with the resident's brief open and a new brief nearby. After being interrupted and leaving to get a supervisor, the aide returned and donned both gloves and a gown to empty the catheter bag, but had to request additional supplies such as a graduate and alcohol wipes. The aide then completed catheter care, removed the protective equipment, and continued with dressing and transferring the resident without following the full EBP protocol throughout the care process.
Inadequate Supervision and Unsafe Wheelchair Transport
Penalty
Summary
The facility failed to provide adequate supervision and timely care to prevent a fall with major injury for a resident with intellectual disabilities, seizure disorder, and pain. The resident, who was dependent on staff for transfers and had moderately impaired cognition, was found on the floor after falling from her wheelchair. Despite previous incidents of the resident leaning forward and nearly falling, the care plan lacked documentation to address these concerns until after the fall occurred. The resident sustained significant injuries, including fractures to the right fibula and tibia, after falling forward out of her wheelchair. The facility also failed to ensure safe wheelchair transport for another resident with Parkinson's disease and respiratory disease. During an observation, a CNA was seen pushing the resident down the hall with one foot off the foot pedal, dragging on the floor. This action was contrary to the facility's policy, which directed staff not to push residents in wheelchairs without pedals, as it could result in serious injury. Interviews with staff revealed that the resident who fell had expressed a desire to go to bed multiple times before the incident, but staff were unable to assist her promptly due to other responsibilities. The facility's fall prevention and management policy required identifying causes of falls and implementing appropriate interventions, which were not adequately followed in these cases.
Inconsistent Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure consistent documentation of code status for a resident, leading to a discrepancy in the resident's advance directives. The resident, who had medical diagnoses including Parkinson's disease and respiratory disease, was cognitively intact as indicated by a score of 13 out of 15 on the Brief Interview for Mental Status exam. The resident's care plan noted a terminal prognosis related to cancer and directed staff to review and respect the resident's advance care planning choices. However, there was conflicting information between the Iowa Physician Orders for Scope of Treatment (IPOST) form, which indicated to perform CPR, and the electronic clinical resident profile, which directed Do Not Resuscitate (DNR). The discrepancy was acknowledged by the Director of Nurses during an interview, who stated that there should not be conflicting information to ensure appropriate resident end-of-life choices. A Registered Nurse admitted to completing the IPOST form incorrectly, marking CPR instead of DNR as per the resident's choice, and had the resident sign it. This inconsistency in documentation could potentially lead to actions that do not align with the resident's wishes in an emergency situation.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during medication administration, as observed in two instances involving Resident #13 and Resident #269. On October 8, 2024, at 7:23 AM, Staff A, an LPN, did not perform hand hygiene after administering medication to one resident before preparing medications for Resident #13. During the preparation, Staff A used her fingers to push acetaminophen pills into a medication cup and touched furosemide and gabapentin pills with her fingers before placing them in the cup. After administering the medications, Staff A continued to handle various items, including a water pitcher and a wheelchair, without washing her hands before starting a new medication pass. Similarly, at 7:29 AM, Staff A prepared medication for Resident #269 and used her finger to push a Senna tablet into a medication cup. Interviews with Staff A, the DON, and the Administrator revealed a lack of clarity and adherence to the facility's policy, which requires hand hygiene before and after each medication pass and prohibits touching pills with bare hands. The facility's policy, dated March 29, 2023, specifies that hands should be washed with soap and water if visibly soiled, or an alcohol-based hand rub should be used if not visibly soiled.
Failure to Maintain Resident Dignity in Dining Room
Penalty
Summary
The facility failed to ensure the dignity of a resident in the main dining room, as observed during a survey. A resident with severe cognitive impairment, as indicated by a score of 00 out of 15 on the Brief Interview for Mental Status (BIMS) exam, was seen with a soiled shirt from spilled liquid and pureed food. The resident, diagnosed with non-traumatic brain dysfunction, Alzheimer's disease, dysphagia, and pain, required supervision or assistance with eating and a mechanically altered diet. Despite these needs, the resident was eating independently and subsequently moved through the dining area in a wheelchair with food on their clothing and beard, which compromised their dignity. Interviews with staff revealed that the facility had discontinued the use of clothing protectors unless requested and provided by the family. A Certified Nursing Assistant (CNA) mentioned that clothing protectors were not readily available in the dining room and had to be brought from another hall, which was not done in this instance. The Director of Nurses (DON) confirmed the policy change regarding clothing protectors and indicated that they would contact the family about the issue. The facility's policy on resident dignity emphasized maintaining or enhancing each resident's dignity and respect, which was not upheld in this situation.
Failure to Provide Adequate Eating Assistance
Penalty
Summary
The facility failed to provide adequate eating assistance to a resident with Parkinson's disease and respiratory disease, who was unable to eat independently due to hand tremors and difficulty holding silverware. The resident, who had an intact cognition as indicated by a BIMS score of 13 out of 15, experienced a significant weight loss of 8.75% over a month. The care plan for the resident included interventions such as hand-over-hand guidance, reminding, prompting, and cueing, but these were not consistently implemented during meal times. Observations revealed that during breakfast, lunch, and dinner, the resident struggled to eat independently, often dropping food and spilling drinks due to tremors. Staff provided minimal assistance, feeding only a few bites during breakfast and offering no assistance during lunch and dinner. The facility's policy on nutrition and hydration emphasized the need to assess and monitor residents' nutritional status and provide care consistent with their needs, but this was not adhered to in the case of the resident, leading to inadequate nutritional support.
Failure to Reposition and Toilet Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care for a resident with impaired skin and a high risk of pressure ulcers. Resident #81, who has Alzheimer's disease, dementia, and other medical conditions, required substantial assistance with transfers and had moisture-associated skin damage. The care plan for this resident included interventions such as repositioning every two hours and toileting assistance due to bladder incontinence. However, during observations on two separate days, the resident was left in a recliner for over two hours without being repositioned or toileted, contrary to the care plan requirements. Further observations revealed that the resident's buttocks were reddened, excoriated, and peeling, with drainage present, indicating a lack of timely care. Staff B, a CNA, acknowledged that the resident had not been toileted for hours. The Director of Nursing confirmed that the expectation was for staff to follow the care plan interventions for residents at risk of pressure ulcers, which included repositioning and toileting. The facility's policy also stated that residents unable to reposition themselves should be repositioned as directed by the care plan.
Failure to Ensure Adequate Hydration for a Resident
Penalty
Summary
The facility failed to ensure adequate hydration for a resident diagnosed with Alzheimer's disease, dementia, urinary tract infection, pain, and cellulitis of the buttocks, who required substantial assistance with transfers and had severely impaired cognition. The resident's care plan included interventions for bladder incontinence and encouraged fluid intake during the morning and afternoon while limiting it in the evening. However, observations revealed that the resident was not offered fluids and had no fluids accessible within reach during multiple periods of observation. A family member expressed concerns about the resident not receiving enough water, noting that an empty cup was often left in the same spot without being refilled. The Director of Nursing acknowledged awareness of the issue, and the Administrator confirmed the lack of fluid accessibility during an observation. The facility's policy on nutrition and hydration required offering sufficient fluid intake and ensuring fresh water was available at the bedside unless contraindicated, which was not adhered to in this case.
Failure to Provide Adequate Bathing Opportunities
Penalty
Summary
The facility failed to ensure residents were provided adequate personal hygiene services, specifically at least two bathing opportunities per week, for two residents. Resident #3, with a mildly impaired cognitive status and requiring maximal to dependent assistance for various activities, missed scheduled bathing opportunities on five occasions in April and May 2024. Resident #9, with a severely impaired cognitive status and requiring moderate to maximal assistance, missed scheduled bathing opportunities on three occasions in the same period. Both residents had significant medical conditions, including peripheral vascular disease, diabetes mellitus, malnutrition, non-Alzheimer's dementia, coronary artery disease, and gastroesophageal reflux disease.
Staffing Deficiency Leading to Missed Bathing Opportunities
Penalty
Summary
The facility failed to provide sufficient staff to ensure resident needs were met and bathing opportunities were provided as scheduled. Interviews with staff members revealed that the facility often operated with fewer aides than necessary, particularly on the 300 and 400/500 halls. Staff members reported that at times, only one aide was available to cover shifts that required at least two aides to meet resident needs. This staffing shortage was confirmed by Daily Assignment Records, which showed instances where only one aide was scheduled for shifts that required more personnel. Resident #3, who had a mildly impaired cognitive status and required maximal to dependent assistance with mobility, transfers, dressing, toilet use, and personal hygiene, was directly affected by the staffing deficiencies. The resident was scheduled to receive showers on Wednesdays and Saturdays but missed multiple scheduled bathing opportunities due to insufficient staffing. Specifically, Resident #3 did not receive showers on 4/17, 5/4, 5/11, 5/15, and 5/18, as documented in the bathing records and corroborated by the Daily Assignment Records showing inadequate staffing on those dates.
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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