Good Samaritan - Red Oak
Inspection history, citations, penalties and survey trends for this long-term care facility in Red Oak, Iowa.
- Location
- 201 Alix Avenue, Red Oak, Iowa 51566
- CMS Provider Number
- 165191
- Inspections on file
- 20
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Good Samaritan - Red Oak during CMS and state inspections, most recent first.
Two cognitively impaired residents were observed by a CNA with their hands in each other's pants at the nurses’ station and were separated, with a nurse documenting the event and notifying the DON, social services, and the Administrator. The Administrator, after a phone discussion with the nurse and without directly interviewing the CNA or reviewing video, concluded the residents had only been holding hands in laps and decided the incident was not reportable, and no formal abuse investigation or state notification was made. The DON, who was on vacation and received only limited information, did not report the incident either. This response conflicted with the facility’s abuse policy, which required immediate reporting and investigation of all alleged or suspected abuse, including resident-to-resident incidents.
Two cognitively impaired residents were observed by a CNA with their hands down each other’s pants at the nurses’ station, after which they were separated and a nurse documented no trauma and notified leadership. The Administrator, relying on second-hand clarification that the residents were only holding hands in a lap and noting both had dementia, decided the incident was not reportable and did not initiate a formal investigation. The DON was not fully informed of the specific allegation, Social Services did not document the event, and no comprehensive abuse investigation consistent with the facility’s abuse/neglect policy was conducted, resulting in a failure to immediately and thoroughly investigate an allegation of potential abuse.
Two residents with cognitive impairment and a history of falls experienced repeated incidents due to the facility's failure to consistently implement and document fall prevention interventions, including not removing wheelchair pedals and not completing required assessments or care plan updates after falls. Staff interviews and record reviews confirmed lapses in supervision and adherence to facility policy.
Staff did not measure pureed foods before serving, resulting in incorrect portion sizes for residents requiring texture-modified diets. Despite facility policy and supervisory expectations to measure and divide pureed foods to ensure proper nutrition, pureed items were served without confirming correct serving sizes.
A staff member was observed handling food without proper hand hygiene, touching multiple surfaces and their own clothing before serving food with bare hands, and placing utensils on unclean surfaces between uses. These actions did not comply with the facility's infection control and hand hygiene policy.
Staff did not adhere to infection control protocols during care for three residents, including leaving an open pressure ulcer exposed during transfer and shower, failing to use gloves during enteral tube care, and not performing hand hygiene between glove changes or after catheter care. These lapses resulted in exposure of wounds to potential pathogens and improper handling of medical devices.
A resident with moderate cognitive impairment and total dependence on staff for personal hygiene did not receive oral care for at least 30 days, as shown by a lack of documentation and physical findings of poor oral hygiene upon hospital admission. Staff were unable to locate the resident's toothbrush, and there was uncertainty about oral care procedures and documentation, despite facility policy requiring both.
The facility did not ensure comprehensive care plans were developed and implemented for two residents: one who was a smoker and another with suicidal ideation. For the smoker, the care plan required cigarettes and a lighter to be stored at the nurse's station, but the resident kept the lighter in her pocket and staff were inconsistent about storage procedures. For the resident with depression and suicidal ideation, the care plan lacked documentation and interventions addressing her mental health crisis, even after an incident requiring emergency evaluation. The DON confirmed care plan interventions were not implemented for suicidal ideation.
A nurse left Nystatin suspension at a resident's bedside for self-administration without direct supervision, despite the resident not having an assessment, care plan, or provider order for self-administration. Facility policy required these steps, and the DON confirmed they were not completed.
A resident with a PEG tube received medications and water via a piston syringe using a slow push method, rather than by gravity as required by facility policy. The RN reported this was due to resistance in the tube and the resident's preference, but the method was not documented in the care plan. The DON confirmed the policy did not allow for pushing medications, resulting in a deficiency.
Two residents with significant cognitive and physical impairments did not receive proper pressure ulcer care, including missed or undocumented wound treatments, failure to apply ordered dressings, and lack of documentation and measurement of new skin breakdowns. Facility staff did not consistently follow wound care policies, resulting in inadequate treatment and monitoring of pressure injuries.
The facility failed to maintain sanitary conditions in food storage and preparation, as observed with improper food storage, undated items, and inadequate hand hygiene practices by staff. The kitchen's refrigerator had a black fuzzy area, and food items were found uncovered and undated. Staff did not follow proper glove use and handwashing protocols during meal preparation, contributing to the deficiency.
The facility failed to serve food at safe and appetizing temperatures to three residents. A resident reported that baked potatoes were served raw and food was not always warm. Observations showed room trays left on a cart for extended periods, resulting in food temperatures outside safety standards. Another resident reported food frequently served cold, and a third resident noted a pork sandwich was not hot and coleslaw was not cold. The facility's policy required periodic temperature checks, which were not followed.
The facility failed to implement proper infection control practices, leading to potential cross-contamination of invasive medical devices. A resident with an indwelling catheter had the drainage bag improperly positioned, and staff failed to perform hand hygiene during catheter care. Another resident with a supra pubic catheter experienced similar issues, with staff not adhering to hand hygiene protocols.
The facility did not update the daily nursing staffing data as required, with outdated information observed on two consecutive days. The DON identified an LPN as responsible for updating the staffing sheet, which was expected to be changed daily. The facility's policy mandates daily posting of current staffing data, including staff hours and resident census.
The facility failed to notify a resident's family when a large bruise developed on the resident's right thigh. Despite the resident's pain and the bruise being documented by staff, the family was not informed until the resident's condition declined the following day. Staff interviews revealed a lack of clear recollection and absence of a specific policy for family notification.
A facility failed to notify management in a timely manner when a resident was found to have a large, painful bruise on her right hip/thigh. The bruise was first documented by an RN, but management was not informed until the following day. The resident had a history of heart failure, stroke, hemiplegia, and depression, and required substantial assistance with mobility. Staff interviews revealed uncertainty about reporting the bruise, and the facility's policy on immediate reporting was not followed.
The facility staff failed to supervise medication administration by leaving a resident's medication on their bedside table. The resident, with severe cognitive impairment, was observed with TUMS on two occasions without an order for self-administration. The resident's son also reported finding multiple pills in a medication cup during his visits. The DON and Administrator acknowledged the issue, which had been a problem in past surveys.
A resident with no cognitive impairment and limited mobility due to a stroke reported pain and bruising, which was first documented by an RN but not followed up. The bruise was present for about a month before the resident's passing, and multiple CNAs reported it to nurses who did not document or assess it further. The DON and Administrator acknowledged that incidents should be reported and investigated promptly, but this protocol was not followed.
A facility failed to notify hospice when a resident with no cognitive impairment and requiring substantial assistance was found with a large, painful bruise on her right thigh. Despite documentation and family-provided photos showing extensive bruising, there was no record of hospice being informed. Staff interviews revealed a lack of communication regarding the resident's condition, contrary to the facility's agreement with the hospice provider.
Failure to Report Alleged Resident-to-Resident Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents who were observed inappropriately touching each other. Resident #1 had moderate cognitive impairment with a BIMS score of 11 and a diagnosis of early-onset Alzheimer's disease. Resident #2 had severe cognitive impairment with a BIMS score of 3 and a diagnosis of vascular dementia with behavioral disturbance. On 12/20/26, a CNA (Staff H) observed Resident #1 and Resident #2 sitting at the nurses’ station with their hands down each other's pants. Staff H separated the residents, assisted Resident #2 back to his room, and reported the incident to the nurse (Staff A) and another nurse (Staff I). A progress note entered by Staff A documented that both residents were assessed for trauma and none was observed, and that the DON, Social Services Director (Staff G), and the Administrator were aware of the incident. The Administrator later stated that he determined the incident was not reportable because both residents had documented dementia. He reported that, after speaking with Staff A, he understood the situation as the residents holding hands in each other's laps rather than having hands down each other's pants, and on that basis decided not to report the incident to the state agency or conduct a formal investigation. The Administrator acknowledged that he did not interview the CNA or nurse directly at the time and did not review available camera footage from the lobby for the date of the incident. The DON stated she was on vacation at the time, was only told there was an “incident” without details, and believed the Administrator handled the situation. She also stated she was not aware that Resident #2 had his hands down another resident’s pants and therefore did not report the incident to the state agency. Staff H consistently described the event as both residents having their hands in each other's pants or waistbands, possibly with Resident #1 holding Resident #2’s penis, and stated she knew it needed to be reported to the nurse for safety reasons. Staff G recalled being informed that Resident #2 was reaching toward Resident #1 but did not document the incident and did not convey specific details such as “hands in pants” to the DON. A subsequent progress note on the same day documented Resident #2 reaching to touch another resident and becoming combative when redirected. Both residents later told surveyors they felt safe, were treated with dignity and respect, and denied inappropriate touching, though both had cognitive impairment. Family members of both residents reported being notified of an incident in December involving inappropriate touching or hands in waistbands, but did not recall being told it was considered abuse. The facility’s abuse and neglect policy required that all alleged or suspected abuse, including mistreatment by other residents, be immediately reported to the Administrator and designated agencies within specified time frames, but the allegation involving Residents #1 and #2 was not reported to the state survey agency as required. The facility’s written policy on abuse and neglect specified that all alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse, including injuries of unknown origin, must be promptly reported and investigated, and that designated agencies, including the State Survey and Certification Agency, must be notified in accordance with state law. The policy further required immediate reporting of allegations of abuse or serious bodily injury, and reporting within 24 hours for other allegations, as well as documentation of notifications and review of incidents by an investigation team. Despite this policy, the Administrator and DON did not initiate or complete a formal abuse investigation or report the allegation to the appropriate state agency after being made aware, at least in part, of the incident between Resident #1 and Resident #2. This failure to follow the facility’s own abuse reporting and investigation procedures led to the deficiency for not timely reporting suspected abuse to the proper authorities.
Failure to Investigate Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately and comprehensively investigate an allegation of potential resident‑to‑resident sexual abuse involving two cognitively impaired residents. Resident #1 had moderate cognitive impairment with a BIMS score of 11 and a diagnosis of early-onset Alzheimer’s disease. Resident #2 had severe cognitive impairment with a BIMS score of 3 and a diagnosis of vascular dementia with other behavioral disturbance. On 12/20/26, a CNA (Staff H) reported to nursing staff that she observed Resident #1 and Resident #2 sitting at the nurses’ station with their hands down each other’s pants. The residents were separated, Resident #2 was taken to his room, and a nurse (Staff A, RN) documented that both residents were assessed for trauma with none observed. The RN’s progress notes also documented that the DON, Social Services Director (Staff G), and the Administrator were aware of the incident, and that the Administrator stated the incident was not reportable because both residents had documented dementia. Additional documentation in Resident #2’s record on the same date showed that later that day Resident #2 was observed reaching to touch another resident and had to be redirected by a CNA, after which he hit staff and told them to leave him alone. Interviews with the involved CNA confirmed that she had seen the two residents with their hands in each other’s pants and that she believed Resident #1 might have been holding Resident #2’s penis, although she did not see movement. She reported that she separated the residents and informed the RN and an LPN. She also stated she did not see the nurses complete an assessment at that time and that she reported the incident to the nurse because of safety concerns and the possibility that Resident #2 might repeat the behavior. The Social Services Director recalled being informed of an incident involving Resident #2 reaching toward Resident #1 around the time before Christmas but stated she did not document the incident, did not clearly report that there were hands in pants, and could not recall the exact wording used when she notified the DON. The DON stated in interview that she had not been made aware that Resident #2 had his hands down another resident’s pants and acknowledged she had not completed an investigation into the reported incident documented on 12/20/25 between Resident #1 and Resident #2. She indicated that if she had been notified of such behavior, she would have come in and completed an investigation, including talking to residents and staff, and that she should have been informed. The Administrator reported that he spoke with the RN by phone and was told that the CNA initially thought the residents had their hands in each other’s pants but later believed they were holding hands in a lap, and based on that, he decided the situation did not warrant reporting or further investigation. He acknowledged that he did not interview the nurse or CNA in person, did not review available camera footage at the time of the incident, and concluded that no investigation was needed. The facility’s abuse and neglect policy required that all alleged or suspected abuse, including mistreatment by other residents, be reported immediately to the Administrator or designee, that the charge nurse complete an initial investigation, and that an investigation team review all incidents by the next working day. Despite this policy, no comprehensive investigation was initiated or completed in response to the CNA’s allegation that the two residents had their hands down each other’s pants. Interviews with both residents later indicated that each reported feeling safe at the facility, believed staff treated them with dignity and respect, and denied that other residents had touched them inappropriately or that they had touched others inappropriately. Family interviews showed that Resident #2’s son was informed of an incident of inappropriate touching between the two residents and considered it inappropriate but did not view it as abuse, and Resident #1’s daughter recalled being told of an incident described as the residents holding hands or having hands in each other’s waistbands. However, these later perceptions and characterizations did not change the fact that the original CNA report described hands down each other’s pants and that the facility’s own policy required immediate reporting and investigation of such allegations. The failure to follow the abuse policy, to fully clarify and document the allegation, to interview all involved staff promptly, and to conduct a comprehensive investigation into the reported incident constituted the deficiency. The facility’s written abuse and neglect policy, revised 7/6/23, specified that all alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse, including injuries of unknown origin, must be reported immediately to the Administrator and, in the Administrator’s absence, to designated leaders such as the DON or Social Services Director. The policy required the charge nurse to assess the situation, determine if emergency treatment or action was required, complete an initial investigation, and ensure that any potential for further abuse was eliminated. It also required timely notification of designated agencies, the physician, and family, and mandated that an investigation team (social worker, Administrator, and DON) review all incidents no later than the next working day. In this case, despite a documented allegation that two residents with dementia were observed with their hands down each other’s pants, the DON was not fully informed, the Administrator decided the incident was not reportable without a thorough fact-finding process, and no formal investigation consistent with policy requirements was conducted. The DON later acknowledged that she should have been informed and that an investigation should have been started if such an incident occurred. The Administrator acknowledged that if the residents had indeed had their hands down each other’s pants, it would have been a different situation, but he relied on a second-hand clarification that the residents were only holding hands in a lap and did not pursue further inquiry. No contemporaneous documentation by Social Services was made, and there was no evidence that the investigation team convened or that a structured review of the incident occurred by the next working day. This sequence of actions and inactions—failure to clearly communicate the nature of the allegation up the chain of command, failure to follow the facility’s abuse reporting and investigation policy, and the Administrator’s decision not to investigate further—led to the deficiency for not completing a comprehensive investigation immediately when an allegation of abuse was reported for Resident #1.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to establish and implement effective interventions to prevent falls and injuries for two residents with known fall risks. One resident with severe cognitive impairment and a history of multiple falls experienced repeated incidents involving wheelchair pedals. Despite documentation in the care plan and fall scene huddle worksheet that the resident had tripped on wheelchair pedals, staff did not consistently remove the pedals when not in use, as was indicated as a corrective action. This resident suffered multiple falls, including one that resulted in a head injury and subsequent admission to hospice care due to traumatic cerebral hemorrhage. Observations and staff interviews confirmed that the pedals were left on the wheelchair, and staff were not always able to supervise or intervene in time to prevent falls. Another resident with moderately impaired cognition and a history of falls, including fractures, experienced a fall that was not properly documented or investigated. The care plan lacked documentation of the fall and any new interventions following the incident. Progress notes described the fall and the resident's uncooperative behavior, but there was no incident report, falls tool assessment, or fall scene huddle worksheet completed for this event. The DON acknowledged that the fall was missed in documentation and that the incident was not fully assessed or followed up according to facility policy. Facility policy required prompt assessment, documentation, and investigation of falls, including completion of a fall scene huddle worksheet, falls tool, and care plan updates with new interventions. In both cases, the facility did not follow its own policy for fall prevention and management, resulting in missed opportunities to identify root causes and implement effective interventions to prevent further accidents.
Failure to Measure and Portion Pureed Foods Correctly
Penalty
Summary
Staff failed to provide a well-balanced diet that meets the nutritional and special dietary needs of residents by not using correct serving size portions for meals. During meal preparation, staff pureed brownies, green beans, and ham and beans, adding thickener as required, but did not measure the pureed food before serving. The pureed items were placed into serving bowls or onto the steam table without determining the correct portion sizes. Staff A indicated that extra servings were made, but there was no measurement of the pureed food to ensure each resident received the appropriate amount. Interviews with the Food and Nutrition Supervisor and the Administrator confirmed that the expectation was for pureed foods to be measured after blending to ensure correct scoop sizes and portion control. Review of the facility's policy on textured-modified diets also specified that the total volume of pureed food should be measured and divided by the original number of portions to ensure accuracy. The failure to follow these procedures resulted in the deficiency.
Failure to Follow Safe Food Handling and Hand Hygiene Practices
Penalty
Summary
Staff was observed failing to follow safe food handling practices during meal service. Specifically, one staff member touched various surfaces including plate warmer lids, menus, scoop handles, and their own clothing, then proceeded to handle food items in the warmers with bare hands. The staff member also placed the scoop on top of the lids of the warmer pans after use and touched multiple items between serving food from the steam table. Facility policy requires all employees to maintain adequate hand hygiene by adhering to specific infection control practices, which was not followed in this instance.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to follow infection prevention and control practices for three residents. One resident with a stage 4 pressure ulcer on the sacral region was transferred using a mechanical lift sling after the dressing and packing were removed by CNAs, leaving the wound open and exposed. The wound bled during the transfer and soiled the sling, and the resident was taken to the shower with the wound still open and in contact with the soiled sling. The dressing was not dated and was soiled prior to removal. The wound was left open throughout the shower, and the sling remained soiled with blood. The treatment nurse later provided wound care but failed to perform hand hygiene after removing gloves and before leaving the room. Another resident with an enteral feeding tube received medication and water administration from an RN who initially performed hand hygiene and donned appropriate PPE. However, after changing the split sponge and removing gloves, the RN applied tape to the split sponge without gloves and only performed hand hygiene after removing the gown and leaving the room. The DON confirmed that gloves should have been used during all care involving the enteral tube. A third resident with a suprapubic catheter had care performed by two CNAs who did not cleanse the catheter tip before replacement and allowed the catheter bag to rest on the floor. During the care process, hand hygiene was not performed between glove changes or when moving from one area of the body to another. One CNA left the room and began care for another resident without performing hand hygiene. Facility policy required hand hygiene at specific moments, including after glove removal and when moving between contaminated and clean body sites.
Failure to Provide and Document Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide oral care for a resident with moderate cognitive impairment and total dependence on staff for activities of daily living, including personal hygiene. According to the resident's care plan, staff assistance was required for oral care, shaving, and grooming. A review of the clinical record and Point of Care documentation over a 30-day period showed no evidence that oral care was provided to the resident during that time. Additionally, when the resident was admitted to the hospital, he was found to have crusty skin at the corners of his mouth and a yellow film buildup in his mouth and on his teeth. During an observation, staff were unable to locate the resident's toothbrush in the bathroom and only found one in a dresser drawer after searching. Staff interviews revealed uncertainty about the location of the resident's oral care supplies. The DON stated that staff were expected to set up the toothbrush and encourage the resident to brush his own teeth, with documentation required in the electronic medical record. Facility policy also required documentation of oral care in the electronic record.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific needs. For one resident who was identified as a smoker with intact cognition, the care plan specified that cigarettes and a lighter should be stored at the nurse's station. However, observation revealed the resident kept the lighter in her pocket after smoking, and staff interviews indicated inconsistency in the storage of smoking materials, with some staff stating items should be kept in room lockboxes instead. The Director of Nursing expected the lighter to be stored at the nurse's station, but this was not consistently followed. For another resident with moderately impaired cognition and a history of depression, anxiety, and dementia, the care plan addressed antidepressant use but did not include documentation or interventions for suicidal ideation, despite a recent incident where the resident expressed a desire to kill herself and was sent to the emergency room for evaluation. Upon return, new medication orders were implemented, but the care plan was not updated to reflect interventions for suicidal ideation. The Director of Nursing confirmed that the care plan was not implemented for the interventions related to the resident's suicidal ideation.
Medication Left at Bedside Without Assessment or Order
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left a prescribed medication, Nystatin mouth and throat suspension, at a resident's bedside for self-administration without direct supervision. The resident, who had no cognitive impairment as indicated by a BIMS score of 15 and received medications via an enteral feeding tube, was observed to have the medication left at the chair side table to take later. The nurse exited the room and closed the door, leaving the resident to self-administer the medication without nurse visualization. Review of the resident's records showed there was no assessment for self-administration of medications, no care plan reflecting permission for self-administration, and no provider order authorizing this practice. Facility policy required an interdisciplinary team assessment, a care plan, and a provider order for self-administration of medications, none of which were present in this case. The Director of Nursing confirmed that the required assessment and documentation were not completed for this resident.
Improper Administration of Enteral Medications via Feeding Tube
Penalty
Summary
Staff failed to follow facility policy and procedures regarding the administration of medications via a feeding tube for a resident with a PEG tube. The resident, who was cognitively intact as indicated by a BIMS score of 15, required tube feeding and received medications through the enteral tube. During observation, a registered nurse used a piston syringe to slowly push medications and water into the resident's enteral tube, rather than administering them by gravity as outlined in the facility's policy. The nurse stated that medications were not given by gravity due to resistance in the tube, and that the resident preferred a light push during administration. The Director of Nursing confirmed that the facility's policy did not specify that pushing medications was acceptable practice and acknowledged that this method was not included in the resident's care plan. The policy reviewed indicated that medications should be administered slowly and steadily, with the flow rate determined by the elevation of the syringe, not by pushing. The deviation from policy and lack of care plan documentation for the resident's preferred method led to the deficiency.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents with significant skin integrity issues. One resident with moderate cognitive impairment and total dependence on staff for care had a Stage II pressure ulcer on the right buttocks and an unstageable ulcer on the left heel. Despite physician orders for a Mepilex dressing to be applied and changed every three days, the resident was observed without the required dressing, and staff acknowledged the omission. Documentation showed inconsistencies, with the treatment marked as completed earlier that day, but the dressing was not present during the observation. The resident's history included recent hospitalization for pneumonia, UTI, and pressure injuries, with conflicting accounts from facility staff regarding the presence of wounds prior to hospital transfer. Another resident, also with moderate cognitive impairment and multiple comorbidities including malnutrition and COPD, had a Stage IV pressure ulcer on the sacrum. This resident was bedfast, incontinent, and dependent on staff for all mobility and hygiene. During care observations, staff failed to document and measure three additional areas of skin breakdown on the resident's legs, and the primary wound dressing was found to be soiled, undated, and improperly removed by a CNA rather than a nurse. The wound was left open during a shower and exposed to a soiled lift sling, contrary to best practices. Review of treatment records revealed multiple missed or undocumented wound care treatments as ordered by the physician. Facility policy required daily and weekly wound documentation and monitoring for residents with impaired skin integrity, but this was not consistently followed. The lack of proper documentation, failure to apply and maintain ordered dressings, and missed wound care treatments contributed to the deficiency. The facility did not ensure that residents with pressure ulcers received necessary care to promote healing, prevent infection, and prevent new sores from developing, as required.
Deficiency in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards in the preparation, serving, distribution, and storage of food, as observed during a survey. On multiple occasions, the kitchen's refrigerator/freezer was found to have a black fuzzy area, and the refrigerator contained uncovered and undated food items, including a gallon of milk and packages of pizza. The walk-in dry goods pantry had empty cardboard boxes and condiment packages on the floor, and the walk-in refrigerator contained strawberries with a white fuzzy appearance. These observations indicate a lack of proper food storage and sanitation practices. Additionally, during meal preparation, staff failed to follow proper hand hygiene and glove use protocols. A cook was observed handling food with improper glove use, touching his face, and placing dirty gloves on the food preparation counter. The Dietary Manager acknowledged the issues with the refrigerator cleanliness and the improper handling of gloves, which contradicted the facility's policies on hand hygiene and general sanitation. These actions and inactions contributed to the deficiency in maintaining sanitary conditions in food preparation and storage areas.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to three residents, as identified through clinical record review, resident interviews, observations, staff interviews, and policy review. Resident #31, who was cognitively intact and independent with eating, reported that baked potatoes were served raw and food was not always warm. Observations on June 30, 2024, showed that room trays were left on a cart for extended periods before delivery, resulting in food temperatures that did not meet safety standards. Specifically, the coleslaw was served at 72.8 degrees and the pulled pork sandwich at 106 degrees, both outside the acceptable temperature range. The Dietary Manager acknowledged that room trays should not sit for over 10 minutes before delivery and suggested using Styrofoam containers to maintain cold food temperatures. Resident #30, also cognitively intact, reported that food was frequently served cold, at least once a week, and noted that she ate every meal in her room. Resident #40, with no cognitive impairment, stated that the pork sandwich was not hot and the coleslaw was not cold during lunch on June 30, 2024. The facility's policy on food temperature monitoring required that temperatures be retaken periodically throughout meal service to ensure food safety, but this was not adhered to, leading to the deficiency.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices, leading to potential cross-contamination of invasive medical devices. In one instance, a resident with an indwelling catheter was observed with the catheter drainage bag improperly positioned on the wheelchair frame and the tubing lying on the floor. The resident, who had moderately impaired cognition and required supervision with toileting hygiene, relied on staff for catheter care. During a catheter care observation, staff members failed to perform hand hygiene and change gloves after emptying the urine collection bag, and one staff member placed alcohol wipe packets on the floor before use. In another instance, a resident with a surgically placed supra pubic catheter was observed during catheter care. Staff members failed to perform hand hygiene after glove removal and before resuming resident care tasks. The facility's hand hygiene policy required hand hygiene after glove removal, before and after resident care, and when entering or exiting a resident's room. However, staff did not adhere to these guidelines, as evidenced by one staff member who removed gloves, opened a door, and walked to the nurse's station before completing hand hygiene.
Failure to Update Daily Nursing Staffing Data
Penalty
Summary
The facility failed to comply with the requirement to post daily nursing staffing data, as observed during a survey. On two consecutive days, the posted staffing information was outdated, displaying the date of June 29th, 2024, instead of the current date. This discrepancy was noted on June 30th and July 1st, 2024. The Director of Nursing (DON) acknowledged that the responsibility for updating the staffing sheet lay with Staff H, an LPN and Wound Nurse. The DON expressed an expectation that the Daily Staffing Form should be updated daily, with the possibility for overnight nurses to print it as well. The facility's policy, revised on February 28th, 2024, mandates the daily posting of current staffing data, including the number and hours worked by various nursing staff and the resident census, incorporating registry and pool staff members.
Failure to Notify Family of Resident's Bruise
Penalty
Summary
The facility failed to notify the family of a resident when a bruise developed. The resident, who had a BIMS score of 15 indicating no cognitive impairment, had a history of heart failure, stroke, hemiplegia, and depression. The resident required substantial staff assistance with bed mobility and used a repositioning/turn sheet. On 11/5/23, a large purple bruise was documented on the resident's right thigh by a registered nurse (RN). However, there was no documentation that the family was notified about the bruise at that time. The following day, a licensed practical nurse (LPN) noted the resident's condition had declined, and the resident's daughter was informed, but the initial bruise was not mentioned in the notification. Interviews with the resident's family revealed that they were aware of the resident's pain and possible bruising on 11/5/23, but they were not officially notified by the facility. Staff interviews indicated that the RN who documented the bruise could not recall notifying the family, and the LPN who noted the resident's decline also could not remember specific details about the notification process. The Director of Nursing (DON) confirmed that family should be notified of new skin concerns but acknowledged that the facility did not have a specific policy or procedure related to family notification.
Failure to Timely Report Bruising on Resident
Penalty
Summary
The facility failed to notify management in a timely manner when a resident was found to have a bruise on her right hip/thigh. The bruise was first documented by a Registered Nurse (RN) on 11/5/23 at 10:35 AM, but management was not notified until 11/6/23. The resident, who had a BIMS score of 15 indicating no cognitive impairment, had a history of heart failure, stroke, hemiplegia, and depression. She required substantial staff assistance with bed mobility and used a repositioning/turn sheet. The bruise was described as large, purple, and painful to touch. The family provided photos showing extensive bruising on the resident's right hip and thigh, which were taken on 11/6/23 at 8:33 AM. Staff interviews revealed that the Licensed Practical Nurse (LPN) who documented the resident's condition on 11/6/23 could not recall seeing the bruising earlier and was unsure if she had reported it to management. The RN who first documented the bruise suggested it might have been caused by the mechanical lift used for the resident. The Director of Nursing (DON) stated she was notified of the bruising on 11/6/23 but did not see it herself as the resident was being sent to the emergency room. The facility's policy required immediate reporting of suspected abuse, neglect, or injuries of unknown origin to the Administrator or designated individuals, which was not followed in this case.
Failure to Supervise Medication Administration
Penalty
Summary
The facility staff failed to supervise medication administration by leaving a resident's medication on their bedside table. Resident #3, who had a BIMS score of 4 indicating severe cognitive impairment, was observed with a medication cup containing TUMS on two separate occasions. The resident's care plan did not include an order for self-administration of medications, and no Self-Administration of Medication assessment had been completed for her. The resident's son also reported finding multiple pills in a medication cup during his visits, which he brought to the attention of the DON, who assured him that she would address the issue with the staff. The DON confirmed that staff should watch residents take their medications unless there is an order for self-administration. Despite this, the DON acknowledged that she had not had issues with staff leaving medications in residents' rooms for them to take later, nor had she received complaints from family members. The Administrator also noted that while he had not noticed medications being left in resident rooms recently, it had been an issue in past surveys. The facility's policy on Resident Self-Administration of Medication outlines a detailed procedure to determine if a resident can safely self-administer medications, including obtaining a physician's order and documenting the process in the care plan. However, this procedure was not followed for Resident #3, leading to the deficiency observed by the surveyors.
Failure to Timely Assess and Intervene for Resident's Bruise
Penalty
Summary
The facility failed to assess and intervene timely for a bruise on a resident's right thigh. The resident, who had no cognitive impairment and was dependent on staff for mobility due to a stroke, reported pain and bruising to her family on a visit. The bruise was first documented by a Registered Nurse (RN) on 11/5/23, but there was no follow-up documentation or assessment of the bruise in the clinical records or hospice notes. The resident's condition declined, and she was sent to hospice care the following day, where significant bruising was noted by a Licensed Practical Nurse (LPN). The family provided photos showing extensive bruising of varying colors, indicating different stages of healing. Interviews with staff revealed that the bruise had been present for about a month before the resident's passing, and multiple Certified Nursing Assistants (CNAs) had reported the bruise to nurses, who did not document or assess it further. The Director of Nursing (DON) and the Administrator acknowledged that incidents should be reported and investigated promptly, and skin assessments should have been conducted regularly. However, this protocol was not followed, leading to a lack of timely intervention and documentation for the resident's bruise.
Failure to Notify Hospice of Resident's Bruising
Penalty
Summary
The facility failed to notify the hospice provider when they found a bruise on a resident's right hip and thigh. The resident, who had no cognitive impairment and required substantial assistance with mobility due to a stroke, was found to have a large purple bruise on her right thigh that was painful to touch. This bruise was documented by a registered nurse, but there was no subsequent documentation indicating that hospice was notified about the bruise. The resident's family provided photos of the bruising, which showed extensive discoloration on her hip and thigh. Despite the severity of the bruising, the hospice coordination notes revealed no record of the hospice being informed about the bruise. Interviews with staff and the hospice nurse indicated a lack of communication regarding the resident's condition. The hospice nurse was aware of bruising on the resident's lower leg but not on her hip or thigh. The registered nurse who documented the bruise suggested it might have been caused by the mechanical lift used for transfers but did not confirm notifying hospice. The Director of Nursing stated that hospice would not need to be notified if there was no change in the resident's condition. However, the facility's agreement with the hospice provider required regular and as-needed communication to ensure resident needs were met, which was not adhered to in this case.
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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