Good Samaritan - Villisca
Inspection history, citations, penalties and survey trends for this long-term care facility in Villisca, Iowa.
- Location
- 202 North Central Avenue, Villisca, Iowa 50864
- CMS Provider Number
- 165189
- Inspections on file
- 23
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Good Samaritan - Villisca during CMS and state inspections, most recent first.
A resident with a recent below-the-knee amputation and severe cognitive impairment was admitted with physician orders for PT and OT, but these services were not initiated until nearly a month later due to missed orders. Staff and DON confirmed the delay, which was not in accordance with facility policy requiring timely implementation of therapy orders.
A resident with severe cognitive impairment and stage 2 pressure ulcers did not receive the required weekly wound assessments with measurements as ordered, due to gaps in documentation and staff absence. Although a contracted wound nurse provided some care, facility RNs did not complete the necessary weekly assessments, contrary to facility policy.
A resident with multiple medical conditions did not consistently receive physician-ordered compression stockings for lower extremity edema, with documentation showing frequent unavailability and staff admitting to possible inaccurate charting. The resident reported not having the correct stockings, and staff interviews confirmed a lack of follow-up with providers when the ordered supplies were not available or used as directed.
A resident with severe cognitive impairment and total dependence for transfers was moved multiple times using a mechanical lift by only one CNA, contrary to the care plan and facility policy requiring two staff for such procedures. Staff interviews and facility documentation confirmed that two staff should be present for safety during these transfers, but the CNA performed the tasks alone, placing the resident at risk.
A facility failed to provide a resident and their family with adequate notification of financial responsibility when Medicare Part A services were scheduled to be discontinued. The resident, who had severe cognitive deficits and multiple diagnoses, required assistance with daily activities. The absence of a required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 in the resident's chart highlighted the deficiency, as the facility's policy mandates issuing the ABN before service delivery to inform beneficiaries of potential non-coverage and financial liability.
A resident with epilepsy and profound intellectual disabilities was observed using foot straps on her wheelchair without proper consent or physician orders. The facility's care plan and consent documents only referenced a seatbelt, not the foot restraints. Staff acknowledged the oversight, as the facility's policy requires consent and orders for any device restricting movement.
The facility failed to obtain bed hold notifications for two residents transferred to a hospital after suffering hip fractures. The facility's policy requires informing residents or their representatives of the bed hold policy before and upon transfer, but this was not done. Staff indicated that the necessary documentation was not completed due to the absence of the social worker and lack of clarity on who should complete the forms after hours.
A resident with severe cognitive deficits and a history of falls was transferred without a gait belt by a CNA, contrary to the care plan and facility policy. The resident required partial assistance and had limited weight-bearing ability. The DON confirmed that staff were expected to use gait belts for transfers, highlighting a deficiency in following safety protocols.
A resident in an LTC facility reported that a staff member refused to transfer him to bed until he used the bathroom, attempting to pry his hand off a mechanical lift. The resident, who required assistance with daily activities, experienced distress due to the staff member's actions. Despite grievances from the resident and family, the facility's administration did not promptly address the issue, and the staff member continued to provide care until the matter was investigated. Interviews revealed inadequate investigation and communication by the facility's administration.
A resident with moderate cognitive impairment was subjected to rough handling by a CNA during a shower, resulting in multiple injuries. The CNA, who had a history of behavioral issues, used inappropriate language and did not adhere to the facility's policies on abuse and resident dignity. Despite previous interventions, the incident led to the CNA's termination.
Failure to Initiate Physician-Ordered Therapy Services Upon Admission
Penalty
Summary
The facility failed to provide needed services in accordance with professional standards by not initiating physician-ordered physical therapy (PT) and occupational therapy (OT) for a resident following admission. The resident, who had a right below-the-knee amputation and severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 3, was admitted with physician orders for PT and OT on 8/4/25. However, these therapy services were not started until nearly a month later, despite the orders being present in the electronic health record. Staff interviews confirmed that the therapy department did not receive the order until 8/27/25, and therapy services began in early September. The Director of Nursing acknowledged that the initial orders from 8/4/25 were missed and not followed, resulting in a delay in therapy services. Facility policy required timely and accurate implementation of physician orders, including therapy, upon admission, but this was not adhered to in this case.
Failure to Complete Required Weekly Pressure Ulcer Assessments
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of two stage 2 pressure ulcers did not receive the required weekly wound assessments with measurements as ordered by the physician and outlined in facility policy. The resident's treatment orders included daily wound observation and dressing changes, as well as weekly skin observation and wound measurements. However, review of the electronic health record and treatment administration records showed that no measurements of the right sacral wound were documented from early May to the end of May. The facility's wound nurse was on medical leave during this period, and although a contracted wound nurse visited the resident and performed some assessments, there were gaps in the documentation of wound measurements and descriptions. Interviews with staff confirmed that the required weekly wound assessments with measurements were not completed by facility RNs during the wound nurse's absence. The Director of Nursing acknowledged that assessments with measurements should have been performed weekly and that this did not occur between the specified dates. Facility policy required licensed nurses to record the location, measurements, and characteristics of any pressure ulcer at least weekly, but this standard was not met for the resident in question.
Failure to Follow Physician Orders for Compression Stockings and Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident with diagnoses including quadriplegia, seizure disorder, anxiety, and respiratory failure. Physician orders required daily and evening wound care to the lower extremities and the use of compression stockings in the morning and removal in the evening to address edema. Documentation and interviews revealed that the resident did not consistently receive the ordered compression stockings, with records showing they were unavailable on 30 occasions, refused 25 times, and applied only 6 times over a period of more than a month. The resident reported not having the correct stockings, and when stockings were received, they were the wrong size and returned. Staff interviews confirmed that the resident did not have the appropriate stockings and that there was a lack of follow-up with the physician or provider when the ordered supplies were not available or not being used as directed. Further, staff admitted to possible inaccuracies in documentation, with one LPN stating that staff may document treatments as completed when they were not, including the application of compression stockings. The facility's policy emphasized the importance of accurate and timely processing of physician orders, but this was not followed in practice. The outside provider noted that the resident's wounds would likely be healing better if the compression stockings had been used as ordered. Observations confirmed the resident was not wearing compression stockings, and multiple staff acknowledged the lack of follow-up and communication regarding the unavailability and non-use of the ordered medical supplies.
Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfers
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including cerebrovascular accident and dementia, was not provided adequate supervision and assistance during transfers and toileting. The resident required total staff assistance for activities of daily living, including transfers and toileting, as documented in the care plan, which specified the use of a dependent non-weight bearing mechanical lift with two staff members present. Despite these requirements, a single Certified Nurse Assistant (CNA) performed three separate movements using the mechanical lift without the assistance of a second staff member. During observation, the CNA completed the transfer and toileting tasks alone, including moving the resident from a recliner to a wash basin, then to a wheelchair, using the mechanical lift. Staff interviews confirmed that the expectation and facility policy required two staff to be present and engaged when operating the mechanical lift for dependent residents. The CNA acknowledged performing the tasks alone and stated this was the usual practice for this resident, despite the care plan and facility policy. Further interviews with other staff, including CNAs, the Clinical Care Coordinator, the Director of Nursing (DON), and the Administrator, all confirmed that two staff should be present for such transfers to ensure safety. The facility's Safe Resident Handling Program also outlined the need for a 'TIME OUT' safety stop and two staff for full weight-bearing support with the total lift. The failure to follow these protocols resulted in the resident not being adequately protected from possible accidents and injury during transfers.
Failure to Provide Adequate Notification of Financial Responsibility
Penalty
Summary
The facility failed to provide adequate notification of financial responsibility to a resident and their family when Medicare Part A services were scheduled to be discontinued. This deficiency was identified for one resident out of three reviewed, with the facility having a total census of 42 residents. The resident in question had a severe cognitive deficit, as indicated by a Brief Interview for Mental Status (BIMS) score of 1, and was diagnosed with conditions including cancer, anemia, renal insufficiency, and cerebrovascular accident (CVA). The resident required assistance with ambulation, toileting, and transfers due to self-care performance deficits related to acute transverse myelitis in demyelinating disease of the central nervous system. The facility's failure was highlighted by the absence of a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 in the resident's chart. The social worker confirmed that the resident was not cognitive enough to participate in decision-making and that the necessary form was not located or signed by the family. According to the facility's policy, the ABN must be issued before the delivery of the service in question, allowing the beneficiary enough time to make an informed decision about receiving the service and accepting potential financial liability. The lack of this documentation indicates a failure to comply with the policy, potentially leaving the resident or their family unaware of their financial responsibilities after the discontinuation of Medicare Part A services.
Failure to Obtain Consent and Physician Orders for Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper consent and physician orders. The resident, who had epilepsy and profound intellectual disabilities with limited mobility, was observed using bilateral foot straps on her wheelchair for safety. However, the facility did not obtain consent from the family or a physician's order for these foot restraints. The resident's care plan and physician orders only referenced the use of a seatbelt, not the foot restraints, and the consent documents signed by the resident's Power of Attorney also did not include the foot restraints. During observations, staff were seen fastening both the seatbelt and foot straps when transferring the resident to her wheelchair. The Director of Nursing and MDS Coordinator acknowledged that the foot straps were considered restraints and should have required consent and physician orders. The facility's policy on restraints indicated that any device restricting movement, such as leg or ankle restraints, required consent, a physician's order, and regular documentation in the care plan. Despite this, the necessary procedures were not followed for the foot restraints used on the resident.
Failure to Obtain Bed Hold Notifications for Hospital Transfers
Penalty
Summary
The facility failed to obtain bed hold notifications for two residents who were transferred to a hospital, as required by their policy. Resident #3 was transferred to a hospital after falling at home and suffering a right hip fracture. The resident was on a paid hospital leave from 5/11/24 to 5/14/24, but the facility did not have a signed bed hold notification. Staff E, a social worker, indicated that she was not present when the resident left the facility, and therefore, the document was not completed. Similarly, Resident #20 was transferred to a hospital after being found on the floor with a right hip fracture. The resident was on a no-pay hospital leave from 10/19/24 to 10/24/24, but again, the facility did not have a signed bed hold notification. Staff E stated that a nurse was supposed to complete the document, but it was not done. The Director of Nursing acknowledged that bed holds should have been completed and mentioned that charge nurses could be trained to complete them. The facility's bed-hold policy requires that the resident or their representative be informed of the bed hold policy before and upon transfer, and in emergencies, the notice should be sent with the resident to the hospital and provided to a family member within 24 hours.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to practice safe transfer techniques for a resident with severe cognitive deficits and a history of falls. The resident required partial assistance for transfers and had limited weight-bearing ability due to a right patella fracture. Despite the care plan directing staff to use assistive devices during transfers, a Certified Nurse Aide (CNA) was observed transferring the resident to and from the toilet without using a gait belt. Instead, the CNA used the resident's arm and clothing to assist with standing, which was not in accordance with the facility's policy. The facility's policy on gait-transfer belts, last reviewed in May 2024, stated that gait belts should be used to stabilize transfers and aid residents in maintaining balance. The Director of Nursing (DON) confirmed that staff were expected to follow the care plan and use a gait belt for any resident requiring assistance with transfers. However, the observation of the CNA's actions indicated a failure to adhere to these guidelines, leading to a deficiency in providing adequate supervision and safety during resident transfers.
Resident's Rights Violated by Staff Member
Penalty
Summary
The facility failed to treat a resident with respect and dignity during care, as evidenced by an incident involving a staff member and a resident. The resident, who had intact cognitive ability and required substantial assistance with daily activities, reported that a staff member refused to transfer him to bed until he went to the bathroom. The staff member attempted to pry the resident's hand off a mechanical lift, causing distress to the resident. The resident's family member also reported the incident, expressing concern that the resident's rights had been violated. The incident occurred when the resident put on his call light for assistance, but the staff member delayed responding and insisted on the resident using the bathroom before being transferred to bed. The resident, who experienced swelling in his legs and needed to elevate them, was distressed by the staff member's actions. Despite the resident's and family member's grievances, the facility's administration did not promptly address the issue, and the staff member continued to provide care to the resident until the matter was investigated. Interviews with various staff members revealed that the facility's administration, including the Director of Nursing (DON) and the Administrator, did not adequately investigate the incident or communicate with the resident and family member about the allegations. The DON did not report the incident to state authorities or complete an incident report, as they did not believe it rose to the level of abuse. The Social Worker, responsible for handling grievances, also delayed addressing the issue and did not interview the resident until several days after the incident.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) identified as Staff A. The resident, who had a history of moderate cognitive impairment and required assistance with activities of daily living, was reportedly subjected to rough handling during a shower. The resident sustained multiple injuries, including abrasions and bruising on the face, chest, and hand, which were documented in the facility's records and observed by staff. The resident reported that Staff A was rough during the shower and did not stop when asked, although the resident later denied being hit or harmed in other ways. Staff A had a documented history of behavioral issues, including previous disciplinary actions for inappropriate tone and approach with residents. On the day of the incident, another staff member overheard the resident yelling in the shower and Staff A responding with inappropriate language. After the shower, the resident was observed with visible injuries, prompting an assessment and subsequent transfer to the emergency room for evaluation. The facility's investigation included interviews with staff and residents, revealing that Staff A had been previously counseled on her behavior and approach to resident care. The facility's policies on abuse and resident dignity were not adhered to, as evidenced by the rough handling and inappropriate language used by Staff A. Despite previous interventions and education provided to Staff A, the incident occurred, leading to the resident's injuries and the eventual termination of Staff A's employment. The facility's failure to ensure the resident's safety and dignity resulted in a deficiency related to abuse prevention and resident care.
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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