Good Shepherd Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mason City, Iowa.
- Location
- 302 Second Street Ne, Mason City, Iowa 50401
- CMS Provider Number
- 165072
- Inspections on file
- 26
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Good Shepherd Health Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, multiple chronic conditions, and a history of falls developed noticeable bruising and swelling on the right hip and thigh area that staff observed over multiple days. CNAs reported the bruising to an LPN, but the nurse did not assess the area when first notified, and no assessment occurred until the resident began expressing pain with transfers and movement. At that point, staff documented a large, multi-colored bruise extending from the upper inner thigh to the buttock and down the posterior thigh, with leg shortening, outward knee rotation, edema, and pain on passive range of motion, despite existing care plan and skin program expectations for prompt assessment and follow-up of skin changes and unusual occurrences.
A resident with Alzheimer’s disease, Parkinson’s disease, depression, and impaired decision-making experienced progressive weight loss while requiring supervision with eating and drinking. The care plan called for staff assistance when the resident was not eating, small frequent meals, house supplements, RD evaluation, and weekly weights, yet clinical notes documented repeated refusals of food, supplements, and assistance, along with episodes of pushing food away and dumping liquids. Despite this, the record lacked evidence of appropriate individualized interventions to address the unintended weight loss, and after an order for 2 liters of water per day with 1:1 assistance, there was no documentation that the ordered fluid intake was consistently provided, contrary to facility policy on managing unintended weight loss.
A resident with a recent hip repair and severe cognitive impairment experienced an unwitnessed fall, after which he reported increased pain and required more assistance with transfers. Despite ongoing reports of pain and functional decline from CNAs and nurses, the facility delayed sending him for emergency evaluation, instead providing PRN Tylenol and contacting the physician by fax. The resident was only sent to the ER several days later, where he was diagnosed with a new pelvic fracture, hypoxia, and COVID-19. Staff interviews confirmed that the resident's change in condition warranted earlier emergency intervention.
A resident with severe cognitive impairment and a history of combative behavior was physically struck on the hand by a CNA and subjected to derogatory language during an episode of agitation while being assisted to the bathroom. The staff member responded to the resident's aggression with both physical and verbal retaliation, and the incident was not immediately reported. Assessment revealed bruising and redness on the resident's hand and wrist, and facility policy requiring respectful treatment was not followed.
A resident with severe cognitive impairment and multiple medical conditions was struck on the hand by a CNA after an altercation. The incident was witnessed by another CNA, who failed to report the event to facility management within the required 2-hour timeframe, resulting in delayed notification to state authorities as mandated by policy.
A facility failed to transmit an MDS assessment for a resident within the required timeframe. The resident was discharged home, and the MDS assessments completed were not transmitted, although previous assessments had been. A nurse admitted to completing the discharge MDS but not submitting it to CMS. The facility lacked a policy for MDS submissions and followed the RAI Manual, which requires submission within 14 days after completion.
A resident in the facility had multiple instances of abnormal blood pressure readings that were not reassessed as required. The resident's TAR indicated an order for regular blood pressure monitoring, but several low and high readings were not followed up on. An LPN admitted to not rechecking the readings, and the DON confirmed the oversight, acknowledging that the charge nurse and physician should have been informed. The facility's policy on blood pressure measurement was not adhered to in this case.
A resident with cerebral palsy and dementia did not receive necessary palm guards to prevent contractures, despite being provided with them after occupational therapy. Observations showed the resident without the guards, and staff interviews confirmed they had been missing for some time without replacement requests. The facility failed to follow the care plan and maintain communication for the resident's needs.
A resident with moderately impaired cognition and recent fall history had their call light placed eight feet away, contrary to facility policy requiring accessibility. This oversight occurred despite the resident's independence in mobility and resulted in a fall and arm fracture. The DON and Administrator confirmed the expectation for call lights to be within reach.
A resident was catheterized without a medical order by a new RN during orientation, leading to distress for the resident. The RN confused residents and performed the procedure on the wrong individual, resulting in her termination. The facility acknowledged the error and confirmed that catheterization should only occur with a proper order.
The facility did not conduct a comprehensive assessment to determine necessary resources for resident care, failing to evaluate needs such as ADLs, bowel/bladder status, mental abilities, skin integrity, special care, treatments, and medications. The absence of a form in the current EHR system led to this deficiency, as acknowledged by the DON and Administrator.
The facility failed to follow infection control practices during medication administration. A CMA was observed handling medications with bare hands for two residents, contrary to the facility's policy requiring gloves or tools to avoid direct contact. Interviews with LPNs and the DON confirmed that touching pills with bare hands is against the facility's procedures.
A resident with intact cognition and independent mobility fell while getting off a facility van due to the van driver's error in managing the van lift. The resident, who had a history of cancer, hypertension, and malnutrition, experienced wrist pain but declined further medical evaluation.
A resident with multiple medical conditions fell and complained of new rib pain, but the LTC facility delayed sending him to the hospital for over two hours. Despite family concerns, the facility's policy requiring a physician's order for hospital transfers contributed to the delay. The resident was later found to have severe injuries and passed away after being admitted to the ICU.
The facility failed to respond to resident call lights within the regulated 15-minute timeframe, affecting multiple residents. One resident's call light was on for 16 minutes before an LPN entered without addressing the call light, and two CNAs later turned it off without assisting. Another resident's daughter reported delays of up to an hour, leading to self-transfers and soiled clothing. A third resident experienced 45-minute waits, causing pain. These issues occurred across shifts, violating resident rights to timely assistance.
A resident's call light was left unanswered for 16 minutes before an LPN entered the room with a nutritional drink and pain patch. The LPN then displayed unprofessional behavior by speaking in a derogatory tone, rolling her eyes, and making negative facial expressions towards the resident and their family member. The family member reported this behavior as consistent. The facility's Resident Rights form requires treating residents with respect and dignity.
Failure to Timely Assess Extensive Bruising and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and care for a significant bruise on a resident’s right inner/outer thigh and hip area after staff became aware of it. The resident had moderate cognitive impairment with a BIMS score of 11, could understand and be understood by others, and had diagnoses including hypertension, Alzheimer’s disease, anxiety, depression, low back pain, and a history of falls. The resident required total assistance with toileting and substantial to maximal assistance with hygiene and dressing, and had a care plan focus for risk of skin breakdown with interventions including observation of skin with cares and notification of the nurse or provider of concerns. On 2/13/26, CNAs reported noticing purple/green swelling and bruising on the resident’s right hip and under the buttocks, described as noticeable, and another CNA reported it took two staff and a gait belt to transfer the resident and that they noticed a bruise while in the bathroom. On 2/14/26, a CNA stated they told the nurse about the bruises at 8:45 AM, but the LPN later admitted they did not look at the bruise that day, stating it slipped their mind. During this period, the resident reportedly did not show signs of pain on 2/14/26, and no nursing assessment of the bruised area was documented until the following day. On 2/15/26 at 10:40 AM, staff called the nurse to the resident’s bathroom due to the resident’s discomfort when transferring from the toilet to the wheelchair, and a large dark purple bruise was observed extending from the right upper inner thigh to the buttock, with various colors including purple, brownish, and faded yellow, and faint yellow bruising on the left thigh. Later that day, the resident was observed in bed with the right leg appearing shorter than the left, the right knee turned outward, non-pitting edema of the thigh and knee, and pain with gentle passive range of motion. Facility documentation, including a risk management form, health status note, incident notes, and an investigation file, consistently described the extensive bruising and the resident’s pain with movement, and administrative staff acknowledged that the nurse failed to assess the bruise when first alerted on 2/14/26, contrary to expectations and the facility’s skin program, which required use of risk management for identification of skin issues and follow-up observation.
Failure to Implement Interventions for Weight Loss and Hydration
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate interventions to prevent weight loss and ensure sufficient hydration for a cognitively impaired resident with Alzheimer’s disease, Parkinson’s disease, and depression. The resident’s MDS showed short- and long-term memory problems, severely impaired decision-making, and a need for supervision with eating and drinking, with an initial weight of 230 pounds and no documented weight loss at that time. The care plan identified an ADL self-care performance deficit and included interventions such as staff assistance when the resident was not eating, provision of small frequent meals, house supplements as ordered, RD evaluation for diet changes, and weekly weights. Subsequent weight records showed a progressive decline from 234.5 pounds to 217.4 pounds over several weeks, reaching at least a 5% weight loss, while behavior and health status notes documented repeated refusals of food, supplements, and assistance with feeding, as well as episodes of the resident pushing food away, clamping his mouth shut, and dumping liquids on the floor. Despite these documented behaviors and the ongoing weight loss, the clinical record did not show that appropriate individualized interventions were implemented or adjusted to address the unintended weight loss, as required by the facility’s policy on interventions for unintended weight loss. An after-visit summary later specified that the resident required 2 liters of water per day and 1:1 assistance for water intake and diet orders, but review of the electronic health record showed that from that point forward there was no documentation that the resident actually received 2 liters of water daily. Point-of-care fluid intake records lacked evidence of the ordered hydration, and the DON acknowledged that the record did not document the required 2 liters of water per day or appropriate interventions to prevent further unintended weight loss, in contrast to the facility’s written policy to identify, monitor, and implement individualized interventions for residents with unintended weight loss or malnutrition.
Failure to Provide Timely Emergency Care After Resident Fall
Penalty
Summary
A resident with a history of a recently repaired right hip fracture and severe cognitive impairment experienced an unwitnessed fall in the facility's bathroom. Following the fall, the resident reported pain in the right hip and required increased assistance with transfers, as documented by both nursing and CNA staff. Despite these changes, the nurse on duty faxed the physician rather than arranging for immediate evaluation or emergency care, and the resident was assisted back to bed by two CNAs. Over the following days, the resident continued to report significant pain, demonstrated by high pain scores and increased need for pain medication, and required two-person assistance for transfers, which was a change from his previous baseline. Multiple staff members, including CNAs and nurses, observed and reported the resident's increased pain and decreased mobility to the nursing leadership. Documentation shows that the resident received PRN Tylenol for pain on several occasions, but the pain persisted and even escalated to severe levels. Despite these ongoing symptoms and the resident's inability to bear weight, the facility did not send the resident for emergency evaluation until several days after the initial fall. The delay in intervention occurred even though staff interviews revealed that several team members believed the resident should have been sent to the hospital earlier due to his change in condition. When the resident was finally sent to the emergency room, he was found to have a new pelvic fracture, hypoxia, and COVID-19. The facility's own policy required staff to respond properly to incidents affecting resident well-being, but the response to this resident's change in condition was not timely. Interviews with staff and nursing leadership confirmed that the resident should have been sent for emergency evaluation earlier, given the clear change in his condition and increased care needs following the fall.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
A resident with severe cognitive impairment, a history of dementia, recent hip fracture, and multiple comorbidities required substantial assistance with all activities of daily living and was known to exhibit combative and verbally aggressive behaviors. The resident was dependent on staff for transfers and toileting, often becoming agitated during care, and had a documented history of hitting, cursing, and biting staff. On the night in question, the resident pressed the call light for assistance to the bathroom and was being transferred using a mechanical lift by three CNAs when he became agitated and struck one of the aides. In response, one CNA struck the resident's hand multiple times and verbally retaliated with derogatory language after the resident insulted her. The exchange escalated, with both the staff member and the resident exchanging profanities. The incident was not immediately reported to the nurse by the witnessing staff, and one staff member left the facility soon after. When the incident was eventually reported, an assessment found a reddened area and bruises on the resident's hand and wrist, consistent with the area where the staff member had struck him. Facility documentation and staff interviews confirmed that the staff involved did not treat the resident with respect and dignity as required by policy and resident rights. The staff failed to maintain a professional and respectful environment, instead engaging in physical and verbal altercations with the resident, which did not promote or enhance the resident's quality of life.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required 2-hour timeframe to the Department of Inspection and Appeals and Licensing (DIAL). The incident involved a certified nurse aide (CNA) who witnessed another CNA strike a resident on the hand multiple times after the resident became agitated and hit the staff member. The witnessing CNA did not immediately report the incident to the facility, instead waiting until the following day, which was outside the mandated reporting window. The resident involved had a history of severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 5, and required substantial to maximal assistance with all activities of daily living. The resident also had multiple diagnoses, including benign prostatic hyperplasia, diabetes mellitus, arthritis, a recent hip fracture, and mild cognitive impairment. During the incident, the resident exhibited behavioral symptoms such as yelling and physical aggression, which escalated the situation with staff. Upon eventual reporting, the nurse assessed the resident and documented physical findings, including a reddened area and bruises on the resident's hands and wrists. The facility's policy required immediate reporting of all abuse allegations to the charge nurse and subsequent notification to the administrator and DIAL within two hours. However, the delay in reporting by the witnessing CNA resulted in noncompliance with this policy and state requirements.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) assessment for one resident within the required timeframe. The resident was discharged to home, and the discharge summary was dated June 26, 2024. The MDS assessments completed on June 1, 2024, and June 26, 2024, were not transmitted, although previous MDS assessments had been accepted, indicating they were transmitted. During an interview, a Registered Nurse/Care Plan Nurse admitted to completing the discharge MDS but failing to submit it to the Centers for Medicare and Medicaid Services (CMS). The facility did not have a policy for MDS submissions and followed the Resident Assessment Instrument (RAI) Manual, which requires submission of a discharge return not anticipated MDS no later than 14 days after completion. The facility should have completed the MDS within 14 days after the discharge date.
Failure to Reassess Abnormal Blood Pressures
Penalty
Summary
The facility failed to reassess blood pressures for a resident, identified as Resident #67, who exhibited both high and low blood pressure readings. The resident's Treatment Administration Record (TAR) for September and October 2024 included an order to obtain blood pressure and temperature every shift. However, several instances of abnormal blood pressure readings were not reassessed. These included extremely low readings on multiple occasions and a high reading on one occasion. Staff J, an LPN, acknowledged that she did not recheck the resident's blood pressures on specific dates despite recognizing the abnormal values. The Director of Nursing (DON) confirmed that the blood pressures should have been rechecked and that the charge nurse and physician should have been notified. The DON also noted that the blood pressure reading on one occasion did not make sense and acknowledged the lack of further rechecks for the abnormal readings. The facility's policy on measuring blood pressure was referenced, which defines normal, borderline, and hypertensive ranges, as well as conditions like hypotension and orthostatic hypotension. Despite these guidelines, the facility did not adhere to the necessary reassessment and notification protocols for Resident #67's abnormal blood pressure readings.
Failure to Provide Necessary Equipment for Resident's Range of Motion
Penalty
Summary
The facility failed to provide necessary services to prevent the reduction in range of motion for a resident with cerebral palsy and dementia, identified as having a functional loss in range of motion on one side of the upper body. After completing occupational therapy, the resident was provided with specially modified palm guards to protect her hand from contractures. However, multiple observations revealed that the resident did not have the palm guards in place, and staff interviews confirmed that the guards had been missing for some time without any attempts to contact therapy for replacements. The resident's care plan and treatment administration records indicated that she was to wear the palm guard during the day and have rolled gauze in her hand at night. Despite these orders, the resident was frequently observed without the palm guard or any substitute, such as a washcloth or gauze, in her hand. Staff members, including CNAs and LPNs, reported that the palm guards were either lost or discarded, and no new guards were requested from therapy. The lack of palm guards resulted in the resident's fingers digging into her palm, indicating a failure to follow the prescribed care plan. Interviews with staff revealed a lack of communication and understanding regarding the maintenance and replacement of the palm guards. The Director of Nursing expected the nursing staff to coordinate with therapy to obtain new guards if they went missing, but this did not occur. The facility's Restorative Nursing Services Policy emphasized individualized and resident-centered care, yet the failure to provide the necessary equipment for the resident's condition demonstrated a deficiency in adhering to this policy.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident had their call light within reach at all times, which is a requirement to prevent accidents. This deficiency was identified for one of the three residents reviewed for recent falls. The resident in question, who had a moderately impaired cognition with a BIMS score of 10, was independent with bed mobility, walking, sitting, and toilet use. However, the resident reported that their call light was placed approximately eight feet away from their recliner, making it inaccessible. This resident had recently fallen in the bathroom and fractured their arm. The facility's policy required that call lights be within reach of residents while in bed or confined to a chair, a standard that was not met in this instance. Interviews with the Director of Nursing and the Administrator confirmed the expectation that call lights should be within reach at all times when residents are in their rooms.
Unauthorized Catheterization of Resident
Penalty
Summary
The facility failed to ensure that catheterization was performed only with a proper medical order, as evidenced by an incident involving a resident who was catheterized without an order. The resident, who had a Brief Interview of Mental Status (BIMS) score indicating no cognitive impairment, required substantial assistance with toileting hygiene. Despite this, a registered nurse, while still in orientation, mistakenly catheterized the resident without an order, leading to distress for the resident who protested the procedure. The incident was reported by the resident, who expressed dissatisfaction with the nurse's actions and the lack of adherence to proper protocol. The Director of Nursing confirmed that the nurse, who was new and in orientation, confused the residents and performed the procedure on the wrong individual. The facility acknowledged the error, and the nurse involved was subsequently terminated. The incident highlights a lapse in following established procedures for catheterization, which requires a valid medical order.
Facility Assessment Deficiency
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for resident care during both routine operations and emergencies. The assessment did not evaluate the needs of the current residents, including activities of daily living (ADLs), bowel and bladder status, mental abilities, skin integrity, special care requirements, treatments, and medications. The facility, which reported a census of 159 residents, lacked a system to assess these specific needs due to the absence of a form in their current electronic health record (EHR) system. The Director of Nursing (DON) and the Administrator acknowledged the deficiency, noting that the previous process for facility assessment was no longer in use.
Inadequate Infection Control During Medication Administration
Penalty
Summary
The facility failed to implement adequate infection control prevention practices during medication administration. Observations revealed that a Certified Medication Aide (CMA), identified as Staff E, handled medications with bare hands while administering them to residents. Specifically, Staff E was observed touching a methylphenidate tablet and a Vitamin D tablet with her bare hands before placing them into a medication cup for Resident #213. Similarly, Staff E handled a Certavite tablet with bare hands while preparing medication for Resident #26. These actions were contrary to the facility's infection control procedures, which require the use of gloves or other tools to avoid direct contact with medications. Interviews with other staff members, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed that the facility's policy prohibits touching oral pills with bare hands. Staff F and Staff G, both LPNs, stated that medications should be handled using a tongue depressor, spoon, or gloves. The DON reiterated the expectation that gloves should be used if there is a need to touch oral pills during medication administration. The facility's Medication Pass Policy/Procedure, revised on the same day as the observations, directed staff to adhere to established infection control procedures, including the use of gloves, during medication administration.
Resident Fall During Van Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation, resulting in a fall incident. The resident, who had intact cognition and was independent with transfers, fell while getting off the facility van. The incident occurred when the van driver accidentally left the van lift in the ground level position and fell backward, pulling the resident out of the van to the ground. The resident was later found to have wrist pain but declined further medical evaluation. The resident had a history of cancer, hypertension, and malnutrition and was receiving hospice services. The incident report indicated that the resident fell in his room during a self-transfer and later fell again during the van incident. The facility's investigation revealed that the van driver inadvertently caused the fall by not properly managing the van lift, leading to the resident being tipped out of the wheelchair.
Delayed Response to Fall Leads to Resident's Death
Penalty
Summary
The facility failed to implement timely interventions for a resident following a fall, which resulted in a delay in treatment and an immediate jeopardy situation. The resident, who had a history of impaired vision, moderately impaired cognition, and multiple medical conditions including osteoporosis and spinal stenosis, fell and immediately complained of new rib pain. Despite the resident's family's repeated inquiries, the facility delayed sending the resident to the hospital for 2 hours and 36 minutes after the fall. The facility's policy required a nursing management assessment following an incident, but it took approximately an hour for the nursing supervisor to assess the resident. After the assessment, the nursing supervisor attempted to contact the physician for an order to send the resident to the hospital. The resident was eventually transferred to the hospital, where he was found to have a punctured lung, multiple rib fractures, and injuries inconsistent with the reported fall. The hospital staff intubated the resident and admitted him to the ICU. The resident's condition led to a decision by the family to transition to comfort measures, and he passed away shortly thereafter. Interviews with facility staff revealed a lack of immediate response and assessment following the fall. Staff members noted the resident's complaints of new rib pain, but the decision to send him to the emergency room was delayed, partly due to the facility's requirement for a physician's order for hospital transfers. The facility's failure to act promptly and according to policy contributed to the resident's deteriorating condition and eventual death.
Removal Plan
- Revised post-incident protocol to include provisions for nursing staff in the instance of a suspected injury or change of condition.
- If the house supervisor is not available, the charge nurse can and should contact emergency personnel and arrange transportation to the emergency department if the situation is deemed emergent or urgent.
- If the physician does not respond to a phone call to request to transfer to ED, the supervisor or designee should call emergency response and arrange for transport, followed by continued efforts to contact the physician to notify of the transfer.
- Include a review of resident's medications to determine what factors those medications could potentially have upon the assessment of the resident and potential outcomes.
- Provided reeducation to House Supervisors and charge nurses to include the revised protocol.
- Summary placed on the electronic communication board for all clinical staff to read.
- Policy placed at each nurses' station for staff signature, with tracking of signatures against the staff roster to ensure all nurses received the education prior to their next shift.
- New staff, agency, and contract staff orientation will include the revised policy prior to their first shift.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner, exceeding the regulated 15-minute response time for three out of five residents reviewed. Resident #4's call light was observed to be on for 16 minutes before an LPN entered the room, who then failed to address the call light or check if the resident still needed assistance. The LPN's interaction with the resident and her daughter was described as defensive and derogatory. Later, two CNAs entered the room and turned off the call light without addressing the resident's needs. Resident #4 was reported to be unwell, with a temperature and potential dehydration, leading to a planned hospital transfer. Resident #3's daughter reported that the facility often took up to an hour to respond to call lights, causing her father to self-transfer due to frustration and resulting in soiled clothing. She expressed concerns about her father's falls since admission, which were discussed with the facility. Resident #5 reported waiting up to 45 minutes for call light responses, causing her pain when left on the commode. The call light issue was noted to occur on every shift. Another call light was observed to be on for 17 minutes, further indicating the facility's failure to provide timely assistance as required by resident rights.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility staff failed to treat a resident with dignity and respect during care and communication, as observed in an incident involving a Licensed Practical Nurse (LPN) and a resident, along with the resident's family member. On the specified date, the resident's call light was observed to be on for 16 minutes before the LPN entered the room. Upon entering, the LPN brought a nutritional drink and a pain patch for the resident. However, the LPN displayed unprofessional behavior by speaking in a derogatory tone, rolling her eyes, and making negative facial expressions towards the resident and the family member present. The family member reported that this behavior was consistent and had been previously observed. The facility's Resident Rights form, dated October 2017, mandates that residents be treated with respect and dignity, and the LPN's job description emphasizes the importance of maintaining a good attitude at work.
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 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.
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.
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.
Two residents who were cognitively impaired and dependent on staff for personal care did not receive bathing assistance at least twice weekly as required by facility policy. Facility records showed multiple instances where bathing was documented as refused or not applicable, resulting in gaps of 6, 7, and 11 days between baths. The care plan for one resident specified total dependence on staff for bathing, and the facility’s policy required showers to be offered at least twice weekly and on the next available day if missed. The DON reported that staff are expected to continue offering showers and try different approaches after refusals, but the documented bathing intervals did not reflect this practice.
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.
A resident with COPD, pneumonia, and respiratory failure was transferred to the hospital for acute respiratory distress and later deemed medically ready for discharge, but the facility delayed readmission by three days due to staffing and admission timing practices. Facility staff, including an RN, MDS coordinator, ADON, DON, and Administrator, reported that they avoided weekend and evening admissions, required two nurses for admissions, and were concerned about entering medication orders into the EMR in time for pharmacy delivery when only one nurse was on duty. They did not notify the provider about the planned discharge back, did not arrange alternative pharmacy or transport options, and cited shared transport and lack of additional nurses as reasons the readmission was not feasible, despite the facility’s stated commitment to 24-hour nursing care and medication management.
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.
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.
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 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.
Failure to Provide Twice-Weekly Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance at least twice weekly, as required by its own policy, for two residents who were dependent on staff for bathing. For one resident with anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive impairment, the MDS documented total dependence on staff for bathing. Facility documentation showed that bathing was recorded as refused on one date, with actual baths provided on dates that resulted in a 6‑day interval without a bath on two separate occasions. The resident’s care plan indicated the resident was totally dependent on staff to provide a bath as necessary. For another resident with diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, facility records showed multiple dates where bathing was documented as refused or as not applicable. Review of the Follow Up Question Report demonstrated several extended gaps between baths: 6 days on two occasions, 7 days on one occasion, and 11 days on another, despite the facility policy requiring showers to be offered at least twice weekly and, if missed, to be offered on the next available day. In an interview, the DON stated that when a resident refuses a shower, staff are expected to continue to offer, try multiple times, try a different person, and continue to try the next day until the resident bathes, which was not reflected in the documented bathing intervals for these two residents.
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.
Delayed Hospital Readmission Due to Insufficient Nursing Staff and Admission Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and related processes to support the timely readmission of a hospitalized resident, resulting in a three-day delay in the resident’s return. The resident had moderately impaired cognition, with a BIMS score of 12/15, and medical diagnoses including COPD with acute exacerbation, pneumonia, and respiratory failure. The resident was transferred to the hospital after staff observed labored respirations, use of accessory muscles, diaphoresis, an oxygen saturation of 85% on room air, and wheezing, with improvement after oxygen was applied but continued labored breathing. Hospital records show the resident was admitted and later determined medically stable and ready for discharge, with documentation that the patient was planned for discharge but was not accepted back to the facility due to timing issues and would remain in the hospital over the weekend. Hospital progress notes documented that the resident was medically ready for discharge and that discharge was planned but not completed because the facility would not accept the resident later in the day. A hospital case management/social work note indicated confirmation that the facility could take the patient on the day the resident ultimately returned. The facility’s EHR showed the resident’s billing status changed to STOP BILLING on the date of hospital transfer and back to active several days later, corresponding to the delayed readmission. The resident reported spending three days in the hospital before being able to return to the facility. Multiple staff interviews described facility practices that contributed to the delay in readmission. An RN stated the facility tried not to do admissions on weekends and did not want admissions after 2 p.m. so nurses could complete admission tasks and enter medications into the computer in time for pharmacy delivery. The MDS Coordinator stated the facility liked residents readmitted before 2 p.m. to obtain medications, that the hospital had informed them the resident would not return until early evening, and that the facility needed two nurses in the building for an admission; the coordinator also stated the facility did not do admissions on weekends and was unsure about using another pharmacy or family to obtain medications. The ADON and DON both stated that with only one nurse on duty, a readmission later in the day was not feasible due to the time needed for admission assessments and medication entry, and they cited concerns about not having medications on time and the workload of one nurse caring for existing residents and completing a readmission. The DON further stated the facility did not accept evening or Saturday admissions for safety reasons, did not notify the provider about the planned discharge back to the facility, and did not explore hospital-supplied medications or alternative transport options, while acknowledging the presence of on-call nurses. The Administrator confirmed that with only one nurse, a readmission was considered not doable. The facility lacked written transportation or readmission policies and relied on general CMS and Resident Rights guidance, while its Resident Handbook stated residents receive individualized 24-hour nursing care and medication management.
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