Grandview Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oelwein, Iowa.
- Location
- 800 Fifth Street Se, Oelwein, Iowa 50662
- CMS Provider Number
- 165340
- Inspections on file
- 18
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Grandview Healthcare Center during CMS and state inspections, most recent first.
Multiple residents did not receive their medications within the required 1-hour window before or after the scheduled dosing time, as confirmed by medication administration audits and staff interviews. Facility policy and DON expectations were not followed, resulting in repeated late or early medication administration for several residents.
A resident with quadriplegia and contractures did not consistently receive prescribed passive range of motion exercises or have hand splints and palm protectors applied as recommended by therapy. Observations showed splints were often not in use, documentation was inconsistent, and staff were unclear about program frequency and responsibilities. The care plan lacked clear instructions, and there was no facility policy for restorative nursing, resulting in failure to provide and document the required restorative care.
A nurse failed to prime an insulin pen and did not hold it at the injection site for the recommended duration while administering insulin to a resident with diabetes. Other nursing staff and facility policy confirmed that the expected procedure is to prime the pen and hold it in place to ensure proper medication delivery.
A resident with chronic wounds and an MDRO infection received wound care from an LPN who failed to place a barrier between the resident's foot and the bed linen, allowing the wound to come into direct contact with the linen. Both the LPN and DON acknowledged the omission, and the bed linens were not changed immediately after the procedure, contrary to facility infection control guidelines.
A resident with edema did not receive physician-ordered tubi-grip compression sleeves due to staff unawareness and incorrect documentation of refusals. The facility lacked the correct size in stock, leading to improper treatment. The resident reported not having the sleeves since a therapy company change, and staff confirmed their absence on multiple occasions.
Two residents with significant weight loss were not served the correct puree portion sizes as prescribed. Despite preparation instructions, dietary staff failed to provide the appropriate amount of food, resulting in both residents receiving less than required. Observations showed that the residents consumed all their meals, indicating insufficient portions.
The facility failed to complete SCSA MDS assessments within the required time frame for two residents in hospice care. One resident's MDS was completed 21 days after a significant change, exceeding the 14-day requirement. Another resident's MDS was not finalized by the required date. Staff G confirmed the lack of an MDS policy and misunderstanding of time requirements.
The facility failed to accurately complete the MDS for three residents, leading to deficiencies in documenting anticoagulant medication and PASRR conditions. One resident was incorrectly documented as taking anticoagulant medication, while two residents had inaccurate PASRR documentation regarding their mental health diagnoses. These errors were confirmed by staff, who admitted to not following the RAI manual's guidance.
The facility failed to properly coordinate and submit PASRRs for two residents, leading to deficiencies in their care plans. One resident's PASRR was not resubmitted despite new diagnoses, while another's PASRR omitted significant diagnoses and medications. Staff interviews revealed a lack of awareness and verification of PASRR accuracy.
Failure to Administer Medications Within Prescribed Time Frame
Penalty
Summary
The facility failed to administer medications within the required time frame of 1 hour before to 1 hour after the scheduled dosing time for five residents. Clinical record reviews, policy review, and staff interviews revealed that all five residents had multiple instances over a 15-day period where medications were given outside of this two-hour window. Specifically, each resident had medications scheduled up to four times daily, and the Medication Administration Audit Reports showed consistent deviations from the prescribed administration times for nearly every day reviewed. Facility policy, last revised in May 2023, directs staff to administer medications in accordance with physician orders and within the specified time frame. During an interview, the DON confirmed the expectation that medications should be given within the 1-hour window before or after the scheduled time. Despite this, the audit reports for all five residents demonstrated repeated failures to meet this standard, as medications were not administered as ordered by the physicians.
Failure to Implement and Document Restorative Nursing Program for Resident with Contractures
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care to maintain or improve range of motion (ROM) and mobility for a resident with significant functional impairments. The resident, who was in a persistent vegetative state with quadriplegia and contractures, was dependent on staff for all self-care and mobility needs. Occupational therapy discharge recommendations specified daily passive range of motion (PROM) exercises for both upper and lower extremities, as well as a hand splint program with splints to be worn two hours on and two hours off, with palm protectors used when splints were not in place. Despite these recommendations, observations revealed that the resident was frequently found in bed without hand splints or palm protectors in use, and the splints were often seen lying unused on the window ledge. Documentation in the electronic medical record was inconsistent, with several days lacking any record of the restorative nursing program (RNP) being completed, and some staff reporting that they marked the resident as refusing the program when, in fact, they had not attempted to apply the splints due to lack of training. Interviews with staff indicated confusion about the frequency and responsibility for the RNP, with some staff unaware of the specific therapy recommendations or unsure who was responsible for carrying out the program on days when the primary restorative staff member was not present. The care plan for the resident lacked clear direction regarding the RNP and the use of hand splints, and there was no facility policy or procedure for restorative nursing. The task record and treatment administration record (TAR) did not consistently reflect the use of hand splints or palm protectors, and nursing staff did not always review therapy discharge recommendations when setting up the RNP. Family members also reported never seeing the hand splints in use during visits. These actions and omissions resulted in the facility's failure to implement and document the prescribed restorative care program for the resident as recommended by therapy.
Failure to Follow Insulin Pen Administration Protocols
Penalty
Summary
A deficiency was identified when a nurse failed to follow manufacturer instructions for administering insulin using an insulin pen for a resident with diabetes mellitus. The nurse removed the resident's Lantus Glargine pen from the medication cart, checked the physician's order, and set the pen to the prescribed dose of 45 units. However, the nurse did not prime the pen with two units of insulin as required by the manufacturer's guidelines. The nurse then injected the insulin into the resident's lower right abdominal quadrant, pushed the button to administer the dose, and withdrew the pen without holding it in place for the recommended 10 seconds. Interviews with other nursing staff revealed that the expected practice is to prime the insulin pen with one or two units until insulin is visible at the needle tip, then administer the prescribed dose and hold the pen at the injection site for several seconds to ensure full delivery. The facility's policy, consistent with manufacturer instructions, directs staff to prime the pen and hold it in place for 6-10 seconds during administration. The Director of Nursing confirmed that staff are expected to follow these procedures. The failure to prime the pen and hold it for the appropriate duration constituted a significant medication error for the resident.
Failure to Use Barrier During Wound Care Results in Infection Control Deficiency
Penalty
Summary
A deficiency occurred when staff failed to place a barrier between a resident's foot and the bed linen during wound care treatment, as observed by surveyors. The resident had a history of coronary artery disease, peripheral vascular disease, diabetes mellitus, and a multi-drug-resistant organism (MDRO), and was being treated for two unstageable pressure ulcers on the left foot, one of which was infected. The treatment orders required cleansing, application of betadine, and covering the wounds with dressings, but did not specify the use of a barrier between the wound and bed linen. During the observed wound care procedure, an LPN donned appropriate personal protective equipment and prepared the treatment supplies on a barrier on the treatment cart. However, while performing the wound care, the LPN allowed the resident's left foot, which had open wounds and drainage, to rest directly on the bed linen multiple times without placing a barrier underneath. The LPN acknowledged after the procedure that a barrier should have been used to prevent cross contamination. The DON also confirmed that no barrier was used during the treatment. Additionally, the resident reported that the bed linens were not changed after the wound care procedure, and a CNA confirmed that linens are typically changed once per week, with the resident's linens changed the morning after the observed treatment. Facility policy required the use of standard precautions and enhanced barrier precautions for residents with chronic wounds, and contaminated linen should be bagged at the time of use. The failure to use a barrier and to change potentially contaminated linens was inconsistent with these guidelines.
Failure to Administer Physician-Ordered Treatment
Penalty
Summary
The facility failed to administer a physician-ordered treatment for a resident who required tubi-grip compression sleeves due to edema. The resident, who had no cognitive impairment and required total assistance for transfers, was observed without the prescribed tubi-grip sleeves on multiple occasions. The resident's care plan and physician order specified the use of size D tubi-grip from fingers to elbow and size J from elbow to shoulder, to be worn during the day and removed at night. However, the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented frequent refusals of the treatment, and staff interviews revealed a lack of awareness and adherence to the order. Staff members, including CNAs and CMAs, were either unaware of the order or incorrectly documented the resident's refusal without verifying compliance. The facility also failed to maintain an adequate stock of the required size J tubi-grip, leading to the use of an incorrect size as a temporary measure. The resident reported not having the tubi-grips since a change in therapy companies, and staff confirmed the absence of the sleeves on several occasions. The deficiency was further highlighted by the lack of communication and coordination among staff, as well as the failure to ensure the availability of necessary supplies.
Failure to Serve Correct Puree Portion Sizes
Penalty
Summary
The facility failed to serve the correct puree portion size for two residents, both of whom experienced significant weight loss over the past six months. Resident #26, with severe cognitive loss and a history of non-Alzheimer's dementia, was on a mechanically altered diet due to significant weight loss. The resident's weight dropped from 231.4 pounds to 206.5 pounds over six months, indicating an 11.4% weight loss. Similarly, Resident #19, with moderate cognitive loss and diagnoses of aphasia and paranoid schizophrenia, also required a mechanically altered diet. This resident's weight decreased from 264.5 pounds to 231.1 pounds, reflecting an 11.9% weight loss over the same period. The deficiency occurred when the dietary staff failed to follow the prescribed portion sizes for the pureed diet. During meal preparation, Staff B prepared six servings of a pureed ham and cheese sandwich, using a chart to determine the correct portion size. The chart indicated that each resident should receive two #8 scoops and one #30 scoop of the puree. However, Staff C and Staff D did not adhere to these guidelines. Staff C served only one #8 scoop to Resident #26 and another resident, while Staff D used only the #30 scoop for Resident #19, resulting in both residents receiving less than the required portion. Observations revealed that both residents consumed all of their meals, with Resident #26 continuing to scrape and lick his empty bowl, indicating insufficient food. Staff B confirmed that the correct portion sizes were not served, as the #30 scoop was not used. The facility's procedure for determining portion sizes was not followed, leading to the deficiency in serving the appropriate amount of food to residents on pureed diets.
Failure to Timely Complete Significant Change MDS Assessments for Hospice Residents
Penalty
Summary
The facility failed to complete Significant Change in Status (SCSA) Minimum Data Set (MDS) assessments within the required time frame for two residents who were reviewed for hospice care. Resident #22 had a physician order for hospice referral dated 4/29/24, but the MDS was not completed until 5/21/24, which was 21 days after the determination of a significant change. According to the Resident Assessment Instrument (RAI) guidelines, the MDS should have been completed no later than 14 days after the determination of a significant change in the resident's status. Staff G, the Resident Care Coordinator, confirmed the dates and acknowledged the lack of an MDS policy, relying solely on the RAI for guidance. Similarly, Resident #29 was admitted into hospice care on 6/11/24, with the family signing the Hospice Election Statement on the same day. However, the MDS assessment reference date was 6/21/24, and the assessment was not completed by the required date of 6/24/24. During an interview, Staff G expressed a lack of understanding regarding the time requirements for completing the significant change assessment as per the RAI manual. This oversight resulted in the MDS not being signed, finalized, and locked within the required time frame.
Inaccurate MDS and PASRR Documentation
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for three residents, leading to deficiencies in the assessment process. For one resident, the MDS inaccurately documented the use of anticoagulant medication, while the physician's orders only included clopidogrel, an antiplatelet medication. This discrepancy was confirmed by the Co-Director of Nursing, who acknowledged that clopidogrel should not have been coded as an anticoagulant. The facility lacked a specific MDS policy and relied on the Resident Assessment Instrument (RAI) and an MDS Drug Class Index, which correctly listed clopidogrel as an antiplatelet medication. Additionally, the facility failed to accurately document the Pre-Admission Screening and Resident Reviews (PASRR) for two residents. One resident's PASRR indicated a diagnosis of schizoaffective disorder, bipolar type, but the MDS incorrectly marked the resident as not having a serious mental illness. Another resident's PASRR documented a diagnosis of bipolar I disorder and major depressive disorder, but the MDS failed to reflect the major depression diagnosis. These inaccuracies were confirmed by the staff responsible for completing the MDS, who admitted to not following the RAI manual's guidance for coding PASRR conditions.
Failure to Ensure Accurate PASRR Submission for Residents
Penalty
Summary
The facility failed to ensure proper coordination and submission of Pre-admission Screening and Resident Review (PASRR) for two residents, leading to deficiencies in their care plans. Resident #19 was initially approved for a short-term 60-day stay in 2018, with new diagnoses documented in her medical record. However, the facility did not resubmit her PASRR for review of needed services. During interviews, staff members, including a social worker, an LPN, and the administrator, were unaware of the short-term PASRR requirement for Resident #19. It was only on 7/3/24 that a new PASRR was received for this resident. For Resident #22, the facility failed to accurately complete the PASRR prior to admission, omitting significant diagnoses and medications. The admission MDS documented major depressive disorder and psychotic disorder with delusions, and the resident was prescribed quetiapine, Namenda, and lorazepam upon admission. However, the PASRR Level 1 completed on 8/31/23 did not reflect any known or suspected mental health diagnoses, and only included lorazepam and Namenda as medications. An LPN admitted during an interview that she does not verify PASRRs for accuracy regarding diagnoses and medications.
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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