Granger Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Granger, Iowa.
- Location
- 2001 Kennedy Street, Granger, Iowa 50109
- CMS Provider Number
- 165208
- Inspections on file
- 22
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Granger Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide appropriate ROM services and implement ordered interventions for two residents with post-stroke hemiplegia and hand contractures. One resident had a tightly contracted hand with fingernails pressing into the palm, no splint or padding in place, no therapy for the contracture, and no specific orders or care plan interventions addressing the hand, leading the resident to place tissues in the palm independently. Another resident had contracted fingers with no padding, reported no restorative exercises and no splint, despite a physician’s order for a left hand splint. The ARNP and OT cited insurance coverage issues and had not completed evaluations or treatments, and the DON was unable to identify what actions had been taken to follow the splint order, contrary to facility policy requiring therapy referral and provision of appropriate ROM interventions and equipment.
Surveyors found that medications in one of the medication carts were not stored and labeled according to professional standards. A resident’s Latanoprost eye drops, labeled as requiring refrigeration and expiring 42 days after opening, were kept in the cart instead of a refrigerator and lacked a written expiration date. Additionally, four bottles of prescribed eye drops and nine prescribed inhalers in the same cart were not labeled with open dates. An RN acknowledged not knowing how long these medications were good after opening, and the DON stated there was no facility policy on post-opening expiration, despite pharmacy guidance and a storage policy requiring refrigeration for certain drugs.
Surveyors found that staff failed to follow the facility’s infection control and EBP requirements during wound care for a resident with PVD and a venous leg ulcer. A RN placed wound care supplies directly on the bed, did not wear a gown, did not change gloves between dirty and clean steps, and then returned used supplies to a shared treatment cart. Interviews with a CMA and the DON confirmed that facility policy required gown and gloves for high-contact care such as wound care, glove changes with hand hygiene when moving from dirty to clean tasks, and use of a barrier for supplies.
A resident with insomnia and other conditions had an order for Ambien 5 mg at bedtime, with doses documented on the MAR over two months. The individual narcotic record for this controlled medication showed an initial quantity altered from 30 to 31 tablets, while the pharmacy manifest confirmed only 30 were dispensed. Administration and waste entries reduced the count over time, but a shift-change narcotic count revealed that one Ambien tablet was unaccounted for, and recounts documented a sudden change from 14 to 12 tablets remaining. Staff interviews showed conflicting explanations about a dropped pill, an RN’s initial refusal to sign the narcotic count due to a discrepancy, and acknowledgment that the received quantity entry appeared overwritten. The DON and ADON confirmed a missing tablet and lack of supporting documentation such as a bubble-pack photocopy, and the facility’s controlled substances policy requiring accurate receipt counts, end-of-shift counts, discrepancy documentation, and a written investigation was not fully followed, resulting in a failure to maintain accurate control and accountability of this controlled drug.
The facility lacked a clinically qualified nutrition professional, as the Dietary Manager was not certified and the Registered Dietician was only present one day a week. The Dietary Manager had not completed certification courses and lacked food safety certifications, while the Registered Dietician's limited presence was confirmed by both the dietician and the Administrator.
The facility failed to maintain a safe environment, with surveyors observing damaged baseboard heaters with bent or missing safety grates. Residents expressed dissatisfaction, and staff interviews revealed the issue had been ongoing. Maintenance logs showed delayed repairs, despite the facility's policy requiring safe and operable systems.
The facility was found deficient in food service safety standards due to improper handling of food by staff. Observations revealed that the Dietary Manager and other staff members, including CNAs and CMAs, made direct contact with food and serving surfaces with ungloved hands and failed to perform hand hygiene. Interviews confirmed that these actions were against the facility's policies, which prohibit bare hand contact with food and require frequent hand washing.
The facility failed to uphold residents' rights to dignity and respect, as evidenced by reports from three residents with intact cognition. They described a CNA's rude behavior, excessive wait times for assistance, and dismissive attitudes, particularly during the night shift. Despite grievances filed, residents felt no action was taken. Interviews and facility documentation corroborated these issues, highlighting a failure to adhere to policies on dignity and respect.
The facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC) to two residents receiving skilled care under Medicare A. Instead, the facility provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) and lacked documentation for the NOMNC. The Social Services Director was not trained on the NOMNC form, leading to this deficiency.
The facility failed to update care plans for two residents, leading to deficiencies in care. One resident, with mental health issues and a foot lesion, was non-compliant with wearing prescribed boots, which was not documented in the care plan. Another resident, with memory impairments and a history of pressure ulcers, used a body pillow for positioning, but this was not reflected in the care plan. Staff acknowledged these issues, but the care plans were not revised accordingly.
A facility was found to have a medication error rate of 16% during a medication pass, exceeding the acceptable rate of less than 5%. Errors included a CMA crushing an extended-release tablet for a resident and administering incorrect dosages and formulations to another. Additionally, the ADON did not follow proper insulin pen procedures, potentially affecting insulin delivery. These issues highlight a failure to adhere to medication administration protocols.
Failure to Provide ROM Interventions and Implement Hand Splint Orders
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide services and treatment to maintain or improve range of motion (ROM) and prevent further decline for residents with contractures. Resident #40 had a history of stroke with left-sided hemiplegia and documented functional limitations in ROM of the left upper and lower extremities. Her care plan problem for history of CVA with left-sided weakness included goals to prevent complications such as contractures, but listed only general interventions such as administering medications, allowing time to communicate, and therapy as ordered, without specific interventions for her left hand contracture. Observations showed her left hand was tightly closed with fingers curled into the palm, no padding or device in place, and visible indentations in the palm from fingernails. Resident #40 reported she could not open her left hand due to contracture, did not receive therapy for the contracture, and that the facility did not provide anything to keep her hand open or prevent her fingernails from digging into her skin. She stated she sometimes placed Kleenex in her palm herself for relief. A review of her EHR revealed no orders or interventions addressing the left hand contracture. The ARNP confirmed the resident had a left hand contracture, stated she had recommended a splint but believed insurance would not pay, and acknowledged there was no order for a washcloth or foam block despite having discussed these options with the resident. The OT reported he was only working with the resident on power wheelchair safety and had not evaluated or treated her hand contracture or assessed her for a splint. Resident #44 also had a history of stroke with hemiplegia and documented ROM impairment on one side. Observation showed the four fingers of her left hand curled into the palm with the thumb extended and no padding between the fingers and palm. She reported having contractures from strokes, being unable to open her fingers independently, sometimes using gauze under her fingers, not receiving restorative exercises for her hand, and not having a splint, stating she was not able to receive therapy due to insurance. Her orders included a physician’s order for her to be fitted for and receive a left hand splint for contracted fingers, but the ARNP and OT stated that insurance would not cover a splint or evaluation, and the OT had not completed an evaluation or provided treatment. The DON was unsure what had been done since the splint order was received or what else had been done to prevent further contracture, despite a facility policy stating that residents with ROM limitations would be referred to therapy for focused assessment and that the facility would provide appropriate interventions, exercises, therapy, and equipment such as braces or splints.
Improper Storage and Labeling of Eye Drops and Inhalers
Penalty
Summary
Surveyors identified a failure to properly store and label medications in one of two medication carts reviewed on the 100/200 hall. During observation with an RN, a bottle of Latanoprost eye drops prescribed for dry eye syndrome for Resident #35 was found in the medication cart with a label indicating it needed refrigeration, an open date, and a statement that it expired 42 days after opening, but no actual expiration date was written. The Latanoprost was a bedtime medication that should have been refrigerated rather than kept in the cart. The Medication Administration Record showed the resident had been receiving the Latanoprost nightly during the review period. In the same medication cart, surveyors also found four bottles of prescribed eye drops and nine prescribed inhalers that were not labeled with an open date. The RN present acknowledged that the Latanoprost should be refrigerated and stated she did not know how long eye drops and inhalers were good for after opening. The DON reported the facility did not have a policy for expiration dates on medications after opening and stated they would follow pharmacy recommendations. A faxed document from the pharmacist indicated that Latanoprost expires 42 days after opening, and the facility’s Medication Storage Policy instructed that all medications requiring refrigeration are to be stored in refrigerators in each medication room.
Failure to Follow Enhanced Barrier Precautions and Proper Wound Care Infection Control
Penalty
Summary
Surveyors identified a failure to follow the facility’s infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and wound care practices for one resident. The resident’s MDS dated 2/6/26 documented diagnoses of peripheral vascular disease and a venous ulcer, and the care plan initiated on 8/8/25 required EBP due to a PVD wound on the left lower leg, with EBP to be instituted during high-contact activities. Facility policy dated 3/25/24 stated that gloves and gown must be applied before performing high-contact resident care activities, including wound care. During an observation, a RN entered the resident’s room and placed wound treatment supplies directly on the resident’s bed, applied gloves without donning a gown, removed the resident’s sock and leg dressing, and cleansed scattered open wounds on the left lower leg. The RN then continued the procedure with the same gloves on while wrapping the leg with medicated dressing, gauze, and Coban, and only after completing the treatment removed gloves and performed hand hygiene. The RN then placed the wound cleanser and medicated dressing box back into the treatment cart with other residents’ supplies. A CMA interview confirmed that the EBP sign on the door meant staff should wear gown and gloves with all hands-on care, and the DON stated the expectation was to change gloves and perform hand hygiene when going from dirty to clean during wound treatment, to wear gown and gloves for the treatment, and to place supplies on a barrier.
Failure to Maintain Accurate Control and Accountability of Ambien for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate control and accountability of a Schedule IV controlled hypnotic medication (Ambien) for one resident. The resident had diagnoses including diabetes, depression, and primary insomnia, with an MDS indicating no cognitive impairment and use of a hypnotic. Physician orders on the MAR for Ambien 5 mg at bedtime were documented for December and January, with administration entries showing doses given on multiple days and held on days when the resident was hospitalized. The resident’s Individual Patient’s Narcotic Record for Ambien showed an order dispensed on 12/12/25 with a quantity documented as 30, later altered to appear as 31 by writing a “1” over the “0,” and the first dose recorded as given on 12/20/25 with 30 pills remaining. The controlled drug record entries documented one tablet administered daily from 12/20/25 through 12/29/25, and then from 1/2/26 through 1/6/26, with the running balance decreasing by one each time. On 1/7/26, the record showed one tablet dropped and wasted with two staff initials, leaving 15 remaining, and another tablet given the same day, leaving 14. On 1/8/26, two separate recount entries were made, both signed by two staff, documenting 12 tablets remaining. Staff interviews revealed that during the 1/8/26 morning shift change narcotic count, an RN and an LPN identified that the Ambien count was off by one or two tablets, with the RN stating the count was incorrect and refusing initially to sign off on the narcotic count. The RN reported that the LPN, who had the cart keys on night shift, suggested pills may have popped out of the card due to a full drawer, but the RN did not find any loose pills in the drawer. Further interviews clarified that the facility’s Controlled Drugs-Count Record for that date nonetheless contained signatures from the RN and the LPN, with a comment of the total number of controlled cards and bottles, and an instruction on the form that signing acknowledges agreement with the quantities on hand. The DON stated he was notified of a discrepancy on the cart and that no one was willing to sign for the cart being accurate, and he verbally interviewed staff but did not document those interviews or obtain written statements. The ADON reported that upon recount she determined that one Ambien tablet was unaccounted for, based on the count sheet showing a jump from 14 remaining to 12 remaining, and she confirmed there was no photocopy of the bubble pack to verify the original quantity or any pills that may have popped out. The pharmacist and pharmacy shipping manifest confirmed that only 30 Ambien tablets were dispensed and delivered, while the narcotic record had been altered to appear as 31 received. The nurse who signed as receiving the medication stated she documented 30, denied changing the number, and explained she would have properly lined out and initialed any correction rather than writing over the number. The CMA who first administered the medication also denied altering the received quantity and stated she believed there were 30 tablets remaining after the first dose, consistent with her documentation. The facility’s Controlled Substances policy required accurate counting upon delivery, proper documentation of quantity received, end-of-shift counts by oncoming and outgoing nurses, documentation and reporting of discrepancies to the DON, and investigation of any narcotic reconciliation discrepancies, which was not fully supported by the documentation and events surrounding the missing Ambien tablet and altered quantity on the narcotic record. An additional staff interview indicated that on the evening before the count discrepancy, the night-shift nurse reported dropping an Ambien tablet, which another nurse observed and then observed being disposed of in the dissolvable medication waste container. The next morning, during the narcotic count with the RN and the night-shift nurse, the count was short by one pill, and the night-shift nurse reported that one pill was missing. The Director of Clinical Services confirmed that following the documented administration pattern, the record would show a discrepancy of two pills short on 1/8/26 and noted that the received quantity on the narcotic record appeared to have been changed from 30 to 31 by writing a “1” over the “0.” These combined documentation irregularities, the unaccounted-for Ambien tablet(s), and the lack of clear, contemporaneous investigative documentation demonstrate that the facility did not ensure accurate control and accountability of this controlled medication for the resident, in contrast to its written controlled substances policy. The facility’s own policy on controlled substances, revised December 2012, required that controlled substances be counted upon delivery by both the receiving nurse and the delivery person, with both signing the designated record, and that an individual resident controlled substance record include the quantity received and number on hand. It also required nursing staff to count controlled medications at the end of each shift, with both oncoming and outgoing nurses making the count together and documenting and reporting any discrepancies to the DON, and required the DON to investigate any discrepancies and provide the administrator with a written report of findings. In this case, the altered quantity on the narcotic record, the missing Ambien tablet(s), the inconsistent count documentation, and the absence of a written investigative report or staff statements show that these policy requirements were not fully met for this resident’s controlled medication. Overall, the events leading to the deficiency include the pharmacy’s documented dispensing of 30 Ambien tablets, the facility’s narcotic record being altered to appear as 31 tablets received, the administration and waste documentation that did not reconcile with the remaining count, the discovery of a missing tablet during shift-change counts, and the lack of complete, accurate documentation and investigation consistent with facility policy. These factors resulted in the facility’s failure to ensure accurate control and accountability of the resident’s controlled hypnotic medication.
Deficiency in Nutrition Professional Qualifications
Penalty
Summary
The facility failed to employ a clinically qualified nutrition professional who met the required qualifications of a Certified Dietary Manager or a full-time Registered Dietician. The Dietary Manager admitted to not having certification as a dietary manager, although she had completed courses to obtain it, with the classes scheduled to finish on 1/15/2025. Additionally, the Registered Dietician was only physically present in the facility one day a week, as confirmed by both the dietician and the Administrator. Facility records further indicated that the Dietary Manager did not hold any certifications in food safety, had not taken the test to become a Certified Dietary Manager, and had not been in the role for two years or more.
Facility Fails to Maintain Safe Environment Due to Damaged Heaters
Penalty
Summary
The facility failed to maintain a clean and safe environment, as evidenced by multiple observations of damaged baseboard heaters throughout the facility. On several occasions, surveyors noted that the safety grates on the baseboard heaters were bent, broken, or completely removed, allowing easy access to the interior of the heating units. Residents expressed dissatisfaction with the state of their rooms, specifically pointing out the damaged heaters. One resident mentioned that the heater had been in disrepair since their admission, and another described the appearance as 'trashy.' Interviews with staff, including a Certified Medication Aide, a Registered Nurse, the Assistant Director of Nursing, and the Director of Maintenance, revealed that the issue with the baseboard heaters had been ongoing for a significant period. The Director of Maintenance acknowledged the chronic nature of the problem and the challenges in receiving timely reports from staff about broken grates. Maintenance logs indicated that requests for repairs had been made months prior, with some repairs only recently completed. The facility's maintenance policy, last revised in 2009, mandates that the maintenance department is responsible for ensuring the safety and operability of the building's systems, including heating systems.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during multiple instances of improper food handling by staff. On one occasion, the Dietary Manager was seen opening a package of crackers with ungloved hands and making direct contact with the crackers before serving them to a resident. Additionally, the Dietary Manager served a plate of food to a resident while touching the top of the plate and the food with ungloved hands, without performing hand hygiene after assisting a previous resident. Similar lapses were observed with other staff members, including a Certified Nurse Aide (CNA) and Certified Medication Aides (CMAs), who were seen touching the interior of plates and the serving ends of utensils with bare hands, and failing to perform hand sanitation during food service. Interviews with staff, including the Dietary Cook and the Dietary Manager, revealed that the facility's expectations were not being met, as staff should avoid contact with the tops of plates, interior surfaces of cups and bowls, and the serving surfaces of utensils. The facility's policy documents, such as 'Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices' and 'Dish & Utensil Handling', clearly state that contact between food and bare hands is prohibited and that hand hygiene should be performed frequently. Despite these guidelines, the observations indicated a failure to comply with these standards, leading to the deficiency in food service safety.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by the treatment of three residents, all of whom had intact cognition as indicated by their BIMS scores. Resident #12 reported that a CNA, identified as Staff A, exhibited rude behavior, making her feel like a burden and causing her to wait excessively for assistance, resulting in incontinence. Despite filing grievances, Resident #12 felt that no action was taken to address her concerns. Resident #13 also reported similar issues with Staff A, noting that he was rude and dismissive, particularly during the night shift. She recounted an incident where she waited nearly an hour for assistance, and when her call light was finally answered, Staff A instructed her to perform tasks she required assistance with, such as removing her socks, under the guise of it being good exercise. Resident #14 echoed these sentiments, describing Staff A's behavior as making her feel like "a piece of garbage" due to the long wait times and dismissive attitude. Interviews with other residents and staff corroborated these accounts, with additional grievances filed regarding rude staff and delayed response times to call lights. The Director of Social Services acknowledged receiving multiple grievances about staff behavior but was uncertain about any actions taken. Facility documentation revealed that Staff A had previously received a written warning for neglectful behavior, yet issues persisted. The facility's policy on dignity and respect emphasized the importance of treating residents with respect and providing prompt care, which was not adhered to in these instances.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC) to two residents who were receiving skilled care under Medicare A. Resident #7 began receiving skilled care on August 5, 2024, and Medicare covered the stay until August 23, 2024. However, the facility could not provide documentation that Resident #7 received the NOMNC form. Instead, they provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). The SNF Beneficiary Protection Notification Review form indicated that the resident did not receive a NOMNC because the resident informed therapy staff that she was done and refused further therapy. Similarly, Resident #142 began receiving skilled care on September 13, 2024, with Medicare coverage extending until October 18, 2024. The facility also failed to provide documentation of a NOMNC form for this resident, instead providing a SNF ABN form. The SNF Beneficiary Protection Notification Review form noted that the resident did not receive a NOMNC due to receiving the SNF ABN. The Social Services Director, who had been employed for eight months, stated she was only trained to provide the SNF ABN form and was not trained regarding the NOMNC form.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents, leading to deficiencies in their care. Resident #24, who had a history of mental health issues and an open foot lesion, was observed outside in cold weather without the prescribed walking boot or CAM boot, wearing only gripper socks. Despite being non-compliant with wearing the boots, the care plan did not document this non-compliance or any education provided to the resident regarding foot care. The Director of Nursing acknowledged the resident's non-compliance and stated that education had been given, but this was not reflected in the care plan. Resident #32, who had memory impairments and a history of a Stage III pressure ulcer, was observed with a body pillow used for positioning to prevent falls and assist in healing. However, the care plan did not document the use of the body pillow for positioning, despite staff acknowledging its purpose. The Assistant Director of Nursing and other staff members confirmed the use of the pillow for repositioning and fall prevention, but the care plan failed to reflect these interventions. The facility's policy requires care plans to be updated with changes in the resident's condition, but this was not adhered to in these cases.
Medication Administration Errors Observed in Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 16% during a medication pass. Staff B, a Certified Medication Aide, was observed preparing and administering medications for Resident #22, including crushing an extended-release tablet of Oxybutynin, which should not be crushed. Additionally, Staff B administered an incorrect dosage of Fenofibrate and the wrong formulation of Senna to Resident #21. The errors were attributed to incorrect medication preparation and failure to verify medication orders accurately. Furthermore, the Assistant Director of Nursing (ADON) was observed administering insulin to Resident #28 without following the manufacturer's instructions for the insulin pen. The ADON failed to prime the pen correctly and did not hold the pen in place for the recommended duration after administration, potentially compromising the delivery of the full insulin dose. These observations indicate a lack of adherence to proper medication administration protocols, as outlined in the facility's policy, which requires triple-checking medication labels against the Medication Administration Record (MAR) and following specific procedures for insulin administration.
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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