Greater Southside Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Moines, Iowa.
- Location
- 5608 Sw 9th Street, Des Moines, Iowa 50315
- CMS Provider Number
- 165175
- Inspections on file
- 34
- Latest survey
- October 27, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Greater Southside Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents experienced abuse—one involving unwanted sexual contact from another resident and another involving verbal abuse and withholding of pain medication by an LPN. In both cases, staff failed to follow facility policy for reporting and investigating abuse allegations, and the incidents were not reported to the State Survey Agency or Administrator as required.
Two residents experienced incidents involving suspected abuse or neglect that were not reported to the state agency in a timely manner as required by facility policy. In one case, a non-verbal, dependent resident was found being touched inappropriately by another resident, and in another, a cognitively intact resident alleged verbal abuse and medication withholding by an LPN. Staff documented and discussed the incidents internally, but failed to promptly notify the appropriate authorities.
A facility failed to conduct a timely and thorough investigation after a CNA observed one resident, who was non-verbal and quadriplegic, being sexually abused by another resident. Although staff separated the residents and notified the Administrator, there was no formal investigation, incident report, or care plan update documented for either resident, and the care plan addressing hypersexual behavior was not revised until days later. Required procedures for reporting, documentation, and care plan updates were not followed.
A resident with multiple complex medical conditions was admitted without timely physician orders, resulting in missed doses of essential medications including insulin, cardiac, pain, and psychotropic drugs. Nursing staff were unclear about responsibility for entering orders, leading to the resident experiencing significant pain and distress, and ultimately leaving the facility without receiving necessary care.
Two residents experienced inadequate pain management due to delays in transcribing and administering physician-ordered pain medications. One resident with a femur fracture did not receive prescribed pain relief in a timely manner, and staff interactions included inappropriate language. Another resident with acute osteomyelitis had a delay in receiving as-needed oxycodone, resulting in severe, unmanaged pain until the order was processed.
The facility did not provide enough nursing staff to meet resident needs, as shown by reports of long call light response times, missed care such as wound dressing changes and assistance with meals, and staff and family concerns about insufficient staffing. Documentation and interviews confirmed that staffing levels frequently fell below the facility's own requirements, with the DON occasionally working the floor to cover shortages.
A resident with severe intellectual disability and moderately impaired cognition, who required assistance with dressing, was observed sitting in a dining room with her buttocks fully exposed while multiple staff and other residents were present. Staff failed to promptly address the situation, leaving the resident uncovered for several minutes in violation of facility policy on dignity and privacy.
A resident with multiple pressure ulcers did not receive wound care and dressing changes as ordered by the physician. The care plan lacked information about a right foot wound, and documentation showed dressing changes were not performed or recorded as required. Staff confirmed that dressings should be dated and initialed with each change, but observation revealed a dressing that had not been changed according to orders.
Staff failed to consistently use Enhanced Barrier Precautions (EBP) during wound care and high-contact activities for three residents with wounds or indwelling devices. In multiple instances, staff did not wear gowns or change gloves as required by care plans and facility policy, despite the presence of conditions such as pressure ulcers, paraplegia, and quadriplegia. Staff interviews and policy review confirmed that PPE, including gowns and gloves, should have been used, but these protocols were not followed during observed care.
Staff did not consistently follow Enhanced Barrier Precautions, including the use of gown and gloves during high-contact care for residents with indwelling devices, and failed to disinfect shared equipment such as a mechanical lift between uses. These lapses were observed during catheter care, tube feeding, medication administration, incontinence care, and resident transfers, despite facility policy and CDC guidance requiring these infection control measures.
During meal service, staff failed to provide the correct supplements and side dishes as indicated on meal tickets, and did not measure or serve the correct portion sizes of pureed meat for residents on modified diets. The CDM was unsure of the standard procedure for preparing liquefied diets, and staff did not follow the facility's guidelines for processing the correct number of servings, resulting in several residents not receiving their prescribed nutritional items.
Dietary staff did not maintain clean and sanitary kitchen conditions, with observations of unclean equipment, improper food labeling and storage, and unsanitary food handling during meal service. Staff were seen touching food and utensils with bare hands, failing to perform hand hygiene, and not following proper thawing procedures, all in violation of facility policies and food safety standards.
Two residents had discrepancies between their IPOST forms and the code status recorded in the EHR and physician orders. One resident's IPOST indicated DNR while the EHR listed Full Code, and another resident's IPOST indicated Full Code while the EHR listed DNR. Staff were unable to locate the correct IPOST documentation in the designated binders, and the facility did not consistently follow its policy for reviewing and updating advance directives, resulting in inaccurate code status documentation.
A resident with severe cognitive impairment and multiple diagnoses was administered PRN Ativan for anxiety and yelling over a period longer than 14 days without a documented 14-day practitioner re-evaluation, as required by facility policy for psychotropic medications.
Three residents with documented PASRR Level II determinations for serious mental illness or intellectual disabilities did not have this status accurately reflected in their MDS assessments. Each resident's PASRR identified specific diagnoses and required specialized behavioral health services, but the MDS failed to code this information as required. An LPN responsible for MDS completion indicated that issues with EHR record transfers after a facility name change may have contributed to the omissions.
A resident with multiple medical conditions and recent falls was admitted and required significant assistance with daily activities. The facility did not complete a baseline Care Plan within 48 hours of admission, and the plan that was eventually created lacked key information about the level of staff assistance needed. Staff interviews revealed confusion about responsibilities for initiating the Care Plan, and the facility's policy for timely care planning was not followed.
A resident with a history of arthritis, muscle weakness, and a right above-the-knee amputation did not receive restorative exercises or ambulation assistance as recommended by therapy and outlined in the care plan. Despite multiple therapy evaluations and clear directives, staff did not consistently implement or document restorative programs, and interviews revealed confusion about responsibility and documentation. The facility's policy required individualized restorative care, but this was not provided, resulting in a deficiency.
A resident with severe cognitive impairment, malnutrition, and pressure injuries did not receive a morning meal or snack after missing the scheduled breakfast. Staff failed to communicate the need for a replacement meal, and the resident was left with only juice, despite facility policy requiring food to be available at all times.
A resident with COPD was found to have unsecured nebulizer medication vials left at the bedside, which the resident self-administered without documented assessment or authorization for self-administration. Facility policy requires medications to be stored securely and only accessible to authorized personnel, but this was not followed in this instance.
Surveyors identified that the facility's medication error rate exceeded 5% after two residents received medications not in accordance with physician orders: one received the wrong formulation of Vitamin D, and another was given Atenolol despite a pulse below the ordered threshold. Staff interviews and record reviews confirmed these errors, which were observed during medication administration.
A resident with dementia and dysphagia, requiring a puree diet and maximum eating assistance, was served a bowl of regular textured potato salad in addition to their prescribed puree meal. Although the potato salad was not fed to the resident, this did not align with the resident's dietary order or facility policy.
A resident with schizoaffective disorder was transferred with incorrect medical records due to failure to verify patient identifiers. The social services supervisor forwarded paperwork containing another individual's information, leading to the resident not receiving prescribed psychotropic medications for two weeks and requiring hospitalization. Staff interviews revealed that the paperwork was not properly checked before being sent, despite facility policy requiring verification.
Two residents experienced ongoing abnormal vital signs and changes in condition that were not consistently reported to a physician or documented according to facility policy. One resident had repeated episodes of low blood pressure and elevated heart rate, as well as shortness of breath, without appropriate follow-up or care plan updates, and was eventually transferred to the hospital after a significant decline. Another resident with chronic cardiac conditions had multiple episodes of bradycardia and hypotension, with medication held as ordered but lacking timely provider notification, and suffered several falls and a fatal respiratory event. Staff interviews confirmed that abnormal findings were not always communicated as required.
The facility failed to respect residents' dignity by entering rooms without proper announcement and not ensuring appropriate clothing for weather conditions. A resident with intact cognition experienced staff entering without knocking, and another was inadequately dressed for outdoor conditions due to laundry issues. These actions violate the facility's policy on resident dignity and respect.
A resident with moderate cognitive impairment was financially abused by a CNA who accessed the resident's secured drawer and took $55 in cash. The incident was discovered through video footage installed by the resident's family. The facility's policy on abuse prevention was violated, leading to the CNA's termination for breaching trust and misappropriating resident property.
A facility failed to complete before and after dialysis assessments for a resident with end-stage renal disease. The resident reported inconsistent vital sign checks and assessments, and electronic records showed missing or incomplete documentation. Staff interviews revealed a recent change in the assessment process, but the forms were not consistently uploaded. The facility's policy outlined specific care procedures, but the Director of Nursing acknowledged that several assessments were not completed or located.
A resident with multiple health conditions and intact cognition was unable to communicate with staff due to a malfunctioning call light system. Despite attempts to use the call cord, the system failed to activate, and staff were aware of ongoing issues with the call system. Temporary measures were in place for other residents, but the facility's policy to provide a means of communication was not met.
A resident with quadriplegia sustained a second-degree burn from excessively hot water in a shower room. Despite the resident's report of the injury, the facility continued to use the shower room without addressing the hazard. A subsequent inspection found the water temperature to be dangerously high, and staff interviews revealed awareness of the issue but no preventive measures were taken.
A resident with end-stage renal disease was not provided with transportation to a new dialysis center by the facility, despite being informed of the new schedule. The resident missed appointments due to the facility's inability to accommodate early morning transport, although staff indicated they could have adjusted their schedules if requested. The facility's Admission Packet stated they would arrange transportation for healthcare services, but the resident was not offered alternative options like a taxi or Uber.
The facility failed to provide timely care and equipment management for several residents. A resident with a history of anemia and dementia experienced a decline in condition, but staff delayed necessary interventions, leading to an emergency hospital transfer. Another resident's wound therapy machine alarm went unaddressed, and two residents requiring oxygen therapy were found without it due to staff oversight and equipment mismanagement.
The facility failed to secure resident information on laptops, as observed in two incidents where medication carts were left unlocked with visible resident data. In one case, a CMA left a cart unlocked and a laptop open by mistake. In another, a cart was found unsecured with 12 residents' information visible, and no authorized staff present. The facility's policy requires PHI to be stored securely, and the DON confirmed the need to lock screens before leaving.
A resident with dementia and other medical conditions experienced a decline in condition, prompting their relative to request hospitalization due to suspected UTI. Despite notifying staff and the DON, the request was not acted upon, and the resident's condition worsened until they became unresponsive. The facility failed to inform the medical provider of the relative's request, violating the resident's rights.
A resident with severe cognitive impairment and multiple health conditions experienced a medication change from scheduled to PRN Lorazepam after a fall. The facility failed to notify the resident's family or representative about this change, as required by policy. The LPN responsible for the notification was no longer employed, and the nurse practitioner did not communicate the change, leaving the task to other staff.
The facility failed to follow physician orders and document accurately for two residents. A resident with chronic respiratory failure was observed without oxygen despite orders for continuous use, and staff inaccurately documented oxygen use. Another resident's medication was not administered as recorded, indicating a documentation discrepancy.
The facility failed to follow physician's orders for a resident, resulting in a missed urinalysis due to an unentered order in the EHR. The ADON delayed entering the order, leading to a lack of notification to the medical provider and continued decline in the resident's condition. Additionally, a medication error occurred when an RN documented administering Acetaminophen, but the medication was found in the cart the next day, indicating it was not given. The DON outlined steps for handling such errors, but the report does not confirm these were followed.
A resident with a pressure ulcer did not receive proper wound vac care due to staff's lack of knowledge and failure to respond to alarms. The wound vac was found disconnected, and the resident reported previous battery issues. After attending a festival, the wound vac was not reapplied promptly.
A resident requiring continuous oxygen therapy was found with an empty portable oxygen tank, leading to low oxygen saturation levels. The facility's staff failed to adhere to the policy of reassessing and documenting the oxygen flow, resulting in a deficiency in providing necessary respiratory care.
A resident experienced rectal bleeding after an LPN performed an enema roughly without proper visualization or digital stimulation, contrary to the physician's order. Another resident did not receive wound vac care over a weekend due to staff's lack of knowledge. Both incidents highlight the facility's failure to maintain competent staff, as acknowledged by the DON.
The facility failed to secure medication carts, as observed in two incidents where carts were left unlocked and unattended. On one occasion, a CMA admitted to leaving the cart unlocked by mistake, while another incident involved a cart left in a dining room with residents present and no authorized staff nearby. Facility policy requires carts to be locked when not in use and within sight if not locked.
A resident with a history of wandering and elopement left a facility unattended due to unsecured exit doors and inadequate supervision. The resident, who had diagnoses including schizophrenia and a hip fracture, was found two days later after admitting himself to the Emergency Department for knee pain. The facility's records showed inconsistencies in monitoring the resident's wander guard, and staff interviews revealed issues with staffing levels and familiarity with residents.
Two residents with severe cognitive impairment and dysphagia were served inappropriate meals, posing choking risks. One resident was given bread products despite a recommendation against it, leading to heavy coughing. Another resident received Cheeto Puffs and a salad on a pureed diet. The facility's dietary practices, including outdated diet slips and lack of adherence to guidelines, contributed to these deficiencies.
A resident with severe cognitive impairment was admitted to the facility, but the designated Power of Attorney (POA) was not invited to participate in the care plan conference. The facility's EHR lacked documentation of a care plan conference, and the MDS Coordinator confirmed that a 72-hour care conference was not held or scheduled. Training materials directed staff to review the baseline care plan with the responsible person within 48 hours, but this was not completed.
The facility failed to conduct Level II PASRR evaluations for two residents after new serious mental disorders were diagnosed. One resident, with moderate cognitive impairment, had changes in diagnoses and medication but was not referred for a Level II PASRR. Another resident, rarely understood, was diagnosed with anxiety disorder and Schizoaffective disorder, yet no Level II PASRR was completed. The Social Services Director acknowledged the oversight.
The facility failed to provide adequate nail care for two residents, one with severe cognitive impairment and another who is paraplegic and legally blind. Both residents were found with long, jagged toenails despite care plans requiring regular checks and trimming during bi-weekly showers. Staff documentation and interviews revealed that these care instructions were not consistently followed, leading to the observed deficiencies.
The facility did not ensure clean and safe bathroom conditions for residents, as observed in four bathrooms. A resident's bathroom had missing tiles and a black substance on the walls, while another had a brown substance on the toilet. Two residents shared a bathroom with missing tiles and broken pieces on the floor. The facility's cleaning policy was not followed, as confirmed by the DON.
A resident with intact cognition and multiple diagnoses experienced shoulder pain after an incident during transport due to faulty wheelchair brakes. The facility failed to notify the resident's family of the change in condition, despite policy requirements. Staff interviews revealed prior knowledge of the brake issue, which was not resolved, leading to the incident.
A resident with diabetes and impaired circulation did not receive leg wraps as ordered, experienced delayed meal delivery after insulin administration, and lacked audiology services despite a request. Staff misunderstood treatment orders, and meal trays were not delivered promptly, leading to inconsistent care.
A resident with intact cognition and multiple medical conditions experienced shoulder pain after being improperly secured during transport in a van. The CNA reported that the wheelchair brakes were not secure, causing the wheelchair to move when the van hit a bump. The Maintenance Supervisor had attempted to fix the brakes but did not resolve the issue, leading to the decision to switch chairs. The facility's policy required locking wheelchair brakes, which was not effectively followed.
Two residents with complex medical histories experienced significant health declines due to inadequate assessment and monitoring. One resident, with multiple comorbidities including cognitive deficits and respiratory failure, was not on a turning/repositioning program despite being at risk for pressure ulcers. This oversight led to sepsis and death. Another resident, with cardiorespiratory conditions and mild cognitive impairment, experienced a delay in identifying acute respiratory failure due to insufficient assessments and documentation, resulting in hospitalization for acute hypoxic respiratory failure, pneumonia, and lactic acidosis.
Failure to Protect Residents from Abuse and Inadequate Reporting of Allegations
Penalty
Summary
The facility failed to protect residents from abuse and did not follow its own policies regarding the reporting and investigation of abuse allegations. In one incident, a resident with quadriplegia and profound intellectual disabilities, who was non-verbal and completely dependent on staff, was found by a CNA being touched on the face by another resident who was masturbating at the bedside. The non-verbal resident was observed trying to cry and move his head away, indicating distress. Staff immediately separated the residents and reported the incident to an LPN, who, along with the CNA, documented the event. However, the Administrator, after being notified, did not report the incident to the State Survey Agency or initiate a facility investigation, as required by policy, and did not consider the event to meet the threshold for reporting. The care plan for the resident exhibiting sexual behaviors lacked interventions for such behaviors prior to the incident. In another case, a cognitively intact resident alleged verbal abuse and withholding of pain medication by an LPN. Multiple staff statements corroborated that there was a loud verbal altercation between the resident and the LPN, during which profanities were used and the LPN stated the resident would not receive pain medication. The resident reported only receiving pain medication once and experiencing significant pain. Staff interviews confirmed that the LPN and the resident exchanged raised voices and profanities, and the LPN walked out of the room after the altercation. The Administrator was not informed of the incident immediately, contrary to facility policy. The facility's policy requires immediate reporting and investigation of all alleged violations involving abuse, neglect, exploitation, or mistreatment, including those involving resident-to-resident abuse and staff-to-resident abuse. The policy also specifies that steps must be taken to protect residents after a report of possible abuse and that all incidents must be reported to the Administrator and State Survey Agency within specified timeframes. In both incidents, the facility failed to follow these procedures, as neither incident was reported to the appropriate authorities nor was a timely investigation initiated.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse to the Department of Inspections, Appeals and Licensing (DIAL) in a timely manner for two residents. In one incident, a resident with quadriplegia and profound intellectual disabilities, who was non-verbal and completely dependent on staff, was found by a CNA being touched on the face by another resident who was masturbating. The CNA immediately intervened, separated the residents, and reported the incident to an LPN, who documented the event and notified the Administrator. Despite this, the Administrator determined the incident did not need to be reported to DIAL at that time, and the event was not reported as required by facility policy and state regulations. In another case, a cognitively intact resident alleged that an LPN withheld medication and used profanities towards him. Multiple staff statements confirmed a verbal altercation involving yelling and cursing between the resident and the LPN, with the LPN reportedly making inappropriate comments about the resident's pain medication. The Administrator was not informed of the incident until several days later, after the resident reported the alleged abuse directly. Facility policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be reported immediately to the Administrator and the State Survey Agency, with specific timeframes for reporting depending on the severity of the incident. Staff interviews and record reviews confirmed that these requirements were not met in both cases, resulting in a failure to report suspected abuse in a timely manner.
Failure to Investigate and Document Alleged Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough and timely investigation following an allegation of sexual abuse involving two residents, one of whom was non-verbal, quadriplegic, and completely dependent on staff for care. The incident occurred when a CNA observed one resident masturbating and rubbing his hand on the face of the non-verbal resident, who was unable to defend himself and appeared to be in distress. The CNA immediately intervened, separated the residents, and reported the incident to an LPN, who also recognized the seriousness of the situation and contacted the facility Administrator. Despite the immediate actions taken by staff to separate the residents and notify the Administrator, the facility did not complete a formal investigation into the incident. There was no documentation in the clinical records for either resident regarding the incident, including the absence of care plan updates, incident reports, or resident assessments. The care plan for the resident exhibiting hypersexual behavior was not updated until several days after the incident. Additionally, there was no evidence of timely family notification or a comprehensive review of the situation as required by facility policy. Interviews with staff and review of facility policy confirmed that the expected procedures following an allegation of abuse—such as reporting to the appropriate agencies, completing a facility investigation, updating care plans, and documenting the incident—were not followed. The lack of a prompt and thorough investigation, as well as insufficient documentation and care plan updates, constituted a failure to respond appropriately to the alleged violation.
Failure to Provide Timely Admission Orders and Medications
Penalty
Summary
The facility failed to ensure that a newly admitted resident received complete and timely physician orders for immediate care upon admission. The resident, who had a complex medical history including a right femur fracture, acute kidney failure, chronic congestive heart failure, diabetes, obesity, bipolar disorder, anxiety disorder, hypertension, COPD, and leukemia in remission, did not receive essential medications such as insulin, cardiac drugs, pain medication, and psychotropic drugs. Documentation showed that only two doses of pain medication were administered, and there was no evidence that other critical medications or blood sugar checks were provided as ordered by the hospital discharge summary. Multiple staff interviews revealed confusion and lack of clarity regarding responsibility for entering and verifying admission orders. Nursing staff reported not having access to the necessary orders in the system and were unsure who was responsible for completing the admission process. The resident repeatedly requested pain medication and other necessary treatments but was told by staff that they were not in the system and had no medications available. The resident experienced significant pain and distress, ultimately leading to their decision to leave the facility with family assistance after contacting the police. The facility's own policy required informing the physician of admission, verifying transfer and admission orders, initiating required treatments, and ordering medications from the pharmacy. However, these steps were not completed in a timely manner, resulting in the resident not receiving critical medications and care. Staff interviews confirmed that the delay in obtaining and entering orders led to the resident's unmet medical needs and unnecessary pain during their stay.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for two residents who required such services. One resident, admitted from the hospital with a femur fracture and other conditions, was cognitively intact and had physician orders for multiple pain and anxiety medications, including oxycodone. Upon admission, there was a significant delay in entering and obtaining medication orders, resulting in the resident not receiving prescribed pain medications, muscle relaxants, and psychotropic medications in a timely manner. Staff interviews revealed confusion and lack of communication regarding the arrival and administration of medications, with the resident experiencing severe pain and only receiving pain medication once during the night. Staff interactions with the resident were marked by raised voices and inappropriate language, and the resident ultimately left the facility with family after not receiving adequate pain relief. Another resident with acute osteomyelitis and chronic pain was admitted and required both scheduled and as-needed pain medications. The care plan directed staff to administer analgesics per orders and prior to treatments. However, after the nurse practitioner documented an order for as-needed oxycodone following a report of severe pain, there was a delay in transcribing and initiating this order. The resident reported that pain was unbearable upon arrival and only improved after the correct pain medication order was implemented. Staff interviews confirmed that the as-needed order was not promptly processed, resulting in inadequate pain control for several days. The deficiencies were directly related to failures in timely transcription, communication, and administration of physician-ordered pain medications. Documentation and staff statements confirmed that both residents experienced unnecessary pain due to these lapses, and the facility did not follow its own policy for pain management, which requires prompt assessment, documentation, and intervention to maintain resident well-being.
Failure to Maintain Adequate Nursing Staff Levels
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple confidential resident and family interviews, staff interviews, clinical record reviews, and facility policy review. Residents with intact cognition reported long call light response times, insufficient assistance during meals, and delays in receiving care such as wound dressing changes and transfers to bed. Family members expressed concerns about residents not being changed properly at night, insufficient staff to assist with feeding, and fear of retaliation for reporting concerns. Staff interviews confirmed that staffing levels were often below the facility's own assessment requirements, with only two CNAs and one nurse per floor on about half of the shifts, and at least one instance where the DON worked the floor overnight due to staffing shortages. A review of time card data on selected dates showed the required number of CNAs was not met on several shifts. Resident Council notes documented ongoing issues with call light response times exceeding 15 minutes and unmade beds. The facility's own assessment indicated a need for at least five CNAs on day and evening shifts and four or more on overnight shifts, which was not consistently achieved. These findings collectively demonstrate that the facility did not maintain sufficient nursing staff to meet the care needs of its residents as required.
Resident Left Uncovered in Dining Room, Dignity Not Maintained
Penalty
Summary
A resident with severe intellectual disability and schizoaffective disorder, who had moderately impaired cognition and required partial to moderate assistance with lower body dressing, was observed sitting in a dining room chair with her buttocks fully exposed. The resident's care plan indicated a need for assistance with activities of daily living, including dressing, and directed staff to provide one-person assistance for dressing. Despite these documented needs, the resident was left exposed in a public area where nine other residents, including a male resident facing her, were present. Multiple staff members, including four who were waiting to serve food, walked past the resident without addressing her exposed state. The resident remained uncovered for at least eight minutes until a certified medication aide placed a blanket to cover her. Facility policy required all residents to be treated with dignity and privacy, ensuring they are appropriately dressed to maintain bodily privacy. The failure of staff to promptly cover the resident resulted in a lack of dignity and privacy for the resident.
Failure to Administer Wound Care and Dressing Changes as Ordered
Penalty
Summary
The facility failed to administer wound treatments and perform dressing changes as ordered by the physician for one resident. Clinical record review and observation revealed that the resident had multiple pressure ulcers, including a Stage 3 ulcer on the left ankle, a Stage 1 ulcer, and an unstageable ulcer. The care plan was updated to address wounds on the left inner ankle and coccyx, but did not include information about a wound on the right foot. Physician orders directed staff to cleanse the right lateral foot wound, apply calcium alginate, and cover it with a silicone absorbent dressing daily and as needed. Documentation showed that dressing changes for the right lateral foot were only recorded on specific days, and during observation, the dressing on the right lateral foot was found to be dated several days prior. Staff interviews confirmed that dressings should be dated and initialed each time they are changed, and that the frequency of changes should match physician orders. The Director of Nursing stated that the date and initials on the dressing are used to verify when and by whom the dressing was changed. Policy review indicated that the facility is required to implement treatment orders accurately and in accordance with the resident's care plan. The lack of documentation and failure to perform dressing changes as ordered led to the identified deficiency.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement appropriate infection control practices, specifically Enhanced Barrier Precautions (EBP), for three residents with conditions requiring such measures. For one resident with a history of septicemia, hip fracture, paraplegia, and a pressure ulcer, staff were observed performing wound care without all team members donning the required personal protective equipment (PPE). During the procedure, a CNA did not wear a gown while assisting with care, and an LPN used the same gloves to touch potentially contaminated surfaces and then cleanse the wound bed, contrary to infection control protocols. Multiple staff interviews confirmed the expectation that all care team members should wear PPE, including gowns and gloves, when providing care to residents requiring EBP. Another resident with multiple pressure ulcers and a history of infections was observed receiving wound care from an LPN and a nurse practitioner. During the dressing change and debridement, neither staff member wore a gown as required by the resident's care plan and facility policy for EBP during high-contact care activities. The care plan specifically directed the use of gown and gloves for such procedures due to the presence of wounds. A third resident with quadriplegia and impaired skin integrity was observed receiving wound care without the staff member wearing a gown or changing gloves between dirty and clean tasks. The care plan and physician's orders required EBP, including gown and gloves, for high-contact care activities due to wounds and an indwelling medical device. Staff interviews and policy review confirmed the expectation for PPE use and proper glove changes during wound care. The facility's infection control policy outlined the need for EBP to prevent the spread of multi-drug resistant organisms, but these practices were not consistently followed during the observed care activities.
Failure to Follow Enhanced Barrier Precautions and Equipment Disinfection Protocols
Penalty
Summary
Staff failed to follow infection prevention and control protocols related to Enhanced Barrier Precautions (EBP) and equipment disinfection for multiple residents with indwelling medical devices. For a resident with a Foley catheter due to neurogenic bladder, staff were observed performing catheter care and draining the catheter without donning a gown, despite facility policy and posted signage requiring both gown and gloves for high-contact care activities. The staff member acknowledged awareness of the EBP requirements but did not comply during the observed care. Another resident with a feeding tube and frequent incontinence was observed receiving tube feeding and medication administration from an LPN who only wore gloves, omitting the required gown and mask during high-contact activities involving the G-tube. The LPN later admitted this was an error and that full PPE should have been used. During incontinence care for the same resident, CNAs wore gloves and gowns, but one CNA's gown was not properly secured and repeatedly fell from his shoulders, compromising the effectiveness of the barrier precautions. Additionally, the same CNA was observed touching multiple surfaces in the room with contaminated gloves before changing them, increasing the risk of cross-contamination. In a separate incident, two CNAs used a mechanical lift to transfer a resident who required total assistance. After the transfer, the lift was not disinfected before being moved to a common storage area, contrary to facility protocol and staff interviews indicating that equipment should be wiped down after each use. The facility's policy and CDC guidance both require cleaning and disinfection of shared equipment and the use of gown and gloves for high-contact care activities involving residents with indwelling devices or wounds.
Failure to Follow Prescribed Menus and Portion Sizes During Meal Service
Penalty
Summary
The facility failed to ensure that lunch menus and meals met the nutritional needs and preferences of residents, as evidenced by multiple discrepancies during meal preparation and service. Observations revealed that a cook pureed two pork steaks for lunch service without measuring the final volume of the puree, despite a chart indicating the required portion size. Three residents received approximately three-fourths of a #8 scooper serving size of pureed pork, even though only two residents were on a pureed diet and one was on a liquefied diet. The liquefied diet was prepared by mixing pureed meat with hot water in a mug, and the Certified Dietary Manager (CDM) was unsure of the standard procedure for preparing liquefied food. Sample menus indicated that the correct number of servings should be processed to meet dietary requirements, but this was not followed. Additionally, there were several instances where residents did not receive the supplements or side dishes indicated on their lunch tickets. One resident did not receive a Magic Cup supplement, another received a Mighty Shake instead of a Magic Cup, three residents did not receive a Mighty Shake supplement, one resident did not receive a side dish of cottage cheese, and one resident did not receive ice cream. These omissions and substitutions were confirmed by staff interviews and direct observation, indicating a failure to follow prescribed menus and meal tickets, and to meet the documented nutritional needs and preferences of the residents.
Failure to Maintain Sanitary Food Handling and Storage Practices
Penalty
Summary
Dietary staff failed to maintain clean and sanitary conditions in the kitchen, as evidenced by multiple observations of unclean equipment and improper food storage. During kitchen tours, surveyors found a large trash barrel with the lid partially off, broken down cardboard boxes blocking freezer access, and a sticky, soiled freezer handle with dried liquid and food crumbs inside. Several food items, including blueberries, chicken/noodles/broth, diced peaches, and dressings, were found unlabeled and undated. Bulk containers of sugar and flour were improperly labeled or undated, and a scoop was stored with its handle in direct contact with sugar. Additionally, frying pans were observed to be blackened, charred, and missing Teflon coating. Ground meat was left thawing in a sink without running water, contrary to policy, and the same unsanitary conditions persisted on follow-up visits. During meal service, staff were observed handling food and utensils in ways that could lead to contamination. One cook touched the inside of plates with bare hands while plating food, and an aide touched the end of a straw before inserting it into a milk carton for a resident. Another staff member failed to perform hand hygiene after picking up plastic lids from the floor and resumed meal tray preparation. Additionally, a staff member used bare hands to retrieve tongs from a pan of barbeque pork steaks, with the tongs slipping into the food multiple times, and no gloves or extra utensils were available. These actions were inconsistent with facility policies and professional standards for food safety and hygiene.
Failure to Accurately Document and Maintain Resident Code Status
Penalty
Summary
The facility failed to accurately document and maintain the correct code status for two residents, resulting in discrepancies between the residents' wishes as indicated on their Iowa Physician Orders for Scope of Treatment (IPOST) forms and the code status recorded in the electronic health record (EHR) and physician orders. For one resident with diagnoses including metabolic encephalopathy, diabetes, hypertension, and respiratory failure, the IPOST form indicated a Do Not Resuscitate (DNR) status, while the EHR and physician orders listed the resident as Full Code. The Director of Nursing (DON) confirmed the inconsistency, noting that the resident's code status may not have been updated following hospitalizations. The facility's policy required routine review and updating of advanced directives, but this was not followed, leading to conflicting documentation regarding the resident's code status. For another resident, the IPOST form indicated a desire for Full Treatment and Cardiopulmonary Resuscitation (CPR), but the EHR listed the resident as DNR. Staff were unable to locate the resident's IPOST in the designated binders at either nursing station, and an LPN initially stated the resident was DNR based on the EHR. Upon further review, the LPN found the IPOST in the EHR, which showed the resident wished to be Full Code, and subsequently updated the EHR to reflect this. The facility's policy required that a copy of any advance directives be included in the medical record and that the care plan team be informed of any changes, but these procedures were not consistently followed, resulting in inaccurate documentation of residents' code status.
Failure to Complete 14-Day Re-Evaluation for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure timely follow-up for the initiation of a PRN psychotropic medication for one resident. Clinical record review showed that the resident, who had severe cognitive impairment and diagnoses including aphasia, autistic disorder, and profound intellectual disabilities, was prescribed Ativan as a PRN medication for anxiety and yelling. The physician's order for PRN Ativan did not include a stop date, and the medication was administered multiple times over a period exceeding 14 days. Documentation in the electronic health record did not show that the prescribing practitioner completed a required 14-day evaluation for the continued use of the PRN Ativan. The facility's policy on psychotropic drug use requires that PRN orders for such medications be limited to 14 days unless the practitioner documents a rationale for extending the order and specifies the duration. The policy also states that psychotropic medications should only be administered when necessary to treat a diagnosed condition and after non-pharmacological interventions have failed. Despite these requirements, the facility did not obtain or document the necessary 14-day re-evaluation for the continued use of PRN Ativan for the resident.
Failure to Accurately Document PASRR Level II Status in MDS Assessments
Penalty
Summary
The facility failed to accurately document the PASRR Level II status for three residents in their Minimum Data Set (MDS) assessments, despite each resident having a valid PASRR Level II determination on file. For each of the three residents, the PASRR identified serious mental illness and/or intellectual or developmental disabilities, along with specific diagnoses such as Major Depressive Disorder, Generalized Anxiety Disorder, Alcohol Dependence, Schizoaffective Disorder, Mood Disorder, and Intermittent Explosive Disorder. The PASRRs also outlined the need for specialized services, including ongoing psychiatric medication management and individual therapy by licensed behavioral health professionals. However, the corresponding MDS assessments failed to reflect the residents' PASRR Level II status as required by the 2024 RAI Manual. Staff interviews revealed that the MDS Coordinator relied on the electronic health record (EHR) and, if necessary, consulted the facility Social Worker to determine PASRR status. It was noted that after a facility name change and EHR transition, some medical records did not transfer correctly, which may have contributed to the omission. Despite the PASRR documents being uploaded into the EHR prior to the MDS completion dates, the required information was not accurately coded in the MDS, contrary to facility policy and RAI Manual instructions.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline Care Plan within 48 hours of admission for a resident who was admitted with multiple diagnoses, including anemia, atrial fibrillation, non-Alzheimer's dementia, and unsteadiness on feet, with a recent history of falls. Documentation showed that the resident required significant assistance for transfers, toileting, and mobility, as indicated by therapy and nursing communication forms. However, the initial Care Plan was not initiated until several days after admission and did not include essential information regarding the level of staff assistance and supervision needed for activities of daily living such as bed mobility, transfers, toileting, and personal hygiene. Interviews with facility staff revealed a lack of clarity and established process for initiating baseline Care Plans, particularly following recent staffing changes in the MDS Coordinator position. The facility's policy required that a baseline Care Plan be developed and implemented within 48 hours of admission, including all necessary healthcare information and a written summary provided to the resident or their representative. This policy was not followed in the case reviewed, resulting in the deficiency.
Failure to Provide Restorative Care and Follow Therapy Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate restorative care and follow therapy recommendations for a resident with limited range of motion (ROM) and mobility issues. The resident, who had a history of arthritis, muscle weakness, and a right above-the-knee amputation with a prosthesis, was identified as needing ongoing restorative nursing programs (RNP) and therapy interventions to maintain or improve functional status. Despite multiple therapy evaluations and clear recommendations for restorative ambulation and ROM programs, documentation revealed that the resident did not receive restorative exercises or activities for extended periods, as indicated by the absence of restorative program documentation in the electronic health record and Minimum Data Set (MDS) assessments showing zero days of RNP during several look-back periods. Interviews with staff and the resident confirmed that restorative activities were not consistently provided. The resident reported not receiving any exercise program or ambulation assistance after being discharged from therapy services, stating that staff left him alone and he was on his own to perform exercises. Staff interviews revealed confusion and lack of clarity regarding responsibility for restorative care, with restorative duties assigned to staff who were also tasked with other responsibilities such as medication administration and transportation, making it difficult to consistently implement restorative programs. Staff also indicated that the restorative program had not been active for some time and that there was uncertainty about documentation and care plan updates related to restorative services. Policy review showed that the facility's restorative care policy required individualized restorative services based on assessment and care planning, with all employees responsible for providing restorative care. However, the lack of implementation and documentation of restorative activities for the resident, despite therapy recommendations and care plan directives, led to a failure in maintaining or improving the resident's ROM and mobility as required.
Failure to Provide Required Meal or Snack to Dependent Resident
Penalty
Summary
Staff failed to provide a morning meal or snack to a resident who was dependent on staff for eating assistance and had significant cognitive impairment, as well as a history of malnutrition and weight loss. The resident was observed in the dining room after breakfast time with only a cup of juice, and staff confirmed that the breakfast tray had already been discarded and no replacement was provided. The dietary manager and cook both stated they were not informed that the resident needed a meal or snack, despite facility policy requiring food and substantial snacks to be available 24 hours a day and for residents to be offered meals or snacks if they missed a scheduled meal. The resident's care plan specified a puree diet with nectar-thick liquids and documented the presence of severe pressure injuries. The facility's policies outlined open dining and the availability of food at all times, but these were not followed in this instance. Staff interviews revealed a lack of communication and follow-through to ensure the resident received appropriate nutrition after missing the scheduled breakfast.
Unsecured Nebulizer Medication Left at Bedside Without Authorization
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of emphysema and COPD was observed to have unsecured vials of nebulizer medication at their bedside, with no nursing staff present. The resident reported that staff provided as many vials of nebulizer medication as needed and left them at the bedside, allowing the resident to self-administer the medication. The resident's care plan did not indicate that self-administration of medication was permitted, and there was no documentation of an assessment for self-administration in the clinical record. Facility policy requires all drugs and biologicals to be stored in locked compartments and accessible only to authorized personnel. During observations, staff verified the presence of unsecured medication at the resident's bedside. Interviews with staff revealed that the resident had not been assessed or authorized for self-administration, and the facility's procedures were not followed regarding medication storage and access.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with a calculated error rate of 7% based on 2 errors out of 27 observed medication administrations. During medication administration, a Certified Medication Aide (CMA) prepared and administered Vitamin D to a resident, but the order specified Vitamin D3, 25 mcg, indicating the wrong formulation was given. In another instance, the CMA administered Atenolol 50 mg to a different resident despite the order specifying the medication should be held if the resident's pulse was below 60 beats per minute; the resident's pulse was documented at 53 at the time of administration. The facility's policy requires medications to be administered according to physician orders and for staff to verify the drug and dosage against the Medication Administration Record (MAR) and drug label prior to administration. Staff interviews confirmed the errors, with the CMA acknowledging the administration of the incorrect Vitamin D formulation and the failure to hold Atenolol as ordered. The errors were observed and verified through direct observation, record review, and staff interviews.
Resident Served Incorrect Food Texture Despite Puree Diet Order
Penalty
Summary
A resident with dementia and dysphagia, who was assessed as having moderate cognitive impairment and required maximum assistance with eating, was ordered to receive a puree texture diet with moderately thick liquids. During a lunch service observation, the resident was served a meal consistent with their diet order, but an unknown staff member subsequently placed a bowl of regular textured potato salad in front of the resident. Although the potato salad was not fed to the resident, this action was acknowledged by the Certified Dietary Manager as not being in accordance with the resident's prescribed puree diet. Facility policy required that food be provided at the proper texture and consistency to meet individual needs.
Failure to Verify Patient Identifiers Results in Transfer of Incorrect Medical Records
Penalty
Summary
The facility failed to verify patient identifiers before sending transfer paperwork, resulting in the receiving facility obtaining inaccurate medical records for a resident being discharged. The error occurred when the social services supervisor forwarded discharge paperwork that included a fax cover sheet with the correct resident name but an incorrect date of birth and facility name. The attached medical records belonged to a different individual, and the social services supervisor did not review the details of the paperwork before sending it to the receiving facility. The nurse involved in the transfer provided a verbal report about the resident's mental health status and medications but did not handle the physical paperwork, which was managed by social services. The resident involved had a primary diagnosis of schizoaffective disorder and was prescribed psychotropic medications. Due to the incorrect paperwork, the receiving facility placed orders incorrectly, and the resident did not receive her prescribed medications for approximately two weeks. This lapse in medication administration led to a hospitalization related to her mental health condition. The error was only identified after the receiving facility noticed discrepancies and contacted the advanced registered nurse practitioner (ARNP), who then corrected the orders. Interviews with facility staff revealed a lack of verification processes for transfer paperwork. The social services supervisor admitted to noticing the wrong facility name but did not check other identifiers such as date of birth or the content of the orders. The director of nursing and administrator were unaware of how the incorrect paperwork was included in the resident's electronic health record, and the ARNP confirmed she was not involved with the third facility named on the paperwork. The facility's policy required verification of patient information before disclosure, but this was not followed in this instance.
Failure to Report and Address Abnormal Vital Signs and Changes in Condition
Penalty
Summary
The facility failed to identify and report ongoing abnormal vital signs and did not complete required respiratory assessments for two residents. For one resident, there were multiple instances where abnormal vital signs, such as low blood pressure and elevated heart rate, were documented without physician notification. This resident also exhibited shortness of breath on exertion for several days, but the care plan did not address respiratory or cardiovascular concerns, and there was no evidence of follow-up or reporting to the physician. The resident experienced a significant change in condition, including loss of consciousness and irregular breathing, which ultimately led to a hospital transfer. Documentation was incomplete regarding the incident leading to the transfer and the vital signs at the time of a prior fall were not recorded. For the second resident, who had a history of Parkinson's Disease, coronary heart disease, and hypertension, there were repeated episodes of bradycardia (low heart rate) and hypotension. The medication administration record included parameters to hold antihypertensive medication for low blood pressure or heart rate, and the medication was held on several occasions. However, documentation frequently lacked evidence of timely physician notification regarding the persistent abnormal vital signs. The resident experienced multiple falls, episodes of unresponsiveness, and eventually a respiratory arrest that resulted in hospital transfer and subsequent death. Staff interviews confirmed that abnormal vital signs were not always communicated to the provider as required by facility policy. Facility policy required that all significant changes in condition, including abnormal vital signs, be reported to the physician prior to the end of the shift and that all actions and communications be documented in the nursing progress notes. Despite this, the records showed gaps in both notification and documentation for abnormal findings and changes in condition for both residents. The Director of Nursing and other staff confirmed expectations for reporting and documentation, but the review found these were not consistently followed.
Failure to Respect Resident Dignity and Ensure Appropriate Clothing
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect by not adhering to proper protocols when entering residents' rooms and ensuring appropriate clothing for weather conditions. For Resident #2, who has intact cognition and self-care deficits, staff entered the room without waiting for a response after knocking, which the resident found discourteous. A visitor corroborated this behavior, noting it happened frequently. Similarly, Resident #4, who also has intact cognition and self-care performance deficits, experienced a staff member entering their room without knocking, interrupting a private conversation. The staff member acknowledged the mistake but the incident highlights a pattern of disrespectful behavior. Additionally, Resident #1, who has multiple diagnoses including traumatic brain dysfunction and renal disease, was observed inadequately dressed for the weather while waiting to go outside for a supervised smoking break. The resident was wearing a short-sleeved shirt and shorts, exposing their abdomen and leg stumps, while other residents were dressed appropriately for the rainy and windy conditions. The resident indicated that most of their clothing was in the laundry, suggesting a lack of available appropriate clothing. These incidents demonstrate a failure to ensure residents are treated with dignity and respect, as outlined in the facility's policy.
Resident Financial Abuse Due to CNA Misconduct
Penalty
Summary
The facility failed to protect a resident from financial abuse, as evidenced by an incident involving the misappropriation of the resident's property. The resident, who had a moderate cognitive impairment and required assistance with daily activities, was the victim of theft by a Certified Nurses Aide (CNA). The incident was discovered when the resident's family member reviewed footage from a camera installed in the resident's room, which showed the CNA accessing a secured drawer and taking $55 in cash. The CNA denied taking the money but was recorded on video accessing the drawer without the resident's consent. The facility's policy on abuse prevention and prohibition was violated, as it mandates that residents have the right to be free from abuse, neglect, and misappropriation of property. The CNA's actions were a serious breach of trust and a violation of the facility's policies, which emphasize the importance of respecting residents' rights to personal privacy and property. The facility's administrator confirmed the incident after reviewing the video footage and terminated the CNA's employment for violating the zero-tolerance policy regarding the misappropriation of resident property.
Failure to Complete Dialysis Assessments
Penalty
Summary
The facility failed to ensure that before and after dialysis assessments were completed for a resident with end-stage renal disease who required dialysis. The resident, who had no cognitive impairment, reported that staff did not consistently check vital signs before leaving for dialysis appointments or assess them upon return. The resident recalled feeling very ill after a dialysis session in January and felt dismissed by the staff. Interviews with staff revealed that there was a recent change in the process, requiring a form to be completed before and after dialysis, but the forms were not consistently uploaded to the resident's record. A review of the electronic records from February to March showed multiple instances where dialysis assessments were either incomplete or missing. The facility's policy on dialysis care, last reviewed in March 2023, outlined specific pre- and post-dialysis care procedures, including assessing blood pressure, checking the dialysis access site, and reporting any significant changes in the resident's condition. However, the Director of Nursing acknowledged that several assessments were not completed or could not be located, indicating a failure in adhering to the established policy and procedures for dialysis care.
Deficiency in Call System Functionality
Penalty
Summary
The facility failed to provide a properly functioning call system for a resident, leading to a deficiency in resident-to-staff communication. The resident, who had a traumatic brain injury, heart disease, respiratory failure, diabetes, renal disease, depression, schizophrenia, and bilateral leg amputations, required substantial assistance with daily activities. Despite having intact cognition, the resident was unable to effectively communicate with staff due to a malfunctioning call light system. During an observation, the resident attempted to use the call cord, but the call light did not activate, indicating a failure in the system. Staff interviews revealed that the call light system was known to have issues, and temporary measures, such as providing a button to alert the nurse's station, were in place for other residents. The facility's administrator acknowledged the problem and mentioned plans to replace the entire call light system, which had been delayed. The facility's policy required providing residents with a means of communication with staff, which was not met in this instance, leading to the deficiency.
Failure to Prevent Burn Injury Due to Hot Water Hazard
Penalty
Summary
The facility failed to identify and mitigate a hazard in the shower room, leading to a resident sustaining a second-degree burn. On October 28, 2024, a resident with quadriplegia, who was dependent on staff for bathing, reported a red mark on their right forearm after a shower. The mark measured 10.3 cm by 5.6 cm and had scattered blisters. The resident attributed the injury to the hot water in the shower room. Despite this report, the facility continued to use the shower room without addressing the potential hazard. On November 5, 2024, a Department of Inspection, Appeals and Licensing (DIAL) staff member measured the water temperature in the shower room and found it to be 145.2 degrees Fahrenheit, significantly higher than the recommended safe temperature. This high temperature posed a risk of burns to residents, as evidenced by the injury sustained by the resident. Interviews with staff revealed that the water temperature in the shower room was known to be excessively hot, yet no measures were taken to regulate it or prevent its use until the issue was resolved. The facility's maintenance logs lacked documentation of water temperature checks in the shower rooms, focusing instead on resident rooms and other areas. Staff interviews indicated that the water temperature in the shower room was variable and could become dangerously hot if turned all the way up. Despite these known issues, the facility did not implement adequate supervision or preventive measures to ensure resident safety, resulting in the resident's injury.
Removal Plan
- Resident #2 had treatment in place of the area on the right arm.
- The 3 residents that were given showers had complete head to toe skin assessments completed and were questioned about the temperature of water.
- Weekly skin assessments are recorded in each resident's chart in Point Click Care (PCC), no residents voiced concerns about shower temperature, or any injuries noted from skin assessments.
- All showers were put out of use immediately after DIL staff reported water temperature finding of 145.2 degrees. The high temperature had the potential to harm other residents in the facility that receive showers.
- All showers are regulated to prevent water temperatures above 120 degrees.
- Plumber services contacted to assess the current plumbing system with additional monitoring thermometer installed on the water heater. Plumber's report isolated an incident of sediment build up that was resolved by maintenance staff with no further interventions required for safe water temperatures.
- Maintenance will check water temperature in each shower room daily for the next 7 days and then on a weekly basis as a part of weekly system checks through TELS. Weekly system checks have no end date.
- All nursing staff will be educated on how to monitor water temperature with a thermometer placed in the shower room. If the water temperature is greater than 120 degrees, they are to cease the shower for the resident, and report to the administrator, maintenance or charge nurse and cease showers until the water temperature has been checked and deemed to be at a safe level.
Failure to Provide Dialysis Transportation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis treatments was provided with appropriate transportation arrangements to and from the dialysis facility of his choice. The resident, who had a BIMS score of 15 indicating no cognitive impairment, had diagnoses including end-stage renal disease, atrial fibrillation, coronary artery disease, and diabetes mellitus. The resident had changed his dialysis center to a location closer to the facility with appointments scheduled for early mornings. Despite being informed of the new schedule, the facility did not arrange transportation for the resident, who was aware that the facility van was not available at the required time. The resident had previously been informed about transportation options but had initially stated he could arrange his own transportation. However, when the time came for his appointments at the new dialysis center, the facility did not provide transportation, and the resident missed appointments. The facility staff, including the Administrator and DON, were aware of the resident's new dialysis schedule but did not make arrangements to accommodate the early appointment times. The facility's transportation staff indicated they could have adjusted their schedules if requested, but this was not arranged. The facility's Admission Packet stated that they would arrange for appropriate transportation for residents to healthcare services outside the facility. However, the resident reported that he was not offered alternative transportation options such as a taxi or Uber. The facility's failure to provide transportation was attributed to the resident's indication that he would arrange his own transport, but ultimately, the facility did not fulfill its responsibility to ensure the resident's access to necessary medical care.
Failure to Provide Timely Care and Equipment Management
Penalty
Summary
The facility failed to provide timely assessment and intervention for Resident #10, who had a history of anemia, hyponatremia, non-Alzheimer's dementia, and other conditions. Despite signs of decline, such as increased lethargy and elevated white blood cell count, staff did not promptly act on these changes. The resident's family expressed concerns about the resident's condition, suspecting a urinary tract infection, but the necessary urine analysis was delayed due to miscommunication and lack of follow-through by the staff. This delay resulted in the resident becoming unresponsive and requiring an emergent transfer to a hospital. Resident #4 experienced issues with their negative pressure wound therapy (NPWT) machine, which was audibly beeping for an extended period without staff intervention. Multiple staff members entered the room but did not address the alarm, and the machine was found unplugged. The care plan required regular changes to the wound vac, but the lack of response to the alarm suggests a failure to adhere to the care plan and monitor the resident's equipment properly. Resident #8, who required continuous oxygen therapy, was found without oxygen on multiple occasions. The oxygen concentrator was unplugged, and the resident reported not using oxygen for several days. Despite the resident's moderate cognitive impairment, staff did not ensure the oxygen equipment was functional or that the resident was using it as prescribed. Similarly, Resident #9 was found with an empty portable oxygen tank, and there was confusion about the correct oxygen flow rate, indicating a failure to follow physician orders and ensure proper oxygen administration.
Failure to Secure Resident Information on Laptops
Penalty
Summary
The facility failed to protect resident information from unauthorized access, as observed in two separate incidents involving medication carts and laptops. On one occasion, a medication cart on the 200 resident hall was left unlocked with resident information visible on the laptop screen, and no staff was present. Staff A, a Certified Medication Aide (CMA), admitted to leaving the cart unlocked and the laptop open by mistake. In another instance, a medication cart was again found unlocked with 12 residents' information visible on the laptop screen in a dining room with 8 residents present and no authorized staff nearby. Staff B, another CMA, acknowledged that it was not customary to leave the laptop and cart unsecured when away from the cart. The facility's policy, titled Safeguards for PHI, dated January 2017, requires that all documents containing Protected Health Information (PHI) be stored securely in a locked location with limited access to authorized personnel. The Director of Nursing (DON) confirmed that staff should activate the lock feature on the screen before leaving the area.
Failure to Honor Resident Representative's Request for Hospitalization
Penalty
Summary
The facility failed to ensure the rights of a resident's representative were met, specifically for a resident who was unable to communicate effectively due to various medical conditions, including non-Alzheimer's dementia and metabolic encephalopathy. The resident's relative expressed concerns about the resident's declining condition and requested hospitalization, suspecting a urinary tract infection. Despite notifying the nursing staff and the Director of Nursing (DON) about the resident's symptoms and the need for hospital care, the relative's requests were not acted upon promptly. The resident's condition continued to decline, with increased lethargy and elevated white blood cell count, but the facility did not contact the medical provider as requested by the relative. The resident's condition worsened, leading to unresponsiveness, at which point the facility finally obtained orders to send the resident to the hospital. Interviews with staff revealed a lack of recollection regarding the relative's requests, and the medical provider confirmed they were not informed of the relative's desire for hospitalization. The facility's policy on resident rights emphasized the importance of informing residents and their representatives about treatment options and respecting their choices, which was not adhered to in this case.
Failure to Notify Family of Medication Change
Penalty
Summary
The facility failed to notify the family or representative of a resident about a medication change, specifically the discontinuation of Lorazepam, which was initially scheduled to be given four times a day. The resident, who had severe cognitive impairment and was dependent on staff for various activities, was under hospice care and had a history of congestive heart failure, diabetes, and other conditions. The resident experienced a fall, leading to the decision to switch Lorazepam to a PRN basis. However, there was no documentation of family notification regarding this change. The facility's policy required prompt notification of the resident's family or representative about significant changes in the resident's condition or treatment. Despite this, the documentation and interviews revealed that the family was not informed of the medication change on the specified date. The LPN responsible for notifying the family was no longer employed at the facility, and the nurse practitioner confirmed that she did not communicate with the family about the medication change, leaving the responsibility to the hospice RN or facility nurses.
Failure to Follow Physician Orders and Accurate Documentation
Penalty
Summary
The facility failed to ensure physician orders were followed and documented accurately for two residents. Resident #8, who had multiple diagnoses including chronic respiratory failure and utilized oxygen therapy, was observed multiple times without oxygen despite a physician's order for continuous oxygen use. The oxygen concentrator was found unplugged, and the resident reported not using oxygen for several days because staff had moved the concentrator and failed to plug it back in. Despite this, staff documented oxygen saturations as if the resident was using oxygen, indicating a discrepancy in documentation. For Resident #2, there was a discrepancy in medication administration documentation. An observation revealed that acetaminophen intended for administration on a specific date was still in the medication cart, yet the electronic medication administration record indicated it had been given. The Director of Nursing acknowledged that documentation should reflect actual events and stated that any discrepancies would be investigated to determine if they were accidental or intentional errors.
Failure to Follow Physician Orders and Medication Error
Penalty
Summary
The facility failed to ensure physician's orders were followed for two residents. For one resident, a physician ordered a urinalysis (UA) with culture and sensitivity, increased gastric tube flushes, and monitoring for signs of infection. However, the UA order was not entered into the Electronic Health Record (EHR) by the Assistant Director of Nursing (ADON), who was responsible for doing so. The ADON delayed entering the order due to uncertainty about the need for straight catheterization to collect the urine sample. Consequently, the UA was not collected, and the medical provider was not notified of this failure. The resident's condition continued to decline, and the family expressed concerns about the resident's symptoms, which they associated with a urinary tract infection. For another resident, a medication error occurred when a Registered Nurse (RN) documented administering Acetaminophen 325mg, two tablets, on the Electronic Medication Administration Record (EMAR), but the medication was found in the medication cart the following day, indicating it was not given. The Director of Nursing (DON) stated that staff should notify the doctor, file an incident report, notify the family, and monitor the resident's condition for 72 hours if a medication error occurs. However, the report does not indicate that these steps were taken following the error.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate treatment and services to promote the healing of a pressure ulcer for a resident with intact cognition and multiple diagnoses, including a neurogenic bladder, hip fractures, traumatic brain injury, and a pressure ulcer. The resident required assistance with various activities of daily living and was receiving nonsurgical dressings. The care plan directed staff to change the wound vac on specific days and as needed. However, a grievance indicated that weekend staff did not provide wound vac care due to a lack of knowledge, leading to a change in treatment days. On a specific day, the resident's wound vac machine was observed to be beeping, indicating an issue, but staff entering the room did not respond to the alarm. Later, the wound vac was found disconnected from the power supply, not providing suction. The ADON eventually changed the wound vac dressing and reconnected the device, but the resident reported previous instances of the battery running down. Additionally, the resident was observed without the wound vac after attending a festival, and it was not reapplied until the following day, despite expectations for it to be reapplied sooner.
Failure to Ensure Continuous Oxygen Supply for Resident
Penalty
Summary
The facility failed to ensure that oxygen was available for a resident who required continuous oxygen therapy. During an observation, it was noted that the resident was resting in a wheelchair with an empty portable oxygen tank, despite being prescribed 4 liters of oxygen via nasal cannula continuously. The Certified Medication Aide assessed the resident's pulse oximetry, which showed low oxygen saturation levels between 85-89%, indicating the oxygen tank was empty. The Assistant Director of Nursing (ADON) was involved in obtaining a new portable oxygen tank and switching it, which improved the resident's oxygen saturation to 95% on 3 liters. Further observations revealed that the resident was again found with a portable oxygen tank that was nearly empty, indicating a need for a refill. Interviews with the ADON revealed a lack of documentation and verification processes for checking the remaining amount in portable oxygen tanks. The facility's policy on oxygen administration required reassessment of the oxygen flowmeter for correct liter flow and documentation of all appropriate information in the medical record, which was not adhered to in this case.
Incompetent Staff Leads to Improper Enema and Missed Wound Care
Penalty
Summary
The facility failed to maintain competent staff to perform an enema on Resident #10, who reported that an LPN performed the procedure roughly, resulting in rectal bleeding. The resident, who had intact cognition and required maximum assistance with daily activities, had a physician's order for a Lactulose enema with digital stimulation. However, the LPN did not perform the digital stimulation, citing a discontinued order, and inserted the enema wand without proper visualization or positioning, leading to resistance and bleeding. Witnesses, including a CNA and the resident's family member, confirmed the rough handling and lack of adherence to the procedure. Additionally, the facility failed to provide wound vacuum care for Resident #4 over a weekend, as the staff reported they did not know how to operate the wound vacs. This resident, who also had intact cognition, required wound vac changes three times a week for a pressure ulcer. The care plan and physician's order specified the need for regular wound vac application, but the staff's lack of competency led to missed treatments. The Director of Nursing acknowledged the confusion among nurses regarding the enema order and the lack of competency in wound vac procedures. The facility did not have completed competency checklists for staff, which contributed to the deficiencies in care for both residents.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to properly secure medications from unauthorized access, as observed in two separate incidents involving medication carts. On the morning of September 24, 2024, the medication cart on the 200 resident hall was found unlocked and unattended, with Staff A, a Certified Medication Aide (CMA), admitting to leaving it unlocked by mistake. Later that day, the medication cart on the 100 resident hall was also observed unlocked in the dining room with eight residents present and no authorized staff nearby. Staff B, another CMA, confirmed that it was not customary to leave the cart unlocked when unattended. Additionally, at 11:15 AM on the same day, the medication cart on the 200 resident hall was again found unlocked and unattended while Staff A entered a resident's room, leaving the cart out of sight across the hall. The facility's policy, revised on August 1, 2024, mandates that medication carts must be locked at all times when not in use and remain in the line of sight if not locked. The Director of Nursing (DON) reiterated that staff should lock the cart if they leave it.
Resident Elopement Due to Inadequate Supervision and Unsecured Exit Doors
Penalty
Summary
The facility failed to properly secure exit doors and ensure adequate supervision for a resident at risk of wandering and elopement. The resident, who had a history of wandering and elopement, was last seen by staff in the evening and was not found until two days later. During this time, the resident left the facility unattended, walked several blocks to a retail store, and later admitted himself to the Emergency Department for evaluation due to knee pain. The resident's care plan initially lacked information regarding wandering or elopement risk, and there was no wander guard alarm documented in the Medication Administration Record or Treatment Administration Record. The resident had been admitted to the facility from another LTC facility and had diagnoses including debility, diabetes, malnutrition, schizophrenia, and a hip fracture. Despite being alert and oriented, the resident was deemed an elopement risk upon admission, and a wander guard was initially applied. However, the facility's records and staff interviews revealed inconsistencies in monitoring and documenting the wander guard's placement and functioning. Staff interviews indicated that the resident was independent and often sat near exit doors, which may have contributed to the elopement. On the night of the incident, a cultural event was taking place, and staff were occupied with various activities, which may have led to a lack of supervision. The facility's exit doors were not properly secured, as evidenced by a rock being used to prop open a door, allowing the resident to leave unnoticed. Staff interviews highlighted issues with staffing levels and familiarity with residents, as well as the absence of cameras to monitor exit doors. The facility's failure to adequately supervise the resident and secure exit doors resulted in the resident's elopement and subsequent admission to the Emergency Department.
Inappropriate Meal Service for Residents with Dysphagia
Penalty
Summary
The facility failed to provide therapeutic meals according to physician orders and speech therapy recommendations for two residents. Resident #26, who has severe cognitive impairment and dysphagia, was served inappropriate food items that posed a choking risk. Despite a recommendation to remove bread from her diet due to coughing while consuming bread products, she was served a garlic breadstick and pound cake, leading to heavy coughing. The Speech Language Pathologist had to intervene to prevent further consumption and educate staff about the resident's dietary restrictions. This incident highlighted ongoing issues with the kitchen serving improper diets, as the resident had previously been served large chunks of chicken instead of a mechanically softened diet. Resident #4, also with severe cognitive impairment and dysphagia, was served a pureed diet with inappropriate additions of Cheeto Puffs and a lettuce salad. The resident consumed several Cheeto Puffs before staff intervention. The dietary staff had printed diet slips in advance, which did not reflect recent changes to the resident's diet. This practice contributed to the resident receiving an incorrect diet. Staff interviews revealed a lack of a formal system to notify care staff of diet changes, leading to confusion and improper meal service. The facility's dietary practices were further scrutinized, revealing that the kitchen staff did not follow IDDSI guidelines and lacked proper documentation for menu substitutions. The dietary cook admitted to substituting pound cake without approval due to a shortage of blushing pears. The facility's failure to adhere to dietary guidelines and update diet slips in a timely manner resulted in residents being served inappropriate meals, posing a risk of choking and aspiration.
Removal Plan
- 100% Audit of Resident diet orders
- 100% Audit of resident diet cards
- 100% Care plan audit for all residents to verify diet and texture are accurate
- 100% Audit completed of diet type and texture, with any additional diet texture restrictions to follow a triple check process
- All staff educated on the signs and symptoms of choking or swallowing issues
- All staff were educated for competency of providing correct textures in regard to modified diets
- An in-service was completed in person by the dietician and verbally communicated by nurse management to staff members regarding diet textures
- A Quality Assurance and Performance Improvement (QAPI) meeting was held to address the IJ.
Failure to Include Resident Representative in Care Plan Conference
Penalty
Summary
The facility failed to include the resident representative in the care plan participation conference for a resident with severe cognitive impairment. The resident, who was admitted with a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment, had a family member designated as Power of Attorney (POA) for care, financial, and healthcare decisions. This family member, who was also the responsible party and care conference person, reported not being invited to or attending any care conference to discuss the resident's plan of care. The facility's Electronic Health Record (EHR) for the resident lacked documentation of a care plan conference. The MDS Coordinator confirmed that a 72-hour care conference was neither completed nor scheduled for the resident, and the resident and family member were not invited to participate. The facility's training materials directed staff to review the baseline care plan with the resident or responsible person within 48 hours of admission, but this process was not followed. The facility did not provide a policy on care conferences, only a power point training on care plan development.
Failure to Conduct Level II PASRR Evaluations
Penalty
Summary
The facility failed to refer two residents with a Level I Preadmission Screening and Resident Review (PASRR) for a Level II evaluation when new serious mental disorders were diagnosed. Resident #29, who had moderate cognitive impairment, was initially screened with a Level I PASRR in November 2022, which documented anxiety disorder and depression as primary diagnoses. However, subsequent diagnoses included delusional disorders and major depressive disorder, and the resident was prescribed Escitalopram. Despite these changes, a Level II PASRR was not submitted, as acknowledged by the Social Services Director (SSD). Similarly, Resident #36, who was rarely understood, had a Level I PASRR in December 2019, which did not document any mental health diagnoses. The resident was later diagnosed with anxiety disorder and Schizoaffective disorder and was prescribed Hydroxyzine and Quetiapine Fumarate. Despite these significant changes, a Level II PASRR was not completed. The SSD confirmed that a Level II PASRR should have been submitted for both residents due to changes in medication and mental health diagnoses.
Deficiency in Nail Care for Two Residents
Penalty
Summary
The facility failed to provide necessary grooming services for two residents, leading to deficiencies in nail care. Resident #33, who has severe cognitive impairment and limited mobility due to conditions such as Alzheimer's disease and osteoporosis, was observed with long and jagged toenails, some of which were growing into the skin. Despite the care plan's instructions to check and trim nails during bi-weekly showers, records showed multiple refusals of showers by the resident, and on the occasions when showers were given, staff documented that the toenails did not need trimming. A family member reported requesting nail trimming since mid-June, but the request was not fulfilled. The Assistant Director of Nursing (ADON) confirmed that staff are expected to observe and trim toenails during showers, acknowledging that Resident #33's nails should not have reached such a state. Resident #57, who is paraplegic and legally blind, was also found with very long and jagged toenails. The resident, dependent on staff for personal hygiene, reported that his toenails had only been trimmed once since admission four months prior. Despite expressing a preference for shorter nails, the resident's lack of sensation in the lower legs and blindness prevented self-awareness of the nail length. The care plan for Resident #57 similarly included instructions for bi-weekly bathing and nail care, which were not adequately followed, resulting in the observed deficiency.
Facility Fails to Maintain Clean and Safe Bathroom Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the bathrooms of four resident rooms, as observed during a survey. In the bathroom of a room occupied by Resident #3, a tile was missing on the back wall, and a black substance was present on the edges of the tiles. Similarly, the bathroom shared by Residents #4 and #6 had a missing tile with a black substance on the walls and accumulated in the corners. The bathroom of Resident #1 had a brown substance on the toilet seat hinges and the outside of the toilet. Additionally, the bathroom shared by Residents #10 and #11 had two missing tiles near the toilet, with broken tile pieces on the floor. The facility's policy, dated October 2022, required staff to clean under the toilet bowl, spot clean walls, mop the floor, and conduct maintenance checks for repairs. However, these policies were not adhered to, as evidenced by the observations and the statement from the Director of Nursing, who acknowledged that bathrooms should be free of black substances and tiles should be in good condition.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the family of a resident's change in condition after an incident involving the resident's wheelchair during transport. The resident, who had intact cognition and was diagnosed with acute respiratory failure with hypoxia, heart failure, and diabetes, reported shoulder pain after being transported in a van where the brakes did not work properly. The incident occurred when the van stopped suddenly, causing the resident's wheelchair to move and the resident to hit his shoulder. Despite the incident, there was no documentation of the resident's representative being notified. Staff interviews revealed that the resident's wheelchair brakes were reported as faulty two weeks prior to the incident, but the issue was not resolved. The Maintenance Supervisor attempted to fix the brakes, but the problem persisted, leading to the incident. The Director of Nursing was under the impression that the resident's representative was aware of the incident, but this was not the case. The facility's policy required staff to notify the resident's representative of any accidents or incidents, which was not followed in this situation.
Failure to Follow Professional Standards in Resident Care
Penalty
Summary
The facility failed to adhere to professional standards of care for a resident with multiple health conditions, including diabetes and impaired circulation. The resident's care plan required daily application of leg wraps to manage lymphedema, but staff did not consistently follow this order. On several occasions, the leg wraps were not applied as prescribed, and staff misunderstood the treatment order, leading to inconsistent care. Additionally, the facility did not ensure timely meal delivery after insulin administration for the resident. The resident received insulin before breakfast, but the meal was delayed, sometimes by several hours, which is contrary to the manufacturer's guidelines that recommend eating within 5-10 minutes after insulin administration. This delay in meal service was acknowledged by staff, who noted that meal trays were not always delivered promptly. The facility also failed to arrange for audiology services for the resident, despite a request from the resident's representative. There was no documentation of an audiology appointment being scheduled or followed up on for several months. The Director of Nursing was unaware of the request, indicating a lapse in communication and follow-up regarding the resident's care needs.
Failure to Secure Resident During Transport
Penalty
Summary
The facility failed to ensure the safety of a resident during transport, resulting in the resident bumping his shoulder. The resident, who had intact cognition and medical conditions including acute respiratory failure, heart failure, and diabetes, reported shoulder pain after a transport incident. The incident occurred because the resident's wheelchair was not properly secured in the van, leading to movement when the van hit a bump. The CNA responsible for the transport confirmed that the wheelchair was strapped in, but the brakes were not secure, causing the wheelchair to move and the resident to hit his shoulder. The CNA had previously reported issues with the wheelchair brakes to the Maintenance Supervisor, who attempted to fix them but did not resolve the problem. The Maintenance Supervisor acknowledged that the brakes would lock initially but failed under weight, leading to the decision to switch chairs. The Director of Nursing was aware of the incident and informed the Nurse Practitioner, but there was uncertainty about the resident's representative being fully informed. The facility's policy required staff to lock wheelchair brakes after loading, which was not effectively implemented in this case.
Assessment and Monitoring Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide appropriate assessment and interventions for two residents, Resident #2 and Resident #3, who presented with a change in condition. Resident #3 had multiple comorbidities including cognitive communication deficit, anemia, atrial fibrillation, hypertension, renal insufficiency, diabetes mellitus, respiratory failure, and morbid obesity. Despite being at risk for pressure ulcers, the resident was not on a turning/repositioning program. The facility staff failed to properly assess the resident's deteriorating health status, leading to missed opportunities for timely interventions. This lack of assessment and monitoring resulted in the resident's condition worsening, ultimately leading to sepsis and death. Similarly, Resident #2 had a history of cardiorespiratory conditions, pneumonia, COPD, and mild cognitive impairment. The resident required supervision to moderate assistance with activities of daily living. The facility's failure to conduct timely assessments and document changes in the resident's condition resulted in a delay in identifying acute respiratory failure. This lack of assessment and monitoring led to the resident being admitted to the hospital with acute hypoxic respiratory failure, pneumonia, lactic acidosis, and fever. The facility's inadequate monitoring and assessment practices contributed to the resident's deteriorating health status.
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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