Greenfield Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenfield, Iowa.
- Location
- 615 Se Kent Street, Greenfield, Iowa 50849
- CMS Provider Number
- 165383
- Inspections on file
- 23
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Greenfield Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
A resident with hypertension and other comorbidities was admitted with a physician order for doxazosin mesylate BID, but the facility failed to obtain and administer the medication as ordered. The script sent to pharmacy differed from the dose entered on the MAR, the drug was not available in the building or emergency kit, and multiple scheduled doses over several days were not given. Staff documented a code on the MAR directing review of progress notes, yet documentation only reflected that the first missed dose was due to waiting for pharmacy delivery, with no explanation for later missed doses. The resident informed family that medications were not received, and the charge nurse told the family that the day nurse had not followed through with the orders, contrary to the facility’s admission policy requiring immediate-care medication orders.
A resident with paraplegia, ulcerative colitis, and frequent urinary and bowel incontinence, who required substantial/maximal assistance with toileting and personal hygiene, reported that overnight staff often failed to provide incontinent care despite her use of the call light. She stated staff would sometimes ignore the call light or enter, say they would return, turn off the light, and not come back, leaving her wet about once a week. Her care plan required staff to check and change her brief daily and PRN, perform peri care after each incontinent episode, and wash, rinse, and dry the perineum. Two CNAs confirmed the resident’s complaints and reported that overnight staff were not consistent in keeping residents dry or thoroughly cleaning her when bowel movements spread to the front. The Administrator was unaware of these issues, while the DON stated staff were expected to round every two hours for incontinence care per facility policy.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not complete and transmit comprehensive MDS assessments within the federally mandated 14-day period for several residents. The DON, who lacks detailed MDS regulatory knowledge, relied on verbal or informal notifications from the MDS Coordinator, an LPN, to sign off on assessments, and the facility had no formal policy guiding the MDS process.
A resident did not have a required Quarterly MDS Assessment completed within the federally mandated timeframe. Review of the EHR showed that after the resident's re-entry, the next quarterly MDS was due but was not scheduled or completed. The MDS Coordinator indicated she was unaware that the quarterly assessment was still required after completing a Medicare 5-day assessment, and the facility lacked a specific policy for MDS Assessments.
Two residents had inaccurate MDS assessments: one did not have therapy minutes properly recorded due to a software issue and lack of verification, while another was incorrectly documented as receiving insulin injections when only a GLP-1 RA medication was administered. These errors were acknowledged by the MDS Coordinator and were not supported by the clinical record or medication administration documentation.
A resident who transferred from Assisted Living to LTC did not have a Baseline Care Plan implemented within 48 hours of admission. The previous care plan from Assisted Living was not closed, and a new LTC-specific plan was not initiated until nearly two weeks later. Staff confirmed the oversight, and the facility's policy lacked clear timelines for care plan completion.
Surveyors observed deficient infection control practices involving indwelling urinary catheters, including drainage bags being placed on a trash can and the floor, and inconsistent use of PPE and hand hygiene by staff during catheter care. Residents affected had significant medical conditions requiring strict adherence to infection prevention protocols, but staff failed to follow care plans and facility policies regarding catheter management and PPE use.
The facility failed to create comprehensive care plans for four residents, leading to deficiencies in addressing their medical needs. A resident with intact cognitive ability was on high-risk medications without a care plan to monitor side effects. Another resident with severe cognitive deficits lacked a care plan addressing medication side effects and dementia symptoms. Two other residents with severe cognitive impairments had care plans that did not specify side effects to monitor. The facility's policy required comprehensive care plans, but this was not followed.
The facility failed to adhere to food safety and hygiene practices, as observed during a survey. A staff member was found with an uncovered beard, and there were undated and uncovered food items in storage. Additionally, a dietary aide used improper glove usage during food preparation. These actions violated the facility's policies on hair restraints, food storage, and glove usage, potentially compromising food safety.
The facility failed to update care plans for two residents, leading to deficiencies. A resident with arthritis and a recent hip replacement was using compression stockings not documented in the care plan. Another resident with Parkinson's and a history of strokes was using oxygen, which was also not documented. Staff interviews confirmed these oversights, contrary to facility policy requiring comprehensive care plans.
A resident with moderate cognitive deficits was prescribed 100 mg of Sertraline, but the pharmacy provided 75 mg doses, which were administered 26 times without staff noticing the error. The discrepancy was discovered during a medication pass when an RN decided to recheck the orders. The facility's records showed the correct order, but the pharmacy was unaware of the change.
A facility failed to provide proper respiratory care for a resident with moderate cognitive impairment and a history of serious health conditions. Despite physician orders for oxygen use, the resident's care plan and records lacked instructions for oxygen tubing changes. Observations showed unmarked tubing near the floor, and staff interviews revealed non-compliance with the facility's policy for weekly tubing changes and documentation.
A resident with severe cognitive impairment and dementia received incorrect medication documentation due to a failure to update the MAR after a telehealth appointment increased the Rivastigmine Patch dosage. Staff interviews revealed unawareness of the discrepancy, and the facility lacked a specific medication administration policy.
A facility failed to ensure proper hand hygiene and Enhanced Barrier Precautions (EBP) during catheter care for a resident with an indwelling catheter. A CNA did not change gloves or perform hand hygiene between tasks and used the same gloves to obtain and apply barrier cream. The DON intervened but no additional PPE was used. The resident had intact cognition and multiple diagnoses, including neurogenic bladder. The facility's infection control policies were not adhered to, and EBP equipment installation was delayed due to a tornado.
Failure to Obtain and Administer Ordered Antihypertensive Medication at Admission
Penalty
Summary
The deficiency involves the facility’s failure to obtain and administer all ordered medications for a newly admitted resident in accordance with professional standards and its own admission policy. A cognitively intact resident with diagnoses including hypertension, hip fracture, stroke, depression, cognitive communication deficit, and atrial fibrillation was admitted with a physician order for doxazosin mesylate 2 mg, 0.5 tablet PO BID. The script sent to the pharmacy reflected this order, but the MAR was entered as doxazosin mesylate 1 mg, 0.5 tablet PO BID, and the medication was not available in the building. On the MAR for several scheduled doses over three days, staff documented the code “6” (see progress notes) instead of administering the medication. Progress notes documented that the medication was not given on the night of admission because staff were waiting for pharmacy delivery, but there was no documentation explaining why subsequent doses on the following days were not given. Blood pressure readings during this period showed varying values, and review of the emergency kit list confirmed that doxazosin was not stocked there. The resident’s family reported that the resident called to say she did not receive her medications on the day of admission or that night, and when the family member spoke with the charge nurse, the nurse stated the day nurse had not followed through with the orders. Staff interviews revealed that the usual admission process includes obtaining prior MARs, securing physician orders, entering them into the computer, and faxing them to the pharmacy, and that if medications are not available, staff may obtain an order to start later or use the emergency kit if immediate administration is needed. The DON stated that if the medication had not been delivered, staff should have initiated calls to obtain it as soon as possible and checked the emergency kit. The ADON/MDS Coordinator later identified that the script sent to the pharmacy did not match the MAR order and noted that staff should have documented in progress notes why the medication was not given. The facility’s admission policy requires that the attending physician provide medication orders needed for the immediate care of the resident prior to or at admission.
Failure to Provide Required Overnight Incontinent Care and ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care and assistance with activities of daily living during the overnight shift for one resident. The resident had a BIMS score of 15/15, indicating no cognitive impairment, and required substantial/maximal assistance with toileting hygiene and personal hygiene due to bilateral upper and lower extremity impairments. The MDS documented that the resident was frequently incontinent of urine and always incontinent of bowel, with diagnoses including ulcerative colitis, paraplegia, anxiety, and depression. The resident’s care plan directed staff to change her disposable brief daily and as needed, check her for incontinence per her request and as required, wash, rinse, and dry the perineum, and provide peri care after each incontinent episode. During interview, the resident reported that on the overnight shift she was not being changed as she should be, stating that when she had a bowel movement and pulled her call light, staff would sometimes let the call light go unanswered or enter the room, state they would return, turn off the call light, and then not come back. She indicated this occurred about once a week and always when she was incontinent of urine, and that staff would not assist her with incontinent cares; she also reported having issues with skin in the affected area and the use of cream to help prevent skin issues. Two CNAs confirmed that the resident had complained to them about overnight staff not cleaning her up after incontinence and described that overnight staff were not very good about ensuring residents were not wet and that not all staff cleaned her properly when bowel movements came up the front. The Administrator stated she was not aware of issues with overnight incontinent care, while the DON stated staff were expected to round every two hours to check and change incontinent residents and offer or remind toileting, consistent with the facility’s ADL policy requiring care according to the individualized care plan.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Complete and Transmit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within the federally required timeframe for six out of eleven residents reviewed. According to the 2024 Resident Assessment Instrument (RAI) Manual, the MDS Completion Date must be no later than the 14th calendar day after a resident's admission. In multiple cases, the MDS assessments were completed and signed well beyond this 14-day window, with completion dates ranging from day 16 to day 26 of the residents' stays. The clinical records for these residents showed that the required comprehensive assessments were not finalized in accordance with federal guidelines. Interviews with facility staff revealed that the Director of Nursing (DON), who is responsible for signing the MDS assessments, does not possess detailed knowledge of MDS regulations and relies on the MDS Coordinator, an LPN, to inform her when assessments are ready for signature. The DON stated that she typically signs the assessments on the same day she is notified, but there is no formal policy in place regarding the MDS assessment process. The facility administrator confirmed that there is no written policy and that the facility follows the RAI Manual guidelines.
Failure to Complete Timely Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a required Quarterly Minimum Data Set (MDS) Assessment within the federally mandated timeframe for one resident. Clinical record review showed that after the resident's re-entry, the next quarterly MDS was due but was neither scheduled nor completed, as confirmed by the MDS tracker in the electronic health record. The last assessment completed was a Medicare 5-day MDS, which is a payment assessment and does not fulfill the OBRA assessment schedule requirements. The MDS Coordinator stated she was unaware that the quarterly assessment was still required after completing the 5-day assessment. The facility did not have a policy regarding MDS Assessments and relied on the RAI Manual guidelines.
Inaccurate MDS Assessments Due to Documentation and Data Entry Errors
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two of thirteen sampled residents. For one resident, the MDS assessment did not reflect the actual therapy minutes received during the seven-day lookback period, despite the resident having completed and participated in multiple therapy sessions, as confirmed by both the resident and a therapy minutes report. The MDS Coordinator acknowledged that therapy minutes are typically pulled automatically into the assessment, but due to a recent software change, the data did not transfer as expected. The Coordinator did not verify the therapy minutes with the therapy department, resulting in the omission of therapy services from the resident's MDS. For another resident with a diagnosis of diabetes mellitus, the MDS assessment incorrectly documented that the resident received insulin injections during the lookback period. However, the Medication Administration Record (MAR) did not show any insulin administration for the month. The MDS Coordinator stated she had recorded an insulin injection because the resident was receiving Ozempic, not realizing that Ozempic is not an insulin but a GLP-1 receptor agonist. The facility did not have a specific policy for MDS assessments and relied on the RAI Manual for guidance.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency was identified when a resident transferred from the facility's Assisted Living to the Long Term Care (LTC) section and did not have a Baseline Care Plan implemented within 48 hours of admission, as required. The resident's clinical record showed an admission date to LTC, but the most recent Care Plan was not initiated until 12 days after admission. The earliest documented initiation date for any focus area within the Care Plan was 17 days post-admission. Staff interviews confirmed that no Baseline Care Plan was created upon the resident's transfer to LTC, and the previous Assisted Living Care Plan was not closed or replaced with a new one specific to LTC needs. The Director of Nursing (DON) and the MDS Coordinator both acknowledged the oversight, with the MDS Coordinator stating that she typically initiates key focus areas immediately but was unaware of why this did not occur for this resident. The facility's care planning policy, approved in December 2024, did not specify required timelines for completing baseline or comprehensive care plans. This lack of timely care planning upon admission resulted in the failure to meet the resident's immediate needs as required by regulation.
Deficient Infection Control Practices in Catheter Care
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices related to the management of indwelling urinary catheters. For two residents, staff failed to properly secure urinary drainage bags, with one bag observed hanging from a trash can and another resting on the floor. These actions were contrary to both the residents' care plans and facility policy, which require catheter bags to be kept off the floor and positioned below the level of the bladder. Staff interviews revealed uncertainty about appropriate placement of catheter bags, and some staff admitted to using the trash can as a hanging point due to a lack of alternatives. In another instance, a staff member providing catheter care to a resident did not consistently follow proper hand hygiene protocols during glove changes and failed to don a gown as required by enhanced barrier precautions. The staff member also handled clean and dirty items without appropriate hand hygiene and did not use a dignity cover for the catheter bag. The resident's care plan and posted CDC guidance required the use of gloves and gowns for high-contact care activities, but these were not consistently followed during the observed care. All three residents involved had significant medical histories, including chronic kidney disease, neurogenic bladder, renal insufficiency, and a history of urinary tract infections. Their care plans specified interventions for catheter care, positioning, and infection prevention, but these were not adhered to during the survey observations. Staff and the Director of Nursing confirmed that the observed practices did not meet facility expectations or policy requirements.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to establish comprehensive, resident-specific care plans for four residents, leading to deficiencies in addressing their medical needs. Resident #9, with intact cognitive ability, was taking high-risk medications for conditions such as heart failure, diabetes, and depression. However, her care plan did not include references to these medications or instructions for staff to monitor for specific side effects. Similarly, Resident #13, who had severe cognitive deficits and was dependent on staff for daily activities, was on antipsychotic and opioid medications. His care plan lacked details on managing the side effects of these medications and did not address his dementia symptoms beyond medication administration. Resident #4, with severe cognitive impairment, was on multiple medications, including antipsychotics and antidepressants. The care plan directed staff to monitor for side effects but failed to specify what those side effects were. Resident #26, also with severe cognitive impairment, was receiving medication for anxiety and dementia, but the care plan did not detail the side effects to monitor. The Assistant Director of Nursing acknowledged that certified nursing assistants needed guidance on medication side effects, which should be included in the care plans. The facility's policy required comprehensive care plans to address all relevant care issues, but this was not adhered to in these cases.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, as observed during a survey. On an initial tour of the kitchen, a staff member was found with an uncovered beard, contrary to the facility's policy requiring hair restraints to prevent hair from contacting exposed food. Additionally, the refrigerator contained uncovered drinks and an undated open bag of shredded lettuce, while the dry storage area had an undated open bag of Cheerios. These observations indicate a lack of adherence to the facility's food storage policy, which mandates that all food items be labeled with the name and date by which they should be consumed or discarded. During a lunch service observation, a dietary aide was seen using improper glove usage, handling multiple food items with the same gloved hand without changing gloves or using utensils like tongs, as required by the facility's hand washing and glove usage policy. The dietary manager acknowledged the need for staff education on glove use and hand hygiene to prevent cross-contamination. These deficiencies highlight lapses in the facility's adherence to professional standards for food preparation and hygiene, potentially compromising food safety for the residents.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to review and revise the care plans for two residents, leading to deficiencies in their care. Resident #7, who had a history of arthritis, pain in the right leg and hip, and a recent hip replacement, was observed wearing compression stockings, which were not documented in the care plan. Despite physician orders for compression stockings starting on 8/9/24, the care plan printed on 8/28/24 did not reflect this intervention. Staff interviews confirmed that the care plan should have included information about the use of compression garments for edema management. Similarly, Resident #15, with a history of Parkinson's Disease, transient ischemic attack, cerebral infarction, and COVID-19, was using oxygen, which was not documented in the care plan. Physician orders indicated the use of oxygen as needed to maintain oxygen saturation above 90%, starting on 8/9/24. However, the care plan printed on 8/28/24 did not include information about oxygen use or parameters. Observations confirmed the presence of oxygen equipment in the resident's room, and staff interviews acknowledged the oversight in care plan documentation. The facility's policy required comprehensive care plans to address all relevant care issues, which was not adhered to in these cases.
Medication Administration Error Due to Dosage Discrepancy
Penalty
Summary
The facility failed to follow physician's orders for a resident during medication administration. The resident, who had moderate cognitive deficits and was taking antidepressant and antianxiety medications, was prescribed 100 mg of Sertraline daily. However, the pharmacy provided a bubble pack containing 75 mg doses, which was administered 26 times without the discrepancy being noticed by the staff. This error was discovered during a medication pass when a registered nurse noticed the incorrect dosage and decided to recheck the orders. The facility's records showed that the order for 75 mg of Sertraline had been discontinued and replaced with a 100 mg order. Despite this, the pharmacy was unaware of the change and continued to supply the incorrect dosage. The Director of Nursing acknowledged that the nursing staff should have adhered to the 5 rights of medication administration, which would have prevented the error. The facility's Skills Checklist also required staff to compare medication labels to the Electronic Medication Administration Record, a step that was evidently missed in this case.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident requiring the use of oxygen. The resident, who had a moderate cognitive impairment and a history of Parkinson's Disease, transient ischemic attack, cerebral infarction, and COVID-19, was noted to have physician orders for oxygen use at 1-2 liters as needed to maintain oxygen saturation above 90%. However, the resident's care plan and medication administration record did not reflect the need for oxygen or instructions for changing the oxygen tubing. Observations over several days revealed that the oxygen tubing in the resident's room was unmarked and hanging near the floor, contrary to the facility's policy that required weekly changes and marking of the tubing. Interviews with staff, including registered nurses and the Director of Nursing, indicated a lack of adherence to the policy, as the tubing was not marked or documented on the medication administration record. The facility's policy on oxygen administration did not specify when the tubing should be changed, contributing to the oversight.
Medication Documentation Error for Resident with Dementia
Penalty
Summary
The facility failed to document the correct medication provided for a resident with severe cognitive impairment, as identified in a clinical record review. The resident, who had diagnoses of non-Alzheimer's dementia and anxiety disorder, was receiving antianxiety and dementia medication. The Medication Administration Record (MAR) for August 2024 showed entries for two different dosages of Rivastigmine Patch, 4.6MG/24HR and 9.5MG/24HR, which were both active from 8/22 through 8/27. This discrepancy arose after a telehealth appointment on 8/21/24, where the Advanced Practice Registered Nurse (APRN) increased the Rivastigmine Patch dosage to 9.5MG/24HR due to the progression of the resident's dementia. Staff interviews revealed that the Registered Nurse (RN) was unaware of the two different orders on the MAR, and the Director of Nursing (DON) acknowledged that the old order should have been removed when the new order was implemented. The Assistant Director of Nursing (ADON) confirmed being present during the telehealth appointment and stated that the old order should have been discontinued. The facility lacked a specific policy for medication administration, and the provided document, "Administration of Meds (Oral)," was undated and only instructed staff to document medications administered in the clinical record.
Inadequate Hand Hygiene and EBP During Catheter Care
Penalty
Summary
The facility failed to provide adequate hand hygiene and Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter. During an observation, a Certified Nursing Assistant (CNA) was seen performing catheter and peri care on the resident without changing gloves or performing hand hygiene between tasks. The CNA also used the same gloves to open a drawer and obtain barrier cream, which was then applied to the resident. The Director of Nursing (DON) intervened by providing a clean glove for the barrier cream, but the CNA did not utilize any additional personal protective equipment during the procedure. The resident involved had a Brief Interview for Mental Status (BIMS) score indicating intact cognition and was diagnosed with conditions including benign prostatic hypertension, end-stage renal disease, neurogenic bladder, and senile degeneration of the brain. The facility's policies on infection prevention and control, including hand hygiene and EBP, were not followed during the care of this resident. The Assistant Director of Nursing (ADON)/Infection Preventionist acknowledged familiarity with EBP but noted that equipment for EBP had not been installed due to a tornado delaying the process.
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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