Griswold Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Griswold, Iowa.
- Location
- 106 Harrison St, Griswold, Iowa 51535
- CMS Provider Number
- 165351
- Inspections on file
- 15
- Latest survey
- October 8, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Griswold Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
The facility inaccurately submitted the PBJ Staffing Data Report, failing to reflect 24-hour licensed nursing coverage on several dates, despite evidence from Facility Daily Assignment Sheets showing such coverage was present. The Administrator acknowledged the inaccuracy, which affected the reported staffing for a census of 31 residents.
A resident with severe cognitive impairment experienced issues with their trust account, including missed insurance payments and restricted access to funds. The facility failed to send quarterly statements and did not provide access to funds during nights and weekends, contrary to policy.
A facility failed to provide quarterly financial statements to residents and their POAs, as required by federal regulations. This was highlighted by a case where a resident's POA reported discrepancies in the trust account balance. The Business Office Manager admitted to not sending any statements since starting the position, and the Administrator confirmed the lack of compliance with the facility's policy.
A resident with severe cognitive impairment had a trust account balance exceeding the Medicaid limit, but neither the resident nor their POA was notified. The Business Office Manager failed to send statements or provide accurate account information, and the Administrator acknowledged the oversight in communication regarding the need for a spend down.
The facility did not adhere to its policy of completing background checks before employment, as evidenced by Staff K, a CMA, working shifts before their background check was finalized. The Administrator and Business Office Manager acknowledged this oversight, which contravened the facility's policy requiring all employees to have completed checks before working with residents.
The facility failed to provide restorative care to maintain or improve the range of motion for two residents. One resident with cerebral palsy and quadriplegia did not receive passive range of motion exercises as indicated in their care plan. Another resident, who had completed physical therapy without improvement, was not provided with a restorative program despite recommendations. Staff interviews confirmed the absence of a restorative program, and the facility lacked a formal policy, which was under development.
A resident with incontinence issues reported delays in receiving care due to insufficient staffing at the facility. Staff interviews confirmed that staffing levels were often inadequate, with only one CNA available at times, leading to delays in care. The ADON acknowledged the facility was operating below minimum staffing levels, and there was no clear policy on staffing or answering call lights.
A resident with severe cognitive impairment and a history of Guillain Barre was given a flu vaccine despite instructions from emergency contacts not to administer it. The facility's records incorrectly listed the POA, and there was no documentation of consent or declination. The facility lacked a policy for determining and documenting POA, leading to the administration of the vaccine against the resident's and emergency contacts' wishes.
The facility failed to accurately assess the need for anticoagulant therapy for two residents. One resident's MDS did not document the use of Apixaban, an anticoagulant, despite a physician's order, while another resident's MDS incorrectly documented Plavix as an anticoagulant. The ADON acknowledged the miscoding, and the facility lacked a policy on MDS assessment accuracy.
A facility failed to include anticoagulant therapy in a resident's care plan, despite a physician's order for Apixaban. The resident, with no cognitive impairment, had no care plan focus, goals, or interventions for this therapy. The DON and Administrator acknowledged the oversight, noting the absence of a policy for care plan development.
A resident with moderately impaired cognition did not consistently receive prescribed tubi grips for edema, as documented in the TAR. Despite the resident's preference for wearing them, staff interviews revealed that the grips were often not applied, and there was no documentation of refusal. The Assistant DON noted that treatments were incorrectly marked as completed, indicating a failure to follow physician orders.
A resident with dementia, diabetes, and stroke experienced a decline in ADL abilities due to the facility's failure to provide a restorative nursing program. Initially requiring minimal assistance, the resident's condition worsened, necessitating substantial assistance with toileting and no ambulation attempts. Staff interviews revealed the absence of therapy and restorative program evaluations, contributing to the decline.
A facility failed to provide a well-balanced diet for a resident on a pureed diet. Staff H served incorrect portion sizes by using a regular diet menu instead of the appropriate pureed diet chart. The Dietary Manager confirmed that staff lacked knowledge of correct scoop sizes for pureed diets, leading to the deficiency.
A facility failed to serve food at appropriate temperatures and in an appealing manner for a resident. The Dietary Manager did not document food temperatures before serving a pureed diet, reheating the food multiple times in a microwave, which resulted in an unappealing presentation. This action was against the facility's policy requiring temperature documentation for all meals.
A facility failed to follow proper infection prevention practices during the care of a resident with an indwelling catheter. Two staff members did not perform hand hygiene between glove changes, despite handling feces and transitioning from dirty to clean tasks. The ADON acknowledged the missed hand hygiene opportunities, which are crucial for preventing infection transmission.
A resident with severe cognitive impairment and a history of Guillain Barre syndrome received a flu vaccine despite their POA's declination. The facility failed to follow its procedures for obtaining consent, as the ADON could not find any documentation of consent or declination. The facility's manual required documentation of declination, which was not adhered to, resulting in the vaccine being administered without proper consent.
The facility failed to document consent for COVID-19 immunizations for two residents, one with severe cognitive impairment and another rarely understood. The ADON confirmed the absence of consent documentation and could not provide a policy with vaccination guidelines. The facility's policy stated residents should be counseled on the vaccine's importance.
The facility failed to maintain accurate medication administration documentation and obtain medications as ordered for three residents. A resident with severe cognitive impairment did not receive Olanzapine IM due to its absence in the Emergency Kit, and there was no documentation explaining the lack of administration. Another resident had missing documentation for daily vitals and several medications, with the facility running out of medication on specific dates. A third resident had medications coded as unavailable without supporting documentation, highlighting issues in the facility's medication ordering and documentation processes.
Inaccurate PBJ Staffing Report Submission
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report covering the period from April 1 to June 30. The report indicated a failure to maintain licensed nursing coverage 24 hours a day on specific dates, including 5/28, 6/14, 6/15, 6/16, 6/19, 6/20, and 6/28. However, a review of the Facility Daily Assignment Sheets for these dates showed that 24-hour nursing coverage was indeed present. The Administrator acknowledged that the PBJ was submitted inaccurately, despite the facility's expectation for accurate staffing descriptions. The facility reported a census of 31 residents during this period, and the discrepancy was identified through a review of staffing reports and staff interviews.
Failure to Manage Resident's Financial Affairs
Penalty
Summary
The facility failed to honor a resident's right to manage their financial affairs, specifically regarding access to personal funds and management of a trust account. Resident #24, who has severe cognitive impairment, was affected by this deficiency. The resident's power of attorney (POA) and daughter reported issues with the resident's trust account, including missed payments for secondary health insurance and restricted access to funds. The facility did not provide access to the resident's funds during nights and weekends, and there were discrepancies in the trust account management, such as missing money and double payments for insurance. Staff interviews revealed that the facility did not send quarterly statements to residents or their representatives, and there was confusion about the billing account. Staff B, the Business Office Manager, acknowledged missed insurance payments and a lack of understanding of the billing account. Staff J, the Private Pay Manager, noted a change in personnel and issues with receiving insurance payments. The facility's administrator confirmed the lack of quarterly statements and acknowledged the absence of available funds outside business hours, contrary to the facility's policy.
Failure to Provide Resident Financial Statements
Penalty
Summary
The facility failed to provide individual financial records to residents and their power of attorney (POA) in the form of quarterly statements and upon request, as required by federal regulations. This deficiency was identified through a review of clinical and financial records, interviews with family and staff, and policy review. Specifically, the facility did not send out quarterly statements for resident trust accounts, which was confirmed by the Business Office Manager, Staff B, who acknowledged not sending any statements since starting her position in May. The Administrator also confirmed that no quarterly statements had been sent to residents or their POAs. The issue was highlighted by the case of a resident with severe cognitive impairment, whose POA/daughter reported discrepancies in the resident's trust account balance. The daughter had requested an accurate statement from Staff B, who inaccurately reported the trust account balance as approximately $1500, while the actual balance was documented as $3,877.19. The facility's policy stated that trust account statements should be available upon request, but this was not adhered to, leading to confusion and concern over the management of the resident's personal funds.
Failure to Notify Resident of Excess Trust Account Balance
Penalty
Summary
The facility failed to notify a resident receiving Medicaid benefits when their account balance reached $200 less than the SSI resource limit for one person. Resident #24, who had a severe cognitive impairment as indicated by a BIMS score of 5, had a trust account balance that exceeded $2000 since June 3, 2024. Despite this, the resident's power of attorney (POA) was not informed of the excess funds, and no quarterly statements were provided. The POA was misinformed by the Business Office Manager, Staff B, about the trust account balance, being told it was approximately $1500 when it was actually $3,877.19 as of August 31, 2024. Staff B, who started in May, admitted to not sending out any statements during her tenure and acknowledged the oversight in notifying the resident or their representative about the excess funds. The Administrator also recognized the failure to notify the POA and the resident about the need to complete a spend down to maintain Medicaid eligibility. The facility's policy required notification and discussion with the resident or responsible party when the trust account neared the state-specified maximum balance, which was not adhered to in this case.
Failure to Complete Background Checks Before Employment
Penalty
Summary
The facility failed to implement its abuse and neglect policy by not completing background checks prior to staff employment. Specifically, Staff K, a Certified Medication Assistant (CMA), was hired on 5/26/22, but their background check was not completed until 6/7/22. Despite this, Staff K worked 1 hour on 5/26/22 and 7.75 hours on 6/1/22, before the background check was finalized. The Business Office Manager and the Administrator both acknowledged that the facility's expectation was to complete background checks before staff began working with residents, which did not occur in this instance. The facility's policy, revised in January, mandates that all employees undergo criminal background checks, state and federal required checks, employment reference checks, and license confirmation prior to employment.
Failure to Provide Restorative Care for Range of Motion
Penalty
Summary
The facility failed to provide restorative care to maintain or improve the range of motion for two residents, leading to a deficiency in care. Resident #2, diagnosed with cerebral palsy, quadriplegia, and seizure disorder, had documented limitations in both upper and lower extremities. Despite the care plan indicating a need for passive range of motion (PROM) exercises, the Minimum Data Set (MDS) assessment showed no restorative nursing program (RNP) was provided during the 7-day look-back period. Staff interviews confirmed that Resident #2 did not participate in therapy services due to his diagnoses, but it was acknowledged that he would benefit from PROM exercises. Similarly, Resident #8, who had recently completed physical therapy without improvement, was recommended for a restorative program. However, the care plan was not updated following the end of physical therapy, and no restorative program was implemented. Interviews with staff revealed that the facility did not currently offer a restorative program, and the Assistant Director of Nursing (ADON) was in the process of developing one. The facility lacked a formal RNP policy, which was noted to be under development by the ADON.
Inadequate Staffing Leads to Delayed Care for Resident
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of a resident, as evidenced by the experiences of Resident #11. The resident, who had no cognitive impairment and was frequently incontinent of urine, reported that there was not enough staff to attend to her needs. She stated that after requesting assistance to change her brief, staff would return only after several hours, leaving her in a soiled brief for extended periods. This was corroborated by staff interviews, which revealed that staffing levels were often inadequate, with only one CNA available at times, leading to delays in care. Staff members, including CNAs and agency staff, confirmed the insufficient staffing levels, which affected their ability to provide timely care. One CNA mentioned that incontinence care was only provided when the resident activated her call light, and another staff member reported being the only CNA on the floor at times, which delayed response times to call lights. The ADON acknowledged that the facility was operating below the minimum staffing levels on specific dates, and there was no clear policy on staffing or answering call lights. The facility's administration, including the ADON and the Administrator, admitted to the staffing challenges and the lack of a formal policy on call light response. The Administrator believed that staffing was adequate once additional non-certified staff arrived, although these staff members could not perform hands-on care. The report highlights the facility's failure to maintain adequate staffing levels, which directly impacted the quality of care provided to residents, particularly those with incontinence needs.
Failure to Honor Resident's Self-Determination in Vaccine Administration
Penalty
Summary
The facility failed to honor a resident's right to self-determination regarding the consent or declination of vaccines and the designation of a Power of Attorney (POA). Resident #28, who had a severe cognitive impairment and a history of Guillain Barre, was administered a flu vaccine despite explicit instructions from both emergency contacts that the resident should not receive it due to medical history. The facility's records incorrectly listed emergency contact #2 as the POA, although neither emergency contact had signed any paperwork to become the POA. The facility's process for obtaining consent for vaccines was not followed, as there was no documentation of consent or declination from the POA. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged the errors in the facility's documentation and procedures. The ADON clarified that emergency contact #1 had financial POA, but no one had medical POA for Resident #28. The facility lacked a policy for determining and documenting POA, which contributed to the confusion and subsequent administration of the flu vaccine against the resident's and emergency contacts' wishes. The facility's Infection Prevention and Control Manual required documentation of education and refusal if a vaccine was declined, which was not adhered to in this case.
Inaccurate MDS Assessment for Anticoagulant Therapy
Penalty
Summary
The facility failed to accurately assess the need for anticoagulant therapy for two residents during the observation period of the Minimum Data Set (MDS). For Resident #5, the MDS assessment documented no use of anticoagulant therapy, despite the Medication Administration Record (MAR) showing a physician's order for Apixaban, an anticoagulant, to be administered twice daily. Additionally, Resident #5's Care Plan lacked any focus, goals, or interventions related to anticoagulant therapy. The Assistant Director of Nursing (ADON) acknowledged that the MDS was miscoded by not documenting Apixaban as an anticoagulant. For Resident #24, the MDS documented the use of anticoagulant therapy, but the MAR indicated a physician's order for clopidogrel Bisulfate (Plavix), which is not classified as an anticoagulant. The Care Plan for Resident #24 incorrectly focused on anticoagulant therapy with Plavix. The ADON confirmed the MDS was miscoded by documenting Plavix as an anticoagulant. The facility did not have a policy on the accuracy of MDS assessments, as stated by the Administrator.
Lack of Comprehensive Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident on anticoagulant therapy. The resident, who had no cognitive impairment as indicated by a BIMS score of 14, was receiving Apixaban 2.5 mg orally twice daily as per a physician's order. However, the resident's care plan did not include any focus, goals, or interventions related to the anticoagulant therapy. This omission was acknowledged by the Director of Nursing, who confirmed that a care plan should have been created. The facility's Administrator also stated that anticoagulant therapy should have been included in the care plan, but noted that the facility lacked a policy on the development of care plans.
Failure to Apply Edema Wear as Ordered
Penalty
Summary
The facility failed to adhere to physician orders for a resident requiring edema wear, specifically tubi grips, which were to be applied twice daily. The resident, who had moderately impaired cognition and required total assistance with lower body dressing, did not consistently receive the prescribed treatment. Documentation in the Treatment Administration Record (TAR) showed inconsistencies, with some entries left blank and others marked as completed without evidence of application. Interviews with the resident revealed that the tubi grips were not applied daily, and the resident expressed a preference for wearing them. Staff interviews indicated that the resident often removed the tubi grips independently, yet there was no documentation of refusal in the Electronic Health Record or the care plan. The Assistant Director of Nursing acknowledged that the treatment was documented as completed, despite the lack of application, and stated that refusals should have been recorded as such. This discrepancy between the documented records and the actual care provided highlights a failure to meet professional standards of quality in following physician orders.
Failure to Maintain Resident's ADL Abilities
Penalty
Summary
The facility failed to maintain or improve the activities of daily living (ADL) abilities of a resident, who was admitted with diagnoses of dementia, diabetes, stroke, and a history of repeated falls. Upon admission, the resident required setup or clean-up assistance with eating, supervision or touching assistance with toileting hygiene, and walking. However, a subsequent assessment revealed a decline in the resident's ADL abilities, requiring substantial assistance with toileting hygiene and no attempt at ambulation due to medical or safety concerns. The resident's range of motion was also noted to be impaired, and there was no restorative nursing program (RNP) in place during the assessment period. Observations during meal times showed the resident receiving hands-on assistance with transfers and meals. Interviews with staff revealed that the resident had not attended therapy since admission and there was no request for a restorative program evaluation. The Assistant Director of Nursing confirmed that the facility did not offer a restorative program at the time, which contributed to the resident's decline in ADL abilities. The Business Office Manager noted the resident's decline in ADL abilities since admission, attributing it to cognitive decline, which affected the resident's ability to walk and feed themselves.
Failure to Provide Correct Pureed Diet Portions
Penalty
Summary
The facility failed to provide a well-balanced diet that meets the nutritional and special dietary needs of its residents, specifically for one resident on a pureed diet. During an observation, it was noted that Staff H, a cook, used a 4 oz ladle to serve pureed braised beef tips with gravy and green beans, following a regular diet portion size menu instead of the appropriate pureed diet portion sizes. Staff H admitted to not following a chart for special diets and incorrectly assumed that the portion sizes were correct because they matched the regular diet portions. Upon reviewing the Diet Spreadsheet, it was confirmed that the regular diet portion size was 6 oz for braised beef tips with gravy, and Staff H did not measure the portion size after pureeing the food. The Dietary Manager observed the process and acknowledged that the chart for measuring portion sizes for special/altered diets was not utilized. During an interview, the Dietary Manager confirmed that dietary staff lacked the necessary knowledge to determine the correct scoop sizes for pureed diets and that Staff H was not reading the menu correctly. The facility's document titled 'Therapeutic Diets' indicated that diets should be determined in accordance with the resident's informed choices, preferences, treatment goals, and physician's diet order, which was not adhered to in this instance.
Failure to Serve Food at Proper Temperature and Presentation
Penalty
Summary
The facility failed to serve food within appropriate temperature ranges and in an attractive and palatable manner for one resident. During an observation, the Dietary Manager was seen preparing a pureed diet for a resident without documenting the serving temperature of each food item. The manager placed the plated food in a microwave, stirring and reheating it multiple times, which resulted in the food appearing unappealing. There was no documentation of the food temperatures before serving, as confirmed by the Dietary Manager during an interview. The facility's policy requires that food temperatures be taken and documented for all hot and cold foods prior to serving to ensure proper serving temperatures.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to adhere to appropriate infection prevention practices during personal care for a resident, specifically in the area of hand hygiene. The incident involved a resident with no cognitive impairment, as indicated by a BIMS score of 15, who had an indwelling catheter. During a care procedure, two staff members, Staff N and Staff O, assisted the resident with personal care, including peri care and catheter cleaning. However, they did not perform hand hygiene between glove changes, despite having contact with feces and transitioning from dirty to clean tasks. The Assistant Director of Nursing (ADON) was present during the care and acknowledged the missed opportunities for hand hygiene. The facility's Infection Prevention and Control Manual emphasizes the importance of hand hygiene as a primary means of preventing infection transmission. The manual also highlights the necessity of performing hand hygiene even when gloves are used, especially in preventing contamination with C. difficile spores. Despite these guidelines, the staff failed to perform hand hygiene at critical points during the care process, leading to a deficiency in infection control practices.
Failure to Adhere to Vaccination Consent Procedures
Penalty
Summary
The facility failed to implement its policies and procedures regarding influenza vaccinations, resulting in a resident receiving a flu shot despite a clear declination from their power of attorney (POA). Resident #28, who had a severe cognitive impairment and a history of Guillain Barre syndrome, was administered the influenza vaccine against the wishes of their POA. The POA had communicated to the facility that the resident should not receive the flu vaccine due to a previous adverse reaction. Despite this, the vaccine was administered, as documented by the Director of Nursing. The facility's process for obtaining consent for vaccinations was not followed, as the Assistant Director of Nursing (ADON) could not locate any consent or declination documentation from the POA. The facility's Infection Prevention and Control Manual required that residents or their representatives have the opportunity to decline vaccinations, and any declination should be documented in the medical records. However, this procedure was not adhered to, leading to the administration of the vaccine without proper consent and against medical contraindications.
Lack of COVID-19 Vaccine Consent Documentation for Two Residents
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure proper documentation of consent for COVID-19 immunizations in the medical records of two residents. Resident #2, who was rarely or never understood, had no electronic documentation of consent for the COVID-19 vaccine. Similarly, Resident #24, who had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment, also lacked electronic documentation of consent for the COVID-19 immunization. The Assistant Director of Nursing (ADON) confirmed the absence of consent documentation for these residents and was unable to provide a policy with administration guidelines for COVID-19 vaccination. The facility's SARS-CoV-2 Infection Policy, dated August 22, 2024, stated that residents should be offered resources and counseled about the importance of receiving the COVID-19 vaccine.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain accurate medication administration documentation and obtain medications as ordered for three residents. Resident #1, who entered the facility with severe cognitive impairment, had an order for Olanzapine IM for agitation, which was not administered as the facility did not have it in their Emergency Kit. The medication was supposed to be delivered from the pharmacy, but there was no documentation in the Progress Notes explaining the absence of administration. The resident was observed receiving medication in a crushed form, requiring prompts to take it. Resident #2, also with severe cognitive impairment, had missing documentation for daily vitals and several medications, including Rexulti and Aspirin, which were coded as unavailable without supporting Progress Notes. The DON acknowledged the use of code 6 without documentation and noted that the facility ran out of medication on specific dates. Staff interviews revealed that missing medications were not a regular occurrence, but the facility did run out of medication on certain occasions. Resident #3, who was cognitively intact, had several medications coded as unavailable on their MAR without supporting documentation. The facility's process for ordering medications involved reviewing them upon admission, but orders were not completed until the resident was admitted. The DON stated that refills were typically completed in 1-2 days, but there was a lack of documentation for certain medications. The facility's pharmacy services manual outlined procedures for contacting the pharmacy and using the E-Kit, but these were not effectively followed in these cases.
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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