Grundy Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grundy Center, Iowa.
- Location
- 102 East J Avenue, Grundy Center, Iowa 50638
- CMS Provider Number
- 165241
- Inspections on file
- 28
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Grundy Care Center during CMS and state inspections, most recent first.
A resident with a history of neurogenic bladder, anxiety, bipolar disorder, depression, PTSD, and paraplegia was subjected to physical and mental abuse by a CNA. The CNA engaged in inappropriate interactions, including kissing and sending inappropriate pictures, which continued until the CNA resigned. The resident experienced increased isolation and depression due to the relationship, and the facility failed to implement its abuse prevention and reporting policy effectively.
The facility failed to ensure 24/7 licensed nurse coverage as required by policy. The PBJ Staffing Data Report indicated missing coverage on specific dates, and the facility could not immediately verify shifts due to reliance on an external company for time card management. Staff provided a list of scheduled nurses, but verification was pending. The policy mandates continuous licensed nurse presence for supervision and care.
The facility failed to maintain appropriate staffing levels, lacking RN coverage and a DON on several occasions. The DON left without notice, and the facility relied on temporary staff. The PBJ report showed missing RN coverage on multiple dates, and the facility's policy of having an RN for at least eight hours daily was not met.
The facility failed to notify a resident's representative and the LTC Ombudsman of transfers to the hospital for two residents, as required by federal regulation. One resident's guardian was not informed of the hospital admission, and the facility's administrator acknowledged the oversight in notifications.
A facility failed to update the PASRR evaluation for a resident diagnosed with a new mental health condition, delusional disorder. Despite the resident's intact cognition and initial diagnoses of anxiety and depressive disorders, the facility did not request an updated PASRR following the new diagnosis. Interviews with the ADON and DON confirmed the oversight, acknowledging the requirement for a new screening per facility policy.
The facility failed to supervise a resident during medication administration and did not accurately process physician orders, leading to continued administration of a discontinued medication. Additionally, the facility did not notify a physician about a resident's high blood glucose level as required, lacking documentation of such notification.
A resident with moderate cognitive impairment and multiple diagnoses developed a UTI associated with an indwelling catheter. The facility failed to prevent the catheter tubing from dragging on the floor, as observed during a walk with a CNA. The DON and ADON acknowledged the infection control lapse, which contradicted the facility's catheter care policy.
The facility failed to keep medication and treatment carts locked when not supervised, as observed during a survey. On several occasions, the carts were found unlocked and unattended in the hallway, with staff and residents passing by. Despite the facility's policy requiring locked compartments for medications, the carts were repeatedly left unsecured, indicating a lack of adherence to the policy.
The facility failed to store food safely, as observed in the kitchen's refrigerators and freezers where opened items were unsealed and lacked proper labeling. The Dietary Manager acknowledged the oversight, and the Administrator confirmed the expectation for labeling. The facility's policy requires all stored foods to be covered, labeled, and dated.
The facility failed to maintain the highest well-being of residents by not sustaining their Plan of Correction to ensure required members attended quarterly QAPI meetings. Despite a POC, the DON and IP were frequently absent from these meetings, as shown by attendance records. The Interim Administrator confirmed the expectation for all department heads and the Medical Director to attend.
The facility failed to ensure the required members, including the DON and IP, were present at QAPI meetings. Attendance records showed the DON was absent from several meetings, and the IP was also missing from multiple sessions. The Interim Administrator confirmed the expectation for quarterly meetings with all key members present, as per facility policy.
Two residents with severe cognitive impairments and mobility issues were not repositioned according to the facility's policy, leading to skin care deficiencies. One resident was left in a recliner for hours, resulting in severe excoriation and bleeding, while another was observed in the same position for extended periods, contrary to the required repositioning schedule. Staff acknowledged the lack of repositioning, which was inconsistent with the facility's policy for preventing skin breakdown.
A resident was transferred to the hospital without the facility providing the Bed Hold policy to the resident or their representative. The facility's records lacked documentation of notification, and the resident's guardian was not informed of the hospital admission. The facility's policy requires notification of Bed Hold policies at least twice, but this was not adhered to in this instance.
A facility failed to accurately document and manage a resident's pressure ulcers, leading to inconsistent wound assessments. The resident's records showed discrepancies in the measurement and staging of a wound on their right buttock, with different nurses documenting varying details each week. Staff interviews revealed a lack of specialized training in skin assessments, contributing to the inconsistency in documentation.
A long-term care facility failed to maintain licensed nurse coverage 24/7, leaving a gap from 6:45 AM to 8:41 AM. During this time, a resident with a tracheostomy and another with diabetes requiring insulin were at risk due to the absence of a licensed nurse. Staff were aware of the situation but unable to perform necessary medical interventions, highlighting a significant lapse in care and oversight.
The facility failed to follow the planned menu for residents, serving a different meal than listed without obtaining dietitian approval. The Dietary Manager made last-minute changes without informing the dietitian, and the cook improvised due to unavailable menu items, leading to unmet nutritional needs.
A cook at the facility was observed handling ready-to-eat food with contaminated gloves during meal service, touching various surfaces before serving the food to residents. The Dietary Supervisor confirmed the expectation to prevent foodborne illness by not using bare hands or contaminated gloves, as per the Food Code.
The facility failed to employ sufficient staff with the necessary competencies in the food and nutrition service. A part-time consultant Dietitian was employed, and the Dietary Supervisor lacked required certification and experience, having only worked at the facility for two weeks and not completed necessary education or certification programs. The facility could not provide documentation of the Dietary Supervisor's certification.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical and mental abuse by a Certified Nurse Aide (CNA), identified as Staff A. The CNA engaged in inappropriate interactions with a resident, including accepting money, kissing, sending inappropriate pictures via text, and exchanging inappropriate touch. These interactions continued until the CNA resigned from the facility. The resident involved had a history of neurogenic bladder, anxiety, bipolar disorder, depression, PTSD, and paraplegia, and was reported to have almost constant pain and multiple pressure injuries. The resident's Minimum Data Set (MDS) assessment indicated intact cognition and required assistance with activities of daily living due to paraplegia. The resident was described as pleasant and cooperative, with a good appetite and fluid intake. However, there were fluctuations in the resident's mood, with periods of isolation and depression noted in the health status notes. The resident reported feeling uncomfortable with a young CNA and expressed embarrassment due to the colostomy bag smell, which contributed to his isolation. The inappropriate relationship between the CNA and the resident was discovered after the CNA resigned. The resident reported that the CNA initiated contact and that the relationship included sexual conversations and physical interactions. The resident felt guilty, judged, and taken advantage of, leading to increased isolation and depression. The facility's investigation revealed that the CNA had spent excessive time with the resident, and other staff members were aware of the relationship but did not report it. The facility's policy on abuse prevention and reporting was not effectively implemented, leading to the deficiency.
Removal Plan
- Resident #1 will receive on-going psychiatry services as indicated by the provider and as needed (PRN).
- The facility interviewed all interviewable residents to determine no additional concerns.
- The facility interviewed all staff, and concerns raised about Resident #1 isolating himself. The administrator interviewed Resident #1 about these concerns and addressed the concerns.
- The facility educated all staff. The facility provided and reviewed a copy of the abuse policy and procedure for reporting, trauma informed care, and education regarding psychosocial well-being of the residents.
- All newly hired staff and agency staff will complete annual training for trauma-informed care upon hire and be provided with the policy for abuse and abuse reporting.
- Quality Assurance and Performance Improvement (QAPI review), with on-going audits that include interviews with residents and staff.
Failure to Provide 24/7 Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide licensed nurse coverage 24 hours a day, 7 days a week, as required by their policy. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 3 2024 revealed that the facility did not have licensed nurse coverage on several specific dates. Interviews with the Interim Administrator indicated that the facility was unable to provide immediate verification of licensed nurse coverage for these dates, as they were waiting for information from an external company that managed their time cards. Staff C, a Certified Medical Assistant and Scheduler, provided a list of licensed nurse coverage for the dates in question, indicating that both agency and facility nurses were scheduled. However, there was a lack of immediate verification of these shifts. The facility's policy, revised in August 2022, mandates that a licensed nurse must be on duty at all times to supervise nursing services and provide resident care. Despite this policy, the facility was unable to demonstrate compliance for the specified dates, leading to the deficiency finding.
Deficiency in RN Coverage and Lack of DON
Penalty
Summary
The facility failed to ensure appropriate staffing, specifically lacking Registered Nursing (RN) coverage and a Director of Nursing (DON) on multiple occasions. The Assistant Director of Nursing (ADON) reported that the DON left without notice, and there was no replacement at the time of the survey. Interviews with staff indicated a need for more staff, as the DON and Administrator had both quit, leading to reliance on temporary staff. The Facility Assessment highlighted the necessity of having a DON and RN full-time to meet resident needs, but this was not adhered to. The Payroll Based Journal (PBJ) Staffing Data Report revealed the facility lacked 8 hours of RN coverage on several dates, and the Interim Administrator was unable to provide verification of RN coverage for those dates. Additionally, the facility's nursing schedules showed that the contracted DON did not provide the required 8 hours of RN coverage on several days in October. The facility's policy stated that a registered nurse should provide services for at least eight consecutive hours every 24 hours, seven days a week, which was not met, leading to the deficiency.
Failure to Notify Resident Representatives and Ombudsman of Transfers
Penalty
Summary
The facility failed to notify a resident's representative and the Long Term Care Ombudsman of the discharge or transfer of residents as required by federal regulation. Specifically, Resident #3 was transferred to a hospital and reentered the facility without documentation of notification to the resident's representative or the Ombudsman. The resident's guardian expressed concern about not being informed of the hospital admission, highlighting the lack of communication from the facility. Similarly, Resident #20 was transferred to a hospital and later reentered the facility without the required notification to the Ombudsman. The facility's administrator acknowledged the failure to notify both the Ombudsman and Resident #3's guardian, despite the expectation of accurate and timely notifications. This deficiency was identified through record reviews, staff interviews, and policy reviews, affecting two out of four residents reviewed for discharge or transfer.
Failure to Update PASRR Evaluation for New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit an updated Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was diagnosed with a new mental health condition. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, was initially admitted with diagnoses of anxiety disorder and depressive disorder. However, on March 9, 2023, the resident received a new diagnosis of delusional disorder, which was not followed by a request for an updated PASRR evaluation as required. Interviews with the Assistant Director of Nurses (ADON) and the Director of Nurses (DON) confirmed their awareness of the PASRR requirements, which mandate a new screening when there is a change in mental health diagnosis. Both acknowledged that an updated PASRR should have been requested following the resident's new diagnosis. The facility's policy, dated 2001, also directed that new or changed behaviors indicating a serious mental disorder should be referred for a Level II PASRR evaluation, which was not done in this case.
Failure to Supervise Medication Administration and Notify Physician
Penalty
Summary
The facility failed to adhere to professional standards by not supervising a resident during medication administration and not accurately processing physician orders. During an observation, a resident was seen taking medication unsupervised, which was against the facility's policy that requires nurses or certified medication aides to be present until medications are administered. Additionally, a review of Resident #3's records revealed that despite a physician's order to discontinue a specific dosage of Oxybutynin, the medication was still administered throughout September and part of October, indicating a failure to accurately follow and process physician orders. Furthermore, the facility did not notify a physician as required for a resident with high blood glucose levels. Resident #23, who had a history of diabetes mellitus, coronary artery disease, heart failure, and peripheral vascular disease, had a blood sugar reading of 461, which necessitated physician notification according to the sliding scale insulin order. However, there was no documentation of such notification, which was confirmed by the interim administrator who could not locate any record of provider notification. This oversight was contrary to the facility's policy on notifying physicians of acute changes in a resident's condition.
Inadequate Catheter Care Leads to UTI
Penalty
Summary
The facility failed to provide appropriate interventions to minimize or prevent complications of infections for a resident with urinary conditions. Resident #10, who has moderate cognitive impairment and diagnoses including diabetes, anxiety, depression, lung disease, and renal insufficiency, had an indwelling catheter due to obstructive uropathy and urinary retention. The care plan for Resident #10 included monitoring for signs and symptoms of urinary tract infections (UTIs). However, an Emergency Department report documented that Resident #10 developed a UTI associated with the indwelling catheter, requiring antibiotic treatment. During an observation, it was noted that Resident #10's catheter tubing dragged on the floor while walking with a CNA. The CNA acknowledged the issue, stating that the resident previously had a shorter tube and was unaware of the current tubing dragging. Interviews with the DON and ADON confirmed that for infection control purposes and to prevent falls, the catheter tubing should not have been allowed to drag on the floor. The facility's catheter care policy from 2009 also emphasized keeping catheter tubing and drainage bags off the floor to prevent catheter-associated UTIs.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that medication and treatment carts remained locked when not under staff supervision, as observed during a survey. On multiple occasions, the medication cart and treatment cart were found unlocked and unattended in the central hallway next to the nurses' station. This occurred despite the facility's policy requiring that compartments containing medications and biologicals be locked when not in use. During the observations, various staff members and residents passed by the unlocked carts, indicating a lack of adherence to the facility's medication labeling and storage policy. Specifically, on one occasion, a staff member, identified as Staff D, RN, was observed removing supplies from the treatment cart, locking it, and then leaving it unattended again shortly after. Additionally, Staff D placed insulin pens on top of the medication cart and left them unattended while entering a resident's room. The facility administrator confirmed that the expectation is for medication and treatment carts to remain locked when not in use or supervised, aligning with the facility's policy. However, the repeated observations of unlocked carts suggest a failure to consistently implement this policy.
Failure to Store Food Safely
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During an initial observation of the kitchen's refrigerators and freezers, it was found that there were opened items that were unsealed and lacked labeling to identify the product, open date, and use-by date. This observation was made with a reported census of 26 residents in the facility. In an interview, the Dietary Manager acknowledged that these items should have been sealed, labeled, and dated when opened. Additionally, the facility's Administrator stated that the expectation is for all opened and stored foods to be labeled with identification of the product, open date, and expiration date. A review of the facility's policy titled 'Food Receiving and Storage,' revised in November 2022, indicated that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated.
Failure to Sustain QAPI Meeting Attendance
Penalty
Summary
The facility failed to effectively and efficiently maintain the highest well-being of each resident by not sustaining their Plan of Correction (POC) dated 9/12/23. This POC was intended to ensure that required members were present at the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. The facility, which reported a census of 26 residents, was cited during their annual recertification survey on 8/17/23 for not having the required members present at these meetings. Despite implementing a POC, the facility did not maintain compliance, as evidenced by attendance sheets from QAPI meetings on 12/12/23, 4/18/24, 7/29/24, and 10/8/24, which showed the Director of Nursing (DON) was not in attendance. Additionally, the Infection Preventionist (IP) was absent from meetings on 12/12/23, 3/22/24, 4/18/24, and 7/29/24. An interview with the Interim Administrator on 11/7/24 confirmed the expectation that all department heads, the Medical Director, and any other interested staff should attend these meetings.
QAPI Meeting Attendance Deficiency
Penalty
Summary
The facility failed to have the required members present at their Quality Assurance and Performance Improvement (QAPI) meetings, specifically the Director of Nursing (DON) and the Infection Preventionist (IP). The attendance records showed that while the required members attended the meeting on 9/12/23, the DON was absent from the meetings on 12/12/23, 4/18/24, 7/29/24, and 10/8/24. Similarly, the IP was not present at the meetings on 12/12/23, 3/22/24, 4/18/24, and 7/29/24. The Interim Administrator acknowledged the absence of these key members and stated that the expectation was for the QAPI committee to meet at least quarterly with all department heads, the Medical Director, and any other interested staff present. The facility's policy required the QAPI committee to consist of no less than five members, including the Administrator, DON, IP, Medical Director or Physician designee, and at least two additional facility staff.
Failure to Reposition Residents Leads to Skin Care Deficiencies
Penalty
Summary
The facility failed to ensure proper repositioning and skin care for two residents, leading to deficiencies in their care. Resident #4, with severe cognitive impairment and Moisture Associated Skin Damage (MASD), was observed sitting in a recliner for an extended period without being repositioned. The resident was dependent on staff for transfers and required assistance from two staff members. Observations revealed that the resident had not been repositioned since breakfast, resulting in severe excoriation and bleeding on the buttocks. The Director of Nursing (interim) and Certified Nursing Assistants (CNAs) acknowledged the lack of repositioning and the resident's discomfort. Resident #20, also with severe cognitive impairment and multiple medical conditions, including a tracheostomy and gastrostomy, was observed in a recliner for several hours without repositioning. The resident was dependent on staff for all activities of daily living and required full assistance for repositioning. Observations showed the resident leaning to one side with a mechanical lift sling under them, indicating a lack of movement. The facility's repositioning policy required residents in chairs to be repositioned every hour, but documentation showed repositioning occurred only three times a day. The facility's failure to adhere to its repositioning policy resulted in inadequate care for both residents. The policy, revised in May 2013, emphasized the importance of repositioning to prevent skin breakdown and promote circulation. Despite this, staff interviews revealed that repositioning schedules were not followed, and residents were not moved as frequently as required. This lack of adherence to the policy contributed to the residents' skin issues and discomfort.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide the Bed Hold policy to a resident or their representative during a hospital transfer. Resident #3 was admitted to the hospital on 10/5/24, but the facility did not discuss or provide the Bed Hold policy to the resident or their representative. The clinical record lacked documentation of notification regarding the Bed Hold policy, and the resident's guardian expressed concern about not being informed of the hospital admission. The facility's Administrator acknowledged the failure to notify the resident's representative of the hospital transfer and the Bed Hold policy. The facility's policy, revised in October 2022, requires that residents or their representatives receive written information about Bed Hold policies at least twice: in advance of any transfer and at the time of transfer, or within 24 hours if the transfer was an emergency. However, this procedure was not followed in the case of Resident #3.
Inconsistent Documentation of Pressure Ulcers
Penalty
Summary
The facility failed to accurately document and manage pressure ulcers for one resident, leading to a deficiency in care. The resident's medical records showed inconsistent documentation regarding a wound on their right buttock. As the wound worsened, the facility did not update the stages of the pressure ulcer to reflect these changes. The assessments showed discrepancies in the measurement and staging of the wound, with different nurses documenting varying details each week. The resident's Minimum Data Set (MDS) assessment initially indicated no pressure ulcers, but subsequent weekly skin assessments revealed the presence of an abscess and skin tear on the right buttock. The measurements and staging of these wounds varied, with some assessments not assigning a stage to the abscesses. The inconsistency in documentation made it difficult for healthcare providers to accurately assess the wound's condition and provide appropriate care. Interviews with staff revealed a lack of specialized training in skin assessments, contributing to the inconsistency in documentation. The Advanced Registered Nurse Practitioner expressed concern over the inconsistent documentation, which hindered the ability to determine the wound's condition until it was observed in person. The facility's Nurse Consultant acknowledged the inconsistency in skin assessments and staging, further highlighting the deficiency in the facility's wound management practices.
Lack of Licensed Nurse Coverage in LTC Facility
Penalty
Summary
The facility failed to ensure licensed nurse coverage 24 hours a day, resulting in a period on 6/15/24 when there was no licensed nurse on duty from 6:45 AM to 8:41 AM. During this time, the night nurse clocked out, and the day nurse had not yet arrived. Despite being informed of the situation, the Director of Nursing (DON) and the Administrator did not act immediately to provide licensed coverage. This lapse in coverage occurred while the facility had 15 diabetic residents, 8 of whom were insulin-dependent, and one resident with a tracheostomy requiring regular care. Resident #2, who had a tracheostomy, required total assistance and had severely impaired cognitive skills. The resident's care plan included specific orders for tracheostomy care, which could only be performed by a licensed nurse. During the time without nurse coverage, there was a risk of the tracheostomy becoming dislodged, which would require immediate intervention. Additionally, Resident #7, who had diabetes and severely impaired cognitive skills, had a blood glucose reading of 65, indicating hypoglycemia, which required assessment and intervention by a licensed nurse. Staff interviews revealed that the facility staff were aware of the absence of a licensed nurse and expressed concerns about the potential risks to residents. Staff D, a Certified Medication Aide, took blood sugar readings but could not administer insulin or assess residents with low blood sugar, as it was outside her scope of practice. The Interim Administrator acknowledged the lack of a formal policy regarding nursing staffing and medication administration, which contributed to the deficiency. The facility's documentation confirmed the absence of a licensed nurse during the specified time, highlighting a significant lapse in care and oversight.
Failure to Follow Planned Menu and Obtain Dietitian Approval
Penalty
Summary
The facility failed to adhere to the planned menu for residents on all diet types, as observed during a lunch meal service. The unsigned dietary menu for the specified day listed a meal of cheeseburger on a bun, French fries, creamy coleslaw, scotcheroo bars, and milk. However, the meal served to residents included a ham salad sandwich, French fries, beets, a cookie, and milk. This discrepancy was noted during an observation of the lunch meal service, and it was found that the menu had not been signed by the dietitian, as required. Interviews with the Dietary Manager and the Corporate Dietitian revealed a lack of communication and protocol adherence. The Dietary Manager admitted to making last-minute changes to the menu without obtaining the necessary approval from the dietitian, who was unaware of the changes. Additionally, the cook reported that they sometimes had to improvise due to the unavailability of menu items, which led to the deviation from the planned menu. This lack of coordination and failure to follow established procedures resulted in the facility not meeting the nutritional needs of the residents as per the planned menu.
Failure to Prevent Food Contamination During Meal Service
Penalty
Summary
The facility failed to protect food from contamination during meal service, as observed during a lunch service. Staff A, a cook, was seen handling ham salad sandwiches and French fries with gloved hands that had touched various surfaces, including the outside of a hamburger bun bag, the counter, a scoop handle, tong handle, serving lids, and her cheek. Despite wearing gloves, Staff A did not change them after touching these surfaces, leading to potential contamination of the ready-to-eat food served directly to residents. During an interview, the Dietary Supervisor acknowledged witnessing Staff A's actions and stated that staff are expected to handle food in a manner that prevents foodborne illness, which includes not touching ready-to-eat food with bare hands or contaminated gloves. The Food Code mandates that food employees must not touch ready-to-eat food with bare hands and should use suitable utensils or clean gloves, emphasizing the need for hand hygiene before food preparation and when changing tasks to prevent cross-contamination.
Insufficient Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies to carry out the functions of the food and nutrition service. The facility employed a corporate Dietitian on a part-time consultant basis and designated a person who lacked the required certification and/or experience to serve as the Dietary Supervisor. The Dietary Supervisor had only worked at the facility for two weeks and had previously worked as a cook at another facility for one year. She had not completed education on safe service or food handling to prevent foodborne illness and had not completed or enrolled in the Certified Dietary Manager certification program. The Corporate Dietitian confirmed that she worked at the facility on a consultant basis and not a full-time basis. The Administrator also confirmed that the Dietary Supervisor did not have her certification and that the facility employed the Dietitian as a part-time consultant. The facility was unable to produce documentation of certification for the Dietary Supervisor.
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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