Hallmar Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Cedar Rapids, Iowa.
- Location
- 8900 C Avenue Ne, Cedar Rapids, Iowa 52402
- CMS Provider Number
- 165798
- Inspections on file
- 14
- Latest survey
- October 2, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Hallmar Village during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Several residents reported being treated roughly and without dignity by a CNA, including being handled harshly during transfers and personal care, ignored when requesting assistance, and witnessing staff using cell phones and earbuds during care. Staff interviews confirmed the CNA's rude behavior and inappropriate handling of residents, including performing a two-person lift alone.
Staff failed to consistently use required gowns and gloves during high-contact care activities for three residents with wounds and indwelling devices. In multiple instances, staff performed wound care and catheter care wearing only gloves, despite care plans and posted signage directing the use of both gowns and gloves. Supplies were available in resident rooms, but staff did not adhere to the facility's Enhanced Barrier Precautions policy.
A resident with moderate cognitive impairment fell and was injured after her walker was left out of reach, and she was not checked on for several hours during a night shift. The CNA responsible was found sleeping and failed to conduct required safety rounds, leaving multiple residents without call lights in reach. The facility's call light policy was not followed, contributing to the incident.
The facility failed to treat residents with dignity and respect, as evidenced by multiple observations and interviews. A resident with moderate cognitive impairment was denied assistance by staff despite her requests, leading to frustration and feelings of neglect. Another resident reported issues with receiving showers at her preferred time, feeling that her reasonable requests were not accommodated. Resident council meetings highlighted ongoing issues, including staff not introducing themselves, ignoring requests for assistance, and discussing private matters in public settings.
The facility failed to provide consistent bathing for two residents, leading to a deficiency in care. One resident, with intact cognition, expressed dissatisfaction with the timing of her showers, which were often delayed. Another resident, fully dependent on staff, experienced inconsistencies in receiving scheduled baths. The Clinical Administrator was unaware of these issues, despite complaints in resident council meetings.
The facility failed to maintain accurate medical records and transcribe orders correctly for two residents. One resident did not have documentation for Lorazepam administration, while another did not receive Carbidopa-Levodopa due to transcription errors. These deficiencies led to lapses in care, with one resident experiencing worsened Parkinson's symptoms. The facility's record-keeping and order transcription processes were inadequate.
A resident with intact cognitive ability and independence in mobility left the unit without staff knowledge on two occasions, despite a care plan requiring communication with staff before leaving. The facility's policy mandates a sign-in/sign-out log, but the resident's departures were not documented, indicating a lapse in monitoring procedures.
A facility failed to promptly address a bedbug infestation, affecting two residents with severe cognitive impairments. One resident developed scratches and another had itchy blisters due to delayed pest control treatments. The facility's pest control policy was not effectively implemented, resulting in discomfort for the residents.
A resident with vascular dementia and psychoactive substance abuse attempted to leave the facility unaccompanied, triggering a door alarm. Despite being independent with ambulation, the resident had intermittent confusion and a desire to go home. The Care Plan was not updated promptly to address the elopement risk, as acknowledged by the DON during an interview.
A resident with multiple health conditions experienced severe pain and bleeding due to improper catheter insertion by an RN, leading to hospitalization. Despite using sterile technique, the catheter was not correctly placed, causing significant trauma and blood loss. The resident required hospital intervention for acute gross hematuria and potential clot formation.
The facility did not comply with professional standards for food service safety. Observations revealed multiple food items in the prep area's fridge, walk-in cooler, walk-in freezer, and dry storage area were open, undated, and unlabeled. The Dietary Manager confirmed these findings, which violated the facility's policy requiring proper labeling and dating of ready-to-eat and potentially hazardous foods.
A resident did not receive their Parkinson's medication, Carbidopa-Levodopa, at the prescribed times. The medication was scheduled to be given five times daily, but on one occasion, the 2 p.m. dose was administered late, and the 6 p.m. dose was given shortly after, violating the facility's policy for timely medication administration.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
Multiple residents experienced a lack of respect and dignity in their care, as evidenced by interviews and clinical record reviews. One resident, with fluctuating cognitive status, reported that a CNA assisted her in a harsh and rough manner, both in the dining room and in her own room, including being jerked up from a seated position without warning. The resident also stated that the CNA was demanding, not gentle during showers, and dismissive when bathroom assistance was requested. Despite reporting these concerns to the administrator, the resident did not observe any improvement in the CNA's behavior. Another resident, cognitively intact, expressed that staff did not treat her or others with dignity. She described being awakened during the night for skin audits and wound treatments, and reported that staff would answer her call light but not return to provide the needed assistance. The resident also observed staff using cell phones and listening to music with earbuds while providing care. She recounted an incident where a CNA refused to assist another staff member with her transfer, and after reporting a near fall, the CNA confronted her, called her a liar, and threatened to write her up. Following this, the resident felt the CNA intentionally ignored her call lights. A third resident, also cognitively intact and requiring extensive assistance for transfers, reported being treated roughly and like a "rag doll" by a CNA, which caused her to fear injury. The resident stated the CNA showed little interest in helping and was rough when dressing her. Staff interviews corroborated these accounts, noting the CNA's rude behavior towards both residents and staff, and confirming that the CNA performed a two-person lift alone. The facility's own investigation documented multiple residents reporting rough care and inappropriate handling by the CNA.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) and standard precautions to prevent the spread of infections for three residents with wounds and/or indwelling medical devices. For one resident with a recent surgical procedure and a groin incision, a registered nurse performed wound care without donning a gown, despite signage and care plan instructions requiring both gloves and a gown for such procedures. The nurse stated she considered wearing a gown but decided against it because the wound was not open. Another resident with diabetes, heart disease, wounds, and an indwelling Foley catheter required total assistance for transfers and had a care plan directing staff to use EBP, including gown and gloves, during high-contact care activities. A certified nursing assistant emptied the resident's catheter bag wearing only gloves, failing to use a gown as required by the care plan and posted signage. The staff member later acknowledged awareness of the EBP signage but did not follow the protocol. A third resident with cognitive abilities, a stage three inter-gluteal pressure ulcer, and an indwelling urinary catheter required extensive assistance and use of a mechanical lift. During care involving transfer, incontinence care, and wound cleansing, three staff members wore gloves but did not don gowns, contrary to the care plan and facility policy. Additionally, wash cloths used for wound care were placed directly on the bed sheet without a barrier, and a graduated cylinder used for emptying the Foley bag was placed on the bed frame without a barrier. The facility's policy clearly required gowns and gloves for high-contact care activities involving wounds and indwelling devices.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision for residents, particularly affecting a resident with moderate cognitive impairment who was left without her walker within reach, leading to a fall and injury. The resident, who was independent in her room with her walker, was found on the floor with a head wound after attempting to reach her walker, which had been placed out of reach. The incident occurred during a night shift when the resident was not checked on for a significant amount of time, resulting in her lying on the floor for several hours before being discovered by staff. The night shift staff, including an LPN and a CNA, failed to perform safety rounds as required. The CNA responsible for the resident's care was found sleeping during the shift and did not conduct the necessary rounds or respond to call lights promptly. This negligence left several residents without call lights in reach and others with unanswered call lights, further compromising their safety and care. The CNA had previously been coached on the importance of rounding and maintaining resident room order, but these protocols were not followed during the shift in question. The facility's call light policy, which mandates prompt response to call lights and regular safety checks, was not adhered to, contributing to the resident's fall and subsequent injury. The failure to conduct rounds and ensure residents' needs were met resulted in the resident being left in a vulnerable position for an extended period. The incident highlights a breakdown in staff responsibilities and adherence to established care protocols, leading to harm to the resident.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with dignity and respect, as evidenced by multiple observations and interviews. Resident #3, who has moderate cognitive impairment, was observed being denied assistance by staff despite her requests. An occupational therapist instructed staff not to assist the resident with tasks such as applying chapstick, asserting that the resident was independent. However, Resident #3 expressed frustration when she was left in soiled briefs and was denied timely assistance, which she reported to management. Additionally, she mentioned missing baths due to staff not returning with necessary supplies. Resident #4, who has intact cognition, reported issues with receiving showers at her preferred time. She expressed dissatisfaction with staff delaying her shower until after she was dressed, despite her request for an early morning shower. She felt that her request was reasonable and should be accommodated, but staff often cited being too busy with other residents. This issue was also raised in resident council meetings, where residents voiced concerns about staff not respecting their preferences and needs. The resident council meeting notes highlighted several ongoing issues, including staff not introducing themselves, ignoring residents' requests for assistance, and discussing private matters in public settings. Residents reported feeling disrespected and neglected, with staff failing to respond promptly to call lights and leaving soiled linens in rooms. The facility's policy on resident rights emphasizes person-centered care and collaboration with residents, but the reported incidents indicate a failure to uphold these standards.
Inconsistent Bathing Schedules for Residents
Penalty
Summary
The facility failed to provide consistent bathing for two residents, leading to a deficiency in care. Resident #4, who has intact cognition and requires substantial assistance for bathing, expressed dissatisfaction with the timing of her showers. She prefers to bathe once a week on Saturdays at 6:45 am, but staff often delay her shower until after she is dressed, citing busyness and other residents' needs. Over the past month, Resident #4 received baths at times inconsistent with her preference, and on one occasion, bathing was marked as refused. Resident #7, who is fully dependent on staff for bathing, also experienced inconsistencies in receiving scheduled baths. The records show that he received baths on only a few occasions, with several instances marked as not applicable. The Clinical Administrator was unaware of these issues and acknowledged the need for better accountability, as complaints about bathing schedules were a recurring topic in resident council meetings.
Deficiencies in Medical Record-Keeping and Order Transcription
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in their care. For Resident #6, the facility did not document the administration of Lorazepam, an anti-anxiety medication, despite having an order for it. The medication was never used, and the facility could not locate the complete Controlled Drug Receipt/Record/Disposition form, which should have documented the medication's receipt and destruction. The Clinical Administrator confirmed that the medication was delivered and later destroyed, but the lack of documentation indicates a failure in record-keeping. For Resident #7, the facility inaccurately transcribed medical orders, resulting in the resident not receiving Carbidopa-Levodopa, a medication for Parkinson's Disease, for a period of time. The ARNP had ordered the continuation of the medication, but the facility's records incorrectly showed it was discontinued. This error was discovered when the resident's family provided a copy of the correct order. The resident experienced worsened Parkinson's symptoms during the time the medication was not administered. The Clinical Administrator acknowledged the error and noted that the staff member responsible for the transcription had prior performance issues. The facility's record retention policy requires that all records comply with federal and state regulations, but the deficiencies in documentation for both residents indicate a failure to adhere to these standards. The lack of proper documentation and transcription of medical orders led to significant lapses in the care provided to the residents, highlighting issues in the facility's record-keeping and order transcription processes.
Failure to Monitor Resident Leaving Unit
Penalty
Summary
The facility failed to implement an effective process to monitor a resident who left their unit without staff knowledge on two occasions. The resident, who had diagnoses including poly substance abuse, vascular dementia, and acute kidney failure, was noted to have intact cognitive ability and independence in ambulation, transfers, and dressing. Despite a care plan update on 9/26/24, which required the resident to communicate with staff before leaving the unit and for staff to place a reminder sign on the exit door, the resident left the unit without signing out on 10/18/24 and 10/19/24. The facility's Wandering and Elopement Policy, modified in December 2022, mandates a sign-in/sign-out log for residents leaving the unit. However, the sign-in/sign-out sheet for the relevant period did not include the resident's name, indicating a failure to document the resident's departures. During an interview, the Director of Nurses acknowledged the expectation for the resident to sign out, highlighting a lapse in adherence to the policy and care plan interventions.
Delayed Pest Control Response Leads to Resident Discomfort
Penalty
Summary
The facility failed to maintain an effective pest control policy, resulting in a bedbug infestation affecting multiple residents. Resident #5, who had severe cognitive impairments and required assistance for mobility, was first observed with a bedbug in their room on October 17, 2024. Despite the presence of bedbugs, the initial treatment for Resident #5's room was not administered until October 21, 2024, after a delay in signing the pest control proposal. The resident subsequently developed scratches on their face and groin, indicating potential bedbug bites. Another resident, Resident #2, also experienced issues related to the bedbug infestation. This resident, who had severe cognitive impairment and used a wheelchair, developed multiple blisters and bumps on their back, which were itchy. The resident's room was not treated until November 5, 2024, despite the presence of bedbug bites being noted by the ARNP on October 21, 2024. The delay in treatment led to the resident experiencing ongoing itching and new bites on their arms and face. The facility's pest control policy, as outlined in their 2020 guidelines, was not effectively implemented. The policy required timely inspection and treatment of affected areas, which was not adhered to in this case. The facility's Director of Nursing acknowledged the delay in treatment and the need for more timely pest control measures. The pest control service, Plunkett's, confirmed that proposals for treatment were sent but not promptly signed by the facility, leading to delays in addressing the infestation.
Failure to Update Care Plan After Resident Elopement Attempt
Penalty
Summary
The facility failed to update the Care Plan for a resident who attempted to leave the facility without staff supervision. The resident, who was assessed with a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment, had diagnoses of vascular dementia and psychoactive substance abuse. Despite being independent with ambulation, the resident was noted to have intermittent confusion and a desire to go home, as documented in an Elopement Risk Assessment. On a specific date, the resident left the facility unaccompanied, triggering a door alarm. Staff intervened and provided education to the resident about the need for staff accompaniment when going outside. The Director of Nursing (DON) acknowledged during an interview that the Care Plan should have been updated promptly following such an incident. However, the Care Plan was not updated until the time of the interview, indicating a delay in addressing the resident's elopement risk. The resident's statement revealed that the reason for leaving was to find an ATM to withdraw cash for purchasing a cigar, and he forgot to inform the nurse before exiting. This oversight in updating the Care Plan represents a deficiency in the facility's response to the resident's elopement risk.
Improper Catheter Insertion Leads to Hospitalization
Penalty
Summary
The facility staff failed to properly insert a catheter for a resident, leading to hospitalization. The resident, who had a history of Parkinson's Disease, End Stage Renal Disease, Benign Prostatic Hyperplasia, Bladder Neck Obstruction, Urinary Tract Infection, and Diabetes Mellitus, required maximum assistance with activities of daily living and had a catheter. On the day of the incident, a registered nurse, Staff B, attempted to change the resident's catheter but encountered resistance during insertion. Despite using sterile technique, the resident experienced significant pain, grimacing, and sweating, indicating improper placement. Staff B, with the assistance of a certified nursing assistant, Staff D, and later a licensed practical nurse, Staff C, attempted to adjust the catheter. However, the catheter was not properly placed, as evidenced by the excessive length protruding from the resident's penis and the lack of urine return. Staff B inflated the balloon, causing the resident to bleed profusely from the penis, and the resident continued to express severe pain. Despite the obvious signs of improper placement, Staff B sought multiple opinions before deciding to remove the catheter, which resulted in a significant amount of bright red blood loss. The resident was transferred to the hospital due to excessive bleeding and pain. The hospital's emergency department noted acute gross hematuria and concerns about potential clot formation. A urology consultation confirmed that the catheter had likely been inflated at the prostate, causing trauma. The resident required extensive bladder irrigation and additional interventions to manage the bleeding. Interviews with staff and family members revealed that this was not the first incident involving Staff B and catheter changes, as a similar event had occurred previously, also resulting in physician intervention.
Failure to Adhere to Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the prep area's stand-up fridge, two long squeezable tubes of whipped topping were found open and undated, contrary to the facility's policy requiring them to be stored in a zip lock bag, labeled, and dated. Additionally, icing and barbeque sauce in squeeze bottles were not labeled or dated. In the walk-in cooler, five cheesecake bites in a Styrofoam container were not labeled or dated, and the Dietary Manager indicated they likely belonged to a staff member. An open bag of basil leaves was also found undated. In the walk-in freezer, an open bag of hash browns and an opened bag of frozen green beans were not dated. Furthermore, in the dry storage area, an open and unsealed bag of egg noodles was found undated. The Dietary Manager confirmed these observations, which were inconsistent with the facility's updated Labeling and Dating Policy that requires ready-to-eat and potentially hazardous foods to be labeled with the product name and the date they were opened, prepared, or when they must be used or discarded.
Failure to Administer Parkinson's Medication on Schedule
Penalty
Summary
The facility failed to adhere to physician's orders for a resident's medication administration, specifically Carbidopa-Levodopa, which is used to manage Parkinson's disease. The Medication Administration Record (MAR) for the resident indicated that the medication should be administered five times a day at specific times: 2 a.m., 6 a.m., 10 a.m., 2 p.m., and 6 p.m. However, a review of the Medication Administration Audit Report revealed that on one occasion, the 2 p.m. dose was administered late at 4:51 p.m., and the subsequent 6 p.m. dose was given at 5:31 p.m., resulting in a very short interval between doses. This deviation from the prescribed schedule was contrary to the facility's Medication Administration Policy, which emphasizes the importance of timely drug therapy.
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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