Harmony Davenport
Inspection history, citations, penalties and survey trends for this long-term care facility in Davenport, Iowa.
- Location
- 815 East Locust Street, Davenport, Iowa 52803
- CMS Provider Number
- 165033
- Inspections on file
- 26
- Latest survey
- October 2, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Harmony Davenport during CMS and state inspections, most recent first.
An LPN made an unprofessional and disrespectful comment about a resident's condition within earshot of a family member, failing to uphold the resident's right to dignity and respect. The resident had multiple serious health conditions and was on hospice care. The incident was overheard by the family, who found the remark inappropriate and reported it to facility management.
A resident with a history of poly substance overuse and respiratory diagnoses was allowed to smoke independently, even when under the influence, due to incomplete assessments and care planning. Staff observed the resident exhibiting unsafe smoking behaviors while intoxicated, such as letting cigarettes burn down to his fingers and burning a hole in his jacket, but the care plan did not address the need for supervision or additional safety measures during these times.
The facility failed to submit accurate agency staffing data for the PBJ report, leading to a trigger for Excessively Low Weekend Staffing. An audit revealed 20 agency staff were not included in the PBJ data, despite consistent staffing schedules. The Administrator noted the data submission was handled by the corporate office and identified the omission of agency staff, with no policy or procedure in place for the PBJ process.
The facility failed to label and date opened food items in the refrigerator, freezer, and dry storage areas, as observed during a kitchen tour. Various food items were found open without labels or dates, contrary to the facility's policy. Staff confirmed that opened food items should have been labeled and dated, indicating non-compliance with food storage procedures.
The facility failed to maintain proper catheter hygiene for two residents, as catheter bags and tubing were repeatedly observed on the floor, contrary to care plans and facility policy. Despite staff observations, including a CNA and the DON, the issue was not addressed, leading to a deficiency in care.
The facility failed to follow infection control protocols for residents with specific medical needs. A resident with a colostomy did not receive proper hand hygiene during bag changes, and another resident's wound care was conducted without changing gloves or washing hands. Additionally, Enhanced Barrier Precautions were not implemented for a resident with an indwelling catheter, as staff were unaware of the need for gowns and gloves.
The facility failed to maintain consistent water temperatures in showers, affecting resident dignity. Residents reported refusing showers due to cold water, and staff confirmed ongoing issues with achieving warm water. The problem persisted despite attempts to address it, with water temperatures fluctuating significantly during checks.
The facility failed to maintain shower water temperatures between 110 and 120 degrees Fahrenheit, as required. A resident reported insufficient water temperature, leading to the discovery of a faulty cartridge in the 2nd floor shower. Despite repairs, water temperatures remained inadequate, with staff and residents noting prolonged wait times for warm water and issues when the dishwasher was in use. The facility was seeking estimates for a new boiler due to a leak.
A facility failed to follow physician orders for a resident with multiple conditions, including osteomyelitis and pressure ulcers. The resident's care plan required specific wound care and limited time in a wheelchair, but records showed a lack of documented wound care for seven days and non-compliance with positioning orders. Observations and interviews revealed staff were unaware of the resident's restrictions, and the Wound Nurse admitted to not transcribing orders promptly.
A resident with intact cognition and complete dependency on staff for care was given a shower against her wishes, causing significant distress and pain. Despite expressing a preference for bed baths due to fear and discomfort with the mechanical lift, staff proceeded with the shower, leading to a deficiency in treating residents with dignity and respect.
The facility failed to maintain a sanitary kitchen, ensure proper disinfectant solution levels, label food appropriately, wear hair restraints correctly, and dispose of expired food items. Observations included residue on kitchen equipment, debris on the floor, expired milk in the refrigerator, and improper hair restraint use by staff.
The facility pharmacy failed to deliver medications in a timely fashion for four residents, resulting in missed doses of critical medications. Staff interviews confirmed frequent delivery issues, and the DON was aware of the problem.
The facility failed to properly manage the feeding tube care for a resident with no cognitive impairment, diagnosed with sarcoidosis of the lung, paraplegia, and pneumonia. Staff struggled with connecting the tubing to the pump, did not date the water bag and tubing, and failed to check the pump settings before exiting the room, resulting in incorrect feeding and flushing rates.
A resident with anxiety and other medical conditions did not receive prescribed Lorazepam for several days due to procedural and communication failures. Despite multiple requests and evident distress, the facility staff struggled to obtain the medication from the med bank and faced issues with the pharmacy and healthcare providers.
A resident with Multiple Sclerosis and other conditions fell and was injured after a CNA attempted to transfer her alone without using the required lift or gait belt, contrary to the care plan. The incident revealed inconsistencies among staff regarding the resident's transfer requirements and a lack of adherence to the care plan.
Staff Made Disrespectful Comment About Resident in Presence of Family
Penalty
Summary
A staff member failed to treat a resident with dignity and respect when an LPN made an inappropriate comment about a resident's condition in the presence of a family member. The incident occurred near the nurse's station, where the LPN instructed other staff to check on the resident to see if he was alive, not realizing a family member was present. The family member overheard the remark, found it unprofessional and unkind, and observed another employee attempting to signal the LPN to stop speaking. The family member identified themselves to the LPN and expressed concern about the disrespectful nature of the comment. The resident involved had multiple complex medical conditions, including pulmonary fibrosis, chronic respiratory failure with oxygen dependence, adult failure to thrive, peripheral vascular disease, diabetes, dementia, and was receiving hospice services. The resident's care plan included interventions for pain management and comfort. The LPN later acknowledged the comment was disrespectful and reported the incident to the on-call manager. The facility's policy requires all residents to be treated with dignity and respect, which was not upheld in this instance.
Failure to Ensure Smoking Safety for Resident with Substance Use History
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident with a history of poly substance overuse, specifically regarding smoking safety when under the influence. The resident, who had diagnoses including anxiety, asthma, and respiratory failure, was assessed as having intact cognition and was permitted to smoke independently per the facility's Smoking Program assessments and care plan. However, these assessments did not address the resident's safety when smoking while under the influence of substances. On the night in question, the resident returned to the facility after an outing with family and was observed to be intoxicated, loud, belligerent, and uncooperative. Despite staff interventions, the resident insisted on smoking independently on the patio for several hours, during which time he was in possession of alcohol and exhibited impaired judgment. Staff interviews revealed that the resident was not safe to smoke independently when intoxicated, with reports of him letting cigarettes burn down to his fingers and burning a hole in his jacket, although no injuries were documented. The facility's documentation and care planning did not address the increased risk associated with the resident's substance use and its impact on his ability to smoke safely. Staff recognized the resident's unsafe behaviors when under the influence, but the care plan and smoking assessments failed to include interventions or supervision requirements for these circumstances, resulting in a lack of adequate supervision and failure to mitigate accident hazards related to smoking.
Failure to Submit Accurate Agency Staffing Data
Penalty
Summary
The facility failed to submit accurate agency staffing data for the Payroll Based Journal (PBJ) Staffing Data Report for the first fiscal year 2025, which triggered a report for Excessively Low Weekend Staffing. Despite the Daily Nursing Staffing Schedules for September, October, and December 2024 showing a consistent number of staff during the week and weekends, an audit revealed that 20 agency staff were not submitted to the PBJ. The Administrator reported that the data submission for the PBJ and staffing reports were completed by the corporate office. It was later identified by the Administrator that twenty nursing staff from agencies were not included in the PBJ data, and the facility lacked a policy or procedure for the PBJ process.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to adhere to proper food labeling and dating procedures, as observed during a kitchen tour. Several food items, including apple sauce, cheese, cabbage, ranch dressing, breadsticks, biscuits, slider rolls, waffle fries, breaded fish fillets, vegetables, fruit-flavored cereal, and toasted flake cereal, were found open without any labels or dates in the refrigerator, freezer, and dry storage areas. Staff G confirmed that opened food items should have been labeled and dated, indicating a lapse in following the facility's food storage policy. The Dietary Manager acknowledged that it is expected for kitchen staff to label and date any opened food items, as per the facility's policy revised in December 2023. The policy outlines specific procedures for date marking dry storage, refrigerated, and freezer food items to ensure safe food storage. However, the observations during the survey revealed non-compliance with these procedures, potentially increasing the risk of foodborne illness among the facility's 66 residents.
Failure to Maintain Catheter Hygiene
Penalty
Summary
The facility failed to ensure proper care for residents with indwelling urinary catheters, specifically by not keeping catheter bags and tubing off the floor, which is necessary to minimize the risk of urinary tract infections. Resident #37, who has a neurogenic bladder and a history of urinary tract infections, was observed multiple times with the catheter bag and tubing resting on the floor. Despite the care plan's directive to keep the tubing off the floor, staff members, including a CNA and the Director of Nursing, were observed leaving the room without addressing the issue. Similarly, Resident #121, who has type 2 diabetes mellitus, benign prostatic hyperplasia, and obstructive uropathy, was also observed with the catheter bag and tubing on the floor on several occasions. Interviews with staff revealed a lack of consistent action to address the issue, with some staff members indicating they would report it to a nurse, while others stated they would expect the CNA to handle it. The facility's policy requires that catheter tubing be kept off the floor, but this was not adhered to, leading to the deficiency.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control protocols during the care of residents with specific medical needs. For Resident #2, who has a colostomy and paraplegia, the staff did not perform hand hygiene before, during, or after changing the colostomy bag and wafer. This was observed when a Licensed Practical Nurse (LPN) changed the colostomy bag without washing hands after removing gloves and before putting on new ones, despite the resident's care plan requiring Enhanced Barrier Precautions due to colonized multidrug-resistant organisms. In another instance, Resident #37, who is cognitively intact and has a neurogenic bladder, septicemia, and a urinary tract infection, did not receive proper wound care. A Registered Nurse (RN) was observed failing to perform hand hygiene or change gloves between cleaning the wound and applying treatment. This was contrary to the facility's policy, which mandates hand hygiene and glove changes during different stages of wound care. Additionally, the facility did not implement Enhanced Barrier Precautions for Resident #121, who has an indwelling urinary catheter. There was no signage indicating the need for such precautions, and staff did not wear gowns when providing care, despite the resident's care plan indicating the necessity for Enhanced Barrier Precautions. This oversight was acknowledged by staff, who were unaware of the requirement for gowns and gloves for this resident.
Inconsistent Water Temperatures Affect Resident Dignity
Penalty
Summary
The facility failed to provide dignified care to residents due to issues with water temperature in the showers, which unpredictably changed from a comfortable temperature to a cold temperature. This issue affected six residents who were reviewed for dignity. The problem was first reported to the facility Administrator on 11/12/24 by a resident, prompting the Administrator to contact a local plumbing company. The plumbing company identified that the 2nd floor central shower required a new cartridge, which was replaced on 11/15/24. However, subsequent water temperature checks by the State Agency on 11/20/24 revealed significant fluctuations, with temperatures ranging from 62.8 F to 112.4 F in various showers. Interviews with residents and staff highlighted ongoing issues with water temperatures. Residents reported refusing showers due to cold water and experiencing discomfort when the water temperature dropped during showers. Staff members confirmed that they had to run both the sink and shower simultaneously to achieve a warmer temperature, and that the water temperature issues had persisted for several months. The Maintenance Director admitted that water temperatures had been a problem since he started working at the facility in January 2024, and that it was challenging to get service providers to address the issue promptly. Further observations and interviews on 11/26/24 showed continued problems with water temperatures, with some showers taking up to 15 minutes to reach a suitable temperature. Staff members reported that the best time to shower residents was before breakfast, as the water temperature was more likely to be warm. The Maintenance Director also revealed that water temperature logs for the 2nd floor were not consistently recorded, and a staff member responsible for maintenance had never taken water temperatures or been instructed to do so.
Deficiency in Maintaining Shower Water Temperatures
Penalty
Summary
The facility failed to maintain essential equipment in acceptable operating condition, specifically regarding the water temperatures in resident showers. The deficiency was identified when a resident reported that the shower water was not hot enough. The facility's Administrator contacted a local plumbing company, which identified that a new cartridge was needed for the central shower on the 2nd floor. Despite the replacement of the cartridge, water temperatures remained below the required range of 110 to 120 degrees Fahrenheit. Observations and interviews revealed that the water temperatures fluctuated significantly and did not reach the required levels, particularly on the 2nd floor. Staff interviews indicated that the water temperature issue had been ongoing since January 2024, and it was difficult to get service providers to address the problem promptly. Maintenance logs showed that water temperatures for the 2nd floor showers were not recorded, and staff had to run both the sink and shower simultaneously to increase the water temperature. Residents and staff reported that the water had to run for extended periods to become warm enough, and the dishwasher's operation affected the availability of hot water for showers. The facility was in the process of obtaining estimates for a new boiler due to a leak in the current one, as identified by another plumbing company.
Failure to Follow Physician Orders for Wound Care and Positioning
Penalty
Summary
The facility failed to adhere to physician orders for wound care and positioning for a resident diagnosed with multiple conditions, including osteomyelitis, hypertension, peripheral vascular disease, paraplegia, and hemiplegia. The resident was assessed as being at risk for developing pressure ulcers and had two Stage 4 pressure ulcers. The care plan included interventions such as administering treatment per physician orders and limiting time in a chair to one hour or less, with repositioning every 30 minutes. However, the Treatment Administration Record showed no documented wound care for the left ischial pressure ulcer for seven days, and the directive to limit chair time was not included in the treatment orders. Observations and interviews revealed that the resident was left in a wheelchair for longer than the recommended time, and staff were unaware of the restrictions on the resident's time in the wheelchair. The resident expressed that he was supposed to be in bed and not up for more than 30 minutes, but he could not access his call light. Staff interviews indicated a lack of awareness and communication regarding the resident's care plan and physician orders. The facility's Wound Nurse acknowledged that the physician orders for wound care had not been transcribed in a timely manner.
Failure to Respect Resident's Right to Refuse Shower
Penalty
Summary
The facility failed to honor a resident's right to refuse a shower, leading to a deficiency in treating residents with dignity and respect. The resident, who had intact cognition and was completely dependent on staff for personal care, expressed a clear preference for bed baths due to pain and fear associated with being lifted. Despite this, staff proceeded to give the resident a shower using a mechanical lift, causing the resident significant distress and pain. The incident occurred when staff decided that a shower was necessary after the resident was incontinent. Although the resident initially did not object, she began to scream and express discomfort once lifted into the air. Staff did not offer to stop the shower or provide an alternative, such as a bed bath, despite the resident's protests. The resident's distress was evident as she yelled profanities and later reported feeling degraded during the shower process. Interviews with staff and the resident's Power of Attorney confirmed that the resident's wishes were not respected, and the incident caused her mental distress. The Director of Nursing and the Administrator were initially unaware of the issue, but the resident had already contacted the Elder Abuse hotline. The facility's failure to respect the resident's autonomy and address her pain and fear during the shower process led to the deficiency finding.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen, ensure the disinfectant solution was within the proper test range, label food appropriately for storage, wear hair restraints appropriately, and dispose of expired food items. During an initial tour of the kitchen, surveyors observed significant cleanliness issues, including black/brown residue on the Vulcan stove, debris on the kitchen floor, and white debris in the Hoshizaki ice machine. The Dietary Director was unable to achieve a proper sanitizer test reading, indicating potential issues with the sanitizer solution or test strips. Additionally, the Frigidaire refrigerator in the kitchenette contained expired milk and an uncovered plastic container with cake that was not dated. Staff K was observed with a long braid that repeatedly fell out of the hair restraint while plating food, further compromising kitchen sanitation. The Dietary Director admitted that equipment such as the stove top, ice machine, and ovens should be cleaned at least once a week, with a deep cleaning schedule occurring once a month. However, the cleaning chart was not signed off to show tasks had been completed. The Dietary Director also acknowledged that there was no clear designation of responsibility for checking the kitchenette refrigerators for outdated items. Facility policies indicated that sanitizing solutions should be tested daily and changed according to manufacturer instructions, and that a cleaning schedule should be posted and validated by the Director of Food and Nutrition Services. These policies were not adhered to, leading to the observed deficiencies.
Pharmacy Delivery Failures
Penalty
Summary
The facility pharmacy failed to deliver medications ordered to the facility in a timely fashion for four residents. Resident #47 did not receive ticagrelor, a medication to prevent blood clots, as it was unavailable on 4/25/24. The MAR directed to see Nurses Notes, which confirmed the medication was not available. Staff interviews revealed that the pharmacy often failed to deliver medications on time, and the Director of Nursing (DON) was aware of the issue but it persisted nonetheless. Resident #70, admitted on 4/27/24, did not receive five scheduled bedtime medications, including antipsychotics, cholesterol medication, heart medication, eye drops, and an antidepressant, due to delays from the pharmacy. Staff interviews confirmed that the pharmacy frequently failed to deliver medications, citing reasons such as needing a prescription or it being too soon to replace the medication. The DON was also aware of these issues. Resident #22, admitted on 3/29/24, did not receive Lyrica, an antiseizure medication, for six days, resulting in ten missed doses. The medication was repeatedly reported as unavailable, and the pharmacy was notified multiple times. Resident #30, who had COPD and other conditions, did not receive his inhalers on 4/19/24 and 4/20/24, marked as unavailable and held, respectively. The DON confirmed knowledge of delivery difficulties related to the pharmacy. The facility's policy on medication administration aimed to ensure safe and accurate preparation and administration of medications, but it was not followed effectively in these cases.
Feeding Tube Management Deficiency
Penalty
Summary
The facility failed to properly manage the feeding tube care for a resident with no cognitive impairment, diagnosed with sarcoidosis of the lung, paraplegia, and pneumonia. The resident's care plan required nutrition through a PEG tube due to dysphagia. During an observation, staff failed to date the water bag and tubing, struggled to connect the tubing to the pump, and did not ask for assistance. The Director of Nursing (DON) had to intervene multiple times. Ultimately, the staff failed to check the settings on the pump before exiting the room, resulting in incorrect settings for the feeding and flushing rates. Staff interviews revealed that the LPN responsible for the feeding tube care was inexperienced and did not seek help when needed. The DON acknowledged that staff should have contacted someone for assistance and verified the pump settings before leaving the room. The facility's policy on enteral tube feedings required verification of physician orders, proper labeling, and checking for patency, which were not followed in this instance.
Failure to Administer Prescribed Lorazepam
Penalty
Summary
The facility failed to obtain a physician order to provide Lorazepam for a resident, leading to a deficiency in medication administration. Resident #30, who had a BIMS score of 15 indicating intact cognitive status, was diagnosed with Atrial Fibrillation, Peripheral Vascular Disease, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease. The resident reported difficulty in receiving Lorazepam after being discharged from hospice services, which caused significant anxiety and fear of sleeping due to breathing issues. Despite multiple requests and evident distress, the resident did not receive the medication for several days. The care plan for Resident #30 included administering psychoactive medications as ordered and monitoring for adverse reactions. However, a review of the Medication Administration Records (MARs) showed that the prescribed Lorazepam was not administered as required. Progress notes indicated that the facility staff struggled to obtain the medication from the med bank and faced communication issues with the pharmacy and healthcare providers. The resident's primary care physician eventually provided a prescription, but there was a delay in administration. Observations and interviews revealed that staff were aware of the resident's need for Lorazepam but were unable to provide it due to procedural and communication failures. The Director of Nursing acknowledged that the nurse should have verified the active order and contacted the provider for the correct dose to pull from the med bank. The facility's policy on medication administration did not address the process for obtaining medication from the med bank if not ordered, contributing to the deficiency in care for Resident #30.
Failure to Follow Care Plan and Provide Adequate Supervision
Penalty
Summary
The facility failed to follow the care plan for Resident #55, who was identified as cognitively intact with a BIMS score of 15 and had diagnoses including Diabetes Mellitus, Multiple Sclerosis, and Depression. The care plan specified that Resident #55 required assistance with transfers using a stand lift due to immobility and impaired range of motion. However, on 3/29/24, Staff F, a CNA, transferred Resident #55 without assistance, without using a lift or gait belt, and attempted to transfer the resident to an unlocked wheelchair, resulting in a fall. Resident #55 fell on her knees and hit her head on the bottom of a tray table, causing a red mark on her left cheek from a crystal rock that fell off the bedside table during the fall. Interviews with various staff members revealed inconsistencies in their understanding of the care plan for Resident #55's transfers. Some staff believed the resident required a Hoyer lift with the assistance of two staff members, while others thought a stand lift or a gait belt with one staff member was sufficient. Staff F admitted to not having a gait belt and attempting the transfer alone because the other CNA had left before the second shift arrived. The incident report and subsequent interviews confirmed that the care plan was not followed, and the care plan was not updated with new interventions after the fall. The Director of Nursing confirmed that the fall could have been prevented if the staff had checked the Kardex on the electronic record and followed the care plan, which required two staff members and the use of a lift. The investigation revealed that Staff F did not use the required equipment or seek assistance, leading to the fall and injury of Resident #55. The facility's failure to adhere to the care plan and provide adequate supervision resulted in the resident's fall and injury.
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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