Harmony House Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterloo, Iowa.
- Location
- 2950 West Shaulis Road, Waterloo, Iowa 50701
- CMS Provider Number
- 165152
- Inspections on file
- 22
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 24 (2 serious)
Citation history
Health deficiencies cited at Harmony House Health Care Center during CMS and state inspections, most recent first.
A resident who was NPO with all nutrition provided via enteral tube feeding experienced significant, unexplained weight loss while the facility failed to follow care plan interventions and its change-in-condition policy. The resident had multiple chronic conditions, including muscular dystrophy, diabetes, and malnutrition, and was ordered tube feedings several times per day, but frequently refused scheduled feedings without consistent notification to the physician or RD as expected. The facility reduced the tube feeding frequency from five times to two times per day, substantially lowering daily intake, without documented physician orders or indication and without informing the RD. Weight records showed a marked decline over time, while the RD later reported not being notified of the refusals or the feeding reduction, and the facility’s policy requiring consultation and notification for significant status changes and treatment alterations was not followed.
The facility failed to respond promptly to resident call lights and an essential medical alarm, resulting in repeated, prolonged delays in assistance. One resident with impaired cognition, myotonic muscular dystrophy, diabetes, and malnutrition experienced multiple call light waits ranging from about 18 minutes to over an hour, despite a care plan requiring assistance with ADLs and ready access to the call light. Another cognitively intact resident, dependent for toileting and transfers and diagnosed with DM2, anxiety, depression, chronic respiratory failure with hypoxia, and asthma, reported staff turned off her call light and left after she had waited over an hour, and call light logs showed numerous waits of 30–50+ minutes, including one lasting nearly 2 hours. A third cognitively intact resident with DM, arthritis, anxiety, depression, PTSD, asthma, and intellectual disabilities, at risk for falls and with bladder incontinence, reported having a call light on for 2 hours without response and needing a roommate to press the call light because hers was out of reach; logs showed waits of 36 and 51 minutes. Additionally, a resident dependent on tube feeding had a feeding pump alarm sounding continuously for close to an hour while multiple staff, including housekeeping, other staff, the DON, and an LPN, did not respond until prompted by a surveyor, and the facility lacked a written policy on timely call light response.
Staff failed to consistently communicate with residents in a dignified and respectful manner. One resident with a tracheostomy and intact cognition reported that an RT performed suctioning roughly, instilled saline while he was talking causing choking and gagging, and then spoke in a mocking way about his complaint in the hallway within his hearing. Another resident with myotonic muscular dystrophy and chronic respiratory failure, who used a communication board, was not care planned for impaired communication and was brought to tears when an RT entered the room and spoke in a rude tone asking what was wanted. A third resident with severe cognitive impairment and traumatic brain injury was observed waiting in a wheelchair for a bath when a staff member mimicked his exhalation and made sarcastic remarks about how terrible life was, rather than interacting respectfully.
A cognitively intact resident with paraplegia, seizure disorder, respiratory failure, malnutrition, MDD, antisocial personality disorder, and PTSD alleged physical abuse by a respiratory therapist. Although staff reported promptly notifying leadership and obtaining written statements, the facility’s investigation file contained only limited, unsigned statements and lacked the original witness and resident statements, as well as documentation of additional resident and staff interviews that were later identified. Despite concluding there was no evidence to support the allegation, the facility failed to maintain complete, signed documentation and supporting materials as required for a thorough abuse investigation under its own policy.
The facility failed to ensure medications were administered and documented as ordered for multiple residents with complex neurological, respiratory, and systemic conditions. One resident with a seizure disorder and tube feeding had repeated undocumented or missed doses of Keppra, Baclofen, and famotidine over two months, confirmed by MAR gaps and medication event reports. Another resident with TBI, quadriplegia, and a trach had missing documentation for scheduled ipratropium‑albuterol treatments and was found with morning doses of glycopyrrolate and Baclofen still in the medication card, indicating they were not given by agency staff. A third resident with myotonic muscular dystrophy, diabetes, and malnutrition had MAR entries showing bedtime medications as given, but staff later discovered Midodrine, Eliquis, escitalopram, and quetiapine doses still in the card. Staff interviews and documentation confirmed that nurses found medications not given on prior shifts, and leadership acknowledged MAR gaps and the absence of a policy guiding medication administration.
The facility failed to ensure that dependent residents received regular baths or showers as outlined in their care plans and facility policy. One cognitively intact resident with multiple serious medical conditions reported not receiving showers for a week, and records for the month showed only one documented shower and one refusal. Another resident with impaired decision-making, myotonic muscular dystrophy, diabetes, and malnutrition had only one shower documented for the month, with several days left blank and several days noted as no shower given, despite a care plan requiring assistance with bathing and a stated preference for bed baths. Staff interviews linked missed showers to reduced staffing ratios, and the DON acknowledged that completion of baths and showers needed improvement, despite an expectation of twice-weekly bathing and a policy requiring EHR documentation.
Two residents experienced significant changes in condition that were not promptly recognized or reported to a provider. One resident with atrial fibrillation and functional dependence returned from a CT scan, after which the guardian reported possible lung blood clots; a nurse documented low pulse ox requiring O2 but did not immediately notify a provider, and treatment for a confirmed PE was delayed for two days. Another resident with paraplegia, seizure disorder, CAD, and respiratory failure had two prolonged unresponsive episodes with abnormal respirations during transfers, followed by recurrent dizziness and a BP of 60/40 with position changes; these events were not documented by nursing, no timely physician notification occurred, and the care plan lacked interventions for orthostatic hypotension or unresponsive episodes.
A resident with intact cognition but a history of TBI, aphasia, and seizure disorder was care planned as a dependent smoker requiring staff assistance to designated smoking areas and supervision while smoking, and had an elopement risk score indicating a risk to wander. The facility failed to complete required annual updates to the resident’s smoking and elopement risk assessments and did not perform any additional assessments after the initial ones. On one occasion, a nurse took the resident outside, lit a cigarette, and then left the resident unattended, contrary to the Care Plan and the facility’s smoking policy, which required supervision for dependent smokers. The incident was reported via a grievance, but there was no corresponding documentation in the resident’s EHR describing the occurrence.
The facility failed to follow physician orders and ensure complete documentation for tube feeding care for two residents. One resident with neurological impairments and dysphagia, dependent on G-tube feeding and NPO, had multiple undocumented enteral feedings, water flushes, residual checks, and pre- and post-medication water administrations across several shifts, with staff acknowledging awareness of missed feedings and incomplete audits. Another resident dependent on tube feeding for hydration had no ordered water flush amount on the MAR for medication administration; during an observed med pass, an RN relied on the DON’s statement of a "standard" 60 cc flush before and after medications, despite no written order and no clear facility policy guiding medication administration via feeding tube.
A resident with intact cognition, multiple medical and psychiatric diagnoses, and a history of substance overuse was admitted to hospice with an order for lorazepam concentrate 2 mg/mL at 0.25 mL every 2 hours PRN for anxiety or restlessness. An MDS coordinator, who was also working as a floor nurse, transcribed the order into the EHR as 0.5 mL every 2 hours PRN without a second-nurse double-check and later administered 0.5 mL, which was later identified as an incorrect dose. The MAR showed multiple administrations of lorazepam under this incorrect order by various staff, and the facility could not produce a controlled substance log for the lorazepam, despite leadership expectations that such a log be initiated and completed with each administration and the absence of formal written medication administration policies beyond the general "6 rights."
A resident on hospice with paraplegia, seizure disorder, respiratory failure, malnutrition, and cachexia had comfort-medication orders for low-dose morphine and lorazepam concentrates. When these orders were entered into the EHR, the morphine dose was incorrectly transcribed as 2 mL q2h PRN instead of 0.25 mL, and the lorazepam dose was doubled to 0.5 mL q2h PRN. Nursing staff then administered morphine and lorazepam according to the erroneous MAR, including a documented 2 mL morphine dose and multiple 0.5 mL lorazepam doses, while a narcotic log for lorazepam was not found. One RN reported feeling rushed and not having a second nurse double-check the transcription, and another RN administered the higher morphine dose without first verifying against the controlled substance log, discovering the discrepancy only after the medication was given.
A resident with hemiplegia and limited mobility, who communicated needs by moving his right foot, did not have his call light within reach as required by facility policy. Observations and staff interviews confirmed the call light was not consistently positioned by the resident's right foot, and care documentation lacked instructions for proper placement.
Two residents were not properly notified when their Medicare Part A SNF coverage ended and they remained in the facility, as the required SNF Advance Beneficiary Notice of Non-Coverage (ABN) was not provided. Although the NOMNC was given, documentation and staff interviews confirmed that residents were not informed of their financial responsibility for continued services, and the facility lacked a policy for such notifications.
The facility did not consistently answer call lights within the expected timeframe, as shown by call light system data and resident interviews. Several residents, including those with both intact and impaired cognition, experienced significant delays—sometimes over an hour—before staff responded to their requests for assistance, despite facility policy requiring timely response.
A cook at the facility was observed preparing and serving food without washing hands and using the same glove to handle multiple food items, contrary to FDA 2022 Food Code guidelines. This improper technique affected several residents during meal service. The CDM expected staff to use tongs and avoid touching food with contaminated gloves, but the facility lacked a specific food handling policy.
A facility failed to provide adequate PPE for a resident in COVID-19 isolation, leading to improper use by staff. A resident with severe cognitive loss and multiple health conditions was placed in isolation, but staff lacked sufficient face shields, resulting in inadequate eye protection. Staff interviews revealed inconsistencies in PPE protocol understanding. Additionally, clean laundry was transported uncovered, and a contaminated fan blew onto clean clothes, indicating gaps in infection control practices.
The facility failed to treat residents with respect and dignity, as evidenced by a resident being left without sheets and staff using loud voices and profanity in the presence of residents. A CNA initially dismissed a resident's concern about missing sheets, later assisting without further communication. Additionally, staff were reported to have used profanity near residents, making them uncomfortable.
The facility did not ensure that a Registered Nurse held a current and valid license, as required by state laws. Staff F continued to work in nursing roles after their license expired, which was not detected due to an oversight in the facility's license tracking system. The Administrator and DON acknowledged the lapse, and Staff F admitted to missing the renewal notification.
Failure to Maintain Nutritional Status and Notify Physician/RD of Significant Weight Loss and Tube Feeding Changes
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s nutritional status and follow care plan interventions and policy regarding significant weight changes and treatment alterations. The resident had moderately impaired cognitive skills and diagnoses including myotonic muscular dystrophy, diabetes mellitus, and malnutrition, and was NPO with all nutrition provided via enteral tube feeding. The care plan directed staff to provide the ordered NPO diet, monitor weights, and notify the physician and Dietitian of significant weight changes, and identified that the resident had tube feedings related to gastrostomy status with a goal to tolerate feedings and remain free of complications. An intervention noted that the resident might refuse feedings. The Dietitian’s nutrition assessment documented that the resident’s enteral feeding provided all nutrition and recommended increasing the feeding volume from 240 mL to 250 mL five times per day and increasing water flushes due to the resident being below estimated needs. The MAR for February showed an order for enteral feedings of 250 mL five times daily with water flushes, which was discontinued later in the month. During that period, the resident refused multiple scheduled tube feedings, particularly at the 10:00 AM, 6:00 PM, and 10:00 PM times. Despite these frequent refusals, there was no documented notification to the physician or Dietitian as required by the care plan and as expected by the DON when refusals occurred more than twice. On 2/26, the enteral feeding regimen was reduced to 300 mL twice daily, significantly decreasing the total daily volume, and this order was later discontinued and then restarted in March, without documentation of a physician’s order or indication for the reduction. The resident’s recorded weights showed a decline from 130 pounds in early January to 121.1 pounds in mid-February and 119.5 pounds in late March, representing a significant, unexplained weight loss. The Dietitian reported not being informed of the frequent refusals of tube feedings in February or of the reduction in feedings to twice per day, and could not find an order or indication from the physician for this change. The facility’s policy on Notification for Change in Condition required immediate consultation with the physician and notification of significant changes in status and significant alterations in treatment, but this was not followed in relation to the resident’s weight loss and feeding regimen changes.
Failure to Respond Timely to Call Lights and Tube Feeding Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide timely responses to resident call lights and alarms, resulting in prolonged wait times for assistance. For one resident with moderately impaired cognition, myotonic muscular dystrophy, diabetes mellitus, and malnutrition, the care plan required assistance with ADLs and keeping the call light within reach due to fall risk. Despite this, call light log data showed multiple instances where this resident’s calls were not answered for extended periods, including waits of 46 minutes, 37 minutes, 27 minutes, 18–19 minutes, and one episode lasting 1 hour and 21 minutes. The resident reported that it took up to 2 hours for someone to answer her call light, and a CNA reported observing this resident’s call light on for over an hour during an overnight shift without staff notifying the nurse on duty. Another resident, cognitively intact but dependent on staff for toileting hygiene, bed mobility, and transfers, with diagnoses including type 2 diabetes mellitus, anxiety, depression, chronic respiratory failure with hypoxia, and asthma, also experienced prolonged call light response times. This resident’s care plan required assistance with ADLs and keeping the call light within reach due to fall risk. The grievance log documented that the resident reported staff refused to lay her down, turned off the call light, and left, after she had her call light on for over an hour. Call light logs showed multiple delays for this resident, including waits of approximately 33 minutes, 56 minutes, 32–33 minutes, 31 minutes, 20 minutes, 29 minutes, and one episode of 1 hour and 47 minutes before the call was answered. A third cognitively intact resident with diabetes, arthritis, anxiety, depression, PTSD, asthma, and intellectual disabilities, who was at risk for falls and had occasional bladder incontinence, also reported unaddressed call lights. This resident’s care plan required that the call light be kept within reach. The grievance log recorded that from 1:00 AM to 3:00 AM the resident had her call light on and no one answered, and that she had to ask her roommate to press the call light because her own was not within reach. Call light logs for this resident showed waits of 51 minutes and 36 minutes. In addition, a resident with paraplegia, seizure disorder, CAD, respiratory failure, malnutrition, and dependence on a feeding tube for more than half of daily calories and fluids had a tube feeding pump alarm sounding continuously for nearly an hour. Multiple staff, including housekeeping, another staff member, the DON, and an LPN, passed by or were present in the hallway without responding to the audible alarm until the surveyor alerted the LPN, who then identified an occlusion-related cassette error on the pump. The facility did not have a written policy to ensure timely call light response, and the DON acknowledged that residents had complained about call light wait times and that some documented waits were too long.
Failure to Ensure Dignified and Respectful Communication With Residents
Penalty
Summary
The deficiency involves failures to honor residents’ rights to dignity, respectful communication, and self-determination. One resident with intact cognition, paraplegia, respiratory failure, seizure disorder, malnutrition, and significant psychosocial diagnoses (MDD, antisocial personality disorder, PTSD) reported that a respiratory therapist (Staff G) suctioned his tracheostomy in a way he perceived as rough and distressing. He stated that Staff G instilled a large amount of saline into his tracheostomy tube while he was talking, causing choking, coughing, and gagging, and that it felt as though she was trying to “shut him up” and “drown” him. After leaving his room, he reported hearing Staff G in the hallway, within his hearing distance, laughing and mocking his concern by repeating that he said she was going to drown him. Another respiratory therapist (Staff H) recalled the resident’s report that Staff G laughed with another staff member in the hallway about his concern, and an LPN (Staff A) confirmed that Staff G told her in the hallway that the resident had accused her of trying to drown or kill him, after which the resident began banging on the wall and yelling. A second resident with moderately impaired decision-making, myotonic muscular dystrophy, chronic respiratory failure with hypoxia, anxiety disorder, and MDD used a communication board but did not have this communication need or intervention identified in the care plan. When asked about concerns with Staff G, this resident nodded yes and spelled out “rude” on the communication board. A CNA (Staff J) reported witnessing Staff G enter this resident’s room and say, in a rude tone, “what do you want? As they were just in there,” which made the resident cry. The lack of care plan identification of the resident’s impaired communication and use of a communication board, combined with Staff G’s rude verbal interaction, demonstrated a failure to support and respect the resident’s communication needs and emotional well-being. A third resident with severe cognitive impairment (BIMS score of 4), traumatic brain injury, seizure disorder, and depression had a care plan noting impaired cognitive function and frustration when unable to express words, leading to cussing and yelling. During observation, this resident was seated in a wheelchair outside the shower room awaiting assistance for a bath and made a loud exhaling noise. A staff member at a nearby medication cart repeated the sound in a mocking manner and said to the resident, “life is so tough isn’t it, it’s so terrible.” The resident did not respond. These interactions, including mocking comments and conversations about residents within their hearing distance, were inconsistent with the facility’s policy requiring residents to be treated with dignity and respect and not to be laughed at or talked about within hearing distance.
Failure to Thoroughly Document and Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of physical abuse made by Resident #3 against a respiratory therapist (Staff G). Resident #3 had intact cognition with a BIMS score of 15 and multiple diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, major depressive disorder, antisocial personality disorder, and PTSD. The resident’s care plan emphasized psychosocial well-being, including interventions to assist the resident in processing feelings, verbalizing concerns, and validating and resolving complaints. Despite this, when Resident #3 alleged physical abuse by Staff G, the facility’s subsequent investigation did not fully document all relevant information and interviews. The facility’s self-reported incident documentation stated that, after completing interviews with Resident #3 and staff, there was no evidence to support the allegation and that Resident #3 reported feeling safe with Staff G and denied that Staff G was physically rough or provided care without explanation. However, the investigation file contained only limited written statements dated 2/22/26: an interview by Staff F (MDS coordinator) with Resident #3, an interview with Staff H that lacked Staff H’s signature, and an interview with Staff G by the DON that lacked Staff G’s signature. The investigation documentation omitted written witness statements that Staff H reported having written, as well as the original statement Staff H helped Resident #3 write, which Staff F reportedly took. The investigation also lacked documentation of interviews with three additional residents and three additional staff members whose names were later provided by the DON. Interviews with staff further highlighted gaps in the investigation record. Staff H confirmed that on the date of the incident they were working with Resident #3, received the abuse allegation against Staff G, immediately notified the administrator and Staff F, and wrote a witness statement before assisting Resident #3 in writing a statement with an LPN present. Staff F confirmed being notified of the allegation, coming into the facility, speaking with Staff H, the LPN, and Resident #3, and using Staff H’s written statement to write statements for both Staff H and Resident #3. Staff G confirmed being contacted by the DON about the alleged incident but reported no further contact from the facility. The facility’s abuse policy required timely, thorough, and objective investigations with documentation of the allegation and collection of supporting documents, but the investigation file lacked complete, signed statements and documentation of all resident and staff interviews referenced by the facility, resulting in a failure to maintain evidence that the allegation was thoroughly investigated.
Failure to Administer and Document Medications as Ordered for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to administer medications as ordered and failed to document administration for multiple residents. One resident with a history of traumatic cerebral hemorrhage, seizure disorder, dysarthria, anarthria, and dependence on tube feeding had multiple omissions or undocumented doses of famotidine, Keppra, and Baclofen across January and February. The Medication Administration Records (MARs) for this resident showed missing documentation for several scheduled doses of these medications on specific dates and times, and incident reports documented that staff discovered missed doses of Baclofen and Keppra for an evening shift and additional missed doses later in the month. Another resident with traumatic brain injury, traumatic brain dysfunction, quadriplegia, and severe cognitive impairment had missing documentation on the March MAR for ordered ipratropium‑albuterol nebulizer treatments via trach four times daily. A progress note documented that evening shift staff found the morning doses of glycopyrrolate and Baclofen still in the medication card, indicating they had not been given by agency staff. An incident report further documented that the facility attempted to contact the resident’s representative to update them about the missed medications. Staff interviews confirmed that nurses had found medications not given on prior shifts. A third resident with myotonic muscular dystrophy, diabetes mellitus, and malnutrition had a February MAR that indicated all bedtime medications were given on two consecutive days, but a subsequent health status note documented that staff later found evening and bedtime doses from one of those days still in the medication card. The missed medications included Midodrine, Eliquis, escitalopram, and quetiapine. An incident report described this as a medication event/missing medication. During interviews, the MDS coordinator acknowledged awareness that one resident had missed medications, and the DON acknowledged gaps on the MARs and stated that the facility followed the six rights of medication administration but lacked a policy directing staff how to administer medications.
Failure to Provide and Document Regular Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document weekly bathing or showers for dependent residents, as required by resident care plans and facility policy. One resident with intact cognition, respiratory failure, heart failure, morbid obesity with hypoventilation, and an MRSA infection required partial to moderate staff assistance with bathing and had a care plan directing staff to assist with baths or showers per schedule. This resident filed a grievance stating she was not getting showers and reported not having received one in a week. Electronic health records for the month reviewed showed only one documented shower and one refusal, with no other baths or showers recorded, despite the resident’s expressed concerns. Another resident with moderately impaired decision-making, myotonic muscular dystrophy, diabetes mellitus, and malnutrition also required assistance with ADLs and had a care plan directing staff to assist with scheduled baths or showers, later updated to note a preference for bed baths while still requiring staff to offer showers. For this resident, documentation for the month showed only one shower provided, multiple refusals, several days left blank, and several days explicitly documented as no shower given. Staff interviews revealed that since a decreased staff-to-resident ratio was implemented, residents had not been receiving showers, and staff reported residents going a week or more without a shower. The DON acknowledged that completion of resident baths and showers needed improvement and stated the expectation was two baths or showers per week, while facility policy required staff to document completed baths and showers in the EHR.
Failure to Recognize and Report Significant Changes in Condition for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to identify and act on significant changes in condition requiring timely physician notification for two residents. For one resident with atrial fibrillation, mild intellectual disability, and dependence on staff for ADLs and transfers, the resident was sent out for a CT scan and returned the same day. Progress notes documented that the paperwork from the scan could not be printed and that staff planned to follow up in a few days for faxed dictation. Later that day, the resident’s guardian called the facility reporting possible abnormal blood clot results in the lungs and requested an update. A nurse assessed the resident, found a low pulse oximetry reading, placed the resident on oxygen until the saturation normalized, and documented that the resident denied breathing or pain issues. The resident was then assisted to a wheelchair and taken to the dining room, with no incident or concerns noted at that time. Despite the guardian’s report of possible blood clots in the lungs and the documented low pulse ox requiring supplemental oxygen, there was no documented immediate physician notification or initiation of treatment on that day. Two days later, the MDS coordinator received a call from a provider with CT scan results confirming a pulmonary embolism and an order to send the resident to the ED, after which the resident returned on anticoagulant therapy. The medical director later stated he expected the facility to notify the provider as soon as they knew of the pulmonary embolism and confirmed there was a delay in treatment. Staff interviews indicated that the nurse who assessed the resident after the guardian’s call believed he needed to wait for documentation of the PE or a provider call to validate the PE, and another staff member reported it took two days to obtain treatment orders, noting that the DON did not check her voicemail regularly. For a second resident with intact cognition and diagnoses including paraplegia, seizure disorder, CAD, respiratory failure, and malnutrition, the respiratory therapist documented two separate episodes of unresponsiveness and dizziness during transfers on the same day. In the morning, during a bed-to-wheelchair transfer, the resident reported dizziness, then developed a fixed gaze and became unresponsive to verbal stimuli for about eight minutes, with respirations of 12–14 per minute, before gradually returning to baseline. In the late afternoon, during another transfer with nursing staff present, the resident again developed a blank stare lasting over 15 minutes, with slowed respirations of 7–8 per minute, grayish lips, no response to sternum rub, and nonreactive pinpoint pupils, before suddenly awakening and reporting thirst, dizziness, and hunger. The EHR contained no nursing documentation, assessment, or physician notification related to these unresponsive episodes. Subsequently, the respiratory therapist discussed the unresponsive episodes with the DON and they agreed to track the resident’s blood pressure during episodes. Later, the therapist documented that the resident reported a history of low blood pressure treated with medication at another facility and experienced dizziness and near-syncope when the head of the bed was elevated, requiring lowering of the bed angle. A blood pressure of 60/40 was recorded after the resident became lightheaded with positional change. Despite this severely low blood pressure and repeated dizziness with position changes, the EHR still lacked nursing documentation, assessment, or physician notification of these events on that date. The care plan, initiated earlier, did not identify or include interventions for orthostatic hypotension or unresponsive episodes during position changes. The facility’s own policy required immediate physician consultation and notification of the resident and representative for significant changes in status, including loss of consciousness, but this was not followed in these instances.
Failure to Supervise Dependent Smoker and Maintain Updated Safety Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide required supervision and maintain updated assessments for a resident identified as a dependent smoker with a risk of wandering. The resident’s MDS dated 1/20/26 showed a BIMS score of 15 (intact cognition) and diagnoses including traumatic brain injury, aphasia, and seizure disorder. A Care Plan focus initiated 10/21/24 documented that the resident used tobacco, with a goal to adhere to the smoking policy, and interventions specifying that a dependent smoker must be assisted to designated smoking areas at designated times and supervised while smoking. A smoking assessment dated 10/21/24 indicated the resident had cognitive loss and could not light a cigarette safely, and an elopement risk assessment on the same date showed a score of 9, indicating risk to wander. The electronic health record contained no additional smoking or elopement risk assessments after 10/21/24, despite the facility’s practice of completing these at admission and annually. On 1/4/26, a nurse took the resident outside to smoke, lit the cigarette, and then returned inside, leaving the resident unattended, contrary to the Care Plan directive that staff supervise the resident while smoking. A grievance reported to the Administrator on 1/5/26 described this event, and the Administrator and DON became aware that the resident had been left unsupervised while smoking. The facility’s grievance log referenced this concern, but the resident’s electronic health record lacked documentation related to the incident, such as a progress note or incident report, even though the DON stated staff must document any occurrence outside the resident’s plan of care. The facility’s smoking policy, revised January 2024, required determining whether a resident is an independent or dependent smoker before allowing smoking, and directed that dependent smokers be supervised while smoking and have their Care Plans updated with needed safety interventions, but the facility did not consistently follow these procedures for this resident.
Failure to Follow Tube Feeding Orders and Document Enteral Nutrition and Flushes
Penalty
Summary
The deficiency involves the facility’s failure to provide tube feeding care and related water flushes and residual checks according to physician orders and to ensure complete documentation for residents receiving enteral nutrition. For one resident with moderately impaired cognition, traumatic cerebral hemorrhage, seizure disorder, dysarthria, anarthria, and dysphagia requiring G-tube feeding and NPO status, the care plan directed enteral nutrition as ordered. The January and February MARs contained orders for Fibersource HN 375 ml four times daily as a nutritional supplement, 150 ml water flushes with each feeding, residual checks of 5–20 ml prior to every medication pass or feeding each shift, and 60 ml water before and after medications every shift. Surveyors found multiple instances across January and February where feedings, water flushes, residual checks, and pre- and post-medication water administrations were not documented as completed. The clinical record review showed specific missed documentation dates and times for this resident’s tube feedings and associated water flushes, including several lunch and hour-of-sleep doses in January and mid-afternoon and evening doses in February. Residual checks and 60 ml water flushes before and after medications were also not documented on multiple shifts. The Medical Director acknowledged awareness that the resident missed a few feedings and confirmed the expectation that staff follow provider orders as written. An LPN and the MDS Coordinator both reported knowing that the resident had missed some feedings, and the MDS Coordinator stated that if it is not documented, it is not done and that audits were not completed, confirming gaps in both performance and documentation of ordered enteral nutrition and hydration. For a second resident with intact cognition and diagnoses including stroke, heart failure, hypertension, diabetes mellitus, and dependence on tube feeding for nutrition and hydration, the care plan directed flushing the feeding tube as ordered. However, the March MAR did not specify the amount of water to flush the feeding tube before and after medication administration. During an observed medication pass, an RN asked the DON about the required flush amount; the DON left the room and returned stating that 60 cc of water should be used before and after medications, describing this as the standard amount, despite no corresponding order on the MAR. The RN and DON then administered 60 cc water flushes based on this verbal direction. The ADON confirmed she did not see an order for the water flush amount, and the DON acknowledged the lack of a policy directing staff on how to administer medications via tube feeding, while the existing enteral feeding policy only addressed verifying physician orders for formula, rate, and frequency.
Failure to Maintain Controlled Substance Records and Accurate Lorazepam Dosing
Penalty
Summary
The deficiency involves the facility’s failure to maintain required controlled substance records for lorazepam administered to one resident and to ensure accurate transcription and dosing of that medication. The resident had intact cognition with a BIMS score of 15 and diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, major depressive disorder, antisocial personality disorder, PTSD, and a history of substance overuse. The care plan directed staff to administer medications as ordered, remain non-judgmental, monitor for behavioral changes, increase supervision as needed, and conduct medication review with pharmacy per facility protocol. Hospice admission orders for lorazepam concentrate 2 mg/mL directed 0.25 mL (0.5 mg) by mouth/sublingual every 2 hours as needed for anxiety or restlessness. However, when the order was entered into the EHR, it was transcribed as lorazepam oral concentrate 2 mg/mL, 0.5 mL by mouth every 2 hours as needed, and this order remained active until it was discontinued several days later. The March MAR showed multiple administrations of lorazepam under the incorrectly transcribed order by various staff on several dates and times. The facility was unable to locate a controlled substance log for the resident’s lorazepam solution, despite the expectation that a controlled substance log be initiated and completed with each administration. The MDS Coordinator reported she transcribed the lorazepam order while working as a floor nurse, was in a rush, did not have another nurse double-check the order, and administered 0.5 mL of lorazepam, later identified as an incorrect dosage. The DON stated that nurses were expected to administer medications as ordered and double-check orders with another nurse, and that a controlled substance log should be used for lorazepam. The Administrator reported there were no written policies and procedures for medication administration and that the facility followed the general “6 rights” of medication administration.
Transcription and Dosing Errors for Morphine and Lorazepam
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and administer physician orders for two controlled substances, morphine sulfate concentrate and lorazepam concentrate, resulting in a resident receiving significantly higher doses than ordered. The resident had intact cognition with a BIMS score of 15 and diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, and cachexia. Hospice admission orders dated 3/6/26, noted by the facility on 3/7/26, specified morphine sulfate concentrate 20 mg/mL at 0.25 mL (5 mg) by mouth/sublingual every 2 hours as needed for pain or shortness of breath, and lorazepam concentrate 2 mg/mL at 0.25 mL (0.5 mg) by mouth/sublingual every 2 hours as needed for anxiety or restlessness. However, when the orders were entered into the EHR on 3/7/26, the morphine order was transcribed as morphine sulfate concentrate 100 mg/5 mL with instructions to give 2 mL by mouth every 2 hours as needed, and the lorazepam order was transcribed as 0.5 mL every 2 hours as needed, doubling the intended lorazepam dose. The EHR and MAR reflected these incorrect orders, and nursing staff administered medications according to the erroneous entries. On 3/8/26 at 1:11 AM, a nurse (Staff A) documented administering morphine concentrate 100 mg/5 mL, 2 mL, for a reported pain level of 8. The controlled substance log for morphine showed that earlier doses had been logged as 0.25 mL, but at 1:12 AM on 3/8/26, 2 mL was dispensed, reducing the remaining amount from 29.5 mL to 27.5 mL. The resident’s MAR also showed multiple administrations of lorazepam oral concentrate 2 mg/mL at 0.5 mL every 2 hours as needed for anxiety or restlessness, which was twice the ordered 0.25 mL dose, and the facility was unable to locate a controlled substance log for the lorazepam solution. An encounter note later documented that, due to the transcription error, the MAR listed morphine as 2 mL every 2 hours as needed and that the resident received lorazepam 1 mg every 2 hours instead of the intended 0.5 mg. Staff interviews further clarified the actions and inactions that led to the medication errors. Staff F, the MDS Coordinator, stated she entered the morphine and lorazepam orders into the EHR on 3/7/26 and acknowledged that she felt pressured to enter the orders quickly while also working as a floor nurse, and no second nurse double-checked her work. Staff A reported that on the night of the incident, she checked the doctor’s orders and MAR, both of which showed a 2 mL morphine dose, and administered that dose without first checking the controlled substance log. She stated she questioned the high dose given the resident’s recent hospice admission and thin condition but could not locate the original hospice orders. Only after returning to sign out the narcotic in the controlled substance log did she notice that the previous dose had been 0.25 mL, revealing the error. The DON stated that nurses were expected to administer medications as ordered and double-check orders with another nurse, while the Administrator reported there were no written policies and procedures for medication administration, and that the facility followed the general “6 rights” of medication administration.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with significant physical limitations had their call light within reach at all times, as required by facility policy. The resident had a history of cerebral vascular accident (CVA) with hemiplegia affecting both sides, limited range of motion in all extremities, and was dependent on staff for bed mobility and transfers. The resident communicated basic needs by moving his right foot or leg, as documented in his care plan. However, the care plan and Kardex did not provide specific instructions regarding the use or placement of an adaptive call light for this resident. Observations revealed that the resident's call light was not consistently placed within his reach. On one occasion, the call light was found on the resident's lower left side, out of reach, and the resident was observed to be cold but unable to call for assistance. Staff interviews confirmed that the call light should have been positioned next to the resident's right foot, which was his method of communication. The Director of Nursing also verified that the Kardex lacked information about the call light placement, and the facility's policy required call lights to be within reach for residents who could use them.
Failure to Provide Required Notification of Medicare Coverage Changes
Penalty
Summary
The facility failed to notify residents or their responsible parties when there was a change in their level of care and services, specifically when Medicare Part A skilled nursing facility (SNF) coverage ended and the residents remained in the facility. For two residents, the facility initiated discharge from Medicare Part A services while benefit days remained, but did not provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). Although the Notice of Medicare Non-Coverage (NOMNC) was provided, there was no documentation that the SNF ABN was given to inform the residents of their financial responsibility for continued services. Staff interviews revealed that the person responsible for providing these notifications had not received proper training and was under the impression that the SNF ABN was not necessary if the resident had Medicaid as a payor source. Additionally, the facility was unable to provide a policy related to the notification of services to residents or their representatives. Facility records and progress notes lacked documentation that the required notifications were given, resulting in residents not being properly informed of their potential liability for services not covered by Medicare.
Failure to Timely Respond to Resident Call Lights
Penalty
Summary
The facility failed to consistently answer resident call lights in a timely manner, as required by policy and regulatory standards. Multiple resident interviews revealed that call lights were often not answered within 15 minutes, with one resident reporting frequent delays and another stating they had to wait over an hour for assistance while on the commode. Call light system reports for several rooms over a one-week period documented numerous instances where response times exceeded 15 minutes, with some calls going unanswered for over an hour. The average response times for certain rooms ranged from 11 minutes to over 1.5 hours, far exceeding the facility's expectations for timely response. Residents involved had varying levels of cognitive function, as indicated by their BIMS scores, with some having intact cognition and others moderate impairment. Staff interviews confirmed that call lights should be answered promptly and that staff are expected to monitor call light notifications on their mobile devices. Facility policy requires call lights to be answered in a timely manner, but documented response times and resident reports indicate this standard was not consistently met during the review period.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to proper food handling practices as outlined by the FDA 2022 Food Code, resulting in a deficiency. During an observation, Staff A, a cook, was seen preparing and serving food without washing her hands and using the same glove to handle multiple food items. Specifically, Staff A used her right gloved hand to touch a bun, scoop macaroni salad, and prepare fish sandwiches for residents. This improper technique was used to serve four residents, identified as Residents #9, #13, #22, and #31, in the main dining room. Additionally, Staff A had already served fish sandwiches to residents in the A wing dining room before being corrected by the Certified Dietary Manager (CDM). The CDM later reported that she expected dietary staff to use tongs and avoid touching food with gloves that had contacted other items. Despite this expectation, the facility did not have a specific food handling policy in place, relying instead on the most up-to-date food code. The FDA 2022 Food Code specifies that food employees must wash their hands and use suitable utensils to prevent contamination from hands. The incident highlights a lapse in following these guidelines, as observed during the meal service.
Inadequate PPE and Laundry Handling in COVID-19 Isolation
Penalty
Summary
The facility failed to maintain an adequate supply of personal protective equipment (PPE) for a resident in COVID-19 isolation, leading to improper use of PPE by staff. Resident #146, who had severe cognitive loss and multiple health conditions, tested positive for COVID-19 and was placed in isolation. However, the facility did not provide sufficient face shields for staff entering the isolation room, resulting in staff using inadequate eye protection. The Administrator acknowledged the shortage and mentioned that more face shields were on order, but did not provide guidance on whether existing shields should be sanitized or disposed of. Staff interviews revealed inconsistencies in understanding and implementing PPE protocols. A Certified Nurse Aide (CNA) entered the isolation room wearing only prescription glasses without additional eye protection, contrary to the facility's policy requiring a face shield or goggles. The CNA admitted to not wearing a face shield due to the lack of availability in the isolation bin. Other staff members also demonstrated a lack of clarity regarding the correct PPE requirements, with some believing that prescription glasses sufficed as eye protection. Additionally, the facility failed to ensure proper handling and transport of laundry, which could lead to cross-contamination. Observations showed that clean laundry was transported uncovered through resident areas, and a fan in the laundry room was heavily contaminated with dust and lint, blowing directly onto clean clothes. The facility lacked specific policies for laundry handling and fan cleaning, and staff did not document fan cleaning, indicating a gap in infection control practices.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by two specific incidents involving residents. In the first incident, a resident was observed without sheets on their bed. When the resident informed a CNA about the missing sheets, the CNA initially dismissed the concern by stating the sheet was stained but acceptable. After a brief pause, the CNA returned with linens and assisted the resident in making the bed without further communication. This interaction demonstrated a lack of respect and dignity towards the resident's needs and concerns. In another incident, staff members were reported to have used loud voices and profanity in the presence of residents. A specific event in July involved a CNA becoming loud and using profanity at the Nurse's Station, which was near the dining room where residents were present. Both an LPN and an RN confirmed the incident, noting that they attempted to deescalate the situation while addressing an acute resident concern. A resident also reported that staff sometimes became too loud and used profanity, which made him feel uncomfortable. These incidents highlight the facility's failure to maintain a respectful and dignified environment for its residents.
Failure to Ensure Valid Nursing Licenses
Penalty
Summary
The facility failed to ensure that professional nursing staff held current and valid licenses, as required by state laws. Specifically, the employee file of Staff F, a Registered Nurse, contained a license verification from Nursys indicating that their license had expired. Despite this, Staff F continued to work in the roles of floor nurse and Health Services Supervisor for a period of time after the expiration date. The job descriptions for both positions, which Staff F had signed, required a current and active license. During interviews, Staff F admitted to missing the renewal email from the Board of Nursing, and the Administrator acknowledged that Staff F was overlooked in their system for tracking professional licenses. The Director of Nursing expressed an expectation that all nurses maintain a valid license.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
