Harmony Marshalltown
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshalltown, Iowa.
- Location
- 910 East Olive, Marshalltown, Iowa 50158
- CMS Provider Number
- 165385
- Inspections on file
- 30
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 26 (2 serious)
Citation history
Health deficiencies cited at Harmony Marshalltown during CMS and state inspections, most recent first.
A resident's transfer or discharge was not conducted in a manner that met their needs and preferences, and the facility did not adequately prepare the resident for a safe transition.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as identified by surveyors.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
Multiple residents requiring assistance with ADLs, including those with muscle weakness, multiple sclerosis, diabetes, anxiety, and CHF, experienced call light response times exceeding 15 minutes. Staff and resident interviews confirmed that low staffing and the need to escort residents outside for smoking contributed to missed or delayed care, resulting in residents arriving late for meals and feeling upset.
A resident with intact cognition and a history of dementia, anxiety, and depression was left outside overnight. After the incident, facility leadership told the resident it was her responsibility to always carry a cell phone to regain entry, which made her feel blamed and disrespected. This response did not align with the facility's policy requiring staff to treat all residents with dignity and respect.
A resident with intact cognition and independence in ADLs was left outside overnight after being unable to open a heavy door to re-enter the facility. Although the resident later reported weakness and the nurse notified the physician of this symptom, there was no documentation that the physician was informed about the incident of the resident being left outside, as required by facility policy.
A resident who was left outside overnight was not properly documented in the EHR as required. Staff were directed by administration to record the incident only on a concern form, despite professional standards and facility policy mandating clinical record documentation. The resident, who was cognitively intact and independent in ADLs, was assessed after the incident and found to have no injuries.
A resident with severe cognitive impairment and multiple health issues was not thoroughly assessed after staff observed facial bruising and after an elopement event. Staff failed to initiate timely neurological checks and did not complete a head-to-toe assessment following these incidents. Interviews revealed confusion among nursing staff about assessment requirements, and the DON confirmed the absence of a facility policy for such assessments.
A resident with severe cognitive impairment and a history of elopement was able to leave the facility unsupervised despite having a wander guard and being identified as high risk for wandering. Staff did not immediately notice the resident's absence after a door alarm sounded, and the resident was later found cold and confused at the front door. The care plan and elopement risk procedures were not effectively implemented, and staff were unclear about some security protocols.
Nursing staff did not perform required head-to-toe or neurological assessments after a resident with severe cognitive impairment was found with facial bruising and after the same resident eloped and was returned to the facility. Staff interviews revealed a lack of knowledge about assessment requirements, and the facility lacked clear policies to guide appropriate responses in these situations.
Two residents with severe cognitive impairment did not have complete or adequate medical records. One resident's elopement event was not fully documented, with missing details and an unlinked incident report in the EHR. Another resident's multiple skin injuries were not properly assessed or followed up in the clinical record, and required documentation was missing. The facility lacked a policy for staff documentation, and the process outlined in the Skin Management Guide was not consistently followed.
The facility failed to prevent food contamination during meal service. Dietary staff were observed preparing food while touching various surfaces with gloved hands, including bread, countertops, and containers, without changing gloves. The Dietary Supervisor confirmed that staff should wear gloves when handling ready-to-eat food and prevent contamination, as per facility policy.
A resident with acute and chronic respiratory failure was prescribed oxygen therapy at 3 L/NC as needed for shortness of breath. However, observations showed the resident receiving oxygen at 4.5 L/NC, contrary to the physician's order. The MAR lacked documentation of oxygen administration, and the TAR did not indicate whether the resident was on room air or oxygen during assessments. Staff interviews revealed a lack of awareness of the resident's specific oxygen orders, and the facility's policy required adherence to active orders.
A facility failed to complete a PASRR for a resident with mental health changes. The resident's MDS assessment showed an incomplete BIMS due to inability to complete the interview, with diagnoses of psychiatric and mood disorders. Despite using psychotropic medications, the care plan lacked an updated mental health diagnosis. The initial PASRR indicated no known mental health diagnosis, but later medical records showed delusional disorders, major depressive disorder, generalized anxiety disorder, and hallucinations. No new PASRR screening was conducted after these updates.
The facility failed to update Care Plans for three residents, missing critical diagnoses and treatment details. A resident's Care Plan lacked dementia-related information, while another's did not reflect updated mental health diagnoses. Additionally, a resident's history of UTIs and prophylactic antibiotic use was omitted. Staff acknowledged these oversights.
A resident with severe cognitive impairment and an indwelling catheter was observed with the catheter bag improperly managed, leading to it being on the floor and under the wheelchair wheel. Staff failed to secure the catheter bag properly, and there was a misunderstanding regarding the resident's consent for a bag change. The facility's policy to keep catheter bags off the floor and in a dignity bag was not followed.
The facility did not meet the Federal Regulations requirement of having an RN on duty for eight consecutive hours per day. On one day, there was no RN present, and on another, an agency RN only provided two hours of coverage. The Administrator acknowledged the issue and noted the absence of a specific RN staffing policy.
A resident with severe cognitive impairment and an indwelling catheter was not properly managed under transmission-based precautions for C. diff infection. Despite completing antibiotics, the facility failed to send a final stool sample for testing, delaying clearance from contact precautions. Observations showed staff misunderstanding and non-compliance with infection control protocols, including improper use of gloves and gowns. The facility's guidelines, based on CDC recommendations, were not adequately followed.
The facility failed to document and offer pneumococcal vaccinations to two residents, one with moderately impaired cognition and another with intact cognition, after they had received the PCV13 vaccine. The Infection Preventionist confirmed the lack of documentation for offering or declining additional vaccinations, and the facility's policy did not align with updated CDC recommendations.
The facility failed to document the offer and education of COVID-19 vaccinations for two residents, one with severe cognitive impairment and another with intact cognition. Despite the Infection Preventionist's claim of offering the vaccinations, there was no documentation of consent or refusal, violating CDC guidelines and facility policy.
A resident's family member found another resident's death certificate in their room, which was a breach of confidentiality. The family member, who works in healthcare, reported the issue to the DON. The facility's Compliance Plan requires the protection of residents' PHI, but the DON could not determine how the document ended up in the room.
The facility failed to maintain Smart Stand Lifts properly, compromising resident safety during transfers. Two lifts were missing essential safety hook spring tabs, as required by the service manual. Staff reported that the lifts lacked these safety tabs since they started working at the facility, and the Maintenance Man confirmed the necessity of these components for safe operation.
The facility failed to provide adequate clean linen soaker pads and washcloths for resident care, impacting the quality of care. Staff reported a shortage of essential supplies due to a management transition, making it difficult to perform their duties. A resident confirmed the lack of sufficient supplies, hindering proper care. Although new washcloths were available in the laundry area, they were not readily accessible to staff, leading to the deficiency.
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in care. One resident, with severe cognitive impairment and multiple health issues, did not have their weight monitored as prescribed due to Covid isolation. Another resident, with no cognitive impairment and various health conditions, did not receive the ordered compression stockings as the facility failed to measure their legs. These oversights indicate a lapse in following prescribed care plans.
Two residents reported delays in call light responses, exceeding the facility's 15-minute policy. One resident, needing blood sugar monitoring, experienced a 45-minute delay, while another confirmed similar delays. Staff and the Administrator acknowledged the expectation for timely responses, highlighting a failure to meet facility standards.
The facility did not follow the dietitian-approved menus for residents' meals on several occasions. Meals served on different days did not match the planned menus, with substitutions made without adherence to the approved plan. The Corporate Dietitian noted the absence of a Dietary Supervisor, with the Administrator handling food orders until a new supervisor starts.
The facility did not maintain hot food items at the required temperature, as observed during a meal service where French fries were served at 127°F, below the required 135°F. A test tray confirmed the French fries were cool and chewy. The Corporate Dietitian acknowledged the issue, noting plans to replace the steam table to maintain consistent temperatures.
The facility was found to have deficiencies in food handling and kitchen sanitation. During an inspection, several food items were discovered open, unlabeled, and undated, including potato and ham salad, meat patties, taco shells, and buns. Additionally, chocolate milk was past its best-by date. The kitchen area was also found to be unsanitary, with food debris on the handwashing station, prep counter, oven griddle, steam table, and inside refrigerators and freezers. These findings were confirmed by the Corporate Dietitian, who noted the absence of a Dietary Supervisor.
A CNA failed to follow infection control protocols while assisting a resident with toileting, leading to a breach in hygiene practices. The CNA handled soiled materials and touched various surfaces and equipment without changing gloves, contrary to the facility's infection control policy. The resident required total assistance due to multiple medical conditions.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the needs and preferences of the resident and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the planning and execution of the transfer/discharge process, specifically noting that the resident's individual needs and preferences were not fully considered or addressed, and that the necessary preparation for a safe transition was lacking.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified by surveyors based on observations or events that indicated the environment posed risks for accidents and that supervision was insufficient to prevent such incidents. No additional details about specific residents, their medical history, or the exact nature of the hazards or accidents are provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Delayed Call Light Response Due to Staffing Issues
Penalty
Summary
The facility failed to consistently answer call lights within a reasonable amount of time, defined as 15 minutes or less, for four residents. Resident interviews revealed that staff response times exceeded 15 minutes, resulting in residents arriving late for meals and experiencing distress. Specifically, one resident reported waiting over an hour for assistance, while others described repeated delays that caused frustration and upset. Staff interviews confirmed that call lights often went unanswered for longer than 15 minutes, particularly when staff were required to take residents outside to smoke, which left fewer staff available to respond to other residents' needs. The affected residents had varying degrees of assistance required for activities of daily living (ADLs), including transfers, dressing, personal hygiene, and meal attendance. Their medical histories included conditions such as muscle weakness, multiple sclerosis, diabetes mellitus, anxiety, and congestive heart failure. The facility's policy required prompt response to call lights, but both staff and residents reported that low staffing levels contributed to missed or delayed care, directly impacting the timeliness of assistance provided.
Resident Not Treated with Dignity After Being Left Outside
Penalty
Summary
A resident with intact cognition, as indicated by a BIMS score of 14, and diagnoses including non-Alzheimer's dementia, anxiety, depression, and dizziness, was identified as being independent with activities of daily living. The resident's care plan included interventions related to tobacco use, such as completing smoking evaluations as needed, keeping smoking accessories secured, checking in and out, carrying a cell phone while smoking, and smoking only in designated areas or times. On one occasion, the resident was left outside all night and subsequently reported feeling degraded and disrespected after being told by the DON and Administrator that it was her responsibility to always have her cell phone to re-enter the facility. Interviews with the Administrator and DON confirmed their expectation that the resident should ensure she had her cell phone at all times to regain entry. The resident expressed that this made her feel blamed for the incident and led her to avoid going outside alone. The facility's policy on dignity and respect instructs staff to treat all residents with dignity and respect, maintaining and enhancing self-esteem and self-worth, and providing reasonable accommodation of individual needs. The actions and statements of the facility leadership did not align with this policy, resulting in a failure to treat the resident with the required respect and dignity.
Failure to Notify Physician After Resident Left Outside Overnight
Penalty
Summary
The facility failed to notify the resident's physician of a significant incident involving a resident who was left outside all night. The resident, who was cognitively intact with a BIMS score of 14 and independent in activities of daily living, reported being unable to re-enter the facility after going outside to smoke due to difficulty opening a heavy door. The incident was discovered when a staff member heard the resident pounding on the courtyard door the following morning. Documentation shows that the resident reported feeling too weak to open the door, and while the nurse notified the physician of the resident's reported weakness, there was no documentation that the physician was informed about the resident being left outside overnight. The facility's policy requires immediate notification of the physician and the resident's representative in the event of an accident or change in condition. During interviews, the facility physician confirmed they were not informed of the incident and expressed that they expected to be notified. The DON also verified that the clinical record lacked documentation of physician notification regarding the incident, despite facility expectations for staff to report such events.
Failure to Document Resident Incident in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was left outside overnight. Although the incident was documented on a concern form and a handwritten note, it was not entered into the resident's electronic health record (EHR) as required by professional standards and facility policy. Staff members reported being directed by administration to document the incident only on a concern form and not in the clinical record, despite expressing discomfort with this approach. The resident involved was cognitively intact, had a history of non-Alzheimer's dementia, anxiety, depression, and dizziness, and was independent with activities of daily living. The incident involved the resident being unable to re-enter the facility after being outside, resulting in her remaining outside all night. Upon discovery, the resident was assessed and found to have no injuries or acute medical issues. The lack of documentation in the EHR meant that the incident, the resident's condition, and the follow-up actions were not properly recorded in accordance with accepted professional standards and facility policy, which requires all incidents and changes in resident status to be documented in the clinical record.
Failure to Complete Timely Assessments After Injury and Elopement
Penalty
Summary
The facility failed to initiate and complete timely and thorough assessments for a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease, muscle weakness, and a history of fracture. On one occasion, staff observed facial bruising on the resident after she reported being knocked into a wall by another resident, but did not conduct a comprehensive head-to-toe assessment or initiate neurological checks at the time of discovery. Documentation of vital signs was inconsistent, and neurological checks were not started until the following day, with incomplete entries and no ongoing monitoring as required. Additionally, after the resident eloped from the facility and returned, staff did not perform a thorough assessment to evaluate her condition post-elopement. Interviews with nursing staff revealed a lack of understanding regarding the need for assessments after such incidents, and the Director of Nursing confirmed that assessments should be completed after falls, altercations, or elopements, but acknowledged the absence of a facility policy guiding these practices. The facility also lacked documentation of a policy for head-to-toe assessments or neurological checks.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment. The resident, who had a BIMS score of 7 indicating severe cognitive impairment, required substantial to maximum assistance with transfers and ambulation, and had a history of elopement and exit-seeking behaviors. The care plan included the use of a wander guard, regular checks of the device, and staff assistance with mobility and reorientation. Despite these interventions, the resident was able to leave the facility unsupervised. On the morning of the incident, staff statements and interviews revealed that a CNA heard a door alarm and subsequently noticed the resident was missing from their room. Staff searched both inside and outside the building, and the resident was eventually found at the front door, cold and confused, wearing a wander guard that was still functional. Staff accounts indicated that the resident had attempted to leave the facility multiple times in the days prior, and another resident reported seeing the individual moving quickly down the hall earlier that morning. The nurse on duty had exited the building around the time of the incident, and the front door alarm was triggered, but the resident was not immediately located. The facility's elopement risk evaluation and care plan identified the resident as high risk for elopement, with a history of not responding to redirection and attempts to remove the wander guard. The facility's missing patient response plan outlined procedures for searching and notification, but the resident was able to exit and re-enter the building without staff immediately realizing. There were no operational cameras, and staff were unclear about certain security procedures, such as locking the sun room door, under new management.
Failure to Ensure Nursing Staff Competency in Resident Assessment After Injury and Elopement
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary knowledge and competencies to initiate appropriate clinical responses during resident care, as evidenced by the care of one resident with severe cognitive impairment and multiple medical conditions. The resident required substantial to maximum assistance with transfers and ambulation, had a history of falls, dementia, and used a wander/elopement alarm. Despite these needs, the clinical record showed that when facial bruising was first observed on the resident, staff did not perform a comprehensive head-to-toe assessment or initiate neurological checks, as would be expected following an unexplained injury. Additionally, after the resident eloped from the facility and was subsequently found, staff again failed to conduct a thorough nursing assessment or neurological checks within an hour of the incident. Interviews with nursing staff revealed a lack of awareness regarding the need for such assessments following incidents of injury or elopement. One nurse assumed the bruising had already been addressed and did not further assess the resident, while another was unaware of the requirement to perform a head-to-toe assessment after the resident was found outside the facility. The facility did not have a policy in place regarding the completion of nursing head-to-toe assessments or neurological checks, although the Missing Patient Response Plan instructed staff to examine the patient and document findings. The absence of clear protocols and staff knowledge led to incomplete assessments and documentation following significant events involving the resident.
Failure to Maintain Adequate Medical Records and Documentation
Penalty
Summary
The facility failed to ensure that the medical records for two residents contained sufficient and adequate information in accordance with accepted professional standards. For one resident with severe cognitive impairment, a history of falls, and a risk for elopement, the clinical record did not include a detailed account of an elopement event. While a progress note documented physician communication regarding the elopement, there was no further progress note detailing the specifics of the event, such as the time, summary, or the resident's condition. Additionally, the incident report related to the event was not properly linked within the electronic health record due to formatting issues, resulting in incomplete documentation. For another resident with severe cognitive impairment and dependent on staff for mobility and transfers, the clinical record lacked adequate documentation and follow-up assessments for multiple skin injuries. After a skin tear was identified, there was no further documentation of skin assessments or the healing process. Similarly, when bruises and another skin tear were later noted, the required skin condition reports and follow-up assessments were missing from the record. The facility's process for documenting and closing out skin injuries was not consistently followed, and there was no policy in place guiding staff documentation practices. The facility's Skin Management Guide required that skin alterations be evaluated and documented by a licensed nurse, with a specific form initiated upon identification of a skin injury and used for ongoing documentation. However, this process was not adhered to, resulting in incomplete medical records for the residents involved. The lack of comprehensive documentation for significant events and injuries constituted a failure to maintain medical records in accordance with professional standards.
Failure to Prevent Food Contamination During Meal Service
Penalty
Summary
The facility failed to protect food from contamination during meal service, as observed on multiple occasions. Staff F, a Dietary Aide, was seen preparing peanut butter and jelly sandwiches while repeatedly touching the bread with gloved hands. During the preparation, Staff F also touched various surfaces such as the outside of the bread bag, the counter, a pen, the peanut butter container, the jelly squeeze bottle, and storage bags, all with the same pair of gloves. Similarly, Staff G, a Cook, was observed preparing toast and touching the bread after handling different surfaces like the countertop, drawer handle, and toaster with gloved hands. Additionally, Staff E, another Dietary Aide, was observed preparing a grilled turkey and cheese sandwich while touching the bread, cheese, and turkey with gloved hands. Staff E also touched several surfaces, including the counter, refrigerator doors, and items inside the refrigerator, as well as containers of butter and cheese slices, and turkey packaging. Furthermore, Staff E used the same knife to spread butter on the bread after using it to open the plastic turkey package. The Dietary Supervisor confirmed that staff were expected to wear gloves when handling ready-to-eat food and to prevent foodborne illness by not touching food with bare hands or contaminated gloves. The facility's policy on disposable glove use required gloves to be worn for single tasks only and to be discarded if soiled, torn, or contaminated.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders and manage oxygen use for a resident with acute and chronic respiratory failure. The resident, who had intact cognition, was prescribed oxygen therapy at 3 liters per nasal cannula (L/NC) as needed for shortness of breath. However, observations revealed that the resident was receiving oxygen at a rate of 4.5 L/NC, which was not in accordance with the physician's order. The Medication Administration Record (MAR) lacked documentation of the administration of oxygen, indicating non-compliance with the prescribed treatment. Additionally, the Treatment Administration Record (TAR) did not document whether the resident was breathing room air or receiving oxygen during respiratory assessments. Interviews with staff revealed a lack of awareness regarding the specific details of the resident's oxygen orders, and the facility's policy required that active orders be followed as written. The administrator confirmed that staff should adhere to physician orders and seek clarification if needed, highlighting a deficiency in the facility's management of the resident's respiratory care.
Failure to Complete PASRR for Resident with Mental Health Changes
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) for a resident who experienced mental health changes. The resident's Minimum Data Set (MDS) assessment indicated an incomplete Brief Interview for Mental Status (BIMS) due to the resident's inability to complete the interview. The resident had diagnoses of psychiatric and mood disorders, including anxiety, depression, and psychotic disorders, and was using antipsychotic and antidepressant medications. Despite these conditions, the resident's care plan did not reflect an updated mental health diagnosis. The PASRR Level I Screen Outcome initially indicated that the resident did not have a known or suspected mental health diagnosis and was not receiving mental health services. However, subsequent medical diagnoses included delusional disorders, major depressive disorder, generalized anxiety disorder, and hallucinations. The clinical record did not show a new PASRR screening following these updated diagnoses. A Licensed Practical Nurse acknowledged the need to resubmit a PASRR with the new mental health diagnosis, and the Administrator noted that the facility did not have a specific policy for PASRRs.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to fully review and revise the comprehensive Care Plan for three residents, leading to deficiencies in their care management. Resident #1, with a BIMS score indicating intact cognition, had a diagnosis of unspecified dementia, among other conditions. However, the Care Plan lacked information related to the dementia diagnosis. The MDS Coordinator acknowledged missing this aspect, and the Administrator confirmed the expectation for the Care Plan to include dementia-related focus, goals, and interventions. Similarly, Resident #40's Care Plan did not reflect updated mental health diagnoses, despite the resident's use of psychotropic medications and a history of psychiatric disorders. Staff C, an LPN, admitted to missing the addition of these diagnoses to the Care Plan. Resident #38's Care Plan also lacked critical information, specifically regarding the history of urinary tract infections (UTIs) and the use of a prophylactic antibiotic. The MDS assessment indicated intact cognition, and the resident had a history of various medical conditions, including UTIs. The MDS Coordinator initially included the history of UTIs in the Care Plan but resolved it without considering the prophylactic antibiotic. This oversight was acknowledged by the MDS Coordinator, who recognized the expectation for the Care Plan to include such details.
Inadequate Management of Urinary Catheter
Penalty
Summary
The facility failed to adequately manage a resident's urinary catheter, which increased the risk of infections. The resident, who had severe cognitive impairment and an indwelling catheter due to obstructive uropathy, was observed with the catheter bag on the floor and under the wheelchair wheel. Staff D, a CNA, acknowledged that the catheter bag had two hooks and if only one was hooked, it would not stay in place. Despite this, the catheter bag was not properly secured, leading to it being on the floor. On another occasion, the resident was seen holding the catheter bag, which had come loose and was dragging. Staff H, another CNA, initially walked past the resident without addressing the issue until prompted by the surveyor. Staff H noted that the tubing was too short, which contributed to the problem. The Nurse Manager, Staff C, later offered to change the catheter bag, but there was a misunderstanding with the resident, who initially declined the change. The facility's policy required that catheter bags be secured off the floor and in a dignity bag, which was not adhered to in this case.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours per day as required by Federal Regulations. The deficiency was identified through a review of the facility's Daily Staffing Sheets, which revealed that on Saturday, 11/23/24, there was no RN present, and on Sunday, 11/24/24, an agency RN only worked from 10:00 PM to 6:00 AM, providing just two hours of RN coverage for the entire day. The facility had a census of 55 residents at the time. The Administrator acknowledged the lack of RN coverage during an email communication on 12/12/24, stating that they had identified the issue the week prior to the survey. The Administrator also confirmed that the facility did not have a specific policy for RN staffing, as they were following Federal Regulations.
Failure to Maintain Infection Control for Resident with C. diff
Penalty
Summary
The facility failed to maintain proper infection control interventions for a resident on transmission-based precautions due to Clostridium difficile (C. diff) infection. The resident, who had severe cognitive impairment and an indwelling catheter, was receiving antibiotic therapy for C. diff. Despite the completion of antibiotics, the facility had not yet cleared the resident from contact precautions as they had not sent the final stool sample for testing as per the physician's order. Observations revealed that a sign on the resident's door indicated contact precautions, requiring visitors to report to the nursing station, perform hand hygiene, and wear gloves and gowns when entering the room. However, staff interviews and observations indicated a lack of adherence to these precautions. A CNA reported that the resident had not been cleared from contact precautions, and an LPN confirmed that the final stool sample had not been sent for testing. Additionally, a staff member from Social Services interacted with the resident without following the required precautions, mistakenly believing that gloves and gowns were only necessary for direct care involving the catheter. This misunderstanding was later corrected by the nursing staff, who directed the staff member to wash their hands. The facility's infection control guidelines, adapted from the CDC, emphasized the importance of contact and standard precautions for C. diff, including consistent environmental cleaning and handwashing with soap and water due to the ineffectiveness of alcohol-based hand rubs against C. diff spores.
Failure to Document and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to properly screen, offer, educate, and document consent or refusal for pneumococcal vaccinations for two residents. Resident #33, with moderately impaired cognition, was admitted to the facility and had previously received the PCV13 vaccine. However, there was no documentation indicating that the resident was educated about, offered, or consented to additional pneumonia vaccinations such as PPSV23, PCV20, or PVC21. Similarly, Resident #24, who had intact cognition, also lacked documentation of being educated about or offered additional pneumonia vaccinations after receiving the PCV13 vaccine. The facility's Infection Preventionist confirmed the absence of documentation for offering or declining additional pneumonia vaccinations for both residents. The facility's policy, dated September 2023, required reviewing a resident's immunization status upon admission and offering the PPSV23 vaccine one year after receiving PCV13. However, the policy did not reflect the updated CDC recommendations, which suggested offering PCV20 or PVC21 at least one year after PCV13. This oversight in policy update and documentation led to the deficiency identified during the survey.
Failure to Document COVID-19 Vaccination Offers and Education
Penalty
Summary
The facility failed to properly screen, educate, offer, and document COVID-19 vaccinations for two residents, leading to a deficiency in compliance with CDC guidelines and facility policy. Resident #56, who has severe cognitive impairment, was admitted on 8/29/24, and although he received a COVID vaccination on 7/6/22, there was no documentation of an offer or education regarding an additional COVID-19 vaccination since his admission. Similarly, Resident #24, with intact cognition, was admitted on 5/21/24 and had received a COVID vaccination on 11/17/23, but there was no documentation of an offer or education for an additional vaccination since her admission. The Infection Preventionist confirmed the lack of documentation for both residents, acknowledging that while the vaccinations were offered, the necessary documentation or declination forms were not completed. The facility's policy requires reviewing a resident's immunization status upon admission, determining eligibility, and documenting consent, refusal, or ineligibility for the COVID-19 vaccine. The policy also mandates obtaining physician orders if the resident consents to vaccination and recording the administration in the medical record. The deficiency was identified through clinical record reviews, staff interviews, and policy reviews, highlighting a failure to adhere to established procedures for COVID-19 vaccination management.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records, specifically involving a death certificate of another resident. Resident #27 reported that their family member discovered the death certificate of another resident who had passed away on 11/23/34 on a bedside table in Resident #27's room. The family member, who works in the healthcare field, identified this as a confidentiality issue and reported it to the Director of Nursing (DON). The family member initially mistook the document for a list of upcoming appointments before realizing it was a death certificate. The DON confirmed the incident, acknowledging that Resident #27's family member brought the document to her attention. However, the DON was unable to determine how the death certificate ended up in Resident #27's room, as no staff admitted to leaving it there. The facility's Compliance Plan, last revised on 1/1/24, mandates the protection of residents' Protected Health Information (PHI) in accordance with state and federal privacy laws, which includes maintaining the confidentiality of all resident-related information.
Inadequate Maintenance of Smart Stand Lifts
Penalty
Summary
The facility failed to ensure the safety of residents during transfers by not maintaining adequate equipment. Specifically, two out of four Smart Stand Lifts observed were missing essential safety components. The Smart Stand Lift Service Manual, dated 6/7/24, requires that safety tabs be checked to ensure they are correctly installed and not missing or torn, with any deficiencies rectified before use. However, on 9/21/24, one lift was found missing a safety hook spring tab on one side, and another lift was missing both safety hook spring tabs. Staff interviews revealed that the Smart Stand Lifts had been without safety tabs since the staff members began working at the facility. Additionally, the Maintenance Man confirmed that the lifts should have safety tabs where the loops connect to the harness for safety.
Inadequate Linen Supply and Accessibility
Penalty
Summary
The facility failed to provide adequate clean linen soaker pads and washcloths for resident care, as observed during an environmental tour and through interviews with staff and residents. A Certified Nursing Assistant (CNA) reported a shortage of essential supplies such as washcloths and gloves, attributing the issue to a transition in management, which was delaying the ordering of new supplies. This shortage made it difficult for staff to perform their duties effectively, impacting the quality of care provided to residents. A resident confirmed the lack of sufficient washcloths, soaker pads, and linens, which hindered the staff's ability to care for her properly. Further investigation revealed that while the facility had a stock of new washcloths in the laundry area, these were not readily accessible to the staff on the floors. Staff members had to go to the laundry area themselves to retrieve necessary supplies, as they were not consistently stocked in the linen rooms or on the carts. The Housekeeping Supervisor indicated that linens were delivered only once a day, although staff could request additional supplies if needed. Despite the availability of supplies in the laundry area, the lack of efficient distribution and accessibility led to the deficiency in providing a safe and comfortable environment for the residents.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to deficiencies in care. Resident #3, who had severely impaired cognition and multiple health issues including heart disease and kidney failure, was prescribed daily weight monitoring due to their use of a diuretic. However, the facility did not obtain Resident #3's daily weights on several occasions because the resident was in isolation due to Covid. This failure to monitor the resident's weight as ordered by the physician represents a lapse in adhering to the prescribed care plan. Resident #4, who had no cognitive impairment and was diagnosed with conditions such as cancer, heart failure, and diabetes, returned from a wound clinic with new treatment orders, including the daily use of compression stockings. Despite the physician's order, the facility did not measure the resident's legs for the compression stockings, and the resident confirmed this oversight. A registered nurse verified that the facility's policy required staff to follow physician's orders as written, yet this was not done in Resident #4's case, indicating a failure to implement the necessary care as prescribed.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by interviews with residents and staff, and a review of facility policy. Resident #2, who has intact cognition and requires assistance with various activities of daily living, reported that staff took over 30 minutes to respond to a call light. This delay occurred when Resident #2 needed their blood sugar checked due to a tendency for low blood sugar levels. The blood sugar was eventually checked at 2:45 AM, revealing a level of 200. Staff C, a CNA, confirmed that it took over 15 minutes to answer the call light, which is against the facility's expectation of a 15-minute response time. Similarly, Resident #4, who also has intact cognition and requires total dependence for toileting hygiene and transfers, verified that their call light was on for longer than 15 minutes. The facility's Call Light Policy, dated September 2023, instructs staff to respond promptly to residents' calls for assistance, with a procedure to answer call lights in a timely manner. The Administrator confirmed the expectation for staff to answer call lights within 15 minutes, indicating a failure to adhere to the facility's policy.
Failure to Follow Dietitian-Approved Menus
Penalty
Summary
The facility failed to adhere to the dietitian-approved menus for residents' meals on multiple occasions. On 9/9/24, the lunch menu was supposed to include fire braised pork on a bun, baked yams, pea salad, bread with margarine, and fruit crisp. Instead, residents were served fire braised pork ribs, baked yams, buttered peas, and pudding. Similarly, on 9/10/24, the menu called for a cheeseburger on a bun, French fries, creamy coleslaw, and a scotcheroo, but residents received an ice cream cone or ice cream sandwich instead of the scotcheroo. On 9/11/24, the menu was supposed to include Italian pasta bake, seasonal vegetables, garlic toast, and pears, but residents were served [NAME] beans and a dinner roll instead of the seasonal vegetables and garlic toast. The Corporate Dietitian confirmed that the facility expected staff to follow the approved menu as written. However, the facility was operating without a Dietary Supervisor at the time, and the Administrator was responsible for ordering food supplies. A new Dietary Supervisor was expected to start at the end of the month. The facility's policy, dated 2020, indicated that menus should be planned in advance, varied, and revised semi-annually, taking residents' input into consideration.
Non-compliance with Food Temperature Standards
Penalty
Summary
The facility failed to maintain hot food items at the required temperature of 135 degrees Fahrenheit or greater, as observed during a noon meal service. Specifically, the temperature of French fries was recorded at 127 degrees Fahrenheit, which is below the required minimum. A test tray provided by the facility contained a cheeseburger, coleslaw, and French fries, where the French fries were noted to be cool and chewy, indicating they were not palatable. The Corporate Dietitian acknowledged the non-compliant temperature of the French fries and noted that the kitchen would be acquiring a new steam table to help maintain consistent temperatures. The facility's policies from 2020 require hot food items to be held at temperatures between 135 degrees Fahrenheit and 170 degrees Fahrenheit.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to proper food handling and storage protocols, as observed during an inspection of the kitchen. Several refrigerated and frozen food items were found open, unlabeled, and undated, including tubs of potato and ham salad, bags of meat patties, taco shells, and buns. Additionally, 11 gallons of chocolate milk were discovered with a past best-by date. These lapses in labeling and dating food items contravene the facility's food handling policy, which mandates that all prepared food must be covered, labeled, and dated before storage. The inspection also revealed significant sanitary issues within the kitchen area. The handwashing station sink, prep counter, oven griddle, steam table, and both the three-door refrigerator and two-door freezer were found to be dirty, with food debris and crumbs present. The facility's cleaning rotation policy requires that work tables and counters be cleaned after each use, and that the stove top, grill, steam table, and handwashing sink be cleaned daily, with refrigerators and freezers cleaned monthly. The Corporate Dietitian confirmed these expectations and noted the absence of a Dietary Supervisor, although one had been hired to start at the end of the month.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the care of a resident. The incident involved a Certified Nursing Assistant (CNA), identified as Staff E, who did not adhere to hand hygiene protocols while assisting a resident with toileting. The resident, who had a BIMS score of 13 indicating no cognitive impairment, required total dependence on staff for toileting hygiene and transfers due to medical conditions including cancer, heart failure, and respiratory failure. During the observation, Staff E was seen handling soiled materials and then touching various surfaces and equipment without changing gloves, which is a breach of infection control procedures. The resident was observed to be soiled with urine, and Staff E, after removing the soiled pad, continued to touch the full-body mechanical lift, its remote, the sling, a clean soaker pad, and the wheelchair without changing gloves. This action was contrary to the facility's infection control policy, which requires changing gloves after handling soiled items. The facility's Administrator confirmed that staff are expected to follow these procedures, indicating a lapse in adherence to established infection control protocols.
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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