Harmony Utica Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Davenport, Iowa.
- Location
- 3800 Commerce Blvd, Davenport, Iowa 52807
- CMS Provider Number
- 165575
- Inspections on file
- 26
- Latest survey
- April 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Harmony Utica Ridge during CMS and state inspections, most recent first.
The facility did not accurately report weekend staffing hours in its PBJ submission for a quarter, resulting in a trigger for excessively low weekend staffing. The Administrator confirmed agency hours were not entered correctly, and the facility lacked a policy for PBJ reporting. The reported census was 88 residents.
Surveyors found that expired lettuce and pre-filled salads were stored in the walk-in refrigerator, and the Dietary Manager could not confirm if expired lettuce had been used in meal preparation. Additionally, meal temperature logs were incomplete for several days, and the facility lacked policies for food storage and temperature monitoring.
A resident with heart failure, renal disease, and dementia experienced multiple significant weight fluctuations while on a diuretic, but staff failed to consistently notify the provider as ordered. Documentation of provider notification was lacking, and staff interviews revealed inconsistent practices regarding communication and record-keeping, contrary to facility policy.
Quarterly MDS assessments were not completed on time for four residents, with assessments finalized days to weeks after the required dates. Staff cited increased infection control duties as a reason for the delays and acknowledged the issue, while also noting the absence of a facility policy for MDS assessment procedures.
The facility did not accurately code medication use on MDS assessments for two residents, including one with intact cognition and another with severe cognitive impairment. The MDS indicated use of medications not supported by the medical record or physician orders, and staff confirmed these were coding errors. The facility also lacked a policy for MDS accuracy.
Two residents did not have their care plans updated to include essential treatments: one receiving regular dialysis and another prescribed an anticoagulant for atrial fibrillation and heart failure. Despite staff and policy indicating these interventions should be documented, the care plans lacked focus areas and interventions for these critical needs.
Staff failed to consistently use wheelchair foot pedals and implement fall prevention interventions, resulting in multiple residents being transported without proper safety measures and experiencing falls, despite care plans and staff education outlining these requirements.
A resident with a suprapubic catheter was repeatedly observed with their catheter bag and tubing resting on or dragging along the floor, both in their room and while moving in a wheelchair. Staff present did not intervene to correct the situation, and interviews revealed inconsistent understanding of proper catheter care. Facility policy requires catheter bags and tubing to be kept off the floor, but this was not followed, resulting in a deficiency.
The facility did not properly document the acceptance or refusal of the pneumococcal vaccine for three residents, including two with severe cognitive impairment and one with intact cognition. Records lacked dates of refusal and evidence that education or declination information was provided, and staff interviews confirmed inconsistent documentation practices.
A resident with a recent below-the-knee amputation did not receive wound care as ordered by the physician, as staff substituted Xeroform for Vashe Wound Cleanser without proper documentation or provider notification. The DON confirmed that staff are expected to follow active orders and notify the provider if a treatment is refused, but this process was not followed.
A resident admitted with a recent ankle fracture and a history of cancer and mood disorder experienced frequent, severe pain due to delays in receiving both scheduled and as-needed pain medications. Despite prescriptions for hydrocodone-acetaminophen and pregabalin, there were lapses in medication administration and pharmacy delivery, leading to inadequate pain relief and significant resident distress.
A resident with a suprapubic catheter did not receive proper Enhanced Barrier Precautions during catheter care, as a CNA failed to wear an isolation gown while emptying the catheter bag. This action was inconsistent with the resident's care plan and facility policy, which require both gown and gloves for high contact activities involving indwelling medical devices.
A resident with severe cognitive impairment and multiple wounds received wound care from an RN who failed to follow infection control protocols. The RN did not change gloves between tasks and exited the room wearing an isolation gown to access supplies, contrary to facility policy. Interviews with staff confirmed the expected procedures were not followed, resulting in a deficiency in infection control practices.
A resident at an LTC facility developed a severe pressure ulcer due to inadequate care and documentation. Despite being at risk, the resident's wound was not properly assessed or treated, leading to a severe infection and hospitalization. Staff interviews revealed issues with undocumented dressings and inconsistent wound care documentation, contributing to the resident's deteriorating condition and eventual death.
A facility failed to conduct necessary pre- and post-dialysis assessments for a resident with end-stage renal disease and diabetes. The resident's care plan lacked directions for these assessments, and the Treatment Administration Record showed multiple instances of missing documentation. The Director of Nursing acknowledged the expectation for such assessments, but the facility's policy did not provide clear guidance, leading to missed evaluations.
A facility failed to update a resident's PASRR after new diagnoses of bipolar 2 disorder and schizophrenia were identified. The resident, with moderate cognitive impairment, was experiencing hallucinations and had started counseling. The oversight was acknowledged by the administrator during the survey.
Inaccurate PBJ Weekend Staffing Reporting
Penalty
Summary
The facility failed to ensure accurate reporting of weekend staffing hours in its Payroll Based Journal (PBJ) submission for Quarter 1 2025, which covered the period from October 1 to December 31, 2024. Review of the PBJ report revealed that the facility triggered for excessively low weekend staffing during this time. During an interview, the Administrator acknowledged that agency hours had not been entered correctly. Additionally, when requested, the facility reported that they did not have a policy related to PBJ reporting. The facility reported a census of 88 residents during the period in question.
Failure to Discard Expired Food and Incomplete Meal Temperature Monitoring
Penalty
Summary
The facility failed to properly manage food storage and temperature monitoring in accordance with professional standards. During an inspection, surveyors observed that the walk-in refrigerator contained multiple trays of pre-filled side salads and a large container of shredded lettuce, both of which were past their labeled use-by dates. The Dietary Manager confirmed that the lettuce had expired and was unsure if it had been used in recent meal preparations. Additionally, a review of the facility's meal temperature logs revealed that temperatures for evening meals were not recorded for three out of seven days reviewed. The facility also lacked policies related to food storage, expiration, and monitoring of food temperatures. The census at the time of the survey was 88 residents. No specific residents or their medical conditions were mentioned in relation to the deficiency.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to notify the medical provider of significant weight changes, as ordered, for a resident with multiple complex medical conditions, including chronic systolic heart failure, renal insufficiency, end stage renal disease, and non-Alzheimer's dementia. The resident was on a diuretic and had specific physician orders requiring daily weights and immediate provider notification for a weight gain of 3 pounds or more in one day, or a loss of 3 pounds in one day. Clinical record review showed multiple instances where the resident's weight fluctuated by 3 pounds or more within a day, but there was no documented evidence that the provider was notified of these changes as required by the physician's order and facility policy. Staff interviews revealed inconsistent practices regarding provider notification and documentation. One LPN stated she notified the doctor via text message but did not document this in the resident's progress notes and deleted the messages after receiving a response. Another LPN claimed to have notified the provider and documented it, while the RN Unit Manager indicated that such notifications should be found in progress notes or paperwork submitted to the provider. The Director of Nursing confirmed that staff should notify the doctor after reweighing the resident and that the Unit Manager is responsible for auditing and educating staff. Facility policies reviewed required that active orders be followed and that significant changes in a resident's condition be immediately communicated to the provider.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for four residents, as required. Clinical record review showed that the MDS assessments for these residents were completed several days to weeks after the designated Assessment Reference Dates (ARDs). Staff interviews revealed that the MDS Coordinator was unable to complete the assessments on time due to increased infection control responsibilities and did not request additional assistance. The Director of Nursing acknowledged the issue with timeliness and stated that assessments should be completed within the appropriate timeframe. Additionally, the facility did not have a policy in place to address MDS assessment procedures.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Section N, Medications, on the Minimum Data Set (MDS) assessments for two residents. For one resident with intact cognition, the MDS indicated use of an antiplatelet medication, but review of the Medication Administration Record (MAR) for the relevant month showed no administration of such medication, and the MDS Coordinator confirmed the resident was not on an antiplatelet. For another resident with severely impaired cognition, the MDS assessment indicated use of a diuretic, but neither the physician orders nor the medical record supported this, and both the MDS Coordinator and Director of Nursing acknowledged the resident was not prescribed a diuretic and that this was likely a coding error. Additionally, the facility did not have a policy in place for ensuring MDS accuracy.
Failure to Include Dialysis and Anticoagulant Use in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all of the residents' needs, specifically omitting dialysis services and anticoagulant use for two residents. For one resident with a history of fluid overload, coronary artery disease, and renal insufficiency requiring dialysis, the clinical record and staff interviews confirmed that the resident was receiving dialysis three times a week. However, the care plan did not include any focus areas or interventions related to dialysis services, despite orders and staff acknowledgment of the ongoing treatment. Similarly, another resident with diagnoses including atrial fibrillation, heart failure, and a hip fracture was prescribed an anticoagulant (Rivaroxaban). The care plan for this resident did not address the use of the anticoagulant, even though the medication order was present in the record and staff confirmed that such interventions should be included. The facility's own policy requires that care plans be person-centered and developed after comprehensive assessment, but these requirements were not met for the two residents identified.
Failure to Use Wheelchair Foot Pedals and Inconsistent Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that foot pedals were utilized when residents were transported in wheelchairs and did not consistently implement fall prevention interventions for several residents. Multiple observations revealed that staff pushed residents in wheelchairs without foot pedals, requiring residents to hold their feet above the floor during transport. This occurred despite the facility's policy and repeated staff education on the requirement of using foot pedals during wheelchair transport. In several instances, staff acknowledged that the 'no pedals, no push' rule was not always followed, particularly by new staff members. For one resident with severely impaired cognition and a history of right hemiparesis due to a cerebrovascular accident, the care plan included specific fall prevention interventions such as the use of Dycem in the wheelchair, removal of the sling after transfers, and use of non-skid footwear. However, the resident experienced multiple falls, including one where he was found on the floor with a head laceration and another where he slid out of his chair while the sling was still under him. Observations and interviews confirmed that interventions like Dycem and gripper socks were not consistently in place at the time of these incidents. Other residents, including one with intact cognition and another requiring moderate assistance with transfers, were also observed being transported in wheelchairs without foot pedals. Staff interviews and documentation confirmed that these safety interventions were not reliably implemented, despite being included in care plans and discussed in staff education sessions. The facility census at the time was 88 residents.
Failure to Maintain Proper Positioning of Indwelling Catheter Bag and Tubing
Penalty
Summary
A deficiency was identified when a resident with a history of neurogenic bladder, scoliosis, and intestinal-genital tract fistulae, who utilized an indwelling suprapubic catheter, was repeatedly observed with their catheter bag and tubing resting on the floor. Multiple observations documented the catheter bag and tubing either on the floor or dragging as the resident self-propelled their wheelchair, both in the resident's room and in the hallway. Staff present during these incidents did not intervene to correct the position of the catheter bag and tubing. Interviews with nursing staff revealed inconsistent responses regarding the appropriate action when a catheter bag or tubing is found on the floor. Some staff indicated the bag should be replaced, while others stated it should be wiped off and repositioned. The facility's policy directs that catheter tubing should not be positioned above the bladder and that the drainage bag should be kept off the floor and in a dignity bag. Despite these guidelines, the observed failure to maintain the catheter bag and tubing in the correct position led to the deficiency.
Failure to Document Pneumococcal Vaccine Refusals and Education
Penalty
Summary
The facility failed to provide adequate documentation regarding the acceptance or refusal of the pneumococcal vaccine for three out of five residents reviewed. For two residents with severely impaired cognition, there was no documentation in the electronic medical record (EMR) of vaccine refusal, and the unit immunization tracking forms indicated declination without specifying dates. Additionally, there was no evidence that education or declination information was provided to the residents or their representatives. For a third resident with intact cognition, the EMR noted a refusal of the PCV13 vaccine, but again, no date was recorded, and the tracking form lacked a date as well. There was also no documentation of education or declination provided to this resident. Staff interviews revealed that attempts were made to contact family members for residents with low cognitive scores, but documentation of these efforts was inconsistent or missing. The Director of Nursing acknowledged that if refusals were not documented in the EMR, they should have been recorded on paper, indicating a lapse in following the facility's vaccination and screening policy. The policy required offering pneumococcal vaccines upon admission to residents who had never been vaccinated or had previously refused, but the facility did not maintain complete records as required.
Failure to Follow Physician Orders for Wound Care Treatment
Penalty
Summary
Staff failed to follow physician orders for wound care treatment for a resident with a left below-the-knee amputation surgical site. The resident had intact cognition and required specific wound care interventions as documented in the care plan and treatment administration record, including the use of Vashe Wound Cleanser and Vashe-moistened gauze as part of the dressing change protocol. During an observed dressing change, a registered nurse cleansed the wound with normal saline and applied Xeroform instead of the ordered Vashe treatment. The resident reported that Vashe had not been used for the past three days and that Xeroform was used instead. The nurse explained that the process for changing a treatment order involved documenting the resident's refusal of Vashe and notifying the provider to request a new order for Xeroform, with documentation required in the nursing progress notes. However, the director of nursing confirmed that Vashe was unavailable prior to the dressing change and emphasized the expectation that staff follow physician orders and notify the physician if a treatment is refused. Facility policy requires that active orders be followed as written and that any changes be properly documented and communicated.
Failure to Provide Timely Pain Management and Medication Availability
Penalty
Summary
The facility failed to ensure the timely availability and administration of both scheduled and as-needed pain medications for a resident admitted with a tri-malleolar fracture and a history of malignant carcinoid tumors and adjustment disorder with depressed mood. Upon admission, the resident was prescribed hydrocodone-acetaminophen (Norco) as needed for moderate pain and pregabalin for nerve pain. Documentation showed that the resident experienced frequent, moderate to severe pain, with pain scores of 8-9 out of 10, and reported inadequate pain relief after receiving the as-needed medication. The Medication Administration Record indicated that pregabalin was not documented as given at bedtime on the day of admission, and only administered during the morning medication pass the following day. Nursing progress notes revealed that the resident expressed significant distress due to pain and the lack of timely medication, even considering leaving the facility against medical advice. Staff interviews confirmed delays in obtaining and administering the prescribed medications, with pharmacy deliveries not arriving as scheduled and the e-kit being accessed only after the resident's complaints. The facility's policy required that services needed by residents be readily available, and that prescriptions be obtained within a few hours of admission, but these expectations were not met in this case.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling suprapubic catheter. The resident was identified as cognitively intact and had diagnoses including neurogenic bladder and intestinal-genital tract fistulae. The care plan directed staff to wear a gown and gloves for high contact activities, such as emptying the catheter bag. During an observation of catheter care, a CNA donned a mask and gloves but did not wear an isolation gown while emptying the resident's catheter bag, despite the presence of PPE supplies and signage indicating EBP requirements in the resident's room. Interviews with staff and the Director of Nursing confirmed that EBP, including the use of gowns and gloves, should be followed for residents with indwelling catheters during high contact care activities. Review of the facility's policy also documented that gowns and gloves are required for such activities. The failure to don an isolation gown during catheter care was inconsistent with both the care plan and facility policy.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to adhere to infection control standards during wound care for a resident with multiple wounds and severe cognitive impairment. The resident, who was dependent on staff for mobility and had a history of skin breakdown, was observed receiving wound care from a registered nurse (RN) who did not follow proper infection control protocols. The RN did not change gloves between different wound care tasks and exited the resident's room wearing an isolation gown to access supplies from a common medication cart, which compromised infection control measures. During the wound care observation, the RN was seen removing dressings, cleansing wounds, and applying new dressings without changing gloves between tasks. The RN also exited the room twice while wearing the isolation gown to retrieve supplies, allowing the gown to come into contact with the medication cart. This action was contrary to the facility's policy, which required the removal of isolation gowns and gloves, and hand hygiene before leaving the room. Interviews with other staff members, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that the expected procedure was to change gloves when soiled and to remove isolation gowns and gloves before exiting the room. The facility's policies on dressing changes and enhanced barrier precautions were not followed, leading to a deficiency in infection control practices during the wound care of the resident.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for a resident, leading to severe health complications. The resident, who had diagnoses of Parkinson's, anxiety, and depression, was assessed as being at risk for pressure ulcers. Despite this, a wound on the resident's right buttocks was identified by nursing staff without prior documentation or provider notification for a treatment order. This oversight resulted in the resident developing a severe infection, including MRSA and E. coli, which ultimately required hospitalization for sepsis and a urinary tract infection. Interviews with staff and the resident's daughter revealed a lack of consistent wound assessment and documentation. The resident's daughter reported seeing a dressing applied to her mother's wound, which was initially described as a surface wound by the nursing staff. However, the wound worsened over time, and the resident's condition deteriorated, leading to hospitalization. Staff interviews indicated that there were instances of undocumented dressings found on residents, and there was frustration among staff regarding the lack of documentation and timely treatment orders. The facility's documentation showed inconsistencies in wound assessments and treatment records. Progress notes and skin sheets for the resident lacked timely and accurate documentation of the wound's condition and treatment. The resident's condition worsened, with the wound becoming unstageable and emitting a foul odor, which was not addressed promptly. The resident was eventually transferred to the hospital, where the wound was diagnosed as a Stage IV infected pressure ulcer, contributing to the resident's death.
Removal Plan
- Nurse education re-initiated to be completed 100% for all nurses prior to their next scheduled shift on skin practice guidelines that include direction on how to identify skin areas and wound care/dressing change, and Medical Director and family notification.
- Baseline audit of skin on current patients in house.
- Nursing education on skin preventative measures including repositioning.
Failure to Conduct Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete necessary nursing assessments and monitoring for a resident requiring dialysis care. Resident #72, who has end-stage renal disease and type 2 diabetes mellitus with diabetic chronic kidney disease, was not consistently assessed before and after outpatient dialysis sessions. The care plan for the resident did not include directions for pre- and post-dialysis assessments, despite the resident's condition and the physician's orders requiring such evaluations. Observations revealed bruising on the resident's arm near the fistula, and the resident reported that post-dialysis assessments were often missed due to staff being busy. The Treatment Administration Record (TAR) for May and June 2024 showed multiple instances where pre- and post-dialysis assessments, as well as fistula assessments, were not documented. The Director of Nursing stated that the expectation was to conduct assessments before and after dialysis, including checking vitals and the fistula site, as per physician orders. However, the facility's policy lacked clear instructions for pre-dialysis assessments, contributing to the oversight in care for Resident #72.
Failure to Update PASRR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a Change in Status Preadmission Screening and Resident Review (PASRR) assessment for a resident after two new mental health diagnoses were identified. The resident, who had a documented Brief Interview of Mental Status (BIMS) score indicating moderate cognitive impairment, was diagnosed with bipolar 2 disorder and schizophrenia during a physician visit. However, these diagnoses were not updated in the PASRR until the survey was conducted, several months later. The administrator acknowledged that the new diagnoses were overlooked, and the resident had been experiencing hallucinations and had started counseling, which should have prompted the PASRR update.
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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