Harmony Waterloo
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterloo, Iowa.
- Location
- 201 West Ridgeway Avenue, Waterloo, Iowa 50701
- CMS Provider Number
- 165034
- Inspections on file
- 31
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Harmony Waterloo during CMS and state inspections, most recent first.
A resident dependent on staff for transfers and personal care was left soiled, uncovered, and without access to assistance after an argument with two CNAs during bedtime care. The resident's calls for help went unanswered for about an hour, leading to significant distress and increased anxiety. Staff interviews revealed failures in communication, lack of timely response, and inadequate adherence to abuse prevention and reporting protocols by both direct care staff and facility leadership.
A staff member exploited a resident by using her credit card to pay a personal cell phone bill after routinely accepting the card to purchase soda from a vending machine. The resident, who was dependent on staff for mobility and had multiple medical conditions, discovered the unauthorized charge after discharge, prompting a police investigation that linked the transaction to the staff member. Staff interviews revealed it was common for residents to give staff money or cards for vending machine purchases, despite facility policies prohibiting financial exploitation and personal cell phone use during work.
The facility failed to maintain a comfortable temperature in the shower room, as required by regulations, affecting two residents who reported the room was cold despite warm water. Maintenance confirmed the temperature was below the required range due to heating system issues. Although heat lamps were intended as a temporary solution, residents reported they were not used. The administrator acknowledged a delay in addressing the issue due to communication lapses.
The facility failed to accurately document MDS assessments for two residents. One resident's MDS omitted documentation of a diuretic medication, despite its administration being recorded in the MAR. Another resident's MDS incorrectly noted routine anti-psychotic medication use, which was not supported by MAR records. The DON confirmed these errors, and the facility lacked a specific MDS policy, relying on the RAI manual.
A facility failed to submit a PASRR for a resident with new mental health diagnoses. The resident, with intact cognition, had existing diagnoses of diabetes, hypertension, alcohol abuse, and a history of stroke. Despite being on an anti-psychotic medication, the PASRR did not document any mental health conditions. Neuropsychiatry notes revealed diagnoses of anxiety and Bipolar depression, with the resident on an anti-psychotic and a new antidepressant. The facility's records lacked a new PASRR submission, and the Social Services Director was unaware of the new diagnosis. The Administrator noted the absence of a PASRR policy, relying on federal regulations.
A facility failed to follow up on abnormal blood sugar levels for a diabetic resident. The MAR required notifying the MD for levels outside specified parameters, but on two occasions, the resident's blood sugar exceeded the threshold without proper follow-up. The nurse was unable to contact the MD on the first occasion and placed the notification in the fax folder, while the second occasion lacked documentation. Facility policy required reporting abnormal levels to the physician and following active orders.
A facility failed to respect resident dignity and rights when an LPN reprimanded two residents for expressing concern about another resident's hospitalization. One resident, with intact cognition and multiple diagnoses, felt degraded by the LPN's actions. The Director of Nursing later stated that residents are not bound by HIPAA and saw no issue with the conversation.
A resident with dementia fell from her wheelchair, resulting in a forehead bruise. The fall was witnessed by an RN, but neurological checks were not initiated immediately, and the family was not promptly informed. The resident was later found to have a hematoma, prompting further assessment and hospital transfer. There was a lack of communication and documentation among staff regarding the incident.
The facility failed to treat residents with dignity, as several were left in the dining room for extended periods after meals. A resident with ALS reported waiting up to three hours for assistance, while another with Parkinson's disease felt alone and forgotten due to long waits. A CNA confirmed that residents often waited a long time for help back to their rooms, indicating a systemic issue in providing timely assistance.
A resident with ALS and anxiety disorder did not receive his prescribed diazepam due to the facility running out of the medication. The facility's process required staff to reorder medications when low, but this was not done. The pharmacist noted the lack of a reorder and a missing physician's signature on a new order, causing further delays. The DON acknowledged the oversight in ordering and issues with hospice orders.
The facility failed to provide a clean and homelike environment, with issues including urine spills, dried fecal matter, and improper handling of urinals. Additionally, meal trays were not removed in the dining room, detracting from the homelike atmosphere.
The facility failed to maintain dignity for two residents by not providing timely grooming care. A female resident was observed with lengthy chin hairs, and a male resident had multiple days of facial hair growth despite preferring to be clean-shaven.
A resident with COPD and other respiratory conditions was observed using oxygen therapy without a current physician order. The last order was discontinued, and the Care Plan team accidentally deleted the oxygen therapy order, leading to a deficiency in providing appropriate respiratory care.
The facility failed to store food according to professional standards, with several items found unsealed, undated, and unlabeled, including moldy bread. The Dietary Manager acknowledged the oversight, which violated the facility's Food Storage policy.
Resident Left Unattended and Deprived of Care Following Staff Argument
Penalty
Summary
A resident with diagnoses including congestive heart failure, diabetes mellitus, morbid obesity, anxiety, and depression, who was cognitively intact and dependent on two or more staff for transfers and personal care, was deprived of care and left in a vulnerable state. On the evening in question, the resident requested assistance with her usual nighttime routine, which involved transfer from a recliner to bed, cleaning, and changing into clean clothes. Two CNAs responded, but an argument ensued regarding the resident's care preferences. The resident asked one CNA not to return, after which both CNAs left her on the bed, soiled with urine, without a blanket, and with her call light and personal items out of reach. The resident's repeated calls for help went unanswered for approximately an hour, during which she became increasingly distressed, cold, and anxious. Multiple staff interviews confirmed that the resident was left unattended and that her requests for assistance were ignored. The resident was found later by another CNA, who provided care and comfort. The resident reported ongoing fear and anxiety, especially as the staff involved continued to work in the facility and pass by her room. The incident was not documented in the progress notes for that day, and the resident's anxiety and requests for medication increased following the event. Staff interviews revealed a lack of training, confusion about protocols, and failure to respond appropriately to the resident's distress and allegations of abuse. Leadership in the facility, including the DON and charge nurse, failed to address the resident's immediate concerns or investigate the incident in a timely manner. The DON was made aware of the situation but did not intervene or follow up with the resident, and staff were directed to ignore the resident's calls for help. The facility's abuse prevention policy required immediate reporting and investigation of abuse allegations, but these procedures were not followed. The resident's care plan, which included specific instructions for communication and reassurance, was not adhered to during the incident.
Staff Member Exploits Resident's Credit Card for Personal Use
Penalty
Summary
A staff member at the facility exploited a resident financially by using the resident's credit card to pay a personal cell phone bill. The resident, who was dependent on staff for mobility and required full assistance, frequently gave staff her credit or debit card to purchase soda from the vending machine, as she was unable to access it herself. After the resident was discharged, her bank notified her of an overdraft charge related to a cellular phone bill, which she did not authorize. A police investigation determined that the account holder for the cellular phone bill was a staff member who had worked at the facility during the resident's stay. Multiple staff interviews confirmed that it was common practice for residents, especially those who were bedbound, to give staff money or cards to purchase items from vending machines. Several staff members admitted to accepting residents' cards or cash to buy soda, while others stated they refused to take cards but acknowledged the practice was widespread. The facility's policies and employee handbook prohibited financial exploitation and the use of personal cell phones during work, but staff reported that cell phones were often present at the nurses' station and sometimes carried in pockets. The policy lacked specific direction regarding the handling of residents' credit, debit, or cash app cards. The resident involved had significant medical needs, including paraplegia, stage four pressure ulcers, osteomyelitis, diabetes, anxiety, and depression, and was cognitively intact. The incident was discovered after the resident's discharge, when she noticed the unauthorized charge and contacted the police. Staff schedules and timecards confirmed that the implicated staff member worked in the area where the resident lived during the relevant period. The facility did not identify other residents who reported misuse of their cards, but staff acknowledged that the practice of taking residents' cards for vending machine purchases had been ongoing.
Facility Fails to Maintain Comfortable Shower Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable temperature in the shower room, as required by regulations, which should be between 71 to 81 degrees. This deficiency was identified through observations and interviews with residents and staff. Resident #38, who has intact cognition and requires supervision for bathing, reported that the shower room was cold, despite the water being warm. This issue had been raised in resident council meetings since November, but no effective action was taken. Maintenance confirmed the shower room temperature was 66.7 degrees and acknowledged ongoing issues with the heating system, affecting multiple areas including the PARS lounge and physical therapy room. Although heat lamps were supposed to be used as a temporary measure, Resident #38 reported that staff did not utilize them. Similarly, Resident #65, who also has intact cognition and requires substantial assistance with bathing, reported experiencing a cold shower room during her shower. She confirmed that staff did not use the heat lamp, which was intended to mitigate the cold temperature. The facility's administrator was aware of the issue but noted a delay in addressing the concern due to a lapse in communication from the activities department. The concern form regarding the cold shower rooms was not assigned until late December, despite being received earlier, indicating a breakdown in the facility's internal communication and response processes.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to accurately document and submit the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. For Resident #36, the MDS dated 11/16/23 did not include documentation of the resident being on a diuretic, despite the Medication Administration Record (MAR) showing that Lasix was administered during the 7-day look-back period. The Director of Nursing (DON) confirmed that the MDS was incorrect and should have included the diuretic medication. The facility lacked a specific policy for MDS, relying instead on the Resident Assessment Instrument (RAI) manual, which requires documentation of high-risk medications like diuretics during the look-back period. For Resident #65, the MDS dated 12/19/24 incorrectly documented the resident as receiving an anti-psychotic medication on a routine basis. However, a review of the MAR for November 2024, December 2024, and January 2025 showed no record of such medication being administered. The DON acknowledged the error, stating that the MDS was coded incorrectly and the resident was not on an anti-psychotic medication. These inaccuracies in the MDS assessments highlight a failure in the facility's documentation process, impacting the accuracy of resident care records.
Failure to Submit PASRR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was submitted for a resident who had new diagnoses documented in her medical record. The resident, identified with a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition, had diagnoses of diabetes, hypertension, alcohol abuse, and a history of stroke. The resident's PASRR dated 10/09/24 documented no mental health conditions and did not require a level II to be completed, despite the resident being on an anti-psychotic medication without a given diagnosis. Provider Intake Notes from Neuropsychiatry indicated the resident had a diagnosis of anxiety and Bipolar depression, for which she was on an anti-psychotic medication and started on a new antidepressant. The facility's Electronic Health Records lacked a new PASRR submission reflecting these new diagnoses and medications. The Social Services Director was unaware of the new diagnosis, and the Administrator reported the facility does not have a PASRR policy, instead following federal regulations.
Failure to Follow Up on Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to follow up on blood sugar levels that were outside of physician-defined parameters for a diabetic resident. The Medication Administration Record (MAR) for the resident included an order for fingerstick blood sugar checks four times a day, with instructions to notify the Medical Doctor (MD) for levels less than 70 or greater than 300. On two occasions, the resident's blood sugar levels were recorded as 364 and 375, both exceeding the threshold. On the first occasion, the nurse attempted to contact the MD but was unsuccessful and placed the notification in the fax folder. There was no documentation of follow-up for the second occasion. The facility's policy required staff to report any abnormal blood sugar levels to the physician and to follow active orders as written. The Director of Nursing stated that she expected the MD to be notified of such levels and to be informed if there were issues reaching the MD, with a progress note documenting the abnormal level, MD notification, and any new orders received.
Failure to Respect Resident Dignity and Rights
Penalty
Summary
The facility failed to treat residents with dignity and respect, as evidenced by the interactions involving two residents and a staff member. Resident #65, who has intact cognition and diagnoses including congestive heart failure, hypertension, diabetes, and anxiety, reported feeling degraded by an LPN, Staff A. The incident occurred when Resident #65 and another resident, Resident #8, expressed concern for Resident #11, who was in the hospital. Staff A reprimanded them for discussing another resident, which made Resident #65 feel bad, despite Resident #11 not being upset by the conversation. The Director of Nursing later stated that residents are encouraged not to discuss others, but they are not bound by HIPAA, and there was no concern with the conversation that took place. Resident #8, who frequently visits other residents as they are her only family, corroborated the account, stating that she and Resident #65 expressed genuine concern for Resident #11's well-being. Staff A's intervention, telling them they couldn't talk about other residents, left Resident #8 feeling upset. Staff A admitted she did not directly hear the conversation but was informed by another staff member, whose identity she could not recall. The Director of Nursing did not see any issue with the conversation and felt there was no need to address it with Resident #65.
Failure to Conduct Timely Assessment and Notification After Resident Fall
Penalty
Summary
The facility failed to complete a full assessment, including neurological assessments, and did not notify the family and provider in a timely manner for a resident who fell out of her wheelchair. The resident, who had a history of non-Alzheimer's dementia, unspecified dementia with behavioral disturbances, and repeated falls, was dependent on staff for transfers. On the evening of the incident, the resident fell and hit her forehead, resulting in a 5 cm bruise. Despite the fall being witnessed by a registered nurse, neurological checks were not initiated immediately, and the family was not promptly informed. The incident occurred when the resident attempted to retrieve a baby doll that had fallen from her wheelchair. Staff A, who witnessed the fall, did not start neurological checks or document the incident immediately, citing being occupied with medication pass and believing the resident was acting fine. Staff A also failed to notify the on-call nurse about the fall, which was against the facility's policy. The resident was later found to have a hematoma on her forehead, and her condition prompted further assessment and eventual transfer to the hospital. There was a lack of communication and documentation among the staff regarding the fall. Staff C, who came on duty later, was not informed about the fall until days later and noticed the hematoma during her assessment. The resident's daughter was not informed of the fall until much later, and there was confusion among staff about the timing and details of the incident. The facility's policy required immediate assessment and notification following a fall, which was not adhered to in this case.
Failure to Uphold Resident Dignity in Dining Room
Penalty
Summary
The facility failed to treat four residents with dignity, as observed by surveyors. Residents were left in the dining room for extended periods after meals, with some waiting up to three hours for assistance to return to their rooms. Resident #2, with moderately impaired cognition and dependent on staff for mobility due to ALS, reported waiting long periods after meals. Resident #6, with intact cognition and Parkinson's disease, also experienced long waits in the dining room after meals, feeling alone and forgotten. Resident #7, who could self-propel in a wheelchair, noted that other residents who couldn't self-propel had to wait a long time for assistance. Resident #8, with intact cognition and hemiplegia from a stroke, was observed asleep at the dining table after breakfast, indicating prolonged waiting times. Staff interviews confirmed the issue, with a CNA acknowledging that residents who couldn't return to their rooms independently often waited a long time due to staff being busy. The facility's policy on Resident Rights, Dignity, and Respect emphasizes the right to considerate and respectful care, yet the observations and interviews indicate a failure to uphold these standards. The facility reported a census of 84 residents, highlighting the potential for systemic issues in providing timely assistance to residents dependent on staff for mobility.
Failure to Administer Anxiety Medication
Penalty
Summary
The facility failed to ensure the administration of anxiety medications for a resident with moderately impaired cognition, diagnosed with ALS, anxiety disorder, and depression. The resident reported not receiving his anxiety medication, diazepam, because the facility ran out. The Medication Administration Record showed multiple doses coded as unavailable, indicating the medication was not administered. The facility's process required nursing staff to notify the pharmacy when medication was low, but there was no record of the diazepam being reordered before it was depleted. The pharmacist confirmed that no reorder was received for the resident's diazepam, and the new order to increase the dose lacked a physician's signature. This led to delays as the pharmacy had to contact the hospice-affiliated physician. The Director of Nursing acknowledged the oversight in ordering the medication timely and the issue with hospice orders lacking physician signatures, which contributed to the resident missing several doses of his medication.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable, clean, and homelike environment for its residents. Resident #21 had difficulty managing his urinal, frequently spilling it, which resulted in a strong urine odor in his room and the hallway outside. Despite the resident's complaints and visible evidence of urine spills, the issue persisted over several days. Staff interviews confirmed that the facility was aware of the problem but had not yet found a suitable solution for the resident's urinal management. Additionally, housekeeping staff acknowledged the presence of urine odors and spills but did not adequately address the issue in a timely manner. Resident #51's room had dried fecal matter on the floor that remained for over 24 hours. Observations over multiple days showed that the fecal matter was not cleaned, despite the facility's policy of daily room cleaning. Interviews with housekeeping staff and the facility administrator confirmed that the fecal matter was present and had not been addressed promptly. This indicates a failure in the facility's cleaning protocols and communication between staff members. Resident #60's room had a hand urinal that was not emptied and was placed on the floor and later on a heating unit, both of which had visible urine stains. The resident expressed concerns about the staff not emptying the urinal in a timely manner. Staff interviews revealed that the facility's policy required urinals to be emptied every two hours and surfaces to be sanitized, but these procedures were not followed. Additionally, during meal times, residents in the dining room received their meals on trays, which were not removed and placed on the tables, further detracting from a homelike environment.
Failure to Maintain Resident Dignity Through Proper Grooming
Penalty
Summary
The facility failed to maintain dignity for two residents by not providing appropriate grooming care. Resident #6, a female, was observed on multiple occasions with lengthy chin hairs, which were only removed after several days. Resident #65, a male, was seen with multiple days of facial hair growth despite expressing a preference to be clean-shaven. These observations were made over several days, indicating a lack of timely grooming assistance for these residents.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician order for the use of oxygen therapy for a resident. Resident #19, who had diagnoses of asthma, chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome, and chronic bronchitis, was observed wearing oxygen set at 2 Liters (L) without a current physician order. The last documented order for oxygen was discontinued on 4/15/24, and the resident's Minimum Data Set (MDS) and clinical records lacked documentation of oxygen use between 12/26/23 and 5/17/24. Interviews with the resident and staff revealed that the resident had been using oxygen therapy and a CPAP machine since admission. However, the Care Plan team had accidentally deleted the oxygen therapy order. This oversight was confirmed by the Assistant Director of Nursing (ADON), who acknowledged the error during an interview. The facility's failure to maintain a current physician order for oxygen therapy for Resident #19 constitutes a deficiency in providing appropriate respiratory care.
Food Storage Deficiency
Penalty
Summary
The facility failed to store food in accordance with professional standards, as observed during a survey. Several food items in the kitchen's storage and freezers were found opened, unsealed, undated, and unlabeled, including a frozen bag of strawberries, frozen premade omelets, frozen cookie dough, a package of hot dog buns, and a package of bread with visible mold. During an interview, the Dietary Manager acknowledged the failure to seal, label, and date the items when opened, as required by the facility's Food Storage policy dated 2020. This policy mandates that all food items be labeled with the name of the food and the date received, and once opened, packages should be re-dated with the date opened and used according to safe food storage guidelines or the manufacturer's expiration date.
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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