Harmony West Des Moines
Inspection history, citations, penalties and survey trends for this long-term care facility in West Des Moines, Iowa.
- Location
- 5010 Grand Ridge Drive, West Des Moines, Iowa 50265
- CMS Provider Number
- 165601
- Inspections on file
- 35
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Harmony West Des Moines during CMS and state inspections, most recent first.
The facility failed to follow its own policies and resident care plans for safe transfers and ambulation, including use of gait belts and mechanical lifts, and did not ensure adequate supervision or orientation of agency CNAs. A resident with severe cognitive impairment, muscle weakness, and a care plan requiring assisted ambulation with a gait belt and non‑mechanical lift transfers was instead assisted without a gait belt, found on the floor after attempting to walk to the bathroom, and was manually lifted to bed without a mechanical lift despite being unable to bear weight, later diagnosed with right humeral and olecranon fractures. Another resident with weakness and unsteadiness, whose care plan required one‑person assist with a gait belt and front‑wheeled walker, slid to the floor during peri care when an agency CNA assisted her by the arm without a gait belt, and two agency CNAs then struggled to lift her by the arms into a wheelchair before an LPN arrived; she was later found to have an acute trimalleolar ankle fracture. Agency CNAs reported minimal orientation, lack of access to PCC care information, unfamiliarity with facility lifts, and chaotic staffing conditions, contributing to these failures in accident prevention and supervision.
The facility received an Infection Prevention & Control deficiency for the fifth consecutive survey. Despite having a QAPI Plan with a monitoring process, it failed to address previously identified deficiencies. The Administrator noted staff education efforts, but the facility remained non-compliant.
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, lacking personalized non-pharmacological interventions and specific target behaviors for monitoring. Staff interviews revealed gaps in communication and adherence to care plans, indicating deficiencies in care planning and monitoring processes.
The facility failed to provide appropriate serving sizes for puree diets and did not monitor final cooking temperatures for meal items. A cook prepared puree pea servings but did not communicate the correct portion size to other staff, resulting in residents receiving inadequate portions. Additionally, a staff member did not check the temperatures of macaroni and cheese and instant potatoes before serving, contrary to facility policy.
A resident with intact cognition was not given the opportunity to participate in recent care planning meetings, despite having attended a team meeting in October where they expressed concerns. Facility staff confirmed that no formal meeting occurred with the resident during the last annual updates, highlighting a failure to ensure resident involvement in care planning.
The facility failed to accurately document the status of three residents in their MDS assessments. A resident's PASRR Level II requirement due to Major Depressive Disorder was not reflected in the MDS, and another resident's Schizoaffective disorder was similarly undocumented. Additionally, a resident's hospice care status was not accurately recorded during the lookback period. The MDS Coordinator acknowledged an oversight, and the facility lacks a specific policy for MDS completion.
A facility failed to implement a complete Baseline Care Plan within 48 hours for a resident with intact cognition, as required by policy. The resident did not receive a copy of the care plan and expressed a need for discharge planning assistance. The baseline care plan lacked initial goals, therapy services, and additional physician orders, and the Comprehensive Care Plan was delayed. A Care Conference was held, but the care plan was not provided to the resident.
A hospice resident with severe cognitive impairment and multiple health conditions was left unattended with an uncovered lunch tray for 40 minutes. Despite needing assistance, the resident was not properly helped until prompted by a state surveyor. The facility lacked a specific policy for assisting residents with eating, and the DON acknowledged the oversight.
The facility failed to implement a Restorative Program for three residents requiring assistance with ADLs. A resident with intact cognition expressed a need for individualized leg exercises, which were not provided. Another resident was dependent on staff for several ADLs and required a mechanical lift, yet did not receive restorative services. A third resident had functional limitations in ROM and required substantial assistance, but their Care Plan lacked restorative programs. The facility administrator acknowledged the absence of restorative programs, with plans for future implementation.
A facility failed to follow professional standards for administering medications via a gastric tube for a resident with dysphagia. The RN did not use a table barrier, check tube placement, or follow Enhanced Barrier Precautions (EBP) during the process, as required by the care plan and facility policy. The Infection Control RN confirmed these deficiencies and noted the need for improved processes.
A facility failed to manage oxygen use for a resident with coronary artery disease and heart failure, as the MAR and TAR lacked documentation of the physician's order for oxygen therapy. The resident used oxygen continuously in the room, contrary to the order for bedtime use only. The DON and Administrator confirmed the transcription error and the need for staff and resident education.
A facility failed to attempt a Gradual Dose Reduction (GDR) for a resident on psychotropic medications, including Sertraline and Olanzapine, over a nine-month period. Despite the prescribing provider's assessment of the regimen as appropriate, no trial of a lower dose was attempted. The Consultant Pharmacist admitted an oversight in not recommending a GDR for Olanzapine, which should have been suggested twice in the first year. The facility's policy requires consideration for dose reduction, which was not followed.
A CNA was observed using bare hands to assist a resident with eating, contrary to the facility's food handling policy. The resident, who required assistance due to severe impairments, was given food directly by hand, and a previously used paper towel was employed during the meal. The DON highlighted the need for hand hygiene and the use of barriers like gloves or utensils.
A resident with an indwelling urinary catheter experienced inadequate infection control practices by staff, leading to a deficiency in preventing UTIs. The resident, with a history of multiple UTIs and chronic conditions, did not receive proper catheter care as staff failed to perform hand hygiene at critical points and did not clean the catheter tubing as required. The facility's policies for hand hygiene and catheter care were not followed, contributing to the deficiency.
A resident with multiple medical conditions was not provided a barrier during personal care, resulting in dried cream flakes on the bed's blanket. The CNA did not change the blanket after care, and the ADON acknowledged the oversight, which violated the facility's dignity policy.
A resident with cirrhosis and failure to thrive was not properly monitored for bowel movements, leading to a lack of physician notification about the need for treatment change. The resident, who was on Lactulose, had only one bowel movement over four days, resulting in increased confusion and hallucinations, and was eventually sent to the ER. The facility lacked a standardized bowel protocol, and the failure to notify the physician violated the facility's policy on significant treatment changes.
A resident with a stage 3 pressure injury did not have wound care treatments documented on multiple occasions, despite orders for daily care. The resident confirmed he did not refuse treatment. The DON and ADON acknowledged the lack of documentation and could not verify if treatments were completed, despite the facility's policy requiring adherence to active orders.
The facility failed to follow infection control practices during catheter care for two residents. A CNA did not change gloves after touching potentially contaminated surfaces and did not change an incontinence brief for one resident. For another resident, the CNA did not wear a gown despite the requirement for Enhanced Barrier Protection. The ADON acknowledged these lapses.
A facility failed to ensure privacy for a resident during perineal care, as observed when two CNAs did not close the window curtains while providing care. The resident, who required total assistance and was incontinent, was exposed to public view from a busy street, violating her right to dignity and respect.
A resident with severe cognitive impairment and incontinence issues did not receive proper perineal care from CNAs, as observed during a survey. The CNAs failed to cleanse the resident's buttocks or hips after cleaning the mid gluteal region, which was against the facility's policy requiring thorough cleansing of all affected areas.
Facility staff failed to follow infection control protocols during care for two residents with severe cognitive impairment and incontinence. CNAs did not change gloves between different stages of care, contrary to facility policy, leading to potential contamination. The staff continued to use the same gloves for multiple tasks, including handling personal items and applying barrier cream.
Failure to Use Gait Belts, Lifts, and Adequate Supervision Resulting in Resident Falls With Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, follow its own transfer and ambulation policies, and use appropriate assistive devices to prevent accidents for multiple residents. For one resident with diabetes, stroke, heart failure, severe cognitive impairment (BIMS 3), muscle weakness, and limited ROM, the MDS showed she did not walk 10 feet due to medical/safety concerns and normally used a manual wheelchair. Her care plan identified a brain injury, impulsivity, and non‑compliance with directions, and directed staff to assist her to ambulate with a gait belt and front‑wheeled walker and to transfer using a non‑mechanical lift. She was not on a restorative program, and staff interviews indicated she was mostly in bed, required significant assistance, and had not been ambulating to the bathroom for some time, with CNAs typically changing her in bed and transferring her to a recliner with assistance of two and a gait belt. On the date of the fall, an incident report and nursing progress notes documented that a CNA reported the resident lost her balance and fell while ambulating to the bathroom, and that the resident was found on the floor on her right side, screaming in pain, without a gait belt, with her walker tipped over nearby and her wheelchair by the bathroom wall. The RN and CNA assisted her back to bed without using a mechanical lift, despite her inability to bear weight, by grabbing her pants and sliding and lifting her into bed. EMS documentation and ED records described that EMS found her after a fall from her wheelchair with severe right shoulder pain, and the ED history stated she fell when trying to use her wheelchair for support while getting out of the shower. Imaging revealed an impacted right humeral fracture and a comminuted olecranon fracture with elbow effusion, and she was admitted for trauma management. The resident’s daughter reported that her mother had been mostly bedbound, could not walk during prior visits, and that she was told by the RN that the CNA had followed the resident with a wheelchair as she walked to the bathroom, which conflicted with her understanding of her mother’s abilities. Staff interviews revealed inconsistent accounts of the event and failures to follow policy and care plan directions. The RN stated the resident had not gotten up by herself in a long time, that she was found on the floor without a gait belt, and that a mechanical lift was not used to get her off the floor, contrary to facility policy for non‑weight‑bearing or extensive‑assist residents. The CNA involved gave differing versions of the incident, at one point stating the resident was assisted up from the recliner with a gait belt and walker and that a mechanical lift was used to get her into bed, which was contradicted by another CNA who entered the room and observed the resident being placed in bed without a gait belt and without a mechanical lift present. Investigative notes documented that the resident was impulsive, did not always follow directions or wait for staff, and had been caught ambulating on her own, yet the facility’s own documentation also stated she had not been ambulating and required significant assistance, indicating a lack of consistent implementation of care plan interventions and safe transfer policies. A second resident with weakness, unsteadiness on feet, and intact cognition required one‑person assistance with ambulation and maximal assistance for hygiene and toileting. Her care plan directed staff to assist with ambulation and transfers with moderate assistance of one staff using a gait belt and front‑wheeled walker. On the day of her incident, she walked to the bathroom with her walker, used the toilet, and activated the call light to request staff assistance for peri care. She reported that she waited a long time for help, that when the CNA arrived and began assisting her, she felt herself slipping and told the CNA, who responded "I've got you" but did not prevent her from sliding to the floor. She stated the CNA held her by the arm rather than using a gait belt, and that a second agency CNA came in and both attempted to get her into the wheelchair by her arms while she was unable to stand due to right leg pain, before the nurse arrived. Facility documentation of this fall described that the resident’s legs became weak during peri care and she was lowered to the floor, and that she was later found in the bathroom in a wheelchair with a gait belt on. The NP’s progress note, however, recorded the resident’s description that she slid down between the toilet and wheelchair when the caregiver did not use a gait belt despite her warnings that she was slipping. X‑rays revealed an acute trimalleolar fracture of the right ankle, and she required hospital evaluation, pain management with Fentanyl, and stabilization with a soft cast. The facility’s fall report and physician form characterized the event as a fall during transfer from toilet to wheelchair with legs becoming weak, but did not reconcile the resident’s account that a gait belt was not used and that she was lifted by her arms by two agency CNAs. Interviews with the agency CNAs involved in this second resident’s care showed that they were new to the facility, had not been oriented to the electronic record (PCC), did not know resident‑specific information, and were unfamiliar with the facility’s equipment and procedures. One agency CNA described the day as hectic, with staff sick and leaving, and stated that she answered a bathroom call light for a resident she did not know, assisted with peri care, and the resident started to fall. She called another agency CNA for help, and together they struggled to get the resident into the wheelchair before a nurse arrived; she reported that no one asked her what happened and she was not contacted afterward. The second agency CNA similarly described the shift as chaotic, stated she had no idea how to operate the facility’s mechanical lifts, and reported that she found the first CNA with the resident on the floor in front of the toilet, called for a nurse, and helped get the resident up. Nursing and administrative staff interviews acknowledged that agency CNAs were working with minimal orientation, that the ADON and DON were not directly overseeing their onboarding, and that there was uncertainty about how agency staff accessed care plans and fall‑prevention information, contributing to failures to use gait belts and appropriate transfer methods as required by facility policy. Facility policies on fall occurrences, gait belts, mechanical lifts, and non‑mechanical transfers specified that gait belts should be used when a patient is weak but can bear some weight and is a fall risk, and that mechanical lifts should be used for non‑weight‑bearing or total/extensive assist transfers, while non‑mechanical lifts are appropriate only when a patient can bear partial weight and follow commands. In both residents’ cases, the documented conditions (weakness, impaired balance, need for significant assistance, and in one case inability to bear weight after the fall) and the care plan directions were not consistently followed. Staff failed to use gait belts during transfers and ambulation, did not use mechanical lifts when residents could not safely bear weight, and did not ensure that agency CNAs were adequately oriented to resident needs and facility safety policies, leading to falls with significant injuries for the residents involved.
Repeated Infection Control Deficiency
Penalty
Summary
The facility failed to ensure an effective process to address previously identified quality deficiencies, resulting in an Infection Prevention & Control deficiency for the fifth consecutive recertification survey. The CASPER Report indicated that the facility had received this deficiency in August 2019, December 2021, March 2023, and December 2023. At the conclusion of the recertification survey on February 20, 2025, the facility was again found to be non-compliant in this area. The facility's QAPI Plan, dated June 23, 2024, included a monitoring process with multiple data sources but did not identify a process to address previously identified quality deficiencies. The Administrator stated that the facility had provided staff education on enhanced barrier precautions, conducted staff audits on peri care, and offered one-on-one education on infection control issues as needed.
Deficiencies in Personalized Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for five residents, as required by the 2024 Resident Assessment Instrument (RAI) Manual and facility policy. For Resident #22, the care plan did not specify personalized non-pharmacological interventions for managing anxiety and depression, nor did it detail the target behaviors or potential side effects of the psychotropic medications prescribed. Similarly, Resident #86's care plan lacked personalization in non-pharmacological interventions and failed to identify specific target behaviors for monitoring. Resident #7's care plan did not include specific target behaviors associated with the use of antipsychotic medication, nor did it provide non-pharmacological interventions for staff to attempt if behaviors were observed. Staff interviews revealed a lack of awareness of the resident's target behaviors, indicating a gap in communication and documentation. Resident #25's care plan also lacked interventions for monitoring psychotropic targeted behaviors and did not personalize interventions for acute expressions of behavior. For Resident #87, the care plan required staff assistance of two for bed mobility, but staff interviews indicated that care was being provided by a single staff member, contrary to the care plan. This inconsistency suggests a lack of adherence to the care plan and potential risk to the resident. Overall, the facility's failure to personalize and implement comprehensive care plans for these residents highlights deficiencies in care planning and monitoring processes.
Deficiency in Puree Diet Serving Sizes and Food Temperature Monitoring
Penalty
Summary
The facility failed to provide appropriate side dish serving sizes for residents on puree diets and did not obtain final cooking temperatures for resident meal items. During an observation, a cook prepared puree pea servings for residents on a puree diet, using a #12 scoop size to determine the portion. However, there was no communication to other kitchen staff regarding the appropriate serving size, leading to another cook providing only one scoop instead of the required two scoops for the puree diets. This lack of communication resulted in residents not receiving the correct portion sizes as per the facility's policy. Additionally, during the lunch service, a kitchen staff member prepared a frozen individual serving of macaroni and cheese and instant potatoes without obtaining the final cooking temperatures before plating them for resident trays. The Certified Dietary Manager acknowledged the oversight and stated that the expectation was for kitchen staff to ensure food temperatures reach 165 degrees Fahrenheit before serving. The facility's policy requires that food temperatures be taken and documented to ensure proper serving temperatures, which was not adhered to in this instance.
Resident Participation in Care Planning Not Ensured
Penalty
Summary
The facility failed to ensure that a resident was given the opportunity to participate in the development and implementation of their person-centered plan of care. Specifically, Resident #9, who has intact cognition as indicated by a BIMS score of 15 out of 15, did not recall attending any recent care conference meetings or meetings to discuss concerns or changes. The resident, who has diagnoses of anemia, arthritis, and vision deficits, reported attending resident council meetings but not any recent care discussions. The last documented participation of the resident in a team meeting was on 10/29/24, where the resident expressed concerns about new insurance. Interviews with facility staff confirmed that the resident had not been involved in a formal care conference since the last annual updates were completed in December 2024. The Social Worker acknowledged that the last care conference the resident participated in was in October 2024, and the RN confirmed that while the required MDS assessments and care plan updates were completed, a formal meeting with the resident did not occur. The facility's Administrator acknowledged the need for process improvements to ensure residents have the option to participate in their care planning.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to accurately reflect the status of three residents in their Minimum Data Set (MDS) assessments, as identified through clinical record review and staff interviews. Resident #83's Pre Admission Screening and Resident Review (PASRR) indicated a requirement for Level II services due to a diagnosis of Major Depressive Disorder, but the MDS dated 11/21/24 did not document this requirement. Similarly, Resident #95's PASRR identified a need for Level II services due to Schizoaffective disorder, but the MDS dated 1/20/25 failed to document this. These discrepancies suggest a failure to follow the 2024 Resident Assessment Instrument (RAI) Manual's guidelines for accurately coding PASRR Level II conditions. Additionally, Resident #86's records showed inconsistencies regarding hospice care documentation. The resident was initially enrolled in hospice care on 5/1/24, discharged on 10/6/24 due to hospital admission, and re-enrolled on 10/9/24. However, the Quarterly MDS dated 11/6/24 did not reflect the resident's hospice status during the lookback period. The MDS Coordinator acknowledged the oversight in Resident #83's assessment, attributing it to a change in PASRR status and a different employee completing the assessment. The facility lacks a specific policy for MDS completion, relying instead on the RAI manual guidelines.
Failure to Implement Timely Baseline Care Plan
Penalty
Summary
The facility failed to implement a complete Baseline Care Plan within 48 hours of admission for a resident, as required by their policy. The resident, who had an intact cognition as indicated by a BIMS score of 14, reported not having seen his care plan and expressed a need for assistance with discharge planning, meals, and laundry. The facility's process involved creating a baseline care plan from the User-Defined Assessment (UDA) for admission, which was integrated into the Electronic Health Record. However, the baseline care plan did not include the resident's initial goals, therapy services, or additional physician orders beyond psychotropic and diuretic medications. The Comprehensive Care Plan, which was supposed to be developed within 48 hours, was delayed and only included discharge planning and additional cardiac medications after the deadline. Furthermore, a Care Conference was held with the resident and a nursing staff member, but a copy of the care plan was not offered to the resident. The facility's policy, revised in July 2023, mandates that the baseline care plan should minimally include initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, which was not adhered to in this case.
Failure to Assist Hospice Resident with Eating
Penalty
Summary
The facility failed to provide necessary eating assistance to a hospice resident with severely impaired cognition and multiple health conditions, including congestive heart failure, coronary artery disease, diabetes mellitus, and chronic respiratory failure. The resident, who was unable to feed himself, was observed with an uncovered lunch tray set up on his bedside table while he was asleep in an upright position. Despite being identified as needing assistance, the resident was left unattended with his meal for 40 minutes. Staff interactions included a CNA and an LPN, who eventually assisted the resident with drinking and attempted to feed him, but the food was not reheated until prompted by a state surveyor. The resident's care plan indicated the need for set-up assistance with eating, and the hospice care plan directed the hospice aide to assist with meals. However, the facility did not have a specific policy for assisting residents with eating. The Director of Nursing acknowledged that the tray should not have been left in the resident's room and should have been reheated when the resident was ready to eat. The resident eventually ate about 50% of his lunch after the food was reheated.
Failure to Implement Restorative Program for Residents
Penalty
Summary
The facility failed to implement and maintain a Restorative Program for three residents who required assistance with their Activities of Daily Living (ADL). Resident #22, with intact cognition, required supervision for various ADLs but did not receive any Restorative Nursing services. The resident expressed a desire for more individualized exercise, particularly for leg exercises, which were not provided. The Care Plan for Resident #22 did not document any restorative nursing programs, despite the resident being at risk for pain and falls due to limited mobility. Resident #74 was dependent on staff for several ADLs and required substantial assistance for others, yet did not receive Restorative Nursing services. The Care Plan noted the resident's risk of falls and need for a mechanical lift but lacked any restorative programs. Similarly, Resident #86 had functional limitations in range of motion and required substantial assistance for multiple ADLs. The Care Plan identified risks related to limited mobility but did not include restorative programs. The facility administrator acknowledged the absence of restorative programs and stated that the therapy department was not writing any programs at the time, with plans for future implementation.
Failure to Follow Protocols for Gastric Tube Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for a resident requiring medications via a gastric tube. The resident, who had a feeding tube due to dysphagia, was observed during a medication administration process where the registered nurse did not use a table barrier for the medication cups and supplies, did not check the tube placement, and did not follow Enhanced Barrier Precautions (EBP) by wearing a gown and gloves. The care plan for the resident directed staff to check gastric-tube placement prior to feeding and to follow EBP to minimize the risk of transmission during high-contact care activities. During the observation, the registered nurse placed the medication supplies on the bedside table without a barrier, leading to water spillage. The nurse also failed to check the tube placement or residual as per the physician's orders documented in the Medication Administration Record (MAR). The facility's policy on medication administration via enteral tubes required verification of tube placement, checking residuals, and flushing the tube with a minimum of 30 milliliters of water. The Infection Control RN confirmed the failure to follow EBP and the lack of a barrier for supplies, acknowledging the need for education to improve the process.
Failure to Manage Oxygen Use for a Resident
Penalty
Summary
The facility failed to manage oxygen use for a resident, as evidenced by the lack of proper documentation and adherence to physician orders. The resident, who had intact cognition and multiple diagnoses including coronary artery disease and heart failure, was prescribed oxygen therapy at 2 liters per nasal cannula at bedtime. However, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January and February did not include this order, indicating a failure in transcription and documentation. The resident reported using oxygen at all times while in the room and expressed confusion about the need for oxygen outside the room. Observations confirmed the resident was using oxygen at 2 liters per nasal cannula both day and night. The Director of Nursing and the Administrator acknowledged the oversight in transcription and agreed that staff and the resident should be educated about the physician's orders. The facility's policy on transcription of physician orders was not followed, contributing to the deficiency.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) of psychotropic medications for a resident diagnosed with non-Alzheimer's dementia, depression, psychotic disorder, and PTSD. The resident received antipsychotic and antidepressant medications, including Sertraline and Olanzapine, without any attempt to reduce the dosage over a nine-month period. The prescribing provider deemed the medication regimen appropriate and consistent with the diagnosis, stating the resident was stable at the optimal dose. However, the facility did not attempt a trial of a lower dose to determine if the resident could maintain stability on a reduced dosage. The Consultant Pharmacist acknowledged an oversight in not recommending a GDR for the resident's Olanzapine, which should have been suggested twice within the first year of admission. The Director of Nursing (DON) mentioned that the resident's family had not previously voiced concerns about medication dosage reductions, despite a past incident where lowering dosages was unsuccessful. The facility's policy on Medication Regimen Review requires consideration for dose reduction and optimal dosing, which was not adhered to in this case.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure proper food handling practices were followed while assisting a resident to eat. During lunch, a Certified Nursing Assistant (CNA) was observed using their bare hand to give a resident a sandwich and hash brown patty, despite eating utensils being available on the resident's plate. The CNA also used a paper towel, which they had previously used to dry their hands, to assist the resident throughout the meal. This action was contrary to the facility's policy, which requires the use of gloves, tongs, or other dispensing devices to handle ready-to-eat food. The resident involved was severely impaired in daily decision-making and had multiple diagnoses, including adult failure to thrive, depression, epilepsy, and hydrocephalus. The resident also had severe vision impairment and moderate hearing difficulties, requiring supervision or touching assistance when eating. The Director of Nursing (DON) stated that staff should complete hand hygiene before and after meal assistance and use a barrier, such as gloves or utensils, to hand food to residents. The DON also emphasized the importance of separating dirty items, like a used paper towel, from clean areas, such as a meal place setting.
Inadequate Infection Control Practices for Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices for a resident with an indwelling urinary catheter, leading to a deficiency in preventing urinary tract infections (UTIs). The resident, who had a history of chronic kidney disease, heart failure, obstructive uropathy, diabetes mellitus, and quadriplegia, was observed with an indwelling catheter and had experienced multiple UTIs in the past. The care plan for the resident included specific instructions for catheter care, which were not adequately followed by the staff. During an observation, two staff members, a Certified Nurse Aide (CNA) and a Certified Medication Aide (CMA), performed catheter and perineal care for the resident. They failed to perform hand hygiene at critical points, such as after touching potentially contaminated surfaces and before handling clean supplies. Additionally, the CNA did not clean the catheter tubing or the part of the resident's scrotum that contacted the catheter tubing, which was contrary to the facility's policy for catheter care. The Director of Nursing (DON) and the Infection Preventionist (IP) were present during the observation and acknowledged the lapses in infection control practices. The CNA admitted to not performing hand hygiene between certain tasks and not cleaning the catheter tubing unless there was bowel incontinence, which was incorrect according to the facility's policy. The facility's hand hygiene policy and catheter care policy were not adhered to, contributing to the deficiency in infection prevention and control.
Failure to Maintain Resident Dignity During Personal Care
Penalty
Summary
The facility failed to uphold the dignity of a resident during personal care activities. A Certified Nursing Assistant (CNA) was observed assisting a resident with personal care without providing a barrier on the bed's blanket, resulting in flakes of dried cream landing on the blanket. The resident, who had intact cognition and required assistance with activities of daily living due to various medical conditions, was not offered a towel barrier during the care process. After completing the care, the CNA did not change the blanket, leaving the dried cream flakes on it. The Assistant Director of Nursing (ADON) acknowledged the oversight, noting that a barrier should have been provided and the blanket should have been changed after the care was completed. The facility's policy on Resident Rights-Dignity and Respect emphasizes treating residents with dignity and respect, which was not adhered to in this instance. The incident involved a resident with multiple medical diagnoses, including heart failure and morbid obesity, who required partial to moderate assistance for personal care.
Failure to Notify Physician of Treatment Change for Resident with Cirrhosis
Penalty
Summary
The facility failed to notify the physician of a needed change in treatment for a resident diagnosed with cirrhosis and failure to thrive. The resident was prescribed Lactulose, a laxative, to be administered four times a day to help manage cirrhosis by removing toxins from the blood. However, the resident's bowel movement record indicated only one bowel movement over a four-day period, from July 12 to July 15, 2024. Despite this, there was no communication with a medical prescriber regarding the lack of bowel movements until the fourth day. On July 16, 2024, the resident was sent to the emergency room due to increased confusion, slow processing of information, and hallucinations. The hospital discharge summary noted the resident was admitted for acute metabolic encephalopathy secondary to hepatic encephalopathy, with an abdominal x-ray revealing a large amount of colonic stool and a distended gastrointestinal tract. The facility's Director of Nursing stated there was no standardized bowel protocol, and each resident had an individualized protocol. The facility's policy required immediate notification of the physician when there was a need to alter treatment significantly, which was not adhered to in this case.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to ensure that wound care treatments were completed as ordered for a resident with a stage 3 pressure injury on the right heel. The resident, who had intact cognition and diagnoses including heart failure, diabetes, and morbid obesity, was supposed to receive daily wound care treatments. However, there were multiple instances where documentation of the wound care was missing, specifically on 6/7/24, 6/26/24, 6/29/24, 8/7/24, 8/21/24, 9/11/24, 9/14/24, and 10/30/24. The resident confirmed that he did not refuse or decline the wound care treatments. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that they were aware of the lack of documentation for the wound care treatments. They acknowledged that a combination of agency staff and permanent facility staff were working on the dates in question, but neither could verify if the treatments were completed. The facility's policy required that active orders be followed and carried out as written, but this was not adhered to in the case of the resident's wound care.
Infection Control Lapses in Catheter Care
Penalty
Summary
The facility failed to adhere to infection control practices during urinary catheter care for two residents. Resident #8, who has intact cognition and multiple diagnoses including heart failure and renal failure, was observed receiving catheter care from a CNA. The CNA did not change gloves after touching potentially contaminated surfaces such as the resident's shoes and bed blankets before handling the catheter. Additionally, the CNA did not change the resident's incontinence brief after completing the care. The Assistant Director of Nursing (ADON) acknowledged these lapses in infection control practices. Resident #5, also with intact cognition and similar medical conditions, was observed during a catheter care procedure where the CNA did not wear a gown, despite the presence of an Enhanced Barrier Protection (EBP) sign indicating the need for such precautions. The CNA cited the absence of gowns in the bathroom as the reason for not wearing one. The ADON confirmed the requirement for gown use during high-contact care activities, as outlined in the facility's policy on Enhanced Barrier Precautions.
Failure to Provide Privacy During Perineal Care
Penalty
Summary
The facility failed to provide privacy for a resident during perineal care, which is a violation of the resident's right to dignity and respect. During an observation, two Certified Nursing Assistants (CNAs) were seen transferring a resident from a wheelchair to her bed using a lift device. The CNAs then proceeded to provide perineal care without closing the shade or curtains of the resident's window, which faced a busy street. This lack of privacy exposed the resident to public view, compromising her dignity. The resident involved required total assistance for personal hygiene, lower body dressing, and toileting hygiene, as documented in the Quarterly Minimum Data Set (MDS). The MDS also noted that the resident was always incontinent of bowel and bladder. The facility's policy on Resident's Rights emphasizes the importance of treating residents with dignity and respect, which was not adhered to in this instance.
Failure to Provide Proper Perineal Care
Penalty
Summary
The facility failed to properly provide perineal care for one resident, identified as Resident #9, who was observed to have several medical conditions including Benign Prostatic Hyperplasia, Aphasia, Cerebrovascular Accident, and Non-Alzheimer's Dementia. The resident had a severely impaired cognitive status with a BIMS score of 7 out of 15 and was frequently incontinent of bowel and bladder, requiring staff assistance for toileting hygiene. During an observation, two CNAs, Staff A and Staff B, were seen providing perineal care to the resident. Staff A cleaned the anterior perineal area but failed to cleanse the resident's buttocks or hips after cleaning the mid gluteal region, despite the presence of stool. This action was contrary to the facility's Incontinent Care policy, which requires cleansing from the perineum toward the rectum and turning the resident to cleanse all affected areas.
Infection Control Breach During Resident Care
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control protocols during personal care for two residents. Resident #9, who has severe cognitive impairment and is frequently incontinent, was observed receiving care from two CNAs. During the care, one CNA did not change gloves after providing initial care and before repositioning the resident and cleansing the gluteal region, which involved contact with stool. The CNA only changed gloves after removing the soiled brief, which is contrary to the facility's policy that requires glove removal and hand hygiene before changing gloves. Similarly, Resident #10, who also has severe cognitive impairment and is always incontinent, was observed receiving care from two CNAs. One CNA failed to change gloves after cleansing the resident's anterior perineal area and before proceeding to cleanse the gluteal region and apply barrier cream. The CNA continued to use the same gloves to handle the resident's clothing and bedding, and to access items from the bedside stand. This practice was inconsistent with the facility's policy, which mandates glove removal and hand hygiene before donning new gloves during the care process.
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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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