Harvest Acres Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Keota, Iowa.
- Location
- 204 North Keokuk Washington Road, Keota, Iowa 52248
- CMS Provider Number
- 165355
- Inspections on file
- 20
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Harvest Acres Nursing And Rehab during CMS and state inspections, most recent first.
Two residents did not have comprehensive, person-centered care plans developed or updated as required. For one, the care plan lacked individualized interventions for cognitive impairment, behavioral issues, and adjustment needs, despite frequent staff attention and wandering behaviors. For another, the plan was missing specific interventions for psychotropic medication use, behavioral concerns, and did not address anxiety or depression. Facility leadership confirmed the care plans were incomplete and not current.
A resident with severe cognitive impairment and Type II diabetes had multiple blood glucose readings over 400 mg/dl without documented provider notification, despite physician orders and facility policy requiring such action. Staff interviews confirmed the expectation to notify providers for high readings, but this was not consistently done or documented, and the DON acknowledged gaps in documentation.
Surveyors identified multiple medication administration errors, including late administration of Levothyroxine, off-label and early use of PRN melatonin, improper insulin injection technique, and failure to locate or document a missing scopolamine patch. These errors involved residents with complex medical needs and were not followed by appropriate provider notification or documentation, resulting in a medication error rate above 5%.
An LPN was observed administering medications without adhering to proper hand hygiene, including handling pills with bare hands, applying a medicated patch without washing afterward, and touching multiple surfaces and personal items between medication passes. Despite facility policy and infection control training, the LPN administered medications to multiple residents without washing or sanitizing hands between residents.
A facility failed to protect residents from sexual and physical abuse. A cognitively impaired resident was subjected to unsolicited sexual touching by another resident, despite family instructions against such contact. Additionally, a resident with a history of aggression physically assaulted multiple residents. The facility's policies on abuse were not effectively enforced, leading to these incidents.
The facility failed to investigate allegations of abuse and resident incidents, affecting multiple residents. One resident with cognitive impairment sustained a fracture of unknown origin, and the facility's investigation lacked a root cause analysis. Another incident involved two residents with a mutual friendship, where one allegedly groped the other, but the facility did not document or investigate the incident. Additionally, a resident with a history of aggression was not adequately monitored, leading to multiple incidents. The facility did not report these incidents or separate the involved residents.
The facility failed to report abuse allegations timely, including staff rough treatment and resident altercations, involving ten residents. Incidents included a resident's shoulder fracture of unknown origin and inappropriate touching between residents. The facility did not adhere to its abuse reporting policy, contributing to Immediate Jeopardy to resident safety.
The facility failed to adequately assess and intervene for residents experiencing changes in condition. A resident experienced a significant decline after a fall, leading to a subdural hematoma and death. Another resident did not receive proper post-fall neurological assessments, and a third resident with dysphagia was served incorrect food consistency, causing excessive coughing. These incidents highlight deficiencies in resident care and monitoring.
The facility failed to ensure proper evaluation and use of mobility devices, leading to falls and injuries for residents. A resident with impaired cognition was given an inappropriate walker, resulting in a fall and a shattered humerus. Another resident experienced multiple falls due to inadequate supervision, despite being at high risk. Additionally, a resident with a seizure disorder was not properly supervised during transfers, leading to a fall. These deficiencies highlight a lack of adherence to care plans and insufficient monitoring.
Two residents in an LTC facility were served incorrect diets, posing potential health risks. A resident requiring a pureed diet due to swallowing difficulties was given regular food, leading to excessive coughing. Another resident with severe cognitive impairment was served coleslaw instead of steamed cabbage, contrary to their mechanical soft diet order. Staff acknowledged the errors, which violated the facility's therapeutic diet policy.
The facility failed to provide sufficient nursing staff, resulting in multiple incidents where a resident with severely impaired cognition physically assaulted others, and another resident with a history of seizures and falls did not receive timely assistance, leading to a fall and injury. Staff interviews revealed inadequate staffing levels, particularly during night shifts, which hindered effective monitoring and care.
The facility failed to address previously identified deficiencies, resulting in repeat issues with advanced directives, care plan revision, incontinence care, and the absence of a qualified Infection Preventionist. Despite monthly QA meetings and ad hoc QAPI efforts, the facility's QAPI plan was not effectively implemented, as evidenced by the recurrence of these deficiencies.
The facility failed to follow accepted clinical practices by preparing medications in advance for several residents. An LPN was observed with unlabeled medication cups containing multiple medications in the medication cart, intended for residents who had not yet received them. The DON confirmed that medications should not be set up ahead of time, and the facility's policy requires drugs to be stored securely and in their original packaging.
The facility did not employ a certified Infection Preventionist as a required member of the QA committee to oversee infection control. The DON acted in this role without confirmed certification, and no Infection Preventionist was present at QAPI meetings. The facility could not provide certification for an Infection Preventionist, despite policy requirements.
The facility did not have a certified Infection Preventionist to oversee its Infection Prevention and Control Program. The DON acted in this role, but the facility could not confirm their certification. During a state survey, the facility was unable to provide documentation of a certified Infection Preventionist, and the DON was unavailable for further information.
A facility failed to maintain resident dignity and respect, particularly for a resident with moderate cognitive impairment who was found in unsanitary conditions multiple times. Hospice providers noted the resident was often left in soiled incontinence products, and a CNA made inappropriate comments in the dining room. Staff interviews highlighted concerns about the CNA's demeanor, contradicting the facility's policy on treating residents with kindness and respect.
The facility failed to protect residents' personal and medical information, as observed by the State Agency. On several occasions, the computer at the nurses' desk was left unattended with the PCC system open, displaying residents' names. An LPN also left a resident's chart open while stepping away. The facility's policy prohibits unauthorized access or disclosure of resident information.
A facility failed to notify the State LTC Ombudsman of a hospital transfer for a resident with severe cognitive impairment. The resident, diagnosed with diabetes, non-Alzheimer's dementia, and a psychotic disorder, was transferred to the ER for evaluation and treatment. The facility's policy required notification of such transfers, but documentation of this notification was missing.
The facility failed to update care plans for four residents after significant changes in their conditions and treatments. A resident's care plan was not revised after discontinuing antidepressant medication, another's did not reflect the start of hospice services, and a third's inaccurately stated their transfer abilities. Additionally, a resident's care plan lacked updates for new skin concerns identified in a review.
A facility failed to maintain consistent documentation of a resident's code status, leading to confusion between CPR and DNR orders. The resident, with severely impaired cognition, had conflicting information in their IPOST form and electronic orders. Staff and the DON acknowledged the discrepancy, noting the resident's status changed to DNR after hospice services began, but the paper chart was not updated. The facility's policy required CPR if DNR status was unclear, emphasizing the need for accurate documentation.
A facility failed to conduct a significant change assessment for a resident who began hospice services. The resident, with severely impaired cognition, started hospice care, but the MDS assessment did not reflect this change, and the next assessment was still in progress. Facility policy requires immediate comprehensive assessment for significant changes, but this was not done.
The facility failed to provide timely incontinence care and positioning for three residents and eating assistance for one resident. A resident with severe cognitive impairment was left in a soiled brief for over three hours, another was found in a urine-soaked bed, and a third with moderate cognitive impairment was not assisted with eating. The facility's policies for toileting and meal assistance were not followed.
The facility failed to provide ongoing, resident-centered activities for two residents with severe cognitive impairments. Despite care plans outlining various activities, observations and documentation revealed limited engagement, with residents primarily watching TV or movies. Staff interviews indicated residents were often bored, and the Activity Director struggled to provide adequate activities due to additional duties.
A resident with severely impaired cognition and frequent urinary incontinence experienced a delay in the treatment of a UTI due to slow lab processing and communication issues. Despite showing symptoms on 10/25/24, the urinalysis was not sent until 10/29/24, and the culture results were received on 11/1/24. The antibiotic treatment was not initiated until 11/5/24, contrary to the facility's antibiotic stewardship policy requiring prompt communication of lab results to prescribers.
A facility failed to ensure bed rail safety for a resident with severely impaired cognition, resulting in gaps larger than the recommended 4 3/4 inches. The resident, who used bed rails for mobility and security, was at risk of entrapment or injury. The Maintenance Director was unaware of the gap size requirement, and the Administrator believed nursing and therapy staff should check side rail safety. The facility's policy required compliance with FDA guidelines, which was not followed.
A facility failed to provide necessary behavioral health care for a resident with a history of traumatic brain injury, depression, and alcohol abuse. The resident exhibited various behavioral symptoms, but the care plan lacked recent interventions to guide staff. The facility's policy did not address psychiatric services, which were inconsistent due to staffing changes. The absence of documentation for psychiatric services beyond April and the need to reestablish consistent services contributed to the deficiency.
A facility's medication error rate reached 12% due to an LPN administering an incorrect dose of Vitamin D3, failing to prime insulin pens, and not timing insulin administration with meals. The errors were identified through observations and interviews, revealing non-compliance with medication orders and facility policies.
A resident with diabetes received rapid-acting insulin without timely food consumption, as breakfast was delayed after insulin administration. Additionally, an LPN failed to prime insulin pens before use, contrary to instructions. The facility's policy requires medications to be administered according to orders, including timing, which was not adhered to in this case.
The facility failed to serve menu items as listed for two residents on a pureed diet. One resident with Cerebral Palsy and another with nutritional problems were not given the menu items specified, such as smoked sausage and roll with margarine. Instead, they were served a pureed hot dog with bun and sauerkraut, deviating from the planned menu.
The facility failed to maintain accurate medical records for two residents, one receiving hospice services and another with a change in condition. Discrepancies were found in hospice documentation, with records inaccurately indicating continued hospice care after discharge. For the second resident, documentation inconsistencies were noted regarding an unwitnessed fall and shoulder fracture, with no clear cause identified. The facility's policy requires complete and accurate documentation to ensure effective communication among the care team.
A facility failed to follow infection control practices when an LPN administered medications to a resident. The LPN picked up a dropped pill with her bare hand and placed it back in the resident's mouth, contrary to the facility's policy requiring the use of gloves. The DON from a sister facility confirmed the need for gloves in such situations.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two of five residents reviewed. For one resident with severe cognitive impairment, multiple diagnoses, and a recent admission, the care plan lacked specific, individualized information in focus areas such as hypertension, adjustment to the facility, trauma history, and behavioral problems. Interventions were generic and did not address the resident's unique triggers, behaviors, or needs, nor were they updated as required at the 14-day mark or with subsequent revisions. Observations showed the resident required frequent 1:1 staff attention, wore a wander guard, and exhibited behaviors such as wandering and difficulty with redirection, none of which were adequately addressed in the care plan. Another resident, who had intact cognition and multiple medical conditions including a lumbar fracture, hypertension, anxiety, depression, and chronic pain, also had an incomplete care plan. The plan did not include individualized interventions for psychotropic medication use or behavioral issues, and failed to address anxiety and depression altogether. Interventions for skin integrity were not resident-specific, and documentation of actual skin impairments or treatments was missing. Revisions to the care plan did not consistently reflect the resident's current status or needs. Interviews with facility leadership confirmed that care plans were expected to be complete and person-centered, but acknowledged that the plans reviewed were incomplete and lacked current, individualized information. The facility's policy required comprehensive care plans with measurable objectives and timeframes to be developed within specified timeframes, but this standard was not met for the residents reviewed.
Failure to Notify Provider of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to notify the provider when a resident's blood glucose levels exceeded 400 mg/dl, as required by physician orders and facility policy. The resident in question had a diagnosis of Type II diabetes mellitus, was severely cognitively impaired, and was receiving insulin therapy. The care plan and physician orders specifically directed staff to call the medical provider for blood glucose readings above 400 mg/dl. Despite this, multiple blood glucose readings over 400 mg/dl were documented in the electronic medical record without corresponding documentation that the provider was notified. Staff interviews confirmed that it was standard practice to notify the provider for such readings, but one LPN stated she did not recall ever calling for this resident's high blood sugars. The DON acknowledged the lack of documentation and suggested that nurses may have called but failed to chart it. The resident's medical record showed several instances where blood glucose levels were significantly elevated, including readings as high as 584 mg/dl, without evidence of provider notification. Nursing notes indicated attempts to administer insulin were refused by the resident, and while there was some communication with a doctor regarding symptoms and monitoring, there was no documentation of provider notification for all high readings as required. The facility's policy required nurses to notify the physician of changes in the resident's condition, including specific instructions for blood glucose thresholds, but this was not consistently followed or documented.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as evidenced by surveyor observations, record reviews, and staff interviews. Out of 31 medications observed, 3 were not administered according to provider orders or medication guidelines, and a medicated patch intended for removal was missing and unaccounted for. The issues involved multiple residents with complex medical histories, including severe cognitive impairment, diabetes, schizophrenia, and other chronic conditions. One resident with severe cognitive impairment and hypothyroidism received Levothyroxine significantly later than the ordered administration time and not on an empty stomach as required by the medication guidelines. The nurse administering the medication acknowledged the timing was incorrect but did not notify the provider, and the facility's records did not reflect any follow-up. Another resident with severe cognitive impairment was given PRN melatonin for agitation and anxiety, although the medication was only ordered for trouble sleeping at bedtime. The medication was administered several hours before the prescribed time, and there was no documentation of provider notification or follow-up regarding the resident's behavior or the off-label use of the medication. Additional deficiencies included improper insulin administration technique for a resident with diabetes, where the LPN did not follow the manufacturer's instructions for holding the insulin pen in place, and could not articulate the correct procedure. Another resident with diabetes and severe cognitive impairment received a scopolamine patch without the nurse checking for or removing the previous patch, and the missing patch was not located or documented. The nurse did not follow up with other staff or the provider regarding the missing patch, and there was no documentation in the progress notes about its loss or removal.
Failure to Maintain Sanitary Medication Administration Practices
Penalty
Summary
During medication administration, a nurse was observed failing to follow sanitary procedures as required by facility policy. Specifically, the nurse was seen popping pills into her bare hand before placing them into medication cups, applying a medicated patch without washing her hands afterward, and touching multiple surfaces and personal items between medication passes without performing hand hygiene. The nurse administered medications to several residents, including controlled substances and a transdermal patch, and handled various items such as the medication cart, computer mouse, cabinet doors, and her personal water bottle, all without washing or sanitizing her hands between residents or after potential contamination. The facility's hand hygiene policy, revised in October 2023, requires handwashing immediately before and after resident contact, after touching contaminated surfaces, and after glove removal. Despite this, the nurse administered medications to 17 residents between hand washes and did not use hand sanitizer during the observed period. When questioned, the nurse acknowledged receiving infection control training but admitted to sometimes forgetting to wash her hands. The DON confirmed that nurses are expected to wash their hands between residents and are trained on these procedures before working independently.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically involving two residents. One resident, who was severely cognitively impaired, was subjected to unsolicited sexual touching by another resident. This included incidents where the resident was touched on the breast and buttock. Despite the family of the cognitively impaired resident explicitly instructing the facility staff that they did not consent to any sexual contact, the incidents occurred, indicating a failure in monitoring and intervention by the facility staff. Additionally, the facility did not adequately protect residents from physical abuse. A resident with severely impaired cognition and a history of aggressive behavior physically assaulted multiple other residents. This included hitting, scratching, and slapping other residents. The care plans for this resident included interventions to monitor and redirect behavior, but these measures were insufficient to prevent the physical altercations, suggesting a lack of effective implementation or staffing to ensure resident safety. The facility's policies and procedures regarding abuse were not effectively enforced, as evidenced by the repeated incidents of both sexual and physical abuse. Staff interviews revealed inconsistencies in understanding and applying consent and monitoring protocols, contributing to the failure to protect residents. The facility's abuse policy clearly stated the right of residents to be free from abuse, yet the incidents demonstrated a significant lapse in adherence to these standards.
Removal Plan
- Care Plan revision for Resident #12 and Resident #19.
- All staff education about abuse.
- An ad-hoc Quality Assurance Performance Improvement (QAPI) meeting completed.
Failure to Investigate Allegations of Abuse and Resident Incidents
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse, including injuries of unknown origin, staff rough treatment towards residents, and resident-to-resident incidents. This deficiency affected eight out of twelve residents reviewed for abuse, resulting in Immediate Jeopardy to the health, safety, and security of the residents. The facility did not ensure the separation of alleged perpetrators after becoming aware of the allegations. One resident with moderate cognitive impairment was found with a displaced comminuted fracture of the left humeral neck and greater tuberosity, with soft tissue swelling. The facility's investigation into this injury of unknown origin lacked a root cause analysis and did not identify the potential for abuse. The resident had previously complained of rough treatment by a male CNA, but no specific dates or times were provided, and the facility did not conduct a thorough investigation into these allegations. Another incident involved two residents with a mutual friendship, where one resident allegedly groped the other's breast. The facility's self-report list lacked documentation of this incident, and there was no investigation or separation of the residents involved. Additionally, a resident with a history of physical altercations with other residents was not adequately monitored, leading to multiple incidents of aggression. The facility failed to report these incidents and did not take steps to separate the resident from others.
Removal Plan
- All residents interviewed with no further allegations of abuse or neglect identified.
- All staff interviewed with allegations reported to State Agency and initiated investigation. Any associated staff suspended pending investigation.
- Facility provided all staff education on abuse, immediate separation, and reporting of any abuse immediately to the Facility Administrator. Education completed prior to working next shift.
- An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting conducted to review policy on abuse, immediate separation, reporting of abuse, and completing thorough investigation.
Failure to Timely Report Abuse and Neglect
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations, including staff-to-resident rough treatment, resident-to-resident physical altercations, and inappropriate touching incidents. This failure involved ten residents and resulted in Immediate Jeopardy to their health, safety, and security. The incidents included a resident with moderate cognitive impairment who suffered a shoulder fracture of unknown origin, which was not reported as potential abuse until after the injury was discovered. Additionally, there were incidents of inappropriate touching between residents, which were not reported to the State Agency in a timely manner. Another incident involved a resident with a history of aggressive behavior who was involved in a physical altercation with another resident. Despite documentation of the incident, the facility failed to report it as an allegation of abuse. Furthermore, a resident with severely impaired cognition exhibited aggressive behaviors towards other residents on multiple occasions, but these incidents were not reported promptly to the State Agency. The facility also failed to document and report an incident where a resident grabbed another resident's arm. The facility's policy required immediate reporting of suspected abuse, but there was a lack of documentation and timely reporting of several incidents. Staff members were observed handling residents roughly, causing fear and distress, yet these allegations were not reported or investigated as required. The facility's failure to adhere to its abuse reporting and investigation policy contributed to the deficiency, as staff did not consistently report allegations to the Director of Nursing or the Administrator for further investigation.
Removal Plan
- All residents interviewed with no further allegations of abuse or neglect identified.
- All staff interviewed with allegations reported to State Agency and initiated investigations. Any associated staff suspended, pending investigation.
- Facility provided all staff education on abuse, immediate separation, and reporting of any abuse immediately to the Facility Administrator. Education completed prior to working next shift.
- An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting conducted to review policy on abuse, immediate separation, reporting of abuse, and completing thorough investigation.
Failure to Provide Adequate Assessment and Intervention
Penalty
Summary
The facility failed to provide adequate assessment and intervention for residents experiencing a change in condition, leading to significant deficiencies. Resident #25 experienced a significant change in status, including difficulty transferring and an unwitnessed fall, resulting in a laceration to the forehead. Despite the fall and subsequent decline in mobility, the facility did not adequately follow up with the physician or conduct necessary diagnostic tests for the head injury. The resident was later diagnosed with a subdural hematoma and passed away, with the death certificate citing complications from the fall as the cause of death. Additionally, the facility failed to complete neurological assessments and post-fall follow-up documentation for Resident #20 after an unwitnessed fall. The resident, who had moderate cognitive impairment and required assistance for mobility, was found on the floor without injury. However, the facility did not adhere to its policy for post-fall monitoring, which required neurological checks at specified intervals. This lack of documentation and follow-up represents a failure to ensure the resident's safety and well-being. The facility also failed to provide continued assessment for Resident #226 after an episode of excessive coughing caused by consuming the incorrect consistency of food. Despite the resident's known dysphagia and dietary restrictions, they were served regular consistency food, leading to coughing and phlegm production. The facility did not promptly assess the resident's condition or notify the physician, and the resident's vitals were not taken until much later. This oversight in dietary management and resident assessment further highlights the facility's deficiencies in care.
Removal Plan
- A comprehensive head to toe assessment conducted and completed for all residents to identify any changes that deviated from their baseline status.
- All staff members received training on how to identify changes in residents' conditions and the importance of reporting these changes to charge nurse. Staff training completed.
- All Charge Nurse staff trained on how to recognize a change in condition and the expectation to notify the attending provider via phone immediately when a change is identified. Charge Nurse training completed.
- Facility conducted an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to review the change of condition process, assess staff education, and develop auditing mechanisms to monitor and prevent recurrence.
Inadequate Supervision and Equipment Evaluation Leading to Resident Falls
Penalty
Summary
The facility failed to ensure the proper evaluation and use of mobility devices for residents, leading to multiple incidents of falls and injuries. Resident #5, who had a history of falls and severely impaired cognition, was given a three-wheeled walker without a proper evaluation by physical or occupational therapy. This walker was provided by the maintenance department as a replacement for a faulty four-wheeled walker. The resident experienced a fall while using the new walker, resulting in a shattered humerus and hospitalization. Staff interviews revealed that the walker was inappropriate for the resident's needs, and there was a lack of communication and oversight regarding the change in equipment. Resident #22, also severely cognitively impaired, experienced multiple falls, some resulting in injuries such as skin tears and a laceration to the right orbit. The care plan for this resident included several interventions to prevent falls, but the resident continued to experience unwitnessed falls, often in common areas without adequate supervision. Staff interviews indicated that the resident was known to be at high risk for falls, yet there was insufficient monitoring and supervision to prevent these incidents. Additionally, the facility failed to provide adequate supervision for Resident #2, who had a seizure disorder and was at risk for falls. The care plan directed staff to use a gait belt during transfers and to remain with the resident during seizures, but these directives were not consistently followed. An incident occurred where a CNA assisted the resident without a gait belt, resulting in a fall and injury. The facility's failure to adhere to care plan directives and ensure proper supervision and equipment evaluation contributed to the residents' injuries and the overall deficiency in care.
Dietary Errors in LTC Facility
Penalty
Summary
The facility failed to provide the correct diet for two residents, leading to potential health risks. Resident #226, who has a nutritional problem and requires a pureed diet due to chewing and swallowing difficulties, was served regular consistency food by Staff A. This error occurred despite the resident's care plan and dietary orders specifying a pureed diet. After consuming several bites, the resident began coughing excessively, indicating a possible choking hazard. Staff A acknowledged the mistake and corrected it, but the resident continued to cough intermittently even after receiving the correct diet. The Director of Nursing confirmed the dietary requirements and acknowledged the risk of choking if the resident consumed regular consistency food. Resident #11, who has severe cognitive impairment and is on a mechanical soft ground meat diet, was served coleslaw instead of steamed cabbage due to a lack of available ingredients. The Certified Dietary Manager admitted to serving the incorrect food and attempted to mitigate the issue by cutting the coleslaw into smaller pieces. However, this action did not align with the resident's dietary order. The facility's policy on therapeutic diets emphasizes the importance of adhering to diet orders, which was not followed in these instances.
Insufficient Staffing Leads to Resident Altercations and Delayed Assistance
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide care to residents in accordance with their care plans, leading to incidents involving Resident #22, who has a history of physical altercations with other residents. Resident #22, with severely impaired cognition, exhibited physical and verbal behavioral symptoms directed towards others. Despite care plan interventions to monitor and redirect the resident, multiple incidents occurred where Resident #22 physically assaulted other residents, including hitting, scratching, and slapping. These incidents highlight the facility's inability to adequately supervise and manage Resident #22's behavior due to insufficient staffing. Additionally, the facility failed to provide timely assistance to Resident #2, who has a history of falls and seizures. On one occasion, Resident #2 activated the call light during meal time, indicating a need to lie down, possibly due to an impending seizure. However, the nurse left to get assistance, and due to a busy period, returned 10-15 minutes later, during which time the resident fell and sustained a scalp laceration. This incident underscores the facility's failure to have adequate staff available to promptly respond to residents' needs, particularly during critical times. Interviews with staff members revealed that there were often only one nurse and one CNA scheduled for the night shift, which was insufficient to meet the needs of the residents. Staff reported being unable to monitor residents like Resident #22 effectively and having to prioritize tasks, leading to delays in care. The facility's staffing policy, which was supposed to provide sufficient numbers of staff according to resident care plans and facility assessments, was not adhered to, contributing to the deficiencies observed.
Repeat Deficiencies in QAPI Process
Penalty
Summary
The facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies. This resulted in multiple repeat deficiencies identified during the current recertification and complaint survey. The deficiencies included issues with advanced directives, care plan revision, activities of daily living related to incontinence care, and the lack of a qualified Infection Preventionist to attend Quality Assurance meetings. These deficiencies were previously identified during surveys completed in the last twelve months. The facility reported a census of 26 residents. The Administrator explained that Quality Assurance meetings occurred monthly, with ad hoc QAPI conducted as needed to fix processes. However, the facility's QAPI plan indicated that a broad range of sources, including survey findings, should be used for monitoring and gathering data.
Improper Medication Preparation and Storage
Penalty
Summary
The facility failed to adhere to accepted standards of clinical practice by preparing medications in advance for multiple residents. During an observation, an LPN was found to have set up medications ahead of time for a resident, leaving an unlabeled medication cup containing three pills in the top drawer of the medication cart. The LPN identified the medications as Amlodipine, Carbidopa, and Citalopram, intended for a specific resident. This practice was repeated on another occasion when three unlabeled medication cups, each containing multiple medications, were found in the medication cart for three different residents who had not yet received their medications because they wanted to sleep in. The Director of Nursing confirmed that staff should not set up medications ahead of time, and the LPN admitted to the error. Another LPN stated that while she did not set up medications in advance, she would label them if necessary. The facility's policy on the storage of medications, revised in 2007, requires that all drugs be stored in a safe, secure, and orderly manner, and in the packaging in which they were received. The failure to follow this policy resulted in the deficiency noted during the survey.
Lack of Certified Infection Preventionist in QA Committee
Penalty
Summary
The facility failed to employ a required Quality Assurance (QA) committee member, specifically a qualified Infection Preventionist, to perform infection control surveillance and report to the governing body. The facility's QAPI Plan indicated that staff with the most knowledge and commitment to QAPI efforts should participate, yet review of QAPI sign-in sheets revealed no Infection Preventionist was present at meetings. The Facility Assessment reviewed by the Quality Assurance Committee included infection prevention and control as part of the services offered based on resident needs. However, the Facility Administrator reported that the Director of Nursing (DON) had acted as the Infection Preventionist but was unsure if the DON was certified, and the facility could not produce any certification for an Infection Preventionist. The facility's policy on Infection Prevention and Control Program stated that the program should be coordinated and overseen by a certified Infection Preventionist, which was not adhered to.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to provide a qualified Infection Preventionist with specialized training or certification to oversee its Infection Prevention and Control Program. The facility's policy, revised in October 2018, mandates that the Infection Preventionist coordinate and oversee the program. However, during a state survey, the Facility Administrator reported that the Director of Nursing (DON) had been acting as the Infection Preventionist but was unsure if the DON had the necessary certification. The facility was unable to produce any documentation confirming the certification of the Infection Preventionist, and the DON was unavailable to provide further information during the survey. The facility, which had a census of 26 residents, could not present any data indicating that a certified Infection Preventionist was employed at the time of the survey.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain the dignity and respect of residents, particularly Resident #20, who was found in unsanitary conditions on multiple occasions. Resident #20, who has moderate cognitive impairment and requires significant assistance for toilet hygiene, was observed by hospice providers to be frequently left in soiled incontinence products, emitting strong odors of urine. On one occasion, the resident was found lying flat on her back with a lunch plate on her abdomen, eating with her fingers, and with food in her hair. Despite staff claims that the resident refused care, hospice staff noted improvements in cleanliness during more recent visits. Additionally, inappropriate comments were made by a Certified Nursing Assistant (CNA) in the presence of residents in the dining room. The CNA was heard making remarks about a resident's eating habits, which were perceived as unkind. Interviews with staff members, including a CNA and the Director of Nursing from a sister facility, indicated concerns about the demeanor and compassion of the CNA involved. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in these instances.
Failure to Safeguard Resident Information
Penalty
Summary
The facility failed to safeguard residents' personal and medical information, as observed by the State Agency. On multiple occasions, the computer at the nurses' desk was left unattended with the Point Click Care (PCC) system open, displaying several residents' names. Specifically, on one occasion, the computer was left on and unattended from 08:23 a.m. to 08:26 a.m., and again from 09:22 a.m. until it timed out at 09:31 a.m. Later, at 12:54 p.m., the PCC system was open on a resident's chart with no one at the desk. Additionally, at 02:25 p.m., an LPN left a resident's chart open on the computer while stepping away to another room. The facility's Resident Rights Policy, revised in January 2019, prohibits unauthorized release, access, or disclosure of resident information, emphasizing compliance with privacy laws.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a hospital transfer for one resident. The resident, who had diagnoses including diabetes, non-Alzheimer's dementia, and a psychotic disorder, was assessed with a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severely impaired cognition. According to the facility's policy on transfer or discharge, dated October 2022, the facility was required to provide notice of therapeutic discharges to the long-term care ombudsman. However, when the resident was transferred to the emergency room for evaluation and treatment, the facility did not document the notification to the ombudsman. The resident returned to the facility two days later, but the lack of documentation of the notification was identified during the review.
Failure to Update Care Plans Following Changes in Resident Conditions
Penalty
Summary
The facility failed to revise care plans for four residents following significant changes in their medical conditions and treatments. Resident #5's care plan was not updated after the discontinuation of their antidepressant medication, Trazodone, which was stopped on 10/10/24. Despite the medication being discontinued, the care plan still indicated that the resident was receiving antidepressant medication as of 11/19/24. Resident #22's care plan was not updated to reflect the initiation of hospice services, which began on 9/19/24. The care plan still listed hospice services as pending, despite the resident having started receiving these services. Additionally, Resident #3's care plan inaccurately stated that the resident could transfer independently, while observations on 11/6/24 showed that the resident required assistance from staff for transfers. Resident #10's care plan lacked updates for new skin concerns identified in a Weekly Skin Review on 10/07/24. The review documented a stage three pressure ulcer and other skin issues, but the care plan did not reflect these findings or the interventions noted in the Hospice Admission Note dated 10/14/24. These deficiencies indicate a failure to ensure care plans were revised to accurately reflect the residents' current conditions and needs.
Inconsistent Documentation of Code Status for Resident
Penalty
Summary
The facility failed to ensure consistent documentation of code status for a resident with severely impaired cognition, leading to confusion regarding whether to perform CPR or adhere to a DNR order. The resident's care plan did not address their code status, and discrepancies were found between the IPOST form, which indicated CPR/Attempt Resuscitation, and the electronic orders, which noted a DNR status. Staff B, an LPN, acknowledged the inconsistency and noted that the resident's status changed to DNR after hospice services began, but the IPOST form in the paper chart was not updated accordingly. The Director of Nursing (DON) recognized the issue and explained that the facility was waiting for a wet signature on a verbal order for allowing natural death, which had been mailed to the family. The DON expressed concern that if an emergency occurred, the facility would be obligated to perform CPR due to the outdated IPOST form. The facility's policy stated that CPR should be initiated if a resident's DNR status is unclear, highlighting the importance of accurate and up-to-date documentation to ensure residents' wishes are respected.
Failure to Complete Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who began receiving hospice services. The resident, identified as having severely impaired cognition with a score of 00 out of 15 on the Brief Interview for Mental Status (BIMS) exam, started hospice care on 9/19/24. However, the quarterly Minimum Data Set (MDS) assessment dated 9/18/24 did not reflect the initiation of hospice services, and the subsequent MDS assessment was still in progress. The facility's policy requires a comprehensive assessment when there is a significant change in a resident's condition, as per OBRA regulations, but this was not conducted in a timely manner. An interview with a Director of Nursing (DON) from a sister facility confirmed that a significant change MDS should be completed immediately when such changes occur.
Deficiencies in Incontinence and Eating Assistance
Penalty
Summary
The facility failed to provide timely assistance with incontinence care and positioning for three residents and failed to provide eating assistance for one resident. Resident #3, who has severe cognitive impairment and is always incontinent, was observed sitting in a Broda chair for over three hours without being offered toileting or incontinence care. The resident's care plan required frequent toileting, but staff did not adhere to this schedule, resulting in the resident sitting in a soiled brief for an extended period. Resident #22, also with severe cognitive impairment and requiring assistance with activities of daily living, was found naked and cold in a urine-soaked bed. Despite being informed of the situation, staff initially claimed the resident had just been changed and had the right to be naked. However, a registered nurse intervened to change the resident's clothes and bed linens. The resident's care plan indicated a need for a two-person assist for toileting, which was not provided. Resident #20, with moderate cognitive impairment and requiring assistance with eating, was left in bed with a lunch tray that remained untouched. The resident was later moved to a lobby area where staff attempted to feed them, but the resident refused. The facility's policy required supervision and assistance for residents with cognitive and mobility impairments during meals, which was not initially provided. The Director of Nursing from a sister facility confirmed the expectation for such assistance.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide ongoing, resident-centered activities for two residents with severe cognitive impairments. Resident #3, diagnosed with non-Alzheimer's dementia, diabetes, and arthritis, expressed interest in group activities, news, and fresh air. Despite a care plan that included various activities such as playing cards, attending group activities, and outdoor events, observations revealed that the resident spent significant time in a Broda chair in the TV area without engagement in activities or conversation from staff. Documentation showed limited participation in activities, primarily watching TV or movies, with only occasional involvement in music and parties. Similarly, Resident #11, with non-Alzheimer's dementia and anxiety disorder, was observed sitting in the TV room without engagement from staff. The care plan directed staff to involve the resident in simple, structured activities, but documentation indicated the resident primarily watched TV or movies, with sporadic participation in church, current events, and music. Staff interviews revealed that residents were often bored, and the Activity Director struggled to provide adequate activities due to additional social worker duties. The facility's policy required individualized activity plans, but the implementation was insufficient to meet the residents' needs.
Delayed Treatment of UTI Due to Communication and Lab Processing Delays
Penalty
Summary
The facility failed to treat a urinary tract infection (UTI) in a timely manner for a resident with severely impaired cognition, as indicated by a score of 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam. The resident was frequently incontinent of urine and had a care plan in place to monitor for signs and symptoms of UTIs. Despite the resident exhibiting increased urinary incontinence and foul-smelling urine on 10/25/24, the facility delayed in obtaining a urinalysis (UA) and culture and sensitivity (C&S) test. The UA was not sent to the lab until 10/29/24, and the culture results indicating the presence of Klebsiella Pneumoniae were not received until 11/1/24. The facility's policy on antibiotic stewardship required that lab results and the current clinical situation be communicated to the prescriber as soon as available. However, the new order for antibiotic treatment with Macrobid was not issued until 11/5/24, resulting in a delay in treatment. Interviews with staff revealed that while the UA should typically be processed the next day, the C&S results took longer than usual, contributing to the delay. The Director of Nursing from a sister facility indicated that results should be sent to the clinic promptly, and if not received within an hour or two, follow-up actions should be taken. This delay in communication and action led to the deficiency in timely treatment of the resident's UTI.
Failure to Ensure Bed Rail Safety
Penalty
Summary
The facility failed to ensure that the dimensions from the mattress to the bed rail or the bed rail gaps were less than 4 3/4 inches, posing a risk of entrapment or injury for a resident. The resident, who had a seizure disorder, anxiety disorder, and depression, was independent in certain movements but had severely impaired cognition with a BIMS score of 0 out of 15. The resident used bed rails for mobility and security due to a fear of falling out of bed. The facility's care plan acknowledged the risk of injury related to the use of bed rails. During an observation, the Maintenance Director measured the gaps in the resident's bed rail system and found them to be significantly larger than the recommended 4 3/4 inches. The Maintenance Director admitted to not conducting any audits and was unaware of the maximum gap size requirement. The Administrator acknowledged that the bed was old and believed that nursing and therapy staff should be responsible for checking side rail safety. The facility's policy, revised in December 2007, stated that gaps in the bed system should comply with FDA guidelines, which was not adhered to in this case.
Failure to Provide Consistent Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of traumatic brain injury, depression, and alcohol abuse with alcohol-induced mood disorder. The resident exhibited physical and verbal behavioral symptoms directed toward others, as well as other behavioral symptoms not directed toward others, and rejection of care. Despite these behaviors, the resident's care plan lacked recent interventions to guide staff on managing these behaviors during care. The facility's policy on behavioral assessment and intervention did not address the provision of psychiatric services, which were inconsistent due to staffing changes. The resident's Minimum Data Set (MDS) assessment indicated severely impaired cognition, and the care plan entries highlighted the resident's mood disorder and risk for inappropriate behaviors. However, the facility did not provide documentation of psychiatric services beyond a visit in April, despite ongoing behavioral issues noted in behavior notes. The Director of Nursing acknowledged the absence of Telehealth psychiatric services for a period, and the Administrator noted the need to reestablish consistent psychiatric services. The facility's failure to provide necessary psychiatric services and update the care plan with recent interventions contributed to the deficiency.
Medication Administration Errors Lead to 12% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a calculated error rate of 12%. This deficiency was identified through observations, clinical record reviews, policy reviews, and staff interviews. The errors included administering an incorrect dose of Vitamin D3 to a resident, failing to prime an insulin pen before administration, and not administering insulin in a timely manner relative to meal times. Specifically, a Licensed Practical Nurse (LPN) administered 125 micrograms of Vitamin D3 instead of the prescribed 50 micrograms. Additionally, the LPN did not prime the insulin pen before setting the dose for two types of insulin, Humalog and Humulin, and administered the insulin 34 minutes before the resident's breakfast, contrary to the prescribed timing. The facility's policy on administering medications, revised in December 2012, directed staff to follow medication orders, including any required time frames. The Humalog insulin patient information and instructions for use specify that Humalog should be injected within 15 minutes before or right after eating a meal, and the pen should be primed with 2 units before use. Similarly, the Humulin instructions direct priming the needle with 5 units before use. The Director of Nursing (DON) confirmed that residents should receive fast-acting insulin with their meals and acknowledged the error in timing. The DON of a sister facility also stated that staff should follow medication orders.
Failure to Ensure Timely Food Consumption and Proper Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. A resident with diabetes and severely impaired cognition received rapid-acting insulin without consuming food in a timely manner. The resident's blood sugar was checked, and insulin was administered at 6:26 a.m., but the resident did not receive breakfast until 6:46 a.m., despite the facility's policy that fast-acting insulin should be given with meals. The Director of Nursing confirmed that breakfast started at 7:00 a.m., and residents did not receive breakfast earlier, which led to a delay in the resident consuming food after insulin administration. Additionally, the facility failed to prime insulin pens before administration. The LPN responsible for administering the insulin did not initially prime the pens before setting the dosage, which is against the instructions for use of both Humalog and Humulin insulin pens. The facility's policy on administering medications requires adherence to orders, including any required time frames, which was not followed in this instance. The failure to prime the insulin pens and the delay in food consumption after insulin administration contributed to the significant medication error.
Failure to Serve Menu Items as Listed for Residents on Pureed Diet
Penalty
Summary
The facility failed to ensure that all menu items were served to residents on a pureed diet, specifically affecting two residents. Resident #1, who has a diagnosis of Cerebral Palsy and requires a pureed diet with honey thickened liquids, was not served the menu items as listed. The care plan for Resident #1 was revised on 2/20/24, and the diet order dated 10/27/2017 specified a regular, puree texture diet with honey consistency drinks. A nutritional assessment dated 11/04/24 indicated that Resident #1 remains at increased risk for altered nutrition. Similarly, Resident #226, who has nutritional problems and requires a regular diet with pureed texture, was also not served the menu items as listed. The care plan for Resident #226, dated 10/31/24, and the diet order from the same date, specified a regular, puree texture diet with thin liquids. A nutritional assessment dated 11/04/24 noted that Resident #226 is at increased risk for altered nutrition due to co-morbidities, chewing and swallowing difficulties, and modified texture. On 11/05/24, the Dietary Manager served a pureed hot dog with bun and sauerkraut instead of the smoked sausage and roll with margarine listed on the menu, failing to follow the planned menu for residents on a pureed diet.
Inaccurate Medical Records for Hospice and Fall Incidents
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents, one receiving hospice services and another with a change in condition. For the resident receiving hospice services, discrepancies were noted between various records. The Minimum Data Set (MDS) assessment indicated the resident had Parkinson's disease, anxiety, and depression, with moderately impaired cognition. Despite being discharged from hospice on a specific date, subsequent nursing and provider notes inaccurately documented the resident as continuing hospice care. This inconsistency was acknowledged by the facility administrator, who stated that records should be accurate. For the second resident, who had moderate cognitive impairment and a history of falls, the facility's documentation was inconsistent regarding an unwitnessed fall and subsequent injury. The resident was found with swelling and bruising on the left shoulder, leading to an emergency room visit. However, there was no clear documentation of a fall, and the cause of the shoulder fracture remained unknown. The Director of Nursing (DON) was unaware of notes indicating a fall with a fracture, and the facility's investigation summary did not clarify the incident. The facility's policy emphasized the need for complete and accurate documentation to facilitate communication among the interdisciplinary team.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control practices during a medication administration for one of the residents. During an observation, an LPN administered several medications to a resident, including Lisinopril, Olanzapine, calcium and vitamin D, iron, and Omeprazole. One of the pills was dropped by the resident into their lap, and the LPN picked it up with her bare hand and placed it back into the resident's mouth. This action was contrary to the facility's policy, which requires staff to follow infection control procedures, including using gloved hands when handling medications. The Director of Nursing from a sister facility confirmed that staff should use gloves when picking up medications.
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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