Heritage Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Cedar Rapids, Iowa.
- Location
- 200 Clive Drive Sw, Cedar Rapids, Iowa 52404
- CMS Provider Number
- 165310
- Inspections on file
- 35
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Heritage Specialty Care during CMS and state inspections, most recent first.
The facility failed to provide scheduled bathing assistance to several cognitively intact residents who required staff help with ADLs, including individuals with conditions such as heart failure, CKD, diabetes, COPD, stroke with hemiplegia, and epilepsy. Care plans and MDS assessments specified that each resident needed assistance from one staff member for bathing, and residents reported not receiving their twice-weekly showers as scheduled. Bathing records confirmed multiple missed showers over several months. A CNA reported that residents were not receiving baths as planned because CNAs were frequently pulled to cover other units when staff did not report to work, resulting in short staffing and missed hygiene care, contrary to the facility’s ADL policy.
A resident with diabetes and a left foot ulcer did not consistently receive ordered wound treatments and missed multiple wound clinic and infectious disease appointments. The care plan and physician orders required Iodoflex dressings to the left heel on a set schedule, but the TAR showed several missed treatment dates, and a CMA admitted to erroneously signing off all treatments one morning. Observations found undated dressings that remained in place from one day to the next, and an LPN/ADON later removed and changed an undated dressing. The wound clinic provider reported repeated no-shows and missed appointments due to lack of transportation and expressed concern that the resident’s wound care needs were not being met, while the resident stated that rides were sometimes not arranged or no staff were available to drive the van.
A resident with multiple chronic conditions, including CHF, CKD, and type 2 DM, who was cognitively intact and care planned for a low-sodium diet, reported that meals served in his room were frequently cold, late, and did not taste good. During a noon meal observation, residents waited in the dining room while staff struggled to plug in the hot cart and could not provide forks when requested. The resident’s tray was prepared from the hot cart and delivered to his room, where immediate temperature checks showed the meat and potatoes below appropriate hot-holding temperatures and milk near the upper cold-holding limit. Review of meal temperature logs revealed incomplete documentation for side items and reliance on recorded temperatures that did not match the food temperatures observed at the point of service, despite a policy requiring maintenance of proper hot and cold food temperatures.
Three residents dependent on staff for transfers experienced unsafe transfer practices, including the use of incorrect lift equipment, improper sling sizing, and failure to follow individualized care plans. These actions resulted in falls, injuries, and extensive bruising, with staff not consistently referencing lift sizing charts or facility policy.
Multiple residents, including those with a history of falls and mobility impairments, were found without accessible call lights, with devices placed out of reach on bedside stands, walls, floors, or in drawers. Some residents were unable to call for assistance and were found calling out or unaware of their call light's location, contrary to facility policy requiring call lights to be within easy reach.
Large, blackened, and worn carpet areas were observed in the main lobby and skilled unit entrance, with staff confirming that cleaning was ineffective and replacement was delayed. Additionally, a resident's visitor introduced bed bugs, leading to isolation and treatment of the affected room, but the facility's environment remained unclean and not homelike.
The facility did not effectively implement its QAPI and QAA processes to correct and prevent recurring deficiencies in medication administration, as issues identified in a previous survey were found again during a subsequent complaint investigation. Despite regular QAPI meetings and data collection, the same problems persisted, indicating insufficient follow-through on quality improvement activities.
The facility did not ensure that care and services provided met professional standards of quality, as observed through practices that did not align with established guidelines.
A resident with hemiplegia and a history of stroke, who required partial assistance and was at risk for falls, was left without access to a call light after care was provided, resulting in incontinence of bowel and bladder. The call light was placed out of reach, preventing the resident from requesting help, and the issue was discovered by a CNA during the next shift.
Two residents did not receive medications as ordered due to staff errors in medication administration. One resident was given another resident's medications after staff failed to properly identify the individual, resulting in hospitalization. Another resident received an incorrect insulin dose when a nurse did not follow the prescribed order and was unable to recall the correct amount, with the care plan lacking specific double-check instructions.
A resident with severe cognitive impairment and diabetes was given rapid-acting insulin before eating, without adequate follow-up to ensure meal consumption. Staff failed to monitor the resident after insulin administration, and the care plan lacked guidance on hypoglycemia observation and intervention. The resident was later found unresponsive with critically low blood glucose and required hospitalization.
A resident was not protected from a significant medication error, as required, due to a failure in medication administration or management.
Surveyors found that kitchen staff did not consistently monitor the dishwasher's function or maintain adequate sanitation, as evidenced by dust and debris on equipment, lack of knowledge about required testing, and missing documentation of temperature and sanitizer checks. Facility policies requiring cleanliness and monitoring were not followed.
A resident with COPD and respiratory failure did not have their oxygen tubing changed or labeled according to facility policy, with observations showing outdated and unlabeled tubing on both the concentrator and portable tank. Staff and the DON confirmed that tubing should be changed and labeled weekly, but this was not done, resulting in a deficiency in respiratory care.
Staff did not follow the prescribed menu and portion sizes for residents on a pureed diet, resulting in incorrect serving sizes and omission of required food items such as whipped potatoes. The process for preparing and serving pureed meals was inconsistent, and there were no formal policies guiding staff in the preparation and portioning of pureed and mechanical soft diets.
A resident who had previously received a pneumococcal 23 vaccine was admitted and consented to receive an additional pneumococcal vaccination, with an active provider order in place. Despite pharmacy recommendations and updated CDC guidelines indicating eligibility for another pneumococcal vaccine, the vaccine was not administered due to unclear staff responsibilities and outdated facility policy.
A facility failed to conduct and document follow-up skin assessments for a resident at risk for pressure ulcers, despite a care plan requiring weekly documentation. The resident, with multiple health issues, had a bruise on the spine that was not properly assessed or documented upon admission. Staff interviews revealed inconsistencies in the assessment process, with some staff unaware of the bruise and others failing to document or notify emergency contacts. The facility's policy required regular skin assessments, but these were not consistently practiced, leading to the deficiency.
A resident with impaired cognition and mobility issues was transferred without a gait belt, contrary to the Care Plan and facility policy. The resident, who was non-weight bearing on the left lower extremity, was moved by two staff members using a bear hug technique due to her combativeness and pain. The Director of Nursing confirmed that the use of a gait belt is expected for all two-person transfers.
A resident with a history of fractures and dementia experienced unmanaged pain due to the facility's failure to complete pain assessments, update narcotic records, and follow up on ineffective interventions. Despite being on hospice care, the resident's pain was not adequately addressed, leading to concerns from family members and staff about the lack of timely and effective pain management.
The facility failed to maintain a clean and safe environment, with issues such as dust and food particles on tables, exposed insulation, and a hole in the wall caused by a resident's wheelchair. Additionally, a resident's room was left uncleaned after their transfer to the hospital, with food debris and a used Foley catheter found. Maintenance and housekeeping supervisors acknowledged these oversights, citing inadequate checks and coordination.
A resident with chronic lower leg ulcers did not receive daily dressing changes as ordered by the physician, with missed treatments on multiple days. The resident reported staff shortages as the reason, and a nurse admitted to not completing the task due to leaving early. The facility's policy for wound care was not adhered to, leading to this deficiency.
A resident with diabetes did not receive her noon insulin dose during an off-campus appointment because the nurse forgot to send it. The nurse was busy and working alone, leading to the oversight. The facility received a call from the adult day care center about the missing insulin, and a one-time order was made to hold the dose.
A resident with multiple health conditions, including COPD, was sent to an adult day care center without sufficient oxygen supply, leading to a drop in oxygen saturation levels and requiring emergency services. Facility staff were unaware of how long an oxygen tank would last, and the facility's policy lacked guidance on ensuring adequate oxygen for outings.
A resident with cognitive impairment and a history of falls did not receive wound care as prescribed by a physician. Observations showed that wound dressings on the resident's forearms were not changed according to the orders, with bandages dated several days prior. Documentation discrepancies were noted, and an LPN admitted to not performing the dressing change. The DON confirmed the failure to follow the physician's orders.
Two residents experienced significant delays in call light responses, with one waiting 23 minutes and another reporting a one-hour wait. The facility's staffing limitations contributed to these delays, impacting residents with conditions such as dementia and paraplegia who require timely assistance.
A resident with a history of cancer and a hip fracture experienced severe pain due to a delay in receiving a scheduled Fentanyl patch. Miscommunication between the pharmacy, facility staff, and hospice physician led to the patch not being applied for two days, despite the resident's reports of severe pain. The facility's pain management policy was not followed, resulting in inadequate pain management.
The facility failed to maintain a clean, homelike environment, with residents reporting unclean rooms and observations revealing dust, cobwebs, and unmade beds. A resident linked an eye infection to room dust, and another's bed had visible urine stains. Staff interviews showed inconsistencies in cleaning and bed-making practices, and facility policies were not followed.
A facility failed to follow physician orders for a resident's catheter care, resulting in the catheter not being changed as scheduled. The resident, who relied on staff for toileting due to a neurogenic bladder, reported the issue, but the facility's process for handling physician orders was ineffective. Despite a double-check system, the catheter change order was not executed, and staff interviews revealed a lack of clarity and accountability in implementing physician orders.
A resident with a Stage 4 pressure ulcer and an unstageable ulcer did not receive weekly assessments as required, from a visit to a wound clinic until an assessment at the facility over a month later. The resident, with a history of heart failure, cancer, and dementia, was dependent on staff for mobility and care. The facility acknowledged the lapse in conducting weekly measurements, despite the resident's complex medical needs and the importance of regular monitoring for pressure ulcer management.
A resident was observed smoking on the grounds of a smoke-free LTC facility, contrary to the facility's smoking policy. The resident, who was assessed as an independent smoker, wheeled herself to a sidewalk on the premises and smoked without staff supervision. The facility's policy requires residents to leave the grounds to smoke, which was not adhered to, leading to a deficiency.
A resident with intact cognition and specific dietary preferences for a vegetarian diet was repeatedly served meals containing meat and eggs, despite her clear communication of these preferences. The facility's failure to document and honor her dietary choices, compounded by a gap in the Dietary Services Manager position, resulted in inappropriate meal service. Staff were aware of the resident's requests, but the lack of proper documentation and communication led to this deficiency.
The facility failed to provide SNF Advanced Beneficiary Notice (ABN) forms 48 hours before the end of skilled services for two residents, as required by Federal Regulations. This deficiency was identified during a mock survey after the retirement of the long-term social worker, revealing that ABNs were not being completed correctly.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing assistance to multiple residents who required staff help with activities of daily living (ADLs), specifically bathing. Resident #4, who had diagnoses including heart failure, chronic kidney disease, type 2 diabetes, COPD, and a left diabetic foot ulcer, was cognitively intact with a BIMS score of 15/15 and required moderate assistance of one staff member for bathing per the MDS and care plan. He reported not receiving a shower for an entire week, despite being scheduled for showers on Wednesdays and Saturdays, and stated staff told him there was not enough staff and that baths were not done on Sundays. Bathing records showed missed showers on multiple specific dates in December 2025, January 2026, and February 2026. Resident #2, with hemiplegia affecting the right side and a BIMS score of 15/15, also required assistance of one staff member for bathing per the MDS and care plan and reported not receiving twice-weekly baths. Her bathing records showed missed showers on identified dates in December 2025, January 2026, and February 2026. Resident #3, who had a history of stroke with left-side hemiplegia and epilepsy, was cognitively intact with a BIMS score of 15/15 and required assistance of one staff member for bathing per the MDS and care plan; he reported taking baths/showers on Tuesdays and Fridays, but records showed a missed shower on a specific date in January 2026. A CNA stated that residents were not getting their baths as scheduled because staff were pulled to cover other units when staff did not show up for work, leaving units short. This pattern of missed baths conflicted with the facility’s ADL policy, which stated that residents unable to perform ADLs independently would receive services necessary to maintain grooming and personal hygiene.
Failure to Provide Ordered Wound Care and Ensure Attendance at Wound Clinic Appointments
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care as ordered and to ensure attendance at scheduled wound and infectious disease appointments for a resident with multiple comorbidities. The resident had diagnoses including heart failure, chronic kidney disease, type 2 diabetes, and a left diabetic foot ulcer, and was cognitively intact with a BIMS score of 15/15. The care plan identified increased risk for skin impairments and required monitoring and documentation of skin injuries, weekly wound measurements, and continuous use of a wound vac to the left heel. Physician orders included application of Iodoflex iodine pads to the left lateral heel ulcer every other day, with a subsequent order specifying Iodoflex application every two days and use of betadine gauze once Iodoflex was unavailable. Review of the Treatment Administration Records showed that ordered wound treatments were not completed on multiple scheduled dates in January and February. Specifically, the Iodoflex iodine pad treatment ordered every other day was not completed on several listed dates, and the Iodoflex external pad ordered every two days was also missed on multiple dates. The podiatry wound clinic provider reported concerns that the resident’s wound care needs were not being met, including missed wound clinic and infectious disease appointments, and difficulty obtaining wound care supplies. The provider stated she wanted to see the resident weekly, but the resident was a no-show for several wound and infectious disease appointments, and additional appointments were missed due to lack of transportation. Observations and interviews further showed inconsistencies in wound care delivery and documentation. The resident reported having wound clinic appointments every other week and stated that appointments were missed when the facility forgot to arrange transportation or lacked staff to drive the van. On observation, the resident’s left foot dressing was in place without a date, and when the resident asked an LPN about a dressing change, he was told it had already been done, although the TAR showed it had been signed off by a CMA who later admitted she had accidentally signed off all treatments for the resident. On a subsequent day, the same dressing was still in place, again without a date, and was removed and changed by an LPN/Assistant DON. Facility wound care procedure required staff to verify physician orders, review the care plan, and document refusals and physician notification if a resident refused treatment, but the report documents missed treatments and missed appointments without indication of resident refusal.
Failure to Provide Palatable Food at Safe Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide palatable food at safe and appetizing temperatures for one cognitively intact resident. The resident had multiple diagnoses, including heart failure, chronic kidney disease, type 2 diabetes, and a left diabetic foot ulcer, and was care planned for a low sodium, regular texture diet with thin liquids, with staff directed to monitor diet tolerance. The resident reported eating all meals in his room and stated that his food was cold almost every meal, was often served later than scheduled, and did not taste very good. Surveyor observation of a noon meal service on Station 3 showed residents waiting in the dining room while beverages were passed and hot food was delayed as staff attempted to plug in the hot cart, which had to be moved due to a short power cord. Residents requested forks but were told none were available. The resident’s tray was prepared from the hot cart and delivered to his room, where food temperatures were immediately taken and showed the pork chop at 101.8°F, potatoes at 121.8°F, and milk at 45.4°F. Review of temperature logs for that meal showed the meat recorded at 189°F before service and 171°F after service, no temperatures recorded for the potatoes/starch, and milk temperatures of 34°F before and 39°F after service, despite facility policy requiring proper hot and cold temperatures during food service and discarding foods held in the temperature danger zone after four hours.
Failure to Ensure Safe Resident Transfers and Proper Sling Use
Penalty
Summary
The facility failed to provide safe transfers for three residents, resulting in accident hazards and inadequate supervision. One resident, with a history of stroke, heart failure, dementia, and on anticoagulation therapy, was dependent on staff for transfers and required a two-person assist with a stand lift as per her care plan. However, a CNA attempted to transfer her alone using the incorrect full body lift instead of the stand lift, leading to the resident falling from the lift, sustaining a head laceration that required staples, and being sent to the emergency department. Subsequent clinical notes documented extensive bruising and pain, with medical evaluations revealing hematomas and ecchymosis over multiple body areas. Observations and interviews indicated improper placement in the lift and ill-fitting slings contributed to repeated injuries during transfers. For another resident with atrial fibrillation, dementia, and multiple sclerosis, staff used a full body lift with an XXL sling for transfers, despite the resident's weight being below the recommended range for that sling size. Staff were observed to be unaware of the correct sling sizing, and the facility's lift sizing chart was not consistently referenced. The Assistant Director of Nursing confirmed that the wrong sling size was used for this resident, and staff required further education on proper sling selection based on weight and body size. A third resident, with coronary artery disease and severe cognitive impairment, was also transferred using an XXL sling, which was not appropriate for her weight. The facility's policy required individualized assessment for transfer assistance, including proper sling size and fit, but staff relied on judgment rather than established guidelines. The color-coded sling system and sizing chart were not consistently followed, leading to the use of slings that did not fit residents properly, increasing the risk of injury during transfers.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to multiple residents, as observed during staff and resident interviews, clinical record reviews, and direct observation. One resident with no cognitive impairment, a history of falls, and requiring moderate assistance for transfers was found with her call light out of reach on the bedside stand and her bed control on the floor. She confirmed she could not reach the call light and would have to yell for help if needed. Another resident, also with no memory impairment and a history of stroke and hemiplegia, was found calling out for assistance and rattling the bed rail because the call light was on the wall and out of reach. This resident was found incontinent of bowel and bladder and reported being unable to call for help due to the inaccessible call light. A facility-wide call light audit further revealed several instances where call lights were not accessible to residents in their rooms. Observations included call lights hanging on the wall, on the floor, or placed in drawers, all out of reach of residents who were in bed or in wheelchairs. In some cases, residents were unaware of the location of their call lights. The facility's policy requires that call lights be within easy reach of residents when they are in bed or confined to a chair, but this was not consistently followed.
Failure to Maintain Clean and Homelike Environment Due to Worn Carpet and Pest Issues
Penalty
Summary
The facility failed to provide a clean and homelike environment as evidenced by large, blackened, and worn areas of carpet in the main lobby and at the entrance of the skilled unit. Observations revealed that the carpet in these areas was significantly stained and darkened, with measurements provided for the affected spaces. Staff interviews confirmed that the carpet had been cleaned twice in the past six months, but the cleaning was not effective due to the carpet's worn condition. Housekeeping staff reported that the facility was planning to replace the carpet with laminate flooring, but no timeline had been established for completion, and the current state of the carpet persisted. Additionally, the facility experienced an incident involving bed bugs brought in by a resident's visitor. Staff followed facility policy by isolating and treating the affected room, laundering clothing, and working with a contracted pest control company. Despite these actions, the presence of bed bugs and the ongoing issues with the carpet contributed to an environment that was not clean or homelike, as required. Staff interviews indicated that the facility was aware of the problem and had plans for remediation, but the deficiency remained at the time of the survey.
Failure to Correct and Prevent Ongoing Medication Administration Deficiencies
Penalty
Summary
The facility failed to effectively carry out Quality Assurance activities to ensure that previously identified deficiencies, specifically related to medication administration, were corrected and did not persist. Despite the existence of a QAPI plan and regular meetings of the QAPI team, deficiencies in medication administration were identified during a prior survey and again during a subsequent complaint survey. The QAPI team collected data through various channels, including an online program, suggestion boxes, grievance forms, and state agency findings, and prioritized issues affecting residents' quality of life or rights. However, the facility continued to struggle with the same issues, indicating that the measures taken were not sufficient to resolve the deficiency. Interviews with the Administrator and the DON revealed that the QAPI team reviewed medication administration practices, including rights, refusals, and missed medications, and conducted ongoing audits following the previous survey. The QAPI plan outlined responsibilities for reviewing data and prioritizing improvement opportunities, but the recurrence of the same deficiency suggests that the process was not effective in preventing ongoing problems with medication administration. The report does not mention any specific residents or their medical conditions at the time of the deficiency.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the nursing facility did not consistently provide care and services in accordance with accepted standards, but does not specify particular residents, staff actions, or detailed events leading to the deficiency. No additional information about specific patients, their medical history, or their condition at the time of the deficiency is provided in the report.
Failure to Provide Toileting Assistance and Maintain Call Light Accessibility
Penalty
Summary
A resident with a history of stroke and hemiplegia, who required partial assistance for transfers and was identified as a fall risk, was not provided with necessary toileting assistance. The resident's care plan directed staff to encourage the use of a call light and ensure it was within reach. However, on the morning in question, the resident was found calling out for help and rattling the bed rail, with the call light placed out of reach on the wall. The resident was incontinent of bowel and bladder at that time, despite normally being continent. Staff interviews and clinical record review confirmed that the night shift aide had failed to return the call light to an accessible position after providing care, leaving the resident unable to request assistance. The facility's policy required that residents unable to perform activities of daily living independently receive appropriate support, including assistance with elimination. The lack of a room-to-room report between shifts contributed to the oversight, as the day shift CNA discovered the resident's situation upon arrival. The incident was documented in the facility's incident report, and the resident confirmed the event occurred once, with no recall of the staff involved.
Failure to Administer Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for two residents, resulting in significant medication errors. In the first instance, a resident with multiple diagnoses including heart failure, coronary artery disease, wound infection, and diabetes mellitus, who was totally dependent on staff for several activities of daily living, was given another resident's medications in error. This occurred because the resident did not have a profile picture on file, no name tag on the door, and was responding to the other resident's name during the medication pass. The medications administered included several with potential for serious side effects, such as antipsychotics, anticonvulsants, and antihypertensives. Following the error, the resident became lethargic, developed increased confusion, and was ultimately sent to the hospital for further management after a decline in vital signs and mental status. The incident was attributed to human error and a failure to properly identify the resident prior to medication administration. Staff interviews revealed that the nurse responsible was overwhelmed by workload and distractions, leading to a lapse in following the required verification steps, such as confirming the resident's identity and cross-checking medications. The nurse admitted to not adhering to the 'five rights' of medication administration and acknowledged that the error could have been prevented by slowing down and double-checking the resident's identity. The Director of Nursing confirmed that the root cause was the failure to properly identify the correct resident. In a separate incident, another resident with a history of coronary artery disease, heart failure, and diabetes mellitus received the wrong dose of insulin during a medication pass. The nurse administered 12 units of Aspart insulin instead of the ordered 15 units plus an additional sliding scale dose, resulting in a total underdose. The nurse was unable to recall the correct dose and reported difficulty due to being assigned to different units during the shift. The care plan for this resident did not include specific instructions for staff to double-check insulin doses. The Director of Nursing verified that the resident should have received a higher total dose than was administered.
Failure to Monitor and Intervene After Insulin Administration Resulting in Hypoglycemic Event
Penalty
Summary
A resident with severe cognitive impairment, heart failure, urinary tract infection, and diabetes mellitus was dependent on staff for most activities of daily living except eating and oral hygiene. The resident had physician orders for scheduled and sliding scale insulin, with instructions to monitor blood glucose as ordered. However, the care plan did not include directions for staff to observe for signs of hypoglycemia or hyperglycemia, nor did it specify actions to take if such signs were present. On the day of the incident, the resident was administered rapid-acting insulin before consuming her meal. Staff placed the lunch tray in front of the resident and verbally prompted her to eat, but she did not touch her food. The nurse who administered the insulin did not check on the resident again after the administration, and there was no follow-up to ensure the meal was consumed. Several hours later, the resident was found unresponsive with a critically low blood glucose level (25 mg/dL), and emergency medical services were called. Documentation was incomplete, with missing entries regarding the initial blood glucose reading and the administration of Glucagon. Interviews with staff revealed inconsistent understanding and implementation of insulin administration protocols, particularly regarding the timing of insulin relative to meals and the need for post-administration monitoring. Staff acknowledged that the resident typically ate better when assisted to sit up in a chair, but this was not addressed in the care plan. The facility's policy required monitoring and documentation of blood glucose and resident status after insulin administration, but these steps were not followed, contributing to the resident's hypoglycemic event and subsequent hospitalization.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. No further details about the specific actions, inactions, or the condition of the resident(s) at the time of the deficiency are provided in the report.
Failure to Maintain Kitchen Sanitation and Monitor Dishwasher Function
Penalty
Summary
Surveyors observed multiple sanitation and equipment monitoring deficiencies in the facility's kitchen. During an initial tour, a fan above the hand washing sink was found to be covered with mesh and a thick layer of dust, with the fan blowing toward the clean side of the dishwasher. The top of the dishwasher itself was covered with yellow debris, and the fire suppression system spigots had dust particles hanging from them. Staff responsible for dishwashing did not know how to test the dishwasher's function and had not performed the required test before washing breakfast dishes. Additionally, the Dietary Manager was unable to locate a log documenting dishwasher function tests. Review of the Dish Machine Temperature Log revealed missing documentation for required wash and rinse temperature and sanitizer concentration checks for several meals over multiple days. A follow-up visit confirmed that dust remained on both the fire suppression system spigots and the fan. Facility policies required food service areas to be kept clean and for dishwashing machine temperatures to be checked with each cycle, but these procedures were not consistently followed, as evidenced by the observations and lack of documentation.
Failure to Change and Label Oxygen Tubing as Required
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not changing the oxygen tubing as required for a resident with physician orders for oxygen therapy. The resident, who had diagnoses including COPD, respiratory failure, and anxiety, required moderate assistance with activities of daily living and utilized both an oxygen concentrator and a portable tank. Observations revealed that the tubing on the resident's oxygen tank was not labeled with the date it was last changed, and the tubing on the concentrator in the resident's room was last changed over two weeks prior, as indicated by the label dated 5/5/25. Interviews with nursing staff and the DON confirmed that facility policy requires oxygen tubing and cannulas to be changed weekly and labeled with the date and staff initials. Staff were unsure of the required frequency until reviewing the policy, which directs weekly changes. The failure to change and properly label the oxygen tubing for both the concentrator and the portable tank resulted in noncompliance with the facility's infection prevention policy.
Failure to Provide Correct Pureed Diet Portions and Menu Items
Penalty
Summary
The facility failed to ensure that residents on a pureed diet received the correct portion sizes and food items as specified by the menu. During meal preparation, the Dietary Services Manager Assistant prepared pureed Salisbury steak by combining steaks, bread, and gravy, then adjusted the mixture to reach a total of 6 cups. He referenced the Pureed Diet Portion Sizes/Scoops chart, which directed the use of 2 #8 scoops per serving, but during meal service, a different staff member used a #6 scoop (5 1/3 ounces) instead of the specified portion size. Additionally, residents on a pureed diet were served Salisbury steak, carrots, and bread, but did not receive the required whipped potatoes, contrary to the menu instructions. Staff interviews revealed inconsistencies in following the established portion size chart and a lack of policies regarding the pureed and mechanical soft diet process. The Registered Dietician confirmed that residents on a pureed diet should have received mashed potatoes and that there were no formal policies guiding the puree process. The Dietary Manager also stated that staff should use the chart for scoop sizes and expected residents to receive the correct portions, indicating a failure to adhere to menu requirements and established procedures.
Failure to Administer Pneumococcal Vaccine per Updated CDC Guidelines
Penalty
Summary
The facility failed to follow the CDC 2025 Adult Immunization Schedule for pneumococcal vaccination for one resident. The resident was admitted to the facility and had previously received a pneumococcal 23 vaccination several years prior. Upon admission, the resident consented to receive the pneumococcal vaccine, and an active provider order was in place for administration if applicable. Pharmacy consultant notes recommended administration of Prevnar 20 and advised nursing to obtain consents and enter them into the EHR. However, the updated CDC guidelines indicated that the resident was eligible for an additional pneumococcal vaccine, which was not administered. Staff interviews revealed uncertainty regarding responsibility for reviewing pneumococcal vaccination status during the admission process. The facility's policy required assessment of vaccination eligibility within five working days of admission and offering the vaccine within thirty days if indicated, but did not specify who was responsible for this assessment. As a result, the resident did not receive the recommended pneumococcal vaccination according to the most recent guidelines.
Failure to Conduct and Document Skin Assessments
Penalty
Summary
The facility failed to conduct and document follow-up skin assessments for a resident who was at risk for pressure ulcers and had a history of skin tears. The resident, who had multiple diagnoses including anemia, congestive heart failure, and chronic kidney disease, required extensive assistance with daily activities and was on medications such as antidepressants and diuretics. Despite the care plan's requirement for weekly documentation of skin injuries, the facility did not complete an initial skin assessment upon the resident's admission or re-admission. The deficiency was further highlighted by the lack of documentation and follow-up on a bruise found on the resident's spine. Although a bruise was noted on admission, it was not measured or documented until several days later. Staff interviews revealed inconsistencies in the assessment process, with some staff unaware of the bruise and others failing to document or notify emergency contacts about the skin issue. The resident was also out of the facility for dialysis during some scheduled assessments, which contributed to the lack of timely evaluations. The facility's policy required comprehensive skin assessments upon admission and regular inspections during personal care activities. However, the staff did not adhere to these guidelines, resulting in missed assessments and documentation. The Director of Nursing acknowledged the expectation for weekly assessments and follow-ups when residents returned from appointments, but this was not consistently practiced, leading to the deficiency in care for the resident's skin condition.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to provide a safe transfer for a resident, identified as Resident #10, by not utilizing a gait belt during a two-person transfer as directed by the Care Plan. Resident #10 had moderately impaired cognition, was wheelchair dependent, and required maximum assistance with transfers. The Care Plan specified that the resident was to be non-weight bearing on the left lower extremity and required the assistance of two staff members for stand and pivot transfers. However, during an incident on February 23, 2025, staff members did not use a gait belt while transferring the resident, which was against the facility's policy and the Care Plan instructions. Interviews with staff and family members revealed that the resident was combative and in pain during the transfer, which involved moving her from the bed to a wheelchair, then to the toilet, and back. Staff D, a CNA, reported using a bear hug technique instead of a gait belt due to the resident's combativeness. The resident's daughter expressed concerns about the roughness of the transfer and the absence of a gait belt, noting that her mother was in significant pain during the process. The Director of Nursing confirmed that the expectation was for staff to use a gait belt for all two-person transfers if the resident allowed, as per the facility's policy on safe lifting and movement of residents.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident, leading to a deficiency in care. Resident #10, who was admitted for aftercare following a left tibial plateau fracture and later moved to the Chronic Confusion or Dementing Illness Unit, experienced unmanaged pain. Despite being on hospice care for vascular dementia, the facility did not complete pain assessments as directed, update narcotic records with changes in medication prescriptions, or conduct follow-up assessments when pain interventions were ineffective. The resident's care plan included interventions for opioid medication use and pain management, but these were not effectively implemented. The Medication Administration Record/Treatment Administration Record (MAR/TAR) showed multiple instances where pain and anxiety medications were given but found to be ineffective, with no further interventions documented. Additionally, the facility failed to document pain assessments on several dates and shifts, as required by the resident's care plan. Interviews with family members and staff revealed concerns about the resident's unmanaged pain and the facility's failure to administer pain medication as ordered. The Director of Nursing acknowledged the expectation for staff to start a new Individual Narcotic Record with each prescription change and to follow up on ineffective pain interventions. The facility's policy on pain assessment and management emphasized the need for regular assessment and modification of pain management strategies, which was not adhered to in this case.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, homelike, and safe environment for its residents, staff, and the public. Observations revealed multiple deficiencies, including dust accumulation and dried food particles on table bases in dining areas, exposed insulation material at the entrance of the skilled unit, and a hole in the wall on 3-B Hall caused by a resident's electric wheelchair. Additionally, several resident room doors had jagged pieces of hard plastic sticking out, and a radiator cover was frequently falling off in a resident's room. The maintenance supervisor acknowledged these issues, noting that radiator covers were checked daily during weekdays but not on weekends, and room doors were checked monthly without detailed documentation. Further deficiencies were noted in a resident's room on Station 4, where a large amount of food debris, broken plastic fork pieces, a brown spot on the carpet, and a used Foley catheter with dark urine were found. The room had not been cleaned since the resident was transferred to the hospital days earlier. The housekeeping supervisor admitted that the room was overlooked due to a lack of coordination among the housekeeping staff, despite having three staff members assigned to the task over the weekend. The facility's Homelike Environment Policy, dated February 2021, mandates a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to adhere to physician's orders for wound treatments for a resident with non-pressure chronic lower leg ulcers, diabetes, renal insufficiency, stroke, and heart failure. The resident, who had intact cognitive ability, was supposed to receive daily dressing changes as per the care plan. However, observations and record reviews revealed that the dressing changes were not performed on several occasions, specifically on 1/29/25, 1/30/25, and 2/3/25. During an observation on 2/4/25, it was noted that the dressings had not been changed since 2/2/25, despite the presence of the resident's wound physician who emphasized the importance of daily dressing changes to prevent infections. Interviews with the resident and staff further highlighted the issue. The resident reported that staff informed him the dressing change was not done due to insufficient staffing. Staff B-RN, who was responsible for the dressing change on 2/3/25, admitted to not completing the task because she left her shift early and failed to ensure the task was passed on to the relieving nurse. The facility's policy for ulcer/skin breakdown, which outlines the physician's role in guiding care plans and ordering treatments, was not followed, contributing to the deficiency.
Failure to Send Insulin for Off-Campus Appointment
Penalty
Summary
The facility failed to send a resident's insulin medication for an off-campus appointment, resulting in a deficiency. Resident #2, who has multiple diagnoses including diabetes mellitus, was scheduled to attend an adult day care center as part of her discharge plan. According to the care plan, the resident required insulin administration three times a day with meals. However, during her visit to the adult day care center, the noon dose of insulin was not sent with her, as confirmed by the resident and staff interviews. Staff A, the nurse responsible for preparing the medications, admitted to forgetting to send the insulin due to a busy workload. Staff C, upon receiving a call from the adult day care center about the missing insulin, arranged for a one-time order to hold the dose. Staff B, the Director of Nursing, acknowledged that the insulin should have been sent with the resident in the morning. This oversight in medication management led to the deficiency noted in the report.
Inadequate Oxygen Supply for Resident During Outing
Penalty
Summary
The facility failed to provide adequate oxygen services for a resident, leading to a deficiency in respiratory care. The resident, who had a history of debility, cardiac respiratory condition, heart failure, renal failure, diabetes, and Chronic Obstructive Pulmonary Disease, required oxygen therapy. On a day when the resident visited an adult day care center, the facility did not supply enough oxygen, resulting in the resident's oxygen saturation levels dropping into the 70s. The resident's oxygen tank was found empty at the day care center, and emergency services had to be called to provide assistance. Interviews with facility staff revealed a lack of understanding regarding the duration a full E size oxygen canister would last at 2 liters per minute, which is approximately 5 hours according to the oxygen supply company. The staff had miscalculated the resident's return time and did not ensure the resident had sufficient oxygen for the duration of her outing. The facility's Oxygen Administration Policy, dated October 2010, did not provide adequate instructions for preparing residents for outings to ensure their oxygen needs were met.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to follow a physician's order for wound treatment for a resident with multiple diagnoses, including non-traumatic brain dysfunction, Parkinson's, dementia, chronic pain, and a history of falls. The resident, who had moderate cognitive impairment, was identified as a fall risk and had experienced a fall resulting in skin tears. The care plan directed staff to assist the resident with ambulation and remind her to use the call light for assistance. However, observations revealed that the resident's wound dressings on both forearms were not changed as per the physician's orders. The bandages were dated several days prior, indicating that the prescribed daily and every-other-day wound care was not performed. The October Treatment Administration Record showed discrepancies in the documentation of wound care. Staff members signed off on completing the wound care on specific dates, but observations and interviews revealed that the dressings had not been changed as required. An LPN admitted to not performing the dressing change and was unaware of the due date for the treatment. The Director of Nursing confirmed the failure to adhere to the physician's orders, as the bandages observed were dated earlier than the documented treatment dates. This deficiency highlights a lapse in following prescribed wound care protocols and accurate documentation.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to answer resident call lights within 15 minutes of activation for two residents, leading to a deficiency in meeting the needs of residents. Resident #4, who has diagnoses including non-traumatic brain dysfunction, Parkinson's, dementia, chronic pain, and a history of falls, expressed frustration over the delayed response to her call light. Despite being able to ambulate independently with a walker, she sometimes requires assistance due to her condition. On one occasion, her call light was activated at 10:55 am and was not answered until 11:18 am, 23 minutes later, by a CNA who was returning from lunch. The CNA explained that staffing was limited at the time, with only one staff member available to answer call lights. Resident #10, who is alert and oriented with a BIMS score of 15, requires total assistance for transfers, toileting, and personal hygiene due to paraplegia and neuromuscular dysfunction. She reported waiting for an hour for staff to respond to her call light when she needed assistance to get out of bed for a meal. The Director of Nurses stated that floor nurses audit call light response times and expects staff to respond within 15 minutes, but this expectation was not met in these instances.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who was prescribed a Fentanyl patch, resulting in the resident experiencing severe pain. The resident, who had a history of malignant neoplasm of the tongue, a hip fracture, and depression, was supposed to have a Fentanyl patch applied on the evening of 8/19/24. However, due to a miscommunication and delay in prescription management, the patch was not applied until the morning of 8/21/24. During this period, the resident reported being in severe pain, with a pain score of 8 out of 10. The delay was caused by a breakdown in communication between the pharmacy, the facility's staff, and the hospice physician. On 8/19/24, the pharmacy contacted the facility regarding a denial of the Fentanyl patch order and requested to speak with the provider. However, the Assistant Director of Nursing (ADON) was not informed of this request, and a Licensed Practical Nurse (LPN) wrote an order to hold the Fentanyl patch until 8/22/24 without consulting the provider. The Physician's Assistant (PA) managing the resident's Fentanyl patch was only made aware of the issue on 8/20/24 and sent a new prescription that morning, but the patch was still not applied until the following day. The facility's pain management policy, revised in 2017, outlines the responsibilities of physicians and staff in managing pain, including timely identification and treatment. Despite this policy, the resident's pain was not managed appropriately, as evidenced by the delay in applying the Fentanyl patch and the resident's reports of severe pain. The facility's failure to adhere to its pain management policy and ensure effective communication among staff and external providers contributed to the deficiency.
Deficiencies in Cleanliness and Bed Maintenance
Penalty
Summary
The facility failed to maintain a clean, homelike environment for its residents, as evidenced by observations and resident reports. Resident #61, with intact cognition, reported that his room was only cleaned because the state was present, and it had been approximately three weeks since the floors were last cleaned. Observations revealed a black substance on the floor, cobwebs, and heavy dust in the room, despite a housekeeper's claim that rooms were cleaned daily. Resident #71 also reported dissatisfaction with the cleanliness of his room, citing dust and cobwebs, and linked his eye infection to the dust. The facility's deep clean schedule and quality control forms showed inconsistencies and lack of documentation for completed cleanings. Additionally, many unmade beds were observed throughout Station 3, with some beds having visible urine stains and strong odors. Resident #38's bed was noted to have saturated paper chux and urine-soaked sheets, yet the resident was observed in the dining room, indicating a lack of timely bed maintenance. Staff interviews revealed confusion and inconsistency regarding bed-making responsibilities, with some staff unsure why beds were not being made and others stating that beds should be made daily unless residents request otherwise. The facility's policies on cleaning and maintaining a homelike environment were not being followed, as evidenced by the lack of documentation and observed conditions. The Cleaning and Disinfecting Resident Rooms Policy lacked specific directions on the frequency of mopping and window cleaning, contributing to the deficiencies. The Homelike Environment Policy emphasized a clean and orderly environment, which was not upheld, as seen in the unmade beds and unclean rooms.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to follow physician orders for catheter care for Resident #71, who was dependent on staff for toileting and used an indwelling urinary catheter due to a neurogenic bladder. The resident reported that his catheter had not been changed in at least four weeks, despite having informed a staff member who no longer worked at the facility. Observations confirmed the resident's catheter was draining clear yellow urine, but there was no documentation of a catheter change as per the physician's orders. The physician had ordered the catheter to be changed monthly, every 28 days, on the day shift, starting from 8/06/24, but the change had not been completed by 8/21/24. The facility's process for handling physician orders involved a double-check system, where the charge nurse noted the orders, and a second nurse was responsible for double-checking them. However, this process failed in the case of Resident #71, as the catheter change order was not executed. Staff interviews revealed a lack of clarity and accountability in implementing and overseeing physician orders, as evidenced by the failure to change the resident's catheter according to the updated physician order. The Director of Nursing expected nurses to follow physician orders, but the facility's policy lacked specific direction on who was responsible for implementing or overseeing these orders.
Failure to Conduct Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to conduct weekly measurements and assessments for a resident with pressure ulcers, specifically Resident #37, who had a Stage 4 pressure ulcer and an unstageable ulcer. The deficiency was identified through observations, interviews, and record reviews, revealing that the resident did not receive the required weekly assessments from the time he was seen at a wound clinic on July 10, 2024, until an assessment was conducted at the facility on August 20, 2024. This lapse in care was acknowledged by the facility's Director of Nursing, who confirmed that weekly measurements were not being performed. Resident #37 had a medical history that included heart failure, cancer, depression, and non-Alzheimer's dementia, with a documented moderately impaired cognition. The resident was dependent on staff for bed mobility, transfers, and toileting. Despite the resident's complex medical needs and the presence of significant pressure ulcers, the facility did not adhere to the professional standards of practice for pressure ulcer care, which require regular monitoring and assessment to prevent further deterioration. The Assistant Director of Nursing mentioned that the resident was followed by a wound clinic, and his wife preferred this arrangement as it allowed them to spend time outside the facility. However, this did not absolve the facility of its responsibility to perform weekly assessments as required. The facility's failure to conduct these assessments was a clear deviation from established guidelines for pressure ulcer management, which emphasize the importance of regular monitoring to optimize healing and prevent new ulcers from developing.
Resident Smoking on Smoke-Free Campus
Penalty
Summary
The facility failed to ensure that residents adhered to its smoking policy, which led to a deficiency involving a resident smoking on facility grounds. The facility is designated as a smoke-free campus, yet a resident was observed smoking on the premises. This resident, who had recently been readmitted to the facility, was seen wheeling herself to a sidewalk between the building and the parking lot, where she lit a cigarette and smoked. The resident was not accompanied by staff, and she disposed of the cigarette in a trash can outside the exit door. The resident had a care plan initiated that directed staff to educate her on the facility's tobacco and smoking policies. However, the resident stated that she was told by staff that they were too busy to assist her with smoking, although this did not happen often. The facility's Director of Clinical Operations confirmed that the facility is a non-smoking campus and clarified that residents must leave the grounds to smoke, which the resident did not do. The absence of a receptacle for cigarette disposal in the area where the resident smoked further indicated non-compliance with the facility's smoking policy. The facility's smoking policy, revised in July 2017, outlines that smoking is only permitted in designated areas outside the building, and residents must be evaluated for their ability to smoke safely. The resident in question was assessed as an independent smoker, capable of smoking safely. Despite this, the facility's policy was not enforced, as the resident smoked on facility grounds without supervision, contrary to the established guidelines. This lack of adherence to the smoking policy resulted in the observed deficiency.
Failure to Honor Resident's Vegetarian Diet Preference
Penalty
Summary
The facility failed to honor the dietary preferences of a resident, identified as Resident #113, who had chosen to follow a vegetarian diet. Despite the resident's clear communication of her dietary preferences, including her inability to digest meat and eggs, the facility continued to serve her meals containing these items. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), reported multiple instances where she was served meat and eggs, which she could not consume due to her dietary restrictions and personal choice. Interviews with staff members, including dietary aides and a licensed practical nurse, revealed awareness of the resident's request for a vegetarian diet. However, there was a lack of documentation in the resident's care plan and dietary notes to reflect her preferences. The dietary staff failed to update the resident's meal cards to exclude meat and eggs, leading to repeated instances of inappropriate meal service. The facility's dietary communication process was hindered by a gap in the Dietary Services Manager (DSM) position, resulting in inadequate communication and documentation of the resident's dietary needs. The facility's policy on food and nutritional services mandates that resident preferences be considered and that meals be inspected to ensure they meet the residents' needs. However, due to the transition of the Housekeeping Manager into the role of Dietary Manager and the lack of a designated person to review menus with residents, the facility did not adequately address the resident's dietary preferences. This oversight led to the resident being served meals that did not align with her vegetarian diet, highlighting a deficiency in the facility's ability to accommodate resident choices and preferences.
Failure to Provide Timely SNF ABN Forms
Penalty
Summary
The facility failed to comply with Federal Regulations regarding Medicare billing practices by not providing the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) forms 48 hours before the end of skilled services for two residents. Resident #112 received Medicare benefits for skilled services from June 10 to June 21, 2024, but was not given the required SNF ABN (CMS form 10055) to inform them of potential liability if skilled services continued. Similarly, Resident #122 received Medicare benefits for skilled services from April 3 to April 23, 2024, and also did not receive the necessary SNF ABN within the required timeframe. The deficiency was identified during a mock survey in July, which revealed that the ABNs were not being completed correctly following the retirement of the long-term social worker. The facility's policy, dated April 2021, states that the admissions coordinator or business office manager should notify the resident in writing if Medicare may not cover certain skilled services, using the SNF ABN form. This notification is crucial for informing residents of their potential financial liability if they choose to continue receiving services that may not be covered by Medicare.
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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