Hillcrest Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hawarden, Iowa.
- Location
- 2121 Avenue L, Hawarden, Iowa 51023
- CMS Provider Number
- 165245
- Inspections on file
- 24
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Hillcrest Health Care Center during CMS and state inspections, most recent first.
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 The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual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.
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.
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.
Two residents who were cognitively impaired and dependent on staff for personal care did not receive bathing assistance at least twice weekly as required by facility policy. Facility records showed multiple instances where bathing was documented as refused or not applicable, resulting in gaps of 6, 7, and 11 days between baths. The care plan for one resident specified total dependence on staff for bathing, and the facility’s policy required showers to be offered at least twice weekly and on the next available day if missed. The DON reported that staff are expected to continue offering showers and try different approaches after refusals, but the documented bathing intervals did not reflect this practice.
A resident with severe cognitive impairment and multiple falls did not have updated fall prevention interventions added to their care plan. Although staff documented falls and discussed interventions, these were not consistently reflected in the care plan as required. Staff interviews confirmed that nurses are responsible for updating care plans, but the process was not reliably followed.
The facility failed to obtain proper signatures for bed hold notices for four residents with severe cognitive impairments during hospital transfers. Verbal authorizations were documented, but no signatures were obtained, contrary to facility policy. Interviews with the DON and Administrator confirmed the expectation for correct completion of bed holds.
The facility failed to provide adequate bathing opportunities for four residents, as evidenced by clinical record reviews, resident interviews, staff interviews, and observations. A resident with moderate cognitive impairment reported receiving showers only once a week, despite requiring substantial assistance. Another resident with intact cognition also reported infrequent showers, and observations noted greasy and unclean hair. Two other residents, both with no cognitive impairment, were observed with disheveled and greasy hair, indicating a lack of recent bathing. The facility's policy emphasized cleanliness, but refusals were not adequately addressed by staff, leading to the deficiency.
The facility failed to employ a Certified Dietary Manager (CDM) for its food and nutrition service, impacting its compliance with staffing requirements. Interviews revealed that the facility had an interim manager working towards CDM certification, and a certified individual began training recently. The absence of a CDM prior to this and the lack of a policy for certified dietary managers were acknowledged by the facility's administration and consultant.
A facility failed to obtain or document attempts to obtain physical signatures on NOMNC forms for a resident. The resident's representative provided verbal consent, but the forms lacked the required signatures. CMS guidelines mandate in-person delivery and signature, or documented attempts if not possible. The administrator was unaware of the signature requirement, as Social Services handled the forms.
A resident with moderate cognitive impairment reported a missing quilt, which was not replaced by the facility. The inventory of personal property was incomplete, and staff interviews revealed that the inventory list was not updated as required by facility policy.
A facility failed to update a resident's care plan to include the use of high-risk opioid medication and its side effects. The resident, with moderate cognitive impairment and multiple diagnoses, was prescribed oxycodone-acetaminophen, which was not documented in the care plan. The facility's policy requires comprehensive care plans, which was not followed in this instance.
The facility failed to follow physician orders for daily weights for a resident with heart failure and for pressure ulcer dressing changes for another resident. The daily weights were not completed due to a broken scale, and there was no documentation of physician notification. Similarly, multiple dressing changes were missed without notifying the physician, contrary to facility policies.
Two residents with cognitive impairments eloped from an LTC facility due to inadequate supervision and malfunctioning door alarms. Despite being assessed as high risk for wandering, the residents managed to exit the facility, highlighting issues with the alarm system and staff response. Interviews revealed that staff were desensitized to frequent false alarms, delaying their response to actual incidents.
The facility failed to manage and document the use of psychotropic and opioid medications for two residents, leading to deficiencies in their care plans. A resident with COPD and respiratory failure was prescribed Zyprexa without specific targeted behaviors or non-pharmacological interventions documented. Another resident with coronary artery disease and fibromyalgia was prescribed multiple medications, including oxycodone and risperidone, without proper documentation of usage, side effects, or non-pharmacological interventions. The facility's policy on unnecessary drugs was not adhered to, as confirmed by the Administrator.
A facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) during incontinence care for a resident with an indwelling catheter. Two CNAs performed hand hygiene and donned gloves but did not wear gowns while repositioning the resident and completing peri care. The DON expected staff to follow EBP for residents with catheters, as outlined in the facility's policy on Standard and Transmission-Based Precautions.
The facility failed to provide meals in accordance with the dietary needs of three residents, serving meals that did not match their prescribed mechanical soft diets. Interviews revealed a lack of communication and training regarding dietary needs, with the dietary manager making menu changes without consulting the dietician. The facility's policy on therapeutic diets was not followed, leading to residents receiving incorrect meal textures, posing immediate jeopardy to their health and safety.
The facility failed to follow the planned menu for a lunch meal, serving a chicken wrap and lemon pudding instead of fried chicken and strawberry sponge shortcake. The Dietary Manager, new to her role and untrained, made substitutions without consulting the dietician, who was unaware of the changes. The facility's policy requires meals to meet nutritional needs, which was not adhered to in this instance.
The facility failed to serve food at safe temperatures, as observed during a meal service. Dietary trays were found with food temperatures below recommended levels, including fish sticks at 94.3°F, carrots at 93.5°F, and cheesy rice at 102°F. Additionally, pureed cheesy rice was served at 127°F, below the CDC's recommended reheating temperature of 165°F. The Administrator intervened to stop the service and educate the staff.
The facility failed to serve meals at regular times, as meals were consistently late by 15 to 30 minutes. Observations and interviews with residents and CNAs confirmed the delays, which varied depending on the day and the cook. The facility's policy required meals to be served at specific times, but this was not adhered to, causing dissatisfaction.
The facility failed to follow hand hygiene protocols during perineal care, dining service, and food preparation. A resident with severe cognitive impairment did not receive proper perineal care as CNAs did not perform hand hygiene after glove removal. Additionally, a CNA fed two residents without washing hands between them, and kitchen staff did not wash hands between glove changes. The facility's policies on hand hygiene were not adhered to, as confirmed by the ADON and Administrator.
A CNA failed to maintain the dignity of two residents during a dining experience by not communicating with them and improperly handling one resident's arm. The CNA placed a resident's arm across her chest without speaking to her while assisting another resident with eating. This action violated the facility's policy on resident rights, which emphasizes respect and recognition of residents' dignity.
The facility staff failed to ensure call light accessibility for two residents, leading to situations where a resident had to call the front desk for assistance and another felt fearful during a mechanical lift transfer. Despite the facility's policy requiring call lights to be within reach, staff frequently left them out of reach, impacting residents who were dependent on staff for personal hygiene and had no cognitive impairment.
A resident reported multiple incidents of improper use of a mechanical lift, including being banged on the lift, feeling insecure in a wheelchair, and experiencing fear when the emergency button was used during transfers. The facility's policy required two staff members for transfers, but the resident was transferred alone, and the lift was not hooked up correctly.
A resident with severe cognitive impairment and multiple diagnoses did not receive appropriate incontinence care, as two CNAs failed to follow the facility's perineal care policy. The resident was improperly positioned, and the CNAs did not maintain proper hand hygiene during the care process, which could contribute to urinary tract infections.
A facility failed to answer call lights within a reasonable time, affecting residents needing assistance. One resident experienced incontinence due to a delay, while another, requiring help due to hemiplegia, reported long wait times and overheard staff refusing assistance. A third resident reported frequent delays of up to 1.5 hours. Call light logs confirmed multiple instances of response times exceeding the facility's 15-minute policy.
The facility failed to provide meal alternatives or substitutions, as residents were limited to the daily menu or a few alternative options. A grievance highlighted weight loss concerns due to the removal of meal options, and interviews confirmed that residents could not request specific items not on the menu. The facility's policy aimed for a person-centered dining experience, but recent changes to the a la carte menu limited food availability to improve kitchen time management.
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.
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 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.
Failure to Provide Twice-Weekly Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance at least twice weekly, as required by its own policy, for two residents who were dependent on staff for bathing. For one resident with anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive impairment, the MDS documented total dependence on staff for bathing. Facility documentation showed that bathing was recorded as refused on one date, with actual baths provided on dates that resulted in a 6‑day interval without a bath on two separate occasions. The resident’s care plan indicated the resident was totally dependent on staff to provide a bath as necessary. For another resident with diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, facility records showed multiple dates where bathing was documented as refused or as not applicable. Review of the Follow Up Question Report demonstrated several extended gaps between baths: 6 days on two occasions, 7 days on one occasion, and 11 days on another, despite the facility policy requiring showers to be offered at least twice weekly and, if missed, to be offered on the next available day. In an interview, the DON stated that when a resident refuses a shower, staff are expected to continue to offer, try multiple times, try a different person, and continue to try the next day until the resident bathes, which was not reflected in the documented bathing intervals for these two residents.
Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to update care plan interventions for a resident after multiple falls, as required by policy and regulatory standards. Record review showed that a resident with diagnoses of Alzheimer's disease, dementia, and malnutrition, and a BIMS score indicating severe cognitive impairment, experienced several falls over a period of time. Despite these incidents, the care plan did not reflect updated or new interventions to address the resident's fall risk. Incident reports documented each fall, but the care plan remained unchanged regarding fall prevention strategies. Interviews with staff, including an LPN and the DON, confirmed that nurses are responsible for entering interventions into the care plan after a fall. However, it was revealed that while interventions were sometimes documented in progress notes and discussed by the interdisciplinary team, they were not consistently incorporated into the resident's care plan. The DON acknowledged that the process for updating care plans was not always followed, particularly due to reliance on the MDS nurse to finalize interventions, and noted that a new MDS nurse was in training at the time.
Failure to Obtain Proper Bed Hold Signatures
Penalty
Summary
The facility failed to ensure that bed hold notices were properly signed by residents or their representatives when residents were transferred out of the facility. This deficiency was identified for four residents, all of whom had severe cognitive impairments as indicated by their BIMS scores. For Resident #4, the facility documented a verbal authorization from the resident's representative but did not obtain a signature. Similarly, Resident #11 was transferred to a hospital without a signed bed hold notice, and the documentation lacked a signature. Resident #40 was verbally informed about the bed hold, but the form was not signed. Resident #45's representative agreed to the bed hold via telephone, but no wet signature was obtained. Interviews with the Director of Nursing and the Administrator revealed that the facility's expectation was for bed holds to be completed and obtained correctly. The facility's policy, revised in May 2021, requires that residents or their representatives be informed in writing of their right to exercise the bed hold provision in the event of a transfer. However, the facility did not adhere to this policy, resulting in the deficiency. The facility reported a census of 50 residents at the time of the survey.
Failure to Provide Adequate Bathing Opportunities
Penalty
Summary
The facility failed to provide adequate bathing opportunities for four residents, as evidenced by clinical record reviews, resident interviews, staff interviews, and observations. Resident #46, with moderate cognitive impairment, reported receiving showers only once a week, despite requiring substantial assistance with bathing. The facility's records showed that Resident #46 had a shower on 2/16/25 and was marked as unavailable on 2/24/25. Similarly, Resident #202, with intact cognition, reported receiving showers only once a week, and observations noted greasy and unclean hair. The records indicated showers on 2/13/25 and 2/16/25, with a note of 'not applicable' on 2/24/25. Resident #2, with no cognitive impairment but suffering from depression, anxiety disorder, and chronic pain, was observed with disheveled and greasy hair, indicating a lack of recent bathing. The care plan required assistance with bathing twice weekly, but records showed refusals and 'not applicable' entries on several dates. Resident #37, also with no cognitive impairment, was observed with greasy hair and had a care plan requiring assistance with bathing twice weekly. Records showed refusals on multiple occasions, with only two full body baths completed over a month. The facility's policy emphasized promoting cleanliness and relaxation, but interviews revealed that refusals were not adequately addressed by staff, leading to the deficiency in providing necessary bathing care.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a clinically qualified nutrition professional, specifically a Certified Dietary Manager (CDM), which is a requirement for the food and nutrition service. The facility, with a census of 50 residents, did not have a CDM at the time of the survey. An interview with the Administrator on February 24, 2025, revealed that the facility had an interim manager who was working towards obtaining his CDM certification. By February 27, 2025, the Administrator confirmed that a person with CDM certification had started training that week, acknowledging that the facility did not have a CDM prior to this. Additionally, a facility consultant, Staff C, expressed the expectation for a certified dietary manager to be in charge of the kitchen and noted the absence of a policy for certified dietary managers at the facility.
Failure to Obtain Signatures on Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to obtain physical signatures or document attempts to obtain signatures on the Notice of Medicare Non-Coverage (NOMNC) forms CMS-10123 and CMS-10055 for a resident. The resident's representative gave verbal consent for the signature on the specified date, but the forms lacked the necessary physical signature from either the resident or their representative. Additionally, the resident's progress notes did not contain any documentation of attempts to obtain these signatures. The Centers for Medicare & Medicaid Services (CMS) guidelines require that NOMNC forms be delivered in person and signed by the beneficiary or their representative. If in-person delivery is not possible, alternative methods such as telephone, mail, or email can be used, but the facility must document these attempts and retain a copy of the unsigned notice while awaiting the signed version. The facility's administrator was unaware of the requirement for physical signatures, as the responsibility for these forms was delegated to Social Services.
Failure to Protect Resident's Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property from loss or theft, specifically a quilt that went missing from the laundry. The resident, who has moderate cognitive impairment as indicated by a BIMS score of 12, reported the missing quilt to the facility, but it had not been replaced. An inventory document for the resident's personal property was found to be incomplete, with no items marked for personal inventory. Interviews with staff and the resident's representative revealed that the inventory form was not properly filled out at the time of admission, and the inventory list was not updated as required. The facility's policy mandates that an inventory of personal effects should be completed upon admission and updated as new items are brought in. However, this procedure was not followed, leading to the deficiency in protecting the resident's personal property.
Failure to Update Care Plan for Opioid Medication
Penalty
Summary
The facility failed to revise and update the care plan for a resident to include the usage of high-risk opioid medication and the side effects to monitor. The resident, who has diagnoses of coronary artery disease, fibromyalgia, and respiratory failure, was assessed with a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The Minimum Data Set (MDS) assessment and the Order Summary Report revealed an order for oxycodone-acetaminophen, an opioid medication, which was not reflected in the resident's care plan. The facility's policy on Comprehensive Person-Centered Care Planning mandates the development of a comprehensive care plan for each resident, which was not adhered to in this case. An interview with the Administrator confirmed that the medication and its side effects should have been included in the care plan.
Failure to Follow Physician Orders for Daily Weights and Dressing Changes
Penalty
Summary
The facility failed to provide physician-ordered daily weights for a resident with heart failure, hypertension, and coronary artery disease, who had a severe cognitive impairment. Despite a physician's order for daily weights to monitor potential weight gain, the facility's records showed repeated entries indicating that the scale was broken or unavailable over several months. There was no documentation that the physician was notified about the inability to complete the daily weights as ordered, which is a deviation from the facility's policy to accurately implement physician orders. Additionally, the facility did not adhere to physician orders for pressure ulcer dressing changes for another resident with hypertension, anxiety disorder, and edema, who had no cognitive impairment. The resident reported having a sore that required dressing changes twice a day. However, the Treatment Administration Record (TAR) lacked documentation of dressing changes on multiple occasions across three months. The clinical record did not show any notification to the physician about the missed dressing changes, contrary to the facility's wound management policy, which requires necessary treatment and services to promote healing and prevent infection.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate nursing supervision for two residents, leading to incidents of elopement. Resident #22, who had a history of non-traumatic brain dysfunction and Alzheimer's disease, was found outside the facility on two occasions. The resident had previously been assessed as a high risk for wandering, with scores indicating significant risk. Despite these assessments, the resident managed to exit the facility through a hallway into the assisted living portion and was later found in the parking lot. Resident #48, diagnosed with non-traumatic brain dysfunction, bipolar disorder, and non-Alzheimer's dementia, also eloped from the facility. The resident was found returning through the front doors with multiple items of clothing, indicating they had been outside. The door alarms had sounded, but staff interviews revealed that the alarms were not functioning correctly, often going off without being triggered by an actual event. This malfunction led to staff becoming desensitized to the alarms, delaying their response to actual elopement incidents. Interviews with various staff members, including CNAs, the ADON, and the maintenance supervisor, highlighted issues with the door alarm system. The alarms were reported to have been malfunctioning, causing confusion and delayed responses from the staff. The previous administrator was aware of the issues but did not ensure timely repairs, contributing to the residents' ability to elope. The facility's policy on elopement and unsafe wandering emphasized the need for a safe environment and adequate supervision, which was not effectively implemented in these cases.
Deficiencies in Medication Management and Care Planning
Penalty
Summary
The facility failed to properly manage and document the use of psychotropic and opioid medications for two residents, leading to deficiencies in their care plans. Resident #4, who has diagnoses of chronic obstructive pulmonary disease, respiratory failure, and dependence on supplemental oxygen, was prescribed Zyprexa, an antipsychotic medication. However, the resident's care plan lacked specific targeted behaviors for the use of this medication and did not include non-pharmacological interventions to be tried prior to or alongside the medication. This oversight indicates a failure to adhere to the facility's policy on unnecessary drugs, which requires the incorporation of medication-related goals and parameters into the comprehensive care plan. Similarly, Resident #13, with diagnoses of coronary artery disease, fibromyalgia, and respiratory failure, was prescribed multiple medications, including oxycodone, risperidone, and sertraline. The care plan for this resident also lacked information on the usage, side effects, and non-pharmacological interventions for these medications. Additionally, it did not specify the targeted behaviors for the antipsychotic and antidepressant medications. The facility's policy emphasizes the importance of managing and monitoring each resident's medication regimen to promote their highest practicable well-being, which was not followed in these cases. An interview with the Administrator confirmed the expectation that care plans should include side effects, targeted behaviors, and non-pharmacological interventions.
Failure to Implement Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) during incontinence care for Resident #45, who was one of three residents reviewed for infection control. Resident #45 had an indwelling catheter and was diagnosed with neurogenic bladder and hemiplegia following a cerebral infarction. During an observation, two Certified Nursing Assistants (CNAs), Staff A and Staff B, performed hand hygiene and donned gloves before repositioning Resident #45 and completing peri care. However, neither staff member donned a gown while performing these tasks. The Director of Nursing (DON) stated that the expectation was for staff to follow EBP when caring for residents with catheters. The facility's policy on Standard and Transmission-Based Precautions, revised in March 2024, indicated that EBP should be used in conjunction with standard precautions, including the use of gowns and gloves during high-contact resident care activities to prevent the indirect transfer of Multi-Drug Resistant Organisms (MDROs).
Failure to Provide Appropriate Diets for Residents
Penalty
Summary
The facility failed to provide meals in accordance with the dietary needs of three residents, as observed during a meal service. Residents were served meals that did not match their prescribed mechanical soft diets, which require specific textures to accommodate their dietary restrictions. For instance, one resident received a chicken wrap with lettuce and potato chips, which are not suitable for a mechanical soft diet. Another resident was served a similar meal and began eating potato chips, which were also inappropriate for their dietary needs. These observations indicate a failure to adhere to the residents' dietary orders, which are crucial for their health and safety. Interviews with staff revealed a lack of communication and training regarding dietary needs and meal preparation. The dietary manager admitted to making menu changes without consulting the dietician, resulting in inappropriate meal textures being served. Additionally, the dietary manager had only been in her position for a short time and had not received adequate training. Staff interviews further highlighted ongoing issues with serving incorrect food textures and liquids, with CNAs often having to intervene to correct these errors before residents consumed the meals. The facility's policy on therapeutic diets mandates that diets must be prescribed by the attending physician and that a tray identification system should ensure residents receive the correct diet. However, the failure to follow these protocols led to residents receiving meals that did not meet their dietary requirements. This deficiency was identified as an immediate jeopardy to the health and safety of the residents, as the incorrect meal textures could pose significant risks to their well-being.
Failure to Follow Planned Menu and Consult Dietician
Penalty
Summary
The facility failed to adhere to the planned menu for residents, as observed during a lunch meal service. The planned menu for the lunch meal included fried chicken, potato salad, green beans with bacon, strawberry sponge shortcake, and milk. However, the meal served consisted of a chicken wrap, potato salad, potato chips, and lemon pudding. This deviation from the planned menu was due to the Dietary Manager, Staff C, not ordering enough fried chicken and only receiving one spongecake, leading her to make substitutions without consulting the dietician. Staff C, who had been in her position for only a week and a half, admitted to not having received training as a dietary manager and did not maintain a log of substitutions at the facility. The dietician, Staff D, confirmed that she was not contacted for any menu changes and emphasized the importance of appropriate nutritional exchanges for substitutions. The facility's policy on dining and meal service, last updated in 2019, states that meals should be nourishing, palatable, and meet the nutritional and special dietary needs of residents. The Administrator expected the residents to receive the planned menu, highlighting a failure in communication and adherence to established protocols.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was at a proper temperature, as observed during a meal service. During an observation, three dietary trays were noted sitting on a table with covers on. The Dietary Manager, identified as Staff C, was asked to take meal temperatures before the trays were sent to residents. The temperatures recorded were 94.3 degrees Fahrenheit for fish sticks, 93.5 degrees Fahrenheit for carrots, and 102 degrees Fahrenheit for cheesy rice, all of which were below the recommended safe temperature. Staff C left the cover off the meal tray, and approximately 10 minutes later, it was revealed that the room tray needed to be remade. Additionally, a tray with pureed food was observed at the service window. Staff C confirmed that the food was pureed cheesy rice, which had just been microwaved. Upon checking, the temperature of the pureed cheesy rice was found to be 127 degrees Fahrenheit, which is below the recommended reheating temperature of 165 degrees Fahrenheit as per the Center for Disease Control guidelines. Despite this, Staff C covered the bowl and placed it in the service window, indicating it was ready to be served. The Administrator intervened and educated Staff C that the meal was not hot enough to serve.
Facility Fails to Serve Meals on Time
Penalty
Summary
The facility failed to provide meals at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Observations and interviews revealed that meals were consistently served late. On 7/25/24, the first meal was served at 12:23 p.m., and the last meal was served at 1:25 p.m., which was later than the scheduled lunch time of 12:00 p.m. as per the facility's policy. Interviews with residents and staff confirmed that meals were typically served 15 to 30 minutes late, depending on the day and who was cooking. The facility's policy, updated in November 2019, stated that meals should be served at specific times: breakfast at 7:30 a.m., lunch at 12:00 p.m., and dinner at 5:00 p.m. The Administrator expected the lunch meal to be served at noon, but this expectation was not met, leading to dissatisfaction among residents and staff.
Failure to Follow Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during perineal care for a resident with severe cognitive impairment and total dependence on staff for personal hygiene. During an observation, two CNAs were seen providing perineal care to the resident without following the facility's policy, which required the resident to be positioned on her back for proper access. The CNAs did not perform hand hygiene after removing soiled gloves and before touching other surfaces, such as the resident's blankets and pillows, or before repositioning the resident. This failure to follow proper hand hygiene procedures was confirmed by the Assistant Director of Nursing, who stated that staff should adhere to the policy. Additionally, the facility did not ensure proper hand hygiene during dining service and food preparation. A CNA was observed feeding two residents consecutively without performing hand hygiene between assisting each resident. In the kitchen, the Dietary Manager and another staff member were seen changing gloves multiple times without washing their hands after each glove removal, contrary to the facility's hand washing policy. The Administrator confirmed that staff were expected to wash their hands after removing gloves and between assisting residents.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to uphold the dignity of residents during a dining experience, as observed on 7/25/24. A Certified Nursing Assistant (CNA), identified as Staff H, was seen feeding two residents simultaneously. During this process, Resident #17 attempted to sit forward in her wheelchair, at which point Staff H placed the resident's left arm across her chest without any verbal communication. Staff H continued to assist Resident #18 with eating, providing three more bites of food before addressing Resident #17. Staff H then left the table briefly, asking another staff member to watch Resident #17, and upon returning, resumed feeding both residents without speaking to them. This action was contrary to the facility's policy on resident rights, which emphasizes treating residents with consideration, respect, and recognition of their dignity and individuality. An interview with the Administrator on 7/28/24 confirmed that the staff should have engaged in communication with the residents and should not have placed an arm across Resident #17's chest. The facility's policy, reviewed in June 2023, clearly states the importance of respecting residents' dignity and individuality, which was not adhered to in this instance.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility staff failed to provide reasonable accommodation of needs by not placing the call light within reach of residents for two out of six residents reviewed. Resident #1 reported that the call light was left out of reach after care, requiring the resident to call the front desk for assistance. Additionally, during a mechanical lift transfer, the nurse left Resident #1 unattended and without a call light, causing the resident to feel fearful of falling. Resident #6, who had no cognitive impairment and was dependent on staff for personal hygiene, also reported that staff frequently failed to place the call light within reach, necessitating calls to the facility for help. The facility's Call Light policy, last revised in May 2007, requires staff to leave the call device within the resident's reach before leaving the room.
Improper Use of Mechanical Lift Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to use the mechanical lift appropriately, leading to potential hazards and accidents for a resident. The resident reported that during a transfer, her foot was banged on the mechanical lift, and she was placed incorrectly in her wheelchair, causing her to feel as though she might slip out. Additionally, the resident was left unattended without a call light while the nurse went to get help. The resident also experienced fear when staff used the emergency button to lower her into bed, which released quickly and startled her. Further incidents involved the use of the emergency button by CNAs during transfers, which was not in accordance with the facility's mechanical lift policy. The policy required the use of two healthcare personnel during transfers, with one operating the lift and the other assisting. However, the resident reported being transferred alone by a CNA, and the lift was not hooked up correctly, necessitating intervention by another CNA. These actions were contrary to the facility's policy and contributed to the deficiency.
Inadequate Incontinence Care and Hand Hygiene
Penalty
Summary
The facility failed to provide complete and appropriate incontinence care to prevent urinary tract infections for a resident with severe cognitive impairment and multiple diagnoses, including non-traumatic brain dysfunction, dementia, and dysphagia. The resident was totally dependent on staff for toileting hygiene, showering, and personal hygiene. During an observation, two CNAs were seen providing perineal care to the resident in a manner that did not align with the facility's policy. The resident was positioned on her side, which did not allow proper physical and visual access to the perineal area, and the CNAs did not follow the correct sequence of cleansing as outlined in the facility's perineal care policy. Additionally, the CNAs failed to maintain proper hand hygiene during the care process. After removing soiled gloves, one CNA placed them on the bed and touched her scrub pants before performing hand hygiene. The other CNA did not perform hand hygiene after discarding used wipes and gloves and proceeded to handle the resident's blankets, pillows, and wet wipe package. These actions were inconsistent with the facility's policy, which emphasized the importance of hand hygiene and proper positioning during perineal care. The Assistant Director of Nursing confirmed that staff should follow the policy when performing perineal care and hand hygiene.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to consistently answer call lights within a reasonable amount of time, as evidenced by reports from residents and staff interviews. Resident #1 experienced a significant delay in call light response, resulting in incontinence. The grievance resolution form indicated that the call light was activated at 6:30 AM and not answered until 7:30 AM. Resident #8, who requires substantial assistance for personal hygiene due to hemiplegia and an overactive bladder, reported that staff failed to assist her to the bathroom every two hours as needed. She also mentioned overhearing a staff member refusing to help her, leading her to attempt to use the bathroom independently, which resulted in an accident. Resident #15, who requires partial to moderate assistance with toileting hygiene, reported call light response times ranging from 40 minutes to 1.5 hours, occurring five times a week. The call light logs for both Resident #8 and Resident #15 showed multiple instances of response times exceeding the facility's policy of 15 minutes. Staff interviews revealed that call lights were often answered after 15 minutes, depending on the staff on duty, and that nurses and office staff were supposed to assist if CNAs were unable to respond promptly, but often did not.
Failure to Provide Meal Alternatives
Penalty
Summary
The facility failed to provide meal alternatives or substitutions to residents, as observed through resident and staff interviews and a review of facility policies. A grievance filed on April 1, 2024, highlighted concerns about weight loss among residents due to the removal of meal options, with residents being told they could not have items not listed on the menu, such as toast, yogurt, applesauce, pudding, and eggs. Another grievance on June 14, 2024, involved a resident who requested an egg sandwich for breakfast but was denied because it was not on the menu. Interviews with staff and residents confirmed that residents were limited to choosing from the daily menu or a few alternative options, such as deli sandwiches, grilled cheese, and chicken noodle soup. The facility's policy on dining and meal service, last updated in November 2019, stated that the dining experience should be person-centered and supportive of individual needs, providing nourishing and attractive meals that meet nutritional and special dietary needs. However, the administrator revealed that the facility had recently changed the a la carte menu to improve time management in the kitchen, limiting the availability of certain items. This change resulted in residents being unable to request specific food items, such as different types of eggs, unless specifically requested, which was not an option prior to the surveyor's inquiry.
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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