Hillcrest Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sumner, Iowa.
- Location
- 915 West First Street, Sumner, Iowa 50674
- CMS Provider Number
- 165502
- Inspections on file
- 19
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hillcrest Home during CMS and state inspections, most recent first.
A resident's completed MDS assessments were not submitted to CMS as required, due to incorrect documentation of unit certification status and a lapse during a transition in MDS Coordinator staffing. The DON confirmed the omission, despite the facility being dually certified and required to submit these assessments.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall resulting in a hip fracture. Despite complaints of hip pain, staff moved the resident, contrary to facility expectations. The facility failed to implement timely and effective interventions, and their policy lacked documentation of root cause analysis for falls.
A facility failed to promptly resolve a grievance concerning a resident's care, including delayed pain medication, inadequate staffing, and lack of integrated hospice care. Despite receiving a grievance letter, the administrator did not provide a formal response, violating the facility's grievance policy.
A facility failed to promptly implement a new order for increased morphine dosage for a resident who was actively dying, resulting in a delay of nearly 27 hours before the first dose was administered. Family members reported the resident experienced pain and distress, and staff interviews confirmed the delay. The facility's administrator and DON expected immediate implementation of orders, and the resident's primary doctor emphasized the importance of timely pain management.
A facility failed to obtain a doctor's order for increasing a resident's morphine dosage and for suctioning during end-of-life care. The resident, who was moderately cognitively impaired and had a prognosis of less than six months, had her morphine dosage increased without proper documentation. Additionally, suctioning was performed by an LPN at the family's request without a doctor's order, despite hospice advice against it.
A resident with diabetes mellitus, who had moderately impaired cognition, was prescribed Humalog insulin with specific instructions to withhold it if blood glucose was below 120. Despite a reading of 102, an RN administered 30 units of Humalog, violating the facility's medication policy.
The facility did not ensure that a CNA completed mandatory Dependent Adult Abuse training within six months of employment. The CNA's previous training had expired, and the required training was not completed again until a later date. The facility's policy requires such training within six months of hire and every three years thereafter. The Administrator acknowledged the oversight.
The facility did not have the required members present at their quarterly QA meetings as per CMS guidelines. The DON was absent from one meeting, and the IP was absent from another. The Administrator was unaware of the specific required attendees, believing the required attendees were the Administrator, Medical Director, and five other staff members. The facility's QAPI Plan specified the inclusion of the Medical Director, Administrator, DON, and a direct care worker/caregiver.
A resident with dementia and other medical conditions was left unattended in a shower room without a call light, compromising their dignity and quality of life. The resident was found sitting in a wheelchair with the lights off and the shower curtain pulled around them after a CNA left the facility without completing the bath.
The facility failed to follow physician's orders for two residents regarding medication administration. One resident received the wrong medications due to simultaneous setup of multiple residents' medications, while another resident missed two doses of potassium due to improper handling and verification of medication doses.
A resident with moderate cognitive impairment and documented behavioral issues, including anxiety and depression, was given an incorrect medication, resulting in an emergency room visit for acute hypoxemic respiratory failure. The resident was mistakenly administered Seroquel, an antipsychotic not prescribed to her, instead of the ordered Lorazepam for anxiety. A Certified Medication Aide admitted to the error, and a Licensed Practical Nurse received a verbal warning for altering a medication order without proper authorization. The facility's policies on oral medication administration and receiving physician orders were not adequately followed, highlighting deficiencies in medication administration protocols.
Failure to Submit Required MDS Assessments for Certified Beds
Penalty
Summary
The facility failed to submit two completed Minimum Data Set (MDS) assessments for one of five residents reviewed, despite being dually certified for all beds with CMS. Electronic health record (EHR) review showed that for one resident, the quarterly and admission MDS assessments were either marked as 'in progress' or 'completed' but not submitted to the Centers for Medicare and Medicaid Services (CMS). Documentation incorrectly indicated that the unit was neither Medicare nor Medicaid certified, and therefore MDS data submission was not required, despite the facility's actual certification status. Interviews with facility staff, including the Business Office Manager and the DON, confirmed that the facility is dually certified and follows the RAI manual for MDS completion and submission. The DON acknowledged that the required entry and admission MDS assessments had not been submitted as mandated. The facility had been using a third party for MDS completion during a vacancy in the MDS Coordinator position, which contributed to the failure to submit the required assessments.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement root cause analysis interventions for previous falls, resulting in a fall with a fracture for a resident with severe cognitive impairment. The resident, who was dependent on staff for various activities and had a history of falls, experienced an unwitnessed fall in her room. She was found sitting in her doorway, unable to bear weight on her left leg, and was later diagnosed with a left hip closed fracture. Despite the resident's complaints of hip pain, staff moved her from the floor, which was against the facility's expectations for handling such situations. The facility's records showed multiple falls for the resident, with interventions implemented after each incident. However, the interventions were not timely or effective in preventing further falls. The facility's policy lacked documentation of root cause analysis for each fall, and staff interviews revealed a lack of adherence to proper procedures when a resident shows signs of injury. The Director of Nursing acknowledged the need to review and ensure the appropriateness of interventions for all residents with a history of falls.
Failure to Resolve Grievance Regarding Resident Care
Penalty
Summary
The facility failed to promptly resolve and investigate a grievance related to the care of a resident, identified as Resident #2, who was moderately cognitively impaired and had a prognosis of less than six months to live. The grievance, submitted by a family member, highlighted several concerns regarding the care provided on a specific date, including a delay in administering pain medication while the resident was actively dying, incompetent nursing knowledge of state regulations by an LPN, insufficient staffing, and a lack of integrated care between hospice and facility nursing staff. Despite receiving the grievance letter, the facility's administrator did not provide a formal response to the family member's concerns. The facility's grievance policy, which was last revised in December 2022, outlines the responsibilities of the grievance official, including overseeing the grievance process, maintaining confidentiality, and issuing written decisions within 30 days. However, the administrator admitted to not providing a formal response to the family member's letter, which led to the family member's dissatisfaction and lack of resolution. The report indicates that the facility did not adhere to its grievance policy, as there was no evidence of a written decision or appropriate corrective action taken within the specified timeframe.
Delay in Implementing Increased Morphine Dosage for Resident
Penalty
Summary
The facility failed to promptly implement a new order for increased morphine dosage for a resident who was actively dying and required pain management. The resident, who was moderately cognitively impaired and had a prognosis of less than six months to live, had a new order to increase her morphine dosage to 0.5 mL every hour as needed. However, the first dose of the increased morphine was not administered until nearly 27 hours after the order was received, resulting in a delay in pain management. Interviews with family members and staff revealed that the delay in administering the increased dosage caused the resident to experience pain and distress. Family members reported having to prompt staff to check on the resident and administer the medication. The facility's administrator and Director of Nursing both stated that they expected orders to be implemented immediately upon receipt. The resident's primary doctor also indicated that timely administration of pain medication was expected if signs of pain or air hunger were present.
Failure to Obtain Proper Orders for Medication and Suctioning
Penalty
Summary
The facility failed to obtain a proper doctor's order for increasing a PRN morphine dosage for a resident who was actively dying. The resident, who was moderately cognitively impaired and had a prognosis of less than six months to live, had her morphine dosage increased from 0.5 mL to 1 mL without a documented order from a doctor. The hospice nurse and the facility's Director of Nursing (DON) were unable to find documentation of the order, and the resident's primary doctor did not have a record of authorizing the increase. The lack of documentation and proper authorization for the medication adjustment was confirmed through interviews with the hospice nurse, the DON, and the facility administrator. Additionally, the facility failed to obtain a doctor's order before suctioning the same resident during end-of-life care. A Licensed Practical Nurse (LPN) performed suctioning at the request of the resident's family, despite the hospice nurse's advice against it due to potential agitation and ineffectiveness. The DON confirmed that there was no order for suctioning, and the action was taken to comfort the family rather than based on medical necessity. These actions highlight deficiencies in following proper procedures for medication administration and end-of-life care.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for a resident with diabetes mellitus. The resident, who had moderately impaired cognition, was prescribed Humalog insulin to be administered once daily at 7:30 AM, with instructions to withhold the insulin if the blood glucose level was below 120. On the morning of June 19, 2024, a registered nurse conducted a blood glucose test for the resident, which resulted in a reading of 102. Despite this, the nurse proceeded to administer 30 units of Humalog insulin, contrary to the physician's order to hold the medication if the blood sugar was less than 120. This action was in violation of the facility's medication administration policy, which mandates that medications be administered according to physician orders.
Failure to Complete Mandatory Abuse Training
Penalty
Summary
The facility failed to ensure that mandatory Dependent Adult Abuse training was completed within six months of employment for a Certified Nursing Aide (CNA), identified as Staff A. Personnel records indicated that Staff A was hired on a specific date and had previously completed the required training, which expired on another specified date. However, Staff A did not complete the mandatory training again until a later date, beyond the six-month requirement. The facility's policy, titled 'Abuse Prevention Policy,' mandates that employees receive two hours of training related to the identification and reporting of dependent adult abuse within six months of hire and every three years thereafter. During an interview, the Administrator acknowledged that Staff A should have completed the training within the required timeframe after the previous training expired.
Failure to Ensure Required Attendance at QA Meetings
Penalty
Summary
The facility failed to have the minimum required members present at their quarterly Quality Assurance (QA) meetings as mandated by the Centers for Medicare and Medicaid Services (CMS). The facility, which reported a census of 45 residents, conducted QA meetings on specified dates. However, the attendance sheets revealed that the Director of Nursing (DON) was absent from the meeting on 4/11/23, and the Infection Preventionist (IP) was absent from the meeting on 4/8/24. During an interview, the Administrator admitted to being unaware of the specific required attendees for the QA meetings, mistakenly believing that the required attendees were the Administrator, Medical Director, and five other staff members, without realizing the necessity of the DON and IP's presence. The facility's Quality Assurance Performance Improvement (QAPI) Plan, last updated on 1/24/22, specified that the QAPI committee should include the Medical Director, Administrator, DON, and a direct care worker/caregiver, and meet at least quarterly.
Resident Left Unattended in Shower Room
Penalty
Summary
The facility failed to treat a resident with respect and dignity, which compromised the resident's quality of life. Resident #1, who has diagnoses including hypertension, Non-Alzheimer's Dementia, anxiety, and repeated falls, was found in the shower room sitting in her wheelchair with the lights off and the shower curtain pulled around her. The resident, who has moderately impaired decision-making abilities and requires partial assistance with bathing, was left unattended without a call light within reach. This incident occurred after Staff B, a CNA, was supposed to be giving the resident a bath but was seen leaving the facility on video at 8:50 a.m. The resident was discovered missing from the dining room for breakfast, prompting a search by the facility Administrator and other staff members. The facility's policy on Resident Rights emphasizes the importance of treating residents with respect and dignity and ensuring their environment promotes their quality of life. However, the incident report and staff interviews revealed that the resident was left unattended in a vulnerable state, which is a clear violation of these rights. The Administrator confirmed that the staff is expected to treat all residents with dignity and respect, yet this expectation was not met in this case, as evidenced by the resident being left alone in the shower room without proper safety measures in place.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for two residents regarding medication administration. For Resident #3, the nurse administered the wrong medications, including Metolazone, Carvedilol, Depakote, Eliquis, Januvia, Lisinopril, Metformin, Protonix, Torsemide, and Vitamin D3, instead of the prescribed medications such as Calcium, Plavix, Depakote, Colace, Lasix, Gabapentin, Levetiracetam, Synthroid, Lisinopril, and Tylenol. This error occurred because two residents' medications were set up simultaneously to expedite the medication pass, leading to the wrong medications being given to Resident #3. The incident was documented, and vital signs and blood sugars were monitored as a result of the error. For Resident #4, the facility failed to administer additional potassium doses as ordered by the physician after a critically low potassium level was identified. The new medication cards were found in the bottom drawer of the medication cart, and it was discovered that two doses were missed. The resident's potassium level was 3.6 on a redraw. The root cause analysis indicated that the person working the medication cart was busy when the medications arrived and did not verify the doses, leading to the missed administration. The facility's administrator confirmed that staff are expected to follow physician's orders and the policy for giving oral medications.
Medication Administration Error Leads to Emergency Room Visit
Penalty
Summary
The facility failed to follow a physician's order for Resident #2, resulting in an emergency room visit. Resident #2, with a BIMS score of 10 indicating moderate cognitive impairment, had documented behavioral issues including anxiety and depression. Despite a care plan directing staff to administer medications as ordered and monitor for side effects, on 2/15/24, Resident #2 was given a one-time dose of Lorazepam for anxiety. Later that day, she was found on the floor with low vitals and subsequently sent to the emergency department due to acute hypoxemic respiratory failure. It was noted that Resident #2 was mistakenly given Seroquel, an antipsychotic medication not prescribed to her, which may have contributed to her confusion and decline. Staff B, a Certified Medication Aide, admitted to giving Resident #2 Seroquel without a physician order, leading to the medication error. The facility's policy on Oral Medication Administration outlined steps for safe medication administration, emphasizing the importance of following the "5 rights" of medication administration. Additionally, a verbal warning was issued to Staff C, a Licensed Practical Nurse, for changing a resident's medication order without obtaining proper authorization. The facility's policy on Receiving Physician Orders highlighted the legal procedure for nurses to take phone orders but lacked clarity on entering physician orders into the medication administration record. The deficiency in medication administration protocols at the facility was evident through the unauthorized administration of medications to Resident #2. Staff members acknowledged the importance of following physician orders and the correct procedures for medication administration.
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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