Holy Spirit Retirement Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sioux City, Iowa.
- Location
- 1701 West 25th Street, Sioux City, Iowa 51103
- CMS Provider Number
- 165266
- Inspections on file
- 19
- Latest survey
- October 7, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Holy Spirit Retirement Home during CMS and state inspections, most recent first.
The facility did not properly document vaccine refusals in the medical records for several residents with various chronic conditions. Although the electronic health record immunization section showed that vaccines were refused, there were no corresponding entries in the progress notes, and declination forms were not obtained as required by facility policy. Interviews with the DON and Administrator confirmed that refusals were not consistently documented.
Four residents with documented needs for restorative care did not consistently receive or have restorative services documented, despite care plans indicating such interventions were necessary to maintain ADLs. Residents and family members reported infrequent or absent restorative care, and staff interviews revealed that the restorative aide was often reassigned to other duties due to staffing shortages, resulting in restorative care not being performed as required by facility policy.
Staff did not follow the planned menu for a lunch meal, omitting bread and margarine that were listed and selected by residents, including those on pureed diets. Observations and staff interviews confirmed that these items were not prepared or served as required by facility policy.
The facility did not ensure the Medical Director attended required quarterly QAA meetings, as evidenced by missing signatures on meeting minutes and confirmation from the DON. Facility policy specifies the Medical Director must participate in these meetings.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice, but staff failed to update the care plan to include hospice services. Despite documentation confirming hospice admission and ongoing services, the care plan did not reflect this change, contrary to facility policy and expectations.
Two residents who were dependent on staff for ADL support did not receive adequate care, including timely toileting, proper positioning in wheelchairs, and correct management of an indwelling Foley catheter. One resident was left in a urine-saturated brief and without required leg support, while another had a catheter bag improperly placed above the bladder, contrary to care plans and facility policy. Staff interviews and observations confirmed lapses in following required care procedures.
A resident with severe cognitive deficits and total dependence on staff for care was found with an unexplained bruise under her eye. Staff could not determine how the injury occurred, despite the resident's care plan indicating a need for close supervision and specific interventions. The incident was discovered by an LPN, and neither the overnight nurse nor CNA were aware of any event leading to the injury.
Two residents with sleep apnea and respiratory conditions did not have current CPAP settings available to staff, and their CPAP masks and tubing were not monitored or replaced according to policy or supplier schedules. Both residents used visibly worn equipment for extended periods, and neither clinical orders nor care plans included the required settings. Staff interviews confirmed a lack of awareness and procedures for CPAP supply maintenance.
A resident with COPD and other conditions did not receive proper staff support for CPAP use, as no trained personnel were available to monitor or adjust the device. The receptionist, rather than clinical staff, assisted with the CPAP on two occasions due to lack of staff knowledge, and the DON confirmed the absence of trained staff or a respiratory therapist to oversee CPAP settings.
Staff did not follow hand hygiene protocols during incontinence care for a dependent resident with multiple medical conditions. CNAs changed gloves without using hand sanitizer and left the room without washing their hands, despite facility policies requiring proper hand hygiene to prevent infection.
The facility failed to implement proper infection prevention practices, including hand hygiene and enhanced barrier precautions, during care for residents with medical devices. Staff were observed not following hand hygiene protocols, and no enhanced barrier precautions were in place for residents with feeding tubes and catheters. Additionally, the facility lacked documented COVID-19 vaccination policies, despite claiming to follow CDC guidelines.
The facility did not conduct the required Iowa Criminal Background check and dependent adult/child abuse registry check for a CNA before employment. The facility's policy exempted staff under a certain age from these checks, contrary to federal regulations. The Administrator was aware of the federal requirements but not the facility's non-compliant policy.
The facility failed to provide food in the correct consistency for residents on mechanically altered diets. During a lunch service, four residents with dietary needs were served coleslaw instead of the steamed cabbage listed on the menu. Staff F, a Dietary Aide, admitted to the oversight. The facility's policy requires meals to be checked against the therapeutic diet spreadsheet, but this was not followed, as confirmed by the Certified Dietary Manager and Registered Dietitian.
The facility failed to maintain proper food handling and sanitation practices, affecting 61 residents. During a lunch service, a dietary aide did not perform hand hygiene between tasks and handled hamburger buns directly with their hands instead of using tongs. This was contrary to the facility's hand washing policy, which requires hand hygiene to prevent cross-contamination. The Certified Dietary Manager confirmed the improper handling of food.
A resident with severe cognitive impairment was left with food debris on their clothing protector and face after a meal, which was not cleaned up by staff in a timely manner. The resident's family member later addressed the issue, highlighting a failure to adhere to the facility's dignity policy.
A facility failed to refer a resident for a Level II PASRR evaluation after the resident was diagnosed with major depressive disorder and psychotic disorder. Despite these new diagnoses, the facility did not resubmit the PASRR for further evaluation, as required by their policy. The oversight was confirmed by the DON, who expected the social worker to handle the resubmission.
A facility failed to follow a care plan requiring supervision for a resident with moderate cognitive impairment and a high risk of falls. Despite the care plan's directive, the resident was observed unattended in a wheelchair multiple times. Staff interviews revealed a lack of awareness of the supervision needs, and the DON acknowledged the care plan did not reflect the requirement.
A facility failed to follow its policies for feeding tube management for a resident with no cognitive impairment. The staff did not accurately measure the prescribed 330 mL of supplemental formula, instead 'eyeing' the amount to just above 300 mL. Additionally, medications were pushed with a piston syringe rather than administered by gravity flow, contrary to facility expectations. The DON confirmed these actions were not in line with the facility's procedures.
A facility failed to store medications properly, as a bottle of Tums was found in a resident's room on two occasions. The resident's records lacked an assessment for self-administration of medications, and the DON confirmed the resident was not able to self-administer. The facility's policy requires adherence to professional standards, which was not followed.
A resident with COPD was observed using oxygen, but the facility failed to maintain accurate EHR documentation. The resident's care plan included oxygen therapy, yet the most recent order was discontinued months prior, and no current order was found in the MAR or TAR. The DON acknowledged the oversight, noting the order might have been missed after a hospital stay.
Failure to Document Vaccine Refusals in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurately documented electronic health records for four out of five residents reviewed. Specifically, for multiple residents with various diagnoses including heart failure, peripheral vascular disease, renal insufficiency, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease, and respiratory failure, the electronic health record immunization section indicated that these residents refused vaccines such as the Covid-19, influenza, and pneumococcal vaccines. However, there were no corresponding entries in the progress notes documenting these refusals, as required by facility policy. Interviews with the DON revealed that declination forms were not obtained when residents refused vaccines, and documentation was only made if a vaccine was accepted. The DON stated that for residents with lower cognitive scores or a medical POA, the POA would be contacted, and refusals by POA would be documented in the progress notes. The Administrator confirmed that refusals should be charted in the medical record with a signed declination form. Facility policy also required that vaccine refusals be documented in the resident's medical record, which was not done in these cases.
Failure to Provide and Document Restorative Care for Residents
Penalty
Summary
The facility failed to provide and document restorative care for four residents who were identified as needing such services to maintain their activities of daily living (ADLs). Each resident had documented diagnoses such as muscle wasting, weakness, unsteadiness, repeated falls, or stroke, and their care plans included restorative programs to maintain or improve their functional abilities. Despite these documented needs and care plans, restorative care was either not provided as scheduled or was provided infrequently, as evidenced by restorative care flow records and weekly reviews showing little to no restorative care delivered over a 15-day period. Resident interviews confirmed the lack of restorative care, with residents reporting that they only received therapy or restorative interventions once or twice a week, or not at all. Some residents expressed concern about the potential for loss of function due to the lack of regular restorative therapy. Family members also voiced dissatisfaction, noting that the restorative program was not being implemented as expected and expressing concern about the residents' declining abilities. Staff interviews revealed that the restorative aide was frequently reassigned to direct resident care due to staffing shortages, preventing her from performing restorative duties. The DON acknowledged that restorative care was not consistently provided, attributing this to staff turnover and the need to reallocate the restorative aide to cover other care needs. The facility's own policy required that residents receive restorative nursing care as needed to promote optimal safety and independence, but this was not followed for the residents reviewed.
Failure to Serve Menu Items as Planned
Penalty
Summary
Facility staff failed to follow the planned menu for residents, as evidenced by observations and menu reviews. On the specified lunch meal, the planned menu included turkey tetrazzini, buttered peas, bread and margarine, fruited gelatin, and milk. However, during the puree process and meal service, bread and margarine were not pureed or served, despite being listed on the menu and selected by residents as a meal choice. Observations confirmed that no bread and margarine were provided to residents, including those on pureed diets. Staff interviews with the Dietary Manager and Dietician confirmed that bread and margarine should have been served according to the menu and resident selections. Facility policy requires that meals be served as listed on the menu and checked against therapeutic diet spreadsheets, which was not followed in this instance.
Medical Director Absent from Required QAA Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director attended the quarterly Quality Assessment and Assurance (QAA) meetings as required. Review of the Quality Assurance Performance and Improvement Meeting Minutes for a meeting dated 11/13/24 showed that the Medical Director's signature was missing, indicating their absence. The facility's own policy, dated March 2020, specifies that the Medical Director is a required member of the QAA committee, which must meet at least quarterly. During an interview, the Director of Nursing confirmed that the Medical Director should be present at these quarterly meetings. The facility reported a census of 61 residents at the time of the review.
Failure to Update Care Plan for Hospice Admission
Penalty
Summary
The facility failed to update the care plan for one resident after the initiation of hospice services. Specifically, a resident with severe cognitive deficits, total dependence for activities of daily living, and multiple diagnoses including diabetes mellitus, Alzheimer's disease, cerebrovascular accident with hemiplegia, and oral dysphagia, was admitted to hospice on 4/16/25. Despite this significant change in care needs, the resident's care plan, last updated on 4/8/25, did not include a focus area for hospice services, even though documentation confirmed hospice admission and services had begun. Observations and interviews confirmed the resident was receiving hospice care, and the DON stated that hospice should be added to the care plan as soon as a resident is admitted to hospice. Facility policy requires that comprehensive, person-centered care plans include all services necessary to meet the resident's needs, but this was not followed in this case, resulting in the omission of hospice from the care plan.
Failure to Provide Adequate ADL Assistance and Catheter Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents who were dependent on staff for care. One resident, who had severe cognitive deficits, post-polio syndrome, and was non-ambulatory, was observed multiple times in a wheelchair with her feet dangling unsupported and without a padded footrest as directed in her care plan. She was also found sitting in a urine-saturated brief, and during a transfer with a mechanical lift, urine spilled from her clothing and pooled in the wheelchair and on the floor. Staff interviews revealed that this resident was routinely awakened and transferred to her wheelchair before 6:00 AM, often left to sleep in the chair, and not always provided with timely toileting or repositioning as required by her care plan and facility policy. Another resident, who had moderate cognitive deficits and an indwelling Foley catheter, was found in bed with the catheter drainage bag hanging on the bedrail above the level of his bladder, contrary to infection control guidelines and facility policy. Nursing notes indicated that this resident had experienced issues with catheter blockage, cloudy urine, and was treated for a urinary tract infection. Staff acknowledged that the catheter bag should be kept below the bladder to prevent backflow and potential infection, but this was not done during the observation. Facility policies required incontinent residents to be checked and changed every two hours and for catheter care to be provided every shift. Despite these policies, direct observations and staff interviews confirmed that care was not consistently provided as required, resulting in residents being left in soiled briefs, improperly positioned, and with improper catheter management.
Failure to Adequately Supervise Resident to Prevent Injury
Penalty
Summary
A deficiency occurred when the facility failed to adequately supervise a vulnerable resident to prevent injury. The resident, who had severe cognitive deficits, was totally dependent on staff for dressing, toileting, and transfers, and required two staff members and a mechanical lift for transfers. She was observed with a large bruise under her right eye, which staff could not fully explain. The resident was unable to communicate how the injury occurred due to her cognitive condition. Staff hypothesized about possible causes, including accidental contact with the mechanical lift or her glasses, but no definitive cause was identified. The incident was first noticed by an LPN while the resident was in her wheelchair in the dining room, and neither the overnight nurse nor CNA on duty at the time were aware of any accident or incident that could have caused the bruise. The resident's care plan indicated she was at risk for falls and required staff to anticipate and meet her needs, including the use of a padded foot rest and regular toileting assistance. Despite these interventions, the facility was unable to determine how the injury occurred, and there was no documentation or witness to an event that could explain the bruise. The facility's policy required evaluation of injuries of unknown source and changes to the care plan to prevent recurrence, but the lack of supervision or failure to identify the cause of the injury led to the deficiency.
Failure to Maintain and Monitor CPAP Equipment and Settings
Penalty
Summary
The facility failed to provide staff with current CPAP machine settings and did not monitor or maintain CPAP mask and tubing needs for two residents. For one resident with diagnoses including COPD, CAD, and renal insufficiency, observations revealed that the CPAP machine was present at the bedside, but the resident had been using the same mask and tubing since admission, which were visibly worn and misshaped. The resident was unaware of the CPAP settings, and neither the clinical physician orders nor the care plan included the required CPAP settings. Chart review confirmed the absence of documentation regarding CPAP settings or supply changes, and the equipment supplier reported no supplies had been ordered since 2019. For another resident with COPD, insomnia, and renal insufficiency, similar deficiencies were observed. The resident and a family member reported that the same CPAP mask and tubing had been used for over a year, and the family member had to take the machine to the supplier to verify settings due to uncertainty about possible changes. The clinical orders and care plan also lacked CPAP settings, and there was no documentation of supply changes. The equipment supplier confirmed that no supplies had been ordered since the previous year, despite an established replacement schedule. Interviews with facility staff, including the DON, revealed a lack of awareness and procedures regarding the maintenance and replacement of CPAP supplies. The DON acknowledged that the facility is responsible for maintaining CPAP machines and that settings should be available to staff, but admitted to not having considered the supply replacement process. The facility's own policy requires physician orders to specify CPAP settings and mandates regular cleaning and replacement of equipment, which was not followed in these cases.
Failure to Train Staff on CPAP Use and Maintenance
Penalty
Summary
Staff failed to maintain and monitor CPAP settings for a resident diagnosed with COPD, insomnia, and renal insufficiency, who used a non-invasive mechanical ventilator. The resident's CPAP machine was observed on the bedside table, and a family member reported concerns that staff were not knowledgeable about the device, leading her to take the machine to the home supplier to verify its settings. The family member also stated that no staff assisted with the CPAP, and that the receptionist, rather than clinical staff, had to help with the device on two occasions because no one else knew how to operate it. Interviews confirmed that the receptionist assisted the resident with the CPAP due to a lack of trained staff, and the DON acknowledged that the facility did not have staff trained in CPAP use or a respiratory therapist available for consultation. The DON stated that only a respiratory therapist should monitor CPAP settings, but the facility did not have one accessible, resulting in unqualified personnel providing assistance with the resident's CPAP machine.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Staff failed to follow appropriate hand hygiene protocols during incontinence care for a resident with severe cognitive deficits, total dependence for activities of daily living, and multiple complex medical conditions including post-polio syndrome, intracerebral hemorrhage, type 2 diabetes, and chronic kidney disease. On two separate occasions, certified nurse aides (CNAs) provided care to the resident after an episode of incontinence, including transferring her using a mechanical lift and changing soiled clothing and linens. During these cares, staff removed soiled gloves and either failed to wash their hands or did not use hand sanitizer between glove changes. In both instances, staff left the resident's room without performing required hand hygiene. Facility policies required staff to wear gloves when in contact with blood, body fluids, or excretions, and to discard gloves after a single use. The hand hygiene policy mandated that all personnel follow handwashing procedures to prevent the spread of infection. Despite these policies, direct observation and interviews confirmed that staff did not consistently adhere to hand hygiene protocols during resident care, resulting in a failure to implement the facility's infection prevention and control program.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement appropriate infection prevention practices, as evidenced by multiple observations and interviews. Staff E, an LPN, was observed not performing hand hygiene before entering a resident's room and during the administration of enteral feeding. The staff member did not follow the facility's hand hygiene policy, which requires hand hygiene before and after direct resident contact and glove use. Additionally, no enhanced barrier precautions were in place during the care of Resident #24, who had a feeding tube, and no gown was donned during the procedure. In another instance, Staff J, Staff K, and Staff L were observed performing catheter and peri care on Resident #44 without using enhanced barrier precautions or gowns, despite the resident having a suprapubic catheter. Although hand hygiene was performed, the lack of enhanced barrier precautions was noted. The facility's failure to implement these precautions was confirmed through interviews with staff, who indicated that no residents were currently on enhanced barrier precautions, despite the presence of indwelling medical devices. Furthermore, the facility lacked written policies related to COVID-19 vaccinations, as revealed during an interview with the Director of Nursing. The facility claimed to follow CDC guidelines but did not have these guidelines documented. This lack of documentation and adherence to infection prevention protocols, including enhanced barrier precautions for residents with indwelling medical devices, contributed to the deficiencies identified during the survey.
Failure to Conduct Required Background Checks for Staff
Penalty
Summary
The facility failed to ensure that all employees had completed the required Iowa Criminal Background check and dependent adult/child abuse registry check before beginning work. This deficiency was identified for one out of five employees reviewed, specifically a Certified Nurses Assistant (CNA) referred to as Staff N. Staff N was hired on 2/4/24, but their personnel file lacked documentation of the Iowa Criminal Background Check. The facility's policy, as reviewed, indicated that background checks were not required for staff under a certain age, which contradicts federal regulations mandating background checks for all employees regardless of age. During interviews, the Human Resource Generalist confirmed that the facility policy did not require background checks for staff under a certain age. The Administrator, who was new to the facility, acknowledged awareness of the federal regulations requiring background checks for all employees but was unaware of the facility's policy that did not align with these regulations.
Failure to Provide Correct Diet Consistency for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents, specifically those on mechanically altered diets. During a lunch service observation, it was noted that four residents who required mechanical soft diets were served coleslaw instead of the steamed cabbage that was listed on the menu for their dietary needs. This error was attributed to Staff F, a Dietary Aide, who admitted to forgetting to serve the appropriate food to the residents on mechanical soft diets. The residents involved had varying levels of cognitive impairment and dietary requirements, including diagnoses of dysphagia. The facility's policy, titled 'Accuracy and Quality of Tray Line Services,' mandates that meals be checked against the therapeutic diet spreadsheet to ensure accuracy. However, this policy was not followed, as confirmed by Staff G, the Certified Dietary Manager, and Staff H, the Registered Dietitian, who both acknowledged that the menu and modified diets should have been adhered to.
Improper Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation practices, affecting 61 out of 63 residents. During a lunch service observation, a dietary aide, identified as Staff F, initially performed hand hygiene but subsequently failed to maintain it while serving food. Staff F used their left hand to handle hamburger buns directly, instead of using tongs, and continued to serve food without performing hand hygiene between tasks. This practice was repeated for all plates served during the observation period. The facility's hand washing policy, dated 2021, requires hand hygiene to be performed as often as necessary to prevent cross-contamination when changing tasks. Staff G, the Certified Dietary Manager, confirmed that Staff F should not have touched the buns with their hands and should have used tongs to open them.
Failure to Maintain Resident Dignity by Not Cleaning Food Debris
Penalty
Summary
The facility failed to uphold the dignity of a resident by not promptly addressing food debris left on the resident's clothing protector and face after a meal. The resident, identified as having severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 2, was dependent on staff for personal hygiene and required substantial assistance with eating. An observation noted that the resident had 2-3 tablespoons of orange food on their clothing protector and dry orange food on their chin, which was not cleaned up in a timely manner. The incident was confirmed by the resident's family member, who reported finding and cleaning the food debris from the resident's clothing protector and face several hours after lunch. The facility's policy on dignity, which emphasizes treating residents with respect and ensuring their well-being, was not adhered to in this instance. The Director of Nursing (DON) acknowledged that the clothing protector should have been changed and the resident's face cleaned before returning to their room.
Failure to Refer Resident for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II PreAdmission Screening and Resident Review (PASRR) evaluation after the resident was identified with newly evident or possible serious mental disorders. The resident, identified as Resident #48, had a negative Level I PASRR result but was later diagnosed with major depressive disorder and psychotic disorder with hallucinations. Despite these diagnoses, the facility did not follow up with a resubmission for a Level II PASRR evaluation, as required by their Behavioral Assessment, Intervention, and Monitoring policy. The resident's clinical records showed diagnoses of anxiety disorder, depression, and psychotic disorder, and the resident was on medications such as buspirone, donepezil, and sertraline. The facility's failure to act was confirmed during an interview with the Director of Nursing, who stated that the social worker should have resubmitted the PASRR for a Level II screening upon the new diagnoses. This oversight was identified during a review of the resident's chart, which lacked documentation of a follow-up PASRR submission.
Failure to Follow Care Plan for Resident Supervision
Penalty
Summary
The facility failed to adhere to a care plan for a resident with moderate cognitive impairment, depression, muscle weakness, and a history of a left fracture. The care plan, last revised on May 20, 2024, included an intervention initiated on April 2, 2024, requiring staff not to leave the resident unattended in a wheelchair while in his room due to a high risk of falls. However, during the survey, it was observed that the resident was left unattended multiple times while in a wheelchair, both in the hallway and in his room, despite the care plan's instructions. Interviews with staff members, including LPNs and CNAs, revealed a lack of awareness regarding the resident's supervision needs as outlined in the care plan. Staff members incorrectly believed the resident did not require supervision while in his room or in a wheelchair. The Director of Nursing also reported being unaware of the supervision requirement and acknowledged that the current care plan did not reflect the need for supervision. This oversight led to the resident being left unattended, contrary to the care plan's directives.
Failure to Accurately Measure and Administer Feeding Tube Formula
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the technical aspects of feeding tube management for a resident, identified as Resident #24. The resident, who had no cognitive impairment, was documented to have a feeding tube and required 330 mL of supplemental formula to be administered via PEG tube three times daily. However, observations revealed that the staff did not accurately measure the formula as per the physician's order. Instead, the staff member, identified as Staff E, was observed to 'eye' the formula, filling the bag just above the 300 mL line, rather than the prescribed 330 mL. This discrepancy was further evidenced when a significant amount of formula remained in the carton after administration, indicating that the correct volume was not being delivered. Additionally, the facility's procedures for medication administration through the feeding tube were not followed. Staff E was observed pushing medications with a piston syringe, rather than allowing them to flow by gravity as expected by the facility's standards. The Director of Nursing confirmed that the facility's expectation was for nurses to measure the supplemental formula using a graduated cylinder and to administer medications with gravity flow, highlighting a deviation from established protocols in the care of Resident #24.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications in a locked storage area for one resident, as observed during a survey. On two separate occasions, a bottle of Tums was found sitting by the sink in the resident's room. The resident's clinical record did not include documentation of an assessment for self-administration of medications. An interview with the Director of Nursing revealed that the resident was not able to self-administer medications and no self-administration assessments had been completed. The facility's policy, revised in April 2007, requires that policies, procedures, and operational practices conform to current professional standards, which was not adhered to in this instance.
Incomplete Documentation of Oxygen Therapy in EHR
Penalty
Summary
The facility failed to maintain complete and accurately documented electronic health records for a resident, identified as Resident #5, who was observed wearing oxygen in his bedroom. Despite the resident's statement that he had been using oxygen almost daily for a couple of years and his care plan documenting oxygen therapy related to shortness of breath and a diagnosis of COPD, the most recent physician's order for oxygen had been discontinued in January 2023. A Licensed Practical Nurse (LPN) believed there was a PRN order for oxygen to maintain saturation above 90%, but upon review, no current order for oxygen was found in the resident's Medication Administration Records (MAR) or Treatment Administration Records (TAR) for May. The Director of Nursing (DON) confirmed that the facility's expectation was for the current oxygen order to be present in the resident's MAR, but it was missing. The DON suggested that the order might have been discontinued when the resident was hospitalized and not re-entered into the Electronic Health Records (EHR) upon their return. The facility's procedure for noting a physician's order required confirmation in the PointClickCare (PCC) system once processed by the pharmacy, but this step was evidently not completed for Resident #5's oxygen order.
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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