Iowa City Rehab & Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Iowa City, Iowa.
- Location
- 3661 Rochester Avenue, Iowa City, Iowa 52245
- CMS Provider Number
- 165198
- Inspections on file
- 33
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Iowa City Rehab & Health Care during CMS and state inspections, most recent first.
A resident with paraplegia, dementia, malnutrition, and continuous PEG tube feeding at 75 mL/hr was repeatedly observed lying in bed with the head of the bed flat and without the ordered abdominal binder, despite physician orders for continuous tube feeding and binder use at all times. Staff allowed the feeding to run while the resident lay flat and while PEG tubing was under tension after a self-transfer from wheelchair to bed, and multiple staff entries into the room occurred without correcting the bed position or applying the binder. In interviews, staff acknowledged that the head of the bed should be elevated during continuous tube feeding and that the binder was needed to prevent the resident from pulling out the PEG tube, while the facility’s feeding tube policy lacked specific guidance on required head-of-bed positioning.
A resident with Alzheimer’s disease, diabetes, thyroid disease, and atrial fibrillation was admitted on time-limited hospital discharge medication orders that were written for 20 days. MAR review showed that numerous routine medications, including anticoagulants, cardiac, psychiatric, endocrine, and respiratory drugs, were administered only through the 28th of the month and then not scheduled or given for the next three days, and many were not scheduled at all the following month. An ED note documented that the resident’s daughter reported medications had been stopped without explanation and that the pharmacy indicated discharge meds had not been renewed. RNs and the NP gave conflicting accounts of who was responsible for renewing these orders, there was no documentation that nurses notified the provider about the 20-day limits, and the facility’s medication reconciliation and reordering policies requiring systematic review and timely reordering were not followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment, with observations of broken hygienic equipment, rusted heating/AC units, and significant dirt and grime buildup in multiple resident rooms. Staff confirmed ongoing issues with cleaning and equipment repair, and facility policy on routine cleaning and disinfection was not consistently followed.
Two residents did not receive prescribed medications as ordered due to staff failing to order and administer them in a timely manner. One resident missed multiple doses of a narcotic pain medication, while another experienced a delay in starting new medications for respiratory symptoms. These actions were not in accordance with facility policy requiring timely and accurate medication administration.
Three residents with conditions such as COPD, cerebral palsy, and morbid obesity were not provided with restorative nursing programs despite care plans indicating the need for exercise and therapy interventions. Residents expressed a desire to use exercise equipment to maintain or improve mobility, but were denied due to lack of staff and absence of a restorative program, as confirmed by staff and administration.
The facility did not provide enough nursing staff to meet resident needs, resulting in delayed responses to call lights and residents waiting extended periods for assistance. Staff and residents reported that low staffing, especially on one hall, led to frequent delays in care and unmet needs, contrary to facility policy requiring timely response.
Two residents experienced deficiencies in care when staff failed to follow physician orders for wound care, medication administration, and dietary management. Wound dressings were not changed as prescribed, medications were not administered according to schedule, and significant weight loss was not reported to the physician. Wound assessments lacked essential details, and documentation did not accurately reflect the care provided. Staff interviews confirmed inconsistencies in following orders and documentation practices.
A resident with intact cognition and multiple diagnoses was observed with a diuretic pill at bedside, which staff confirmed was taken only after checking back. The clinical record lacked documentation that the resident was assessed as safe to self-administer medications, contrary to facility policy requiring physician and care team determination before allowing self-administration.
A resident who was cognitively intact and discharged home from skilled nursing services under Medicare Part A did not receive the required Notice of Medicare Non-Coverage (NOMNC) due to a lack of staff training and absence of a facility policy, resulting in the resident not being informed of their appeal rights.
A resident with hemiplegia, stroke history, and dysphagia was repeatedly observed eating in bed with the head of the bed elevated less than 15 degrees, despite staff acknowledging the need for upright positioning to prevent choking. Staff practices were inconsistent, and the facility lacked a policy on safe meal positioning.
The facility did not implement a bladder training program or other interventions for a resident with reversible urinary incontinence, despite assessments indicating the resident could participate. Additionally, catheter tubing and drainage bags for another resident with a suprapubic catheter were repeatedly observed resting on or dragging along the floor, contrary to facility policy and infection control standards.
A resident with diabetes received insulin from an LPN who did not prime the insulin pen before injection, despite manufacturer instructions and facility expectations to do so. The LPN believed priming was only needed for the first use, leading to a significant medication error as the pen was not primed before administering the prescribed dose.
Staff were observed using nicotine vape pens in offices near the dining room and during activities with residents present, despite a facility policy restricting tobacco use to designated areas. Multiple staff confirmed these incidents, which occurred in violation of the facility's Tobacco Policy and in the presence of residents.
A resident with a seizure disorder and intact cognition repeatedly reported multiple daily seizures to staff, but nursing staff did not consistently assess, document, or notify the neurology provider as required by physician orders and facility policy. Staff interviews confirmed that although the resident's reports were communicated among staff, the necessary notifications and documentation were not completed.
The facility did not have an Infection Prevention Specialist or Infection Control Nurse, as required for effective infection control. The Administrator reported that the Assistant Director of Nurses, who previously handled infection control, left the facility a month ago, and a replacement was only found recently.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling devices, leading to a deficiency in infection control. Staff did not use gowns during high-contact activities, and rooms lacked appropriate signage and PPE. Interviews revealed a lack of staff education on EBP, exacerbated by the recent loss of key infection control personnel.
The facility failed to provide adequate staffing, resulting in delayed call light responses. On a morning, four call lights were observed blinking in the East Hall, with only one LPN present due to an aide's late arrival. This led to response times as long as 39 minutes. Interviews revealed that residents had previously complained about call light delays, and a call light audit confirmed the issue.
The facility failed to ensure proper personal hygiene in the kitchen when two male dietary employees with facial hair did not wear beard guards, as required by the facility's policy. The Dietary Manager acknowledged the oversight, noting that beard guards were available and had been used in the past.
The facility failed to ensure proper medication administration for two residents with moderate cognitive impairment. Medications were left unattended in residents' rooms without orders for self-administration, contrary to facility policy requiring staff to remain with residents until medications are taken.
A resident with severe cognitive impairment suffered burns from spilled coffee due to inadequate supervision and lack of assistive devices. Another resident, with impaired decision-making, was allowed to smoke independently, violating the facility's smoking policy. The facility failed to implement necessary interventions and ensure adherence to safety measures, resulting in unsafe conditions.
Two residents in a facility were observed with urinary drainage bags in contact with the floor, risking cross-contamination and UTIs. Despite care plans and staff expectations to keep bags off the floor, observations showed non-compliance. The facility lacked specific policies for handling urinary drainage bags, relying on a general infection control policy.
A resident on hospice care, requiring substantial assistance for eating, was observed being assisted by a CNA who used her personal cell phone during the meal, violating facility policy. The CNA attempted to hide her phone when noticed by a surveyor, claiming a family emergency. This action compromised the resident's dignity, as the facility's policies emphasize maintaining a dignified existence and restrict personal phone use to breaks.
Failure to Maintain Head-of-Bed Elevation and Abdominal Binder During Continuous PEG Feeding
Penalty
Summary
The deficiency involves the facility’s failure to maintain appropriate positioning and use of an abdominal binder for a resident receiving continuous PEG tube feedings. The resident was cognitively impaired, diagnosed with paraplegia, non-Alzheimer’s dementia, and malnutrition, and was dependent on continuous gastric tube feedings to meet nutritional needs. Physician orders specified NPO status, continuous Glucerna 1.2 at 75 mL/hr via PEG tube, and an abdominal binder to be worn at all times, placed on backwards to prevent removal by the resident. On multiple observations, the resident was found in bed with the head of the bed flat while the feeding pump continued to run at 75 mL/hr, and without the ordered abdominal binder in place. The PEG tubing was also observed under tension when the resident self-transferred from wheelchair to bed while the feeding remained attached to a pole fixed to the wheelchair. Throughout the observation period, nursing staff, including an RN and a CNA, passed by or entered the resident’s room several times without elevating the head of the bed or ensuring the abdominal binder was applied, despite acknowledging in interviews that the head of the bed should be elevated at least 30–45 degrees during continuous tube feeding and that the binder was required to prevent the resident from pulling out the PEG tube. The facility’s policy on care and treatment of feeding tubes stated that feeding tubes would be used in accordance with current clinical standards of practice with interventions to prevent complications, but it did not provide specific direction on head-of-bed positioning while a feeding pump was running. These actions and omissions led to the identified deficiency in providing appropriate care for a resident with a feeding tube.
Failure to Renew Time-Limited Discharge Medications Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident remained free from significant medication errors when routine medications were not reordered prior to the exhaustion of the supply, resulting in three full days without multiple prescribed medications. The resident had a moderate cognitive impairment with a BIMS score of 11/15 and diagnoses including Alzheimer’s disease, diabetes mellitus, thyroid disease, and atrial fibrillation. The resident had been admitted in early December with a series of hospital discharge medication orders written for 20 days. Review of the December Medication Administration Record (MAR) showed that numerous medications, including aspirin, atorvastatin, bupropion, vitamin D3, divalproex, donepezil, duloxetine, empagliflozin, levothyroxine, pantoprazole, polyethylene glycol, amiodarone, budesonide, Eliquis, formoterol, metoprolol, senna, and carbidopa-levodopa, were administered through December 28 but then had no further doses scheduled for December 29–31, as indicated by "x" marks for all scheduled times on those dates. Review of the January MAR revealed that many of these same medications were not scheduled at all, indicating that they had not been renewed after the initial 20‑day period. An ED note from early January documented that the resident’s daughter called EMS because the resident was missing appointments and medications had been stopped without explanation, and the daughter reported the resident appeared more confused and was not eating; the ED note further stated that, upon speaking with the pharmacy, it appeared the resident’s discharge medications from previous visits had not been renewed while she was going between rehab hospitals. Staff interviews confirmed that the medications were not administered on December 29, 30, and 31, and that there was no documentation that nurses had brought the 20‑day duration of the discharge medications to the provider’s attention. Nursing staff and leadership interviews revealed confusion and inconsistent understanding of responsibility for renewing time‑limited hospital discharge orders. One RN stated that when a resident has medications ordered for a certain time frame after admission, the nurse is responsible for notifying the physician to renew the orders, but also suggested that perhaps the pharmacy did not send the medications and reported believing it was the pharmacy’s responsibility to notify the doctor for renewal. Another RN verified that the resident’s medications were not administered for three days and described that an "X" on the MAR would indicate a scheduled medication, and that if a medication was not given there should be another code to indicate the reason; she also stated that if a medication was discontinued it would not appear on the MAR during pass and that the facility NP was responsible for reviewing medications after a hospital return. The NP could not recall the specific issue or explain why some medications had been discontinued. The DON stated she would have expected the nurse to question why medications were written to be discontinued after 20 days and to speak with the provider, and the ADON stated the nurse should always give discharge paperwork to the provider; the DON verified there was no documentation that nurses had alerted the provider about the 20‑day duration. Facility policies on Medication Reconciliation and Medication Reordering required systematic verification, transcription, ordering, and reordering of medications, including reordering when six or fewer doses remained, but these processes were not effectively carried out for this resident’s time‑limited discharge medications.
Failure to Maintain Safe and Clean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple environmental concerns observed during a survey. Staff interviews revealed that a hopper used for hygienic disposal of body waste had been out of order for an extended period, and the facility was in the process of obtaining bids for its repair. Additionally, staff acknowledged that the floors throughout the facility required cleaning and stripping. Direct observations identified several deficiencies in resident rooms, including moderate rust and missing paint on heating/air conditioning units, heavy buildup of dirt and dark substances on floors, and the presence of a moderate amount of black substance on baseboards. Multiple rooms were noted to have moderate to heavy buildup of dark-colored grime on the floors. Review of the facility's policy on routine cleaning and disinfection confirmed that these practices were not being consistently followed, as required to maintain a safe and sanitary environment.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer medications as prescribed by physicians for two residents. For one resident with chronic pain, COPD, and diabetes, there was a lapse in the administration of scheduled Hydromorphone for pain management. The resident reported not receiving the medication for approximately 20 hours, receiving only an alternative medication that was not effective. Documentation showed multiple missed doses, and staff interviews confirmed that the medication was not ordered in time, compounded by delayed delivery due to bad weather. The medication administration record indicated missed doses, and progress notes reflected that staff had to contact hospice for a new supply after the medication ran out. For another resident with asthma, COPD, and other chronic lung disease, a provider ordered new medications, including an antibiotic, corticosteroid, and inhaler, due to ongoing respiratory symptoms. However, these medications were not started over the weekend as ordered, and administration only began several days later. Staff interviews confirmed that the delay was due to a failure to order the medications in a timely manner. Facility policy requires medications to be administered safely, timely, and as prescribed, but this was not followed in these cases.
Failure to Provide Restorative Program for Residents at Risk of Physical Decline
Penalty
Summary
The facility failed to provide a restorative program for three residents who were at risk of physical decline due to their medical diagnoses and risk of falls. Clinical record reviews and care plans for these residents indicated the need for interventions such as encouraging exercise, providing opportunities for physical activity, and therapy evaluations. Despite these documented needs, observations and interviews revealed that none of the residents were participating in a restorative program, and their requests to use exercise equipment or participate in exercises were denied due to lack of staff or program availability. One resident with chronic obstructive pulmonary disease, pain, diabetes, and spinal stenosis expressed a desire to use the exercise bike to help with leg pain and mobility but was told he could not use it without staff supervision, which was unavailable. Another resident with cerebral palsy and mobility issues reported that he previously used the exercise bike but was no longer able to do so because the facility lacked staff to oversee the activity. He felt he was getting weaker as a result. A third resident with morbid obesity and respiratory failure also wanted to use the therapy room equipment but was similarly denied due to staffing shortages. Staff interviews confirmed that there was no restorative program in place at the facility, and the occupational therapist stated that although she had identified residents who would benefit from such a program, it had not been implemented. The facility's own policy required restorative nursing care to promote safety and independence, but this was not being followed. The administrator acknowledged the absence of a restorative program and indicated that other issues had taken priority.
Insufficient Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by prolonged call light response times and staff and resident reports of inadequate staffing. Observations showed that call lights in resident rooms remained unanswered for extended periods, such as one instance where a call light was activated at 10:40 AM and not answered until 10:58 AM, and another where a resident's call light was activated at 12:15 PM and not addressed until 12:38 PM. During these periods, residents were observed waiting for assistance, including one resident who was unable to begin eating lunch until staff responded to her call light and assisted her with positioning in bed. Interviews with staff and residents confirmed that staffing levels were insufficient, particularly on the East Hall, where only one aide was scheduled instead of the usual two. Residents reported that call lights often went unanswered for up to an hour on all shifts when staffing was low, and staff corroborated that they sometimes had to work late to complete resident care tasks such as baths. The facility's own policy requires timely response to call lights and holds all staff responsible for responding, but these procedures were not consistently followed due to inadequate staffing.
Failure to Follow Physician Orders and Inadequate Wound Care Documentation
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for two residents, resulting in multiple deficiencies. For one resident with complex medical conditions including peripheral vascular disease, renal failure, and recent abdominal surgery, staff did not implement or document physician-ordered treatments as prescribed. Orders for wound care, medication administration, and dietary management were not consistently followed. For example, wound dressings were not changed as frequently as ordered, and medications such as potassium chloride and ferrous sulfate were not administered according to the prescribed schedule. Additionally, significant weight loss was not communicated to the physician, and there was no documentation of the resident's refusal to participate in therapy or the absence of bowel movements. Wound assessments for the same resident were incomplete, lacking essential details such as wound measurements, tissue condition, drainage, and signs of infection. The clinical record did not contain accurate or sufficient documentation of wound status or physician notification regarding the resident's deteriorating condition. During a physician visit, it was noted that all dressings were dated several days prior and had not been changed as ordered, and the resident reported not having a bowel movement for several days. The resident was subsequently hospitalized for failure to thrive, poor wound healing, and weight loss. For another resident with a history of cancer and surgical wound infection, staff failed to follow wound care orders by not using the prescribed wound cleanser and documenting wound care as completed when it had not been performed. Observations revealed wound drainage on the resident's clothing and that wound care supplies were available but not used as ordered. Staff interviews confirmed that wound care was not always provided according to physician instructions, and documentation practices did not accurately reflect the care delivered.
Failure to Assess and Care Plan for Resident Self-Administration of Medication
Penalty
Summary
A deficiency occurred when the facility failed to assess and care plan for a resident to self-administer medications. The resident, who had diagnoses including heart failure, diabetes, and shortness of breath, was noted to have intact cognition with a BIMS score of 14 out of 15. The care plan addressed diuretic therapy for hypertension, and the medication administration record showed an order for bumetanide 1 mg twice daily. During observation, the resident was found with a pill in a medication cup at the bedside and stated it was a pill to make him urinate, indicating he had access to the medication before staff ensured it was taken. Staff interview confirmed that the LPN checked on the resident and verified the pill was taken after the fact. However, the clinical record did not contain documentation that the resident was assessed as safe to self-administer medications. Facility policy requires that residents may only self-administer medications if the attending physician and the interdisciplinary care planning team determine the resident has the decision-making capacity to do so safely. This process was not documented for the resident involved.
Failure to Provide Notice of Medicare Non-Coverage at Discharge
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident who was discharged from skilled nursing services under Medicare Part A. Clinical record review showed that the resident had a planned discharge to home and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident was capable of independently understanding written instructions. However, there was no documentation of the required NOMNC being given to the resident at the time of discharge. Interviews revealed that the responsibility for completing beneficiary notification forms, including the NOMNC, had recently shifted from the business office to the social worker. The social worker, who had started a few weeks prior, did not complete the NOMNC for the resident due to a lack of training. The administrator confirmed the absence of a facility policy addressing beneficiary notification of non-coverage and acknowledged that the resident did not receive information on appeal rights as a result.
Failure to Ensure Safe Positioning During Meals
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia, cerebral infarction, and dysphagia was repeatedly observed eating meals while lying in bed with the head of the bed elevated less than 15 degrees. The resident's care plan noted risks related to altered nutritional status and swallowing difficulties. Despite this, multiple observations showed the resident eating in a reclined position, and the resident reported some difficulty eating in that position. Staff interviews revealed inconsistent practices, with some staff stating they positioned the resident upright for meals, while others acknowledged the resident sometimes refused to be repositioned. The Director of Nursing confirmed that residents should be upright during meals, but stated the resident was resistant to having the bed elevated. The facility did not have a policy on positioning residents while eating. The lack of consistent implementation of safe positioning practices and absence of a formal policy contributed to the failure to ensure the resident was positioned safely during meals, as required to prevent accidents such as choking.
Failure to Implement Bladder Training and Maintain Catheter Care Standards
Penalty
Summary
The facility failed to develop and implement interventions to attempt to restore or improve bladder function for a resident with urinary incontinence. The resident, who had diagnoses including heart failure and diabetes and was assessed as always incontinent of urine and frequently incontinent of bowel, was found to have intact cognition and the ability to communicate the urge to void. Despite an assessment indicating the incontinence was likely reversible and that the resident could participate in a toileting program, there was no evidence in the clinical record of a bladder training program or other interventions being carried out to address the incontinence. The resident also reported not recalling any bladder training or interventions to assist with regaining continence. Additionally, the facility failed to ensure proper catheter care for another resident with a suprapubic catheter. Observations showed that the resident's catheter tubing and drainage bag were repeatedly found resting on or dragging along the floor, both in the resident's room and in the hallway. Staff were observed rehanging the tubing and bag, but the issue persisted, with the tubing continuing to come into contact with the floor and being stepped on by the resident. Multiple staff members acknowledged having seen the tubing on the floor and identified concerns about cleanliness and the potential for the catheter to be pulled. Facility policy required that catheter tubing and drainage bags be kept off the floor and that appropriate services and treatment be provided to help restore or improve bladder function. Despite these policies, the facility did not implement a toileting plan or bladder training for the resident with incontinence, nor did it consistently ensure that catheter tubing and drainage bags were kept off the floor for the resident with a suprapubic catheter.
Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A Licensed Practical Nurse (LPN) failed to prime an insulin pen prior to administering insulin to a resident diagnosed with diabetes, depression, and lack of coordination. The resident was observed receiving insulin injections daily, and during the observed medication administration, the LPN stated that priming was only necessary for the first use of the pen. The LPN proceeded to inject the resident with four units of insulin without priming the pen, contrary to the manufacturer's instructions, which require priming before each injection. Review of the resident's medication orders confirmed the use of a Humalog KwikPen with a sliding scale for insulin administration. The facility's policy on administering medications emphasized safe and timely administration as prescribed, but there was no specific policy regarding insulin pen use. The Director of Nursing confirmed that staff should prime insulin pens prior to each injection, and the manufacturer's instructions also directed priming before every use.
Staff Vaping in Common Areas Violates Resident Rights and Facility Policy
Penalty
Summary
Staff members were observed using nicotine vape pens in common areas of the facility, specifically in offices located off the dining room and during activities such as bingo, while residents were present. Multiple staff, including a CNA, CMA, and housekeeping, reported witnessing activities staff and office staff vaping inside their offices, with doors open and in close proximity to residents. These actions occurred despite the facility having a designated outdoor smoking area and a policy prohibiting the use of tobacco products, including vapes, in patient care areas and non-designated locations. The facility's Tobacco Policy, dated 9/21/23, clearly directed that employees are only permitted to use tobacco products in designated areas and are not allowed to carry such items in patient care areas. Despite this, staff interviews confirmed repeated violations of this policy, with vaping occurring in offices adjacent to resident common areas and during resident activities. The DON acknowledged observing this behavior and stated she directed the staff member to stop, while the Administrator claimed to be unaware of such incidents.
Failure to Assess and Notify Physician After Resident-Reported Seizure Activity
Penalty
Summary
The facility failed to assess a resident and notify the physician after the resident self-reported seizure activity. The resident, who had a documented history of seizure disorder, multiple sclerosis, cerebrovascular accident, schizophrenia, and depression, was cognitively intact and reported experiencing multiple seizures per day. The care plan included specific interventions for post-seizure treatment, documentation, and seizure precautions, and there was a physician order to notify neurology if an increase in seizures was noted. Despite these directives, clinical record review showed only one documented note of a self-reported seizure during the review period, with no further documentation of seizure activity. Multiple staff interviews revealed that the resident frequently reported seizures to staff, who would either check on her or report to the charge nurse. However, nursing staff, including an RN and LPN, admitted to not notifying the neurology provider regarding the resident's reported increase in seizures, as required by the physician's order and facility policy. The facility's policy required prompt notification of the physician for changes in a resident's condition, including specific instructions to notify for changes such as increased seizure activity. Staff interviews indicated a lack of consistent assessment and documentation of the resident's reported seizures, and the required notifications to the physician or neurology provider were not made, despite repeated self-reports by the resident.
Failure to Employ Infection Prevention Specialist
Penalty
Summary
The facility failed to employ an Infection Prevention Specialist, which is a requirement for maintaining an effective infection prevention and control program. During a review of the facility's staff list, it was observed that there was no designated Infection Prevention Specialist or Infection Control Nurse. The Administrator, identified as Staff F, reported that the facility had lost both the Director of Nurses and the Assistant Director of Nurses approximately one month prior. The Assistant Director of Nurses had been responsible for infection control, and since their departure, the facility had not been able to find a suitable replacement for this critical role until the day before the surveyor's interview.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to standard and transmission-based precautions, specifically Enhanced Barrier Precautions (EBP), for four residents, leading to a deficiency in infection prevention and control. Resident #2, who had a surgical wound and an indwelling Foley catheter, did not have appropriate signage or personal protective equipment (PPE) available outside their room. Staff members entered the room and provided care without donning gowns, contrary to the care plan directives. Resident #3, who had open areas on the coccyx and underneath the right breast, also lacked EBP signage and PPE in their room. Staff provided incontinence care and wound dressing changes without wearing gowns, despite the care plan indicating the need for EBP. Similarly, Resident #5, with a suprapubic catheter, had no EBP signage, and staff failed to wear gowns during high-contact activities, such as incontinence care and catheter maintenance. Resident #4, who had a suprapubic indwelling urinary catheter, also did not have EBP signage or PPE readily available. Staff entered the room and performed care activities without donning gowns, as required by the facility's policy. Interviews with staff revealed a lack of awareness and education regarding EBP, compounded by the recent loss of the Director of Nurses and Assistant Director of Nurses, who were responsible for infection control oversight.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in delayed response times to call lights. On the morning of January 13, 2025, four call lights were observed blinking in the East Hall, indicating that residents in rooms 31, 37, 38, and 45 were requesting assistance. At that time, only one LPN, Staff A, was present on the wing, as the scheduled aide had not yet arrived due to car troubles. This staffing shortage led to prolonged response times, with the longest being 39 minutes for one of the rooms. Interviews with residents and staff revealed that the issue of delayed call light responses was not isolated. Resident #6 mentioned that call lights are sometimes not answered promptly when there is insufficient staff to assist with her transfers, which require two staff members. The Director of Nursing, Staff C, admitted to not regularly conducting call light audits unless a problem is reported, and no recent complaints had been noted. However, a call light audit conducted on January 14, 2025, confirmed the delays, and the Activities Director, Staff D, reported that residents had previously voiced complaints about call light response times during a resident council meeting in October 2024.
Failure to Ensure Proper Personal Hygiene in Kitchen
Penalty
Summary
The facility failed to ensure proper personal hygiene practices in the kitchen area, leading to a deficiency in food safety standards. During an observation, two male dietary employees were seen working in the kitchen with hair nets but without beard guards, despite having facial hair. This was contrary to the facility's policy, which mandates that all male employees with facial hair must wear beard guards. The Dietary Manager acknowledged the expectation for facial hair to be covered and admitted he had not noticed the staff's non-compliance at the time of the observation.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for two residents with moderate cognitive impairment. Resident #31, diagnosed with cerebral infarction, cognitive communication deficit, and dysphagia, was observed with a medication cup containing two white tablets on the bedside table. The resident indicated the medication was Tylenol and intended to take it later, despite the medication administration record showing the dose was signed as given by a Licensed Practical Nurse. There was no physician order for self-medication administration for this resident. Similarly, Resident #32, with diagnoses including obstructive hypertrophic cardiomyopathy, psychoactive substance dependence, and other conditions, was found with a medication cup containing several pills, including Gabapentin, unattended on the bedside table. The Certified Medication Aide could not identify the other medications and reported the medications were discarded. The facility's policy required medication staff to remain with residents until all medications were taken, which was not followed in these instances.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to protect a resident from environmental hazards, resulting in a resident acquiring first-degree burns from spilled coffee. Resident #4, who has severe cognitive impairment and physical behavioral symptoms, was not provided with adequate supervision or appropriate assistive devices, such as a lidded mug, to prevent the incident. Despite the resident's known morning tremors and jerky movements, staff did not implement necessary precautions, leading to the resident spilling hot coffee on herself. The care plan and dietary slip lacked updates or interventions to address the risk of hot liquid spills. Additionally, the facility did not ensure that another resident, Resident #28, was properly assessed for independent smoking. Despite having impaired decision-making and a history of smoking in undesignated areas, the resident was allowed to smoke independently without proper supervision. The resident frequently smoked outside the designated area, discarded cigarette butts improperly, and did not adhere to the facility's smoking policy. Staff inconsistently enforced the smoking policy, and the resident's care plan did not adequately address the risks associated with his smoking behavior. The facility's failure to identify and mitigate risks associated with hot liquids and smoking behaviors resulted in unsafe conditions for the residents. The lack of timely interventions and adherence to policies contributed to the incidents involving Resident #4 and Resident #28, highlighting deficiencies in the facility's supervision and environmental safety measures.
Inadequate Catheter Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate catheter care to prevent potential cross-contamination that could lead to urinary tract infections (UTIs) for two residents. Resident #17, who has severe cognitive impairment and a neurogenic bladder, was observed multiple times with the urinary drainage bag and tubing in direct contact with the floor. The care plan and Kardex for Resident #17 directed staff to wear protective gear during high-contact care and to position the catheter bag below the bladder level, but they lacked specific instructions to keep the bag and tubing off the floor. Observations revealed that the urinary drainage bag was often on the floor, and a family representative expressed concerns that this had contributed to past UTIs and hospitalizations. Resident #41, who has intact cognition and requires total staff assistance, was also observed with the catheter bag lying on the floor. The care plan for Resident #41 included goals to prevent catheter-related trauma and complications, but the observation indicated a failure to maintain proper catheter care. Interviews with staff, including a CNA and RN, confirmed that the expectation was to keep the urinary drainage bags off the floor by securing them to the bed frame. However, the facility lacked a specific policy for handling urinary drainage bags, relying only on a general infection control policy. The facility's infection control policy, last reviewed in 2020, aimed to prevent the transmission of infections and manage nosocomial infections. Despite this, the lack of specific guidelines for urinary drainage bag handling contributed to the observed deficiencies. The Administrator acknowledged the absence of a policy for urinary drainage bags and suggested using a wash basin to keep them off the floor, indicating a gap in the facility's infection prevention and control program.
Violation of Resident Dignity Due to Unauthorized Phone Use
Penalty
Summary
The facility failed to uphold the resident's rights and dignity for a resident on hospice care. The resident, who had severe cognitive loss and required substantial assistance for eating, was observed being assisted by a CNA who was using her personal cell phone during the meal. This action was against the facility's policy, which allows personal phone use only during breaks. The CNA attempted to conceal her phone when noticed by the surveyor and claimed it was due to a family emergency, although she did not show any emotional distress. The resident's care plan indicated a need for specific communication techniques and a homelike environment to maintain comfort, which were not adhered to during this incident. The facility's policies, including the Resident Rights and Responsibilities Policy and the Wireless Mobile Device Policy, emphasize the importance of maintaining a dignified existence for residents and restricting personal phone use to non-working times. Despite these policies, the CNA's actions during the meal compromised the resident's dignity and the facility's standards.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
