Ivy At Davenport
Inspection history, citations, penalties and survey trends for this long-term care facility in Davenport, Iowa.
- Location
- 800 East Rusholme Street, Davenport, Iowa 52803
- CMS Provider Number
- 165436
- Inspections on file
- 31
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Ivy At Davenport during CMS and state inspections, most recent first.
Two residents dependent on total body mechanical lifts were transferred using unsafe or incorrect slings. A bariatric resident with morbid obesity and respiratory failure was lifted with a hospital slide sheet instead of a rated lift sling; as CNAs elevated the resident, the sheet’s handles tore, forcing an emergency lowering into an undersized recliner and leaving the resident stuck until fire department personnel manually slid the resident back to bed using the torn sheet. Staff interviews described lack of training on Hoyer and sling use, disorganized sling storage, unreadable sling labels, and reliance on ribbon colors to guess sizes, with reports that appropriate bariatric slings were not available. Another resident with multiple sclerosis and paraplegia, assessed as needing a large sling, was observed sitting on a medium sling with a worn tag that no longer showed the weight limit, contrary to manufacturer instructions requiring correct sling size and capacity and trained, competent operators.
The facility failed to provide a resident with reasonable access to a private telephone for communication. A resident with heart failure, depression, anxiety, and severe cognitive impairment relied on a cell phone sent by a representative, which went missing after about a week. Staff reported that, without a personal phone, residents used phones in the dining room or at the nursing station, both of which lacked privacy, and that the cordless phone was not available or not connected. This practice did not comply with the facility’s policy requiring resident access to a telephone in an area where calls could not be overheard.
A resident with multiple chronic conditions, intact cognition, and a history of depression and anxiety was involuntarily discharged to a homeless shelter after an episode of verbal aggression toward staff. The facility had previously issued unsigned 30‑day and same‑day involuntary discharge notices naming the shelter as the destination. On the day of discharge, an LPN reported the resident blocked her and threatened her during medication administration, the administrator called police, and the resident was ultimately removed in handcuffs. Staff interviews confirmed that no physician was notified, no physician order or updated assessment was obtained, and no comprehensive discharge summary, medication reconciliation, or post‑discharge plan of care was completed with the resident, despite facility policy requiring these steps for transfer/discharge, especially when behavior is cited as endangering safety. The Ombudsman was not notified of the discharge or police involvement, and there was no documented evidence that the resident was adequately prepared or oriented for a safe and orderly discharge.
Surveyors found that the facility failed to provide required bed-hold policy notices to a cognitively intact resident during two hospitalizations, with no documentation of bed-hold forms in the EHR and the resident reporting no discussion of the policy. In a separate case, a cognitively intact resident with multiple chronic conditions was issued unsigned involuntary discharge notices to a homeless shelter, while the SS Director reported the physician was not notified of alleged aggressive behavior and the LTC Ombudsman was not informed, despite facility policy requiring physician documentation, Ombudsman notification, a recapitulation of stay, and a post-discharge plan of care.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised after a CNA, unfamiliar with residents and lacking training on elopement risks, allowed the resident to exit through the front door. The resident was not reported missing until the next morning and was found over a mile away in freezing conditions, inadequately dressed and with decreased oxygen saturation and wheezing. The deficiency resulted from failures in supervision, staff training, and communication between shifts.
Baseboard heater covers in several resident rooms and a common area were found bent, broken, or missing, exposing internal heating elements that were warm to the touch. Beds and tables were positioned near these exposed heaters, and staff interviews confirmed that heater covers frequently became dislodged due to bed or wheelchair movement. The facility's policy requires a safe, homelike environment, but the recurring issue with heater covers resulted in exposed hazards.
A CNA was allowed to work with residents before the completion and clearance of her background check, which remained pending and revealed misdemeanor convictions. Miscommunication between staff led to the CNA being scheduled for shifts despite facility policy requiring background checks to be completed and cleared prior to employment.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severe cognitive impairment alleged that a CNA failed to provide necessary care, leading to the CNA's initial suspension. The CNA was reinstated and resumed care duties before the state agency completed its abuse investigation, despite facility policy requiring resident protection during such investigations.
A deficiency was cited for not ensuring that an area was free from accident hazards and for failing to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring or hazard identification in the area.
The facility did not ensure that psychotropic medications were clinically indicated or necessary for several residents, resulting in the use of drugs like Seroquel and Haloperidol for conditions not supported by FDA indications or resident diagnoses. There was a lack of coordination between psychiatric and primary care providers, with staff administering medications without proper communication or documentation. Care plans and progress notes were incomplete, missing required reviews and monitoring of behaviors, and some residents received psychotropic medications without a mental health diagnosis or evidence of attempted non-pharmacological interventions.
The facility was cited for failing to implement an effective QAPI process, resulting in repeated deficiencies related to care and services, including issues in kitchen operations and communication between staff and leadership. Despite awareness of these ongoing problems, the facility's QAPI activities did not prevent recurrence of the same deficiencies across multiple surveys.
A dietary aide was observed working in the kitchen with long braids not fully restrained by a hairnet, contrary to facility policy requiring all hair to be covered. The aide acknowledged the requirement but was unable to fit all her hair into the hairnet, and the Dietary Manager confirmed this was a recurring issue for staff with long hair or weaves.
Surveyors found that two hallways and a dining area had persistent strong urine odors, and handrails in one hallway had exposed sharp edges due to missing end pieces. Staff interviews indicated the odor may be embedded in the flooring, and the facility lacked a Maintenance Supervisor at the time. Additionally, a dried red substance was observed on a resident room wall and remained uncleaned for at least a day, despite facility policy requiring immediate cleaning of visibly soiled surfaces.
Surveyors identified that food served during a meal was not consistently maintained at safe and appetizing temperatures, with hot food below the required threshold and cold food above the recommended maximum. Two residents reported that their meals were often cold, and temperature checks by the Dietary Manager confirmed the deficiency, contrary to facility policy and expectations.
A resident who discontinued hospice services and opted to pursue cancer treatment did not have a significant change MDS assessment completed as required. The cognitively intact resident signed off hospice, but the MDS Coordinator was not informed, and the assessment was missed due to communication lapses and system updates not being made.
Two residents who were active smokers did not have smoking addressed as a focus area in their care plans, despite being observed smoking under staff supervision and having assessments indicating the need for supervision. Staff interviews confirmed that smoking should have been included in the care plans, but this was not done due to oversight during assessment and care planning processes.
A resident receiving hemodialysis did not have consistent and reliable communication between the facility and the dialysis center. Staff and the DON reported that forms sent to the dialysis center were not always returned, and staff were sometimes unaware of new orders or changes in care. This resulted in a lack of ongoing collaboration as required by facility policy.
A resident with intact cognition who was prescribed PRN antianxiety medication did not have timely follow-up on pharmacist recommendations for required stop dates. The pharmacist repeatedly identified the need for stop dates on PRN orders, but facility staff delayed communicating these recommendations to the physician, contrary to facility policy and regulatory guidelines.
Three residents did not have documentation of receiving required influenza or pneumococcal vaccines, as revealed by record review. The DON/Infection Preventionist reported that immunization status had not been reviewed since her recent start, and no staff were assigned to enter immunization data at admission. Facility policy requires annual offering and documentation of these vaccines, but this was not completed for the affected residents.
A resident's legal representative was not informed of a new medication prescribed for hypersexuality, only learning of it after receiving a pharmacy bill. Despite facility policy and staff expectations requiring notification of such changes, the notification was not made.
The facility did not consistently hold quarterly care conferences or revise care plans after significant changes in resident status. For example, a resident who discontinued hospice services was not updated in the care plan, and several residents or their representatives were not invited to or did not attend required care conferences. Additionally, behaviors such as wandering into other residents' rooms were not addressed in care plans, despite being observed and reported by staff and residents.
The facility failed to administer blood pressure and seizure medications as ordered for two residents, including not holding or giving medications based on vital sign parameters and not providing a prescribed seizure medication due to supply issues. Additionally, weekly weights were not completed as ordered for a resident with severe malnutrition. These deficiencies were confirmed by facility leadership and documented in the medical record.
A resident with moderate cognitive impairment and multiple medical conditions was not provided with the set up assistance for eating as outlined in the care plan. Staff routinely delivered meal trays without offering help, despite the resident's difficulty using his hands and inability to eat independently. Observations and staff interviews confirmed inconsistent assistance, and nursing staff were unaware of updated care needs, resulting in the resident struggling to eat meals without the necessary support.
Staff did not use wheelchair foot pedals when assisting a resident with limited mobility, and failed to use a gait belt during transfers for another cognitively impaired resident, despite both requirements being outlined in the residents' care plans and facility policy. Staff interviews confirmed awareness of these requirements.
A resident with cognitive impairment and an indwelling urinary catheter was observed with catheter tubing dragging on the floor and being stepped on while moving in a wheelchair. Staff interviews confirmed that tubing should be kept off the floor and the facility's policy requires securing catheter tubing, but this was not followed.
Staff failed to follow infection control protocols by not using barriers for a glucometer during medication administration and not donning required gowns during high-contact care for a resident on Enhanced Barrier Precautions. These lapses occurred despite clear facility policies and available personal protective equipment.
A facility failed to follow physician orders for pressure ulcer care for two residents, leading to deficiencies. One resident's Stage 3 ulcer progressed to Stage 4 due to improper wound care and infection control practices. Another resident with a Stage 4 ulcer did not receive prescribed antibiotics, worsening their condition and requiring hospital transfer. The DON acknowledged the oversight in antibiotic administration.
A resident with cognitive impairment eloped from the facility and was found miles away due to staff failing to recognize her absence promptly. The front door alarm system was bypassed by a receptionist unfamiliar with the resident. Additionally, two residents were not provided with proper safety equipment during transfers, violating their care plans.
A resident with multiple health issues and high risk for pressure ulcers experienced a decline in their condition due to inadequate assessment and intervention by the facility. Despite having a care plan, the facility failed to consistently document and follow up on the resident's pressure ulcers, leading to a Stage 4 ulcer and hospitalization. Staff interviews revealed inconsistencies in documentation and adherence to the facility's pressure injury prevention policy.
The facility failed to maintain sanitary conditions and proper food storage temperatures, leading to deficiencies in food safety practices. A freezer was found at 30°F, above recommended levels, with some food items soft to the touch. The kitchen had a greasy stove top, a flooded floor with debris, and dust accumulation. A dietary aide served glasses with bare fingers touching the rims, risking contamination. The facility's policy requires monitoring food temperatures and cleanliness, but these standards were not met.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, leading to deficiencies in infection prevention and control. A resident with MDRO did not receive appropriate EBP interventions, and an LPN did not wear a gown during wound care. Another resident with a feeding tube lacked EBP instructions, and an LPN did not use additional PPE during medication administration. Additionally, housekeeping staff handled laundry without proper PPE, contrary to facility policy.
The facility failed to maintain a pest-free environment, with observations and interviews revealing the presence of raccoons and mice. A significant hole in the soffit was identified as an entry point for raccoons. Residents and staff reported sightings of mice in various areas, indicating ineffective implementation of pest control measures.
The facility failed to maintain an effective QAPI process, leading to repeat deficiencies in areas such as accidents, hazards, and pressure ulcer prevention. Despite previous citations, issues with food procurement and kitchen sanitation persisted. The facility's inability to provide consistent QAPI documentation contributed to these ongoing deficiencies.
The facility failed to provide mandatory education on resident rights and facility responsibilities to five out of six staff members reviewed, including LPNs, CNAs, and a Dietary Aide. Despite policies requiring documentation of training, the facility could not provide evidence of completed education, as confirmed by the Director of Clinical Service.
The facility failed to ensure accurate documentation of advance directives for two residents, resulting in conflicting physician orders for CPR and DNR status. One resident's EHR lacked documentation of the IPOST, and the care plan was inconsistent with the active orders. Another resident's IPOST indicated a preference for DNR, but the care plan stated CPR would be initiated. Staff interviews revealed a lack of adherence to the facility's policy requiring consistency between the plan of care and documented treatment preferences.
The facility failed to ensure timely completion of required training and background checks for staff. A CNA did not have a Dependent Adult Abuse training certificate within six months of hire, and an LPN began working with residents before completing a Single Contact License & Background check. The facility lacked policies on timelines for these requirements.
The facility failed to ensure that a physician conducted the first resident assessment within 30 days of admission for three residents. Residents with varying degrees of cognitive impairment and medical conditions were initially assessed by ARNPs instead of physicians, contrary to the facility's policy. The Director of Clinical Services confirmed the expectation for physician assessments within the first 30 days, highlighting a deviation from policy and regulatory requirements.
The facility failed to conduct routine competency evaluations for CNAs, as revealed by the absence of evaluations for two CNAs hired in 2020 and 2023. Despite requests for documentation, the Director of Clinical Services could not provide a performance evaluation for one CNA, acknowledging that the facility was behind in meeting core competency requirements. The facility's policy requires documented evaluations to be maintained and filed appropriately.
The facility did not ensure that CNAs received the required 12 hours of in-service education annually. A review of education files revealed that a CNA hired in March 2023 did not complete the necessary training. Despite requests, the facility could not provide documentation of the required education. The Director of Clinical Service confirmed the expectation for staff to meet educational requirements, as outlined in the facility's policy.
A resident with severely impaired cognition and a history of stroke and hemiparesis had a skin tear that was not identified, assessed, or documented by the facility. Despite a care plan and physician order for weekly skin evaluations, the skin tear was not recorded in the EHR, and staff were unaware of the injury until it was observed. The facility's policy for skin assessments was not followed.
The facility failed to educate staff on the mandatory QAPI program, as five employees, including LPNs, CNAs, and a Dietary Aide, lacked records of completed education. The General Orientation Plan lacked QAPI training, and the facility did not maintain documentation of completed orientation processes in personnel files.
Improper Mechanical Lift Sling Selection and Unsafe Transfer Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of mechanical lifts and appropriate slings for residents dependent on total body lifts, including a bariatric resident. For Resident #8, who had morbid obesity, acute and chronic respiratory failure with hypoxia, anxiety, depression, and a history of potentially traumatic events, the MDS documented total dependence for transfers and the need for a mechanical total body lift with two helpers. A Mechanical Lift & Sling Size Risk Evaluation identified that this resident’s weight of approximately 535 pounds required an XXL sling on a bariatric lift. Despite this, staff reported that the sling supply was disorganized, that they relied on ribbon colors to guess sling sizes, and that some slings had worn or unreadable tags, making it impossible to verify size and weight limits. Staff also reported that the facility did not have an appropriate sling for the resident’s weight and that the only other available sling was a medium size that would not work. On the evening of 2/26, Resident #8 complained of chest pain/indigestion while lying in bed and requested to be assisted into a recliner. The LPN on duty directed three CNAs to transfer the resident using the mechanical lift. CNAs described that the only sling available for this transfer was a blue and grey hospital slide sheet with multiple loop handles, which they had never used before at the facility and which was not like the regular netted or cloth mechanical lift slings. They placed this slide sheet under the resident, attached its loops to the bariatric lift, and began elevating the resident away from the bed. As the lift was engaged and the resident was moved, the handles on the slide sheet began to tear away from the material. Staff heard ripping sounds, and the resident stated she heard the rip and expressed fear of falling, repeatedly asking how she would get back to bed. CNAs held onto the sling and maneuvered a recliner under the resident, lowering her into a chair that was described as not big enough, with the resident “squished in.” The slide sheet tore further, with loops pulling away from the sheet, and staff were unable to safely transfer the resident back to bed. The facility then relied on the local fire department to attempt to resolve the situation. Fire department personnel found the resident stuck in the recliner on a torn slide sheet and were told by facility staff that the sheet had begun to rip while the resident was elevated during the transfer. The Lieutenant and Fire Chief identified the device under the resident as a hospital slide/transfer sheet, not a mechanical lift sling, and stated that if the handles had completely ripped, the resident would have been seriously hurt. Fire personnel attempted to use the slide sheet again with the lift to raise the resident just enough to place another sling underneath, but the sheet began ripping again, one handle after another, and the resident had to be lowered back into the recliner. Ultimately, additional fire crew members dismantled the bed, positioned it at the foot of the recliner, and manually slid the resident into bed using the torn sheet. Facility documentation and interviews also showed that staff had called the fire department multiple times for this resident’s transfers, that staff reported insufficient equipment and staffing to safely transfer her, and that the nurse on duty had been told at shift change simply to call the fire department when the resident needed to return to bed. For Resident #39, who had multiple sclerosis, paraplegia, renal insufficiency, and bilateral leg impairment, the MDS and a Mechanical Lift & Sling Size Risk Evaluation documented dependence on staff for transfers and the need for a total body lift with a large-size sling at a weight of 248 pounds. However, observation showed this resident sitting in an electric wheelchair on a mechanical lift sling with a purple ribbon, identified on its worn tag as a medium size. The remainder of the tag was too worn to identify the maximum weight limit. Manufacturer safety instructions for the bariatric lift specified that staff should not lift a patient unless trained and competent and must always ensure the sling is suitable for the particular patient and of the correct size and capacity. Interviews with CNAs and the Administrator revealed that staff training on sling selection was lacking, that staff were not provided formal training on Hoyer and sling use, that sling sizes were often inferred from ribbon colors, and that some slings lacked readable labels, contributing to the use of incorrect or unsafe devices for mechanical lift transfers.
Failure to Provide Private Telephone Access for Resident Communication
Penalty
Summary
The facility failed to ensure a resident had reasonable access to a private area for telephone communication. The resident involved had diagnoses including heart failure, depression, and anxiety, and a BIMS score of 4/15 indicating severe cognitive impairment. The resident’s representative reported sending the resident a cell phone, which went missing after about a week, and stated that the facility did not have a portable phone available for residents, making the cell phone the only option for private calls. Staff interviews confirmed that, in the absence of a resident-owned phone, residents were brought to facility phones that did not provide privacy. Multiple staff members, including LPNs and the receptionist, stated that residents could use phones located in the dining room or at the nursing station, but acknowledged these areas were not private. Staff also reported that the facility’s cordless phone was either not available or not connected, and that there was no other cordless phone for resident use. The facility’s written policy on Resident Right to Privacy in Communication required that residents be provided reasonable access to a telephone in an area where calls were not overheard, but the actual practice did not provide such a private area or functioning portable phone for the resident to make calls.
Failure to Assess, Notify Physician, and Plan Safe Discharge Before Involuntary Removal to Homeless Shelter
Penalty
Summary
The deficiency involves the facility’s failure to complete an updated assessment, notify the physician, and provide and document sufficient preparation and orientation to ensure a safe and orderly discharge for one resident. The resident had multiple significant diagnoses, including diabetes mellitus, heart disease, kidney insufficiency, malnutrition, anxiety disorder, depression, osteomyelitis, difficulty walking, and used a manual wheelchair. The MDS showed the resident was receiving opioid pain medication, antiplatelet medication, insulin, and anticonvulsant medication, and had an intact BIMS score of 15/15 with no documented behavioral symptoms toward others. The resident’s care plan included monitoring and documenting any risk for self-harm and signs and symptoms of depression, such as hopelessness, anxiety, sadness, and impaired judgment or safety awareness. The facility issued an involuntary discharge notice on facility letterhead in February, citing endangerment to the safety of individuals in the facility and identifying a homeless shelter as the discharge destination, with an effective and expected transfer date one month later; this notice was unsigned. A second involuntary discharge notice, also unsigned, was issued in March, again citing the same regulatory authority and naming the same homeless shelter as the discharge destination, with the effective and expected transfer date on the same day. On the day of the March discharge, a progress note documented that an LPN attempted to administer medications and offer a pain pill, after which the resident became verbally aggressive, yelled, cursed, threatened the nurse, and blocked her between the meal tray cart and the med cart. The resident eventually moved his wheelchair, the nurse left, and the administrator was notified; the administrator then called the police, who came to the facility, spoke with the resident, and recommended discharge. The resident was given time to pack belongings, and the social worker and nurse attempted to provide discharge paperwork, which the resident refused to sign while continuing to yell. Staff interviews revealed that nursing staff did not notify the physician about the discharge, and the social service director and administrator both confirmed that the physician was not notified. The social service director stated she had been working on transferring the resident since the fall, that the resident had multiple denials for placement, and that he had previously lived in a shelter before admission and lost his leg after an infection. She reported being instructed to give discharge papers to the homeless shelter, that the resident refused to sign, and that the administrator called the police due to the resident’s verbally aggressive behavior. The administrator stated she discharged the resident due to potential for violence and aggressive behaviors, acknowledged that she did not notify the State Agency or Ombudsman for either the 30‑day involuntary discharge notice or the emergent discharge, and stated she expected nursing to notify the physician but was unsure what a recapitulation of stay entailed. The facility’s own transfer and discharge policy required, in situations where a resident’s clinical or behavioral status endangers safety, physician documentation of the reason for transfer or discharge, a physician’s order for transfer or discharge, and completion of a discharge summary including a recap of the stay, final status, medication reconciliation, and a post‑discharge plan of care developed with the resident. These required assessments, notifications, and discharge planning elements were not completed or documented for this resident’s discharge to a homeless shelter following police removal from the facility. Additional information from the Ombudsman and external records further described the circumstances surrounding the discharge. The Ombudsman reported receiving phone messages from the resident stating he was being kicked out because he allegedly pushed a pregnant staff member, which he denied, and that police had been notified; the Ombudsman also stated the facility had not reported the incident, police action, or discharge to the Ombudsman office, although a prior incident involving the resident hitting another resident had been reported the previous summer. A county sheriff’s inmate listing documented that the resident was booked for trespass on the same day as the discharge and released the following day. The administrator later stated she did not know the resident’s whereabouts after learning that another resident’s family member had picked him up after police release and taken him to the hospital, from which he was then discharged. Throughout these events, there was no documentation of an updated assessment, physician involvement, or a comprehensive, resident‑involved discharge plan as required by facility policy and regulation, nor evidence that the resident was adequately prepared or oriented for a safe and orderly discharge to the identified homeless shelter.
Failure to Provide Bed-Hold Notices and Proper Involuntary Discharge Procedures
Penalty
Summary
Surveyors identified that the facility failed to provide required bed-hold notifications to a cognitively intact resident during two separate hospitalizations. Resident #3, who had a BIMS score of 14/15 indicating intact cognition, was admitted to the hospital twice and returned to the facility after each stay. Review of the electronic health record showed no documentation that a bed-hold notice or the facility’s bed-hold policy was issued to the resident for either hospitalization. The resident reported not remembering anyone discussing the bed-hold policy at admission or when he went to the hospital. The Administrator later confirmed by email that no bed holds were issued, despite a facility policy stating that a notice of transfer and the facility’s bed-hold policy would be provided to the resident and representative as part of emergency transfers to acute care. Surveyors also found that the facility failed to properly execute transfer and discharge requirements for Resident #40, who had multiple diagnoses including diabetes mellitus, heart disease, kidney insufficiency, malnutrition, anxiety disorder, depression, osteomyelitis, difficulty walking, and used a manual wheelchair, with a BIMS score of 15/15 indicating intact cognition. The Ombudsman reported receiving phone messages from the resident stating he was being kicked out for allegedly pushing a pregnant staff member, which he denied, and that police had been notified, but the facility had not reported the incident, police action, or discharge. The Social Service Director stated she had been working since fall 2025 to find a community facility for the resident, that he had received discharge papers in February 2026, and that on the day of discharge she was instructed to give him discharge papers to a homeless shelter, including appeal paperwork, which he refused to sign. She acknowledged that the physician was not notified of the aggressive behavior and that she did not notify the LTC Ombudsman. Review of two discharge letters on facility letterhead for Resident #40, dated in February and March 2026, showed notices of immediate involuntary discharge citing federal and state regulations, with an identified homeless shelter as the discharge destination and a statement that right-to-appeal information was included. Both notices were unsigned but indicated they were sent to the physician and Ombudsman. In interviews, the Administrator stated she discharged the resident due to potential for violence and aggressive behaviors, acknowledged that she did not notify the Department of Inspection, Appeals and Licensing or the LTC Ombudsman for either the 30‑day involuntary discharge notice or the emergent discharge, and stated she expected nursing to notify the physician. She also stated she was unsure what a recapitulation of stay entailed, despite facility policy requiring a physician’s order for transfer or discharge, documentation by a physician regarding the reason for transfer or discharge when safety is endangered, evidence that notice was sent to the Ombudsman, and completion of a discharge summary including a recap of the stay and a post‑discharge plan of care developed with resident participation.
Failure to Prevent Elopement Due to Inadequate Supervision and Staff Training
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of wandering, and multiple prior elopement attempts was not provided adequate supervision and assistance to prevent an elopement. The resident was able to leave the facility after a Certified Nursing Assistant (CNA), who was unfamiliar with the residents and had not received training on elopement risks, entered the front door code and allowed the resident to exit the building. The CNA did not recognize the individual as a resident and failed to notify other staff after the resident left the facility. No immediate action was taken to locate the resident, and the incident was not reported to other staff members at the time. The resident was not discovered missing until the following morning, when a staff member driving to work found the resident approximately 1.7 miles from the facility, near a busy road, in below-freezing temperatures with snow on the ground. The resident was inadequately dressed for the weather, wearing only a jacket, lightweight shoes, and no gloves or hat. Upon return to the facility, the resident was assessed and found to have decreased oxygen saturation, wheezing, and cold extremities. The resident was subsequently sent to the emergency department for further evaluation due to abnormal lung findings and a potential pulmonary embolism. The facility's policies required systematic monitoring and management of residents at risk for elopement, including staff awareness and adequate supervision. However, the CNA involved had not received orientation or training regarding residents at risk for elopement and did not consult with other staff when unsure about the resident's identity. Additionally, there was a lack of effective communication between shifts, as the overnight CNA did not receive any report or information about the resident's risk or whereabouts. These failures in supervision, staff training, and communication directly led to the resident's unsupervised exit and subsequent exposure to hazardous conditions.
Failure to Maintain Safe and Homelike Environment Due to Damaged Heater Covers
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as required by policy. Observations revealed that baseboard heater covers in multiple resident rooms and a common area were bent, broken, or missing, exposing internal metal heating elements. In several rooms, the residents' beds were positioned close to these exposed heaters, and the heating elements were warm to the touch. The exposed heaters were found in at least one of three hallways and in the main dining and activities area, which is used by residents for communal purposes. Interviews with facility staff indicated that heater covers frequently became dislodged or damaged due to bed movements or wheelchair contact. The Maintenance Director reported conducting weekly checks to address these issues, and the DON acknowledged the recurring problem with the heater covers, noting that the facility was considering replacement covers due to their deteriorated condition. The facility's policy requires maintaining a safe and homelike environment, but the ongoing issue with heater covers resulted in areas where residents were exposed to potential hazards.
Failure to Complete Background Check Prior to Employment
Penalty
Summary
The facility failed to ensure that a complete background check was conducted prior to allowing a newly hired Certified Nursing Assistant (CNA) to work with dependent adults. Review of personnel records showed that the CNA completed new hire orientation and began working shifts while the results of her national criminal and sex offender background checks were still pending. Additionally, her criminal history required further research, and her file lacked documentation of approval to work following the identification of misdemeanor convictions. Despite these unresolved background check issues, the CNA was scheduled and worked independently for approximately two weeks. Interviews with staff revealed a breakdown in communication between the scheduler and the Administrator regarding the status of the background check. The scheduler believed a note on the CNA's file indicated clearance to work, leading to the CNA being scheduled for shifts. The Director of Nursing confirmed that the CNA worked independently but did not personally check in on her performance. Facility policy requires that all background checks be completed and cleared before employment, and prohibits hiring individuals with findings of abuse, neglect, exploitation, or related offenses.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Resident from Potential Abuse During Investigation
Penalty
Summary
The facility failed to ensure resident protection from potential abuse by allowing an alleged perpetrator to return to work before the initiation and completion of a state agency investigation. A resident with severe cognitive impairment, including schizophrenia, non-Alzheimer's dementia, and anxiety, reported that a night shift CNA did not assist with dressing or toileting. The resident's BIMS score indicated severe cognitive impairment, and she required substantial staff assistance for toileting and hygiene. Following the allegation, the CNA was initially suspended, but was reinstated the same day after the resident changed her description of the staff member involved multiple times. Despite the ongoing investigation by the state agency, the CNA resumed providing care to the resident and continued working subsequent shifts. The facility's policy required protection of residents from potential harm during and after investigations, including measures such as staff suspension and increased supervision. However, the facility reinstated the CNA based on the resident's inconsistent statements before the state agency had completed its investigation, resulting in a failure to fully protect the resident from potential abuse as required by policy.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring within the facility. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision of the area in question. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Clinical Indication and Coordination for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were clinically indicated and necessary for four residents, resulting in the administration of unnecessary medications. Clinical record reviews and interviews revealed that residents were prescribed multiple psychotropic drugs, including antipsychotics and antidepressants, without adequate documentation of the specific conditions these medications were intended to treat. In several cases, the medications prescribed, such as Seroquel and Haloperidol, were not indicated for the residents' documented diagnoses or symptoms, and there was a lack of evidence supporting their use for conditions like anxiety, agitation, or insomnia. For example, one resident received Seroquel and Haloperidol for anxiety and agitation, despite these medications being FDA-approved for schizophrenia and bipolar disorder, not for anxiety or restlessness as documented in the resident's records. The facility also failed to coordinate care between psychiatric providers and primary care providers. There was no documentation that staff communicated with the psychiatric nurse practitioner regarding the administration of certain psychotropic medications, such as Haloperidol, or about changes in the residents' symptoms. Nursing staff reported administering these medications based on primary care physician orders without consulting the psychiatric provider, and the psychiatric nurse practitioner confirmed she was not informed about the use of these medications or the residents' increased anxiety. The Director of Nursing was unaware of the administration of some psychotropic medications and acknowledged the lack of communication and documentation regarding these interventions. Additionally, care plans and progress notes lacked required documentation, such as ongoing review of the need for psychotropic medications, monitoring and recording of target behaviors, and evaluation of non-pharmacological interventions. In some cases, residents were prescribed psychotropic medications without a corresponding mental health diagnosis, and there was no evidence that alternative therapies or behavioral interventions were attempted or documented. Interviews with staff and responsible parties further highlighted concerns about the appropriateness and effectiveness of the medications being administered.
Repeat Deficiencies Due to Ineffective QAPI Process
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process, as evidenced by multiple repeat deficiencies cited during the current and previous surveys. Specifically, deficiencies under F689, F812, and F865 were identified in recertification and complaint surveys conducted in 2023 and 2024, indicating that previously identified quality issues were not adequately addressed. The facility had a census of 65 residents at the time of the survey. Interviews and policy reviews revealed that while the Administrator was aware of the repeated deficiencies, the facility's efforts to address these issues, such as ongoing projects in the kitchen and attempts to improve communication between staff and leadership, were insufficient to prevent recurrence. The QAPI policy required quarterly and as-needed meetings of the Quality Assessment and Assurance (QAA) Committee, but the facility's management meetings were described as informal monthly gatherings and official quarterly meetings, suggesting a lack of a comprehensive, data-driven QAPI program as required.
Dietary Staff Failed to Fully Cover Hair While Handling Food
Penalty
Summary
A deficiency was identified when a dietary aide was observed in the kitchen with multiple long braids of hair not fully covered by a hairnet, as required by facility policy. The aide wore two hairnets, but parts of her braids remained exposed and hung down her back. During interviews, the aide acknowledged that all hair needed to be covered and admitted difficulty in fitting all her hair into the hairnet. The Dietary Manager confirmed that all kitchen staff are required to wear hair coverings that fully restrain their hair, and noted ongoing issues with staff who have weaves or long hair not being able to fully contain their hair within the hairnet. Facility policy specifies that food handlers must wear hair coverings or nets to ensure proper hygiene.
Failure to Maintain Clean, Odor-Free, and Safe Environment
Penalty
Summary
The facility failed to maintain a homelike environment free from strong odors and physical hazards in two of four hallways. Observations revealed a persistent strong odor of urine in the A and B hallways and the back dining room, as reported by a resident representative and confirmed by staff interviews. Staff members, including a CNA, LPN, and RN, attributed the odor to the flooring, suggesting it may be embedded and that replacement might be necessary. Additionally, the handrails outside two resident rooms were missing end pieces, resulting in exposed sharp edges. The facility was without a Maintenance Supervisor at the time, as the previous supervisor had recently resigned. Further observations identified a dried red substance smeared and running down the wall near a resident's bed in one room, which remained unaddressed for at least a day. Both the RN providing wound care and the DON stated they had not noticed the substance during their visits to the room. The facility's policy requires immediate cleaning of visibly soiled surfaces and routine cleaning and disinfection of resident rooms and common areas, but these procedures were not followed in this instance.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
Surveyors found that the facility failed to maintain safe and palatable food temperatures during the noon meal service. On the specified date, a test tray was requested and food temperatures were measured by the Dietary Manager. The refried beans were recorded at 134.2°F, which is below the Dietary Manager's stated expectation of at least 135°F for hot foods. The jello cake with whipped topping was measured at 69.2°F, which is above the expected maximum of 41°F for cold foods. The facility's own policy, last revised in April 2024, requires staff to monitor and maintain proper hot and cold holding temperatures in accordance with the FDA Food Code. Resident interviews further substantiated the deficiency. One resident, with intact cognition and requiring supervision with eating, reported that food delivered to her room was inconsistently hot and had been cold throughout the previous week. Another resident, with moderately impaired cognition and needing set up or clean up assistance, stated that the food usually tasted cold. These findings, combined with the temperature measurements and staff expectations, demonstrate a failure to ensure food was served at safe and appetizing temperatures.
Failure to Complete Significant Change MDS Assessment After Hospice Discontinuation
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment when a resident discontinued hospice services. The resident, who was cognitively intact as indicated by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, expressed a desire to stop hospice care and signed off hospice services with the hospice RN and social worker present. The attending physician was notified, and documentation confirmed the resident was no longer receiving hospice care and wished to pursue cancer treatment. Despite this significant change in the resident's care status, the facility did not initiate a significant change MDS assessment as required. The MDS Coordinator stated she was not informed of the resident's discontinuation of hospice services and would have opened a significant change assessment if notified. The Director of Nursing confirmed that discontinuation of hospice should have triggered a significant change assessment, but it was missed due to a lack of communication and failure to update the payer source in the system. The facility did not have a specific policy addressing significant change assessments, instead following the Resident Assessment Instrument (RAI) guidelines.
Failure to Address Smoking in Resident Care Plans
Penalty
Summary
The facility failed to address smoking as a focus area in the care plans for two residents who were observed to be active smokers. One resident, who was cognitively intact and dependent on staff for several activities of daily living, was observed smoking outside with staff assistance, but her care plan did not include any focus area, goals, or interventions related to smoking. Staff interviews confirmed that smoking should have been included in the care plan, and the omission was attributed to a possible oversight during the admission assessment. Another resident, with moderate cognitive impairment and multiple diagnoses, was also observed smoking in the designated area without a smoking apron for safety. Facility staff described the smoking protocol, including supervision and storage of cigarettes and lighters, and a recent assessment identified the resident as a current smoker requiring supervision. However, the care plan for this resident also lacked a focus area, goals, or interventions addressing smoking, despite staff acknowledging that such information should be included in the care plan.
Failure to Coordinate Communication with Dialysis Center
Penalty
Summary
The facility failed to coordinate effective communication with the dialysis center for a resident receiving hemodialysis. The resident, who was cognitively intact and had a diagnosis of end-stage renal disease, was scheduled for outpatient hemodialysis three times a week. The care plan and physician orders reflected these scheduled treatments. However, the clinical record showed that the most recent communication tool completed between the facility and the dialysis center was dated over a month prior to the survey. Interviews with the resident, nursing staff, and the DON revealed that the process for exchanging information with the dialysis center was inconsistent and unreliable. Staff reported that forms were sent with the resident to the dialysis center, which were supposed to be completed and returned, but this did not consistently occur. The resident sometimes returned with new orders that staff had not received directly from the dialysis center, and staff expressed concerns about not being promptly informed of changes in care. The DON acknowledged difficulties in obtaining completed communication forms from the dialysis center and was unsure how the facility would be notified of changes in the resident's care. The facility's policy required ongoing communication and collaboration with the dialysis center, which was not consistently achieved.
Failure to Timely Address Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up on medication regimen review recommendations made by the pharmacist for a resident who was taking antianxiety medication. The pharmacist identified that PRN orders for Alprazolam and hydroxyzine required stop dates, as per regulatory guidelines, and generated letters to communicate these recommendations on three separate occasions. Despite these repeated recommendations, the facility did not act promptly to address the pharmacist's concerns, and the required communication to the attending physician was delayed. Clinical record review showed that the only documented communication to the physician regarding the need for a stop date or continuation duration for the PRN hydroxyzine order was not completed until several months after the initial recommendation. Interviews with the DON confirmed that the letters from the pharmacist were not being sent to the physician in a timely manner, and the facility was still waiting for responses to the most recent recommendations. Facility policy required staff to act upon all pharmacist recommendations according to established procedures, but this was not followed in this instance.
Failure to Provide and Document Required Immunizations
Penalty
Summary
The facility failed to provide required immunizations for influenza and pneumococcal disease to three out of five residents reviewed. Specifically, two residents did not have documentation of receiving the pneumococcal vaccine, and two residents did not have documentation of receiving the influenza vaccine for the current year. Review of immunization records revealed these gaps, and there was no evidence that the residents or their representatives were provided with education regarding the benefits and potential side effects of the immunizations, or that refusals or contraindications were documented. During an interview, the DON/Infection Preventionist stated that she had not reviewed the immunization status for flu and pneumococcal vaccines since starting at the facility a month prior. She also indicated that there was currently no staff member assigned to enter immunization data upon resident admission. Facility policies require annual offering and documentation of influenza and pneumococcal vaccinations, including assessment, education, and documentation of administration, refusal, or contraindication, but these procedures were not followed for the affected residents.
Failure to Notify Resident Representative of New Medication
Penalty
Summary
A deficiency was identified when the facility failed to notify the resident's legal representative of a change in the medication regimen for one resident. The resident, who was cognitively intact with a BIMS score of 12 and had diagnoses including depression, cognitive communication deficit, and dysphagia, was prescribed Depo-Provera for hypersexuality. The resident's Power of Attorney (POA) reported not being informed of this new medication until receiving a bill from the pharmacy. Interviews with staff confirmed that the expectation was to notify the family or resident representative of any new medications or changes in condition. Review of facility policy also indicated that notification is required when there is a need to alter treatment, such as starting a new medication. Despite these policies, the required notification did not occur in this instance.
Failure to Hold Quarterly Care Conferences and Revise Care Plans
Penalty
Summary
The facility failed to hold care conferences quarterly and did not revise care plans in a timely manner for several residents, as required by both facility policy and federal regulations. Specifically, one resident discontinued hospice services, but the care plan continued to indicate the resident was receiving hospice, despite documentation in the clinical record and physician notes that hospice had ended. The Director of Nursing stated that the MDS Coordinator would typically update the care plan when a significant change was triggered, but this did not occur because the MDS Coordinator was not always present during meetings where such changes were discussed. Additionally, the facility did not ensure that care conferences were held quarterly for multiple residents. For one resident with severe cognitive impairment, the resident's wife reported never being invited to a care conference, and facility staff confirmed that a care conference was overdue. Another resident with intact cognition stated she had not attended a care conference since her initial admission, and staff confirmed that a quarterly care conference was missed. Interviews with staff, including the Director of Nursing and Social Services, revealed a lack of consistent scheduling and documentation of care conferences as required. The facility also failed to update care plans to address new or ongoing behaviors. For example, one resident with severe cognitive impairment exhibited wandering behaviors, including entering other residents' rooms, which was not addressed in the care plan. Staff and another resident confirmed these incidents, and the Director of Nursing acknowledged that such behaviors should have been care planned. Facility policies require comprehensive, person-centered care plans that are reviewed and revised after each assessment and significant change, but these requirements were not met for several residents.
Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to administer blood pressure and seizure medications according to physician orders for two residents, and failed to complete weekly weights as ordered for another resident. For one resident with a history of hypertension and hypotension, the MAR showed that Midodrine was not administered on multiple occasions when the resident's systolic blood pressure was below the ordered threshold, and Metoprolol was given even when the resident's blood pressure was below the hold parameter specified by the physician. The DON confirmed that nursing staff are expected to follow medication parameters as guidance, and facility policy requires holding medications for vital signs outside prescribed parameters. Another resident with a diagnosis of epilepsy did not receive prescribed doses of Epidiolex, a seizure medication, on several occasions. The MAR indicated missed doses with codes for "Other/See Progress Notes" and "medication unavailable," but there was a lack of documentation explaining the missed doses for several days. Notes in the electronic health record revealed the facility was unable to obtain the medication due to pharmacy and DEA issues, and the resident's representative reported increased seizure activity during this period. The resident was later sent to the emergency room and admitted to the ICU after reportedly feeling unwell and possibly experiencing a seizure. A third resident, identified as having severe protein-calorie malnutrition and moderately impaired cognition, had a physician order for weekly weights. However, the only documented weight in the EHR was from several weeks prior, with no further weekly weights recorded. The DON and a consultant confirmed that the weekly weights were not being completed as ordered, and the consultant stated that staff should be weighing the resident rather than relying on dialysis summary sheets.
Failure to Provide Required Eating Assistance to Resident with Impaired Ability
Penalty
Summary
Staff failed to provide required set up assistance for a resident with impaired ability to eat independently. The resident, who had a moderate cognitive impairment and diagnoses including metabolic encephalopathy, Crohn's disease, end stage renal disease, and diabetes, was care planned to require set up or clean up assistance for eating, such as opening packages or cutting meat. Despite this, multiple observations and interviews revealed that staff routinely delivered meal trays to the resident's room without offering or providing the necessary assistance. The resident reported difficulty eating due to impaired hand function and stated that staff did not help him, resulting in challenges such as spilling food and being unable to cut or eat his meal effectively. Staff interviews confirmed inconsistent assistance, with some staff acknowledging that help was not always provided and that the resident did not use adaptive utensils. During observed meals, the resident struggled to eat independently, and staff did not check if assistance was needed. Nursing staff were unaware of any recent changes to the care plan or physician orders regarding eating assistance. The DON was not aware of concerns related to the resident's eating ability, and documentation showed ongoing issues with the resident's ability to eat independently prior to a physician order for increased assistance.
Failure to Use Wheelchair Foot Pedals and Gait Belts During Resident Assistance
Penalty
Summary
Staff failed to ensure the use of wheelchair foot pedals and gait belts as required by residents' care plans and facility policy. For one resident with moderately impaired cognition and limited mobility, staff were observed multiple times pushing the resident in a wheelchair without foot pedals attached, despite the care plan specifying that foot pedals should be used whenever push assistance is given. Staff interviews confirmed that foot pedals should be in place when pushing a resident in a wheelchair, and the Director of Nursing acknowledged this requirement. In another case, a cognitively impaired resident requiring assistance for transfers was assisted by two CNAs without the use of a gait belt, contrary to the care plan and facility policy. The staff instead held the resident under the arms during transfers from bed to wheelchair and vice versa. Interviews with staff confirmed that the resident was care planned to be transferred with a gait belt and walker, and the facility's policy required transfers to be performed according to the resident's plan of care.
Catheter Tubing Not Secured, Dragging on Floor
Penalty
Summary
A deficiency was identified when a resident with cognitive impairment, renal insufficiency, encephalopathy, and malnutrition, who used an indwelling urinary catheter, was observed with catheter tubing dragging on the floor while self-propelling her wheelchair in the dining room. The resident was also seen stepping on the tubing during this observation. The care plan for this resident had identified the use of an indwelling catheter due to urinary retention and obstructive and reflux uropathy. Staff interviews confirmed that catheter tubing should not be on the floor and that staff are expected to pick up the tubing and notify a nurse if this occurs. The facility's catheter care policy, last revised on 1/1/24, directs staff to ensure catheter tubing is secured to prevent it from touching the floor. Despite these expectations and policies, the tubing was not secured, resulting in the observed deficiency.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Surveyors observed multiple failures in the facility's infection prevention and control practices. During medication administration, a registered nurse placed a glucometer directly on a resident's over-bed table and later on the medication cart without using a barrier. The nurse reported cleaning the glucometer only at the beginning and end of her shift, rather than between residents. Another nurse stated that the glucometer should be cleaned between residents and that a barrier should be used when setting it down, which was confirmed by the Director of Nursing (DON), who also acknowledged that staff should sanitize the glucometer between uses. Facility policy required maintaining a safe and sanitary environment to prevent the transmission of communicable diseases. Additionally, staff failed to implement Enhanced Barrier Precautions (EBP) for a resident with significant medical needs, including a feeding tube, chronic wounds, and total dependence on staff for activities of daily living. During wound care, gastrostomy tube site care, and incontinence care, three staff members donned gloves but did not wear protective gowns, despite clear signage and available personal protective equipment outside the resident's room. The staff later admitted to forgetting to use the required gowns. Facility policy specified that gowns and gloves must be used for high-contact care activities, such as wound care and device care, for residents under EBP.
Failure to Follow Pressure Ulcer Treatment Orders and Infection Control Practices
Penalty
Summary
The facility failed to adhere to physician orders for pressure ulcer treatment for two residents, leading to deficiencies in care. Resident #1, who had multiple sclerosis, diabetes, and a history of stroke, was admitted with a Stage 3 pressure ulcer that progressed to Stage 4. The physician's orders required specific wound care procedures, including the application of medi honey and a zinc-antifungal mixture to the peri-wound area. However, during an observation, a registered nurse failed to follow proper infection control practices and did not apply the zinc-antifungal mixture as directed, instead applying it to the groin area. Resident #2, diagnosed with paraplegia, morbid obesity, and encephalopathy, had a Stage 4 pressure ulcer with heavy drainage. The physician ordered daily wound care and an antibiotic regimen of linezolid twice daily. However, the facility did not administer the antibiotic as prescribed, and the resident's wound condition worsened, necessitating hospital transfer for intravenous antibiotics. The wound physician expressed concern over the lack of communication regarding the antibiotic order. The Director of Nursing acknowledged the oversight in administering the antibiotic and confirmed that the Assistant Director of Nursing, who rounds with the wound physician, missed the order. This failure to implement the prescribed treatment contributed to the deterioration of Resident #2's condition, highlighting significant lapses in following medical directives and infection control protocols.
Elopement and Safety Equipment Deficiencies
Penalty
Summary
The facility failed to identify and respond to an elopement incident in a timely manner involving a resident with a history of wandering and cognitive impairment. The resident, who was at risk for falls and required assistance for mobility, eloped from the facility and was found 5.6 miles away by a bystander. The staff did not realize the resident was missing until over an hour after the elopement, and there was a delay in notifying management and calling 911. The facility's front door alarm system, which was supposed to prevent unauthorized exits, was bypassed when a receptionist entered the code, allowing the resident to leave. The receptionist, who was not familiar with the resident, assumed she was a family member and let her out. The facility's elopement book, which should have contained the resident's information, was not updated, contributing to the failure to prevent the elopement. Additionally, the facility failed to utilize proper equipment for resident safety during mobility and transfers for two other residents. One resident was transferred without a gait belt, contrary to their care plan, and another was transported in a wheelchair without foot pedals, posing a risk of injury. These incidents highlight lapses in adherence to safety protocols and resident care plans.
Inadequate Pressure Ulcer Management Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide adequate assessment and intervention for a resident with pressure ulcers, leading to the deterioration of the condition. The resident, identified as mildly cognitively impaired, had multiple diagnoses including anemia, coronary artery disease, peripheral vascular disease, renal insufficiency, and diabetes. The resident required extensive assistance with mobility and toileting and was identified as high risk for pressure ulcers. Despite having a care plan in place that directed staff to monitor and document the condition of the pressure ulcers, there was a lack of consistent documentation and follow-up on the resident's wounds. The facility's records revealed inconsistencies and omissions in the documentation of the resident's pressure ulcers. Initial assessments noted a Stage 3 pressure ulcer on the sacrum, but subsequent records failed to consistently document measurements, stages, or conditions of the wounds. The treatment administration records for January and February 2024 lacked documentation of completed treatments for the sacrum pressure sore. Additionally, there was no evidence of communication with the physician regarding the decline in the wound condition, which eventually led to the resident being admitted to the hospital with a Stage 4 pressure ulcer and a diagnosis of osteomyelitis. Interviews with facility staff highlighted a lack of adherence to the facility's policy on pressure injury prevention and management. Staff members acknowledged the expectation for weekly documentation and measurement of wounds, but admitted to issues such as delays in obtaining wound vac supplies and inconsistent documentation practices. The facility's policy required systematic assessment and treatment of pressure injuries, but the lack of documentation and follow-up contributed to the resident's worsening condition and subsequent hospitalization.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and ensure proper food storage temperatures, leading to deficiencies in food safety practices. During an initial tour of the main kitchen, a stand-alone freezer was found to have a temperature of 30 degrees Fahrenheit, which is above the recommended level for frozen food storage. The freezer contained various food items, some of which were noted to be soft to the touch, indicating potential thawing. Additionally, the kitchen stove top was observed to be coated with a black substance and grease, and the floor was heavily flooded with water containing food particles and debris. Dust was also visible under refrigerator units and on the ceiling above the dishwasher and food preparation areas. During a meal service, a dietary aide was observed serving glasses to residents with bare fingers touching the drinking rim surface, which poses a risk of contamination. The facility's policy requires staff to monitor food temperatures and maintain cleanliness to prevent contamination, but these standards were not met. The facility's freezer temperature log showed inconsistent temperature readings, with one entry as high as 40 degrees Fahrenheit, further indicating issues with maintaining appropriate storage conditions. The dietary manager acknowledged the expectations for cleanliness and proper handling of food and equipment, but these were not adhered to during the survey observations.
Deficiencies in Infection Control and EBP Implementation
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, leading to deficiencies in infection prevention and control. Resident #9, who had diagnoses of venous insufficiency, diabetes mellitus, and a multidrug-resistant organism (MDRO), was not provided with appropriate EBP interventions. The care plan for Resident #9 lacked documentation of the MDRO diagnosis and necessary interventions related to EBP. During wound care, a Licensed Practical Nurse (LPN) did not wear a gown, which is part of the EBP protocol, despite the presence of personal protective equipment (PPE) at the resident's room. The Infection Preventionist acknowledged the absence of necessary signage and PPE instructions for EBP. The facility also failed to handle laundry with appropriate PPE. Observations revealed that housekeeping staff transported clean laundry in an uncovered cart and handled soiled laundry with only gloves, without additional protective equipment such as gowns. This practice was contrary to the facility's policy, which required linens to be transported in covered carts and handled with standard precautions to prevent contamination. The Director of Maintenance confirmed the lack of specific guidelines for staff on handling soiled laundry. Additionally, Resident #25, who had severe cognitive impairment and required a feeding tube, did not have EBP instructions in their care plan. During medication administration via the G-Tube, an LPN did not use additional PPE beyond gloves, and there was no signage or instruction for EBP in the resident's room. The facility's policies did not adequately address the implementation of EBP, contributing to the observed deficiencies in infection control practices.
Pest Infestation Due to Inadequate Control Measures
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by multiple observations and interviews indicating the presence of raccoons and mice. A significant hole in the soffit near the entrance was observed, which staff and a pest control professional confirmed as an entry point for raccoons. Staff members, including a registered nurse and an occupational therapist, reported hearing noises in the ceiling, which they attributed to raccoons. The Director of Maintenance, who had been employed for three months, acknowledged the presence of raccoons and mice since his arrival and noted that pest control services had been engaged to address the issue. Residents with intact cognition reported seeing mice in various areas of the facility, including the dining room and hallways. Staff members also confirmed sightings of mice in different locations, such as the women's bathroom and various halls. The facility's pest control policy outlined measures to prevent and manage pest infestations, including regular inspections and the use of a pest control company. However, the ongoing presence of pests suggests that these measures were not effectively implemented or maintained.
Repeat Deficiencies in QAPI Process and Resident Care
Penalty
Summary
The facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process, resulting in multiple repeat deficiencies identified during the current recertification and complaint surveys. The deficiencies included immediate jeopardy and harm level citations related to accidents, hazards, supervision, and devices, as well as issues with food procurement, storage, preparation, service, and kitchen sanitation. Additionally, there were deficiencies in the treatment and services to prevent or heal pressure ulcers. These issues were previously identified in surveys conducted over the past twelve months, indicating a lack of effective corrective action and monitoring. The facility's current recertification survey revealed ongoing issues with accidents and hazards, as well as services to prevent or heal pressure ulcers. The facility also continued to struggle with food procurement and kitchen sanitation, despite previous citations. The facility's Quality Assurance and Performance Improvement (QAPI) policy required regular meetings and action plans to address deficiencies, but the facility was unable to provide documentation of consistent QAPI activities prior to February 2024. This lack of documentation and effective action contributed to the repeat deficiencies observed during the surveys.
Deficiency in Staff Education on Resident Rights
Penalty
Summary
The facility failed to ensure that staff members received mandatory education on resident rights and facility responsibilities, as evidenced by a review of employee education files. Out of six employees reviewed, five did not have records of completing this essential training. The staff members identified included two Licensed Practical Nurses (LPNs), two Certified Nursing Assistants (CNAs), and a Dietary Aide. This deficiency was discovered during a review conducted on June 20, 2024, which revealed the absence of documentation supporting the completion of required education in the personnel files of these staff members. The Director of Clinical Service acknowledged the expectation that all staff should complete their core competency requirements, including 12 hours of yearly education and yearly competency evaluations. The facility's policy on Orientation, revised in October 2022, mandates that a general orientation plan be created for all newly hired employees, which must be completed before any formal contact with residents. This policy also requires the use of checklists to document training and competency evaluations, with all documentation maintained in the employee's personnel file. Despite these policies, the facility did not provide the necessary documentation upon request, indicating a lapse in adherence to their own training and documentation procedures.
Failure to Ensure Accurate Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that a current copy of residents' advance directives was accurately documented in the medical records for two residents. For Resident #253, there were conflicting physician orders in the Electronic Health Records (EHR) for both full code/cardiopulmonary resuscitation (CPR) and Do Not Resuscitate (DNR) status. The EHR lacked documentation of the Iowa Physician Orders for Scope Of Treatment (IPOST), and there was no evidence that the facility offered or assisted with the completion of advanced directives. The care plan indicated that CPR would not be initiated, which was inconsistent with the active physician orders. Similarly, for Resident #15, there were conflicting orders for full code/CPR and DNR status. The IPOST, signed by the resident's Power of Attorney (POA) and physician, indicated a preference for DNR with comfort measures only, yet the care plan stated that CPR would be initiated. Staff interviews revealed that advanced directives should be found in the EHR, but the Director of Nursing (DON) acknowledged that new residents would receive full code/CPR measures until advanced directives were in place. The facility's policy required that the plan of care be consistent with the resident's documented treatment preferences, but this was not adhered to in these cases.
Deficiencies in Staff Training and Background Checks
Penalty
Summary
The facility failed to ensure that staff completed required training and background checks in accordance with Iowa state requirements. Specifically, a Certified Nursing Assistant (CNA), identified as Staff C, was hired on March 30, 2023, but did not have a Dependent Adult Abuse (DAA) training certificate in her employee file. Despite requests for documentation on June 20, 2024, the facility's Director of Clinical Services confirmed that the DAA training certificate for Staff C was not available, indicating non-compliance with the requirement to complete this training within six months of hire. Additionally, a Licensed Practical Nurse (LPN), identified as Staff J, was hired on May 23, 2024, and began working directly with residents before the completion of a Single Contact License & Background (SING) check. The SING check was completed on June 7, 2024, but Staff J had already worked several 12-hour shifts with residents starting at the end of May. The Director of Clinical Services acknowledged that the SING check should have been completed and reviewed before Staff J's start date, as per Iowa requirements. The facility lacked a policy outlining the timelines for DAA training and SING completion, contributing to these deficiencies.
Failure to Conduct Initial Physician Assessments
Penalty
Summary
The facility failed to ensure that a physician conducted the first resident assessment within 30 days of admission for three residents. Resident #47, with a BIMS score indicating moderately impaired cognition and diagnoses including stroke and metabolic encephalopathy, was admitted to the facility, but the initial visit was conducted by a Nurse Practitioner (ARNP) instead of a physician. Similarly, Resident #50, who had moderately impaired cognition and diagnoses such as fractures and renal insufficiency, was also seen by an ARNP for the initial visit. Resident #304, with severely impaired cognition and conditions like stroke and non-Alzheimer's dementia, was admitted and similarly had their initial visit conducted by an ARNP. The facility's policy, reviewed in December 2022, required that a physician see the resident within 30 days of admission. The Director of Clinical Services confirmed the expectation that each resident should be seen by a physician within this timeframe. However, the review of the clinical records and interviews revealed that the initial assessments for these residents were conducted by ARNPs, not physicians, which is a deviation from the facility's policy and regulatory requirements.
Failure to Conduct Routine CNA Competency Evaluations
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received routine competency evaluations, as evidenced by the review of employee personnel and education files. Specifically, two CNAs, Staff C and Staff K, did not have documented competency evaluations. Staff C was hired on March 30, 2023, and Staff K on April 1, 2020. Despite requests for documentation on June 20, 2024, and a follow-up on June 24, 2024, the Director of Clinical Services could not provide a performance evaluation for Staff K. The Director acknowledged that the facility was behind in completing core competency requirements, which include 12 hours of yearly education and annual competency evaluations. The facility's policy, revised in March 2023, mandates the use of checklists to document training and competency evaluations, which should be maintained in the Staff Development Coordinator's office before being forwarded to Human Resources for filing.
Deficiency in CNA In-Service Education Requirements
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required minimum of 12 hours of in-service education annually, as mandated by their policy. This deficiency was identified during a review of employee education files, which included online training transcripts and in-service sign-in sheets. Specifically, it was found that Staff C, a CNA hired on March 30, 2023, did not complete the required 12 hours of in-service education within the year. Despite requests for documentation of the required education, the facility was unable to provide evidence that Staff C had met the educational requirements. The Director of Clinical Service acknowledged the expectation for all staff to complete their core competency requirements, including the 12 hours of yearly education and competency evaluations. The facility's policy, revised on October 1, 2022, instructed that in-service training should be based on the employment date and that documentation must be maintained in the employee's personnel file.
Failure to Identify and Document Skin Tear
Penalty
Summary
The facility failed to identify, assess, and treat a skin tear on a resident in a timely manner. The resident, who had a severely impaired cognition with a BIMS score of 3 out of 15, had a history of stroke, non-Alzheimer's dementia, and hemiparesis. The care plan for the resident included goals to maintain or develop clean or intact skin, with specific interventions for monitoring and documenting skin injuries. However, a review of the weekly skin notes revealed no documentation of a skin tear on the resident's left arm, despite a physician order for weekly skin evaluations. Observations and interviews with staff indicated a lack of awareness and documentation regarding the resident's skin tear. During an observation, a large dark brown scabbed area was noted on the resident's forearm. Interviews with RNs and the DON revealed that the facility did not have any documentation of the skin tear in the EHR, and the DON was only made aware of the issue after it was observed. The facility's policy required a full body skin assessment upon admission, weekly, and after any new open areas, but this was not followed in the case of the resident's skin tear.
Failure to Educate Staff on QAPI Program
Penalty
Summary
The facility failed to ensure that staff members were educated on the mandatory Quality Assurance and Performance Improvement (QAPI) program. During a review of employee education files, it was found that five out of six employees did not have records of completed education on QAPI. These employees included two Licensed Practical Nurses (LPNs), two Certified Nursing Assistants (CNAs), and a Dietary Aide. The facility's General Orientation Plan, dated 2022, lacked QAPI training, which contributed to this deficiency. The Director of Clinical Service expected all staff to complete their core competency requirements, including 12 hours of yearly education and yearly competency evaluations. However, the facility's policy on orientation, revised in October 2022, required the creation of a general orientation plan that included applicable content for all staff and the use of checklists to document training and competency evaluations. Despite these requirements, the facility failed to maintain documentation supporting the completion of the orientation process in the employees' personnel files, leading to the deficiency.
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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