Kahl Home For The Aged & Infirmed
Inspection history, citations, penalties and survey trends for this long-term care facility in Davenport, Iowa.
- Location
- 6701 Jersey Ridge Road, Davenport, Iowa 52807
- CMS Provider Number
- 165146
- Inspections on file
- 23
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Kahl Home For The Aged & Infirmed during CMS and state inspections, most recent first.
A resident with a history of colon cancer and other conditions had a low potassium lab result, prompting a nurse practitioner to order potassium chloride supplementation and a repeat lab. The order was not entered, processed, or administered, and the repeat lab was not completed. Staff interviews confirmed the order should have been implemented within 24 hours, but it was not transcribed or followed according to facility policy.
Staff did not consistently wear required isolation gowns while providing care to a resident on Enhanced Barrier Precautions for a pressure ulcer. Although some staff followed protocol, a CNA provided care with only gloves and no gown during high-contact activities, contrary to the care plan and facility policy. Nursing staff and the DON confirmed that both gown and gloves were expected for this resident.
A resident with multiple comorbidities and a history of pressure ulcers experienced a worsening left buttock pressure injury over several weeks, as documented in weekly wound assessments. Despite clear evidence of decline, including increased wound size, slough, eschar, and foul odor, there was no documentation that the provider was notified as required by facility policy. The lack of timely intervention and provider notification led to the resident's hospitalization for wound infection and sepsis.
A CNA transferred a resident with a mechanical lift without the required assistance of a second staff member, leading to the resident's foot being dropped onto a Broda chair footrest and causing a skin tear. The resident, who needed maximal assistance for transfers, sustained a laceration to the right fifth toe. Staff interviews and facility policy confirmed that two staff were required for such transfers, but this protocol was not followed.
The facility failed to dispose of expired food items and ensure proper labeling in the kitchen and resident refrigerator, potentially leading to foodborne illness. Numerous expired items were found in the kitchen, and the resident refrigerator contained unlabeled and undated food items. Staff acknowledged the issue and the need for better oversight.
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents, leading to deficiencies in infection prevention and control. A resident with a Stage IV pressure ulcer did not have EBP during wound care, and staff did not wear isolation gowns. Another resident with a Stage III pressure ulcer also lacked EBP during wound care. A resident with an indwelling urinary catheter had tubing dragging on the floor, and EBP was not implemented during catheter care. Additionally, a resident with a feeding tube did not have EBP during gastric tube care, and staff were unaware of EBP requirements.
A resident with moderate cognitive impairment experienced delays in call light responses, with one instance taking 21 minutes for staff to respond. Staff interviews revealed that while trained to respond within 15 minutes, it sometimes took longer, especially in the skilled area. The facility lacked a system to monitor call light response times, contributing to the deficiency.
A resident, dependent on staff for transfers, fell and hit her head during a transfer using a Hoyer lift. The incident involved two CNAs, one of whom was new and inadequately trained. The sling was reportedly secured correctly, but the resident leaned backward and slipped out. The facility's policy on mechanical lift transfers was not followed, contributing to the incident.
The facility failed to document the review of the bed hold policy for three residents transferred to the hospital. A resident with a head injury, another with a possible GI bleed, and a third with a pulmonary embolism were transferred without proper documentation of the bed hold policy review. Staff interviews revealed confusion about responsibilities and timeframes for reviewing the policy.
The facility failed to ensure consistent documentation of code status for a resident, leading to conflicting directives regarding resuscitation. Both a Full Code form and an IPOST form were present in the resident's chart, signed by the provider on the same day, creating confusion about the resident's true code status. Interviews with staff revealed uncertainty about which directive to follow.
The facility failed to follow physician orders to notify the medical doctor of elevated blood sugar levels for a resident with diabetes, resulting in no documentation of such notification despite blood sugar levels exceeding 350 mg/dl on multiple occasions.
Failure to Implement Physician Order for Potassium Supplementation
Penalty
Summary
The facility failed to implement a physician order for potassium chloride 10 mEq daily following a low potassium lab result for a resident diagnosed with colon cancer, arthritis, and aphasia, who was cognitively intact and required varying levels of staff assistance for daily activities. The nurse practitioner documented a low potassium result and ordered potassium chloride supplementation and a repeat basic metabolic panel in one week. However, review of the electronic medical record and medication administration record showed no evidence that the potassium chloride order was entered, processed, or administered, nor was the repeat lab completed. Interviews with nursing staff and the nurse practitioner revealed that new orders are typically left with the floor nurse or unit manager, who are responsible for processing and transcribing them into the system and notifying the pharmacy. The nurse practitioner expected the order to be carried out within 24 hours, and the director of nursing confirmed that the order should have been processed and transcribed to the MAR within that timeframe. Facility policy requires prompt entry and follow-through of provider orders, but in this case, the order was not implemented, resulting in a failure to follow physician instructions after an abnormal lab result.
Failure to Consistently Use Isolation Gowns During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to consistently utilize required isolation gowns when providing care to a resident on Enhanced Barrier Precautions (EBP) due to a pressure ulcer and risk of multi-drug resistant organism transmission. The resident was cognitively intact, dependent on staff for toileting and transfers, and required substantial assistance with activities of daily living. The care plan and facility policy specified that staff must wear gowns and gloves during high-contact care activities, including dressing, bathing, toileting, and wound care. During observations, some staff members wore both gowns and gloves as required, but a CNA was observed providing care with only gloves and no gown during a shower and while drying the resident's back. The CNA acknowledged forgetting to don a new gown after removing the previous one. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for staff to wear both gown and gloves for this resident under EBP, in accordance with facility policy.
Failure to Notify Provider of Worsening Pressure Ulcer Resulting in Hospitalization
Penalty
Summary
A resident with a history of peripheral vascular disease, renal insufficiency, diabetes mellitus, paraplegia, and malnutrition was identified as being at risk for pressure ulcers and was dependent on staff for transfers and mobility. Upon readmission from the hospital, the resident had an unstageable pressure ulcer on the left buttock. The care plan required weekly and as-needed wound assessments, documentation of wound status, and prompt reporting of any improvements or declines to the medical provider. Despite these requirements, documentation showed that the pressure ulcer worsened over several weeks, with increasing size, slough, and eventually eschar formation, as well as the development of foul odor and drainage. Throughout the period of documented wound deterioration, there was a consistent lack of evidence that the facility notified the medical provider of the worsening condition. Weekly wound documentation repeatedly noted the wound was 'worse,' but there was no corresponding documentation of provider notification or intervention. Staff interviews confirmed that the wound nurse relied on other staff to report changes, and the DON was unaware of any direct communication with the wound clinic or higher-level expertise during the period of decline. The resident was only referred to the wound clinic after significant deterioration had occurred, and the wound continued to worsen until the resident required hospitalization for a complicated wound infection and sepsis. Facility policy required notification of the provider for new pressure injuries, lack of healing, or complications such as infection. The clinical record review revealed that these requirements were not met, as there was no documentation of provider notification during multiple episodes of wound decline and complication. The failure to intervene and inform the provider of the worsening pressure ulcer ultimately resulted in the resident's hospitalization for advanced wound care and infection management.
Failure to Use Two Staff for Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) transferred a resident using a mechanical lift without the required assistance of a second staff member, contrary to facility policy. The resident, who had intact cognition but required maximal to dependent assistance with transfers and mobility due to diagnoses including non-Alzheimer's dementia, congestive heart failure, and arthritis, was being prepared for supper. The CNA, after waiting for his partner, decided to proceed with the transfer alone, placed the sling under the resident, and attached it to the lift by himself. During the process of positioning the resident in a Broda chair, the CNA attempted to unfold the footrest while holding the resident's right foot. He accidentally dropped the resident's foot onto the footrest, resulting in a skin tear to the right fifth toe. The injury was documented as a 3 cm by 1 cm by 0.1 cm skin tear. Staff interviews confirmed that the resident required two staff for safe transfers with a mechanical lift, and that the CNA had performed the transfer alone. The incident was reported to nursing staff, who provided wound care and notified the family, physician, and supervisors. Further interviews and documentation revealed that the facility's policy explicitly required two staff members for mechanical lift transfers. Staff training records indicated that in-services on mechanical lift use and proper foot placement in wheelchairs and Broda chairs had been conducted. Despite these policies and trainings, the transfer was performed by a single staff member, directly leading to the resident's injury during the positioning process.
Expired and Unlabeled Food Items Found in Facility
Penalty
Summary
The facility failed to ensure proper disposal and labeling of food items, which could potentially lead to foodborne illness. During an inspection of the kitchen and dry storage room, numerous expired food items were found, including chocolate cake mix, apricot nectar cans, baking powder, poultry seasoning, ground mustard, cornbread mix, whole sesame seeds, nutmeg, lemon juice, ground sage, red hot seasoning, thyme, lasagna noodles, and a balsamic vinegar bottle with no expiration date. The balsamic vinegar bottle was particularly concerning as it was crushed, and the liquid inside appeared separated and lumpy. Staff A, the Certified Dietary Manager, stated that she expected the cooks to dispose of expired items, indicating a lack of oversight and adherence to the facility's policy. Additionally, an observation of the 1st floor north unit refrigerator revealed several unlabeled and undated food items, including an open cup of applesauce, an open container of apple juice, an undated sandwich, and a staff member's meal in a plastic grocery bag. Staff B, a Dietician, and Staff A confirmed that all items in the refrigerator should be labeled with the product name, the date placed in the refrigerator, and the disposal date, which should be three days from the in-date. The refrigerator was intended for resident food only, and a sign on the refrigerator door indicated these expectations. Staff A stated that dietary staff were expected to check the unit refrigerators daily for dates and expired items, but this was not being done effectively. Staff C, another Dietician, acknowledged awareness of the expired food items and the need for a better schedule to check them.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents, leading to deficiencies in infection prevention and control. Resident #12, who was cognitively intact and had multiple diagnoses including a Stage IV pressure ulcer, did not have EBP implemented during wound care. Staff members did not wear isolation gowns, and there was no indication or signage for EBP in the resident's room. Similarly, Resident #41, who was cognitively impaired and had a Stage III pressure ulcer, did not have EBP implemented during wound care, as staff did not don gowns and there was no signage indicating the need for EBP. Resident #68, who was cognitively intact and had an indwelling urinary catheter, was observed with catheter tubing dragging on the floor, which was not addressed by staff. Additionally, EBP was not implemented during catheter care, as staff did not wear isolation gowns and there was no signage indicating the need for EBP. The facility's policy on catheter care did not direct staff to keep catheter tubing off the floor, contributing to the deficiency. Resident #89, who was cognitively intact and had a feeding tube, also did not have EBP implemented during gastric tube care. Staff did not wear isolation gowns, and there was no signage or personal protective equipment available outside the resident's room. Interviews with staff revealed a lack of awareness and understanding of when EBP should be implemented, further contributing to the deficiencies observed in the facility's infection prevention and control program.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to respond to call lights within the expected 15-minute timeframe, impacting the care of a resident with moderate cognitive impairment. This resident required substantial to maximal assistance with toileting hygiene and transfers, as documented in their care plan. On multiple occasions, the resident experienced delays in call light responses, with one instance taking 21 minutes for staff to respond. During this time, staff members, including therapy staff and a CNA, passed by the resident's room without addressing the activated call light. Interviews with staff revealed that while they were trained to respond to call lights within 15 minutes, it sometimes took longer, particularly in the skilled area. The Director of Nursing acknowledged that call light response was a recurring issue and a topic of ongoing staff education. The facility lacked a system to print call light response reports and had not conducted any audits to monitor response times. The facility's policy required all staff to respond to call lights and ensure residents had access to them, but this was not consistently followed, leading to the deficiency.
Improper Use of Mechanical Lift Leads to Resident Fall
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in the resident falling and sustaining a head injury. The resident, who was cognitively intact and had diagnoses including heart failure and renal insufficiency, was totally dependent on staff for assistance with activities of daily living, including transfers. The care plan specified that two staff members should assist with transfers using a Hoyer lift. However, during a transfer to the bathroom, the resident slipped out of the sling and hit her head on the toilet, leading to bleeding and a subsequent hospital transfer. Interviews with staff involved in the incident revealed that the transfer was conducted by two CNAs, one of whom was new and had only two days of training. The CNAs reported that they had secured the sling correctly, but the resident began to lean backward during the transfer, causing her to slip out of the sling. The Director of Nursing confirmed that the sling appeared to be attached correctly but noted that the aides should have used a full body sling instead of a toilet sling, which does not cover the resident below the thighs. The incident report and staff interviews highlighted a lack of proper training and supervision, as the new CNA had not completed a comprehensive orientation or checklist before working independently. Additionally, the facility's policy on mechanical lift transfers was not followed, as the resident was transferred from a wheelchair to the toilet using the lift, contrary to the policy that requires transfers to be made from surface to surface without wheeling the resident in the lift.
Failure to Document Bed Hold Policy Review
Penalty
Summary
The facility failed to document the review of the bed hold policy prior to residents being transferred to the hospital for three of four residents reviewed. Resident #1, who was cognitively intact and dependent on staff for various activities, was transferred to the hospital after an incident where she fell and sustained a head injury. Despite attempts to contact her family, the bed hold policy was not reviewed or documented at the time of her transfer. Her family was only informed of the policy several days after the transfer. Resident #4, who was cognitively impaired and required substantial assistance, was transferred to the emergency room due to a possible gastrointestinal bleed. The progress notes did not show any documentation that the resident's family was informed of the bed hold policy at the time of transfer. Similarly, Resident #5, who was cognitively intact and dependent on staff for assistance, was transferred to the hospital with a diagnosis of pulmonary embolism and cellulitis. There was no documentation indicating that the resident's family was informed of the bed hold policy. Interviews with staff revealed confusion about who was responsible for reviewing the bed hold policy and the timeframe for doing so. The facility's policy stated that the nurse should provide the bed hold policy notice at the time of transfer, but this was not consistently followed. The Director of Nursing and the Administrator both indicated that the social worker was responsible for this task, but there was a lack of clarity and documentation regarding the process.
Inconsistent Documentation of Code Status
Penalty
Summary
The facility failed to ensure consistent documentation of code status for a resident, leading to conflicting directives regarding resuscitation. The resident, who had intact cognition and multiple medical conditions including heart failure and diabetes, had both a Full Code form and an Iowa Physician Orders for Scope of Treatment (IPOST) form in their chart. The Full Code form indicated that resuscitation should be attempted, while the IPOST form indicated a Do Not Resuscitate (DNR) order. Both forms were signed by the provider on the same day, creating confusion about the resident's true code status. Interviews with staff revealed uncertainty about which directive to follow, with one Licensed Practical Nurse (LPN) stating they would need to check with their manager and another Registered Nurse (RN) acknowledging the conflicting information. The facility's policy on Cardiopulmonary Resuscitation (CPR) requires staff to initiate CPR unless a valid DNR order is in place, but the presence of conflicting forms made it unclear which directive was valid. The electronic Clinical Resident Profile also documented the resident's code status as Full Code, further adding to the inconsistency.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to follow physician orders to notify the medical doctor of elevated blood sugar levels for a resident with diabetes mellitus, heart disease, renal disease, anxiety, and depression. The resident's Care Plan, initiated on 10/20/23, stated that the resident should not have any complications related to diabetes, and staff were instructed to give medication as ordered by the doctor and to monitor and document for side effects and effectiveness. However, a review of the March 2024 Medication Administration Record (MAR) revealed that on 3/5/24 and 3/14/24, the resident had blood sugar results of 394 mg/dl and 384 mg/dl, respectively. Despite a physician order started on 3/6/24 that directed staff to notify the medical doctor if blood sugar levels exceeded 350 mg/dl, there was no documentation of such notification in the resident's record for these dates and times. In an interview with the Director of Nursing (DON) on 3/28/24, it was revealed that no evidence could be located regarding physician notification of blood sugars over 350 mg/dl for the dates and times reviewed on the March MAR. The DON acknowledged that the expectation is to follow physician orders. The facility's policy titled 'Physician Orders,' implemented on 3/20/24, directed staff to ensure physician orders are followed, including making appropriate contact or notification. However, this policy was not adhered to in the case of the resident's elevated blood sugar levels.
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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