Kingsley Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingsley, Iowa.
- Location
- 305 West Third, Kingsley, Iowa 51028
- CMS Provider Number
- 165329
- Inspections on file
- 20
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Kingsley Specialty Care during CMS and state inspections, most recent first.
The facility failed to update care plans for three residents to include fall prevention interventions, despite multiple falls and injuries. Residents with cognitive impairments and high fall risk experienced repeated falls without timely updates to their care plans, contrary to facility policy. The administrator expected immediate intervention after falls, which was not implemented.
A resident with dementia and high fall risk experienced multiple falls resulting in injuries due to the facility's failure to update the care plan with appropriate interventions. Despite the facility's protocol requiring review and revision of care plans after falls, staff interviews revealed a lack of communication and coordination, leading to repeated incidents.
The facility failed to implement a Legionella water management program, as interviews revealed a lack of testing, monitoring, and documentation. The Administrator, responsible for the program, could not provide specifics on preventive measures and admitted to not having educated staff or implemented the program. Despite having a policy, the facility did not flush water lines, and key staff were unaware of their roles in the program.
The facility did not meet staffing requirements as it failed to submit staffing data for Fiscal Quarter 3, 2024, had low weekend staffing, and lacked 24-hour licensed nursing coverage for several days. Staffing for nurses and CNAs was scheduled similarly for weekdays and weekends, contributing to the deficiency. The Administrator was aware of the CMS data submission requirement but did not comply.
The facility failed to obtain proper signatures for bed hold notices when residents were transferred out, affecting four residents with various medical conditions. Verbal confirmations were used without securing necessary signatures, and a resident signed a form retroactively. Staff interviews revealed reliance on phone authorizations without proper documentation, which the administrator deemed unacceptable.
The facility was found to have deficiencies in food storage and preparation, with expired items in the dry storage area and unlabeled open items in the kitchen fridge. The facility's policy requires all foods to be labeled and dated, which was not adhered to, as confirmed by the Dietary Manager.
The facility failed to maintain a clean and orderly environment, with boxes stacked around the nurses' station and wheelchairs blocking an emergency exit. Observations over several days showed persistent clutter, and staff interviews revealed no designated person to manage freight, contrary to the facility's policy for a homelike environment.
A facility failed to notify a resident's power of attorney about the resident's hospitalization. The resident, with moderate cognitive impairment, was hospitalized without the son's knowledge, who is rarely informed about her care. The facility lacked documentation of notifying the son for bed hold authorization and did not provide a policy on family notification.
The facility failed to include high-risk medication usage and side effects in the care plans for two residents. One resident, with no cognitive impairment, was prescribed Latuda and Nucynta, but their care plan lacked details on these medications. Another resident, with moderate cognitive impairment, was prescribed Morphine Sulfate and Hydrocodone-Acetaminophen, but their care plan also lacked necessary information. The facility's policy did not provide guidance on including medication usage and side effects in care plans.
A resident with cancer, renal insufficiency, and Parkinson's Disease did not receive ordered physical therapy for shoulder pain. Although the written Physician Orders documented the therapy order, it was not entered into the electronic system, and the resident was not added to the physical therapy case load. Interviews with staff confirmed the oversight, and the facility did not provide a policy on handling physician orders.
A facility failed to provide a restorative program for a resident with mobility concerns, despite recommendations in the Physical Therapy Discharge Summary. The resident, with no cognitive impairment, reported not receiving restorative therapy due to staff unavailability, affecting her leg mobility. Interviews revealed a lack of documentation and implementation of restorative services, contrary to facility policy.
A facility failed to provide appropriate dialysis care for a resident with renal insufficiency, Diabetes Mellitus, and coronary artery disease. The nursing staff did not complete required dialysis evaluations on multiple occasions, despite physician orders specifying the need for evaluations before and after dialysis on certain days. The facility's policy required staff training on assessment data collection, but evaluations were missed on several dates. The Administrator expected nurses to complete these assessments as ordered.
A resident with a urinary catheter experienced a dignity violation when a nurse failed to address a leaking catheter, prioritizing her shift end over the resident's care. The resident, with no cognitive impairment and diagnosed with renal insufficiency, diabetes, and peripheral vascular disease, spent the night soaked in urine, leading to embarrassment and distress. The facility's dignity policy was not followed, and the administrator expected staff to respond promptly to residents' concerns.
The facility failed to provide scheduled bathing assistance to three residents, leading to extended periods without baths. A resident with hypertension and diabetes reported sporadic shower schedules due to staff shortages, while another with severe cognitive impairment was observed with unkempt hair. Documentation showed significant gaps in bathing schedules, contrary to the facility's policy to promote cleanliness and comfort.
A resident with multiple diagnoses, including renal insufficiency and DM, returned from the hospital requiring skilled care. The facility failed to perform daily skilled assessments on several occasions, contrary to its policy. The administrator confirmed the expectation for daily assessments.
Failure to Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to revise and update care plans to include appropriate interventions for residents to prevent repeated falls and injuries. This deficiency was identified for three residents who experienced multiple falls without corresponding updates to their care plans. The facility's policy requires care plans to be reviewed and revised by a team of health professionals, but this was not adhered to, resulting in a lack of fall interventions for the affected residents. Resident #2, with diagnoses including a neurological disorder and stroke, fell four times between November and December 2024. Despite these incidents, the care plan for Resident #2 did not include any focus area or interventions for falls during this period. Similarly, Resident #3, who has coronary artery disease, diabetes, and arthritis, fell six times from October to November 2024. The care plan for Resident #3 lacked fall interventions for several of these incidents, indicating a failure to address the resident's fall risk adequately. Resident #1, diagnosed with dementia and other conditions, was identified as high risk for falls. Despite multiple falls resulting in injuries, the care plan interventions were not timely or adequately updated. The facility's failure to implement appropriate fall interventions after each incident, as required by their policy, contributed to the repeated falls and injuries experienced by these residents. The administrator acknowledged the expectation for immediate intervention following a fall, which was not met in these cases.
Failure to Update Care Plan Leads to Repeated Falls
Penalty
Summary
The facility failed to provide adequate fall interventions and communicate these interventions via the care plan to prevent falls that resulted in injury for a resident. The resident, who had a history of dementia, blindness, cerebral infarction, and heart failure, was assessed to be at high risk for falls. Despite this, the care plan did not include appropriate interventions to mitigate this risk, leading to multiple incidents where the resident fell and sustained injuries. The resident experienced several falls, including one where they were found sitting on the floor with bruises and another where they attempted to stand without assistance, resulting in a fall and a forehead laceration. These incidents highlighted the facility's failure to update the care plan with necessary interventions after each fall. Staff interviews revealed a lack of communication and coordination among the nursing staff, with some staff members unsure of their responsibilities in updating the care plan. The facility's protocol required that all falls be reviewed during daily quality assurance meetings and that care plans be revised with additional interventions. However, this process was not followed, as evidenced by the repeated falls and injuries sustained by the resident. The lack of timely updates to the care plan and inadequate communication among staff contributed to the ongoing risk of falls and injuries for the resident.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement a Legionella water management program, as evidenced by interviews and a lack of documentation. The Maintenance Director indicated that the Administrator was responsible for the program, but no testing or monitoring had been conducted. The Infection Preventionist was unaware of who was in charge of the program. The Administrator admitted to not having specifics on testing and acknowledged that the facility planned to educate staff on the program but had not yet done so. Despite having a 20-page plan, the Administrator could not explain the current measures in place to prevent Legionella growth. Further interviews revealed that the facility had not been flushing water lines, a key preventive measure, and lacked documentation to confirm such actions. The Administrator initially claimed certainty about flushing the lines but later admitted uncertainty after being informed of the Maintenance Director and Infection Preventionist's statements. The facility's policy, revised in July 2017, outlined a water management team that included the Infection Preventionist, Administrator, Medical Director, Director of Maintenance, and Director of Environmental Services. However, the Administrator conceded that a Legionella program had not been implemented.
Failure to Meet Staffing Requirements and Data Submission
Penalty
Summary
The facility failed to meet staffing requirements as per the CMS Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Quarter 3, 2024. The report indicated that no staffing data was submitted for the quarter, there was excessively low weekend staffing, and the facility did not maintain licensed nursing coverage 24 hours a day for four or more days within the quarter. Additionally, the staffing for nurses and Certified Nursing Assistants (CNAs) was scheduled similarly for both weekdays and weekends, which contributed to the deficiency. The facility reported a census of 33 residents during this period. The Administrator acknowledged awareness of the requirement to submit staffing data to CMS but failed to do so for the specified quarter.
Failure to Obtain Proper Bed Hold Signatures
Penalty
Summary
The facility failed to ensure that bed hold notices were properly signed by residents or their representatives when residents were transferred out of the facility. This deficiency was identified for four residents, each with varying degrees of cognitive impairment and medical conditions such as cancer, hypertension, diabetes mellitus, respiratory failure, renal insufficiency, and heart failure. The facility's policy required that written information regarding bed hold rights and limitations be provided to residents and their representatives prior to a transfer. However, in several instances, verbal confirmations were obtained without securing the necessary signatures, and in one case, a resident signed a bed hold form retroactively at the staff's request. Interviews with staff revealed that the facility's practice involved contacting representatives by phone for bed hold authorizations, but the required documentation was not consistently completed. A registered nurse admitted to adding handwritten information and signing bed hold forms, assuming that floor nurses had contacted the representatives. The facility's administrator acknowledged that the bed hold forms should have been addressed before residents were transferred and that it was unacceptable for staff to sign forms or obtain signatures retroactively.
Sanitation Deficiency in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure food was stored and prepared under sanitary conditions, as observed during an initial kitchen tour. In the dry storage area, several items were found with expired dates, including a bottle of kiwi-lime sauce, a bottle of mango sauce, and multiple packages of tortilla shells. Additionally, the kitchen fridge contained open gallons of white and chocolate milk, thickened water, thickened apple juice, and a gallon of orange juice, all without open dates. A container of food thickener was also found open with no open date and a scoop inside. The facility's policy on food receiving and storage mandates that all foods stored in the refrigerator or freezer be covered, labeled, and dated, and that beverages be dated when opened and discarded after twenty-four hours. An interview with the Dietary Manager confirmed that the kitchen should not have expired food stored and all items should be labeled with an open date.
Facility Fails to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a clean, orderly, and homelike environment as evidenced by the presence of boxes stacked around the nurses' station and wheelchairs blocking an emergency exit door. Observations on multiple occasions revealed 16 to 26 boxes stacked along the wall by the nurses' station, with no designated staff assigned to put the freight away. This situation persisted over several days, indicating a lack of timely action to address the clutter. Additionally, two wheelchairs were observed parked at the end of the 300 hallway, blocking an exit door, which could impede emergency egress. Interviews with staff, including a Registered Nurse, revealed that there is no specific person responsible for putting away the freight, leading to the accumulation of boxes around the nurses' station. The facility's policy on maintaining a homelike environment emphasizes a clean, sanitary, and orderly setting, which was not upheld in this instance.
Failure to Notify Resident's Representative of Hospitalization
Penalty
Summary
The facility failed to notify the resident's representative of a hospitalization event for one of the residents, identified as Resident #7. The resident had a documented history of cancer, hypertension, anxiety, and depression, with a BIMS score indicating moderate cognitive impairment. The clinical record review showed that the resident was on hospital unpaid leave and later marked as active, but there was no documentation of the resident's son being contacted for bed hold authorization. Despite a bed hold being dated, the progress notes lacked evidence of communication with the son, who is the power of attorney for healthcare. During an interview, the resident's son expressed that he was not informed about the bed hold or the hospitalization, despite being the power of attorney. He mentioned that he was rarely contacted about his mother's care and was unaware of her hospitalization until he visited the facility and found her absent. The Director of Nursing informed him that his mother was at the hospital receiving blood. Staff B mentioned that the resident had expressed a desire not to have her family notified of changes, but was unsure if the resident could adequately advocate for herself. The facility did not provide a policy on family notification.
Failure to Include High-Risk Medication Usage and Side Effects in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans addressing the usage of high-risk medications and their side effects for two residents. Resident #4, who has diagnoses including hypertension, depression, bipolar disorder, and diabetes mellitus, was prescribed Latuda, an antipsychotic medication, and Nucynta, an opioid medication. Despite these prescriptions, Resident #4's care plan did not include information on the usage of these medications or the side effects to monitor. The Minimum Data Set (MDS) assessment indicated that Resident #4 had no cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 15. Similarly, Resident #33, with diagnoses of renal insufficiency, dementia, and a history of hip fracture, was prescribed Morphine Sulfate and Hydrocodone-Acetaminophen. However, the care plan for Resident #33 also lacked details on the usage of these medications and the side effects to watch for. The facility's Care Plan Process Policy, dated January 2015, did not include instructions for care plan expectations related to medication usage and side effects. Interviews with staff confirmed that the care plans should have included this information, but it was not present.
Failure to Initiate Ordered Physical Therapy
Penalty
Summary
The facility failed to provide professional standards of care by not initiating physical therapy as ordered for a resident. The resident, who had diagnoses of cancer, renal insufficiency, and Parkinson's Disease, reported that a physician had ordered physical therapy for shoulder pain, but the therapy was not initiated. A review of the electronic Physician Orders showed no order for physical therapy, while the written Physician Orders documented the order dated 7/18/24. Further chart review revealed no documentation related to physical therapy. Interviews with the Nurse Consultant and Administrator confirmed that the resident was not picked up on the physical therapy case load and that orders were expected to be entered into the electronic chart and initiated. The facility did not provide a policy regarding physician orders.
Failure to Provide Restorative Program for Resident with Mobility Concerns
Penalty
Summary
The facility failed to provide a restorative program for a resident with mobility concerns, as identified during a survey. The resident, who had diagnoses including hypertension, depression, bipolar disorder, and diabetes mellitus, was assessed with a BIMS score of 15, indicating no cognitive impairment. The resident reported not receiving restorative therapy anymore due to the absence of a staff member to conduct it, which was the only exercise her legs received. She noticed a difference in her legs since the cessation of the therapy. The Physical Therapy Discharge Summary recommended a restorative range of motion program and the use of a lower extremities omnicycle, but the resident's care plan lacked a restorative therapy program. Interviews with facility staff revealed inconsistencies in the documentation and implementation of restorative services. The MDS Coordinator mentioned that the resident had been refusing restorative services, leading to their discontinuation, but was unable to provide documentation of these refusals or any record of the resident receiving restorative therapy since the order date. The facility's policy stated that residents should receive restorative nursing care as needed to promote safety and independence, but the Director of Nursing acknowledged that the order for restorative therapy should have been completed for the resident.
Failure to Complete Required Dialysis Evaluations
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as Resident #37, who required such services. The clinical record review revealed that the nursing staff did not complete all required dialysis evaluations for the resident. The Minimum Data Set (MDS) assessment indicated that Resident #37 had diagnoses of renal insufficiency, Diabetes Mellitus, and coronary artery disease, with no cognitive impairment as per a BIMs score of 14. The physician's order required dialysis evaluations to be completed before and after dialysis on specific days and once on other days. However, the facility did not complete these evaluations on multiple dates, including 8/2/24, 8/4/24, 8/5/24, and several others through 9/11/24. The facility's policy on the care of residents with end-stage renal disease, revised in September 2010, required staff education and training on the type of assessment data to be gathered about the resident's condition. During an interview, the Administrator stated that she expected nurses to complete dialysis assessments as ordered.
Failure to Address Resident's Dignity and Care Needs
Penalty
Summary
The facility failed to respect the dignity of a resident, identified as Resident #32, who had a urinary catheter. The resident, who had no cognitive impairment and was diagnosed with renal insufficiency, diabetes mellitus, and peripheral vascular disease, reported an incident where a nurse neglected to address a leaking catheter. The resident informed the nurse about the leak, but the nurse prioritized leaving at the end of her shift over addressing the issue. As a result, the resident spent the entire night soaked in urine, leading to feelings of embarrassment and distress. The incident was documented in a progress note, which confirmed that the resident, his bed, and dressings were wet with urine the following morning. The resident stated that the catheter had been leaking since the previous night and that the nurse on duty was aware but did not take action. A grievance was filed by the resident, and the facility's dignity policy emphasized the importance of caring for residents in a manner that promotes their well-being and self-esteem. The facility's administrator expected staff to respond promptly to residents' requests and concerns, which was not adhered to in this case.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to three residents, as evidenced by clinical record reviews, resident interviews, and staff interviews. Resident #4, who has diagnoses including hypertension and diabetes mellitus, reported sporadic shower schedules due to staff shortages. Documentation revealed that Resident #4 went without a bath for five days in August and eight days in September, despite being scheduled for baths twice weekly. The care plan for Resident #4 lacked specified bathing frequency. Resident #35, with severe cognitive impairment and diagnoses including cancer and heart failure, was observed with unkempt and oily hair, indicating a lack of regular bathing. Documentation showed that Resident #35 went without a bath for extended periods, including 14 days in July and 11 days in August. Similarly, Resident #23, who has no cognitive impairment and requires partial assistance for bathing, did not receive a bath for over a week in late August and early September. The facility's policy, which aims to promote cleanliness and comfort, was not adhered to, as evidenced by the lack of documentation and failure to bathe residents as scheduled.
Failure to Complete Skilled Assessments for a Resident
Penalty
Summary
The facility failed to complete necessary skilled assessments for a resident, leading to a deficiency. Clinical record review and staff interviews revealed that the nursing staff did not perform all required skilled assessments for one resident out of twelve reviewed. This resident, who had a diagnosis of renal insufficiency, Diabetes Mellitus, and coronary artery disease, returned from the hospital on a skilled level of care after a prolonged stay for sepsis, hypoxia, rhabdomyolysis, DM, COPD, and myocardial infarction. Despite the facility's policy requiring daily skilled assessments, the resident's evaluations were not completed on several specified dates. The facility's administrator confirmed the expectation for daily skilled assessments by nurses.
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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