Lakeside Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Emmetsburg, Iowa.
- Location
- 301 North Lawler Street, Emmetsburg, Iowa 50536
- CMS Provider Number
- 165492
- Inspections on file
- 21
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Lakeside Lutheran Home during CMS and state inspections, most recent first.
A resident with anxiety and depression, who was cognitively intact, reported that a bath-aide was rough during care, including pinching her breast with a gait belt and jamming a toothbrush in her mouth. After the allegation, the aide was only reassigned to a different area and continued working with other residents before being suspended, contrary to facility policy requiring immediate separation of the accused from all residents.
Two residents with no cognitive impairment were not allowed to make choices about their bathing routines, clothing, and bedtime. Staff rushed one resident during bathing, refused to use the whirlpool jets, and did not allow her to wear jewelry, while another resident was made to go to bed early and wear a hospital gown against his wishes, and his input on CPAP use was ignored. These actions did not support resident self-determination as required by facility policy.
A resident with no cognitive impairment reported rough treatment by a CNA during a shower, including being pinched with a gait belt and having a toothbrush jammed into her mouth, resulting in pain and weakness. Although the DON was notified promptly, the physician and the resident's representative were not informed until two days later, failing to meet immediate notification requirements.
A resident with no cognitive impairment reported that a CNA was rough during a bath, including pinching her breast with a gait belt and jamming a toothbrush in her mouth. Although the incident was documented and communicated to staff, the facility did not notify the state agency of the allegation within the required timeframe, as confirmed by the administrator.
A resident with cancer and mobility limitations, who required assistance and had fragile skin, sustained multiple skin tears on the right forearm when a CNA grabbed the wrist instead of using a gait belt during a transfer, contrary to the care plan and facility protocol.
A resident with severe cognitive impairment and high fall risk experienced a fall due to inappropriate footwear. The facility failed to conduct adequate follow-up and pain assessments, leading to a delayed diagnosis of a right femoral neck fracture. Despite signs of pain and mobility issues, the facility did not notify the physician of the fall history, and an x-ray was only ordered after a physical therapy evaluation.
The facility failed to submit accurate staffing data to CMS, as the PBJ report showed a lack of 24-hour nursing coverage on several dates. However, time card records and agency invoices indicated that 24-hour coverage was maintained, but this was not reflected in the PBJ report.
The facility failed to conduct proper background checks for a CNA and the DON, both of whom had a criminal history of operating while intoxicated. There was no documentation of a record check evaluation or approval to work from the Iowa Department of Human Services, yet both were actively working. The facility's abuse prevention policy lacked guidance on employee screening and background checks.
The facility failed to re-evaluate long-term antibiotic use for two residents, leading to potential overuse. One resident was on Cephalexin 500 mg daily for chronic UTIs without a physician's re-evaluation, and another resident missed a urology appointment necessary for monitoring their condition. The lack of oversight in antibiotic use and follow-up appointments indicates a deficiency in the facility's antibiotic stewardship program.
A resident with moderately impaired cognition and multiple diagnoses was improperly administered Fosamax along with other medications after breakfast, contrary to the manufacturer's instructions. The facility's MAR lacked specific directions for Fosamax, leading to its incorrect administration. The DON confirmed the medication should have been given on an empty stomach, with the resident remaining upright for 30 minutes afterward.
A resident with severely impaired cognition was verbally threatened by an RN during a blood sugar check. The RN raised her hand as if to strike the resident and made a threatening statement. Multiple staff members witnessed or were informed of the incident, but it was not immediately reported. The facility suspended the RN pending investigation, revealing a failure in abuse prevention and reporting procedures.
A facility failed to timely report an alleged abuse incident involving a resident and an RN. The incident, witnessed by a CNA, involved the RN raising her hand and verbally threatening the resident during a blood sugar check. Despite the CNA reporting the incident to the DON, the facility only initiated an investigation after being informed by DIAL. The facility's internal investigation lacked police notification, as required by policy.
A facility failed to respond appropriately to an alleged abuse incident involving a resident and an RN. The RN threatened a resident after an altercation, but the incident was not reported or investigated until external authorities intervened. The RN continued working without suspension, contrary to facility policy.
Failure to Immediately Separate Alleged Abuser from All Residents
Penalty
Summary
The facility failed to immediately separate an alleged abuser from all potential victims following an allegation of abuse. A resident with no cognitive impairment, who had diagnoses of anxiety and depression, reported that a bath-aide was rough and rushed her during a shower, including pinching her breast with a gait belt and jamming a toothbrush in her mouth. The incident was reported to a charge nurse and the DON, but the staff member accused of abuse was only reassigned to a different area and continued to work with other residents before being suspended. The facility's abuse prevention policy requires immediate separation of the accused employee from all residents upon receiving an allegation, but this was not followed, resulting in a failure to protect all potential victims during the investigation.
Failure to Support Resident Choice in Daily Routines and Preferences
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not supporting resident choices regarding schedules, clothing, and bathing preferences for two residents. One resident, who had no cognitive impairment and required assistance with bathing, reported that a CNA was rough, rushed her during showers, and refused to use the whirlpool jets or allow her to wear her jewelry, stating she did not have time to accommodate these preferences. Documentation and staff statements confirmed that the CNA prioritized speed over resident choice due to pressure to complete baths quickly, resulting in the resident's preferences being disregarded. Another resident, also cognitively intact and dependent on staff for dressing and transfers, was made to go to bed at a set time and wear a hospital gown against his wishes. Staff did not listen to his requests regarding bedtime, clothing, or the correct use of his CPAP machine. Documentation included a disciplinary report and staff statements confirming that the resident's choices were not respected, and his attempts to communicate his preferences were ignored. The facility's own resident rights policy included the right to self-determination and making choices about significant aspects of life, which was not upheld in these instances.
Delayed Notification of Physician and Representative After Resident Allegation
Penalty
Summary
The facility failed to immediately notify the physician and the resident's representative after a resident reported an allegation of rough treatment by a CNA during a shower. The resident, who had no cognitive impairment and required substantial to maximal assistance with bathing, reported that her breast was pinched with a gait belt and a toothbrush was jammed into her mouth. She also complained of pain in her breast radiating to her back, weakness, and inability to walk. The incident was documented in the progress notes, and the DON was notified on the same day. Despite the immediate internal notification, the physician and the resident's representative were not informed of the allegation until two days later. Documentation shows that the physician was notified via fax and the family was contacted on the same day, both occurring after the initial report by the resident. The delay in external notification constitutes the deficiency, as the required parties were not informed immediately as per regulatory requirements.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) within the required timeframe after an allegation of potential abuse was made by a resident. The resident, who had no cognitive impairment and required substantial to maximal assistance with bathing, reported that a bath aide was rough during a shower, pinched her breast with a gait belt, and jammed a toothbrush in her mouth. The incident was documented in the resident's progress notes, and staff interviews confirmed that the resident communicated these concerns to another staff member. Despite the facility's policy requiring that all allegations of neglect, mistreatment, or abuse be reported to the state agency within two hours if serious bodily injury occurred, or within twenty-four hours otherwise, the administrator confirmed that the incident was not reported to DIAL in a timely manner. The delay in reporting was acknowledged during the investigation, and the facility's own policy was not followed in this instance.
Failure to Use Proper Transfer Technique Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use appropriate transfer techniques for a resident who required partial to moderate assistance with mobility due to weakness and cancer. The resident, who had no cognitive impairment and was care planned to have two staff assist with mobility and to avoid grabbing his arms due to fragile skin, sustained multiple skin tears on his right forearm after the CNA grabbed his wrist instead of using a gait belt during a transfer. The skin tears measured 4 cm by 1 cm, 2.5 cm by 1 cm, and 2 cm by 1 cm, with blood noted from each area. Documentation confirmed the incident and the CNA's violation of facility protocol.
Inadequate Follow-Up and Pain Assessment After Resident Fall
Penalty
Summary
The facility failed to provide adequate follow-up and pain assessments for a resident after a fall. The resident, who had severe cognitive impairment and was at a high risk for falls, experienced a fall while walking with staff. The incident report noted that the resident was wearing inappropriate footwear, which was not marked as a predisposing factor. Despite the resident's refusal to allow neurological assessments, the facility did not complete follow-up assessments or document the resident's condition adequately in the days following the fall. The resident began to exhibit signs of pain and difficulty with mobility, which were not immediately addressed by the facility. Progress notes indicated that the resident complained of right leg pain and showed signs of discomfort, such as facial grimacing and a limp. Despite these observations, the facility did not notify the physician of the resident's fall history when communicating about the resident's condition. It was only after a physical therapy evaluation that an x-ray was ordered, revealing a right femoral neck fracture. Interviews with staff revealed a lack of consistent documentation and follow-up after the fall. The Director of Nursing and MDS Coordinator acknowledged that the facility did not conduct an internal investigation into the resident's hip fracture and failed to adhere to the facility's fall policy, which required thorough documentation and communication with the physician. The facility's policy outlined specific steps for immediate response and follow-up after a fall, which were not followed in this case.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for fiscal year quarter 4 of 2024. The Payroll Based Journal (PBJ) Staffing Data Report indicated that the facility did not have licensed nursing coverage 24 hours a day on multiple dates in July, August, and September 2024. However, the facility provided time card records and agency staffing invoices that documented 24-hour nursing coverage on those dates. Despite this documentation, the information was not accurately reported in the PBJ report, leading to a deficiency finding.
Failure to Conduct Proper Employee Background Checks
Penalty
Summary
The facility failed to conduct appropriate screening prior to employment for two out of five employees reviewed for background checks. Specifically, the personnel files for a Certified Nursing Assistant (CNA) and the Director of Nursing (DON) showed that both had a criminal history of operating while intoxicated, 1st offense. Despite this, there was no documentation in their files indicating that a record check evaluation was conducted or that approval to work was obtained from the Iowa Department of Human Services. Both employees were actively working at the facility at the time of the survey. The facility's administrator acknowledged the absence of documentation approving the employees to work and admitted that the facility's abuse policy did not address the screening of new employees or the completion of background checks. The Business Office Manager confirmed that no further action was taken after receiving the criminal background check history. The facility's existing abuse prevention policy, revised in April 2017, did not include guidance on screening new employees or conducting background checks, which contributed to the deficiency.
Failure to Re-evaluate Long-term Antibiotic Use
Penalty
Summary
The facility failed to ensure that residents on antibiotics were re-evaluated for excessive duration, specifically for two residents. Resident #7, who had a history of chronic urinary tract infections, was on a routine antibiotic therapy with Cephalexin 500 mg daily since April 2022. The resident's clinical record lacked documentation of a physician's re-evaluation for the continued use of the antibiotic. The Pharmacy Consultant noted that the prophylactic dose is usually lower, and the Infection Preventionist confirmed that the antibiotic had not been reviewed in the past year. Resident #7 was unaware of the medications she was taking, indicating a lack of communication and oversight in her care plan. Resident #6, with diagnoses including anxiety, schizophrenia, seizure disorder, and heart failure, was also on prophylactic antibiotic therapy due to a history of frequent urinary tract infections. The resident was supposed to have a urology appointment, which did not occur, and the Director of Nursing was unsure of the reason. This lack of follow-up and re-evaluation of antibiotic use highlights a deficiency in the facility's antibiotic stewardship program, potentially leading to unnecessary or inappropriate antibiotic use.
Improper Administration of Fosamax
Penalty
Summary
The facility failed to administer medications according to the manufacturer's instructions for one resident during a medication pass. The resident, who had moderately impaired cognition and diagnoses including cerebral palsy, non-Alzheimer's dementia, seizures, and moderate intellectual disabilities, was observed receiving Fosamax along with other medications after breakfast. The manufacturer's instructions for Fosamax require it to be taken with plain water at least 30 minutes before any food, drink, or other medications, and the resident should remain upright for at least 30 minutes after taking it. The Certified Medication Aide (CMA) administered the Fosamax along with several other medications, including Levothyroxine, Calcium Carbonate, and Ferrous Sulfate, which could interfere with Fosamax's absorption. The facility's Medication Administration Record (MAR) lacked specific instructions on how Fosamax should be administered, leading to its improper administration. The Director of Nursing (DON) confirmed that the medication should have been given on an empty stomach and with the resident sitting upright for 30 minutes afterward. The facility's policy on medication disbursement emphasized the importance of following special instructions, which was not adhered to in this case.
Failure to Protect Resident from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a staff member. Resident #24, who has severely impaired cognition and is dependent on staff for various activities, was involved in an incident where a staff member, Staff B, RN, verbally threatened the resident. The resident, who has a history of physical and verbal behavioral symptoms, attempted to bite Staff B during a routine blood sugar check. In response, Staff B raised her hand as if to strike the resident and verbally threatened to knock the resident's teeth out. Multiple staff members witnessed or were informed of the incident. Staff A, CNA, was present in the room and intervened by calming the resident, allowing Staff B to complete the blood sugar check. Staff A later reported that Staff B recounted the incident at the nurses' station, repeating the threatening statement. Staff C, CMA, also provided a statement about a similar previous incident involving Staff B, indicating a pattern of inappropriate behavior and frustration management issues. The facility's policy on abuse prevention and reporting was not adequately followed, as the incident was not immediately reported by all staff who were aware of it. The Director of Nursing and the Administrator were informed of the allegations only after a state official reported the incident. The facility suspended Staff B pending investigation, but the delay in reporting and addressing the incident highlights a failure in the facility's procedures to protect residents from abuse.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged verbal and physical abuse incident involving a resident in a timely manner. The incident occurred when a CNA witnessed an RN raise her hand and verbally threaten a resident during a blood sugar check. The CNA reported the incident to the DON later that day, but the DON denied receiving any such report. The facility only initiated an investigation after the Department of Inspection, Appeals and Licensing (DIAL) entered the facility and informed the DON of the allegations. The investigation revealed that the incident took place in the resident's room, where the RN allegedly threatened to knock the resident's teeth out if he attempted to bite her. Multiple staff members were aware of the incident, but there was a delay in reporting it to the appropriate authorities. The facility eventually reported the incident to DIAL ten days after it occurred, and the RN was suspended pending investigation. The facility's internal investigation lacked documentation of police notification, which was required by their policy in cases of suspected abuse. The facility's policy mandates immediate reporting of abuse allegations to the state and law enforcement, but this was not followed. The DON and Administrator both stated they were unaware of the incident until DIAL's intervention, highlighting a breakdown in communication and adherence to reporting protocols.
Failure to Respond to Alleged Abuse Incident
Penalty
Summary
The facility failed to appropriately respond to an alleged incident of abuse involving a resident and a staff member. On the morning of January 6, 2025, a CNA witnessed a Registered Nurse (RN) threaten a resident with physical harm after the resident attempted to bite the RN. The CNA reported the incident to the Director of Nursing (DON) later that afternoon, but the DON denied being informed of the allegation. Despite the serious nature of the accusation, the RN continued to work full shifts on multiple days following the incident, indicating a failure to separate the accused staff member from residents pending an investigation. The facility's investigation into the alleged abuse was only initiated on January 16, 2025, after the Department of Inspections, Appeals and Licensing (DIAL) entered the facility and informed the DON of the complaint. Interviews with staff members revealed that the RN had a history of expressing frustration and making inappropriate comments, although there was no consensus on whether the RN had actually threatened the resident. The facility's policy required immediate suspension of the accused staff member and a thorough investigation, but these steps were not taken until prompted by external authorities. The delay in addressing the allegations and the continued presence of the RN in the facility without any immediate action to protect residents highlight significant lapses in the facility's abuse prevention and reporting procedures. The facility's failure to promptly investigate and report the incident to the appropriate authorities, as well as the lack of immediate protective measures, contributed to the deficiency identified by the surveyors.
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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