Lantern Park Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Coralville, Iowa.
- Location
- 2200 Oakdale Road, Coralville, Iowa 52241
- CMS Provider Number
- 165214
- Inspections on file
- 25
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Lantern Park Specialty Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple psychiatric diagnoses underwent changes in psychotropic medications without documented education or informed consent from the resident or their representative. The facility's records showed only an attempted phone notification to the family, with no follow-up or signed consent form, and the facility's policy did not address informed consent requirements for such medication changes.
A resident with Alzheimer's dementia was admitted to hospice care, but the facility did not complete the required Minimum Data Set (MDS) assessment for a significant change in status within the mandated timeframe, as confirmed by staff and clinical record review.
Quarterly MDS assessments were not completed within the required 92-day timeframe for three residents, with gaps ranging from 95 to 142 days between assessments. Staffing changes and reliance on a corporate support team contributed to the delays, and the issue was not self-identified by the facility during the survey.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
Staff did not deliver care or services in a manner that was trauma informed or culturally competent, failing to meet required standards for addressing residents' trauma histories or cultural needs.
Multiple residents experienced significant delays in call light response, with staff taking between 17 and 40 minutes to respond to requests for assistance. These delays were confirmed through direct observation and resident interviews, despite the administrator's stated expectation that call lights be answered in under 15 minutes.
Two residents requiring substantial assistance for bathing did not consistently receive the scheduled two showers per week, as confirmed by documentation, resident interviews, and staff observations. Both residents, who were cognitively intact, reported infrequent showers, and one exhibited physical signs of inadequate hygiene. The administrator acknowledged that all residents should receive showers twice weekly.
The facility failed to administer medications as prescribed to several residents due to insufficient staffing. Residents with conditions such as hypertension, diabetes, and heart disease missed critical doses of medications like Metoprolol, Digoxin, and insulin. Staff A, a registered nurse, cited a lack of help as the reason for these omissions, which were documented in the residents' MARs and progress notes.
A resident with intact cognition alleged physical abuse, claiming she was hit in the head, causing her glasses to fall off. The facility's investigation was insufficient, as it did not include interviews with staff present during the incident. The Interim Administrator was informed through hospital notes and notified authorities, but there was uncertainty about the completeness of staff interviews. The facility's policy requires thorough investigations, which was not met.
A facility failed to obtain physician orders for supplemental oxygen for a resident with COPD and asthma, leading to undocumented oxygen use. Additionally, another resident missed multiple medication doses due to staffing shortages, with the nurse failing to report the issue to management. The facility's policies and job descriptions were not followed, resulting in deficiencies in care.
A resident with COPD, respiratory failure, and anxiety, requiring moderate assistance with daily living activities, did not receive scheduled baths as per their care plan. Despite a system in place for assigning bath days, the facility failed to provide the necessary hygiene care, with documentation showing only one bath in August and none in September.
A resident with a fall risk and a periprosthetic fracture was injured due to inadequate supervision during ambulation. A CNA failed to use a gait belt, contrary to the care plan and facility policy, resulting in the resident falling and sustaining a non-operable fracture of the right hip. The incident was witnessed by another CNA in training.
A resident with multiple diagnoses required substantial assistance for transfers, but the facility failed to update their care plan to reflect the use of a sit-to-stand lift instead of a front-wheeled walker. Staff interviews confirmed the use of the lift for four months, but the therapy department was not informed, leading to a deficiency in care planning and communication.
A resident with hemiplegia required a mechanical lift for transfers, but staff failed to secure the shin strap due to a missing buckle, leading to unsafe transfer practices. The resident's leg position during the transfer was concerning, and staff training on the use of the lift was inconsistent.
The facility staff failed to treat residents with respect and dignity, as evidenced by incidents involving four residents. A resident with cancer was told by an LPN that he was going to die, causing distress. Another resident was left on the toilet for 20 minutes, feeling scared and uncertain. A third resident reported poor call light response times, leading to incontinence and feelings of unimportance. Additionally, two CNAs were rude to a resident, refusing to assist with toileting. These incidents highlight a pattern of disrespect and inadequate care.
A resident with intact cognition was not informed about changes to her medications or treatment plan, despite facility policies requiring such communication. Staff confirmed that residents with high BIMS scores should be informed, but notifications were only made to the resident's power of attorney, who was not enacted. This lack of communication deviated from the facility's policies on resident rights and dignity.
The facility did not submit complete PBJ data for agency staff during the second quarter, affecting CMS's staffing information. The PBJ report showed a one-star staff rating and low weekend staffing. The Administrator acknowledged the omission of agency staff data, contrary to the facility's policy requiring inclusion of all direct-care staff.
A facility failed to update the PASRR evaluation for a resident with new diagnoses, including Parkinson's disease with dyskinesia and delusional disorders. The resident's care plan was based on an outdated assessment from 2021, and despite new diagnoses documented in the electronic health record, no updated PASRR evaluation was conducted. The facility lacked a specific policy for PASRR completion, relying instead on general regulations.
A resident with a history of falls and multiple diagnoses fell in the shower room, resulting in a nondisplaced fracture of the proximal right femoral neck. The incident occurred because the CNA did not use a gait belt and the resident was not wearing shoes, contrary to the facility's policy and standard practice.
A resident with hypertension, non-Alzheimer's dementia, and orthostatic hypotension fell in the shower room and complained of significant pain in her right hip and pelvis. Despite the resident's inability to flex her right hip and her complaints of pain, an agency nurse used a mechanical lift to place the resident in a wheelchair and took her to her room instead of seeking immediate medical treatment, resulting in inadequate care.
Failure to Obtain Informed Consent for Psychotropic Medication Changes
Penalty
Summary
The facility failed to educate a resident and/or their representative and obtain informed consent prior to making two changes in psychotropic medications for a resident with severe cognitive impairment. The resident had diagnoses including PTSD, depression, and adjustment disorder, and was being treated with multiple psychotropic medications. The care plan included interventions to educate the resident, family, and caregivers about the risks, benefits, and side effects of antidepressant medications. However, when the physician ordered a decrease in duloxetine and initiation and titration of sertraline, there was no documented evidence that informed consent was obtained from the resident or their representative prior to implementing these changes. Review of the electronic health record showed an attempt to notify the resident's wife by leaving a message, but there was no follow-up communication documented to confirm that the representative was informed about the medication changes. Additionally, the facility's provided policy did not address the need for informed consent prior to changes in psychotropic medications, and the informed consent form for the new antidepressant remained unsigned. Staff interviews confirmed that the expectation was for a signed informed consent document to be present when medication changes occurred, but this was not completed in this case.
Failure to Complete Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment for a significant change in status after a resident was admitted to hospice care. Clinical record review showed that a physician order was entered indicating the resident began receiving hospice services for Alzheimer's dementia. According to the Resident Assessment Instrument (RAI) User's Manual, an MDS assessment for a significant change in status must be completed within 14 days of determining the change, and specifically when a terminally ill resident enrolls in a hospice program. Staff interview confirmed that the resident started hospice services, but the required significant change MDS assessment was not completed as mandated.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required timeframe for three residents. Clinical record reviews showed that for one resident, there was a 142-day gap between the admission MDS assessment and the first quarterly assessment. For another resident, there was a 133-day interval between two quarterly assessments, and for a third resident, the gap between quarterly assessments was 95 days. According to the Resident Assessment Instrument (RAI) User's Manual, assessments must be completed no later than 92 days after the previous assessment. Interviews with the new MDS Coordinator and the Administrator revealed that the facility had experienced staffing changes, with the corporate support team intermittently handling MDS assessments while a new Coordinator was being hired. The MDS Coordinator described the process for completing assessments and acknowledged that quarterly assessments should be completed within 92 days. The Administrator confirmed that the previous Coordinator was responsible for the missed assessments, and the new Coordinator had been working to correct identified errors. The facility did not indicate on the Self Identification form that MDS corrections were an ongoing issue.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide care or services that were trauma informed and/or culturally competent. This deficiency indicates that staff did not consider or incorporate trauma-informed approaches or cultural competence in the delivery of care or services to residents, as required. The report does not specify the number of residents affected or provide details about their medical history or condition at the time of the deficiency.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by multiple observations and resident interviews. Three separate instances were documented where call lights remained unanswered for periods ranging from 17 to 35 minutes. Residents reported that it routinely took staff over 15 minutes, and in some cases up to 40 minutes, to respond to their requests for assistance. These delays were directly observed by surveyors, who noted specific times when call lights were activated and the length of time before staff entered the rooms. The facility census at the time was 86 residents, and the administrator confirmed that the expectation was for call lights to be answered in less than 15 minutes.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide at least two baths per week for two of three residents reviewed, despite both residents being assessed as requiring substantial or maximal assistance for showering. Clinical record reviews showed that both residents were scheduled for showers twice weekly, but documentation revealed that the actual number of showers received was inconsistent and often less than scheduled. One resident, with intact cognition and a care plan indicating the need for one-person assistance, reported not receiving showers very often, and records confirmed missed showers over several months. Another resident, also cognitively intact and requiring similar assistance, stated that staff were slow to provide showers and reported not having had a shower for over a week, with physical signs such as greasy hair and slight body odor observed during the survey. Interviews with both residents corroborated the documentation findings, as they expressed concerns about the infrequency of showers. The administrator confirmed that all residents should be receiving showers twice a week, as per facility policy. The deficiency was identified through a combination of clinical record review, resident interviews, and staff interviews, highlighting a failure to consistently provide scheduled bathing assistance to residents unable to perform activities of daily living independently.
Medication Administration Errors Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting six out of ten residents reviewed for medication administration. The errors were primarily due to missed medication doses, as indicated by the residents' Medication Administration Records (MARs) and progress notes. The MARs for several residents showed multiple morning medications marked with a code indicating they were not administered, and progress notes consistently cited a lack of sufficient help as the reason for these omissions. Resident #3, with severely impaired cognition, missed a dose of Metoprolol Succinate for hypertension. Similarly, Resident #15, who had cardiovascular issues, missed a dose of Digoxin. Both cases were attributed to insufficient staffing, as noted by Staff A, a registered nurse. The facility's daily staffing sheet confirmed that only two nurses and one Certified Medication Aide were scheduled for the shift, which was inadequate to meet the residents' needs. Other residents, including those with diabetes, coronary artery disease, and hypertension, also missed critical medications such as insulin, Metoprolol, Furosemide, and Eliquis. These omissions were documented in the progress notes, with Staff A repeatedly citing a lack of help as the cause. Despite notifying providers of the medication errors, no new orders were received, indicating a lack of immediate corrective action. The facility's policy on administering medications, which requires medications to be given as per prescriber orders, was not adhered to, leading to these significant medication errors.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with intact cognition, as indicated by a BIMS score of 15 out of 15. The resident alleged that during the overnight hours, she was hit in the head, causing her glasses to fall off. The incident was reported several days later due to the resident's illness. The facility conducted interviews with other residents and staff, but the investigation lacked thoroughness as it did not include statements from staff who worked during the time of the alleged incident. Additionally, the facility's documentation did not provide sufficient information related to the alleged abuse. The Interim Facility Administrator was made aware of the allegation through hospital notes and took steps to notify relevant authorities. However, there was uncertainty about whether all necessary staff interviews had been conducted. The facility's investigation summary indicated no concerns were noted from the interviews conducted, but it did not address the specific details of the alleged incident. The facility's policy on abuse and neglect requires a thorough investigation to clarify events and identify possible causes, which was not adequately fulfilled in this case.
Deficiencies in Oxygen Administration and Medication Management
Penalty
Summary
The facility failed to obtain physician orders for the use of supplemental oxygen for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and asthma. Despite the resident experiencing low oxygen saturation levels, the care plan did not include interventions related to oxygen use, and the Medication and Treatment Administration Record (MAR/TAR) lacked orders for supplemental oxygen. Nursing staff applied oxygen based on their judgment, and a verbal order was received but not documented in the MAR/TAR. The facility's policy required a physician's order for oxygen administration, which was not followed. Another deficiency involved the failure to administer medications as ordered for a resident on a specific date. Multiple morning and afternoon medication doses were omitted due to insufficient staffing, as noted by a registered nurse. The resident's MAR indicated missed doses, and progress notes confirmed the omissions were due to a lack of help. The facility's staffing sheet showed that only two nurses and one Certified Medication Aide were scheduled for the shift, and the nurse involved did not report the issue to the Regional Director of Clinical Services or the Regional Director of Operations. The facility's Regional Director of Clinical Services and Regional Director of Operations were present on the day of the medication omissions but were not informed of the staffing issues by the nurse. The nurse acknowledged not completing all tasks and requested to return the following day. The Charge Nurse-RN Job Description required compliance with rules and regulations, ensuring residents received necessary care, which was not adhered to in this instance.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to a resident, identified as Resident #1, who required moderate assistance with activities of daily living, including bathing. The resident, who had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, was diagnosed with chronic obstructive pulmonary disease (COPD), respiratory failure, and anxiety. According to the care plan initiated on August 12, 2024, the resident was to receive assistance with baths twice a week, specifically on Mondays and Thursdays. However, documentation revealed that the resident only received one bath on August 29, 2024, and there was no documentation of baths provided in September. Interviews with facility staff, including registered nurses and certified nurse assistants, confirmed that residents are generally scheduled to receive baths twice a week, with a designated bath aide responsible for this task. If bath aides are unavailable, certified nursing assistants are expected to complete the baths. The staff also mentioned a system of assigning bath days based on room numbers, and a master list is used to track which residents need baths. Despite these procedures, the facility failed to adhere to the care plan for Resident #1, resulting in a deficiency in providing necessary hygiene care.
Failure to Use Gait Belt Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide appropriate supervision during ambulation for a resident, resulting in an injury. The resident, who had no cognitive impairment, was identified as having a fall risk due to a periprosthetic fracture of the left hip joint. The care plan required staff to assist the resident with a front-wheeled walker and a wheelchair for mobility, and to use a gait belt during transfers. However, on the day of the incident, a CNA assisted the resident to the bathroom without using a gait belt, which was against the facility's policy. The CNA, who was responsible for the resident's care, admitted to not using a gait belt because she left it in her locker. Instead, she held onto the resident's pants to assist him. During the transfer, the CNA removed the resident's oxygen and turned away from him, leaving him unsupported. As a result, the resident fell in the bathroom, sustaining a fracture to the right hip, which was confirmed by an x-ray as a non-operable fracture of the greater trochanter. The incident was witnessed by another CNA in training, who observed the resident fall after taking a few steps on his own. The facility's policy required the use of gait belts for safe resident transfers, and the CNA involved in the incident had previously been warned for similar infractions. The failure to adhere to the care plan and facility policies directly contributed to the resident's fall and subsequent injury.
Failure to Update Resident Care Plan for Transfer Method
Penalty
Summary
The facility failed to update the care plan of a resident to reflect their current level of functioning, leading to a deficiency. The resident, who had diagnoses including metabolic encephalopathy, legal blindness, lack of coordination, and muscle weakness, required substantial assistance for transfers and ambulation and was totally dependent on staff for toileting. The care plan, last revised in March 2024, indicated the resident should be transferred using a front-wheeled walker with the assistance of two staff members. However, observations and staff interviews revealed that the resident had been transferred using a sit-to-stand mechanical lift (EZ Stand) for the past four months, contrary to the care plan instructions. Interviews with various staff members, including CNAs and LPNs, confirmed the use of the EZ Stand for transfers, which was not documented in the care plan. The therapy department, responsible for assessing and recommending transfer methods, was not informed of the change in the resident's transfer method and did not receive a request for re-evaluation. The Director of Nurses and MDS Coordinators acknowledged the discrepancy between the care plan and the actual transfer method used, indicating a breakdown in communication and documentation processes within the facility.
Deficiency in Safe Transfer Using Mechanical Lift
Penalty
Summary
The facility failed to safely transfer a resident who required a mechanical lift, resulting in a deficiency. The resident, who had no cognitive impairment and was diagnosed with conditions including cerebrovascular accident, hypertension, and hemiplegia, required total assistance for transfers and toileting. The care plan specified the use of a sit-to-stand mechanical lift (E-Z Stand) with assistance from one staff member. However, during an observation, a CNA used the lift without securing the shin strap, which lacked a buckle, and transferred the resident to the bathroom. The resident's left leg was observed to remain straight and tilted back during the transfer, which was noted by a Physical Therapy Aide as a concern. Staff interviews revealed that one CNA had not been trained to buckle the leg harness, while another CNA was aware of the requirement but noted the strap was missing a buckle. The facility had three E-Z Stand lifts, one of which had a broken shin strap. The Director of Nursing confirmed the necessity of applying the leg strap during transfers. The mechanical lift manual indicated the importance of securing the shin strap to keep the patient's legs on the foot plate, highlighting the deficiency in the transfer process.
Failure to Respect Resident Dignity and Timely Response to Needs
Penalty
Summary
The facility staff failed to treat residents with respect and dignity, as evidenced by multiple incidents involving four residents. Resident #78, who had a diagnosis of cancer, reported being mistreated by a nurse, Staff A, who told him he was going to die from his cancer. This conversation was corroborated by an audio recording and other staff members, leading to the termination of Staff A. The incident left Resident #78 upset and angry, highlighting a lack of sensitivity and respect in communication with residents. Resident #13, who had moderately impaired cognition and was dependent on staff for toileting, reported being left on the toilet for 20 minutes, causing her to feel scared and uncertain about when staff would return. Staff interviews revealed that call lights were not always answered promptly, especially during busy times, indicating a systemic issue with staff availability and response times. This delay in assistance compromised the resident's dignity and sense of security. Resident #86, with intact cognition and a history of fractures, reported poor response times to call lights, particularly during evenings and weekends. She experienced incontinence due to delayed assistance, which made her feel unimportant. Additionally, Resident #4 reported rude behavior from two CNAs who refused to assist him with toileting, telling him to try to wipe himself. This incident was confirmed through interviews and led to a grievance being filed. These events collectively demonstrate a pattern of disrespect and inadequate care, affecting the residents' dignity and well-being.
Failure to Inform Resident of Medication Changes
Penalty
Summary
The facility failed to ensure that residents were fully informed and involved in their treatment plans, specifically in the case of one resident with intact cognition. This resident, who had diagnoses of cancer, anxiety, and heart failure, reported that nurses did not explain changes to her medications or the reasons for these changes. Despite having a high score on the Brief Interview for Mental Status (BIMS), indicating intact cognition, the resident was not informed about new medications or changes to her treatment plan. The facility's documentation showed that notifications about medication changes were made to the resident's power of attorney, even though the resident was decisional and the power of attorney had not been enacted. Interviews with staff and the facility administrator confirmed that residents with high BIMS scores should have medication changes explained to them, and that the resident's brother was involved in care conferences by choice, not necessity. The facility's policies emphasized the importance of informing residents about their health status and respecting their dignity and choices. However, the lack of communication with the resident about her medications and treatment plan was a clear deviation from these policies, as evidenced by the absence of documentation showing the resident's involvement in care plan conferences and medication discussions.
Incomplete PBJ Data Submission for Agency Staff
Penalty
Summary
The facility failed to submit complete payroll data for agency staff during the second quarter of the current fiscal year, impacting the accuracy of staffing information reported to the Centers for Medicare and Medicaid Services (CMS). The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year 2024 Quarter 2 indicated a one-star staff rating and excessively low weekend staffing. Upon review, the Administrator provided staff schedules for March, which included both facility and agency staff. However, during an interview, the Administrator admitted that the PBJ data submitted did not include agency staff, acknowledging the impact on CMS's data for the facility. The facility's policy on Reporting Direct-Care Staffing Information, revised in October 2017, required the inclusion of staff hired directly by the facility, through an agency, and contract employees.
Failure to Update PASRR Evaluation for Resident with New Diagnoses
Penalty
Summary
The facility failed to complete an updated Pre-Admission Screening and Resident Review (PASRR) evaluation for a resident with a new diagnosis. The resident, identified as Resident #13, had a history of Parkinson's disease, psychotic disorder, PTSD, and delirium due to a known physiological condition. The Minimum Data Set (MDS) review revealed that the resident had moderately impaired cognition, scoring 10/15 on the Brief Interview for Mental Status (BIMS). The resident's care plan, which included focus areas and interventions for PASRR, was based on an assessment completed prior to admission on 7/9/21. The PASRR outcome from 7/7/21 indicated no Level II was required at that time, as there were no neurocognitive disorders or recent mental health symptoms noted. However, the resident's electronic health record later documented new diagnoses, including Parkinson's disease with dyskinesia dated 10/1/23, delusional disorders dated 11/3/23, and delirium due to a known physiological condition dated 3/15/24. Despite these new diagnoses, the facility did not conduct an updated PASRR evaluation. An email from the Administrator on 8/1/24 confirmed that the facility lacked a specific policy for PASRR completion and relied solely on following regulations. An interview with the Administrator further revealed that the only documentation of a completed PASRR assessment for this resident was from 2021, indicating a failure to update the evaluation in light of the resident's new diagnoses.
Failure to Provide Appropriate Supervision and Use of Gait Belt
Penalty
Summary
The facility failed to provide appropriate supervision to ensure the safety of a resident, leading to a fall incident. The resident, who had diagnoses including hypertension, non-Alzheimer's dementia, and orthostatic hypotension, was identified as being at risk for falls. The care plan included interventions such as encouraging proper footwear and monitoring for an unsteady gait, as well as requiring assistance from one person for various activities of daily living. However, during a bathing session, the resident fell in the shower room, resulting in a nondisplaced fracture of the proximal right femoral neck. The incident occurred because the Certified Nursing Assistant (CNA) did not use a gait belt and the resident was not wearing shoes, contrary to the facility's policy and standard practice as explained by the Director of Nursing (DON). The CNA admitted that she did not have a gait belt on the resident and that the resident was not wearing shoes at the time of the fall. The facility's policy on safe lifting and movement of residents, which was last revised in July 2017, directed staff to use manual lifting devices such as gait belts. The DON confirmed that it is standard practice to use a gait belt and to have hands on the gait belt at all times when assisting a resident. The failure to adhere to these protocols directly led to the resident's fall and subsequent injury.
Failure to Provide Appropriate Post-Fall Assessment and Intervention
Penalty
Summary
The facility failed to complete an accurate assessment and provide appropriate intervention after a fall for a resident diagnosed with hypertension, non-Alzheimer's dementia, and orthostatic hypotension. The resident, who required assistance with activities of daily living, fell in the shower room and complained of significant pain in her right hip and pelvis. Despite the resident's inability to flex her right hip and her complaints of pain, the agency nurse used a mechanical lift to place the resident in a wheelchair and took her to her room instead of seeking immediate medical treatment as per the facility's policy on assessing falls and their causes. A subsequent CT scan revealed a nondisplaced fracture of the proximal right femoral neck. The facility's policy directs staff to provide first aid and obtain medical treatment immediately if there is evidence of an injury after a fall. However, the agency nurse's decision to use a mechanical lift and place the resident in a wheelchair without seeking immediate medical attention demonstrated poor judgment and a failure to adhere to the facility's policy, resulting in inadequate care for the resident after the fall.
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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