Lenox Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lenox, Iowa.
- Location
- 111 East Van Buren, Lenox, Iowa 50851
- CMS Provider Number
- 165235
- Inspections on file
- 18
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Lenox Care Center during CMS and state inspections, most recent first.
Surveyors identified multiple failures in infection prevention and control, including improper use of Enhanced Barrier Precautions (EBPs) for two residents and deficient wound care technique for another. One resident with an indwelling catheter had an EBP care plan requiring gown and glove use during high-contact care, yet CNAs performed transfers, toileting, and catheter handling wearing only gloves. Another resident with diabetic foot ulcers received wound care from an RN who brought a dressing cart into the EBP room, repeatedly opened drawers and handled supplies with contaminated gloves, placed soiled items on the cart, and then reused the cart elsewhere, contrary to facility wound care and infection control policies. Additionally, the facility lacked a fully developed water management program: the Maintenance Director did not know the water flow diagram or Legionella prevention responsibilities, blueprints did not identify service areas or stagnant water risks, flushing of sinks and toilets was not on housekeeping checklists, and devices such as a whirlpool and a fish aquarium lacked documented maintenance protocols, despite policy requirements for annual assessment and control of Legionella and other waterborne pathogens.
Two residents experienced extended periods without a bowel movement, and staff failed to consistently follow physician orders for PRN laxatives and bowel protocols. Medication administration and care plan interventions were not reliably documented or implemented, and there was a lack of required assessments when interventions were ineffective or refused. Staff interviews revealed confusion over bowel movement tracking and the absence of clear facility policies for bowel management and medication administration.
Staff did not adhere to infection prevention protocols while providing catheter care to a resident on Enhanced Barrier Precautions. Hand hygiene and glove changes were missed between tasks, contaminated PPE was worn outside the resident's room, and catheter equipment was not properly cleansed, contrary to facility policy and expectations.
A resident with no cognitive impairment was unable to access personal funds managed by the facility during weekends or evenings, contrary to the facility's policy. The Business Office Manager and Administrator were the only staff with access to the funds, and they were not available outside regular working hours. This resulted in the resident being unable to purchase items when desired.
The facility did not follow the prescribed menu and portion control guidelines for residents on a mechanical soft diet. Staff H processed 8 meatballs but served only 1/3 cup to the last resident, contrary to the requirement of 2 ground meatballs per serving. Both the Certified Dietary Manager and the Contract Registered Dietitian confirmed that all processed meatballs should have been served, highlighting a deficiency in meeting the nutritional needs of 4 residents.
The facility failed to maintain an appetizing and safe temperature for mechanical soft meatballs during lunch service. The AM Cook recorded a temperature of 95 degrees, which was below the required 135 degrees. Both the Certified Dietary Manager and the Contract Registered Dietitian confirmed the deficiency, noting that the facility's policy mandates hot food temperatures of no less than 140 degrees when served.
The facility failed to store food according to professional standards, with several items in the refrigerator dated beyond the facility's policy of discarding after three days. Additionally, a thermometer was not sanitized before rechecking the temperature of reheated meatballs. Staff acknowledged these lapses, which were against the facility's policy.
A CNA witnessed another CNA inappropriately touching a resident but failed to report the incident within the required two-hour timeframe. The incident was observed at 12:30 PM, but the Assistant Director of Nursing was not notified until after 3:10 PM, violating the facility's policy on immediate reporting of abuse allegations.
Two residents in an LTC facility were found to have incomplete care plans, leading to deficiencies in their care. One resident with severe cognitive impairment and multiple diagnoses lacked a care plan for oxygen use, while another resident with complex medical conditions had no care plan for therapy or repositioning. Staff interviews revealed inconsistencies in care, and the facility's policies on individualized care plans were not followed.
The facility failed to update care plans for three residents, including a resident whose walk to dine program was discontinued, another who required smoking interventions, and a third whose POA was not invited to a care conference. Staff acknowledged the care plans were not up to date, and the DON emphasized the need for accurate documentation and family involvement.
A facility failed to provide necessary restorative care to a resident with multiple contractures and other medical conditions. The resident's care plan lacked interventions for restorative therapy, and recommended orthotic devices were not ordered. A system error led to the removal of the restorative program from the EHR, as acknowledged by the DON and Administrator. The resident was discharged from occupational therapy without progress, despite the facility's policy emphasizing individualized care.
A resident experienced significant weight loss due to the facility's failure to maintain nutritional status. The resident, with multiple health conditions, was not consistently awakened for meals, and staff were unaware of the weight loss. The Registered Dietitian was not informed of the issue, and meal refusals were not documented, leading to inadequate monitoring and care.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate. A resident received incorrect dosages of Omeprazole and vitamin C due to errors in the EHR and lack of verification against the MAR. The resident had memory issues and multiple diagnoses, including Alzheimer's and dementia.
A facility failed to follow proper infection control practices during the care of a resident with complex medical needs. An LPN did not perform hand hygiene after glove removal during tracheostomy care, and two CNAs missed hand hygiene opportunities during personal care. The DON acknowledged these lapses, which were against the facility's policy.
A resident with multiple medical conditions, including cerebral palsy and quadriplegia, did not receive adequate assistance with activities of daily living (ADLs) in a facility. The resident was not repositioned regularly, despite needing it to prevent skin breakdown, and received fewer baths than required. Staff believed an air flow mattress provided sufficient pressure relief, but the facility's policies on repositioning and ADLs were not followed.
Inadequate Infection Control Practices and Water Management Program
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program, including improper use of Enhanced Barrier Precautions (EBPs), incorrect wound care practices, and an incomplete water management program. For one resident with heart failure, diabetes, COPD, intact cognition, and an indwelling urinary catheter, the MDS and care plan documented the need for EBPs due to the catheter and directed staff to use gowns and gloves during high-contact care such as transfers, toileting, and catheter care, with hand hygiene before and after care. Surveyors observed that although an EBP sign was posted on the resident’s door and staff wore gloves, two CNAs transferred the resident with a mechanical lift, handled the catheter, removed the resident’s pants and brief, placed a bedpan, and later performed pericare and catheter site cleansing without wearing gowns during these high-contact activities, contrary to the facility’s EBP policy. For another resident with diabetes, peripheral venous insufficiency, lymphedema, and diabetic ulcers on the toes of the left foot, the care plan and TAR directed daily wound care using Vashe solution, betadine, and gauze dressings. During an observed wound treatment, an RN donned mask, gown, and gloves and brought a dressing supply cart into the resident’s room, despite the resident being on EBPs. The RN opened saline bottles and cart drawers, obtained gauze, and performed skin fold and groin cleansing, then removed soiled dressings from the resident’s left foot, cleansed and treated the wounds, and applied new dressings. Throughout the procedure, the RN repeatedly opened and closed cart drawers and handled supplies on the cart with contaminated gloves, placed tape on top of the cart, moved an isolation gown in the drawer, retrieved a pen from a uniform pocket, and wrote on tape while using the cart surface, then returned supplies to the drawers. The RN also placed a soiled pad and towel on top of the cart, later removed the gown and put it in the trash on the side of the cart, and then pushed the same cart to another room and handled the soiled pad and towel again. These actions conflicted with the facility’s wound care policy requiring use of a disposable barrier for supplies and prohibiting return of disposable supplies to the cart, as well as the infection control and hand hygiene policies requiring proper handling of equipment, soiled linens, and glove use with hand hygiene when moving from dirty to clean areas. The facility also lacked a comprehensive and effectively implemented water management program to control Legionella and other waterborne pathogens. The Maintenance Director reported not knowing the location of the water flow diagram, who was responsible for Legionella preventive procedures, or which parts of the building were supplied by the two water heaters. Review of facility blueprints did not identify the service areas for each water supply line or the locations of high-risk stagnant water areas. The Housekeeping supervisor stated that staff flushed sinks and toilets during deep cleaning but that this task was not included on the deep clean checklist, and the checklist itself did not list toilet or sink flushing. The Administrator reported that a whirlpool near the DON’s office was temporarily nonfunctioning and believed it was the last water-supplied device in that hall’s water supply sequence. An annual Legionella environmental assessment documented the presence of a whirlpool without filter change or backwash documentation and a fish aquarium maintained at 77°F without a maintenance protocol, with the last cleaning date noted. These findings did not align with the facility’s water management policy, which required annual assessment of the water system to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and to specify interventions and monitoring when risks were identified. The infection prevention and control policy stated that all staff were responsible for following infection control policies and procedures, that equipment must be cleaned and disinfected per facility policy, and that soiled linen should be collected at the bedside, placed into a linen bag, and then taken to a soiled utility room. The handwashing/hand hygiene policy emphasized that glove use does not replace hand hygiene and that integrating glove use with routine hand hygiene is best practice for preventing infection spread. During interviews, the ADON confirmed that EBPs are used to prevent the spread of germs and protect residents and staff, acknowledged that the dressing supply cart should not have been taken into a room for a resident on EBPs, and agreed that the RN had touched drawers and items on the cart with contaminated gloves, contrary to expectations that staff change gloves and sanitize hands when soiled or when moving from dirty to clean areas. The Administrator later acknowledged that the facility could have done better at implementing the water management plan.
Failure to Follow Physician Orders and Protocols for Constipation Management
Penalty
Summary
The facility failed to follow physician-ordered interventions for two residents who experienced extended periods without a bowel movement. For one resident with a diagnosis of constipation and always incontinent of bowel, electronic health records showed multiple episodes of three or more days without a bowel movement. Although there was a physician's order for milk of magnesia to be given as needed for constipation, medication administration records indicated it was not consistently administered according to the order, and there was a lack of documentation for administration during some periods. The resident's care plan required documentation of bowel movements every shift and adherence to facility protocol for stool softeners, laxatives, or enemas, but these interventions were not consistently followed or documented. For another resident with moderate cognitive impairment and multiple diagnoses, including malnutrition and a history of falls, records showed a gap of three days without a bowel movement. The resident had several as-needed orders for constipation management, including milk of magnesia, Miralax, and bisacodyl suppository, with instructions to escalate interventions if no bowel movement occurred for several days. However, medication administration records showed these interventions were only given on two occasions during the month, and progress notes indicated refusals without documentation of any assessment related to constipation. There was also a lack of abdominal assessments or documentation of change in condition in the resident's records. Interviews with nursing staff and administration revealed inconsistencies in following the bowel protocol and confusion regarding the use of bowel movement reports generated from the electronic health record system. Staff acknowledged that the bowel report was not functioning correctly, leading to missed identification of residents with prolonged periods without a bowel movement. Additionally, the facility lacked a formal bowel protocol policy, a policy for when assessments should be completed, and a medication administration policy, contributing to the failure to provide appropriate treatment and care as ordered.
Failure to Follow Infection Control Practices During Catheter Care
Penalty
Summary
Staff failed to follow appropriate infection prevention and control practices while providing personal and catheter care to a resident on Enhanced Barrier Precautions (EBP). During the observed care, staff performed hand hygiene and donned gloves and gowns initially, but did not change gloves or perform hand hygiene after removing the lift cloth and before proceeding to cleanse the resident's meatus and catheter tubing. Additionally, after handling the catheter and emptying urine, staff did not consistently cleanse the catheter tip as required, and did not remove gloves and gowns or perform hand hygiene before leaving the resident's room. One staff member walked through common areas and hallways wearing contaminated gloves and gown, carrying used equipment, before removing personal protective equipment and performing hand hygiene in the utility room. The resident involved was nonverbal, had an indwelling catheter, and was always incontinent of bowel, as documented in the Minimum Data Set. Facility policy required hand hygiene before and after handling invasive devices, after removing gloves, and before leaving isolation precaution settings. The Director of Nursing confirmed that the observed practices did not meet facility expectations or policy requirements for infection prevention and control, particularly regarding hand hygiene, glove and gown removal, and proper cleansing of catheter equipment.
Facility Fails to Provide Resident Access to Personal Funds
Penalty
Summary
The facility failed to provide access to personal funds managed by the facility for a resident, as required by their policy. The resident, who had no cognitive impairment, expressed a desire to access her personal funds on a weekend to purchase soda but was unable to do so because the funds were not accessible during weekends or evenings. The facility's policy stated that residents should have access to funds of $100 or less within 24 hours, but this was not adhered to. The Business Office Manager, who along with the Administrator, was the only staff with access to the petty cash, confirmed that residents could not access their funds outside of her working hours, which were Monday through Friday, 8:00 AM to 4:30 or 5:00 PM. The Administrator acknowledged that residents did not have access to their funds during weekends or evenings unless they were contacted to come in, which had not occurred. This lack of access was corroborated by a CNA who stated that residents could not get money from the resident trust during these times.
Failure to Serve Correct Portion Sizes for Mechanical Soft Diet
Penalty
Summary
The facility failed to adhere to the prescribed menu and portion control guidelines for residents on a mechanical soft diet. During an observation, it was noted that Staff H processed 8 meatballs for residents requiring a mechanical soft diet and placed them in a plastic container on the steam table. However, when serving the last plate, Staff H measured only 1/3 cup of the remaining meatballs, which was not in accordance with the documented requirement of 2 ground meatballs per serving for mechanical soft diets. Staff I, the Certified Dietary Manager, and Staff E, the Contract Registered Dietitian, both acknowledged that all processed mechanical soft meatballs should have been served, and there should not have been any leftovers. The facility's undated policy on portion control specifies that food should be served according to standard portion sizes to ensure adequate servings and equal portions for residents. The failure to serve the correct portion size resulted in a deficiency in meeting the nutritional needs of 4 out of 24 residents reviewed.
Failure to Maintain Safe Food Temperature
Penalty
Summary
The facility failed to provide food at an appetizing temperature during a lunch service, as observed on 2/26/25. Staff H, the AM Cook, served the last plate for a resident on a mechanical soft diet and recorded a temperature of 95 degrees for the remaining mechanical soft meatballs in the steam table. This temperature was acknowledged as unacceptable by Staff H, who stated that the food should have been held at a temperature of 135 degrees or higher. Staff I, the Certified Dietary Manager, and Staff E, the Contract Registered Dietitian, both confirmed that the mechanical soft meatballs should have been maintained at a holding temperature of 135 degrees or higher. The facility's undated policy on food temperatures documented that hot food temperatures must read no less than 140 degrees when residents are served.
Deficiency in Food Storage and Thermometer Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitation, as observed during a survey. Containers of cut lettuce, tomatoes, turkey gravy, bread stuffing, and cut ham were found in a refrigerator with dates indicating they had been stored beyond the facility's policy of discarding open food after three days. Additionally, a plastic bag of ham and a pitcher of lemonade were dated well beyond this timeframe, and other drink pitchers were undated. Staff I, the Certified Dietary Manager, acknowledged that these items should have been disposed of according to the facility's expectations. Furthermore, the facility did not sanitize a thermometer before rechecking the temperature of mechanical soft meatballs, which were being reheated in a microwave. Staff I used the thermometer multiple times without cleaning it between uses, which was against the facility's policy. Staff E, a Contract Registered Dietitian, confirmed that food should have been discarded after three days and that the thermometer should have been sanitized before use. The facility's policy, revised in July 2014, required all foods stored in the refrigerator or freezer to be covered, labeled, and dated with a use-by date.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility staff failed to report suspected abuse involving a resident and a staff member within the required two-hour timeframe. On February 23, 2025, Staff K, a Certified Nurse Aide (CNA), witnessed another CNA, Staff L, inappropriately tickling a resident's nipple while assisting the resident with dressing. Despite observing this behavior at 12:30 PM, Staff K did not report the incident to the Assistant Director of Nursing (ADON) until after 3:10 PM, which was beyond the two-hour reporting requirement. The ADON was notified at 3:40 PM and subsequently informed the Administrator at 3:45 PM. The facility's policy mandates that all allegations of resident abuse must be reported immediately to the Administrator and to the appropriate state entity within two hours. Staff K had completed a valid Dependent Adult Abuse training in March 2022, indicating awareness of the reporting requirements. However, the delay in reporting the incident was a clear violation of the facility's abuse prevention and reporting policy. The Director of Nursing confirmed that the ADON was the on-call leadership staff on the day of the incident, and the Administrator acknowledged that the staff should have reported the incident immediately after it was observed.
Deficiencies in Comprehensive Care Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident #16, who has severe cognitive impairment and multiple diagnoses including dementia and hypertension, was ordered oxygen therapy as needed. However, the care plan lacked documentation related to respiratory compromise and did not include goals or interventions for oxygen use. Staff interviews revealed inconsistencies in the monitoring and understanding of the resident's oxygen needs, with some staff unaware of when the resident used oxygen. The Assistant Director of Nursing acknowledged that the care plan should have included detailed instructions for oxygen use, but it was not up to date. Resident #5, who has multiple complex medical conditions including cerebral palsy and quadriplegia, required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. The care plan for this resident did not include any focus, goals, or interventions for restorative, physical, or occupational therapy, nor for repositioning. Staff interviews indicated that the resident was not repositioned regularly, and the Director of Nursing admitted that the care plan lacked necessary details for positioning. A system error had caused the restorative program to be removed from the electronic health record, and the Director of Nursing and Administrator acknowledged this oversight. The facility's policies on restorative nursing services, repositioning, and comprehensive person-centered care plans emphasize the need for individualized care plans with measurable objectives. However, these policies were not followed for the two residents in question, resulting in incomplete care plans that did not address their specific needs. The Director of Nursing and Administrator recognized the deficiencies and the need for corrective action, but the report does not detail any specific steps taken to address the issues at the time of the survey.
Care Plan Deficiencies in Resident Interventions and Family Involvement
Penalty
Summary
The facility failed to review and revise the care plan interventions for three residents, leading to deficiencies in their care. Resident #12, who had normal cognition and required assistance for certain activities, was not updated in the care plan after the discontinuation of the walk to dine restorative nursing program. Despite the program being discontinued, the care plan still included an intervention for walking to meals, which was not updated to reflect the resident's current needs. Resident #19, with moderate cognitive impairment and a history of smoking, had a care plan that did not include updated interventions from a smoking assessment. The care plan failed to reflect the need for a smoker's apron and supervised smoking, as indicated in the smoking data collection. This oversight was acknowledged by the staff, who admitted that the care plans might not be up to date and that the interventions from assessments should be included. Resident #2, with severe cognitive impairment, had a care plan conference that did not include the resident's Power of Attorney (POA), despite documentation stating otherwise. The POA was not invited to the care conference, and the staff member responsible for notifying family members admitted to not documenting who was present at the meetings. The Director of Nursing acknowledged that care plan conferences were not being completed appropriately and emphasized the importance of accurate documentation and family involvement.
Failure to Provide Restorative Care for Resident with Contractures
Penalty
Summary
The facility failed to provide necessary restorative care to a resident, identified as Resident #5, to maintain or improve their range of motion. The resident's Minimum Data Set (MDS) indicated multiple medical conditions, including athetoid cerebral palsy, contractures in various body parts, and unspecified quadriplegia. Despite these conditions, the resident's care plan lacked focus, goals, or interventions for restorative, physical, or occupational therapy. The resident's electronic health records (EHR) showed no orders for restorative therapy or orthotic devices, such as palm protectors or carrot hand orthosis, which were recommended by occupational therapy to prevent further contractures and skin breakdown. The deficiency was further compounded by a system error that led to the restorative program being removed from the EHR in September 2024, as acknowledged by the Director of Nursing (DON) and the Administrator. The Certified Occupational Therapy Assistant (COTA) confirmed that the resident had been on occupational therapy from June to July 2024, with a short-term goal of trialing orthotic splints. However, the resident was discharged from occupational therapy upon being transferred to the hospital, with no progress reported in their range of motion. The facility's policy on restorative nursing services emphasized individualized and resident-centered care, which was not reflected in the resident's care plan or treatment records.
Failure to Maintain Nutritional Status
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, resulting in an 11.05% weight loss over six months. The resident, who had moderately impaired cognition and multiple diagnoses including diabetes mellitus and Alzheimer's Disease, was observed not being awakened for meals and seeking food outside of scheduled meal times. The care plan directed staff to monitor and report signs of malnutrition and to provide a regular diet with thin liquids, but these directives were not effectively followed. The Registered Dietitian (RD) was not informed that the resident was not being awakened for meals, which would have prompted further action. Staff members, including Certified Nursing Aides and the Certified Medication Aide, were unaware of the resident's significant weight loss and did not document meal refusals. The Electronic Health Record did not include documented breakfast responses, indicating a lack of proper monitoring and documentation. The facility's policy required assistance with meals to meet individual needs, but this was not adhered to, contributing to the resident's nutritional decline.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 7.14% during a medication administration observation. Staff F, a Certified Medication Aide, administered medications to a resident, including Oxycodone/APAP, Miralax, gabapentin, celecoxib, citalopram, azathioprine, Lisinopril, Omeprazole, a multivitamin, vitamin C, and an Ocuvite gummy. However, discrepancies were noted in the administration of Omeprazole and vitamin C. The resident received Omeprazole 40 mg instead of the prescribed 20 mg, and vitamin C 500 mg instead of the prescribed 1000 mg. The resident involved had a history of memory problems, severely impaired decision-making ability, and diagnoses including diabetes mellitus, anxiety disorder, immunodeficiency, Alzheimer's Disease, and dementia. The resident's care plan included a 1000 mg vitamin C order to promote wound healing for an unstageable pressure ulcer. The errors were attributed to incorrect entries in the Electronic Health Record (EHR) and a lack of verification against the Medication Administration Record (MAR). The Assistant Director of Nursing confirmed the Omeprazole order was incorrectly entered, and the Director of Nursing noted that staff should have clarified the order with the physician.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention practices during the care of a resident, identified as Resident #5, who required complex medical interventions including an enteral tube, tracheostomy tube, and a suprapubic catheter. During an observation of tracheostomy care performed by an LPN, it was noted that the LPN did not perform hand hygiene after removing gloves following the initial removal of the tracheal appliance, which was against the facility's policy. The Director of Nursing (DON) acknowledged this lapse in hand hygiene, which was expected to be completed with all glove changes. Additionally, during personal care provided by two CNAs to the same resident, there were missed opportunities for hand hygiene. The CNAs did not perform hand hygiene and change gloves when moving from the peri area to the suprapubic catheter stoma, from the catheter stoma to the buttocks, and before applying barrier cream. The DON confirmed that hand hygiene and glove changes should have been conducted at these points, as per the facility's hand hygiene policy.
Failure to Provide Adequate ADL Assistance and Repositioning
Penalty
Summary
The facility failed to provide adequate care for a resident who required assistance with activities of daily living (ADLs). The resident, who had multiple medical conditions including athetoid cerebral palsy, contractures, and quadriplegia, was documented as rarely or never understood and required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. The care plan indicated that the resident needed assistance from two people for bathing twice a week and repositioning every two hours to prevent skin breakdown and promote comfort. However, staff interviews revealed that the resident was not repositioned regularly and was left lying on their back with only stuffed animals for support, despite grimacing when repositioned. The Director of Nursing (DON) and other staff members believed that the air flow mattress provided sufficient pressure relief, negating the need for repositioning. Additionally, the facility failed to provide the resident with the expected number of baths. The bathing records showed that the resident received only one bath per week for three out of four weeks, missing scheduled baths on several occasions. The DON acknowledged that the facility's expectation was for the resident to receive two baths per week, and that missed baths should have been made up. The facility's policies on repositioning and ADLs emphasized the importance of individualized care plans to prevent skin breakdown and maintain or improve residents' abilities to perform ADLs, but these were not adhered to in the case of this resident.
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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