Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Living Center West during CMS and state inspections, most recent first.
Failure to provide written bed hold notice at hospital transfer: A resident with HF, renal insufficiency, respiratory failure, and pneumonia was sent to the hospital after the provider was notified of worsening condition, including diminished lung sounds, SOB, confusion, weakness, and slurred speech. Staff reported no completed bed hold form was generated, and the DON said the EHR did not produce one, despite the admission agreement requiring written bed hold information and documentation of the resident or representative’s response.
Failure to use EBP during high-contact care for a resident with a urinary catheter and pressure ulcer. Two CNAs transferred the resident and handled the catheter bag without the required gown and gloves, despite the care plan and room signage directing PPE use for transfers and device care. The room had gloves and masks available, but no gowns, and staff interviews confirmed EBP was expected for these activities.
A CNA at an LTC facility violated a resident's privacy by recording and posting a video of the resident on Snapchat. The resident, who had moderate cognitive impairment and other mental health diagnoses, was filmed without dentures while eating ice cream. The CNA had previously signed agreements prohibiting such actions, leading to their termination after the incident was reported and investigated.
A facility failed to report an abuse allegation within the required 2-hour timeframe. A CNA recorded a video of a resident with cognitive impairment and posted it on Snapchat. The incident was reported to the state agency after the deadline, violating the facility's policy on abuse reporting.
The facility failed to effectively conduct QA activities, resulting in recurring deficiencies identified in both previous and current surveys. The Administrator was unaware of any plans to address past deficiencies due to a lack of information transfer from the previous administrator. The QAPI Program Policies and Procedures outlined responsibilities for the QAA Committee, but there was no evidence of effective action or communication.
A resident's advance directive records were inconsistent, with one document requesting CPR and another indicating DNR status. The facility lacked a centralized location for advance directive information, leading to staff confusion. The resident had intact cognition and the facility's policy required removal of revoked directives, which was not followed.
A resident with moderate cognitive impairment and multiple diagnoses expressed a desire to leave the facility, but the facility failed to initiate discharge planning or evaluate the resident's mental capacity. The resident's care plan required discharge plan reviews, but there was no documentation of decision-making capacity or Durable Power of Attorney. The social worker only advised the resident to discuss discharge with family, who were non-responsive. The facility's policy lacked guidance on discharge planning according to resident goals.
A facility failed to implement its smoking safety policy, allowing a resident with no cognitive impairment but diagnosed with Wernicke's Encephalopathy, bipolar disorder, and tremor to keep smoking materials in his room and smoke unsupervised. Staff interviews revealed that residents generally kept their smoking supplies with them, contrary to the policy requiring storage with nurses. The facility's policy instructed that smoking materials be stored in an area not easily accessible to others, which was not being followed.
A facility failed to document pre and post dialysis site assessments for a resident with end-stage renal disease. The MARs did not direct staff to assess the dialysis site after sessions, and Nurses Progress Notes lacked documentation of site assessments. Interviews with staff revealed inconsistencies in documentation practices, despite facility policies requiring complete documentation and monitoring of the vascular access site.
A resident with dementia and depression was involved in an inappropriate relationship with the Activities Director, who engaged in kissing and personal discussions with the resident. Despite witnessing the conduct, staff failed to report it promptly, and the facility did not investigate or separate the staff member from residents, resulting in Immediate Jeopardy to resident safety.
A facility failed to report an allegation of sexual exploitation involving a resident and a staff member, which was observed by another staff member. The incident, witnessed on May 7, 2024, was not reported to the administration until June 10, 2024, despite the facility's policy requiring immediate reporting to the State Agency. The resident involved had a history of dementia, anxiety, and depression, and expressed feelings of love for the staff member. The situation was further complicated by a lack of communication and action among staff, leading to an Immediate Jeopardy to resident safety.
A facility failed to investigate an allegation of sexual exploitation involving a resident and a staff member, resulting in Immediate Jeopardy. The incident, involving the Activities Director and a resident, was not reported to administration for weeks, and the facility did not separate the alleged perpetrator from residents or report the incident to the state agency promptly. The resident, with a history of dementia and anxiety, had informed their guardian about the relationship, but the facility lacked documentation of an investigation.
A resident was left exposed for several minutes during incontinence care, violating privacy policies. Two CNAs and the DON were involved in the incident, where the resident's frontal perineal area was left uncovered while staff left the room to retrieve supplies. The facility's policy on personal privacy was not followed, as confirmed by staff interviews.
A resident with a history of arthritis, dementia, and weakness, and a BIMS score indicating severely impaired cognition, was not provided with a pressure-reducing cushion as per their care plan. Despite having a Stage 2 pressure ulcer, observations showed the resident without the cushion in their wheelchair on multiple occasions. Staff interviews revealed lapses in replacing the cushion after cleaning or incontinence episodes, contrary to the facility's pressure ulcer prevention policy.
The facility failed to effectively implement QA activities for abuse prevention, lacking comprehensive documentation and a systematic approach to address quality deficiencies. Despite having a PIP in place, there was insufficient evidence of ongoing QAPI activities related to resident treatment and abuse prevention.
Several residents reported feeling rushed and handled roughly by staff, particularly during overnight shifts. Staff interviews confirmed that some CNAs worked too quickly and had attitudes perceived as rude. Residents expressed fear and anxiety about the care they received, indicating a failure to uphold their rights to dignity and respect.
The facility failed to document and assess catheter care for residents, affecting all residents using catheters. A resident with an indwelling catheter lacked specific care interventions, and documentation was inconsistent. Another resident with multiple diagnoses also lacked catheter care documentation. Observations showed catheter care without fluid intake discussions or urine output documentation. Staff interviews revealed poor communication and lack of supplies, with no consistent documentation practices. The facility's policies did not provide comprehensive guidance for catheter care.
The facility experienced significant supply shortages, affecting its ability to provide necessary care to residents. Staff reported running out of essential items like catheter care supplies, medication cups, and wound dressings, leading to improvised solutions and reliance on family members for supplies. The DON confirmed monthly ordering practices and acknowledged the strain of high acuity on supply levels.
A resident with a urinary catheter did not have catheter care orders in place for 27 days after admission, leading to a deficiency in care. The resident, who required supervision and had several medical conditions, began experiencing pain, prompting an LPN to seek orders from a Nurse Practitioner. The facility's catheter care policy lacked procedures for catheter orders and documentation of input/output, and the facility only monitored fluid intake or urine output with a provider's order.
A facility failed to provide ordered wound care for a resident with multiple health conditions, resulting in a hospital transfer due to a severe pressure injury. Staff cited issues with staffing, communication, and supply management. Another resident did not receive proper skin assessments, with a reported bruise from rough handling and missing documentation of skin assessments. Staff interviews revealed awareness of these issues, highlighting gaps in documentation and supply management.
The facility failed to identify and manage pressure ulcers for two residents at high risk. One resident developed two Stage 2 pressure injuries, and another developed a Stage 3 pressure sore due to inconsistent skin assessments and documentation. Staff interviews and observations confirmed the lack of adherence to the facility's wound management policy.
The facility failed to notify the guardian of a resident with moderately impaired cognitive abilities about a skin tear, bruises, and a room change. The lack of communication was confirmed through clinical record reviews and staff interviews, revealing non-compliance with the facility's notification policies.
The facility failed to provide appropriate skin assessment and interventions for two residents. One resident had a skin tear and bruises that were not properly documented or communicated to the guardian, while another resident with chronic wounds did not receive consistent wound assessments. Staff admitted to not following the facility's wound management policy, leading to deficiencies in care.
Failure to Provide Written Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide written bed hold notices at the time of hospital transfer for 1 of 1 residents reviewed for hospitalization. Resident #68’s record showed an admission date of 6/19/25 and diagnoses including heart failure, renal insufficiency, respiratory failure, and pneumonia. The clinical census listed the resident as stop billing on 7/12/25, and the MDS list included a Discharge Return Anticipated/End of PPS Part A stay assessment. A Communication with Physician note documented that on 7/12/25 at 9:00 AM the facility notified the provider of diminished lung sounds, difficulty breathing, confusion, weakness, pale cool clammy skin, and slurred speech, and the provider directed the facility to send the resident to the hospital. During review, Staff C stated there was no completed bed hold form for the hospital transfer, though the clinical record included a note that bed hold information had been discussed with the resident or family. The DON stated the facility did not generate a bed hold form in the EHR and described the bed hold form as a separate paper document that nurses needed to complete. The facility’s admission agreement stated that when a resident is temporarily absent for medical treatment, the facility shall provide written information about the bed hold policy and ask whether the resident or representative wishes the bed open, and shall document that the information was given and the response.
Failure to Use EBP During High-Contact Care
Penalty
Summary
The facility failed to utilize Enhanced Barrier Precautions (EBP) for high-contact resident care for a resident with an indwelling urinary catheter and an unhealed pressure ulcer. The resident’s MDS reflected severe cognitive impairment with a BIMS score of 5, and the medical diagnosis list included retention of urine and a pressure ulcer of the right buttock. The care plan identified a need for EBP related to the pressure ulcer and catheter, with interventions directing staff to wear a gown and gloves for high-contact activities, keep PPE available near the room entrance, and maintain precaution signage on or outside the resident’s door. During observation, two CNAs transferred the resident using a full body lift and handled the urinary catheter bag without wearing PPE. One CNA picked up the catheter bag with ungloved hands, placed it by the resident’s feet, then dropped it on the floor and hooked it under the wheelchair. The resident’s husband reported the CNAs had helped transfer the resident from the wheelchair to the bed and wore gloves but not a gown. The room had a PPE bag on the door with gloves and masks, but no gowns. Staff interviews confirmed the expectation to use EBP for transfers and other high-contact care, and the Infection Preventionist confirmed the EBP sign had been added to the room and that gloves were expected when handling the catheter bag.
Violation of Resident Privacy Due to Unauthorized Video
Penalty
Summary
The facility failed to protect a resident's right to privacy when a Certified Nursing Assistant (CNA), identified as Staff A, took a video of a resident and posted it on a social media platform, Snapchat. The resident involved had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment and was diagnosed with Schizophrenia, moderate intellectual disability, and depression. The incident occurred when Staff A was interacting with the resident, who was eating an ice cream cone, and recorded the resident without dentures, jokingly asking to see their teeth. The video was then shared on Staff A's private Snapchat story. The facility's internal investigation revealed that Staff A had signed a Confidentiality Agreement and a Dependent Adult Abuse Policy Review, which prohibited taking photographs or recordings of residents and posting them on social media. Despite this, Staff A violated these agreements, leading to their termination. The incident was reported to the Department of Inspections, Appeals, and Licensing (DIAL) by the facility after being notified by the former Assistant Director of Nursing (ADON), who had seen the video on Staff A's Snapchat story. The facility's policy explicitly prohibits acts that result in personal degradation, including the unauthorized taking and sharing of electronic images of residents.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation to the state agency within the required 2-hour timeframe. This deficiency involved a resident with moderate cognitive impairment, schizophrenia, moderate intellectual disability, and depression. The incident occurred when a Certified Nursing Assistant (CNA), identified as Staff A, recorded a video of the resident without dentures, jokingly interacting with the CNA while eating an ice cream cone. The video was then posted to Staff A's private Snapchat story, which was accessible to anyone on Staff A's friends list. The former Assistant Director of Nursing (ADON), Staff C, witnessed the video on Snapchat and informed the former Director of Nursing (DON), Staff B, via text message on the same day. Staff B then notified the Facility Administrator the following day. The facility reported the incident to the Department of Inspections, Appeals, and Licensing (DIAL) after the 2-hour window had passed. The facility's policy clearly prohibits staff from engaging in acts of personal degradation, including the distribution of photographs or recordings on social media, and mandates reporting allegations of abuse within 2 hours.
Failure in QA Activities Leads to Recurring Deficiencies
Penalty
Summary
The facility failed to carry out Quality Assurance (QA) activities effectively, as evidenced by the recurrence of deficiencies identified in previous and current surveys. The CMS 2567 form dated 1/18/24 listed concerns under tags F689 and F698, which were also identified in the survey conducted from 9/16/24 to 9/19/24. During an interview on 9/19/24, the Administrator admitted to not knowing if plans were put in place to address the deficiencies from the previous survey, citing a lack of information transfer when the previous administrator left. The facility's QAPI Program Policies and Procedures, which were undated, indicated that the QAA Committee is responsible for developing and implementing plans of action to correct deficiencies, but there was no evidence of such actions being taken or communicated effectively.
Inaccurate Advance Directive Records
Penalty
Summary
The facility failed to maintain accurate advance directive records for a resident, leading to a discrepancy in the resident's code status documentation. The resident, who had intact cognition as indicated by a score of 15 on the Brief Interview for Mental Status exam, had conflicting documents in their chart. One document, titled Policy for Resuscitative Services/Cardiopulmonary Resuscitation, indicated that the resident requested CPR in the event of respiratory or cardiac arrest. However, the Iowa Physician's Orders for Scope of Treatment (IPOST) form, located behind the CPR document, stated that CPR should not be attempted if the resident was not breathing and had no pulse. The inconsistency was discovered during a chart review, and it was noted that the facility did not have a centralized location for advance directive information. A Licensed Practical Nurse (LPN) was unaware of the discrepancy and would have relied on the first document in the chart, which requested CPR. The facility's policy on Advanced Directives required that revoked directives be removed from the resident's medical record to prevent misunderstandings, but this procedure was not followed, resulting in the deficiency.
Failure to Address Resident's Discharge Goals and Needs
Penalty
Summary
The facility failed to address the discharge goals and needs of a resident with moderate cognitive impairment, as indicated by a BIMS score of 12/15. The resident, diagnosed with alcohol cirrhosis of the liver with ascites, non-Alzheimer's dementia, and Diabetes Mellitus, expressed a desire to leave the facility and return home. Despite the resident's verbalized wishes and inquiries about discharge, the facility did not initiate any discharge planning or evaluate the resident's mental capacity to make such decisions. The resident's care plan required quarterly reviews of discharge plans, but there was no documentation of Durable Power of Attorney or mental capacity documents to indicate the resident's inability to make medical decisions. The facility's social worker only advised the resident to discuss discharge with family members, who were reportedly non-responsive and opposed to the resident returning home. The facility's administrator acknowledged the lack of a designated decision-maker for the resident and was uncertain if guardianship had been pursued. The facility's policy on Transfer/Discharge Criteria lacked guidance on discharge planning according to resident goals or determining medical decision-making capacity, contributing to the deficiency in addressing the resident's discharge needs.
Failure to Implement Smoking Safety Policy
Penalty
Summary
The facility failed to implement its policy to ensure the safety of both smoking and non-smoking residents, specifically concerning Resident #65. The Minimum Data Set (MDS) report indicated that Resident #65 had no cognitive impairment and was diagnosed with Wernicke's Encephalopathy, bipolar disorder, and tremor. Despite the Smoking Safety Screen documenting that Resident #65 was to have his lighter and cigarettes stored by the facility for safety, the resident reported keeping his smoking materials in his room and smoking unsupervised. Interviews with staff revealed that residents generally kept their smoking supplies with them, contrary to the facility's policy. The MDS coordinator stated that smoking safety screenings are conducted quarterly and that smoking materials should be stored with the nurses, either at the nurse's station or in a locked medication room. However, both Staff A and Staff B, LPNs, confirmed that residents typically kept their smoking supplies in their rooms. The Administrator acknowledged that residents were informed to keep their smoking materials with the nurse in a lock box due to safety risks for other confused residents, but compliance was an issue. Although the facility is technically non-smoking, alert and oriented residents with a safety assessment are allowed to smoke off campus. The facility's policy instructed that smoking materials be stored in an area not easily accessible to others, which was not being followed in practice.
Failure to Document Dialysis Site Assessments
Penalty
Summary
The facility failed to complete pre and post dialysis assessments, including site assessments, for a resident with chronic kidney disease, stage 4, and end-stage renal disease. The Medication Administration Record (MAR) for the resident did not include directives for staff to assess the dialysis site after the resident returned from dialysis sessions. This oversight was consistent across multiple months, as evidenced by the MARs from July, August, and September 2024. The resident's care plan required assessment of the access site, but the Nurses Progress Notes lacked documentation of such assessments on several occasions. Interviews with facility staff, including a Registered Nurse (RN), a Licensed Practical Nurse (LPN), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed inconsistencies in the documentation and assessment practices. While staff reported checking vital signs and the dialysis site, there was no documentation to support these actions. The facility's Dialysis Binder and policy required complete documentation of hemodialysis forms and ongoing monitoring of the vascular access site, but these procedures were not followed, leading to the deficiency.
Failure to Prevent Sexual Exploitation of Resident by Staff
Penalty
Summary
The facility failed to prevent sexual exploitation of a resident by a staff member, specifically the Activities Director, who engaged in inappropriate conduct with a resident. The incident was first observed when a staff member saw the Activities Director and the resident kissing in the activity room. Despite witnessing this event, the staff member left the room without reporting the incident to the administration until several weeks later. The facility did not take immediate action to separate the staff member from the resident or other residents, nor did they document an investigation into the situation. The resident involved had a history of non-Alzheimer's dementia, anxiety disorder, and depression, with a Brief Interview for Mental Status (BIMS) score indicating intact cognition. The resident required supervision for certain activities and had a care plan that highlighted impaired cognitive function and mood distress. Despite these vulnerabilities, the facility did not adequately protect the resident from the inappropriate relationship, which included kissing and discussions of personal matters by the staff member. The facility's failure to act promptly and investigate the allegations of abuse resulted in an Immediate Jeopardy to the health and safety of the residents. The facility lacked documentation of an investigation into the concerns reported by the resident's guardian and did not report the concerns to the State Agency. This inaction allowed the inappropriate relationship to continue for several months, affecting the resident's mental health and well-being.
Failure to Report Alleged Sexual Exploitation
Penalty
Summary
The facility failed to report an allegation of sexual exploitation involving a resident and a staff member, which was observed by another staff member. On May 7, 2024, a Certified Medication Aide (CMA) witnessed the Activities Director, Staff A, and a resident kissing in the activity room. Despite this observation, the incident was not reported to the administration until June 10, 2024. The facility's policy required that all allegations of abuse be reported immediately to the State Agency, no later than two hours after receiving the report. However, there was no documentation indicating that the concerns were reported to the State Agency following the initial report from the resident's guardian in February 2024. The resident involved, who had a history of non-Alzheimer's dementia, anxiety disorder, and depression, was described as having intact cognition with a BIMS score of 13. The resident's care plan indicated a need for 24-hour care and supervision due to impaired cognitive function and mood distress. The resident had expressed feelings of love for Staff A and had communicated this to his guardian, who reported the situation to the former Administrator via email. Despite this, there was no follow-up or investigation documented by the facility into the allegations or the resident's reported text messages to Staff A. The situation was further complicated by the lack of communication and action among staff members. The CMA who witnessed the incident reported it to a Registered Nurse (RN), who then directed the CMA to report it to the Director of Nursing (DON). However, the RN assumed that Staff A had self-reported the incident, leading to a delay in addressing the situation. The facility's failure to promptly report and investigate the allegations resulted in an Immediate Jeopardy to the health and safety of the residents, as identified by the State Agency.
Failure to Investigate Allegation of Sexual Exploitation
Penalty
Summary
The facility failed to investigate an allegation of sexual exploitation involving a resident and a staff member, which was observed by another staff member. The incident involved the Activities Director, Staff A, and Resident #10, who were seen kissing in the activity room. Despite the observation, the event was not reported to the administration until several weeks later. During this time, the facility did not take immediate action to separate the alleged perpetrator from the resident or other residents, nor did they report the incident to the Department of Inspections, Appeals, and Licensing (DIAL) until months later. Resident #10, who had a BIMS score indicating intact cognition, had a history of non-Alzheimer's dementia, anxiety disorder, and depression. The resident's care plan noted the need for consistent caregivers to reduce confusion. Despite these needs, the facility did not document an investigation into the concerns reported by Resident #10's guardian, who had been informed by the resident about the relationship with Staff A. The guardian had emailed the former Administrator about the situation, but there was no follow-up documented. The facility's failure to act promptly and appropriately in response to the allegations resulted in an Immediate Jeopardy to the health and safety of the residents. The facility's policy required immediate investigation and protective measures, such as suspending the employee or removing them from resident contact, which were not implemented in a timely manner. This lack of action allowed the inappropriate relationship to continue, as evidenced by further observations and admissions by the involved parties.
Resident Privacy Breach During Incontinence Care
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident during incontinence care. Resident #6, who had intact cognition and required total assistance for toileting hygiene, was left exposed for several minutes during a care procedure. The incident occurred when two Certified Nursing Assistants (CNAs), Staff E and Staff F, along with the Director of Nursing (DON), were involved in transferring the resident to the bed using a mechanical lift. After pulling down the resident's pants and unfastening the incontinent brief, Staff F left the room to find a larger brief, leaving the resident's frontal perineal area exposed. Staff E waited for approximately two minutes before proceeding with the cleaning, and the DON returned to the room during this time, indicating that Staff F would return with additional items. Several minutes passed before Staff F returned with a pan of water, which Staff E used to complete the perineal cleansing. Throughout this period, the resident remained exposed without a drape, violating the facility's policy on residents' rights to personal privacy during personal care. Interviews with staff, including an LPN and the DON, confirmed that residents should be covered if staff need to step away during care.
Failure to Provide Pressure-Reducing Cushion for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to adhere to the care plan for a resident with a pressure ulcer by not providing a pressure-reducing cushion in the resident's wheelchair. The resident, who had a history of arthritis, non-Alzheimer's dementia, and weakness, was identified as having severely impaired cognition with a BIMS score of 5 out of 15. The care plan, dated June 12, 2024, specified the use of a pressure-reducing cushion due to the resident's risk for skin breakdown related to impaired mobility, incontinence, and weakness. Despite this, observations on multiple occasions revealed the resident was without the cushion in her wheelchair. The resident had a Stage 2 pressure ulcer on the coccyx, with measurements indicating changes over time. Staff interviews revealed that the cushion was not consistently replaced after being removed for cleaning or due to incontinence episodes. The facility's policy on pressure ulcer prevention emphasized the importance of pressure relief and the use of pressure redistribution devices, which was not followed in this case. The Director of Nursing acknowledged the absence of the cushion but could not provide a specific reason for the lapse, despite the availability of extra cushions.
Deficiency in QA Activities for Abuse Prevention
Penalty
Summary
The facility failed to effectively carry out Quality Assurance (QA) activities to address issues related to resident treatment and abuse prevention. Despite having a Performance Improvement Project (PIP) in place since January 2024, which included abuse prevention training and monitoring, the facility lacked comprehensive documentation of ongoing Quality Assurance and Performance Improvement (QAPI) activities. The facility's QAPI plan, last updated in 2018, was supposed to guide the quality improvement program, but there was no evidence of a systematic approach to identify and correct quality deficiencies, nor was there documentation of monitoring or evaluating the effectiveness of corrective actions. During the survey conducted in July 2024, it was found that the facility had not maintained adequate records of QA activities from January to June 2024, specifically concerning dignity and abuse prevention. The Administrator mentioned that staff had completed abuse training by February 2024 and received education on de-escalation techniques and resident rights. However, the facility did not provide sufficient evidence of an ongoing QAPI program or a structured process to address and rectify quality issues, as required by regulatory standards.
Deficiency in Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of residents during care, as evidenced by multiple reports from residents and staff observations. Resident #3, with intact cognition and requiring total assistance for daily activities, reported feeling rushed and handled roughly by Staff A, a CNA, during overnight shifts. This resident expressed fear of using the call light due to uncertainty about the response they would receive. Staff interviews corroborated these concerns, with several staff members acknowledging that some CNAs, including Staff A, worked too quickly and had attitudes perceived as rude by residents. Resident #6, also with intact cognition and requiring total assistance, reported similar experiences with Staff A, describing instances of being moved too quickly and feeling like a nuisance. The resident's roommate confirmed these observations, noting that Staff A's behavior was affected by long working hours. Staff interviews further highlighted that Staff A had a rigid routine and could become frustrated when it was disrupted, leading to rushed care that residents found distressing. Additional residents, including Resident #7, #8, and #9, reported issues with staff behavior during care. Resident #7 expressed anxiety about the overnight staff's demeanor, while Resident #8 described an incident where a CNA pushed him back into bed, causing fear and helplessness. Resident #9 noted that staff were often too fast and lacked gentleness, although he did not believe they intended harm. These accounts, supported by staff interviews, indicate a pattern of care that compromised the residents' rights to dignity and respect.
Deficiency in Catheter Care Documentation and Assessment
Penalty
Summary
The facility failed to accurately and thoroughly assess and document catheter care for residents using catheters, as evidenced by the lack of documentation regarding fluid intake, voiding patterns, cleaning care, or symptoms associated with long-term catheter use. This deficiency was identified for three residents specifically reviewed for catheter use and extended to all twelve residents in the facility using catheters. The facility's policies did not adequately address the necessary components of catheter care, including assessments, monitoring, and communication with providers. Resident #1, with intact cognition and requiring supervision for mobility, had an indwelling catheter due to urinary retention. The care plan lacked specific interventions for catheter site cleaning, changing the catheter bag, and monitoring fluid intake or urinary output. Documentation was inconsistent, with missing records of catheter care and continence status. Similarly, Resident #2, who required substantial assistance and had multiple diagnoses including paraplegia and pressure ulcers, also lacked documentation of catheter care and related assessments. Resident #9, requiring assistance with mobility and diagnosed with benign prostatic hyperplasia and chronic pain, was observed receiving catheter bag care without discussions on fluid intake or documentation of urine output. Interviews with staff revealed a lack of supplies, poor communication, and no consistent documentation practices for catheter care. The facility's Director of Nursing confirmed the absence of catheter care documentation, and the existing policies did not provide comprehensive guidance for catheter care and monitoring.
Supply Shortages Impact Resident Care
Penalty
Summary
The facility failed to maintain an adequate supply of necessary items to meet the daily needs of its residents, as evidenced by multiple staff reports and observations. The Treatment Administration Record for a resident showed a lack of documentation for 12 treatments over a six-day period. Staff members, including an LPN, CNA, and RN, reported shortages of essential supplies such as catheter care items, medication cups, blood glucose test strips, alcohol squares, tissues, and gloves. These shortages led to improvised solutions, such as using pudding cups instead of medication cups, and even required a family member to bring in colostomy supplies for a new resident. The Assistant Director of Nursing and the Director of Nursing confirmed the supply issues, noting that supplies were ordered once a month, with emergency orders as needed. The DON acknowledged the strain high acuity placed on their supply levels and mentioned efforts to increase stock. Observations of storage areas and medication carts revealed significant shortages of wound dressings, with some staff resorting to locking supplies to prevent them from disappearing. These findings indicate a systemic issue in supply management, impacting the facility's ability to provide consistent care.
Failure to Ensure Catheter Care Orders in Place
Penalty
Summary
The facility failed to ensure catheter care orders were in place for a resident who required such care. The resident, who had intact cognition and required supervision or assistance with mobility, had diagnoses including benign prostatic hyperplasia, chronic kidney disease, and respiratory failure. Despite having a urinary catheter, the resident's care plan lacked interventions for cleaning the catheter site, changing the catheter bag, or changing the catheter itself. There were no documented orders for catheter care in the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) until 27 days after admission. The deficiency was further highlighted when the resident began complaining of pain, prompting a Licensed Practical Nurse (LPN) to contact the Nurse Practitioner for catheter care orders. The facility's policy on catheter care, effective since 2018, did not include procedures for catheter orders, bag replacement, or documentation of input/output. Interviews with the Administrator and Director of Nursing revealed that the facility only monitored fluid intake or urine output if there was a provider's order, and there was no documentation of emptying the bags or tracking fluid intake that could have identified the missing orders.
Deficiencies in Wound Care and Skin Assessment
Penalty
Summary
The facility failed to provide wound care as ordered for a resident with multiple health conditions, including diabetes mellitus, paraplegia, and a stage IV pressure ulcer. The resident required substantial assistance with mobility and had a care plan in place to address skin breakdown. However, the Treatment Administration Record (TAR) showed that numerous treatments were not completed as scheduled, and a Medication Administration Audit Report indicated that most treatments were provided outside their scheduled time frames. The resident was eventually transferred to a hospital with a pressure injury and necrotizing fasciitis, highlighting the severity of the oversight in wound care management. Staff interviews revealed issues with staffing consistency, communication, and supply management, contributing to the missed treatments. Another resident, who required total assistance with mobility and had diagnoses of morbid obesity, anxiety, and depression, did not receive proper skin assessments. The resident reported a bruise resulting from rough handling during repositioning, but the facility's progress notes lacked documentation of a skin assessment or the origin of the bruise. The facility also failed to document completed skin assessments during the resident's showers over several dates. The Administrator acknowledged the lack of documentation and noted that a new tracking log system had been recently implemented, but it was not available for the month in question. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed awareness of the issues with wound care and skin assessments. The DON mentioned challenges with supply management due to high acuity levels and insurance limitations. The LPN reported difficulties in ensuring adequate dressing supplies and noted that agency staff might not have completed all treatments. The Administrator admitted that if documentation was missing, it was assumed the treatment was not performed, indicating a gap in the facility's documentation practices.
Failure to Identify and Manage Pressure Ulcers
Penalty
Summary
The facility failed to identify and properly manage impaired skin for two residents at high risk of developing pressure sores. Resident #5, who had severe cognitive impairment and required extensive assistance for personal hygiene and mobility, developed two Stage 2 pressure injuries on the coccyx and right buttock. Despite the care plan directing staff to monitor the resident's skin condition and provide treatments as ordered, there were no documented skin assessments in the nursing progress notes from 3/7/24 to 5/3/24. The pressure sores were identified during a facility-wide skin assessment mandated by the administrator, revealing a lack of regular skin assessments as per policy. Resident #6, who had moderately impaired cognition and required total assistance for mobility and toileting, also developed a Stage 2 pressure ulcer on the right buttock, which later healed but was not consistently monitored. The resident's care plan directed weekly skin assessments, but the nursing progress notes from 3/1/24 to 5/2/24 lacked documentation of these assessments. The resident later developed a Stage 3 pressure sore on the left buttock, indicating a failure to continue skin assessments as required. Staff interviews confirmed that weekly skin checks were not performed, and the resident's resistance to care was noted as a contributing factor. The Director of Nurses stated that aides are expected to observe and report skin concerns during care, but no bath sheets documenting these observations were found for Resident #5. The facility's policy on wound management requires documented assessments with every dressing change and at least weekly, but this was not adhered to. The facility-wide skin assessment identified additional residents with impaired skin, highlighting a systemic issue with skin assessment and documentation practices.
Failure to Notify Guardian of Resident's Condition and Room Change
Penalty
Summary
The facility failed to notify the guardian of Resident #2 in a timely manner when the resident experienced a change in condition. Resident #2, who had moderately impaired cognitive abilities and a history of falls, was admitted with a skin tear and bruises that were not communicated to the guardian. Additionally, the resident underwent a room change, and the guardian was not informed of this change either. The lack of notification was confirmed through clinical record reviews and staff interviews, where it was revealed that the staff did not follow the facility's policies for notifying the resident's representative of significant changes in condition or room changes. On 4/4/2024, the resident's family discovered additional bruising during a visit, which had not been previously documented or communicated to the guardian. Staff A, an LPN, initiated skin assessment sheets but failed to notify the guardian. Staff B, the DON, acknowledged that the nurse performing the admission assessment should have notified the guardian of any concerns and that it was their responsibility to inform the guardian of room changes. The facility's policies clearly outlined the need for prompt notification of any significant changes in condition or room assignments, which were not adhered to in this case.
Failure to Provide Appropriate Skin Assessment and Interventions
Penalty
Summary
The facility failed to provide appropriate skin assessment and interventions for two residents. Resident #2, who had moderately impaired cognitive abilities and a history of falls, was admitted with a skin tear and bruises that were not properly documented or communicated to the resident's guardian. Observations revealed that the resident had a dark red gauze dressing and scattered bruises, which were not promptly reported to the nurse or the guardian. The Director of Nursing acknowledged that the staff should have initiated skin assessment sheets upon admission and notified the resident's family or guardian of any concerns. Resident #1, who had intact cognitive status but later experienced severe cognitive impairment, had multiple chronic wounds that were not consistently assessed or documented. The resident's care plan required weekly documentation of wound assessments, but nursing progress notes from mid-March to early May failed to include necessary details. Observations revealed that the resident had three significant wounds, and the Primary Care Physician noted that these wounds were unlikely to heal due to severe venous insufficiency. The Director of Nursing admitted that the staff failed to complete weekly skin assessments as per facility policy. Interviews with staff members revealed inconsistencies in wound care practices and documentation. Staff admitted to not measuring wounds weekly as required and acknowledged that the resident had been to the wound clinic inconsistently. The facility's policy on wound management emphasized the importance of regular assessments and documentation, but these procedures were not followed, leading to deficiencies in the care provided to the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cedar Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Cedar Rapids | 1.2 mi | ★★★★★ | 12 | 0 |
| Cottage Grove Place | 1.4 mi | ★★★★★ | 2 | 1 |
| Meth-wick Health Center | 1.9 mi | ★★★★★ | 0 | 0 |
| St Luke's Helen G Nassif Transitional Care Center | 2.8 mi | ★★★★★ | 4 | 0 |
| West Ridge Care Center | 2.9 mi | ★★★★★ | 3 | 0 |
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