Living Center West
Inspection history, citations, penalties and survey trends for this long-term care facility in Cedar Rapids, Iowa.
- Location
- 1050 4th Avenue Se, Cedar Rapids, Iowa 52403
- CMS Provider Number
- 165278
- Inspections on file
- 21
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Living Center West during CMS and state inspections, most recent first.
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.
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.
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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