Luther Manor At Hillcrest
Inspection history, citations, penalties and survey trends for this long-term care facility in Dubuque, Iowa.
- Location
- 3131 Hillcrest Road, Dubuque, Iowa 52001
- CMS Provider Number
- 165513
- Inspections on file
- 27
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Luther Manor At Hillcrest during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow required fall and hazard prevention interventions for multiple residents. A resident with dementia and high fall risk sustained full‑thickness wounds to the knee after being found in bed with the knee against a very hot heater, and later had a fall with head and elbow injuries after being left alone in a wheelchair despite a care plan requiring that he not be left alone in his room. Another resident with severe cognitive impairment, care planned for 2‑person EZ stand transfers, was twice transferred improperly by a single CNA using a pull‑up bar and then a power recliner and gait belt, and was later found to have a fractured ankle. A third resident with repeated falls and gait problems was repeatedly observed standing and transferring in regular socks without shoes or gripper socks, with wheelchair foot pedals attached and brakes not effectively locked, contrary to care‑planned interventions, while staff reported inconsistent knowledge and communication of transfer and safety requirements.
Surveyors identified multiple food service sanitation deficiencies, including dietary staff and cooks wearing hairnets that did not fully contain their hair, leaving hair exposed while working in food preparation areas. Observations revealed unclean conditions in the freezer, dry storage, and ice machine, with spilled food, sticky residues, and visible films on equipment and surfaces. Dead cockroaches and debris were found under kitchen shelving, sinks, and the dish machine, and staff reported seeing both live and dead roaches despite ongoing pest control treatments. Review of cleaning logs showed that routine and deep cleaning tasks for kitchen and dish room floors were often not completed or not documented, contrary to facility policies requiring clean, pest‑free food service areas and proper use of hair restraints to prevent food contamination.
Surveyors found that staff failed to provide complete perineal care after incontinence for two cognitively impaired, fully dependent residents who were always incontinent of bowel and bladder. In one case, CNAs did not separate skin folds, reused the same washcloth surface across multiple areas, and did not cleanse all required areas such as hips and one buttock before applying a clean brief. In the other case, a CNA removed a heavily soaked brief and performed only a single wipe to the rectal area, without cleansing the front peri area or buttocks. Staff interviews and facility guidance confirmed that all skin exposed to urine or stool should be washed front to back, with a clean cloth surface for each stroke, and that this did not occur during the observed care episodes.
Two cognitively intact residents did not receive timely meals when relying on room trays. One resident awoke to find no breakfast tray delivered, reported that staff did not wake her for breakfast and that she often did not receive meals, and instead ate food stored in a mini fridge supplied by family; facility documentation listed breakfast as not applicable for this resident. Another resident did not receive a lunch tray when meals were distributed; staff attempted to contact dietary via walkie talkie without response, and the resident later used the call light to report not having eaten before a CNA finally delivered a tray, after the stated lunch period. The CDM described reliance on meal tickets and walkie calls to identify needed trays, and the DON stated CNAs are responsible for room tray delivery and intake documentation and that residents are expected to be offered three meals daily.
A resident with impaired cognitive skills received wound care to a left knee abrasion in which an LPN failed to follow infection control practices by not removing gloves or performing hand hygiene after cleansing the wound and by applying triple antibiotic ointment directly from the tube to multiple open areas using a single gloved finger instead of sterile applicators. Other RNs, the wound nurse, and the DON described expectations consistent with the facility’s wound care policy, which requires glove removal, handwashing after dressing removal, use of a no-touch technique, and use of sterile applicators for ointment application, highlighting that the observed practice did not follow established procedures.
A resident with multiple chronic conditions and cognitive impairment was found to have multiple Rivastigmine transdermal patches applied simultaneously due to staff failing to remove the old patch before administering a new one. This led to increased confusion, agitation, and falls, ultimately resulting in hospitalization for acute encephalopathy. Staff interviews and record reviews revealed inconsistent practices in patch administration and documentation, as well as a lack of a specific facility policy for transdermal patch use.
A resident with a history of amputation and chronic pain did not receive prescribed opioid pain medication for several days due to lack of availability and delays in obtaining a new prescription. Despite repeated reports of severe pain and requests for medication, staff were unable to provide the medication, resulting in the resident being sent to the ED twice for pain management before the issue was resolved.
Nursing staff did not perform required shift-to-shift narcotic counts for a resident receiving scheduled opioid pain medication, resulting in a missing Tramadol cassette. Multiple RNs and an LPN confirmed that narcotic counts were not completed as per facility policy, which mandates end-of-shift counts by both outgoing and incoming nurses. This failure led to an unaccounted-for controlled substance.
The facility failed to maintain food safety standards, with observations of unclean kitchen conditions and improper glove use by staff, leading to potential cross-contamination. Staff B and Staff D were noted for not changing gloves between tasks, and the kitchen had open, undated food items and uncovered trash cans.
The facility failed to effectively implement Quality Assurance activities to address deficiency F812, as identified in both a previous and current survey. Despite regular QAPI team meetings and a revised QAPI Plan, the facility struggled to correct the issue, indicating ongoing challenges in addressing quality problems.
The facility failed to maintain professional standards in food storage and sanitation. Observations revealed uncovered food in storage, ineffective sanitizing solutions, and improper food transport without covers. Additionally, the puree process was conducted without cleaning between different food items. The acting Dietary Manager was unaware of these issues, and daily cleaning logs were missing.
The facility failed to serve food at appropriate temperatures during two observed meals. Residents reported that their food was not hot, and temperature checks confirmed that food items were below the required range. The facility lacked a dietary manager, and the food temperature log showed numerous missed documentation opportunities. Staff were not covering food trays between servings, and a microwave was often used to reheat food.
Failure to Implement Fall and Hazard Prevention Measures for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and assistance to prevent accidents for multiple residents. For one resident with coronary artery disease, hypertension, peripheral vascular disease, cerebrovascular accident, non‑Alzheimer’s dementia, severe memory problems, and severely impaired decision‑making, the MDS showed dependence on staff for personal hygiene and dressing, substantial assistance needed for bed mobility, and a history of falls. This resident was found with his left knee resting against a metal heater while lying on his side in bed, with his pants pulled up to the knee, resulting in open areas and later‑described superficial burns/abrasions to the left knee. Staff and hospice documentation and interviews described the wounds as skin tears, abrasions, popped blisters, or possible burns, with full‑thickness skin loss in multiple irregularly shaped areas and a large surrounding area of redness. Temperature checks of the heater in the resident’s room showed metal surface temperatures ranging from approximately 107°F to over 139°F, and staff acknowledged the resident’s knee had been against the heater and that the heater was hot or warm to the touch. The same resident, who was care planned as high risk for falls with an intervention that he not be left alone in his room in a wheelchair (identified by a “wheelchair star” tag), experienced a fall when CNAs left him alone in his room in his wheelchair while they went to get an EZ stand lift. He was later found face down on the floor in front of his wheelchair with an abrasion and hematoma to the forehead, a bruise to the nose, and a skin tear to the left elbow. Observations and interviews revealed that the star tag was not present on his wheelchair at the time of survey, some staff were unaware of or stated they no longer used the star program, and there was inconsistency in how staff were informed of residents’ transfer and supervision requirements. Staff interviews confirmed that the resident was not supposed to be left alone in his room in a wheelchair, and the DON stated staff did not follow the plan of care when they left him alone, after which he fell. Another resident with hypertension, diabetes, depression, severe cognitive impairment, and a need for maximal assistance with transfers was care planned to require two‑person assistance with an EZ stand lift. Despite this, one CNA transferred the resident alone using a pull‑up bar, and on a later date another CNA attempted to transfer the resident from an electric recliner using a gait belt and walker after the resident stated she could walk, rather than using the EZ stand with two staff as required. During the latter event, the CNA raised the power recliner, attempted to have the resident bear weight, and the resident slid out of the chair to the floor. The following day, the resident was found with a bruised, swollen, and painful right ankle, unable to move it, and an x‑ray showed a mildly displaced fracture of the lateral malleolus. Multiple CNAs and nurses reported inconsistent or unclear methods for determining transfer status (door signs, wing sheets, binders, magnets, or the electronic kardex), and agency staff reported they had not been educated on where to find transfer information. A third resident with repeated falls, weakness, gait abnormalities, and moderate cognitive impairment was care planned to ambulate with assistance of one and a front‑wheeled walker, to have gripper socks applied, to have auto‑lock brakes on the wheelchair, and to have wheelchair foot pedals removed unless being propelled. The care plan also directed removal of white socks from the room because the resident removed shoes and gripper socks. Observations on multiple days showed the resident repeatedly in bed or standing and transferring while wearing only white socks, without shoes or gripper socks, and often without a gait belt. The resident was seen standing from bed and transferring to a wheelchair without gripper socks or shoes, self‑transferring between bed and wheelchair, and ambulating in the room with wheelchair pedals attached and brakes not locked. During one observation, the resident stood up with the wheelchair brakes not effectively engaged, and the wheelchair rolled backward and bumped into furniture. Staff acknowledged the anti‑lock brakes were not functioning properly and required maintenance, and the DON later stated the resident was not supposed to have white socks in the room, indicating the care‑planned interventions to prevent falls and accidents were not consistently implemented.
Food Service Sanitation and Pest Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to procure, store, prepare, and serve food in accordance with professional sanitation standards, resulting in multiple instances of potential physical contamination in the kitchen. During several kitchen observations, multiple dietary staff, including the Dietary Director, cooks, and dietary aides, wore hairnets that did not fully contain their hair, leaving 1–3 inches of hair exposed over the ears and at the back of the head. Staff interviews confirmed that hair was expected to be fully covered and that hairnets should be worn immediately upon entering the kitchen, but the Dietary Director acknowledged she was not aware her own hair was outside the hairnet until it was pointed out. Surveyors also observed significant cleanliness issues in food storage and preparation areas. In the freezer, whipped cream was sprayed on the right wall and had not been cleaned for several months, despite the Dietary Director knowing about it. In dry storage, there was dry cereal on the floor under and around racks, a plate storage unit with a white granular and clear sticky substance on it, and multiple yellowish-orange splotches under pasta, spices, and baking product shelves. The ice machine had an off‑white film under the door and a sticky brown/orange substance on the inside rim. A blue paper attached to a work surface with tape and plastic left behind a sticky residue and visibly soiled tape and paper when removed. Floor sanitation and pest control issues were also documented. Dead cockroaches and debris were observed under the pots and pans shelf, sanitizing sink, and dish machine on multiple days, and staff acknowledged seeing both live and dead roaches in the kitchen recently. Cleaning logs for the kitchen and dish room floors showed that out of 112 scheduled AM and PM cleaning opportunities in January, floors were documented as swept/washed only 34 times, with numerous days showing no entries for any cleaning tasks and deep cleaning completed only 3 of 36 opportunities. The Dietary Director later acknowledged that the January and February cleaning sheets were not completed accurately and appeared to show the kitchen was not being cleaned. Pest control confirmed ongoing treatments since November, continued findings of live and dead roaches in the kitchen, and identified the kitchen as the source of the infestation. Facility policies required that food service areas be kept clean, free of debris and pests, and that staff wear hair restraints to prevent contamination, but these standards were not met.
Incomplete Perineal Care After Incontinence for Two Dependent Residents
Penalty
Summary
Surveyors identified a deficiency in the provision of complete perineal care after incontinence for two residents who were always incontinent of bowel and bladder and dependent on staff for toileting hygiene and transfers. Resident #11 had severe cognitive impairment, hypertension, diabetes, anxiety disorder, and depression, and a care plan directing frequent incontinence care with barrier ointment. During observed care, two CNAs used a limited number of washcloths, did not separate skin folds while cleansing the perineum, reused the same surface of a washcloth across multiple areas, and failed to wash the hip areas and the right buttock before applying a clean brief. This care did not include washing all areas that came into contact with urine or stool, including abdominal folds, buttocks, and hips, as described by facility staff expectations and the facility’s incontinent care checklist. Resident #84 had dementia, anxiety, severely impaired cognitive skills for decision making, and was always incontinent of bowel and bladder, with a care plan requiring routine and as-needed incontinence care and assistance with post-toileting hygiene. Surveyors observed a heavily soaked brief being removed, described as making a “plop” noise when it hit the trash can, indicating it was very wet. During subsequent care, a CNA used a wipe to swipe the rectal area one time and did not wash the front perineal area or the buttocks before standing the resident with a stand lift. Staff interviews confirmed that all skin areas exposed to urine should be washed front to back, using a clean surface of the cloth with each stroke, and that the front perineal area had not been cleansed for this resident during the observed episode.
Failure to Provide Timely Meals to Residents Receiving Room Trays
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals were provided in a timely manner and in accordance with residents’ needs and preferences for two cognitively intact residents receiving room trays. For one resident with a BIMS score of 15/15, staff were overheard at the nurses’ station discussing that the resident had just awakened and did not have a breakfast tray. The resident later reported she did not get breakfast and that no one woke her up for breakfast, stating she frequently did not receive meals and that her son had purchased a mini fridge so she would always have food available. Surveyors observed the mini fridge in the room and a bag of doughnuts from her family on the overbed table, which the resident chose to eat instead of breakfast because it was close to lunchtime. Facility documentation for that morning’s breakfast was marked “NA” (not applicable) for the resident, indicating breakfast was not provided. For another resident with a BIMS score of 15/15, lunch trays were delivered to the unit, with trays identified either by orange sticky notes or meal tickets. After trays were distributed, staff used a walkie talkie to notify dietary that this resident did not have a tray on the cart, but no response was received. More than 30 minutes after initial tray delivery, the resident activated the call light and reported to a CNA that lunch had not yet been received. The CNA then delivered a room tray to the resident, which occurred after the facility’s stated lunch service window of 11:15 AM to 12:15 PM. The CDM reported that dietary is notified of needed trays via meal tickets or last-minute walkie calls and stated there had never been a problem with residents not being served, while the DON reported CNAs are responsible for taking trays to rooms and documenting intakes and that residents are expected to be offered three meals a day.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices during wound care for Resident #80. The resident’s MDS assessment showed severely impaired cognitive skills for daily decision making. Hospice orders for the resident’s left knee wound directed staff to cleanse the wounds with wound cleanser, apply triple antibiotic ointment, cover with a non-adhesive dressing, and wrap with cotton gauze twice daily and as needed. During an observation of wound care to an abrasion on the resident’s left knee, the LPN (Staff E) removed the dressing and cleansed the wounds but did not remove her gloves or wash her hands after cleansing. She then used her gloved index finger to apply triple antibiotic ointment directly from the tube to four areas on the left knee, three of which had open skin, without using a different finger or an applicator for each area. Other nursing staff and leadership described wound care procedures that differed from what was observed. One RN stated that gloves should be changed after removal of a soiled dressing and that hands should be washed, and that a sterile applicator should be used for each wound area when applying ointment. Another RN explained that after setting up supplies and cleaning the wound, gloves should be removed, hands washed, and ointment applied with gloves on, changing gloves with each area unless treating the same area, followed by glove removal, handwashing, and application of a clean dressing. The facility wound nurse (an LPN) reported she observed Staff E put ointment on her gloved finger and said she would have expected use of an applicator and hand hygiene between cleansing and ointment application. The DON stated staff should wash hands and change gloves between cleansing the wound and applying ointment. The facility’s wound care policy directed staff to remove gloves and wash and dry hands thoroughly after dressing removal, to use a no-touch technique, and to use sterile tongue blades and applicators to remove ointments and creams from their containers.
Failure to Remove Old Transdermal Patch Before Applying New Patch Resulting in Hospitalization
Penalty
Summary
A deficiency occurred when staff failed to remove an existing transdermal Rivastigmine patch before applying a new one to a resident with a history of coronary artery disease, hypertension, Parkinson's disease, and bipolar disorder. The resident, who required extensive assistance with daily activities and had documented cognitive impairment, was found to have multiple Rivastigmine patches on his body over several days. Medication administration records and staff interviews revealed that staff did not consistently locate and remove the old patch prior to applying a new one, and in some instances, staff could not find the previous patch but proceeded to apply another without a thorough body check or proper documentation. The resident subsequently exhibited increased confusion, agitation, and physical instability, including falls and hyperventilation. Staff discovered two patches on the resident during an episode of acute confusion, and further review indicated that the resident had as many as three patches on at one time. The resident's condition deteriorated, leading to hospital admission for acute encephalopathy. Medical records and interviews confirmed that the resident's mental status improved after the excess patches were removed and the medication was discontinued. Staff interviews highlighted inconsistent practices in patch administration, including failure to check for existing patches, improper documentation, and lack of adherence to protocols such as dating and initialing patches. The facility did not have a specific policy for transdermal patch administration, and staff were unclear about the correct procedures, contributing to the medication error and subsequent adverse event.
Failure to Provide Prescribed Pain Medication Resulting in Unmanaged Pain
Penalty
Summary
A deficiency occurred when a resident with a history of peripheral vascular disease, diabetes mellitus, and an above-knee amputation was not provided with their prescribed pain medication, Oxycontin, for several consecutive days. The resident's care plan included scheduled opioid pain management, and clinical documentation showed ongoing severe pain, including phantom limb pain and anxiety related to pain. Despite repeated documentation of pain and requests for medication, the facility failed to ensure the availability and administration of the prescribed pain medication from 8/13/25 to 8/18/25. During this period, medication administration records repeatedly noted that the pain medication was not available, and staff were awaiting a prescription from the primary care provider. The resident reported severe pain, rated as 10/10, and expressed distress and anger over the lack of medication. Staff documented communication attempts with the primary care provider and the orthopedic surgeon, but no new orders were obtained, and the medication remained unavailable. The resident's pain was not managed as required by the care plan and facility protocol, which instructed immediate contact with the prescriber if pain was not controlled. As a result of the unaddressed pain, the resident was sent to the emergency department on two occasions for pain management. Emergency department records confirmed that the resident sought care due to the lack of pain medication at the facility and received the necessary medication at the hospital. The resident returned to the facility with medication, but the issue persisted until the prescription was finally filled. Interviews with staff and the resident confirmed the ongoing pain and lack of medication during this period.
Failure to Reconcile Narcotic Counts Resulting in Missing Controlled Substance
Penalty
Summary
The facility failed to reconcile narcotic and controlled substance counts at the beginning and end of every shift for a resident who was receiving scheduled opioid pain medication. Clinical record review and staff interviews confirmed that nursing staff did not complete the required narcotic counts prior to exchanging keys or at shift changes, as mandated by facility policy and procedure. This lapse resulted in a missing narcotic cassette containing Tramadol, which was discovered during the process of administering medication to a resident with multiple diagnoses, including chronic pain and osteomyelitis. Multiple staff members, including RNs and an LPN, verified that narcotic counts were not performed as required, and acknowledged that it is the expectation to follow the facility's controlled substances policy. The facility's policy, dated April 2019, specifies that controlled medications must be counted at the end of each shift by both the outgoing and incoming nurse, with any discrepancies to be reported immediately to the director of nursing services. The failure to follow this policy led to the unaccounted-for controlled substance.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to food service safety standards, as observed during a kitchen inspection. Staff B, a cook, was initially observed without a hair net, and the kitchen floor was littered with food debris such as grapes, crumbs, and cheese slices. Kitchen counters and shelves were found with open and undated food items, including cereal boxes, peanut butter, and juice containers. The stove and oven were covered with food particles and grease, and trash cans in the kitchen lacked lids. Additionally, several food prep areas were unclean, with food particles and flour present. During lunch service, the kitchen remained in disarray despite being mopped, with wet paper towels and carrot coins on the floor. The stove continued to have dried pasta and grease, and garbage containers were still uncovered. Staff members, including Staff C and Staff D, were observed using gloves improperly, failing to change them between tasks, and touching various surfaces and food items, leading to potential cross-contamination. Staff D, the Dietary Manager, and other staff members handled food and kitchen equipment without changing gloves, further compromising food safety. Interviews with staff revealed a lack of adherence to proper food safety protocols. Staff D, the Dietary Manager, acknowledged the need for food items to be dated and for gloves to be changed between tasks to prevent cross-contamination. However, observations indicated that these practices were not consistently followed. Staff F, the Regional Supervisor of Health Services, noted that garbage containers should have lids and that staff should not wear gloves in the kitchen, instead using utensils to handle food. Despite these acknowledgments, the facility's failure to maintain a clean and safe food preparation environment was evident.
Facility's QAPI Activities Fail to Correct Deficiencies
Penalty
Summary
The facility failed to effectively carry out Quality Assurance activities to address and correct deficiencies, as evidenced by the CMS Statement of Deficiencies form and staff interviews. The facility, with a census of 96 residents, was found to have ongoing issues related to deficiency F812, which was identified in both a previous survey and a current complaint survey. The Administrator acknowledged that the QAPI team met regularly to discuss Performance Improvement Projects (PIP) and collected data from various sources, including online programs, suggestion boxes, grievance forms, and findings from the Department of Inspections, Appeals, and Licensing. Despite having a PIP in place for the previous survey deficiency, the facility continued to struggle with addressing the identified issues. The facility's QAPI Plan, revised in December 2024, outlined a process for reviewing information to identify gaps or patterns in care systems that could lead to quality problems. The plan emphasized prioritizing areas with high risk, high frequency, or problem-prone issues and chartering a PIP team to oversee problem resolution. However, the facility's efforts were insufficient, as they failed to prevent the ongoing prevalence of the deficiency. The QAPI team was expected to use a systemic approach to analyze and understand the root causes of identified problems, but the deficiency persisted, indicating a lack of effective implementation of the QAPI Plan.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, and sanitation, as observed during a kitchen tour and hallway observations. In the dry storage area, a plastic spoon was found on the floor in a brown sticky substance, with a radio covered in a similar substance and food particles. In the walk-in cooler and freezer, a box of hamburger patties was left open and uncovered, with patties covered in ice crystals. The sanitizer bucket in the kitchen did not register any chemical sanitizer, indicating ineffective sanitization. Additionally, during hallway observations, food trays were transported without proper covers, exposing food to potential contamination. During the puree process, Staff A did not clean or sanitize the workspace between different food items, further compromising food safety. The acting Dietary Manager was unaware of the cleanliness issues and the open food in the freezer, and daily cleaning logs could not be located. The facility's policy required all food preparation and service areas to be maintained in a clean and sanitary condition, but this was not adhered to, as evidenced by the observations and the outdated cleaning schedule found in the binder.
Deficiency in Serving Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve food at an appropriate temperature and in a palatable manner during two observed meals. During the breakfast meal service, a resident reported that the food was not hot, and a temperature check of a test tray revealed that the oatmeal, french toast, and sausage were at approximately 125 degrees Fahrenheit. The facility had been using Health Care Services (H.C.S.) to manage the dietary department, but there was no dietary manager present at the time. During the lunch service, a test tray showed that the food temperatures were below the required range, with the country fried steak at 120 degrees and carrots at 110 degrees Fahrenheit. The dietary manager confirmed that food needed to be served between 140 and 160 degrees Fahrenheit. The report also highlighted that the steam cart temperatures were checked and found to be within the acceptable range, but staff were not covering food trays between serving residents. The facility's food temperature log book showed 38 missed opportunities where dietary staff failed to document food temperatures prior to serving. Residents expressed concerns about food palatability, with one resident reporting that their lunch tasted terrible and was not hot. The facility dietician and an LPN noted that the food service was slow, and a microwave was often used to warm up food that was not hot upon arrival from the kitchen.
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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