Manly Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Manly, Iowa.
- Location
- 601 E South Street, Manly, Iowa 50456
- CMS Provider Number
- 165226
- Inspections on file
- 19
- Latest survey
- February 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Manly Specialty Care during CMS and state inspections, most recent first.
The facility failed to employ a qualified nutrition professional, lacking a Certified Dietary Manager or full-time Registered Dietitian as required. The facility has been without a kitchen manager for six months, with Staff A assisting unofficially. The previous Dietary Manager works part-time, and the Registered Dietitian visits monthly. A traveling Certified Dietary Manager has provided occasional assistance.
A facility failed to prevent significant medication errors, affecting eight residents over several months. Errors included incorrect dosages and administration of discontinued medications. Staff concerns about frequent errors, particularly by an RN, were not adequately addressed. The facility's medication administration policy was not effectively implemented, leading to repeated errors.
The facility failed to follow dietary protocols, resulting in residents not receiving appropriate portions or menu items. Residents on pureed and low sodium diets did not receive the correct meals, and the Nutritional Intervention Program was not properly implemented. Staff were unaware of proper procedures, and the Registered Dietitian's expectations were not met.
The facility failed to maintain safe food temperatures during a lunch service. A cook served cold foods, including chef salad and cottage cheese, at temperatures above the safe limit of 41°F. Despite being aware of the temperature issue, the cook proceeded with serving, contrary to facility policy and FDA guidelines. The Registered Dietitian confirmed the expectation for cold foods to be served at 41°F or colder.
The facility inaccurately coded the MDS assessments for two residents. One resident was incorrectly coded as having no serious mental illness despite a Level II PASRR, due to staff confusion. Another resident's MDS failed to document verbal aggression, despite reports of bullying behavior. The facility lacked a specific MDS policy, relying on the RAI Manual, which was not properly followed.
A resident with cerebral infarction, multiple sclerosis, and dysphagia required one-on-one assistance during meals, as per their care plan. However, observations showed the resident was left to eat independently without the necessary support or reminders from staff. Despite staff presence, including CNAs and the DON, the resident did not receive the prescribed assistance, indicating a failure to adhere to the care plan.
The facility failed to update care plans for two residents, leading to unaddressed conflicts and behavioral issues. A resident with intact cognition reported being bullied by another resident with moderate cognitive impairment, but her care plan did not reflect this conflict. The second resident exhibited negative behaviors, yet her care plan lacked documentation of these behaviors and her psychiatric therapy. The MDS Coordinator, new to the role, had not updated the care plans, contrary to facility policy.
The facility failed to provide Dietitian-approved pureed bread to four residents on a pureed diet. Staff were unaware of how to prepare pureed bread, and the CDM removed it from the menu without informing the Dietitian, altering the nutritional content of the meals served. The issue was acknowledged by the Administrator, DON, and ADON.
The facility failed to notify the State Long Term Care Ombudsman of hospital transfers for two residents. The Administrator acknowledged the oversight and the lack of a specific policy for ombudsman reporting.
The facility failed to complete a new PASRR evaluation as required for a resident with moderate cognitive impairment and multiple diagnoses. The MDS Coordinator submitted the new PASRR after the expiration of the approved short-term period, and the facility did not have a PASRR policy.
The facility failed to properly care for and document a resident's pressure ulcers. Staff did not use a cleanser to clean the sacral/coccyx pressure ulcer and were unaware of specific wound care instructions. Additionally, the facility did not accurately update the stages of the resident's pressure ulcers, leading to improper wound care and documentation.
The facility failed to forward a pharmacy recommendation to the physician for re-evaluation of a 14-day PRN Haloperidol (Haldol) order for a resident. The medication was administered 28 times beyond the 14-day period without physician re-evaluation or a new order being issued. The ADON acknowledged the oversight and admitted that the PRN order should have been discontinued as per the facility's policy.
The facility did not meet the required number of members at QAA meetings for the first four of six quarters, including the Administrator, Medical Director, DON, Infection Preventionist, and one other staff member. The DON misunderstood the regulation, believing only five members were needed.
A facility failed to perform proper hand hygiene and follow PPE guidelines during peri-care for a resident with septicemia, recurrent enterocolitis due to clostridium difficile, and hypertension. A CNA used the same dirty gloves to handle clean items without changing gloves or performing hand hygiene. Interviews with the ADON and DON confirmed the expectation to change gloves after peri-care, but the facility's policy lacked specific instructions.
Deficiency in Nutrition Services Staffing
Penalty
Summary
The facility failed to employ a clinically qualified nutrition professional who met the required qualifications of a Certified Dietary Manager or a full-time Registered Dietitian, as indicated in their Facility Assessment. The facility, with a census of 41 residents, has been without a kitchen manager for approximately six months. Staff A, who has been with the facility for about three years, has been assisting with some duties such as ordering supplies but is not officially the kitchen manager. The previous Certified Dietary Manager still works at the facility but no longer holds that position and works approximately 25 hours a week, occasionally picking up extra shifts. The Registered Dietitian visits the facility about once a month, and a traveling Certified Dietary Manager from the corporation has visited several times to assist. Staff F, a cook, was the prior Dietary Manager for the building.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents where residents received incorrect medications or dosages. Over a period from May 2024 to February 2025, eight residents were affected by these errors. These included instances where residents received medications that were either discontinued or administered at incorrect dosages, such as a resident receiving a double dose of Clozapine and another receiving both AM and MD doses of Gabapentin simultaneously. Staff interviews revealed concerns about frequent medication errors, particularly involving a Registered Nurse (RN), Staff G, who was reported to have made several errors. Despite these concerns, the facility did not adequately investigate or address the issues to prevent further occurrences. The Director of Nursing (DON) acknowledged the errors and mentioned that Staff G was written up for a medication error in August, but no further actions or audits were conducted to monitor medication administration practices. The facility's policy on administering medications, revised in April 2019, directed staff to verify the right resident, medication, dosage, time, and method before administration. However, this policy was not effectively implemented, as evidenced by the repeated medication errors. The DON reported that interruptions during medication passes contributed to these errors, but no immediate corrective measures were taken to address this issue.
Failure to Follow Dietary Protocols and Menu Adherence
Penalty
Summary
The facility failed to adhere to the posted menu and serve appropriate portions for residents on specialized diets. During a lunch observation, it was noted that residents on pureed diets did not receive the full menu as posted, including the omission of dinner rolls. Additionally, residents on low sodium diets were served garden rice instead of the prescribed white rice. The facility also failed to provide requested substitutions, such as grilled cheese sandwiches, due to inadequate preparation and stock. The facility's Nutritional Intervention Program (NIP) was not properly implemented, as 9 out of 19 residents did not receive the additional calories or nutrition indicated on their menu cards. This included the absence of extra food items like ice cream, which was out of stock. Staff A, responsible for meal preparation, did not measure the total volume of pureed food as required, and there was a lack of adherence to the puree process instructions posted in the kitchen. Staff interviews revealed a lack of awareness and adherence to dietary protocols, with some staff unaware of the impact of adding broth to pureed food volume. The Registered Dietitian expressed expectations for proper meal preparation and service, which were not met. The Director of Nursing indicated a misunderstanding of the menu card program, suggesting that residents unable to select their meals should receive the full meal within their dietary restrictions.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to serve food within the acceptable temperature range, as observed during a lunch service. Staff A, a cook, was responsible for preparing and serving meals to residents requiring a pureed diet. While the hot foods were at appropriate temperatures, the cold foods were not. Specifically, chilled pears were at 41.5°F, chef salad and cottage cheese were at 45°F, and milk was at 38.9°F. These temperatures were recorded at 11:23 AM, and the items were left at room temperature until service began at 11:30 AM. Notably, the chef salad was served to a resident 21 minutes after it was initially checked, still at an unsafe temperature. Staff A admitted to serving the cold items regardless of their temperature, believing they were acceptable since they had just been taken out of the refrigerator. The Registered Dietitian later confirmed that cold foods should not be served unless they are at 41°F or colder. The facility's policy, revised in April 2019, and the 2022 FDA Food Code both emphasize that potentially hazardous foods must be maintained below 41°F or above 135°F to prevent the growth of harmful pathogens. This oversight in maintaining proper food temperatures led to the deficiency noted in the report.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their records. Resident #1 was identified as having a Level II Preadmission Screening and Resident Review (PASRR) due to a serious mental illness, but their annual MDS assessment incorrectly coded them as a PASRR Level I, indicating no serious mental illness. This error was attributed to confusion among the staff, as reported by the Assistant Director of Nursing (ADON). The Director of Nursing (DON) acknowledged the absence of a specific policy for MDS coding, relying instead on the Resident Assessment Instrument (RAI) Manual, which clearly directs coding for Level II PASRR if a serious mental illness is determined. Resident #33's MDS assessment failed to document verbal behavioral symptoms towards others, despite reports and grievances indicating such behavior. A fellow resident reported being bullied by Resident #33, and the Administrator confirmed that Resident #33 exhibited annoyance and verbal aggression towards others. However, the MDS assessment did not reflect these behaviors during the 7-day lookback period, as required by the RAI Manual. The manual provides specific instructions for reviewing medical records, interviewing staff, and observing residents to accurately code behavioral symptoms, which were not followed in this case.
Failure to Follow Care Plan for Resident Requiring Meal Assistance
Penalty
Summary
The facility failed to adhere to the comprehensive care plan for a resident who required partial/moderate assistance for eating due to conditions such as cerebral infarction, multiple sclerosis, and dysphagia. The care plan specified that the resident needed one-on-one assistance during meals, encouragement to take small bites, alternate bites with drinks, and remain upright after meals. However, observations on two consecutive days revealed that the resident was left to eat independently without the required one-on-one assistance or reminders to follow the prescribed eating strategies. Staff members were present in the dining area but did not provide the necessary support or cues to the resident, contrary to the care plan directives. During the observations, various staff members, including CNAs and the DON, were present in the dining room but did not engage with the resident as required by the care plan. The resident was seen feeding herself without assistance, and staff members were either engaged in conversations with each other or attending to other residents. The DON later expressed uncertainty about the current need for one-on-one assistance, indicating a possible lack of communication or update regarding the resident's care needs. This lack of adherence to the care plan represents a deficiency in the facility's obligation to provide the necessary care and supervision as outlined in the resident's care plan.
Failure to Update Care Plans for Resident Conflicts and Behaviors
Penalty
Summary
The facility failed to update the care plans for two residents, leading to deficiencies in addressing interpersonal conflicts and behavioral issues. Resident #7, who has intact cognition and diagnoses of anxiety disorder, bipolar disorder, and PTSD, reported being bullied by Resident #33, which made her cry. Despite these interactions being known to the staff and the administrator, Resident #7's care plan did not address any conflict with other residents. The facility's staff were aware of the issues between the two residents and attempted to manage the situation by moving Resident #7 to a different dining table, but no formal updates were made to her care plan to reflect these interventions. Resident #33, with moderate cognitive impairment and a diagnosis of non-Alzheimer's dementia, exhibited negative behaviors towards other residents, including yelling and causing another resident to cry. Despite these incidents, Resident #33's care plan did not document any negative or aggressive behaviors or the psychiatric/mental health therapy she was receiving. The MDS Coordinator, new to the job, was responsible for updating care plans but had not yet addressed these issues. The facility's policy requires the interdisciplinary team to develop individualized comprehensive care plans, which was not adhered to in these cases.
Failure to Provide Dietitian-Approved Pureed Bread
Penalty
Summary
The facility failed to provide the Dietitian-approved menu for four residents on a pureed diet. During a lunch observation, it was noted that these residents did not receive pureed bread as specified in their therapeutic menu. The residents involved had varying levels of cognitive impairment and required different degrees of assistance with eating, as documented in their Minimum Data Set (MDS) assessments and doctor's orders. Despite the menu indicating that pureed bread should be served, it was not provided to the residents on the specified date. Staff interviews revealed that the cook and the Certified Dietary Manager (CDM) had never served pureed bread and were unaware of how to prepare it. The CDM admitted to removing the bread from the menu without informing the Dietitian, citing that the residents did not like it. This deviation from the approved menu altered the nutritional content of the meals served. The Registered Dietitian confirmed that the menu was designed to be nutritionally adequate and that pureed bread should have been included. The Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) acknowledged the issue. The Dietitian, who had recently started at the facility, was unaware that pureed bread was not being served and stated that the kitchen staff should follow the approved menus. The facility's policy on menus, revised in October 2017, directed that any deviations from posted menus should be recorded and archived, which was not done in this case.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to send notice to the State Long Term Care Ombudsman regarding the transfer of two residents to the hospital. For Resident #13, the facility did not document the therapeutic leave in November 2023, nor the hospital admissions in January, February, and March 2024 in the Ombudsman reports. The Administrator acknowledged the oversight but was unsure why these residents were missed in the reports. Additionally, the facility lacked a specific policy for ombudsman reporting, although the Administrator claimed they followed the regulations for reporting. For Resident #26, the facility did not document the hospital transfers in September 2023, November 2023, and March 2024 in the Ombudsman reports. The progress notes indicated multiple instances where the resident was transferred to the emergency room and either admitted to the hospital or returned to the facility, but these events were not reported to the Ombudsman. The Administrator confirmed the absence of a policy for ombudsman reporting and was unaware of the reasons for the missed documentation.
Failure to Complete Timely PASRR Evaluation
Penalty
Summary
The facility failed to complete a new Preadmission and Resident Review (PASRR) evaluation as required for one resident. The resident had a Minimum Data Set (MDS) assessment indicating moderate cognitive impairment and diagnoses of depression, bipolar disorder, and dementia. The resident's PASRR Level II Outcome indicated that the short-term approval ended on 4/13/24. However, the MDS Coordinator did not submit a new PASRR for review until 4/13/24, which was determined on 4/18/24, after the expiration of the approved short-term period. The MDS Coordinator was unaware that a new PASRR needed to be completed and determined before the expiration date. The facility did not have a policy for PASRR and reported following the regulations.
Improper Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to properly care for and accurately document pressure ulcers for a resident. During a pressure ulcer dressing change, staff did not use a cleanser to clean the resident's sacral/coccyx pressure ulcer. Instead, a damp towel was used, which was not in accordance with the doctor's orders. The Director of Nursing (DON) and the Licensed Practical Nurse (LPN) involved were unaware of the specific wound care instructions, leading to improper wound cleaning and dressing application. The Advanced Registered Nurse Practitioner (ARNP) acknowledged the concern and stated that the wound order would be revised to ensure proper cleaning and prevent infection. The facility also failed to update the stages of the resident's pressure ulcers accurately. The Minimum Data Set (MDS) assessment documented the presence of Stage 1 and Stage 3 pressure ulcers, but observations and evaluations revealed discrepancies. The Assistant Director of Nursing (ADON) noted that the coccyx pressure ulcer should be classified as unstageable due to the presence of slough, and the Stage 1 pressure ulcer on the right heel should be coded as Stage 2 after verifying the wound's depth. The DON acknowledged the concerns regarding the improper staging of the pressure ulcers. The facility's Wound Care policy, revised in October 2016, directed staff to verify the physician's order for wound care procedures, assemble necessary equipment and supplies, and clean the tissue around the wound with antiseptic or soap and water. However, the staff did not follow these guidelines, leading to improper wound care and documentation. The facility's failure to adhere to proper wound care protocols and accurately document the stages of pressure ulcers resulted in a deficiency in the care provided to the resident.
Failure to Re-evaluate PRN Antipsychotic Medication
Penalty
Summary
The facility failed to forward a pharmacy recommendation to the physician for re-evaluation of a 14-day PRN Haloperidol (Haldol) order for a resident. The pharmacist had recommended that the PRN order, initially prescribed for anxiety and delusions, be reviewed and potentially renewed by the physician after the mandatory 14-day period. However, the facility did not follow this recommendation, and the PRN Haloperidol was administered 28 times from the 15th day to the 32nd day without physician re-evaluation or a new order being issued. The Assistant Director of Nursing (ADON) acknowledged the oversight and could not provide a rationale for continuing the PRN Haloperidol beyond the 14-day period. The ADON admitted that the information should have been forwarded to the physician for review and that the PRN order should have been discontinued after 14 days as per the facility's PRN Medication Policy. This failure to adhere to the policy resulted in the resident receiving the medication without the necessary re-evaluation by a healthcare practitioner.
Failure to Meet QAA Committee Member Requirements
Penalty
Summary
The facility failed to have the minimum required members at the Quality Assessment and Assurance (QAA) meetings, as mandated by regulations. The review of the facility's QAA sign-in sheets revealed that the meetings for the first four of six quarters included the Administrator, Medical Director, Director of Nursing (DON), Infection Preventionist, and one other staff member, falling short of the required six members. During an interview, the DON admitted to misunderstanding the regulation, believing that only five members were required. The facility's Quality Assurance and Performance Improvement (QAPI) Program indicated that the QAA Committee should meet at least quarterly and include representatives from six other departments, as requested by the Administrator.
Failure to Perform Proper Hand Hygiene and PPE Guidelines During Peri-Care
Penalty
Summary
The facility failed to perform proper hand hygiene and follow personal protective equipment guidelines during peri-care for a resident diagnosed with septicemia, recurrent enterocolitis due to clostridium difficile, and hypertension. During an observation, a CNA assisted the resident off a bedpan, performed hand hygiene, and applied a gown and gloves. After completing the peri-care, the CNA used the same dirty gloves to handle a clean brief and other clean surfaces without performing hand hygiene or changing gloves. Interviews with the ADON and DON confirmed that staff are expected to change gloves after peri-care before touching clean items. The facility's policy on perineal care lacked specific instructions for removing gloves after completing peri-care before touching any clean surface.
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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