Mercyone Centerville Medical Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Centerville,, Iowa.
- Location
- One St Joseph Drive, Centerville,, Iowa 52544
- CMS Provider Number
- 16E728
- Inspections on file
- 19
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Mercyone Centerville Medical Center during CMS and state inspections, most recent first.
The facility did not provide or document advance information to residents or their representatives regarding the risks and benefits of prescribed psychotropic medications. Multiple residents with conditions such as dementia, anxiety, depression, and other chronic illnesses received medications like antidepressants and antipsychotics without documented informed consent, as confirmed by staff interviews and record reviews.
Surveyors found 13 cartons of expired Glucerna creamy strawberry nutritional supplement stored with other supplement drinks in the kitchen. The expired product was overlooked during daily checks by dietary staff because no residents were currently using that flavor, despite facility policy requiring expired items to be discarded.
The facility did not notify the State LTC Ombudsman about the hospitalization and discharge of two residents, including one who was hospitalized and returned, and another who was discharged home with hospice. Documentation and staff interviews confirmed the lack of required notifications, and facility leadership was unaware of the notification requirement.
The facility did not complete federally required MDS assessments for two residents. One resident's quarterly MDS assessment was left incomplete, and another resident who was hospitalized and returned did not have the necessary discharge and reentry MDS assessments completed. The MDS Coordinator and DON acknowledged the lapses in timely completion of these assessments.
Two residents' care plans did not address all identified needs, including the use of diuretic and antidepressant medications and the risk of skin breakdown on the coccyx. One resident's care plan omitted guidance on monitoring for medication side effects, while another's did not include the presence of an open area on the coccyx, despite clinical documentation and facility policy requirements.
A resident's care plan was not developed within 7 days of the comprehensive assessment, and the required team of health professionals did not prepare, review, or revise the plan as mandated.
The facility did not consistently provide scheduled activities for residents, as many activities were canceled or not held when the Activity Director was assigned to CNA duties. Several residents with intact cognition and various medical conditions reported that activities were frequently missed, especially on weekends, and documentation confirmed limited participation over several months. Staff interviews supported that staffing shortages led to the cancellation of about 40% of planned activities, contrary to facility policy.
A resident with a history of receiving Pneumovax (PPSV23) did not have documentation of being offered a pneumococcal conjugate vaccine as recommended by CDC guidelines. Facility policy required nursing staff to screen, educate, and document immunization status, but this process was not followed for the resident, as confirmed by staff and record review.
Staff did not ensure a resident with moderate cognitive impairment was dressed appropriately for communal areas, bringing her to the dining room in a nightgown or with only a shirt and brief covered by a blanket. Staff also used double incontinent products instead of providing more frequent changes, contrary to proper care practices. These actions failed to uphold the resident's dignity and respect.
A resident who was unable to perform activities of daily living independently did not receive the necessary care and assistance from staff, resulting in unmet needs for support with ADLs.
The facility failed to properly assess and document skin impairments for a resident with dementia and diabetes, including lack of timely assessment and unauthorized bandage application by a CNA. Additionally, the facility did not include hospice services in care planning or communicate significant changes and medication orders for a resident receiving end-of-life care, resulting in discrepancies between facility and hospice orders and lack of documented collaboration.
Staff did not consistently wear required PPE, such as gowns and gloves, during wound and personal care for two residents on Enhanced Barrier Precautions, and failed to properly identify and implement Transmission Based Precautions for a resident with a VRE infection. Some staff were unaware of the correct precautions or the resident's status, and signage and documentation did not accurately reflect the required infection control measures.
A deficiency in infection control was observed during a meal service when a cook handled food without gloves and served it after sneezing without washing hands. The facility's hand hygiene policy was not followed.
The facility failed to use a gait belt during a transfer for a resident with a history of falls and severely impaired cognition, despite the resident's care plan and facility policy requiring it. Staff assisted the resident without a gait belt, leading to repeated falls and injuries.
The facility failed to maintain accurate advance directive records for two residents. One resident's chart lacked the Iowa Physician's Orders for Scope of Treatment (IPOST), while another resident's IPOST was missing a physician's signature, despite having a DNR order in the electronic health record. The DON confirmed these deficiencies during interviews.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform residents or their representatives in advance about the risks and benefits of psychotropic medications for five residents who were prescribed such medications. Clinical record reviews, policy review, and staff interviews revealed that, despite facility policy requiring notification and consent for the initiation, increase, or decrease of psychoactive medications, there was no documentation that this information was provided to the residents or their representatives. The affected residents had various diagnoses, including dementia, anxiety, depression, diabetes, osteoarthritis, asthma, chronic obstructive pulmonary disease, hemiplegia, and insomnia, and were prescribed medications such as sertraline, trazodone, olanzapine, alprazolam, duloxetine, buspirone, and Tylenol PM. The review of medical records and order summaries for these residents showed that psychotropic medications were administered without documented evidence that the residents or their responsible parties were informed of the associated risks and benefits prior to administration. Interviews with facility staff, including the DON, confirmed the absence of consent forms for these medications, and there was an acknowledgment that the pharmacist would assist in completing them. This lack of documentation and communication represents a failure to comply with facility policy and regulatory requirements regarding informed consent for psychotropic medication use.
Expired Nutritional Supplements Found in Kitchen Storage
Penalty
Summary
During an initial kitchen tour, surveyors observed 13 individual cartons of Glucerna creamy strawberry nutritional supplement with an expiration date of July 2025 stored on a dry storage shelf alongside other supplement drinks. The Dietary Manager confirmed that these Glucerna drinks were expired and acknowledged their presence in the storage area. Staff interviews revealed that the Dietary Aide responsible for checking supplements daily had overlooked the expired product because no residents were currently prescribed that particular flavor. Facility policy required kitchen staff to discard any food item in storage after its expiration date, but this was not followed in this instance.
Failure to Notify Ombudsman of Resident Hospitalizations and Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of the hospitalization and discharge of two residents. For one resident with chronic obstructive pulmonary disease and diabetes, who was cognitively intact, the clinical record showed a hospitalization and subsequent return to the facility, but there was no documentation of Ombudsman notification. The Minimum Data Set (MDS) and progress notes confirmed the resident's transfer to the hospital and return, yet the required notification was not present in the records. The facility administrator confirmed that staff did not notify the Ombudsman and that there was no policy in place for such notifications. For another resident, the records indicated an admission and later discharge to home with hospice services, with the intent for end-of-life care at home. Again, the clinical record lacked documentation of notification to the State Long-Term Care Ombudsman regarding the discharge. The administrator and DON both stated they were unaware of the requirement to notify the Ombudsman in cases of resident discharges and hospitalizations.
Failure to Complete Required MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete required Minimum Data Set (MDS) assessments for two residents. For one resident, the quarterly MDS assessment due in July remained incomplete and was still listed as 'in progress' in the electronic health record as of late August. The MDS Coordinator acknowledged that MDS assessments had not been completed in a timely manner, citing insufficient time to complete the required work. The Director of Nursing confirmed that MDS assessments should be completed within the appropriate time frames. Another resident, who had diagnoses of chronic obstructive pulmonary disease and diabetes and was cognitively intact, experienced a hospitalization in July. The clinical record review showed that the required MDS discharge assessment with anticipated return and the reentry MDS assessment were not completed following the resident's transfer to and return from the hospital. Progress notes documented the resident's transfer to the hospital, admission, and subsequent return to the facility, but the necessary MDS assessments were missing. The Director of Nursing confirmed that these assessments should have been completed.
Failure to Address Medication and Skin Breakdown Risks in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with diagnoses including anxiety, osteoarthritis, asthma, and chronic lung disease, the care plan did not include information about the resident's use of diuretic and antidepressant medications, despite documentation in the Medication Administration Record and the facility's policy requiring care plans to address medications and their potential side effects. This omission left staff without guidance on monitoring for possible medication-related side effects. For another resident with hemiplegia, Parkinson's disease, and muscle wasting, the care plan addressed the risk of impaired skin integrity related to a suprapubic catheter but did not address the risk of skin breakdown on the coccyx. Clinical documentation indicated the presence of an open area on the coccyx, but this was not reflected in the care plan. The Director of Nursing confirmed that care plans should address high-risk medications and all risks for skin impairment.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Provide Consistent Resident Activities Due to Staffing Issues
Penalty
Summary
The facility failed to provide sufficient activities to meet the needs of all residents, as evidenced by the lack of consistent activity programming for three residents with varying medical and psychological diagnoses. Documentation and interviews revealed that scheduled activities were frequently canceled or not held, particularly when the Activity Director, who also worked as a CNA, was assigned to resident care duties. Residents reported that many activities listed on the calendar did not occur, and there were no activities on weekends. Staff interviews confirmed that the Activity Director was unable to complete approximately 40% of scheduled activities due to being pulled to work the floor, and weekend staff did not consistently provide activities as expected. Clinical record reviews showed that residents valued and wished to participate in activities such as reading, group events, religious practices, and outdoor time, but participation records indicated sporadic attendance, with some residents only participating in activities on a handful of days over several months. Observations further confirmed that scheduled group activities were not held as planned, and documentation lacked evidence of activities being offered on many days. The facility's own policy required an ongoing person-centered activity program, but this was not consistently implemented due to staffing issues and competing responsibilities for the Activity Director.
Failure to Offer Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to offer a pneumococcal conjugate vaccine to one of five sampled residents reviewed for immunizations. According to the clinical record, the resident had previously received a dose of Pneumovax (PPSV23) in 2010 and was over the age threshold at the time. The resident's record did not contain documentation that staff had offered or administered a pneumococcal conjugate vaccine (such as Prevnar 20, Prevnar 21, or Vaxneuvance) in accordance with current CDC guidelines. The Infection Preventionist confirmed that the resident should have been offered the vaccine based on their immunization history. Facility policy required nursing staff to screen residents for pneumonia vaccination status upon admission, provide education on the risks and benefits of the pneumococcal vaccine, and document both the education and the resident's consent or declination. However, the review found that this process was not followed for the resident in question, as there was no evidence of an offer, education, or documentation regarding the pneumococcal conjugate vaccine. The deficiency was identified through clinical record review, policy review, CDC guideline comparison, and staff interviews.
Failure to Maintain Resident Dignity and Proper Use of Incontinent Products
Penalty
Summary
Staff failed to ensure a resident was dressed in a dignified manner and that incontinent products were used appropriately. The resident, who had diagnoses including non-Alzheimer's dementia, anxiety disorder, and diabetes, was dependent on staff for lower body dressing and toileting hygiene, with a BIMS score indicating moderately impaired cognition. Observations and staff interviews revealed that the resident was brought to the dining room after a shower wearing only a nightgown and a lap blanket covering her legs, and on another occasion, with only a shirt, a brief, and a blanket. Staff acknowledged this was a dignity issue and that the resident should have been dressed in pants before being brought to the dining area. Additionally, staff were observed and reported to have applied more than one incontinent product to the resident, such as a pull-up with a pad inside, which was not in accordance with appropriate care practices. Staff indicated this was done because the resident was a heavy wetter, but acknowledged that the correct approach would be to change the resident more frequently rather than using double products. The Director of Nursing was not aware of these incidents at the time of the interviews.
Failure to Assist Resident with Activities of Daily Living
Penalty
Summary
A deficiency was identified regarding the provision of care and assistance with activities of daily living (ADLs) for residents who are unable to perform these tasks independently. The report notes that care and assistance were not provided as required for at least one resident who was unable to complete ADLs without help. This failure to provide necessary support directly affected the resident's ability to perform daily self-care activities.
Failure to Assess Skin Impairments and Coordinate Hospice Care
Penalty
Summary
The facility failed to adequately assess and document areas of skin impairment for a resident with multiple diagnoses, including non-Alzheimer's dementia, anxiety disorder, and diabetes. The resident was identified as being at risk for pressure ulcers and had moderately impaired cognition. There was no documentation of assessment or application of bandages for a toe abrasion and a forearm skin tear prior to the dates when these were discovered and recorded. Staff interviews revealed that a CNA had applied bandages, which was against facility policy, and the DON confirmed that CNAs were not permitted to perform this task. Additionally, the facility did not document care planning, collaboration, or communication with hospice services for a resident receiving end-of-life care. The care plan for this resident did not reflect hospice involvement or interventions, despite the resident being on hospice services. There was no evidence that hospice staff were invited to care plan meetings, and the hospice RN confirmed not being invited or notified of changes in the resident's condition or medication orders. The facility's clinical record lacked documentation of communication with hospice regarding significant changes and medication adjustments. There was also a discrepancy between the facility's electronic health record and hospice documentation regarding oxygen orders for the resident on hospice. The facility continued to document and administer oxygen at 2 liters per nasal cannula, while hospice orders specified 5 liters continuous. The facility did not update the EHR to reflect the hospice order, and the DON was unaware of this discrepancy. The facility's contract with hospice required immediate notification of significant changes and coordination of care, which was not documented in these instances.
Failure to Implement and Identify Correct Infection Control Precautions
Penalty
Summary
Staff failed to consistently wear appropriate personal protective equipment (PPE) during high-contact care activities for residents on Enhanced Barrier Precautions (EBP) and did not correctly implement or identify the required level of infection control precautions for a resident on Transmission Based Precautions (TBP). For one resident with arthritis, heart failure, hypertension, and unstageable pressure ulcer, staff measured and cared for wounds while wearing gloves but not a gown, despite facility policy requiring both gown and gloves for wound care under EBP. Staff interviews confirmed knowledge of the policy, but the LPN involved did not wear a gown, stating she did not expect drainage from the wound. Another resident with chronic obstructive pulmonary disease, fibromyalgia, and an indwelling urinary catheter required substantial assistance with personal hygiene and had excoriated areas identified as a yeast infection. During personal care and catheter-related activities, one LPN wore only gloves while assisting with intimate care tasks, including repositioning and perineal care, while another LPN wore both gown and gloves. The LPN who did not wear a gown stated she believed it was unnecessary since she was not performing catheter care, despite direct contact with the resident and the presence of open skin areas. For a third resident with chronic obstructive pulmonary disease, diabetes, and an indwelling urinary catheter, the facility failed to clearly identify and implement the correct level of infection control precautions. Although the resident was on TBP for a Vancomycin Resistant Enterococci (VRE) infection, the signage on the door only indicated EBP, and the resident was not listed on the facility's matrix as being on TBP. Staff interviews revealed confusion between EBP and TBP, and some staff were unaware of any residents on contact precautions, despite the resident's status and facility policy requiring contact precautions for VRE.
Infection Control Breach During Meal Service
Penalty
Summary
During an observation of the noon meal service, a deficiency was identified in the facility's infection control measures. The cook, identified as Staff D, failed to wear gloves while handling buns, which were then served to residents. Additionally, Staff D sneezed on her right arm while holding a plate of food in her left hand and proceeded to serve the plate to a resident without washing her hands. The facility's hand hygiene policy, revised in January 2017, mandates that hands should be washed before handling food and after sneezing, coughing, or blowing the nose. This policy was not adhered to during the observed meal service.
Failure to Use Gait Belt During Transfer
Penalty
Summary
The facility failed to utilize a gait belt during a transfer for a resident with a history of falls, anxiety disorder, and diabetes, who required substantial assistance for toilet transfers and had severely impaired cognition. On multiple occasions, the resident was found on the floor after yelling for help, resulting in injuries such as a laceration on the forehead that required stitches and a goose egg on the head. Despite the resident's care plan indicating a risk for falls and the facility's policy requiring the use of gait belts for transfers, staff did not use a gait belt during a transfer observed on 5/14/24, even though one was available in the room. Instead, staff held the resident under her arms to assist her in standing and walking a few steps to her wheelchair after using the commode. This failure to follow protocol was confirmed by the Director of Nursing, who stated that staff should have used a gait belt with the resident. The resident's care plan entries highlighted her impaired mobility, fluctuating ability to transfer, and poor weight-bearing capacity, which increased her risk of falls. The facility's policy on falls prevention, revised in 4/2024, mandated the use of gait belts for patient transfers based on risk assessments. However, during the observed transfer, staff did not adhere to this policy, leading to a deficiency in ensuring a safe transfer process for the resident. This oversight contributed to the resident's repeated falls and injuries, demonstrating a lapse in the facility's adherence to its own safety protocols.
Deficiency in Advance Directive Documentation
Penalty
Summary
The facility failed to maintain accurate advance directive records for two residents, leading to deficiencies in their care documentation. Resident #8, who was cognitively intact with diagnoses including Coronary Artery Disease and Cerebrovascular Accident, did not have the Iowa Physician's Orders for Scope of Treatment (IPOST) in their chart. This was confirmed during a record review and an interview with the Director of Nursing (DON), who was unable to locate the IPOST initially. Resident #9, who had moderate cognitive impairment and was admitted to Hospice Care, had an IPOST indicating a Do Not Attempt Resuscitation (DNR) choice, but it lacked the necessary physician's signature. The electronic health record showed an active DNR order, but the physical IPOST document was incomplete. The DON confirmed the absence of the physician's signature during an interview, acknowledging the need for the signature to validate the IPOST.
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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