Methodist Manor Retirement Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Storm Lake, Iowa.
- Location
- 1206 West Fourth Street, Storm Lake, Iowa 50588
- CMS Provider Number
- 165359
- Inspections on file
- 18
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Methodist Manor Retirement Community during CMS and state inspections, most recent first.
A resident with cognitive deficits and total dependence on staff reported symptoms of a UTI, but staff delayed obtaining a urinalysis for six days and failed to document vital signs or nursing notes during this period. Communication issues between staff and the family contributed to the delay, and the facility did not follow its own protocols for assessment and documentation of changes in condition.
The facility did not develop or update comprehensive care plans for several residents, omitting critical information such as antipsychotic medication management, interventions for wandering, oxygen therapy, and PASRR-related services. These omissions were confirmed by staff and were not in accordance with facility policy.
The facility did not properly screen, educate, offer, or document COVID-19 vaccination status, consent, or refusal for several residents, including those with severe cognitive impairment and one who was cognitively intact. Clinical records lacked evidence of education or offers for additional vaccine doses, and in one case, a resident not up to date with vaccination was hospitalized for COVID-19. The DON confirmed the absence of required documentation, despite facility policy mandating these actions.
A resident with multiple chronic conditions experienced a fall resulting in a hand injury, followed by days of increasing pain and swelling in the left upper extremity. Despite repeated complaints and administration of PRN pain medication, the physician was not notified of the resident's worsening condition until the pain became severe and a fracture was discovered. Facility policy required prompt physician notification for such changes, but this did not occur.
Two residents were involved in a physical altercation during a meal, with one slapping the other after an exchange of negative comments. Although a nurse intervened and the DON was notified the next day, the required report to DIAL was not submitted within the mandated 2-hour window, and law enforcement was not notified as required by policy.
A resident with schizophrenia and moderate cognitive impairment was incorrectly marked on the MDS as not having a serious mental illness under the PASRR process, despite documentation confirming the presence of a PASRR condition. The nurse manager misinterpreted the PASRR documentation, leading to the inaccurate assessment.
A resident with schizophrenia and moderate cognitive impairment was not provided care planning or assessment that incorporated recommendations from the PASRR evaluation, including needs for neurocognitive evaluation, power of attorney assistance, psychiatric record retrieval, and ongoing psychotropic medication review. Staff only reviewed the PASRR summary and did not address the detailed recommendations, resulting in a deficiency.
A resident with COPD and moderate cognitive impairment was found using oxygen tubing that had not been changed or relabeled for over four months, contrary to facility policy requiring monthly replacement. Staff confirmed the tubing was last changed in November and documented on the TAR, but observations showed the same tubing remained in use.
The facility failed to notify the families of two residents about significant changes in their conditions. One resident experienced multiple episodes of hypoglycemia, while another had significant weight gain. Despite these changes, there was no documentation of family notification, contrary to the facility's policy.
A resident at high risk for falls, with a history of multiple health issues, fell and sustained injuries due to inadequate supervision by a CNA who failed to use a gait belt. The resident was left unattended while the CNA put clothes away, leading to the fall. The facility's standard practice of using a gait belt was not followed, resulting in the resident suffering rib fractures.
The facility failed to ensure proper sanitization of dishes and kitchen equipment, as three out of four dish machines did not consistently reach the required temperature. Temperature logs were incomplete, and high-temperature test strips were not used. Additionally, food thermometers were not adequately sanitized between uses, and staff were observed handling food with soiled gloves and failing to perform proper hand hygiene. These actions indicate a lack of adherence to infection control practices.
A facility failed to complete the required MDS assessment for a resident who was discharged home. The resident's discharge was documented, but the discharge MDS was not completed by the deadline. Nurse Managers responsible for the MDS assessments did not have the resident on their lists, and it was suggested that a notification email may not have been sent, resulting in the missed assessment.
A facility failed to update the Level 2 PASSR for a resident with a new mental health diagnosis and medication changes. The resident had moderate cognitive impairment and was prescribed high-risk medications for anxiety and delusional disorders. The only documented PASSR was from 2015, despite changes in the resident's mental health status. The Unit Manager confirmed that the PASSR had not been updated, contrary to the facility's policy requiring quarterly reviews and updates.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. One resident with intact cognition had a history of urinary tract infections and was on antibiotics, but the care plan lacked details on medications and monitoring. Another resident with severe cognitive impairment was on antidepressant and antianxiety medications, yet the care plan did not document their usage or side effects. These omissions were acknowledged by the RN/Nurse Manager.
A resident with intact cognition and multiple diagnoses, including heart failure and chronic respiratory failure, did not have their oxygen tubing changed as required by the facility's policy. Observations revealed that the tubing had not been updated since March, despite the Treatment Administration Record indicating it should be changed monthly. The DON confirmed the oversight, and the resident reported the tubing had not been changed.
A facility failed to provide a clinical rationale for declining a GDR for a resident on Risperdal, despite policy requirements. The resident, with moderately impaired cognition and diagnoses of anxiety and depression, was on psychotropic medications. Staff acknowledged the absence of a rationale, citing challenges in obtaining it from the physician.
The facility failed to provide adequate puree portion sizes for two residents, leading to insufficient calorie and protein intake. Observations revealed that staff used incorrect scoop sizes, serving less than the required portions. Despite having policies in place, the staff did not follow the correct procedures, resulting in leftover puree and inadequate servings for the residents.
A resident dependent on tube feeding was subject to infection control lapses when an LPN used a tube adapter dated several days prior and failed to change gloves after picking up items from the floor. The feeding equipment was also visibly soiled, and there was no routine cleaning schedule, contrary to the facility's infection control policy.
The facility failed to monitor long-term antibiotic use for two residents. One resident continued on Bactrim DS for bacteriuria without an end date, and another was on Cephalexin for chronic cystitis. The facility lacked a system to ensure the necessity of these antibiotics, despite having a policy for antibiotic stewardship.
Failure to Timely Assess and Intervene for UTI Symptoms
Penalty
Summary
The facility failed to provide timely assessment and intervention for a resident who exhibited signs and symptoms of a urinary tract infection (UTI). The resident, who had moderate cognitive deficits and was totally dependent on staff for activities of daily living, reported burning with urination and had a history of incontinence and previous UTIs. Despite the family reporting symptoms to nursing staff on a weekend, no urinalysis (UA) was ordered until six days later. Staff responses included monitoring and providing peri care, but there was no documentation of vital signs or nursing notes during the period when symptoms were reported. The resident's chart lacked nursing progress notes from several days and no vital signs were recorded for over a week, despite the resident exhibiting symptoms consistent with a UTI. Interviews with staff revealed that communication breakdowns occurred between staff and the resident's family, and that staff did not escalate the resident's symptoms to a physician or obtain a UA in a timely manner. The facility's policy required documentation, assessment, and follow-up for changes in condition, including full vital signs and nursing notes, but these were not completed. The deficiency was identified through observation, interview, and record review, confirming that the facility did not follow its own protocols for assessment and documentation when a resident exhibited a change in condition.
Failure to Develop Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all identified needs for four residents. For one resident with severe cognitive impairment and multiple behavioral health diagnoses, the care plan did not address the use of antipsychotic medication, including target behaviors, potential side effects, or necessary monitoring, despite a physician's order for Risperdal. Staff confirmed that high-risk medications were not included in the care plan as expected. Another resident with severe cognitive impairment and a history of wandering was not care planned for wandering behaviors or interventions to prevent entry into other residents' rooms, despite multiple documented incidents of wandering and redirection by staff. The nurse manager acknowledged that these behaviors and interventions were not addressed in the care plan and should have been. A third resident with moderate cognitive impairment and chronic medical conditions, including COPD, had physician orders for oxygen therapy, but the care plan did not document the use of oxygen. Additionally, a resident with moderate cognitive impairment and a diagnosis of schizophrenia had a PASRR approval requiring the facility to care plan for identified services, but the care plan lacked any reference to the PASRR or related services. Facility policies required individualized, comprehensive care plans addressing all relevant needs, but these were not followed for the residents identified.
Failure to Screen, Educate, Offer, and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to properly screen, educate, offer, and document COVID-19 vaccination status, consent, or refusal for four out of five residents reviewed. Clinical record reviews showed that these residents, some with severe cognitive impairment, were not up to date with their COVID-19 vaccinations, and there was no documentation that they or their responsible parties had been educated about, offered, or had consented to or refused additional COVID-19 vaccinations since their last recorded dose. This lack of documentation was found despite the facility's policy requiring assessment of vaccination status, education, and documentation of consent or refusal for each resident upon admission and for subsequent doses as per CDC guidelines. Specific findings included residents with severe cognitive impairment who had not received updated COVID-19 vaccinations and whose records lacked evidence of education or offers for additional doses. One resident, who was cognitively intact, also had no documentation of being educated or offered the vaccine since admission. In one case, a resident who was not up to date with vaccination tested positive for COVID-19 and required hospitalization. The facility's Director of Nursing confirmed that there was no documentation of education, offer, or consent/refusal for these residents regarding the COVID-19 vaccine. The facility's policy outlined that all residents should be assessed for vaccination status, educated about the vaccine, and provided the opportunity to consent or decline, with all actions documented in the medical record. The policy also required the facility to coordinate vaccine administration and maintain records of all efforts, including off-site vaccination opportunities if on-site administration was not possible. However, the facility did not follow these procedures for the residents reviewed, resulting in the identified deficiency.
Failure to Notify Physician of Change in Condition After Fall
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident following a fall. The resident, who had diagnoses including anemia, neurogenic bladder, and COPD, was found on the floor after sliding from her wheelchair. Initial assessment documented a bruise to the left hand, with no other injuries or pain reported at that time. Over the following days, the resident developed swelling, bruising, and increasing pain in the left upper extremity, including the hand, shoulder, and arm, with pain ratings escalating from 4/10 to 10/10. Despite these ongoing and worsening symptoms, there was no documentation that the physician was notified of the resident's pain and swelling until several days after the fall, when the pain became severe. The resident received as-needed pain medication on multiple occasions due to these symptoms, but the physician was not informed until the pain reached its peak. An x-ray subsequently revealed a fracture in the left elbow area. The facility's policy required that any significant change in a resident's condition, such as accidents resulting in direct harm or physical decline, be promptly assessed and reported to the physician. Staff interviews and record reviews confirmed that the physician was not notified in a timely manner, and the DON acknowledged that the expectation was for staff to notify the physician of such changes, but in this case, monitoring was deemed sufficient until the situation escalated.
Failure to Timely Report Resident-to-Resident Abuse and Notify Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse within the required 2-hour timeframe to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for two residents involved in a resident-to-resident altercation. During a supper meal, one resident made a negative comment to another, who responded by slapping the first resident on the neck. A nurse witnessed the incident and intervened. The incident was reported to the Director of Nursing (DON) the following day, but the official report to DIAL was not submitted until two days after the event, exceeding the facility's policy and regulatory requirements for timely reporting. Additionally, the facility did not notify law enforcement of the suspected abuse or potential crime, as required by both facility policy and federal regulations under the Elder Justice Act. The DON confirmed that law enforcement was not contacted regarding the incident. The facility's policy mandates immediate reporting of abuse allegations to the charge nurse, prompt notification to the administrator, and timely reporting to both DIAL and law enforcement, depending on the severity of the incident. Documentation reviewed during the investigation confirmed these reporting failures.
Inaccurate MDS Assessment Related to PASRR Status
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's status. Specifically, the MDS for a resident with a diagnosis of schizophrenia and a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment was marked as not having a serious mental illness under the state Level 2 Preadmission Screening and Resident Review (PASRR) process. However, documentation from the PASRR outcome indicated that the resident did meet the criteria for a PASRR condition due to her diagnoses of paranoid schizophrenia and delusional disorder, as well as her need for assistance with self-care. The nurse manager stated that she only reviewed the front page of the PASRR, which noted approval without specialized services, and therefore believed no further action was necessary.
Failure to Incorporate PASRR Recommendations into Resident Care Planning
Penalty
Summary
The facility failed to incorporate the recommendations from the Pre-Admission Screening and Resident Review (PASRR) evaluation report into the assessment, care planning, and transition of care for a resident with a diagnosis of schizophrenia and moderate cognitive impairment. The PASRR Level 2 outcome indicated the resident met criteria for serious mental illness and required specific services and supports, including evaluation for neurocognitive disorder, assistance with designating a power of attorney, obtaining archived psychiatric records, and ongoing evaluation of psychotropic medications. However, the clinical record did not show evidence that these recommendations were utilized in the resident's assessment or care planning process. Staff interviews revealed that the nurse manager only reviewed the front page of the PASRR report, which stated approval without specialized services, and therefore did not pursue further actions based on the detailed recommendations. The facility's own PASRR policy required that care plans address the services identified in the PASRR, but this was not reflected in the resident's documentation. The lack of integration of the PASRR findings into the resident's care plan and transition of care constituted the deficiency identified by surveyors.
Failure to Timely Change and Label Oxygen Tubing
Penalty
Summary
The facility failed to change and label oxygen tubing as required for one resident with chronic obstructive pulmonary disease (COPD), hypertension, and depression, who had moderate cognitive impairment. Observations on two consecutive days showed that the oxygen tubing in use was last changed and labeled over four months prior, with the date and staff initials from November. The resident reported using oxygen as needed, and the Treatment Administration Record (TAR) confirmed the tubing was last changed on the 15th of November, matching the observed date. Facility policy requires monthly inspection and replacement of oxygen tubing, as well as proper storage when not in use. Staff interviews confirmed the practice of changing tubing monthly and documenting it on the TAR, but the tubing in use had not been replaced according to policy.
Failure to Notify Family of Resident Condition Changes
Penalty
Summary
The facility failed to notify the family or responsible party of changes in the condition of two residents, which required physician notification. Resident #2, who had moderate cognitive impairment and diabetes, experienced several episodes of hypoglycemia with blood sugar levels dropping as low as 37. Despite these significant changes in condition, there was no documentation that the facility attempted to notify the resident's family. The nurse manager acknowledged that the resident's son was difficult to reach but confirmed that other contacts were available. Resident #3, also with moderate cognitive impairment, had a history of atrial fibrillation, coronary artery disease, heart failure, hypertension, renal insufficiency, and diabetes. The resident experienced significant weight gain over several months, with an 18% increase in weight over 180 days. Although the physician was notified of the weight changes, the facility did not document any attempts to inform the resident's family or responsible party about the new orders or the significant weight gain. The facility's policy required that changes in a resident's condition, such as medication reactions or significant weight changes, should prompt immediate nurse assessment and notification of both the physician and the family or responsible party. However, the facility's records lacked evidence of family notification for both residents, indicating a failure to adhere to this policy.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent a fall for a resident, who was identified as being at high risk for falls. The resident had a history of hypertension, renal failure, hyperlipidemia, and chronic respiratory failure with hypoxia, and was cognitively intact with a BIMS score of 14. The resident used a walker daily and required assistance from one staff member for ambulation. Despite this, the resident experienced a fall in her room while a staff member was present but not providing direct support. The incident occurred when the staff member, a CNA, was assisting the resident with getting clothes for a shower. The CNA left the resident unattended to put clothes away in a dresser, during which time the resident fell and sustained injuries, including abrasions and skin tears. The resident reported feeling dizzy before the fall. The CNA did not use a gait belt, which was against the facility's standard practice, and the resident was left without adequate supervision. Following the fall, the resident experienced significant pain and was later diagnosed with two rib fractures. The facility's policy on accidents and incidents requires thorough assessment and documentation, but the CNA's failure to use a gait belt and provide continuous supervision contributed to the incident. The facility did not have a specific gait belt policy but followed standard practice, which was not adhered to in this case.
Deficiencies in Kitchen Sanitization and Infection Control Practices
Penalty
Summary
The facility failed to ensure that resident dishes and kitchen equipment were properly sanitized, as three out of four dish machines did not consistently reach the appropriate sanitizing temperature. Observations and documentation revealed that temperature logs for the dish machines were incomplete or missing for several days, and there was no evidence of high-temperature test strips being used to verify that the machines reached the required 180°F. Staff interviews indicated a lack of awareness regarding issues with the dish machines and the proper procedures for ensuring they reached the necessary temperatures. Additionally, the facility did not adequately sanitize food thermometers between uses, as dietary staff were observed using the same alcohol prep pad to clean the thermometer probe after taking multiple food temperatures. This practice was noted during lunch services on different floors, with staff changing the prep pad only when it became visibly soiled. The Dietary Manager acknowledged this improper practice during an interview, indicating a lack of adherence to proper sanitization protocols to prevent cross-contamination. Furthermore, during a meal service observation, a staff member was seen handling food with soiled gloves, failing to perform hand hygiene between glove changes, and using the same alcohol wipe for cleaning the thermometer probe multiple times. The facility's infection control policy requires appropriate hand hygiene and the use of new alcohol wipes for each use, but these standards were not followed. This indicates a failure to adhere to infection control practices, potentially compromising the safety and hygiene of food services.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete the appropriate Minimum Data Set (MDS) assessment for a resident who was reviewed for discharge. The resident entered the facility in late December and had an admission assessment completed in early January. The resident was documented to have been discharged home with her spouse at the end of February. However, the discharge assessment reference date was set for the same day as the discharge, with a completion deadline in mid-March, but no additional assessments were completed. Staff interviews revealed that the Nurse Managers responsible for completing the MDS assessments did not have the resident on their lists, and the discharge MDS was not completed. One Nurse Manager stated that typically an email notification would be sent when a resident was discharged, but it appeared that this notification was not sent, leading to the oversight.
Failure to Update PASSR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASSR) evaluation for a resident with a new mental health diagnosis and medication revision. The resident, identified as Resident #5, had a documented Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The resident's diagnoses included anxiety, depression, and a psychotic disorder, and they were prescribed high-risk medications such as an antipsychotic and an antidepressant. The clinical record showed current medication orders for Sertraline HCl and Seroquel, which were related to anxiety and delusional disorders, respectively. The resident's care plan, dated April 19, 2024, included monitoring for adverse consequences of the medications and addressing increased anxiety and paranoia. However, the only documented PASSR in the clinical record was from 2015, which noted a depression diagnosis and the use of Sertraline HCl. During an interview, the Unit Manager confirmed that all PASSRs are located in the resident's permanent record and acknowledged that the PASSR for Resident #5 had not been updated since 2015, despite changes in mental health diagnoses and medications. The facility's policy stated that the MDS Coordinator should review and update the PASSR each quarter or as needed, but this had not been done for Resident #5.
Deficiencies in Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. Resident #22, with intact cognition, had a history of urinary tract infections, neurogenic bladder, and parkinsonism. Despite receiving antibiotics and anti-infective medications for chronic cystitis, the care plan did not include these medications, their potential side effects, or monitoring requirements. Additionally, the care plan lacked information on the resident's risk for bladder infections and the signs and symptoms to observe. This oversight was acknowledged by Staff H, RN/Nurse Manager, who confirmed that the care plan did not address these critical aspects. Similarly, Resident #15, who had severe cognitive impairment, was diagnosed with hypertension, Alzheimer's Disease, and depression. The resident was prescribed sertraline and lorazepam, but the care plan did not document the usage or side effects of these medications. Staff H acknowledged this omission during an interview, confirming that the care plan should have included information on the antidepressant and antianxiety medications. The facility's policy requires that care plans be comprehensive and individualized, yet these deficiencies indicate a failure to adhere to this policy.
Failure to Change Oxygen Tubing for Resident
Penalty
Summary
The facility failed to change the oxygen tubing for a resident who was receiving respiratory services. The resident, identified as having intact cognition, was diagnosed with heart failure, chronic respiratory failure with hypoxia, pneumonia, and obstructive sleep apnea. The resident's care plan indicated the use of continuous oxygen and a CPAP machine at night. The Treatment Administration Record (TAR) specified that the oxygen tubing should be changed on the 15th of each month, and the tubing was reportedly changed on that date. However, observations on May 7th revealed that the oxygen tubing connected to the resident's oxygen concentrator and portable concentrator had not been updated since March, and the tubing for the CPAP machine was not dated. The Director of Nursing (DON) confirmed during an observation that the oxygen tubing had not been changed as required. The resident also reported that the tubing had not been changed. The facility's policy on the administration of oxygen directed staff to change the oxygen cannula and tubing monthly, which was not adhered to in this case. The DON later reported changing the tubing on May 7th and documented it in the nurse's notes, but this action was taken after the deficiency was identified.
Lack of Clinical Rationale for GDR Declination
Penalty
Summary
The facility failed to provide an appropriate clinical rationale for declining a gradual dose reduction (GDR) for a resident receiving psychotropic medication. The resident, who had moderately impaired cognition with a BIMS score of 8, was diagnosed with anxiety and depression and was receiving both antidepressant and antianxiety medications. Despite requests for a GDR for the antipsychotic medication Risperdal, the physician denied these requests without providing a clinical rationale, as documented on facility forms dated December 2023 and February 2024. Staff acknowledged the lack of clinical rationale for continuing the medications without changes, citing difficulties in obtaining this information from the physician. The facility's policy on unnecessary medication and GDRs requires that a rationale be provided by the physician or practitioner to support either an attempted reduction or the continuation of medication if clinical symptoms indicate a need. However, this policy was not adhered to in the case of the resident in question.
Inadequate Puree Portion Sizes for Residents
Penalty
Summary
The facility failed to provide appropriate puree main entree portion sizes to ensure adequate calorie and protein intake for two residents on puree diets. During an observation of puree food preparation, it was noted that the staff had a total volume of 6 cups of pureed hamburger but needed a total of 7 servings, indicating a shortfall in portion size. The staff used incorrect scoop sizes for serving the puree diets, which were not in accordance with the facility's policy. The policy required marking the serving size measurement on the top of each container, but this was not effectively implemented, leading to incorrect portion sizes being served. Resident #48, who was on a pureed diet, was served only a #12 scoop of pureed meat instead of the required #8 and #12 scoops, resulting in inadequate portion size. Similarly, Resident #76, who required substantial assistance with meals, was served with only a #8 scoop of pureed hamburger, contrary to the required #8 and #12 scoops. The dietary staff confirmed the errors in portion sizes during interviews, acknowledging that the correct scoop sizes were not used, and there was leftover puree after meal service, indicating that the residents did not receive the appropriate amount of food.
Infection Control Lapses in Tube Feeding Practices
Penalty
Summary
The facility failed to adhere to infection prevention practices during the care of a resident who was dependent on staff for all care and relied on tube feeding for nutritional intake. The resident had multiple medical diagnoses, including diabetes, renal insufficiency, and cerebral palsy, and was on a diet order of nothing by mouth, receiving nutrition and medication through a gastric tube. During an observation, a Licensed Practical Nurse (LPN) was seen using a tube adapter dated several days prior, and after dropping a cup and syringe on the floor, the LPN picked them up with gloved hands and discarded them without changing gloves. The LPN then proceeded to clean the feeding tube adapter with the same gloves, compromising infection control protocols. Further observations revealed that the feeding equipment, including the feeding pump, pole, and stethoscope, was visibly soiled with a dried yellow substance, identified as formula. A Registered Nurse (RN) acknowledged the equipment was dirty and admitted there was no routine cleaning schedule in place, indicating that staff cleaned the equipment only as needed. The facility's infection control policy mandates the use of standard precautions to prevent the transmission of pathogens, which was not followed in this instance.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to maintain a system to monitor the long-term use of antibiotics for two residents. Resident #61 had an ongoing order for Bactrim DS for bacteriuria without an end date, and the clinical records lacked documentation of monitoring the long-term use of this antibiotic. The Infection Preventionist confirmed that there was no system in place to ensure the continued necessity of the antibiotic. The facility's Antibiotic Stewardship Program policy outlined the role of the Consulting and/or Dispensing Pharmacist in reviewing antibiotics during monthly medication reviews and making recommendations to the Antibiotic Stewardship Committee, but this process was not effectively implemented. Resident #15, who had severe cognitive impairment and was always incontinent of urine, was on a prophylactic antibiotic, Cephalexin, for chronic cystitis without hematuria. The resident's care plan noted the use of Cephalexin for chronic urinary tract infections and instructed staff to monitor for side effects and symptoms of a UTI. However, there was no evidence of a system to monitor the long-term use of this antibiotic, indicating a failure to adhere to the facility's policy on antibiotic stewardship.
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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