Montezuma Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Montezuma, Iowa.
- Location
- 316 Meadow Lane Drive, Montezuma, Iowa 50171
- CMS Provider Number
- 165295
- Inspections on file
- 16
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Montezuma Specialty Care during CMS and state inspections, most recent first.
The facility failed to treat residents with dignity and respect, affecting four residents. A CNA yelled at residents during a dining incident and made inappropriate comments, contrary to care plans. One resident felt bad after being told his falls were recurring, and another was avoided by the CNA for weeks after an incident. The facility's policy on dignity and respect was not followed, and reported concerns were not adequately addressed.
The facility failed to address concerns about staff treatment of residents, involving incidents where a CNA yelled at residents and avoided providing care. Despite reports and written statements from staff, there was no documentation of follow-up by the administration. The facility's policy on dignity and respect was not upheld, affecting residents with varying cognitive conditions.
The facility failed to conduct effective QAPI activities, lacking documentation and structured processes to address quality deficiencies related to resident treatment and dignity concerns. From January to October, there was no evidence of ongoing QAPI program activities, monitoring, or evaluation of corrective actions. The facility's policy outlined the QAPI committee's responsibilities, but the Administrator admitted that past citations had not been discussed in QA meetings.
A resident with multiple health conditions, including risk for pressure injuries, did not receive the prescribed double protein diet as ordered. Despite the care plan and dietary instructions, observations showed meals lacking the required protein portions. Interviews with dietary staff revealed a failure to implement the diet order correctly.
A resident with a history of mobility issues and a recent fracture was observed being pushed in a wheelchair with only one foot pedal, contrary to safety expectations. The CNA acknowledged the missing pedal, and the ADON confirmed the requirement for both pedals for safe transport. The resident expressed frustration over the missing pedal since admission.
The facility failed to treat two residents with dignity by not assisting them with the bedpan and instructing them to urinate or defecate in their incontinent briefs. Multiple staff members confirmed the residents' complaints, but the facility's grievance log did not contain any records of these issues. The staff member involved has been suspended pending investigation.
A facility failed to report and investigate an allegation of abuse where a staff member instructed a resident to urinate and defecate in her brief instead of assisting her with a bedpan. Multiple staff members were aware of the incident but did not document or investigate it properly, leading to a deficiency in compliance with federal requirements.
A resident with a tibia fracture reported that a night shift staff member instructed her to urinate and defecate in her incontinent brief instead of providing a bedpan. This was corroborated by another resident and multiple staff members, but the facility failed to document and investigate the allegations properly, violating their abuse prevention and dignity policies.
The facility failed to create interventions based on root cause analysis of falls to prevent future falls for a resident with severe cognitive impairment and a history of falls. Despite multiple documented falls resulting in injuries, the resident's care plan lacked specific interventions, and the clinical record did not show any analysis or preventive measures.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, affecting four out of twelve residents reviewed. Resident #8, with intact cognition, was directed to be spoken to face-to-face to reduce confusion due to schizophrenia. However, Staff F was reported to have yelled at her during a dining incident, telling her that the conversation was none of her business. Resident #12, with moderately impaired cognition, was directed to receive positive interaction due to her emotional state. Staff F also yelled at her during the same dining incident. Resident #11, who had intact cognition and was diagnosed with depression, anxiety, and paraplegia, reported feeling bad after Staff F commented on his recurring falls. This interaction was contrary to the care plan, which directed staff to speak to him calmly. Additionally, Resident #6, with intact cognition and requiring assistance for bed mobility, reported that Staff F accused her of resisting during care and subsequently avoided her room for three weeks, leaving her care to other staff. The facility's policy on Residents Rights-Dignity and Respect was not adhered to, as evidenced by multiple staff statements and resident interviews. Staff D reported that Staff F yelled at residents and made inappropriate comments, which were documented and submitted to the Administrator but not addressed. The Administrator acknowledged the lack of additional documentation related to grievances or staff concerns, indicating a failure to investigate and address the reported issues adequately.
Failure to Address Staff Misconduct and Resident Dignity Concerns
Penalty
Summary
The facility administration failed to address concerns regarding staff treatment of residents, specifically involving four residents. Resident #8, with intact cognition, was directed to have consistent routines to reduce confusion, yet experienced an incident where Staff F yelled at her during dinner. Resident #12, with moderately impaired cognition, was directed to receive positive interactions, but was also yelled at by Staff F. Resident #11, with intact cognition and paraplegia, was made to feel bad by Staff F after a fall, as Staff F commented on the recurring nature of the falls. Resident #6, with intact cognition and requiring assistance for bed mobility, reported that Staff F accused her of resisting care and subsequently avoided her room for three weeks. The facility's policy on Residents Rights-Dignity and Respect, which mandates respectful and considerate care, was not adhered to in these instances. Written statements from Staff D CNA detailed multiple incidents where Staff F displayed inappropriate behavior, such as yelling at residents and making derogatory comments. Despite these reports, there was a lack of documentation indicating that the administration followed up on these concerns, and Staff D's written statements placed in the Administrator's mailbox did not receive a response. Interviews with various staff members revealed that Staff F's behavior was known among the staff, and there was an awareness of his reluctance to care for Resident #6. The former DON acknowledged awareness of the situation with Resident #6 but could not recall other concerns about Staff F. The Administrator admitted to not having additional documentation related to grievances or staff concerns and stated that the way Staff F spoke to residents was unacceptable.
Lack of Effective QAPI Activities
Penalty
Summary
The facility failed to conduct effective Quality Assurance and Performance Improvement (QAPI) activities, as evidenced by a lack of documentation and structured processes to address quality deficiencies related to resident treatment and dignity concerns. The review of QAPI/QA documentation from January to October revealed an absence of evidence for ongoing QAPI program activities in these areas. The facility did not document any monitoring or evaluation of the effectiveness of corrective actions or performance improvement activities, nor did it revise these activities as needed. The facility's policy on QAPI Program Governance and Leadership, revised in March 2020, outlined the responsibilities of the QAPI committee to identify and resolve negative outcomes and coordinate performance improvement projects. However, the Administrator admitted that since his tenure, past citations had not been discussed in QA meetings.
Failure to Provide Prescribed Double Protein Diet
Penalty
Summary
The facility failed to provide the diet as ordered for a resident reviewed for nutrition. The resident, who had a diagnosis of hyponatremia, COPD, pulmonary embolism, and osteoarthritis, was at risk for pressure injuries and was on a therapeutic diet. The care plan directed staff to provide double protein twice a day, but the resident reported receiving a large amount of starches instead. The resident also mentioned receiving foods high in vitamin K, which she needed to avoid due to being on a blood thinner. Observations confirmed that the resident's meals lacked the prescribed double protein portions. On two separate occasions, the resident received only a single protein source at lunch. Interviews with dietary staff revealed a misunderstanding or failure to implement the diet order correctly, as the dietary manager and registered dietitian both acknowledged the requirement for double protein but did not ensure it was provided. The registered dietitian reviewed the diet order and menu but did not rectify the issue before the surveyor's observation.
Deficiency in Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure the safe transport of a resident in a wheelchair, leading to a deficiency. Resident #18, who has intact cognition and a history of arthritis, osteoporosis, a cerebrovascular accident, and a fractured right humerus, was observed being pushed in a wheelchair by a Certified Nursing Assistant (CNA) with only one foot pedal. The resident's care plan indicated the need for a wheelchair for mobility and assistance due to a recent fracture, with a non-weight-bearing restriction on the right upper extremity. During the observation, the CNA expressed a wish to find the missing wheelchair pedal and instructed the resident to keep their feet up. The Assistant Director of Nursing (ADON) confirmed that the expectation is for both foot pedals to be present for safety when pushing a wheelchair. The resident reported having only one pedal since arriving at the facility, which was upsetting. The facility's assessment identified the resident's mobility issues and the need for proper transfer equipment, including a wheelchair.
Failure to Assist Residents with Toileting and Maintain Dignity
Penalty
Summary
The facility failed to treat two residents with dignity by not assisting them with the bedpan and instructing them to urinate or defecate in their incontinent briefs. Resident #5, who had a tibia fracture and required substantial assistance for toileting, reported that a night shift staff member repeatedly told her to defecate in her brief instead of providing a bedpan. This made Resident #5 feel dirty and humiliated. Resident #6, who was present during the incident, corroborated Resident #5's account and stated that the staff member, identified as Staff A, made similar comments on two separate occasions. Resident #3 also reported hearing Staff A instruct another resident, Resident #11, to urinate in her pants about a year ago. Resident #11 required extensive assistance for toileting due to limited mobility from a hip fracture. Multiple staff members, including CNAs and an RN, confirmed that Resident #5 had reported the issue to them, and they had escalated the concern to the former Director of Nursing (DON) and the Assistant Director of Nursing (ADON). However, the facility's grievance log did not contain any records of these complaints. The former DON stated that she had educated Staff A about ensuring residents were not wet but did not recall being informed about the specific issue of instructing residents to soil themselves. The current Administrator only became aware of the situation recently and suspended Staff A pending an investigation. The facility's policy on dignity, revised in February 2021, emphasized that staff should care for residents in a manner that promotes their well-being and self-esteem.
Failure to Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a staff member who allegedly instructed a resident to urinate and defecate in her incontinent brief instead of assisting her with a bedpan. Resident #5, who had a tibia fracture and required substantial assistance for toileting, reported that a night shift staff member repeatedly told her to go in her brief and even reached into her brief to check if she was wet enough. This incident was corroborated by Resident #6, who was Resident #5's roommate and witnessed the staff member's behavior on two separate occasions. Despite multiple staff members, including CNAs and an RN, being aware of the incident and reporting it to higher authorities such as the former Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the facility failed to document or investigate the complaint properly. The facility's grievance log did not contain any concerns related to the incident, and the former DON claimed she was unaware of the specific allegations. The Administrator only became aware of the situation after the survey team initiated their investigation. The facility's policy on abuse, neglect, and exploitation, which mandates the identification, investigation, and reporting of all possible incidents, was not followed. The policy also emphasizes the importance of maintaining a culture of compassion and caring for all residents, which was evidently not upheld in this case. The failure to report and investigate the abuse allegation promptly led to a deficiency in the facility's compliance with federal requirements for resident care and safety.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse and ensure protection from further abuse for a resident. Resident #5, who had a tibia fracture and required substantial assistance for toileting, reported that a night shift staff member instructed her to urinate and defecate in her incontinent brief instead of providing a bedpan. This incident was corroborated by Resident #6, who witnessed the staff member's actions on two separate occasions. Despite these reports, the facility's grievance log did not contain any concerns related to this issue, indicating a failure to document and investigate the allegations properly. Multiple staff members, including CNAs and an RN, confirmed that Resident #5 had reported the abuse to them, and they had relayed the information to the former Director of Nursing (DON) and the Assistant Director of Nursing (ADON). However, the former DON stated she did not recall receiving such a report and would have investigated it if she had. The ADON also confirmed that she had reported the incident to the former DON after being informed by the residents during her rounds. The facility's policy on abuse prevention and dignity required the identification, investigation, and reporting of all possible incidents of abuse, neglect, and mistreatment. However, the facility failed to adhere to these policies, as evidenced by the lack of documentation and investigation into the reported abuse. The Administrator only became aware of the situation after the survey team began their investigation, leading to the suspension of the implicated staff member and the initiation of an investigation.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to create interventions based on root cause analysis of falls to prevent future falls for a resident with a history of falls and severe cognitive impairment. The resident, who had diagnoses including pelvic fracture, non-Alzheimer's dementia, and heart failure, was dependent on staff for transfers and had a history of falls resulting in injuries such as fractures and lacerations. Despite multiple falls documented in incident reports, the resident's care plan lacked specific interventions to address the falls, and the clinical record did not show any facility analysis of the root causes of each fall or interventions implemented to prevent future falls. The facility's policies on assessing falls and managing fall risks required identifying possible causes of falls and implementing specific interventions to prevent them. However, observations and staff interviews revealed that the facility did not adhere to these policies for the resident in question. The Director of Nursing acknowledged that the lack of care plan interventions for the resident was not in line with the facility's expectations, indicating a failure to follow established protocols for fall prevention.
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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