Montrose Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Montrose, Iowa.
- Location
- 400 South 7th Street, Montrose, Iowa 52639
- CMS Provider Number
- 165304
- Inspections on file
- 20
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Montrose Health Center during CMS and state inspections, most recent first.
A resident with COPD, pneumonia, and respiratory failure was transferred to the hospital for acute respiratory distress and later deemed medically ready for discharge, but the facility delayed readmission by three days due to staffing and admission timing practices. Facility staff, including an RN, MDS coordinator, ADON, DON, and Administrator, reported that they avoided weekend and evening admissions, required two nurses for admissions, and were concerned about entering medication orders into the EMR in time for pharmacy delivery when only one nurse was on duty. They did not notify the provider about the planned discharge back, did not arrange alternative pharmacy or transport options, and cited shared transport and lack of additional nurses as reasons the readmission was not feasible, despite the facility’s stated commitment to 24-hour nursing care and medication management.
A resident with severely impaired cognition sustained burns from hot liquids on two occasions due to inadequate supervision and ineffective interventions. Despite being provided with lidded cups, the resident often removed the lids, leading to spills and burns. The facility's care plan did not specifically address the risk of burns from hot liquids, and staff were unsure if hot liquid assessments were conducted.
A facility failed to submit MDS assessments within the required timeframes for a resident, resulting in a record over 120 days old. The resident's Quarterly MDS assessment and an assessment for death in the facility were submitted late. The delay was due to an oversight where a system question was not updated. The facility lacked a specific policy for MDS submission, relying on CMS guidelines.
The facility failed to update care plans for three residents following significant health changes. A resident with impaired cognition suffered a burn from a hot liquid spill, but the care plan did not address this risk. Another resident with diabetes did not have the condition included in their care plan, despite being on medication. A third resident was incorrectly documented as having diabetes, while they actually had steroid-induced hyperglycemia. The facility lacked a policy for care plan revisions.
A resident with intact cognition had a physician's order for digoxin with instructions to hold the medication if the pulse was below 60. Despite this, the medication was administered on two occasions when the resident's pulse was below the specified threshold. A RN acknowledged the standard practice of holding the medication if the pulse was below 60, and the DON confirmed that the medication should have been held and the provider contacted. The facility's policy on medication administration was not followed.
The facility failed to provide timely assessment and intervention for changes in condition for two residents. One resident with COPD experienced severe respiratory distress that was not promptly addressed, leading to an emergency hospital transfer. Another resident experienced an unwitnessed fall that was not properly assessed or documented, resulting in a hip fracture and subsequent hospitalization.
A facility failed to prevent and manage a pressure ulcer for a resident with a left fibular fracture and cam boot. The care plan lacked guidance on boot use, and there was no order to monitor the skin. The resident developed a blister that worsened into a deep tissue injury and became unstageable. Inconsistent documentation and unclear staff management contributed to the deficiency.
A resident with a history of arterial ulcers experienced significant pain during wound care, but the facility failed to provide adequate pain management. Despite having orders for pain medications, the resident reported that Tylenol was ineffective, and no as-needed pain medications were administered. Observations and interviews revealed a lack of responsiveness from staff and a failure to notify the provider for increased pain.
The facility failed to prevent resident-to-resident altercations, resulting in multiple incidents of physical and verbal aggression among residents with severe cognitive impairments. Despite interventions such as medication administration, monitoring, and separating residents, the facility was unable to effectively protect residents from abuse and ensure their safety.
The facility failed to ensure that a rehired RN completed communication and behavioral health training before working independently with residents. The Administrator confirmed the absence of proof for these trainings during orientation, and the facility assessment did not include these training requirements for all employees.
A facility failed to accurately code a resident's pressure ulcers on the MDS assessment. Despite documentation of multiple stage II pressure areas on the resident's left toes, lateral foot, and heel, the MDS assessment incorrectly indicated no unhealed pressure ulcers. The MDS Coordinator acknowledged the oversight.
The facility failed to ensure the safety of residents during wheelchair transport by not using foot pedals, leading to potential fall risks. A resident with intact cognition and at risk for falls was observed being transported without foot pedals on two occasions. Another resident with severely impaired cognition and a high risk for falls experienced a fall due to the absence of foot pedals. Despite staff education, the resident was later observed self-propelling without foot pedals. A third resident, at high risk for falls, was also observed being pushed in a wheelchair without foot pedals.
The facility failed to timely notify the provider of changes in a resident's urine and catheter, despite multiple instances of abnormal findings such as brown sedimentation and fecal matter in urine. The resident's care plan and urology office instructions were not consistently followed, leading to delayed follow-up and inadequate catheter care.
A resident received medications prescribed to another resident due to a failure to properly identify the resident before administration. The error was documented, and the resident's vital signs were monitored without immediate adverse effects. The facility's procedures for resident identification were not followed.
Delayed Hospital Readmission Due to Insufficient Nursing Staff and Admission Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and related processes to support the timely readmission of a hospitalized resident, resulting in a three-day delay in the resident’s return. The resident had moderately impaired cognition, with a BIMS score of 12/15, and medical diagnoses including COPD with acute exacerbation, pneumonia, and respiratory failure. The resident was transferred to the hospital after staff observed labored respirations, use of accessory muscles, diaphoresis, an oxygen saturation of 85% on room air, and wheezing, with improvement after oxygen was applied but continued labored breathing. Hospital records show the resident was admitted and later determined medically stable and ready for discharge, with documentation that the patient was planned for discharge but was not accepted back to the facility due to timing issues and would remain in the hospital over the weekend. Hospital progress notes documented that the resident was medically ready for discharge and that discharge was planned but not completed because the facility would not accept the resident later in the day. A hospital case management/social work note indicated confirmation that the facility could take the patient on the day the resident ultimately returned. The facility’s EHR showed the resident’s billing status changed to STOP BILLING on the date of hospital transfer and back to active several days later, corresponding to the delayed readmission. The resident reported spending three days in the hospital before being able to return to the facility. Multiple staff interviews described facility practices that contributed to the delay in readmission. An RN stated the facility tried not to do admissions on weekends and did not want admissions after 2 p.m. so nurses could complete admission tasks and enter medications into the computer in time for pharmacy delivery. The MDS Coordinator stated the facility liked residents readmitted before 2 p.m. to obtain medications, that the hospital had informed them the resident would not return until early evening, and that the facility needed two nurses in the building for an admission; the coordinator also stated the facility did not do admissions on weekends and was unsure about using another pharmacy or family to obtain medications. The ADON and DON both stated that with only one nurse on duty, a readmission later in the day was not feasible due to the time needed for admission assessments and medication entry, and they cited concerns about not having medications on time and the workload of one nurse caring for existing residents and completing a readmission. The DON further stated the facility did not accept evening or Saturday admissions for safety reasons, did not notify the provider about the planned discharge back to the facility, and did not explore hospital-supplied medications or alternative transport options, while acknowledging the presence of on-call nurses. The Administrator confirmed that with only one nurse, a readmission was considered not doable. The facility lacked written transportation or readmission policies and relied on general CMS and Resident Rights guidance, while its Resident Handbook stated residents receive individualized 24-hour nursing care and medication management.
Resident with Impaired Cognition Sustains Burns from Hot Liquids
Penalty
Summary
The facility failed to ensure a resident with severely impaired cognition remained free from burns caused by hot liquids. The resident, who scored 06 out of 15 on a Brief Interview for Mental Status (BIMS) exam indicating severely impaired cognition, sustained a second-degree burn to the thigh from a hot beverage on two separate occasions. The first incident occurred on 7/8/24, and the second incident occurred on 9/17/24, resulting in redness to the skin. The resident required set-up or cleanup assistance with eating, as noted in the Minimum Data Set (MDS) assessment. The resident's care plan, revised on 5/29/24, did not specifically address the risk of burns from hot liquids, despite the resident's history of cognitive deficits and physical limitations. Observations revealed that the resident was provided with cups with lids, but the resident often removed the lids. The facility's interventions included providing the resident with a lidded cup and diluting hot tea with ice or tap water. However, these measures were not consistently effective, as the resident continued to spill hot liquids, leading to burns. Interviews with staff indicated that the resident was known to enjoy hot tea and had a history of removing lids from cups. Despite education provided to the resident about the need for lids on cups, the resident's short-term memory issues required frequent reminders. The facility did not have a specific policy addressing accidents and hazards related to hot liquids, and staff were unsure if hot liquid assessments were conducted. The facility's failure to implement effective interventions and adequately supervise the resident contributed to the repeated incidents of burns from hot liquids.
Failure to Submit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were submitted within the required regulatory timeframes for a resident reviewed under the Resident Assessment Instrument Task. The resident in question had an MDS record that was over 120 days old, and not all assessments were documented as accepted or submitted. The resident was initially admitted to the facility on May 8, 2024, and was discharged on an unspecified date. A Quarterly MDS assessment with an Assessment Reference Date (ARD) of August 6, 2024, was submitted late on September 18, 2024. Additionally, an MDS assessment completed for the resident's death in the facility with an ARD of August 19, 2024, was accepted on September 18, 2024. The Nurse Consultant acknowledged the oversight, explaining that a question in the system was not updated, which delayed the submission. The facility did not have a specific policy for MDS submission and followed CMS guidelines.
Care Plan Deficiencies for Residents with Health Changes
Penalty
Summary
The facility failed to revise care plans for three residents following significant changes in their health status. Resident #11, who had severely impaired cognition, experienced a hot liquid spill resulting in a burn, but the care plan did not address the risk of hot liquids. Despite interventions being implemented, the care plan was not updated to reflect these changes. Resident #26, with intact cognition and a diagnosis of diabetes mellitus, did not have diabetes addressed in their care plan, even though they were prescribed medication for the condition. The facility lacked a policy for care plan revisions, relying instead on CMS guidelines. Resident #139 was incorrectly documented as having insulin-dependent diabetes mellitus in their care plan, despite not having a diabetes diagnosis. Instead, the resident had steroid-induced hyperglycemia, which required insulin management. The care plan failed to accurately reflect this diagnosis and the necessary interventions. The facility's Nurse Consultant acknowledged the error and the absence of a written policy for care plan revisions was noted by the Facility Administrator.
Failure to Adhere to Digoxin Administration Parameters
Penalty
Summary
The facility failed to adhere to professional standards of quality in administering digoxin to a resident, as evidenced by a review of clinical records, interviews, and facility policy. A resident with intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status exam, had a physician's order for digoxin with specific instructions to hold the medication if the pulse was below 60. However, the Medication Administration Records showed that the medication was administered on two occasions when the resident's pulse was below the specified threshold: once with a pulse of 59 and another time with a pulse of 55. During an interview, a Registered Nurse acknowledged the standard practice of holding the medication if the pulse was below 60, and the Director of Nursing confirmed that the medication should have been held and the provider contacted. The facility's policy on medication administration, which mandates adherence to physician orders, was not followed in this instance.
Failure to Provide Timely Assessment and Intervention for Changes in Resident Condition
Penalty
Summary
The facility failed to appropriately provide assessment and interventions for necessary care and services during a change in condition for two residents. Resident #6, with a known history of chronic obstructive pulmonary disease (COPD) and respiratory failure, experienced a significant decline in respiratory condition that was not promptly identified or addressed. Despite multiple documented instances of respiratory distress, including shortness of breath, low oxygen saturation, and increased anxiety, the facility staff did not consistently notify the provider in a timely manner. This led to Resident #6 being found unresponsive and requiring emergency transport to the hospital, where they were diagnosed with respiratory distress, respiratory syncytial virus (RSV), and respiratory failure with hypercapnia. Interviews with staff revealed inconsistencies in understanding when to notify the provider and reliance on placing non-emergent issues in a communication binder rather than immediate notification for acute changes in condition. Resident #3 experienced an unwitnessed fall that was not properly assessed or documented by the facility staff. The resident, who had a history of falls and required assistance with mobility, fell while attempting to get into bed. Despite the resident's complaints of pain and the fall being reported by the resident and their roommate, there was no immediate nursing assessment or documentation completed. It was only three days later that an x-ray was ordered, revealing a non-displaced left sub-capital hip fracture. The resident was subsequently admitted to the hospital for surgical repair of the hip fracture. Interviews with staff indicated a lack of adherence to the facility's fall assessment protocol, which requires immediate assessment, documentation, and notification of the provider and relevant parties. The deficiencies in both cases highlight a failure in the facility's processes for monitoring and responding to changes in resident conditions and ensuring timely medical intervention. The lack of immediate and appropriate response to Resident #6's respiratory distress and Resident #3's fall resulted in significant adverse outcomes for both residents. The facility's policies and staff training on these critical aspects of care were found to be inadequate, contributing to the deficiencies observed during the survey.
Removal Plan
- Education provided to all staff nurses on the following topics: Documentation in real time, When to notify the provider via phone call, Acceptable notifications to be left in the provider binder, Physician notification as soon as acute change is noted.
- A review of respiratory assessment parameters and when to notify the provider completed with staff nurses, which included the development of respiratory assessment guidelines to notify the provider of any of the following that aren't resolved with interventions already in place: Respiratory rate greater than 22 respirations/minute with complaints of shortness of breath, Oxygen saturation less than 90%, unless otherwise specified in orders, Acute lung sound changes, including: wheezing, rhonchi, rales, and crackles.
- Audits of the provider binder to be completed by Director of Nursing.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development and worsening of a pressure ulcer for a resident who was admitted with a left fibular fracture and wore a cam boot. The resident's initial care plan did not include guidance on the schedule for applying and removing the cam boot, and there was no order to monitor the skin underneath the boot. Despite the resident being at moderate risk for pressure ulcer development, the facility did not implement timely interventions to prevent pressure ulcers, leading to the development of a blister on the resident's left heel, which later worsened into a deep tissue injury (DTI) and eventually became unstageable with necrotic tissue. The resident's care plan was revised multiple times to reflect the worsening condition of the pressure ulcer, but the facility's documentation and assessment practices were inconsistent and incomplete. The facility's records lacked detailed documentation of the wound's presence, type, and measurements on several occasions. Additionally, there were discrepancies in the documentation of the resident's skin condition, with some notes indicating intact skin while others documented the presence of blisters and discoloration. The facility also failed to notify dietary services about the resident's pressure ulcer, which could have impacted the resident's nutritional support for wound healing. Interviews with staff revealed a lack of clarity and consistency in the management of the resident's pressure ulcer. Staff members were unsure about the resident's initial skin condition upon admission and the appropriate care for the cam boot. The facility's consultant acknowledged the need for an order to remove the boot each shift and inspect the skin, which was not in place. The facility administrator confirmed that there was no pressure ulcer policy in place at the time of the incident, indicating a systemic issue in the facility's approach to pressure ulcer prevention and management.
Inadequate Pain Management for Resident with Ankle Ulcer
Penalty
Summary
The facility failed to identify and adequately treat pain related to an open ulcer on a resident's right ankle during wound care. The resident, who had intact cognition and a history of arterial ulcers, experienced significant pain during dressing changes. Despite having orders for pain medications such as Gabapentin, Tylenol, and Ibuprofen, the resident reported that Tylenol was ineffective, and no doses of as-needed pain medications were administered in April 2024. Observations revealed that the resident exhibited signs of severe pain during wound care, including gasping, screaming, and biting her tongue, yet staff did not offer pain medication or take breaks to alleviate her discomfort. The resident's clinical records and interviews indicated a history of pain complaints related to the ankle wound, which had worsened over time. The wound had increased in size, exhibited signs of infection, and caused significant discomfort during dressing changes. Despite these issues, the facility's staff did not consistently administer pain medication or notify the provider for increased pain. The Nurse Practitioner acknowledged the resident's pain during wound care and suggested pre-medication, but this practice was not consistently followed by the nursing staff. Interviews with the Director of Nursing and other staff members revealed a lack of awareness and responsiveness to the resident's pain. The DON believed that the resident would voice her need for pain medication, despite the resident's reports of frequent and severe pain. The facility lacked a policy or procedure related to pressure ulcers/injuries, contributing to the inadequate pain management and failure to address the resident's discomfort effectively.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure residents remained free from resident-to-resident altercations, resulting in multiple incidents of physical and verbal aggression among residents. Resident #18, who had severe cognitive impairment and a history of physical and verbal behaviors, was involved in several altercations. These included a male resident smacking her buttocks, a verbal altercation over a sandwich, and physical contact with another resident. Despite interventions such as medication administration and monitoring, Resident #18 continued to exhibit aggressive behaviors, including running over another resident's foot with a wheelchair and hitting another resident's leg. The facility's interventions included moving residents to different areas and planning a care conference to discuss other placement options for Resident #18's safety and the safety of others. Resident #141, who had moderately impaired cognition and a history of verbal and physical behaviors, was also involved in multiple altercations. These included hitting another resident on the shoulder, hitting another resident's leg, and being hit by Resident #18 after having her foot run over by a wheelchair. The facility's interventions for Resident #141 included assisting her to a recliner or bed between meals to increase supervision and decrease altercations. Despite these interventions, Resident #141 continued to exhibit aggressive behaviors, leading to further incidents. Resident #1 and Resident #5, both with severely impaired cognition, were also involved in altercations with Resident #141. Resident #1 was hit on the shoulder three times by Resident #141, and Resident #5 was hit on the leg twice by Resident #141. The facility's interventions included separating the residents immediately and assisting them to their rooms or recliners. However, the facility failed to prevent further incidents, indicating a lack of effective measures to protect residents from abuse and ensure their safety.
Failure to Ensure Timely Staff Training
Penalty
Summary
The facility failed to ensure that training for communication and behavioral health was completed before a staff member worked independently with residents. Specifically, a Registered Nurse (Staff D) was rehired on an unspecified date, but the training records showed that communication training was completed on 11/6/20 and behavioral health training on 9/3/22. On 4/25/24, the facility's Administrator confirmed via email that there was no proof of these trainings being provided during orientation for Staff D. Additionally, the facility assessment updated on 2/13/24 did not include requirements for behavioral health or communication training for all employees.
Failure to Accurately Code Pressure Ulcers on MDS Assessment
Penalty
Summary
The facility failed to ensure accurate coding of pressure ulcers on the Minimum Data Set (MDS) assessment for a resident with severely impaired cognition. The resident, who scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, was at risk for developing pressure ulcers. Despite this, the MDS assessment indicated that the resident did not have any unhealed pressure ulcers or venous/arterial ulcers. However, the Nursing Admission Screening/History form and subsequent Skin/Wound Evaluations documented multiple pressure areas, including a stage II pressure area on the left toes, left lateral foot, and left heel, all present since the resident's readmission to the facility. These discrepancies were not reflected in the MDS assessment, which was acknowledged as an oversight by the MDS Coordinator who followed the Resident Instrument Assessment (RAI) Manual. The resident's medical records indicated that the pressure areas were present on admission and had been documented as early as 11/18/23. The Health Status Note also mentioned the resident's non-compliance with wearing heel protectors, which were necessary for the treatment of the wound on the left heel. The MDS Coordinator admitted to the oversight during an interview, explaining that the wounds were not listed in the MDS assessment. This failure to accurately code the resident's pressure ulcers on the MDS assessment constitutes a deficiency in ensuring accurate resident assessments.
Failure to Use Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
The facility failed to ensure the safety of residents during wheelchair transport by not using foot pedals, leading to potential fall risks. Resident #9, with intact cognition and at risk for falls due to muscle weakness and edema, was observed being transported without foot pedals on two occasions. Similarly, Resident #92, with severely impaired cognition and a high risk for falls, experienced a fall when their sock got caught on the wheelchair due to the absence of foot pedals. Despite staff education on the use of foot pedals, the resident was later observed self-propelling in the wheelchair without foot pedals. Resident #7, who has intact cognition and is at high risk for falls due to a history of cerebral vascular accident, polyarthritis, and long-term use of anticoagulants, was also observed being pushed in a wheelchair without foot pedals. The resident's feet skimmed across the floor during transport. The facility's policy on falls did not address the use of wheelchair foot pedals, contributing to the deficiency.
Failure to Timely Notify Provider of Changes in Urine and Catheter
Penalty
Summary
The facility failed to identify and notify the provider in a timely manner of changes in urine and catheter for a resident with an indwelling catheter. The resident, who had diagnoses including vesicointestinal fistula, neurogenic bladder, and renal insufficiency, required close monitoring for signs of infection and other complications. Despite multiple documented instances of abnormal findings such as brown sedimentation, fecal matter in urine, and catheter leakage, the facility did not consistently notify the provider or follow up with the urology office as instructed in the care plan and by the urology office's orders. The resident's care plan, revised on 04/15/24, specifically instructed staff to monitor, document, and report any signs of urinary tract infection or urethral trauma. However, progress notes revealed several instances where abnormal findings were either not reported promptly or not followed up adequately. For example, on 02/27/24, brown sedimentation was observed in the catheter tubing, and although the provider and urology office were notified, the follow-up appointment was delayed until 05/22/24. Additionally, on 03/03/24, feces were present in the drainage bag, but the provider advised waiting until the next day to notify urology, and there was no documentation of immediate follow-up. Interviews with the Nurse Practitioner and Director of Nursing revealed a lack of awareness and inconsistent communication regarding the resident's symptoms. The NP stated that changes in urine color might not require immediate notification unless accompanied by other symptoms, while the DON confirmed that the urology office had instructed nursing to call for changes such as brown sedimentation in urine. This inconsistency in following the care plan and provider instructions contributed to the deficiency in timely and appropriate catheter care for the resident.
Significant Medication Error Due to Failure to Identify Resident
Penalty
Summary
The facility failed to ensure that a resident received medications only prescribed to them, resulting in a significant medication error. Specifically, Resident #14 was administered medications that were prescribed to Resident #10. The error was documented in a Medication Error Report and confirmed through a review of the Medication Administration Record (MAR) for both residents. Resident #14, who had intact cognition as indicated by a BIMS score of 13 out of 15, received multiple medications not listed on their MAR, including Risperdal, Atrovastatin, Calcium plus Vitamin D, Corlanor, Depakote, and Midodrine. The error was identified when the resident's vital signs were monitored, and the Nurse Practitioner was informed. The resident did not report any immediate discomfort or adverse effects at the time of the incident. The Director of Nursing and the MDS Coordinator explained that the facility had procedures in place for identifying residents, such as using pictures and asking residents their names depending on their BIMS score. However, the error occurred due to a failure to properly identify the resident before administering the medication. The facility's Medication Administration Pocket-Guide emphasized the importance of verifying the right drug, dose, time, route, and resident, but this protocol was not followed in this instance. The facility had a census of 36 residents at the time of the incident.
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 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.
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.
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.
Two residents who were cognitively impaired and dependent on staff for personal care did not receive bathing assistance at least twice weekly as required by facility policy. Facility records showed multiple instances where bathing was documented as refused or not applicable, resulting in gaps of 6, 7, and 11 days between baths. The care plan for one resident specified total dependence on staff for bathing, and the facility’s policy required showers to be offered at least twice weekly and on the next available day if missed. The DON reported that staff are expected to continue offering showers and try different approaches after refusals, but the documented bathing intervals did not reflect this practice.
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.
A resident with COPD, pneumonia, and respiratory failure was transferred to the hospital for acute respiratory distress and later deemed medically ready for discharge, but the facility delayed readmission by three days due to staffing and admission timing practices. Facility staff, including an RN, MDS coordinator, ADON, DON, and Administrator, reported that they avoided weekend and evening admissions, required two nurses for admissions, and were concerned about entering medication orders into the EMR in time for pharmacy delivery when only one nurse was on duty. They did not notify the provider about the planned discharge back, did not arrange alternative pharmacy or transport options, and cited shared transport and lack of additional nurses as reasons the readmission was not feasible, despite the facility’s stated commitment to 24-hour nursing care and medication management.
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.
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.
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 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.
Failure to Provide Twice-Weekly Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance at least twice weekly, as required by its own policy, for two residents who were dependent on staff for bathing. For one resident with anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive impairment, the MDS documented total dependence on staff for bathing. Facility documentation showed that bathing was recorded as refused on one date, with actual baths provided on dates that resulted in a 6‑day interval without a bath on two separate occasions. The resident’s care plan indicated the resident was totally dependent on staff to provide a bath as necessary. For another resident with diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, facility records showed multiple dates where bathing was documented as refused or as not applicable. Review of the Follow Up Question Report demonstrated several extended gaps between baths: 6 days on two occasions, 7 days on one occasion, and 11 days on another, despite the facility policy requiring showers to be offered at least twice weekly and, if missed, to be offered on the next available day. In an interview, the DON stated that when a resident refuses a shower, staff are expected to continue to offer, try multiple times, try a different person, and continue to try the next day until the resident bathes, which was not reflected in the documented bathing intervals for these two residents.
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.
Delayed Hospital Readmission Due to Insufficient Nursing Staff and Admission Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and related processes to support the timely readmission of a hospitalized resident, resulting in a three-day delay in the resident’s return. The resident had moderately impaired cognition, with a BIMS score of 12/15, and medical diagnoses including COPD with acute exacerbation, pneumonia, and respiratory failure. The resident was transferred to the hospital after staff observed labored respirations, use of accessory muscles, diaphoresis, an oxygen saturation of 85% on room air, and wheezing, with improvement after oxygen was applied but continued labored breathing. Hospital records show the resident was admitted and later determined medically stable and ready for discharge, with documentation that the patient was planned for discharge but was not accepted back to the facility due to timing issues and would remain in the hospital over the weekend. Hospital progress notes documented that the resident was medically ready for discharge and that discharge was planned but not completed because the facility would not accept the resident later in the day. A hospital case management/social work note indicated confirmation that the facility could take the patient on the day the resident ultimately returned. The facility’s EHR showed the resident’s billing status changed to STOP BILLING on the date of hospital transfer and back to active several days later, corresponding to the delayed readmission. The resident reported spending three days in the hospital before being able to return to the facility. Multiple staff interviews described facility practices that contributed to the delay in readmission. An RN stated the facility tried not to do admissions on weekends and did not want admissions after 2 p.m. so nurses could complete admission tasks and enter medications into the computer in time for pharmacy delivery. The MDS Coordinator stated the facility liked residents readmitted before 2 p.m. to obtain medications, that the hospital had informed them the resident would not return until early evening, and that the facility needed two nurses in the building for an admission; the coordinator also stated the facility did not do admissions on weekends and was unsure about using another pharmacy or family to obtain medications. The ADON and DON both stated that with only one nurse on duty, a readmission later in the day was not feasible due to the time needed for admission assessments and medication entry, and they cited concerns about not having medications on time and the workload of one nurse caring for existing residents and completing a readmission. The DON further stated the facility did not accept evening or Saturday admissions for safety reasons, did not notify the provider about the planned discharge back to the facility, and did not explore hospital-supplied medications or alternative transport options, while acknowledging the presence of on-call nurses. The Administrator confirmed that with only one nurse, a readmission was considered not doable. The facility lacked written transportation or readmission policies and relied on general CMS and Resident Rights guidance, while its Resident Handbook stated residents receive individualized 24-hour nursing care and medication management.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
