Newaldaya Lifescapes
Inspection history, citations, penalties and survey trends for this long-term care facility in Cedar Falls, Iowa.
- Location
- 7511 University Avenue, Cedar Falls, Iowa 50613
- CMS Provider Number
- 165465
- Inspections on file
- 19
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Newaldaya Lifescapes during CMS and state inspections, most recent first.
Staff failed to ensure that the person who applied lidocaine patches to two residents documented the administration on the TAR, with an LPN signing off on treatments performed by a CMA. This practice was confirmed through observation, record review, and staff interviews, and was not in accordance with facility policy requiring accurate documentation by the administering staff member.
A resident with multiple complex medical conditions and a PEG tube required Enhanced Barrier Precautions (EBP) for high-contact care activities. During an observed episode of PEG tube site cleaning and flushing, an LPN failed to wear a gown as required by facility policy and CDC guidance, despite clear signage and care plan instructions. Both the LPN and ADON acknowledged the omission, and the LPN's training records indicated prior competency in EBP procedures.
A resident with intact cognition and multiple diagnoses fell and sustained a head injury, but the family was not notified as required by the facility's policy. The LPN informed the PCP but failed to contact the family, believing the injury was minor. The DON acknowledged this failure, which was against the policy mandating family notification after incidents.
A LTC facility failed to assess and reassess residents for bed rail safety and did not provide adequate risk education, leading to a resident's death by asphyxiation. The resident, with severe cognitive impairment, was found wedged between the bed rail and mattress. Staff interviews revealed inadequate training and understanding of bed rail safety, compounded by an incomplete electronic health record system that omitted risk information.
The facility failed to respect the rights of two residents. One resident did not receive the requested twice-weekly baths, with no documentation of refusals or offers, despite having intact cognition. Another resident experienced bowel incontinence and emotional distress due to a non-functioning call light, leading to a delay in toileting assistance. The resident had to call his daughter for help, and the DON was unaware of the issue, despite the facility's policy to treat residents with dignity and respect.
The facility inaccurately coded the MDS assessments for two residents. One resident was incorrectly documented as having a less severe PASRR level than assessed, while another resident's healed pressure ulcer was mistakenly recorded as active. These errors were acknowledged by the MDS Coordinators, indicating a lapse in adherence to the facility's policy for accurate MDS preparation.
A facility failed to update the PASRR for a resident after new diagnoses were documented, including dementia with behavioral disturbance and a severe episode of major depressive disorder with psychotic features. The Social Worker was not informed of these updates, and the facility's PASRR process lacked direction for handling new diagnoses.
A facility failed to document the use of psychotropic medications and necessary side effect monitoring in a resident's Baseline Care Plan upon admission. The resident, with severe cognitive impairment, was admitted with orders for antidepressants, opioids, and anti-anxiety medications. An LPN confirmed that the Baseline Care Plan should include adverse reactions and side effects, which was not done, contrary to facility policy.
The facility failed to update care plans for two residents. One resident's care plan did not include interventions for new mental health diagnoses, despite documented issues such as dementia with behavioral disturbance and major depressive disorder. Another resident's care plan was not revised to include antibiotic therapy for a bacterial infection. An LPN explained the process for updating care plans, but the facility's policy lacked guidance for new diagnoses.
A facility failed to complete routine pre- and post-dialysis assessments for a resident receiving dialysis services. The resident's clinical orders required these assessments, but they were missing from the electronic health record for a period. An LPN acknowledged the oversight was due to the lack of an automated assessment setup in the EHR. The facility's dialysis policy, which required specific assessments and documentation, was not followed.
A facility failed to complete an Annual MDS assessment on time for a resident with cognitive impairment and multiple diagnoses. The delay was due to issues with new electronic charting software, which caused a discharge MDS to appear instead of triggering the annual assessment. The MDS Coordinator confirmed the oversight.
A resident who began hospice care did not have their Significant Change in Status MDS assessment completed within the required timeframe. The assessment was set up but left unfinished, with several sections incomplete and unsigned. Interviews with MDS Coordinators revealed the oversight, and the facility's policy did not specifically address the completion of these assessments.
Improper Documentation of Topical Medication Administration
Penalty
Summary
The facility failed to ensure that staff who applied lidocaine patches to residents documented the administration on the Treatment Administration Record (TAR) as required. Instead, another staff member, specifically an LPN, signed off on the administration of the lidocaine patches for two residents, despite not having performed the application themselves. Observations confirmed that a Certified Medication Aide (CMA) applied the patches to both residents, but the LPN documented the completion of the treatment on the TAR. Interviews with staff revealed that this practice had been ongoing, with the LPN routinely signing off treatments completed by the CMA if the CMA forgot to document them. Both residents involved had physician orders for lidocaine patches to be applied for pain management, as reflected in their clinical records and Minimum Data Set (MDS) assessments. Facility policy required that the individual who administered the medication document the administration and prohibited the documentation of false information. The Assistant Director of Nursing and Director of Nursing both confirmed that the expectation was for the person who completed the treatment to document it, and that it was an issue if a nurse signed for a treatment they did not perform.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
A deficiency occurred when staff failed to follow Enhanced Barrier Precautions (EBP) during the care of a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who had a history of cancer, anemia, quadriplegia, non-Alzheimer's dementia, and chronic atrial fibrillation, was identified as requiring EBP due to the presence of an indwelling medical device. Facility policy and CDC guidance required staff to wear gloves and a gown for all high-contact activities, including device care such as cleaning and flushing a PEG tube. During an observed care event, a Licensed Practical Nurse (LPN) cleaned the resident's PEG-tube site and performed a water flush without donning a gown, despite signage and care plan instructions indicating the need for EBP. Staff interviews confirmed awareness of the EBP requirements, and the LPN's personnel file showed documented competency in EBP procedures. The Assistant Director of Nursing (ADON) acknowledged that a gown should have been worn and that gowns were available in the resident's closet. The facility's policy, updated prior to the event, clearly outlined the need for gowns and gloves during high-contact care for residents with indwelling devices, and the EBP status was communicated through door signage and the care plan. Despite these measures, the required PPE was not used during the observed care activity.
Failure to Notify Family of Resident's Fall with Injury
Penalty
Summary
The facility failed to notify a family member about a resident's fall with injury, which was a deficiency identified during the survey. The resident involved had a Minimum Data Set (MDS) assessment indicating intact cognition and was diagnosed with medically complex illness, coronary artery disease, osteoporosis, and anxiety. The resident was alert and oriented, and the care plan required staff to use a Hoyer lift with two staff for transfers and not to leave the resident alone on the commode. An incident occurred where the resident fell and sustained a head injury, but the family was not notified as required by the facility's policy. The incident note revealed that a Licensed Practical Nurse (LPN) only notified the Primary Care Physician (PCP) and failed to inform the resident's family about the fall and the resulting head injury. Interviews with staff confirmed that the LPN did not contact the family, as he believed the injury was minor. The Director of Nursing acknowledged the failure to notify the family, which was against the facility's policy that mandates family notification as soon as possible after an incident. The policy also requires the nurse assessing the incident to notify the family and the doctor, especially in cases of head injuries or unwitnessed falls.
Failure to Assess Bed Rail Safety Leads to Resident Death
Penalty
Summary
The facility failed to properly assess and reassess residents for the safe use of bed rails, and did not provide adequate education on the risks and benefits of bed rail use to residents or their legal representatives. This deficiency was identified for three residents, including one who suffered a fatal incident. The facility's failure to conduct thorough assessments and provide necessary education led to the tragic death of a resident who was found with her head wedged between the bed rail and the mattress, resulting in asphyxiation. The resident involved in the fatal incident had severe cognitive impairment and required substantial assistance with bed mobility and transfers. Despite these needs, the facility's care plan directed the use of bilateral bed rails for bed mobility and independence. The bed rail assessment conducted by the facility did not adequately address the risks of entrapment, and the resident's family was not informed of these risks. The resident's condition, including cognitive decline and physical limitations, made her particularly vulnerable to the dangers associated with bed rail use. Interviews with staff revealed a lack of consistent training and understanding regarding bed rail safety and the importance of assessing the risks and benefits. The facility's transition to an electronic health record system resulted in the omission of detailed risk and benefit information from the bed rail assessment form. This oversight contributed to the facility's failure to adequately inform residents and their families about the potential dangers of bed rail use, ultimately leading to the resident's death.
Removal Plan
- Immediately following the incident, the Administrator and the Director of Nursing began an immediate investigation in the building.
- Meeting held discussed the following regarding a review of the incident: Side Rail Policy reviewed, Bed rail assessment form reviewed - noted the risks and benefits not listed in the electronic charting record form that as the form only included a statement identifying they learned of the risks and benefits.
- Bed rail assessment forms initiated on all residents in the building, as they reassessed, every resident, and notified them of the risks and benefits.
- The facility used the paper form which identified the risks and benefits of using a side rail.
- The facility reevaluated the new admissions using the paper form, which indicated the risks and benefits.
- Maintenance completed side rail and checked the bed functionality as a preventative measure in the entire nursing facility for all beds and rails.
- The facility completes Side Rail assessments quarterly, however the facility completed side rails assessments as a preventative on all current resident in the building until completed.
- Any beds in empty rooms had the side rails removed in order to try other interventions upon admission to facility, prior to side rail use.
Failure to Respect Resident Rights and Provide Timely Care
Penalty
Summary
The facility failed to respect the rights and dignity of Resident #98 by not providing the requested twice-weekly baths. Despite Resident #98's intact cognition and clear preference for an evening bath, the facility's documentation lacked any record of her receiving a bath from 5/24/24 to 6/2/24. Furthermore, there was no documentation of her refusing a bath or being offered one at another time. The Director of Nursing confirmed the absence of such documentation and acknowledged that Resident #98 should have been offered two showers a week, as per the facility's policy. Resident #311 experienced a failure in timely toileting assistance, resulting in bowel incontinence and emotional distress. The resident, who was cognitively intact, reported that his call light was not functioning, causing him to sit in his feces for an hour and a half. He had to call his daughter for help, who then contacted the facility. Although the call light was later fixed, the resident was given a hand bell as a temporary measure. The Director of Nursing was unaware of the call light issue and the resident's distressing experience, despite the facility's policy to treat residents with dignity and respect.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their records. Resident #87 was inaccurately coded as a PASRR Level I, despite being assessed as a Level II PASRR, indicating a serious mental illness. This error was acknowledged by the MDS Coordinator during an interview, who admitted to the mistake and indicated a need to correct it. The facility's policy requires timely, accurate, and comprehensive MDS preparation, which was not adhered to in this instance. Similarly, Resident #54's MDS assessment inaccurately documented a stage 4 pressure ulcer, despite a progress note indicating the ulcer had healed months earlier. The MDS Coordinator admitted to the error during interviews, acknowledging that the resident's pressure ulcer had healed. The facility's adherence to the MDS policy and the Resident Assessment Instrument (RAI) Manual was claimed, yet the coding error persisted, highlighting a lapse in accurate documentation.
Failure to Update PASRR for Resident with New Diagnoses
Penalty
Summary
The facility failed to submit a new Pre-admission Screening and Resident Review (PASRR) for a resident after receiving new diagnoses in his medical record. The resident's Minimum Data Set (MDS) assessment indicated memory problems and severely impaired decision-making skills, with diagnoses of dementia, depression, and psychotic disorder. A progress note by the Nurse Practitioner documented new diagnoses, including dementia with behavioral disturbance, a severe episode of major depressive disorder with psychotic features, and an anxiety disorder due to a known physiological condition. However, the current PASRR lacked these new diagnoses. During an interview, the Social Worker explained that she reviewed progress notes quarterly for new diagnoses and relied on communication from nurses for updates. She reported not being informed about the resident's new diagnoses and stated she would submit a referral to PASRR for review. The facility's Social Services PASRR Screens lacked direction on the process for PASRR review when a current resident had new diagnoses.
Failure to Document Psychotropic Medication Use in Baseline Care Plan
Penalty
Summary
The facility failed to include the use of psychotropic medications and the necessary monitoring for side effects in the Baseline Care Plan for a resident upon admission. The resident, identified with a severe cognitive impairment through a BIMS score of 3, was admitted with orders for antidepressants, opioids, and anti-anxiety medications. However, the Baseline Care Plan, dated several weeks after admission, lacked documentation regarding these medications and the side effects staff should monitor. This omission was confirmed during an interview with an LPN, who stated that the Baseline Care Plan should include information on adverse reactions and side effects of psychotropic medications. The facility's policy requires the Baseline Care Plan to include essential healthcare information, such as initial goals based on admission orders and physician orders, but this was not adhered to in this case.
Failure to Update Care Plans for New Diagnoses and Treatments
Penalty
Summary
The facility failed to update the care plan for Resident #72 to include interventions related to new mental health diagnoses. The resident's Minimum Data Set (MDS) assessment identified memory problems and severely impaired decision-making skills, with diagnoses of dementia, depression, and psychotic disorder. A progress note by the Nurse Practitioner on 5/8/24 documented new diagnoses, including dementia with behavioral disturbance, a severe episode of major depressive disorder with psychotic features, and an anxiety disorder due to a known physiological condition. However, the care plan dated 6/26/24 did not reflect these new diagnoses, lacking appropriate interventions and goals. Additionally, the facility did not revise the care plan for Resident #31 after initiating antibiotic therapy. The resident's MDS assessment indicated moderately impaired cognition, and clinical physician orders included an antibiotic medication starting on 6/17/2024 for a bacterial infection. Despite this, the care plan dated 6/26/24 did not include the use of antibiotics or related interventions. During an interview, an LPN explained the process of updating care plans for new diagnoses and antibiotic use, but the care plan policy lacked specific instructions for updating care plans when a resident receives a new diagnosis during their stay.
Failure to Complete Routine Dialysis Assessments
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident who required such services. Specifically, the facility did not complete routine pre- and post-dialysis assessments for a resident receiving dialysis services. The resident's clinical physician orders required pre- and post-dialysis assessments on specific days, but these assessments were missing from the resident's electronic health record for a period of time. Additionally, the facility's dialysis policy required nurses to assess and document vital signs, weights, and monitor the access site before and after dialysis, which was not consistently done. The deficiency was identified through a review of the resident's Minimum Data Set assessment, clinical physician orders, and electronic health record, as well as staff interviews. A Licensed Practical Nurse acknowledged that many pre- and post-dialysis assessments were missed due to the resident's electronic health record not having an automated assessment set up. The facility's dialysis policy outlined specific assessment and documentation requirements that were not followed, contributing to the deficiency.
Failure to Timely Complete Annual MDS Assessment
Penalty
Summary
The facility failed to complete an Annual Minimum Data Set (MDS) assessment within the required timeframe for a resident. The resident, who has moderately cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8, also has diagnoses of hypertension, anxiety, quadriplegia, type II diabetes, and schizophrenia. The MDS assessment was supposed to be completed by the assessment reference date (ARD) plus 14 days, but it was not completed and locked until much later. The delay was attributed to a change in electronic charting software, which caused a discharge MDS to repeatedly appear, preventing the annual assessment from being triggered. This oversight was acknowledged by the MDS Coordinator during an interview.
Failure to Complete Timely MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required time frame for a resident who began hospice care. The resident's electronic census indicated they started hospice care on May 2, 2024. However, the MDS 3.0 Summary Page showed that the assessment was incomplete, with several sections marked as in-progress and the completion box indicating a deadline of May 23, 2024. The Care Area Assessments (CAA) and Care Plan Decision also had specified completion dates, but the assessment remained unsigned in 603 areas. Interviews with the facility's MDS Coordinators revealed that the assessment was set up but not finished, and although one coordinator completed the assessment, it was not signed and locked to finalize it. The facility's MDS Entry/Computerization Policy, reviewed in April 2024, outlined the procedure for timely and accurate MDS completion but did not specifically address the completion of Significant Change in Status Assessments. The LTC RAI 3.0 User's Manual mandates that such assessments be completed no later than 14 days after a significant change in the resident's status is determined.
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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