North Crest Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Council Bluffs, Iowa.
- Location
- 34 Northcrest Drive, Council Bluffs, Iowa 51503
- CMS Provider Number
- 165290
- Inspections on file
- 18
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at North Crest Living Center during CMS and state inspections, most recent first.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident with moderate cognitive impairment and an indwelling catheter had multiple shifts with low or no urinary output, but there was no documentation that as-needed catheter flushes were performed as ordered. Staff interviews confirmed that a flush should have been done when output was 100mL or less, and the resident was later hospitalized for sepsis secondary to a urinary tract infection.
Staff did not follow Enhanced Barrier Precautions when providing catheter and peri care to a resident with an indwelling catheter. Two CNAs failed to perform hand hygiene before care and did not wear gowns as required, despite facility policy and EBP protocols. Staff interviews revealed confusion about when gowns were necessary, and observed practices did not align with infection control policies.
The facility had repeat deficiencies in areas including care planning and catheter care, with incomplete corrective actions despite a Performance Improvement Plan. Staff interviews confirmed that residents with catheters lacked care plans with appropriate focus, goals, or interventions, and at least one resident did not have a physician's order for catheter use prior to survey. The Administrator and DON acknowledged these deficiencies and delays in implementing required orders and care plans.
Laundry staff failed to use proper PPE while sorting soiled laundry, including not wearing gloves and incorrectly donning a gown. The DON, who took over as IP, found lapses in Enhanced Barrier Precautions implementation, such as missing or incorrect signage and incomplete infection surveillance mapping, following the termination of the previous IP for not completing required tasks.
Several residents with catheters, depression, or anxiety did not have individualized care plans with specific goals or interventions addressing their conditions. Care plans lacked resident-specific details for catheter management and behavioral health needs, and staff confirmed that documentation and interventions were not tailored to each resident as required by facility policy.
Several residents reported receiving cold meals in their rooms multiple times per week, with food temperatures observed by staff to be below required standards. Staff acknowledged the issue, and facility policy as well as FDA guidelines were not met, resulting in residents receiving unappetizing and improperly held food.
The facility did not follow required antibiotic stewardship practices, as the DON, acting as Infection Preventionist, used an incomplete tracking spreadsheet and was unaware of the actual number of residents on antibiotics or the use of infection assessment tools. Six residents were on antibiotics, but this was not recognized or monitored according to facility policy.
Three residents were not given the required CMS-10055 form or informed of their options and costs when Medicare Part A coverage ended. Each resident, with varying cognitive abilities and medical needs, transitioned to private pay without receiving proper notification or explanation of their rights and financial responsibilities. The responsible social worker was unfamiliar with the form and facility policy was not followed.
Multiple residents experienced unclean rooms and unmade beds due to a shortage of clean linen and delays in housekeeping, with staff reporting communication issues and low linen supplies. Residents reported irritation and discomfort, and observations confirmed debris and personal items left in rooms throughout the day. Administration could not provide relevant housekeeping or linen policies when requested.
Three residents prescribed high-risk psychotropic medications did not have individualized care plans that identified non-pharmacological interventions or specific target behaviors related to medication use. Instead, care plans contained generic statements and lacked person-centered goals and interventions, despite staff and policy expectations for individualized documentation.
A resident with no cognitive impairment was transferred to the hospital for acute symptoms, but the facility did not provide the required bed hold notice or obtain verification from the resident or representative, as confirmed by EHR review and staff interviews. The DON and Administrator acknowledged the omission, which was not in accordance with facility policy or federal regulations.
Staff failed to obtain and follow physician orders for two residents: one resident's insulin was repeatedly held without doctor-specified parameters or notification, and another resident returned from the hospital with a urinary catheter but without a corresponding physician order. Nursing staff relied on their own judgment for insulin administration, and the facility did not ensure required orders for medical devices were in place, as confirmed by interviews with the DON and administrator.
A resident with multiple chronic conditions requiring continuous oxygen therapy was found to have undated oxygen tubing and no documented orders or instructions for tubing changes. Staff and administration confirmed the absence of a formal policy and inconsistent documentation, resulting in a failure to ensure safe and appropriate respiratory care in accordance with professional standards.
A resident diagnosed with dementia did not receive the necessary treatment and services appropriate for their condition, as required by regulatory standards.
Staff administered influenza vaccines to several residents without obtaining signed consent or providing required education about the vaccine's benefits and side effects. Medical records lacked documentation of consent and education, despite facility policy requiring these steps before vaccination. Leadership acknowledged the process was not consistently followed.
Staff failed to obtain signed consents and provide required education before administering the COVID-19 vaccine to three residents with various medical conditions, as evidenced by missing documentation in their records. The DON and Administrator confirmed that consents were not always properly documented, education was not consistently provided, and verbal consents lacked a second witness, contrary to facility policy.
The facility failed to provide adequate nursing staff, particularly on weekends, affecting resident care. A resident reported delays in call light responses, and staffing data showed lower PPD averages on weekends. Staff confirmed fewer aides were scheduled on weekends, and the facility's assessment acknowledged this discrepancy.
The facility failed to follow standard precautions and enhanced barrier precautions (EBP) in infection control practices. Laundry staff did not wear gloves and gowns while handling laundry, and a resident with an indwelling catheter reported staff not wearing gowns during care. The facility lacked a comprehensive infection prevention control policy, and staff were not adequately trained on EBP, particularly regarding the use of gowns. The infection preventionist and DON expected adherence to EBP, but the facility did not have an annually reviewed infection control policy.
A facility failed to obtain a physician order for a DNR status for a resident, despite the resident's IPOST indicating a DNR with limited interventions. The absence of a signed DNR order in the electronic medical records was confirmed by a social worker and acknowledged by the administrator. The facility's CPR Guideline required DNR orders to be obtained following state-specific guidelines, which was not followed in this case.
A facility failed to notify a resident 48 hours in advance when Medicare Part A coverage or Part B therapies were ending. The absence of an Advanced Beneficiary Notice (ABN) for the resident was noted, and the Administrator admitted the facility could not locate the form. It was also revealed that the facility lacks a specific policy for issuing ABNs, despite claiming adherence to federal regulations.
A facility failed to submit a comprehensive MDS assessment within the required timeframe for a resident, as per CMS guidelines. The assessments lacked transmission dates and acceptance, and a Discharge with Return Anticipated Assessment was missing. The MDS Coordinator, new to the position, was unsure about submission requirements, while the Administrator knew the impact on reimbursement but not the specific procedures.
The facility inaccurately documented medication use in the MDS for two residents, with one resident's MDS showing anticoagulant use without corresponding physician orders, and another's showing hypnotic and antianxiety medications without orders. Staff interviews confirmed these inaccuracies, and the facility lacked a specific policy for ensuring MDS accuracy.
The facility failed to include anticoagulant medication use in the care plans of two residents prescribed Eliquis, lacking interventions for monitoring bleeding and bruising. Staff interviews revealed a misunderstanding about care plan requirements, and the facility lacked a policy for ensuring accurate and personalized care plans.
A resident with heart failure and other conditions was transferred to the ED for chest pain and shortness of breath, but the facility failed to immediately notify the PCP as required. The DON acknowledged the notification was sent via fax without a recorded time, and the PCP confirmed not receiving a call about the transfer.
The facility failed to obtain bed hold notifications for two residents during their hospital transfers. A resident was sent to the emergency room for a forehead laceration after a fall, but no bed hold form was available. Another resident was hospitalized, but the facility did not have a signed bed hold form. The Administrator acknowledged the issue, especially for weekend hospitalizations, and admitted the lack of a specific policy for bed hold notifications.
A resident with heart failure and renal insufficiency did not have daily weights recorded as ordered by the physician. Despite orders for daily weights, the facility failed to document weights over a series of days. The DON was unable to explain the lapse in following the physician's orders.
The facility failed to implement fall prevention interventions for three residents, leading to falls and injuries. A resident with moderate cognitive impairment fell and fractured a femur after being left unattended. Another resident was improperly assisted without a gait belt, increasing fall risk. A third resident with severe cognitive impairment experienced multiple falls due to inadequate adherence to care plan interventions. The facility's protocols for fall prevention and call light response were not effectively followed.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses for two residents with moderate cognitive impairment. One resident experienced delays of 25-35 minutes, particularly during meals, while another resident reported delays leading to self-transfer to the bathroom. Facility records showed multiple instances of call light responses exceeding 15 minutes. Staff acknowledged the expectation to respond within 15 minutes, but this was not always met, especially during meals.
Facility staff failed to maintain infection control practices during personal care for a resident with severe cognitive impairment. Two CNAs were observed performing hygiene and transfer without proper hand hygiene between glove changes, contrary to the facility's handwashing protocol. The DON acknowledged the standard of care requires hand hygiene between glove changes.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Provide Appropriate Catheter Care and Prevent UTI
Penalty
Summary
The facility failed to provide appropriate interventions for a resident with an indwelling urinary catheter, as evidenced by a lack of response to decreased or absent urinary output over multiple shifts. The resident, who had moderate cognitive impairment and a physician's order for as-needed catheter flushes in the event of clogging or dysfunction, consistently had recorded outputs of 100mL or less per shift, including several instances of 0mL output. Despite these findings, there was no documentation in the Medication Administration Record, Treatment Administration Record, or progress notes indicating that the as-needed catheter flushes were performed during the period in question. Staff interviews confirmed that the expectation was to perform a catheter flush when output was 100mL or less per shift, and that such interventions should be documented. Nursing staff acknowledged that they would have performed a flush under these circumstances, and the Director of Nursing stated that nurses should be notified of decreased output and should investigate further. The resident was ultimately hospitalized for acute respiratory failure related to sepsis secondary to a urinary tract infection. Facility policy required preventive measures for infection control in residents with urinary catheters, including changing catheters per orders.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Staff failed to follow appropriate infection prevention and control practices when providing care to a resident with an indwelling catheter who was on Enhanced Barrier Precautions (EBP). During an observed episode of catheter and peri care, two CNAs entered the resident's room, applied gloves, but did not perform hand hygiene prior to care or don gowns as required by EBP protocols. One CNA assisted the resident with standing using a gait belt, while the other performed catheter and peri care, including cleansing the catheter, penis, and buttocks, and then assisted with dressing. After care, one CNA removed gloves and performed hand hygiene, while the other removed gloves, gathered trash, exited the room, and only performed hand hygiene in the hallway outside the soiled utility room. Interviews with staff revealed a lack of understanding regarding the requirement to wear gowns during catheter and peri care under EBP, with some staff believing gowns were only necessary when emptying the catheter or not required during bowel movements. The facility's policies, as confirmed by the DON and LPN, required gowns and gloves for all catheter and peri care, as well as hand hygiene before and after resident contact and glove use. The observed practices did not align with these policies, resulting in a failure to implement proper infection prevention measures for a resident with an indwelling catheter.
Repeat Deficiencies and Incomplete Performance Improvement for Catheter Care and Care Planning
Penalty
Summary
The facility failed to demonstrate good faith attempts to correct previously identified quality deficiencies, as evidenced by repeat deficiencies in three areas and incomplete corrective actions outlined in a Performance Improvement Plan (PIP). Document review showed that deficiencies related to notice of bed hold policy, development and implementation of comprehensive care plans, and provision of services meeting professional standards were cited in a previous recertification survey, with correction dates that had passed. Additionally, a PIP addressing compliance with federal regulation F880 was not completed within the targeted timeframe, and action steps to ensure appropriate catheter orders and care plans were not fully implemented. Interviews with the Director of Nursing (DON) and the Administrator confirmed that residents using catheters did not have care plans with appropriate focus, goals, or interventions, and that at least one resident did not have a physician's order for catheter use prior to the survey. The Administrator acknowledged delays in entering necessary orders and care plans, and recognized that the facility lacked routine orders for catheters. The facility's Quality Assurance and Performance Improvement (QAPI) program documentation indicated a commitment to setting and measuring progress toward performance goals, but the identified deficiencies and incomplete corrective actions demonstrated a failure to achieve compliance.
Failure to Follow Infection Control Standards and Inconsistent Infection Preventionist Oversight
Penalty
Summary
The facility failed to adhere to infection control standards, as evidenced by laundry staff not wearing appropriate personal protective equipment (PPE) while handling soiled laundry. Specifically, an environmental aide was observed sorting dirty laundry without a gown or gloves. When the staff member attempted to don a gown, she initially put it on incorrectly and, after correcting it, still failed to apply disposable gloves before resuming her duties. This lapse in PPE use occurred during the handling of potentially contaminated linens, contrary to facility policy and infection control protocols. Additionally, the facility did not ensure consistent implementation of the responsibilities of the Infection Preventionist (IP). The DON reported assuming IP duties after discovering that the previous IP, the ADON, was not completing required tasks and was subsequently terminated. The DON identified issues such as residents who should have been on Enhanced Barrier Precautions (EBP) lacking appropriate signage and PPE, while others had unnecessary signage. Infection surveillance mapping was incomplete for recent months, and these failures were not in alignment with the facility's own infection prevention and control program policies.
Failure to Develop Comprehensive and Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for several residents, specifically those with indwelling catheters, depression, and anxiety. For multiple residents with catheters, including those with moderate cognitive impairment and recent hospitalizations for fractures, the care plans lacked any focus, goals, or interventions related to catheter use. Documentation and interviews confirmed that these omissions were present at the time of the survey, and the Director of Nursing acknowledged that care plans for catheter use had not been developed as expected. Additionally, residents with diagnoses of depression and anxiety who were prescribed antianxiety and antidepressant medications did not have individualized care plans that identified target behaviors or non-pharmacological interventions. The care plans contained general statements and interventions that were not specific to the individual residents' symptoms or needs. Physician orders for monitoring behaviors were also not tailored to the residents, and documentation did not describe specific signs or symptoms of anxiety or depression. The facility's own policy required that care plan goals and objectives be resident-oriented, behaviorally stated, measurable, and based on comprehensive assessments. However, the care plans reviewed did not meet these standards, as they failed to include individualized, measurable goals and interventions for the residents' identified conditions. Staff interviews further confirmed that the care plans were not personalized and did not provide clear guidance for addressing the residents' specific needs.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors identified that the facility failed to provide food at an appetizing and safe temperature to four residents, as evidenced by resident interviews, staff interviews, observations, and policy review. Multiple residents who ate meals in their rooms reported that their food was often delivered cold, with some stating this occurred several times per week. During a lunch meal service observation, food temperatures on a sample tray were measured and found to be below expected standards, with ham at 105°F, cauliflower at 124.5°F, and sweet potato fries at 109.6°F. Staff acknowledged these temperatures were lower than anticipated, and the Certified Dietary Manager stated that food should be above 130°F, while the Registered Dietitian indicated a point of service temperature of 140°F was needed. The facility's policy and the FDA Food Code require hot foods to be held at 135°F or above to minimize the risk of foodborne illness. Residents affected included individuals with varying levels of cognitive impairment, as indicated by their BIMS scores, and some with significant medical histories such as renal insufficiency, neurogenic bladder, and history of stroke. Residents described the food as cold, tough, dry, and unappetizing, with one resident specifically noting a sandwich was "cold like the icebox" and missing components. The Administrator was unaware of complaints prior to the survey and expressed uncertainty about the required food temperatures and how to address the issue, despite facility policy and regulatory guidance.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and follow antibiotic stewardship practices as required. The DON, who recently assumed the role of Infection Preventionist, presented a newly developed antibiotic tracking spreadsheet that did not include any resident-specific information. During the survey, the DON was unable to accurately identify the number of residents on antibiotics, initially stating there was only one resident after checking the electronic chart, despite the Resident Matrix indicating that six residents were on antibiotics at the time. Additionally, the DON was unaware of any tools, such as the McGeer criteria, being used by nursing staff to assess the need for antibiotics. The facility's policy required the Infection Preventionist to oversee infection control and antibiotic use, but these protocols were not being effectively implemented or monitored.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to inform three residents of their options and costs when Medicare Part A coverage ended, as required by federal regulations. For each of the three residents reviewed, documentation showed that the required CMS-10055 form, which explains non-coverage and provides information about appeal rights and private pay options, was not provided. The residents involved had varying degrees of cognitive impairment and were dependent on staff for activities of daily living. Their care plans included restorative programs and therapy services, and their diagnoses included conditions such as parkinsonism, chronic kidney disease, diabetes, and muscle weakness. Despite the transition from Medicare Part A to private pay status, the necessary notifications and explanations were not documented as given to the residents. Staff interviews revealed that the social worker responsible for providing these notifications was new to the position and unfamiliar with the CMS-10055 form. Upon review, the social worker could not locate the form in facility records and acknowledged that residents should be informed about their financial responsibilities and appeal rights when Medicare coverage ends. Facility policy requires completion of the form and resident signature to confirm understanding, but this process was not followed for the residents in question.
Failure to Maintain Clean, Homelike Environment Due to Linen Shortages and Housekeeping Delays
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and interviews. In several resident rooms, debris such as pieces of paper, used tissues, and cotton were found scattered on the floors, and beds were left unmade for extended periods. One resident, who was cognitively intact, reported that staff did not assist him in getting ready or making his bed, which prevented him from lying down after breakfast as he preferred. The resident expressed irritation at the lack of assistance and the unmade bed, while his roommate's bed was made by staff. Staff interviews revealed that the lack of clean bottom sheets contributed to the delay in making beds. Certified Nurse Assistants (CNAs) stated that laundry was behind and bottom sheets were not available until after midday, resulting in beds remaining unmade until the afternoon. The laundry assistant confirmed that he was not informed about the shortage of bottom sheets in a timely manner and that linen supplies had been running low in recent weeks. The administrator acknowledged a breakdown in communication among staff regarding linen availability and stated that linen should have been on the beds before lunch. Additional observations showed that some resident rooms remained dirty throughout the day, with floors littered with debris and personal items left out, such as shoes in walking areas. Residents reported that their rooms were frequently dirty and that their beds were often left unmade. When requested, the administration was unable to provide policies related to maintaining a homelike environment, routine housekeeping, or timely application of bed linen.
Failure to Individualize Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to properly identify and document non-pharmacological interventions and targeted behaviors in the care plans for three residents who were prescribed high-risk psychotropic medications. For one resident with severe cognitive impairment and diagnoses including anxiety and dementia, the care plan did not include non-pharmacological interventions to be attempted prior to administering opioid or antipsychotic medications, despite the resident receiving these medications multiple times. Staff interviews confirmed that such interventions and targeted behaviors should have been documented in the care plan. Another resident with moderate cognitive impairment and multiple psychiatric diagnoses was prescribed antipsychotic and antidepressant medications. The care plan for this resident did not specify target behaviors related to the use of psychotropic medications or non-pharmacological interventions. Instead, it contained general statements and lacked focus areas with goals and interventions specific to the resident's psychiatric conditions. The facility also failed to individualize the care plan to address the resident's specific needs and behaviors. A third resident with severe cognitive impairment and diagnoses of Alzheimer's, dementia, anxiety, and depression was prescribed several psychotropic medications. The care plan did not identify target behaviors related to the use of these medications or provide person-centered interventions for anxiety and depression. Staff acknowledged that the care plans contained generic statements and did not provide individualized or specific information regarding the use of antipsychotic medications and related behaviors. The facility's policy required care plan goals to be resident-oriented and measurable, but this was not reflected in the care plans reviewed.
Failure to Provide Bed Hold Notice Upon Resident Transfer
Penalty
Summary
The facility failed to provide the required bed hold notice to a resident or the resident's responsible person when the resident was transferred out of the facility. According to the Minimum Data Set, the resident had no cognitive impairment and was transferred to the hospital due to shortness of breath, chest pain, and discomfort, with a request for hospital transfer. Documentation in the Electronic Health Record confirmed the resident's transfer and continued hospital stay, but there was no evidence that a bed hold notice was completed or communicated at the time of transfer. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the bed hold form was not completed as required by both federal regulation and facility policy. The DON acknowledged the absence of documentation and stated that the expectation was for the bed hold to be completed or for the resident's representative to be notified, which did not occur. The facility's policy required residents or their representatives to verify their wish to hold the bed within 24 hours of hospital admission, but this process was not followed for the resident in question.
Failure to Obtain and Follow Physician Orders for Insulin Administration and Catheter Use
Penalty
Summary
The facility failed to obtain and follow physician orders for two residents, resulting in deficiencies in medication administration and device management. For one resident with diabetes mellitus and other comorbidities, staff held fast-acting insulin on multiple occasions without physician-specified parameters or directives. The care plan did not include instructions for insulin use, and there was no documentation that the physician was notified when insulin was withheld. Nursing staff used their own judgment to decide when to hold the insulin, despite the absence of established blood glucose parameters from the physician. Another resident returned from a hospital stay with an indwelling urinary catheter following surgery for a foot fracture. Although the hospital communicated that the resident would return with a catheter, the facility did not obtain a physician order for the device upon readmission. Progress notes documented the presence and function of the catheter, but the clinical physician orders lacked any reference to it. The facility's policy required physician orders for all care and services, including medical devices, but this was not followed in the case of the catheter. Interviews with staff, including the DON and administrator, confirmed that there were no established parameters for holding insulin and that an order for the catheter was not in place prior to the survey. The administrator acknowledged that orders and diagnoses should be entered promptly and that routine orders, especially for catheters, were lacking at the time of the survey.
Failure to Provide Safe and Documented Respiratory Care for Oxygen-Dependent Resident
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident requiring continuous oxygen therapy. The resident, who had a history of heart failure, hypertension, anxiety disorder, obstructive sleep apnea, and pulmonary hypertension, was observed using oxygen at 3 liters per minute via nasal cannula. Multiple observations revealed that the oxygen tubing in use was undated, and there were no documented orders or instructions for changing the oxygen tubing in the resident's Medication Administration Record or Treatment Administration Record. Staff interviews confirmed that oxygen tubing was supposed to be changed weekly, but there was no formal policy in place, and the process was not documented or audited. Further review with the Director of Nursing and the Administrator revealed that the facility did not have a written policy for oxygen tubing changes and relied on manufacturer recommendations, which were inconsistently applied. The lack of documentation and absence of a formal order for tubing replacement contributed to the deficiency, as there was no reliable method to ensure that oxygen tubing was being changed according to professional standards or facility expectations.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A deficiency was identified regarding the provision of appropriate treatment and services to a resident who displays or is diagnosed with dementia. The report indicates that the facility failed to ensure that a resident with dementia received the necessary care and services tailored to their diagnosis and needs. Specific details about the actions or omissions that led to this deficiency, as well as the resident's condition at the time, are not provided in the report.
Failure to Obtain Consent and Provide Education Prior to Influenza Vaccination
Penalty
Summary
The facility failed to ensure that staff obtained signed consents and provided education to residents prior to administering influenza vaccinations. Clinical record reviews for three residents revealed that, despite receiving the influenza vaccine, there was no documentation of signed consent forms or evidence that education regarding the vaccine's benefits and potential side effects had been provided. The residents involved had varying cognitive abilities and medical conditions, including arthritis, dementia, anxiety disorder, cerebrovascular disease, compromised immune systems, and congestive heart failure. Care plans for these residents indicated the need to follow current guidelines for influenza and pneumonia vaccines, but the required documentation was missing from their medical records. Interviews with facility leadership confirmed the lack of proper documentation and education. The DON acknowledged that the immunization process needed improvement and that the current plan to provide consent and education during IDT meetings was not being consistently followed. The administrator expressed a preference for written consent with signatures rather than verbal consent, and the DON admitted that education was not always provided as intended. The facility's policy required that residents or their legal representatives receive information and education about the influenza vaccine prior to administration, with documentation in the medical record, but this was not consistently done.
Failure to Obtain Consent and Provide Education Prior to COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that staff obtained signed consents and provided education to residents prior to administering the COVID-19 vaccine. Clinical record reviews for three residents revealed that, despite receiving the COVID-19 vaccine, their charts lacked documentation of signed consent forms and evidence that education about the vaccine had been provided. These residents had varying cognitive abilities and medical conditions, including arthritis, non-Alzheimer's dementia, anxiety disorder, cerebrovascular disease, compromised immune systems, and congestive heart failure. The facility's policy required that consent be obtained from both the resident and physician, and that education about the vaccine, including benefits and potential side effects, be documented in the resident's permanent medical record. Interviews with facility leadership confirmed the absence of required documentation. The DON acknowledged that the immunization process needed improvement and admitted that while consents were sometimes electronically signed, there was no documentation of education being provided, nor was there a second witness for verbal consents. The Administrator expressed a preference for actual signatures and two witnesses for verbal consents, which was not consistently practiced. These findings indicate that the facility did not follow its own policy regarding COVID-19 vaccination consent and education.
Inadequate Weekend Staffing in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure the safety and well-being of its residents, as evidenced by staffing reviews, interviews, and a Facility Assessment review. The facility, with a census of 56 residents, did not meet its budgeted goal of a Per Patient Day (PPD) of 3, particularly on weekends. Resident #7, who has normal cognition as indicated by a BIMS score of 15, reported that call lights could take longer than 15 minutes to be answered. This delay was attributed to insufficient staffing, especially on weekends, as confirmed by Staff C, a Certified Nursing Assistant, who noted that working on weekends was more challenging due to fewer staff members. The staffing data for Quarter 3 of 2024 revealed a consistent pattern of lower PPD averages on weekends compared to weekdays. For instance, during the week of April 1, the weekday average was 3.29, while the weekend average dropped to 2.69. Similar trends were observed throughout April, May, and June. Staff D, the Scheduler, confirmed the accuracy of the staffing hours and PPD data, noting that there were fewer bath aides and restorative aides scheduled on weekends. The Administrator and Director of Nursing acknowledged the discrepancy in staffing levels between weekdays and weekends, which was reflected in the Facility Assessment updated on April 29, 2024.
Infection Control Deficiencies in PPE Use and Policy Implementation
Penalty
Summary
The facility failed to adhere to standard precautions and enhanced barrier precautions (EBP) in their infection prevention and control practices. Observations revealed that laundry staff were separating laundry without wearing gloves and gowns, despite the presence of COVID-19 positive cases in the facility. Interviews with staff, including the Director of Nursing (DON) and the Administrator, indicated a lack of clarity and adherence to the necessary precautions, with some staff unaware of the requirement to wear gowns during such procedures. Additionally, the facility lacked a comprehensive, written infection prevention control policy. Further deficiencies were noted in the care of a resident with an indwelling catheter. The resident reported that staff did not wear gowns during catheter care, and observations confirmed that a CNA performed catheter drainage without a gown. The resident's care plan did not include information about the catheter or EBP, and staff interviews revealed a lack of education on EBP, particularly concerning the use of gowns during catheter care. The facility's infection preventionist and DON expressed expectations for staff to be trained and follow EBP, especially for residents with indwelling medical devices or wounds. However, the facility did not have an infection control policy that was reviewed annually, as confirmed by the DON. The Centers for Disease Control and Prevention guidelines emphasize the importance of EBP for residents with medical devices or wounds, highlighting the need for proper staff training and availability of personal protective equipment (PPE) at the point of care.
Failure to Obtain DNR Order for Resident
Penalty
Summary
The facility failed to honor a resident's wishes as documented in the Iowa Physician Orders for Scope of Treatment (IPOST) by not obtaining a physician order for a Do Not Resuscitate (DNR) status. Resident #32 had signed an IPOST indicating a DNR status with limited interventions, no artificial nutrition by tube, and transfer to the hospital. However, a review of the resident's clinical physician orders in the electronic medical records revealed that the facility did not have a signed order for the DNR status. Staff A, a social worker, confirmed the absence of a physician order for the DNR status in the electronic medical record. The facility's administrator acknowledged that DNR orders should be reflected in the medical record. The facility's CPR Guideline document stated that DNR orders would be obtained following state-specific guidelines and regulations, but this was not adhered to in the case of Resident #32.
Failure to Provide Advance Notice of Medicare Coverage Termination
Penalty
Summary
The facility failed to provide a resident with the required 48-hour advance notice when Medicare Part A coverage was ending or when all Part B therapies were concluding. This deficiency was identified for one of the three residents reviewed, specifically Resident #146, in a facility with a census of 56 residents. Upon review, it was found that there was no Advanced Beneficiary Notice (ABN) available for Resident #146. During an interview, the Administrator admitted that the facility could not locate a copy of the ABN form for the resident and acknowledged that ABNs should be given with proper notice. Furthermore, a follow-up interview revealed that the facility does not have a specific policy in place for issuing ABNs, although they claim to follow federal regulations.
Failure to Submit MDS Assessment Timely
Penalty
Summary
The facility failed to submit a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one resident, as directed by the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual. The review of the resident's MDS assessment data showed that assessments dated 8/26/24, 8/29/24, and 9/5/24 lacked transmission dates and acceptance. Additionally, the assessment data did not include a Discharge with Return Anticipated Assessment. Staff B, the MDS Coordinator, acknowledged being new to the position and was unsure about the submission requirements. The staff believed that if the MDS page indicated completion, it meant the assessment was done and submitted. The Administrator was aware that MDS submission affected facility reimbursement but lacked specific knowledge of the submission procedures.
Inaccurate MDS Medication Documentation
Penalty
Summary
The facility failed to provide an accurate assessment of residents' medication use as required by the Minimum Data Set (MDS) guidelines. Specifically, for Resident #7, the MDS indicated the use of anticoagulant medications for 7 days during the observation period, despite the absence of any physician's orders for such medications in the resident's Electronic Health Record (EHR). Similarly, for Resident #31, the MDS inaccurately recorded the use of hypnotic and antianxiety medications for 7 days, although there were no corresponding physician's orders in the EHR. These discrepancies were confirmed through staff interviews, where it was acknowledged that the MDS entries did not reflect the actual medication administration. Interviews with facility staff, including the MDS coordinator and the Director of Nursing (DON), revealed an expectation for accurate MDS assessments, yet the facility lacked a specific policy to ensure this accuracy. The Administrator confirmed that the facility relied on the state Resident Assessment Instrument (RAI) manual for guidance but did not have a dedicated policy for MDS accuracy. This oversight contributed to the inaccurate documentation of residents' medication use, as identified during the survey.
Failure to Document Anticoagulant Use in Care Plans
Penalty
Summary
The facility failed to provide a comprehensive care plan for residents using high-risk medications, specifically anticoagulants, for two of the five residents reviewed. Resident #17 and Resident #31 were both prescribed Eliquis, an anticoagulant, to be taken twice daily. However, their care plans did not include documentation of anticoagulant medication use or interventions to guide staff on monitoring for bleeding and bruising, which are critical considerations for residents on such medications. Interviews with facility staff revealed a lack of awareness and understanding regarding the inclusion of anticoagulant medications in care plans. Staff B, the Care Plan Coordinator, admitted to not including Eliquis in the care plans, assuming that staff would refer to the EHR orders page for medication information. The Director of Nursing expressed an expectation for accurate and personalized care plans, while the Administrator acknowledged the absence of a policy for ensuring such care plans, despite following regulations.
Failure to Notify Physician of Resident's Emergency Transfer
Penalty
Summary
The facility failed to notify the physician immediately after a sudden change in a resident's condition and subsequent transfer to the emergency department (ED). The resident, who had diagnoses of heart failure, pulmonary hypertension, respiratory failure, and stroke, experienced sharp chest pain, shortness of breath, and indigestion. Despite the resident's condition and the transfer to the ED, the facility did not immediately inform the primary care physician (PCP) as required by their policy. The PCP was not aware of the situation until the following day, as indicated by the physician's response questioning who authorized the transfer. The facility's policy mandates immediate communication with the resident's physician or delegate in the event of a change in condition or treatment. However, the Director of Nursing (DON) acknowledged that the notification was sent via fax without a recorded time, and the PCP confirmed not receiving a call about the resident's condition or transfer. The DON insisted that the notification was sent but did not address the lack of immediate communication. This oversight in communication was highlighted during staff interviews and the review of the facility's policy.
Failure to Obtain Bed Hold Notifications
Penalty
Summary
The facility failed to obtain bed hold notifications for two residents during their hospital transfers. Resident #1 was sent to the emergency room for treatment of a forehead laceration after a fall, but there was no bed hold form available for review. Similarly, Resident #60 was hospitalized from 8/31/24 to 9/3/24, but the facility did not have a signed bed hold form for this hospitalization. The Administrator acknowledged the absence of bed hold documentation, particularly for weekend hospitalizations, and admitted that the facility does not have a specific policy for bed hold notifications, although they claim to follow regulations.
Failure to Obtain Daily Weights as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of care by not obtaining daily weights for a resident as per physician orders. The resident, who had diagnoses of atrial fibrillation, coronary artery disease, heart failure, and renal insufficiency, was at risk for weight variations due to a history of diuretic use. Despite having physician orders dated 7/25/24 and 7/30/24 for daily weights, the facility did not record weights on multiple consecutive days from 7/25/24 to 8/13/24. The Director of Nursing was unable to provide an explanation for the oversight, acknowledging that daily weights should have been obtained as ordered.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions to reduce hazards and protect residents were followed, resulting in deficiencies for three residents. Resident #1, with moderate cognitive impairment and requiring extensive assistance, fell after being left unattended for a short period. Despite having a call light attached, the resident attempted to stand and fell, later sustaining a femur fracture that required surgery. The facility's call log showed multiple instances of delayed response times, although on the day of the fall, the response time was within 14 minutes. Resident #2, also with moderate cognitive impairment, required assistance with mobility and had a history of falls. Observations revealed that staff did not use a gait belt as required by the resident's care plan, and the resident was seen walking without proper assistance. Staff unfamiliar with the resident's needs were not adequately informed, leading to improper handling and increased risk of falls. The facility's call log indicated several instances of delayed response times for this resident as well. Resident #3, with severe cognitive impairment and a history of multiple falls, was found on the floor multiple times despite interventions in place. Observations showed that staff did not follow care plan interventions, such as using bolsters and turning off the television to decrease stimuli. The facility lacked a protocol for transfers, and the Director of Nursing acknowledged the need for care plan updates and staff adherence to protocols. The facility's fall and call light protocols were not effectively implemented, contributing to the deficiencies observed.
Delayed Call Light Responses for Residents
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, as evidenced by delayed responses to call lights for two residents. Resident #1, who had moderate cognitive impairment and required extensive assistance for daily activities, experienced call light response times ranging from 25 to 35 minutes. A family member reported that the worst delays occurred during meal times when no staff were available in the hall. Facility records showed 41 instances in July where call light responses exceeded 15 minutes for Resident #1's room. Resident #2, also with moderate cognitive impairment and dependent on staff for various activities, reported delays in call light responses, leading the resident to self-transfer to the bathroom. Facility records indicated 18 instances in July where call light responses for Resident #2's room exceeded 15 minutes. Staff interviews revealed that call lights should be answered within 15 minutes, but the Director of Nursing acknowledged that this expectation might not be met during meals. The facility's Call Light Protocol requires all staff to respond to activated call lights and turn off the signal upon entering the resident's room.
Infection Control Deficiency During Resident Care
Penalty
Summary
The facility staff failed to maintain proper infection control practices during personal care for a resident with severe cognitive impairment. The resident, who was always incontinent of bladder and bowel, required assistance from 1-2 staff members for toileting, bed mobility, and hygiene. During an observation, two Certified Nursing Assistants (CNAs) were seen performing personal hygiene and transfer for the resident. Although they initially washed their hands and donned gloves, one of the CNAs did not perform hand hygiene between glove changes throughout the peri care process. The Director of Nursing acknowledged that the standard of care requires hand hygiene between glove changes, although it was noted that in certain situations, such as when a single staff member is managing a large mess, this may not always occur. The facility's handwashing protocol specifies that hand hygiene should be performed before and after direct contact with residents, and before and after removing non-sterile gloves. Despite this policy, the observed practice did not align with the established infection control standards.
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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