Northgate Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waukon, Iowa.
- Location
- 960 4th Street Nw, Waukon, Iowa 52172
- CMS Provider Number
- 165338
- Inspections on file
- 19
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Northgate Care Center during CMS and state inspections, most recent first.
Two residents experienced deficiencies in care when staff failed to properly assess and intervene after a fall and during wound development. One resident with cognitive impairment and a history of falls was moved multiple times after a fall without a thorough assessment, and was also given medications intended for another resident. Another resident with multiple comorbidities had a blister that was not assessed for two weeks, leading to infection. Staff interviews and documentation confirmed failures to follow facility policies for assessment and reporting.
Staff failed to adhere to infection control protocols during direct care, including performing wound treatments without changing gloves between tasks, not sanitizing treatment supplies before returning them to storage, and conducting procedures in public areas without proper barriers. Supplies were handled and returned to carts without sanitization, and hand hygiene was not performed between resident contact and touching surfaces or oneself.
Two residents did not receive care in a manner that maintained their dignity and privacy when an LPN conducted a physical assessment and a dressing change in a public dining/lounge area, in view of others. The LPN was unaware of facility policies regarding privacy during treatments, despite having signed a job description emphasizing the importance of resident rights and dignity.
A resident was given medications intended for another individual, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The facility did not promptly notify the resident's family or representative of the medication error and condition change, as required by policy. The family only became aware of the incident after receiving information from the hospital, rather than from facility staff.
A resident with multiple diagnoses, including heart failure and a history of pressure ulcers, was readmitted with active skin issues that were documented but not fully assessed or addressed in the care plan. The care plan failed to include interventions for the resident's current skin conditions, despite facility policy requiring comprehensive assessment and care planning.
Two residents experienced significant delays in call light response, with one waiting over two hours and another reporting frequent extended waits. CNAs confirmed that staff shortages and management wage caps contributed to the inability to consistently meet the facility's 15-minute call light response policy.
Two residents were affected by significant medication errors when a CMA, distracted by interruptions, administered another resident's medications to the wrong individual, and another resident continued to receive an outdated Seroquel regimen due to a failure to update medication orders. These errors were identified through video review, clinical records, and staff interviews.
Staff failed to maintain accurate and complete medical records for two residents, including improper documentation of a fall assessment and a discrepancy in controlled substance records. An LPN documented an assessment that was not performed, as confirmed by video review and interviews, and a medication was recorded as destroyed but was actually administered to another resident.
A resident was mistakenly given another resident's medications, including Seroquel, due to a CMA's distraction from a personal call. This resulted in over-sedation and hypoglycemia, leading to the resident's hospital admission for observation.
The facility failed to maintain sanitary conditions during meal service. A cook was observed touching the drinking rim surfaces of glasses with bare hands and pushing a beverage cart without sanitizing it or performing hand hygiene. The facility lacked a policy on appropriate hand placement during food service, and further observations revealed multiple staff members handling milk jugs without performing hand hygiene.
Failure to Assess and Intervene After Falls and Wound Development
Penalty
Summary
Staff failed to properly assess and intervene for two residents, resulting in deficiencies in care. One resident with significant cognitive impairment, visual deficits, and a history of falls was observed via facility video to have fallen after tripping over her catheter tubing. Staff present did not immediately respond to the fall, and when they did, they moved the resident multiple times without performing a thorough assessment as required by facility policy. The resident complained of severe leg pain, but staff continued to move and ambulate her without using a gait belt or completing a full assessment, including vital signs and range of motion. The resident was later sent to the emergency department, where a femur fracture was diagnosed. Interviews confirmed that staff did not follow the facility's fall policy, which required a nurse to assess the resident on the floor before moving her, and that documentation of the incident was delayed and incomplete. Additionally, the same resident was administered medications intended for another resident, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The error was not fully reported to the emergency department, as only one of the four medications was disclosed. Staff interviews revealed confusion and lack of adherence to medication administration and error reporting protocols. The Director of Nursing confirmed that the nurse's assessment after the fall was not as thorough as expected and that vital signs were not taken as required. A second resident, with diagnoses including heart failure, diabetes, and dementia, was readmitted with a right trochanter blister. The facility failed to assess the blistered area for two weeks, with no measurements or detailed assessment documented during that period. When the wound was eventually assessed, it had worsened, showing signs of infection and requiring antibiotic treatment. The Director of Nursing confirmed that staff failed to assess the resident's wound as required.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to follow appropriate infection control practices during direct care for three residents. In one instance, an LPN washed and gloved her hands before removing a supportive boot and wound dressing, then performed physician-ordered treatment to multiple areas of a resident's foot using the same gloves. After completing the treatment, the staff member placed unused and/or prescribed treatment supplies into a plastic bag and returned it to the resident's supply basin without sanitizing the surfaces. The Director of Nursing confirmed these observations. Additionally, another staff member performed a dressing change for a resident in a public dining/lounge area without placing a barrier between the table and treatment supplies, and failed to sanitize the supplies before returning them to the treatment cart. This staff member also palpated another resident's hip with bare hands, then touched the resident, furnishings, and herself without washing her hands. The same staff member later confirmed she did not use a barrier or sanitize items as required.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents during care activities, as evidenced by direct observation, video footage review, clinical record review, and staff interviews. In one instance, a Licensed Practical Nurse (LPN) approached a resident seated in a recliner in the dining/lounge area, pulled out the resident's sweatpants at the waistband, and placed her hands inside to palpate the resident's left hip area following a fall. This examination was conducted in the presence of another resident seated approximately 12 feet away, in direct view. The video footage also showed the LPN pressing on the resident's hip, looking under the resident's pajama bottoms, and returning to palpate the area again after donning gloves, all in a public area. In another instance, the same LPN performed a dressing change on a different resident's foot while the resident's leg was resting on a chair in the dining/lounge area, directly across from the first resident. During an interview, the LPN confirmed that she performed the foot treatment in the dining area and was not aware of the facility's policy and procedure regarding treatments and privacy. The facility's policies, as acknowledged by the LPN, require the promotion of resident rights, dignity, and privacy during care, which were not upheld during these incidents.
Failure to Notify Family of Medication Error and Condition Change
Penalty
Summary
The facility failed to notify the family member or representative of a resident after a significant medication error occurred. According to clinical record review and interviews, a resident was mistakenly administered medications intended for another resident, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The error was documented as a late entry in the progress notes, and the family was not directly informed by the facility until several days later. Instead, the family learned of the incident through the hospital's History and Physical report, rather than from facility staff. Interviews with the resident's family confirmed that they were not notified by the facility about the administration of the four incorrect medications. The facility's policy and the LPN's job description both require immediate notification of the resident, physician, and family or legal representative in the event of a significant change in condition or medication error. Despite this, the facility only informed the hospital about one of the medications and delayed direct communication with the family, failing to follow established procedures for notification.
Incomplete Care Plan for Resident with Active Skin Issues
Penalty
Summary
Facility staff failed to maintain a complete and accurate care plan for a resident who was readmitted with multiple diagnoses, including heart failure, diabetes mellitus, non-Alzheimer's dementia, altered mental status, adult failure to thrive, and abnormal weight loss. Upon readmission, the resident was documented as having a right trochanter blister and a scabbed area on the coccyx, with a history of pressure ulcers and being at risk for further ulcer development. However, the care plan did not address these active skin issues or specify expected interventions for their management. Clinical documentation showed that the initial assessment upon readmission noted the presence of skin issues but did not provide further assessment details such as measurements, condition of surrounding skin, drainage, or odor. The facility's own Skin Quick Reference Guide required a head-to-toe assessment, documentation, and initiation of care plan interventions, but these steps were not completed as required. The care plan remained incomplete and failed to reflect the resident's current needs related to skin integrity.
Failure to Provide Adequate Staffing and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple interviews and policy review. One resident reported waiting 2.5 hours for a response to her call light, using the wall clock to time the delay, and expressed frustration over being left in bed in the morning because there were not enough staff available to assist with her transfer, which required 2-3 staff members. Another resident confirmed experiencing extended wait times for staff to respond to call lights, with no particular time of day being worse than others. Certified Nursing Assistants (CNAs) interviewed acknowledged challenges in responding to call lights within the facility's 15-minute policy, citing being occupied in other resident rooms and overall staffing shortages. Staff attributed these issues to difficulties in hiring and retaining healthcare workers, as well as management decisions such as wage caps. The facility's call light policy, revised in September 2023, emphasizes prompt responses, but staff interviews indicated that timely responses were not consistently achieved.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that two out of three residents were free from significant medication errors. In one instance, a Certified Medication Aide (CMA) administered the correct physician-prescribed medications to a resident, but later, due to interruptions including a phone call and a resident's pressure alarm, the CMA mistakenly gave the same resident medications that were prescribed for another resident. The medications erroneously administered included Melatonin, Mirtazapine, Alprazolam, and Apixaban, which were not intended for the resident who received them. This error was confirmed by a review of video footage, clinical records, and a written statement from the Director of Nursing (DON). In another case, a resident continued to receive both Seroquel 12.5 mg and Seroquel 25 mg in the morning, despite a physician's order changing the regimen to Seroquel 25 mg in the morning and 12.5 mg at noon and supper. This discrepancy was discovered during staff rounds, indicating that the medication order change was not properly implemented, resulting in the resident receiving an incorrect dosage for an extended period.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by discrepancies in documentation and assessment following a fall incident. In one case, a resident fell from a recliner in the day room, was witnessed by a nurse, and subsequently complained of left leg pain. Although the progress note indicated that the resident was assessed for physical abnormalities and vital signs while on the floor, video footage revealed that staff did not perform these assessments before moving the resident. The resident was assisted to her feet and walked despite refusing to bear weight on her left leg, and was later found to have a minimally displaced fracture of the left femur. The LPN responsible for the documentation was unable to recall details of the assessment and could not explain where the documented information originated, as confirmed by the DON during an interview. Additionally, there was a discrepancy in the controlled substance record for another resident. The record indicated that Xanax was destroyed, but the DON later confirmed that the medication was actually administered to a different resident. The LPN involved had signed a job description acknowledging the requirement for accurate, contemporaneous charting and completion of medical records in accordance with nursing policies. These failures to accurately document care and medication administration were not in accordance with accepted professional standards and facility policy.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to administer the correct medications to a resident, resulting in the resident receiving another resident's medications, including an anti-psychotic medication, Seroquel. This error led to the resident experiencing over-sedation and hypoglycemia, necessitating hospital admission for observation. The resident, who had no cognitive impairment and did not typically take anti-psychotic medication, was minimally arousable and had a low blood sugar level, likely due to the sedative effects of the Seroquel. The incident occurred when a Certified Medication Aide (CMA) became distracted after receiving an upsetting personal call before the noon medication pass. Despite performing the correct checks, the CMA inadvertently administered the wrong medications to the resident. The error was identified immediately upon returning to the medication cart, and the resident's doctor and the Director of Nursing (DON) were informed. The resident was subsequently sent to the hospital for evaluation and observation.
Sanitary Conditions Not Maintained During Meal Service
Penalty
Summary
The facility failed to maintain sanitary conditions during meal service, as observed during the noon meal on 4/22/24. Staff A, a cook, was seen serving 28 glasses to 19 residents while touching the drinking rim surfaces with her bare hands. Additionally, Staff A pushed the beverage cart throughout the dining room without sanitizing the cart handle and did not perform hand hygiene during the meal service. The Dietary Manager, Staff B, confirmed that staff are trained to avoid touching the drinking rims of glasses and the tines of silverware, and to hold plates by the edge and base. However, the facility lacked a policy regarding dining services and appropriate hand placement during food service. Further observations on 4/23/24 revealed multiple staff members handling milk jugs by the handle without performing hand hygiene prior to touching the jugs.
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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