Oakview Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Burlington, Iowa.
- Location
- 1212 Indian Hills Drive, Burlington, Iowa 52601
- CMS Provider Number
- 165439
- Inspections on file
- 19
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Oakview Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not consistently ensure that providers responded to pharmacist recommendations for gradual dose reductions (GDR) and drug regimen reviews (MRR) for several residents receiving psychotropic and other medications. In multiple cases, documentation of provider review or rationale for declining GDRs was missing, and repeated pharmacist requests went unaddressed, contrary to facility policy.
Three residents, including individuals with respiratory failure, lung cancer, COPD, and cognitive impairment, were not offered or administered the appropriate pneumococcal vaccines as required by CDC guidelines. In each case, either consent was obtained but the vaccine was not given, or the opportunity to consent or refuse was not provided when residents became eligible. The DON reported a lack of knowledge regarding the vaccine schedule and had not proactively identified residents due for immunization.
A resident with a history of stroke and hip fracture, requiring substantial assistance for transfers, requested to be moved from a recliner to a wheelchair. Despite multiple requests and reminders to staff, the resident waited over an hour before being assisted, expressing frustration at not being listened to. Staff interviews confirmed delays and acknowledged that residents should not have to wait this long for assistance, as facility policy requires residents to be treated with dignity and respect.
A resident admitted with a Stage 2 pressure ulcer on the right heel experienced deterioration to a Stage 3 ulcer and developed new pressure ulcers due to inadequate monitoring and intervention by the facility. The facility failed to follow up with a wound clinic, and documentation and communication regarding the resident's condition were insufficient. Staff were inconsistent in their awareness and documentation of the resident's pressure injuries, and facility policies on pressure ulcer prevention and physician notification were not effectively implemented.
The facility failed to revise care plans for three residents, leading to deficiencies in addressing their medical needs. A resident's care plan did not include prophylactic antibiotics despite their use, another resident's wandering concerns were initially omitted, and a third resident's care plan lacked identification of pressure injuries. These oversights were acknowledged by staff and attributed to a new staff member's inexperience in care plan management.
The facility failed to include antiplatelet medication and seizure management in the care plans for two residents. One resident, with moderately impaired cognition, was prescribed Clopidogrel Bisulfate and Aspirin EC, but the care plan did not reflect this. Another resident, with intact cognition, was prescribed Phenytoin Sodium for seizures, yet the care plan did not address this. The MDS Coordinator acknowledged these oversights.
A resident with multiple diagnoses did not receive prescribed medications due to a nurse's error, despite the medications being delivered to the facility. The facility's policy requiring administration per physician order was not followed, leading to a deficiency.
A facility failed to timely initiate antibiotics for a UTI and lacked a clear process for catheter change frequency for a resident with an indwelling catheter. The resident had severely impaired cognition and neurogenic bladder. Inconsistencies in catheter change dates and unclear physician orders were noted, with the Corporate Nurse acknowledging the confusion. Additionally, there was a delay in administering the antibiotic Levofloxacin after a UTI was identified.
A resident with severely impaired cognition did not receive prescribed medications, including a diuretic, antibiotic, and blood pressure medications, due to a failure in delivery from the pharmacy. Facility staff acknowledged issues with prompt medication delivery for new admissions, and documentation indicated the medications were not administered as per physician orders.
Failure to Ensure Timely Provider Response to Pharmacist Drug Regimen Review and Gradual Dose Reduction Recommendations
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews (MRR) and gradual dose reduction (GDR) recommendations made by the consulting pharmacist were consistently and timely addressed by the attending providers for multiple residents. In several cases, the pharmacist identified the need for GDRs for psychotropic and other medications, but the facility was unable to provide documentation that these recommendations were reviewed or acted upon by the prescriber. For example, for one resident with moderate cognitive impairment receiving antidepressant medication, the facility could not produce documentation of a provider's response to a GDR recommendation made in September, and only provided a response dated much later, after repeated requests. Other residents with varying degrees of cognitive impairment and complex medication regimens, including antipsychotics, antidepressants, anxiolytics, and hypnotics, also had GDR recommendations from the pharmacist that were not addressed in a timely manner or lacked provider rationale when GDRs were declined. In some instances, the pharmacist had to repeat GDR requests due to lack of response, and the facility's own documentation confirmed that GDRs for certain residents were not addressed for multiple months. Interviews with facility staff, including the DON, revealed that there was an ongoing issue with providers not documenting rationales for declining GDRs and that unresolved GDRs were sometimes escalated to the medical director or nurse practitioner. Facility policies required that any drug regimen irregularities identified by the pharmacist be reported in writing to the provider, medical director, and DON, and that the provider's response, including rationale for no change, be documented in the medical record. Despite these policies, the facility did not ensure that provider responses to pharmacist recommendations were consistently documented, nor that rationales for declining GDRs were provided, resulting in a deficiency related to the management and oversight of unnecessary medications.
Failure to Offer and Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to offer or administer the pneumococcal vaccine to three out of five residents reviewed for immunizations, despite having policies in place to assess and vaccinate residents according to CDC recommendations. In one case, a resident with respiratory failure and lung cancer, who had intact cognition, consented to receive the pneumococcal vaccine upon admission, but there was no documentation that the vaccine was administered. The administrator confirmed that staff did not follow through with obtaining an order for the vaccine, despite the resident's family member consenting to vaccination. Another resident with acute and chronic respiratory failure and COPD, also with intact cognition, had previously received both Prevnar 13 and Pneumovax but had not been offered or administered a pneumococcal conjugate vaccine (PCV15, PCV20, or PCV21) as recommended five years after the last dose. The clinical record lacked documentation that the vaccine was offered or refused in the years following eligibility, and the resident only recalled being offered the vaccine on admission and again during the survey process. A third resident, with iron deficiency anemia, moderate intellectual disability, and a history of blood clots, had received Pneumovax but had not been offered a pneumococcal conjugate vaccine after becoming eligible. The resident's guardian had consented to other vaccinations but was not given the opportunity to consent or refuse the pneumococcal conjugate vaccine. The DON, responsible for immunization tracking, reported only recently learning the pneumococcal vaccine schedule and had not run reports to identify eligible residents until prompted by the surveyor.
Failure to Timely Assist Resident with Transfer Request, Compromising Dignity and Respect
Penalty
Summary
A resident with a history of cerebral infarction and a left hip fracture, who required substantial to maximal assistance for transfers and had intact cognition, requested to be moved from her recliner to her wheelchair. During a continuous observation, the resident made her request to a CNA during a water pass, and the CNA responded that she would assist the resident 'in a little bit.' Despite completing the water pass in the same pod, the CNA did not return to assist the resident and instead engaged in other activities, including speaking with staff and helping another resident with a puzzle. The resident remained in her recliner for over an hour after her initial request, repeatedly expressing her desire to be moved and her frustration at not being listened to. When a nurse entered the room, the resident again requested to be moved, and the nurse stated she would inform the CNA. The CNA eventually returned with the non-mechanical lift but again delayed the transfer, telling the resident she would assist her 'in a little bit.' The resident was finally transferred to her wheelchair more than an hour after her initial request. Interviews with staff confirmed that the resident required an assist of two with a non-mechanical lift and that there was only one such lift available for three pods. Staff acknowledged that the resident should not have had to wait so long for assistance and that, according to facility policy, residents should be treated with dignity and respect, including timely responses to their requests. The Director of Nursing also stated that residents should be moved when they request, regardless of how recently they were transferred.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide adequate monitoring, assessment, and intervention for a resident with a pressure ulcer present on admission, leading to the deterioration of the existing ulcer and the development of new pressure ulcers. The resident was admitted with a Stage 2 pressure ulcer on the right heel, which worsened to a Stage 3 ulcer by a later date. The clinical record indicated that the resident experienced pain and was referred to a wound clinic, but the right heel ulcer was not assessed or treated during the first clinic appointment. The facility did not follow up with the clinic, resulting in the right heel ulcer progressing to a Stage 3 with necrotic tissue, and new pressure ulcers developing on the left heel and bilateral buttocks. The facility's documentation and communication regarding the resident's condition were inadequate. The admission assessment failed to identify pressure injuries, and subsequent nursing progress notes lacked detailed assessments and measurements of the wounds. The facility's care plan did not document the presence of pressure ulcers or unhealed skin impairments, and there was a lack of timely notification to the primary care provider about the resident's worsening condition. Staff interviews revealed inconsistencies in the awareness and documentation of the resident's pressure injuries, with some staff unaware of the wounds until the survey. The facility's policies on pressure ulcer prevention, skin checks, and physician notification were not effectively implemented. The policies required timely assessments, documentation, and communication with healthcare providers, but these were not consistently followed. The facility's failure to adhere to its policies and procedures contributed to the resident's pressure ulcers worsening and new ulcers developing, ultimately leading to the resident being sent to the emergency department for suspected cellulitis and sepsis.
Care Plan Deficiencies in Addressing Resident Needs
Penalty
Summary
The facility failed to ensure proper revisions to the care plans of three residents, leading to deficiencies in addressing their specific medical needs. For Resident #45, the care plan did not include the use of prophylactic antibiotics, despite the resident having an indwelling catheter and being on cephalexin for prophylaxis. This oversight was acknowledged by the MDS Coordinator, who confirmed that prophylactic antibiotics should have been included in the care plan. Resident #29's care plan initially failed to address wandering concerns, despite the resident's history of ambulating outside unsupervised and the subsequent placement of a wander guard for safety. The resident expressed a desire to go outside independently, but staff interventions were necessary to ensure safety. The facility's Administrator noted that the staff member responsible for care plans was new, which contributed to the omission of wandering concerns and interventions in the care plan. For Resident #9, the care plan lacked identification of pressure injuries or unhealed wounds, despite the presence of a Stage 2 pressure injury on the right heel and other skin impairments noted in the clinical records. The MDS Coordinator confirmed that wounds and pressure injuries should have been included in the care plan, as per the facility's policy on pressure ulcer prevention. This omission highlights a failure to incorporate necessary interventions into the resident's plan of care.
Care Plan Deficiencies for Antiplatelet and Seizure Management
Penalty
Summary
The facility failed to include the use of antiplatelet medication and seizure management in the comprehensive care plans for two residents. For one resident, the Minimum Data Set (MDS) assessment indicated moderately impaired cognition, and the resident was prescribed Clopidogrel Bisulfate and Aspirin EC. Despite the resident receiving these medications consistently, the care plan did not reflect the use of antiplatelet medication. The MDS Coordinator acknowledged this oversight during an interview. For another resident, the MDS assessment showed intact cognition, and the resident was prescribed Phenytoin Sodium for possible seizure activity. The medication was added following adjustments made in the hospital, and the resident was to follow up with neurology. However, the care plan did not address the seizure disorder or the medications prescribed for it. The MDS Coordinator confirmed that the seizure disorder and related medications should have been included in the care plan.
Medication Administration Error Due to Nurse Omission
Penalty
Summary
The facility failed to administer medications as prescribed for a resident, leading to a deficiency in meeting professional standards of quality. The resident, who was admitted with diagnoses including hypokalemia, paroxysmal atrial fibrillation, hypotension, and adult failure to thrive, did not receive their prescribed medications on the day of admission. The medications included Metoprolol Tartrate for hypertension, Levetiracetam for alcohol use, and Potassium Chloride for hypokalemia. The Medication Administration Record (MAR) indicated that these medications were not administered because they were marked as not available from the pharmacy. Upon further investigation, it was revealed that the medications were indeed delivered to the facility, but the nurse responsible for administering them omitted them in error. The nurse consultant confirmed that the medications were delivered together, and the omission was not due to a delay from the pharmacy. The facility's policy on medication administration, which requires medications to be administered per physician order, was not followed in this instance, resulting in the deficiency.
Deficiency in Timely Antibiotic Initiation and Catheter Change Process
Penalty
Summary
The facility failed to ensure timely initiation of an antibiotic for the treatment of a urinary tract infection (UTI) and did not have a clear process for the frequency of urinary catheter changes for a resident with an indwelling catheter. The resident, who had severely impaired cognition, was noted to have an indwelling catheter due to neurogenic bladder. The care plan included interventions such as assessing the need for the catheter quarterly, maintaining a closed system, and providing catheter care twice daily and as needed. The clinical records revealed inconsistencies in catheter change dates and a lack of clarity in physician orders regarding the frequency of catheter changes. The catheter was changed on various dates, but there was no consistent schedule, and the facility's policy did not specify how frequently catheters should be changed. This lack of clarity was acknowledged by the Corporate Nurse during an interview. Additionally, there was a delay in initiating antibiotic treatment for a UTI. A urine sample was obtained and sent for analysis, but the antibiotic Levofloxacin was not administered until several days later. This delay in treatment was documented in the resident's Medication Administration Record, indicating a gap between the identification of the UTI and the start of antibiotic therapy.
Medication Availability Deficiency for Resident
Penalty
Summary
The facility failed to ensure the availability of necessary medications for a resident, identified as Resident #45, who was one of three residents reviewed for medication availability. The resident, who had severely impaired cognition as indicated by a score of 4 out of 15 on the Brief Interview for Mental Status (BIMS) exam, did not receive several prescribed medications, including a diuretic, an antibiotic, and blood pressure medications, because they were not delivered from the pharmacy. This issue was documented in the Orders-Administration Notes and the Medication Administration Record (MAR) for July 1, 2024, where the medications were marked with a code indicating other/see progress notes. Interviews with facility staff, including the MDS Coordinator, Administrator, and Corporate Nurse, revealed concerns about the promptness of medication delivery for new admissions. The Health Status Note from July 1, 2024, indicated that the resident did not receive any medications that day due to the pharmacy's failure to deliver them, and a call was placed to the pharmacy to address the issue. The facility's policy on Medication Administration, revised in April 2023, states that medications should be administered per physician order, highlighting a deviation from this policy in the case of Resident #45.
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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