Osage Rehab And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Osage, Iowa.
- Location
- 830 South Fifth Street, Osage, Iowa 50461
- CMS Provider Number
- 165173
- Inspections on file
- 27
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Osage Rehab And Health Care Center during CMS and state inspections, most recent first.
A resident admitted from a hospital with peripheral vascular disease, diabetes, multiple venous and arterial ulcers, and moderately impaired cognition had hospital transfer orders for collagenase Santyl to the right heel, betadine to eschar on the right foot, and Juven twice daily. These orders were not entered on the January MAR/TAR, and thus were not implemented. The IDON acknowledged she failed to properly transcribe the admission orders, and the facility’s policy on physician-ordered services did not address the transcription and implementation of orders.
The facility did not ensure RN coverage for at least eight consecutive hours per day on several occasions and lacked a full-time DON for an extended period, as confirmed by schedule reviews and staff interviews. The census during this time was 25 residents.
The facility failed to complete required MDS and CAA documentation for two residents—one with unstageable pressure ulcers and another with severe cognitive impairment and significant weight loss. In both cases, the CAA worksheets lacked essential information on impact, rationale, risk factors, and referrals, as confirmed by staff interviews and record review.
A resident developed two unstageable pressure ulcers during their stay, and the facility did not implement detailed, resident-specific interventions to address these wounds. The care plan lacked specifics on treatments, medications, pain management, and input from the resident or external wound care providers, with only general interventions like an alternating air mattress and scheduled repositioning documented.
The facility did not include the resident census or facility name on daily nurse staffing postings over multiple days. The Administrator confirmed that overnight nurses complete the postings but do not include the census, and this omission was verified during a review of the postings.
A resident with moderate cognitive impairment and significant physical needs was not provided transportation back to the facility after a neurology appointment. Although the resident left with a transport van and driver, the family was unable to confirm return transportation and ultimately transported the resident back themselves. Staff confirmed that a staff member was expected to accompany residents to appointments, but this did not occur, and there was no written policy in place.
Surveyors identified a deficiency related to unsanitary and non-homelike conditions, including mold buildup on heating/cooling pipes and persistent toilet leaks with standing water in multiple rooms. Staff and residents confirmed these issues had been ongoing for an extended period, affecting the comfort and safety of residents on one side of the building.
Two residents experienced significant delays in call light responses, with documented instances of waits exceeding 15 minutes and, in one case, up to two hours. Staff interviews confirmed that these delays were due to staffing shortages and agency staff not responding to call lights, in violation of facility policy.
A resident with severe cognitive impairment was allowed to have her cat in her room without staff verifying the animal's vaccination status or having a pet policy in place. The cat displayed aggressive behavior, and during an attempt to remove it, the resident was bitten, resulting in a wound infection that required antibiotic treatment.
A resident experienced repeated delays in call light response, sometimes waiting hours for assistance, due to a malfunctioning call system and insufficient staffing. Staff and maintenance confirmed the call system was inoperative for about a week, and alternative alert methods were ineffective, resulting in unmet resident needs and noncompliance with the facility's policy for timely response.
A resident with intact cognition and identified fall and incontinence risks did not receive timely responses to call light requests, despite care plan interventions requiring prompt assistance. The resident reported prolonged waits for help, including one instance lasting several hours overnight and another resulting in incontinence, reflecting the facility's failure to implement the care plan as directed.
A resident with multiple small cat bite wounds did not receive the prescribed wound care treatment, as the physician's orders for cleaning, antibiotic ointment application, and bandaging were not documented or carried out by staff. The required treatment was missing from the MAR and TAR, and this was confirmed by an LPN and the administrator.
A facility failed to provide a required Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNF/ABN) and Notice of Medicare Non-Coverage (NOMNC) to a resident or their legal representative. The resident, who had severe cognitive impairment and was receiving therapy treatments, was not notified of the discontinuation of Medicare Part A skilled services as required by the facility's policy. The administrator confirmed the notice was not given, and there was no documentation to prove it was done.
A facility failed to complete a baseline care plan for a resident admitted after a left knee replacement. The EHR showed the resident's admission and discharge dates, but lacked a completed baseline care plan. The facility's policy requires a baseline care plan within 48 hours of admission, but the DON mentioned a 72-hour timeframe, showing a policy-practice discrepancy. The Administrator confirmed the care plan was not completed, failing to meet the resident's immediate care needs.
The facility failed to conduct a criminal background check for a CMA, Staff A, who was hired conditionally in December 2022. A review in November 2024 revealed the absence of this check, despite facility policy requiring it before regular employment. The BOM confirmed the oversight and noted that the responsibility for background checks had just been transferred to her.
The facility failed to provide at least two baths/showers per week for two residents, as required. One resident with multiple sclerosis and intact cognition did not consistently receive scheduled showers, with missing documentation on specific dates. Another resident also had missing shower documentation. The ADON acknowledged inconsistent documentation and was unable to locate records, while the DON confirmed the expectation for scheduled showers and reporting deviations.
A facility failed to complete physician-ordered PICC line dressing changes for a resident with MS, who reported inconsistent dressing changes. The care plan required weekly sterile dressing changes and immediate provider contact for complications. However, the treatment administration record lacked documentation for two dates, with no rationale provided. The facility lacked a policy to ensure physician orders are followed.
A facility failed to conduct pre and post dialysis assessments for a resident with ESRD who required hemodialysis. The resident's care plan required immediate intervention for dialysis complications, but assessments were missing from the health record. The ADON acknowledged the oversight, and incomplete assessments were later provided, highlighting a deficiency in dialysis care.
A resident with a gastronomy tube suffered aspiration pneumonia and septic shock after a nurse failed to elevate the head of the bed during feeding, as required by the care plan. Despite the resident's history of pneumonia and dysphasia, the nurse administered the feeding with the bed lowered and did not elevate it when the resident vomited. The resident was found unresponsive with low oxygen saturation and was transferred to a hospital for further care.
A resident with a feeding tube was not properly positioned according to their care plan, leading to an incident where they vomited and became unresponsive. Staff interviews revealed that the resident was found with the head of the bed at an incorrect angle, and EMS was called to transport the resident to the hospital. This was not the first occurrence of improper positioning for this resident.
The facility failed to conduct thorough assessments for two residents following changes in their conditions. One resident experienced issues with a catheter, leading to a hospital transfer for septic shock and aspiration pneumonia, with inadequate documentation of assessments. Another resident's respiratory symptoms were not documented according to facility guidelines, highlighting deficiencies in care practices.
The facility failed to ensure that two staff members met the requirements for Dependent Adult Abuse Training. A CMA had not completed any further training since 1/9/19, and a CNA who started on 3/16/23 had no documentation of the required training. The facility's policy mandates training within six months of employment and every three years thereafter. The Administrator acknowledged the training was overdue.
The facility failed to maintain sanitary conditions during meal service, as staff did not change gloves or perform hand hygiene between tasks, increasing the risk of contamination and foodborne illness. Staff were observed handling various surfaces and food items without proper glove changes or hand hygiene.
A facility failed to ensure staff treated a resident with dignity and respect. A CNA reported that another CNA told the resident she 'smelled like piss' during a change, causing the resident to cry. The resident confirmed this comment was made frequently. The facility's policy lacked documentation on treating residents in a dignified manner.
Failure to Transcribe and Implement Admission Wound Care and Nutritional Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that admission orders were properly transcribed and implemented for a newly admitted resident. The resident was admitted from a short-term general hospital with documented diagnoses including peripheral vascular disease, diabetes, and atherosclerosis of native arteries of the extremities with ulceration. The resident’s MDS assessment identified moderately impaired cognition with a BIMS score of 12 and documented seven venous and arterial ulcers present at admission. The hospital transfer summary included specific admission orders for collagenase Santyl ointment to the right heel, betadine to eschar areas on the right foot daily, and Juven nutritional supplement twice daily. Record review showed that the January Medication Administration Record and Treatment Administration Record did not contain documentation of the Juven orders or the wound care treatment orders for the right foot and heel. During an interview, the Interim Director of Nursing acknowledged that she did not properly transcribe the admission orders and missed the wound care and Juven orders. The facility’s policy on Provision of Physician Ordered Services directed staff to provide a reliable process for the proper and consistent provision of physician-ordered services according to professional standards of quality, but the policy did not include guidance on how to transcribe and implement orders.
Failure to Provide Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours per day as required by federal regulations, with documented absences of RN coverage on specific days in July and November 2025. Additionally, the facility did not have a full-time Director of Nursing (DON) in place from October 18, 2025, until December 1, 2025, as confirmed by both the Interim DON and the Administrator. These deficiencies were identified through review of facility schedules, new hire and termination lists, and staff interviews. The facility had a reported census of 25 residents during this period. No information regarding the medical history or condition of individual residents at the time of the deficiency was provided in the report.
Incomplete MDS and CAA Documentation for Pressure Ulcers and Nutrition
Penalty
Summary
The facility failed to complete required Minimum Data Set (MDS) assessments and Care Area Assessment (CAA) worksheets for two residents. For one resident with no cognitive impairment, the MDS documented two unstageable pressure ulcers that developed during the stay. The CAA worksheet for pressure ulcers was incomplete, as it did not describe the impact, rationale for care planning, risk factors, or need for referral to other health professionals. Staff interviews confirmed that the resident had not developed new pressure ulcers since admission, and the MDS Coordinator responsible for completing the assessments worked offsite. For another resident with severe cognitive impairment and diagnoses including Parkinson's, dehydration, and depression, the CAA worksheet for nutrition was also incomplete. The resident experienced significant weight loss and was on hospice care, but the worksheet lacked documentation of the impact, rationale, risk factors, and referral needs. A weight/skin summary note indicated a meeting with the ADON and dietician regarding the weight loss, but the required CAA documentation was not completed. Attempts to contact the MDS Coordinator were unsuccessful.
Failure to Implement Resident-Specific Interventions for Pressure Ulcers
Penalty
Summary
The facility failed to implement appropriate and resident-specific interventions for a resident who developed two unstageable pressure ulcers during their stay. The resident, who had no cognitive impairment as indicated by a BIMS score of 15, was not admitted with these wounds, which were documented as acquired in the facility. The care plan, revised on 12/12/25, noted multiple pressure areas but lacked detailed interventions tailored to the resident's needs, such as specific treatments, medications, supplies, pain management strategies for wound care, and input from the resident or external wound care providers. The only interventions documented were the use of an alternating air pressure mattress and repositioning every two hours. Additionally, the facility's policy on pressure ulcers did not provide instructions on care planning or the assessment process.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information that includes both the resident census and the facility name. Observations on three consecutive days revealed that the daily staff posting was missing these required elements. During an interview, the Administrator confirmed that overnight nurses are responsible for completing the daily staff postings, which include the number of nurses and CNAs and their hours per shift, but acknowledged that the census was not being included. A review of the posting with the Administrator further confirmed the absence of both the resident census and the facility name on the daily staff posting.
Failure to Provide Transportation for Resident After Off-Site Appointment
Penalty
Summary
The facility failed to provide transportation for a resident following an off-site neurology appointment. The resident, who had moderately impaired cognition (BIMS score of 9), required partial to moderate assistance with activities of daily living and used a wheelchair for mobility. The resident had diagnoses including hypertension, aphasia, cerebrovascular accident, hemiplegia, and anxiety. Documentation showed that the resident left the facility for the appointment with a transport van service and driver, and staff expected a staff member to accompany residents to appointments, although there was no formal policy in place. After the appointment, the resident's family member was unable to confirm with the facility that transportation would return to pick up the resident, as attempts to contact the facility's Social Worker went unanswered. As a result, the family member transported the resident back to the facility themselves. Staff interviews confirmed the expectation that a staff member should accompany residents to appointments, but this did not occur in this instance, and the facility lacked a written policy regarding transportation for such situations.
Deficiency Due to Mold and Persistent Plumbing Issues in Resident Rooms
Penalty
Summary
The facility failed to provide a clean, sanitary, and homelike environment for all residents residing on the East end of the building, as evidenced by a buildup of a black substance resembling mold on the pipes of the heating and cooling elements in all 16 resident rooms on that side. The heating and cooling system, installed in the 1960s, uses water that alternates between hot and cold depending on the season, leading to condensation and moisture buildup, which in turn has caused mold to develop on the pipes. Both the current and previous Maintenance Supervisors confirmed the ongoing presence of this issue, and staff interviews corroborated that the mold had been present for at least two years. Additionally, multiple rooms on the East end had active toilet leaks, resulting in standing water on bathroom floors. Residents confirmed that their toilets had been leaking for an extended period, and staff acknowledged that this was a long-standing problem despite various attempted interventions. Observations and interviews with residents and staff consistently identified these unsanitary conditions, which affected the comfort and safety of the residents in the affected rooms.
Failure to Respond to Resident Call Lights Within Required Timeframe
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by interviews with residents and staff, review of Alarm Response Report forms, and facility policy. One resident reported timing her call light and found it was not answered for over 15 minutes on multiple occasions, with documented delays ranging from 17 to 26 minutes over several days. Another resident reported her call light was left unanswered for up to two hours on an evening shift, particularly when agency staff were present, and the Alarm Response Report confirmed several instances where her call light was not answered within the required 15-minute timeframe. Staff interviews confirmed that call lights were not answered within 15 minutes due to staffing shortages and issues with agency staff refusing to respond to call lights. The facility's policy requires timely responses to call lights, but the documented delays and staff admissions indicate this standard was not met for at least two residents during the review period. The facility had a census of 28 residents at the time of the deficiency.
Failure to Prevent Accident Hazard Resulting in Resident Cat Bite and Infection
Penalty
Summary
Facility staff failed to maintain appropriate supervision and accident hazard prevention when a resident with severe cognitive impairment was allowed to have her cat brought into the facility. The resident, who had a history of cerebrovascular accident, anxiety, depression, disorientation, and mild cognitive impairment, was described as confused and exhibited exit-seeking behaviors. The cat was brought in by the resident's DPOA as a comfort measure, but staff did not obtain written proof of the cat's vaccination status, relying only on verbal confirmation. Multiple staff members reported the cat displaying aggressive behavior, including hissing and growling, and noted that the DPOA had difficulty catching the cat and was bitten in the process. Despite these warning signs, the cat remained in the resident's room. Staff attempts to remove the cat were unsuccessful at first, and the resident was not successfully redirected away from the situation. During the removal attempt, the resident tried to console the agitated cat and was bitten on the left wrist and palm, resulting in multiple puncture wounds. The wounds required cleaning, dressing, and antibiotic treatment, and a subsequent infection developed, necessitating a change in antibiotic therapy. Interviews with staff revealed that there was no facility policy or procedure regarding pets or animals in the building. Staff were unaware of the cat's vaccination status, and the decision to allow the cat to stay was based on the assumption that it was friendly and vaccinated. The lack of supervision, absence of a pet policy, and failure to verify vaccination status contributed to the resident sustaining a cat bite and subsequent wound infection.
Failure to Provide Timely Call Light Response Due to Staffing and Equipment Issues
Penalty
Summary
The facility failed to provide adequate nursing staff and ensure timely response to a resident's call light, resulting in multiple instances where a resident's needs were not met within the regulated 15-minute timeframe. The resident reported that on several occasions, her call light remained unanswered for extended periods, including one instance where it was on from approximately 1:30 AM to 5:30 AM. The resident described feeling ignored, angry, and unhappy, and recounted an episode where a delayed response led to incontinence. Documentation from the Alarm Response Report confirmed numerous occasions over several days where the call light was not answered within the required timeframe, with delays ranging from over 15 minutes to nearly two hours. Staff interviews corroborated the resident's account, revealing that the facility's call light system was nonfunctional for about a week, during which residents were given bells that staff often could not hear, especially when staffing levels were low. Staff confirmed that with only one nurse and one CNA on duty, and with some residents requiring assistance from two or three staff members, it was not possible to consistently monitor or respond to call lights or bells within the required timeframe. Maintenance staff confirmed that the call system had been inoperative on two separate occasions in the past two months. The facility's policy required timely responses to call lights, but this was not achieved during the period in question.
Failure to Implement Care Plan for Timely Call Light Response
Penalty
Summary
The facility failed to implement a comprehensive care plan for one resident, as evidenced by the lack of timely response to call lights and unmet care needs. Clinical record review showed that the resident had intact cognition and was identified as being at risk for falls due to gait and balance problems, as well as incontinence. The care plan required that the call light be kept within reach and that staff respond promptly to all requests for assistance. However, the resident reported multiple instances where her call light was not answered for extended periods, including one occasion where it remained on for approximately four hours overnight, and another where it was unanswered for 45 minutes, resulting in loss of bowel control. These events caused the resident to feel ignored, angry, and unhappy, and were directly related to the facility's failure to implement the care plan interventions as specified.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
Facility staff failed to follow physician orders for a resident who sustained six small cat bite marks on her left arm. The physician had ordered staff to clean the affected areas with normal saline, apply triple antibiotic ointment, and cover with a bandage twice daily and as needed until healed. However, a review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January and February showed that the prescribed treatment orders were not documented or completed as ordered. Staff confirmed that the treatment order was missing from the MAR and TAR during this period. Facility policy required that medications and treatments be administered only upon written order and in accordance with safe and effective order writing principles.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNF/ABN) and Notice of Medicare Non-Coverage (NOMNC) to a resident or their legal representative, documenting an appeal decision and the date of notification of Medicare non-coverage. This deficiency was identified for one of the three residents sampled, specifically Resident #10, who was admitted for Medicare Part A skilled services and discharged on 8/16/24. The resident's medical record lacked documentation of notification regarding the discontinuation of Medicare Part A skilled services. The facility's policy required notification 48 hours prior to the termination of skilled coverage, but the administrator confirmed that the notice was not given, and there was no proof of it being done. Resident #10 had severe cognitive impairment and was receiving speech-language pathology and physical therapy treatments at the time of the deficiency.
Failure to Complete Baseline Care Plan for Resident
Penalty
Summary
The facility failed to complete a baseline care plan for one of the two residents reviewed, specifically for a resident who was admitted following a left knee replacement. The Electronic Health Record (EHR) documented the resident's admission and discharge dates, but lacked a completed baseline care plan. The facility's policy, revised in December 2016, requires a baseline care plan to be developed within 48 hours of admission to address the resident's immediate needs. However, the Director of Nursing stated that the baseline care plan should be completed within 72 hours of admission, indicating a discrepancy between the policy and practice. The Administrator confirmed that the baseline care plan for the resident was not completed, highlighting a failure to adhere to the facility's policy and meet the resident's immediate care needs within the required timeframe.
Failure to Conduct Background Check for Staff Member
Penalty
Summary
The facility failed to conduct a criminal background check for one of the five staff members reviewed, specifically a Certified Medication Aide (CMA) referred to as Staff A. Staff A was offered conditional employment on December 5, 2022, but a review of her file on November 13, 2024, revealed the absence of a background check. The Business Office Manager (BOM), Staff B, confirmed that the facility did not have a criminal background check for Staff A and had attempted to contact the Human Resources personnel responsible for conducting these checks, but they were unavailable. The BOM had recently assumed responsibility for conducting background checks on the same day of the review. The facility's policy, revised on May 20, 2024, mandates that every employee must successfully complete a background check before being granted regular employment, which was not adhered to in this case.
Failure to Provide Scheduled Baths/Showers
Penalty
Summary
The facility failed to ensure that residents received the required number of baths or showers per week, as evidenced by the cases of two residents. Resident #6, who has intact cognition and a diagnosis of multiple sclerosis, was not consistently receiving showers as scheduled. The care plan for Resident #6, revised in May 2022, indicated a need for assistance with bathing due to limited mobility. However, the electronic health record (EHR) lacked documentation of showers or baths being offered or provided on specific dates in October 2024. The facility's policy required documentation of any refusals and notification to supervisors if a shower was not given as scheduled, but this was not adhered to. Similarly, Resident #4, who required assistance with bathing, also had missing documentation for showers on several dates in October and November 2024. The Assistant Director of Nursing (ADON) acknowledged the inconsistency in documentation and was unable to provide further information regarding the missing records. The ADON mentioned that documentation was supposed to be on daily sheets, but these were not found, and it was unclear if they had been shredded. The Director of Nursing (DON) confirmed the expectation that residents receive their showers on scheduled days and that any deviations should be reported to nursing leadership.
Failure to Complete Physician-Ordered PICC Line Dressing Changes
Penalty
Summary
The facility failed to ensure the completion of physician-ordered treatments for a resident with multiple sclerosis (MS), who had intact cognition and required assistance with bathing. The resident reported that the dressing for her peripherally inserted central catheter (PICC) line was not consistently changed as ordered by the physician. The care plan for the resident, initiated in September 2021, directed staff to change the PICC line dressing using sterile technique weekly and to contact the provider if signs or symptoms of PICC line complications were noticed. However, a review of the treatment administration record for October 2024 showed a lack of documentation for the dressing change on two specific dates, with no rationale provided for the omission. The facility did not have a policy ensuring that physician orders are followed, and the Assistant Director of Nursing stated that staff should document if a treatment was not completed as ordered and provide a reason for the omission.
Failure to Conduct Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to conduct pre and post dialysis assessments for a resident with End Stage Renal Disease (ESRD) who required hemodialysis. The resident, who had moderate cognitive impairment, was admitted to the facility and had a care plan directing immediate intervention for any complications from dialysis. However, during an electronic record review, it was discovered that these assessments were missing from the resident's health record. The facility's Administrator and Assistant Director of Nursing (ADON) were unable to locate the assessments, and the ADON acknowledged that the assessments should have been completed. The ADON later provided three incomplete Dialysis Communication assessments and admitted that many more assessments were missing. The facility's policy on dialysis communication and shunt care was highlighted and annotated, indicating it was intended as a guide for nurses. Despite this, the necessary documentation was not completed, leading to a deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Elevate Head During Tube Feeding Leads to Aspiration
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a gastronomy tube, leading to a serious health incident. The resident, who had a history of pneumonia, dysphasia, and other medical conditions, required his head of bed to be elevated during and after tube feedings to prevent aspiration. However, during a feeding, the nurse administered the feeding with the resident's head of bed lowered, and when the resident began to vomit, the nurse did not elevate the bed as required. This failure to follow proper procedure resulted in the resident developing aspiration pneumonia and septic shock. The resident's care plan clearly indicated the need for the head of bed to be elevated to 45 degrees during and after feedings, yet this was not adhered to. Staff interviews revealed that the resident was often left in a supine position, contrary to the care plan. On the day of the incident, the resident was found unresponsive with tube feeding formula draining from his nose, and his oxygen saturation was critically low. Despite these alarming signs, the nurse failed to perform a thorough assessment or take immediate corrective action. The situation was further exacerbated by the lack of communication and proper response from the nursing staff. The nurse involved did not recall the events accurately and failed to inform other staff members of the resident's true condition. The resident was eventually transferred to a hospital, where he was diagnosed with aspiration pneumonia and septic shock, conditions that were preventable had the proper care procedures been followed.
Failure to Follow Care Plan for Tube Feeding
Penalty
Summary
The facility failed to follow the care plan for a resident who required a feeding tube due to a swallowing problem. The care plan specified that the resident was dependent on staff for tube feedings and water flushes, and required monitoring for aspiration, shortness of breath, abnormal breath/lung sounds, and nausea and vomiting. Additionally, the care plan directed that the head of the bed (HOB) should be elevated 45 degrees during and thirty minutes after a tube feeding. However, during an incident, the resident was found with the HOB at approximately 15 degrees after vomiting, which was not in accordance with the care plan. Staff interviews revealed that a CNA and an RN found the resident lethargic and responsive after vomiting, with the HOB improperly positioned. Later, an LPN observed the resident in a supine position with tube feeding formula draining from his nose and found him non-responsive. The facility called EMS, who found the resident unresponsive with a high temperature and transported him to the hospital. The EMS crew noted that this was not the first time they found the resident in a supine position, indicating a recurring issue with following the care plan for this resident.
Failure to Conduct Thorough Assessments Following Condition Changes
Penalty
Summary
The facility failed to complete thorough assessments and interventions for two residents following a change in their conditions. For one resident, the progress notes indicated a catheter change due to discomfort, with blood noted in the catheter drainage bag. However, there were no assessments documented between the catheter change and the subsequent observation of blood, nor were there additional assessments after the blood was noted until the resident was discharged to the hospital. The resident was later found unresponsive with a high fever and was transferred to the emergency department, where he was diagnosed with septic shock and aspiration pneumonia. The hospital records indicated a blocked catheter and significant medical interventions were required, including intubation and administration of antibiotics. Another resident's assessment noted a non-productive cough and wheezing, but the facility's documentation guidelines for such symptoms were not followed. The guidelines required detailed documentation of vitals, symptom descriptions, and notifications, which were not present in the records. This lack of thorough assessment and documentation for both residents following changes in their conditions represents a deficiency in the facility's care practices.
Failure to Ensure Staff Completed Dependent Adult Abuse Training
Penalty
Summary
The facility failed to ensure that two of six staff members met the requirements for Dependent Adult Abuse Training. Specifically, Staff A, a Certified Medication Aide (CMA), had completed the required training on 1/9/19, which was valid for five years, but had not completed any further training since then. Staff B, a Certified Nursing Assistant (CNA) who started on 3/16/23, had no documentation of having completed the required Dependent Adult Abuse Training. The facility's policy, revised in April 2023, mandates that each employee complete two hours of training on the identification and reporting of dependent adult abuse within six months of initial employment and an additional two hours every three years. The Administrator acknowledged that both staff members were completing the training but confirmed it was overdue.
Failure to Maintain Sanitary Conditions During Meal Service
Penalty
Summary
The facility failed to serve food under sanitary conditions, increasing the risk of contamination and foodborne illness. During an observation, Staff D, a cook, was seen washing her hands and applying gloves before starting the supper service. However, Staff D did not change her gloves throughout the process of serving meals to 15 residents. She touched various surfaces, including containers, menus, plates, bowls, utensils, and food, without changing gloves or performing hand hygiene. Additionally, Staff E, a dietary aide, was observed adjusting his ballcap and then handling glasses and drinks without performing hand hygiene. Staff E delivered drinks to 12 residents by carrying the glasses by the rim, further compromising sanitary conditions. Staff D continued to use the same gloves to open the refrigerator and handle food items, including chicken salad sandwiches and cookies, without changing gloves or performing hand hygiene between tasks. The facility's sanitation policy, revised in June 2015, directed staff to change gloves with each new task but lacked specific instructions on hand hygiene between glove changes and between surfaces. The Dietary Manager confirmed that staff were expected to use utensils when serving food and not to use gloves when handling food during serving.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure staff treated residents with dignity and respect, as evidenced by an incident involving a resident with intact cognition and multiple diagnoses, including hypertension, diabetes, schizoaffective disorder, borderline personality disorder, anxiety, and traumatic brain injury. During an interview, a CNA reported that another CNA told the resident she 'smelled like piss' while assisting with a change, causing the resident to cry. The resident confirmed that this comment was made almost every time she was changed. The Director of Nursing stated that all staff are expected to treat residents with dignity and respect. The facility's policy on Residents Rights and Responsibilities lacked documentation of residents being treated in a dignified manner by staff.
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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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