Oskaloosa Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oskaloosa, Iowa.
- Location
- 605 Highway 432, Oskaloosa, Iowa 52577
- CMS Provider Number
- 165589
- Inspections on file
- 25
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Oskaloosa Care Center during CMS and state inspections, most recent first.
A resident with clear documentation as Full Code did not receive CPR when found unresponsive due to staff misreading chart information, confusion over code status indicators, and unfamiliarity with emergency procedures. Staff failed to initiate resuscitation or promptly call 911, and the resident was incorrectly identified as DNR, resulting in no life-saving measures being taken.
A resident with a history of cardiac issues repeatedly complained of chest pain and showed signs of lethargy and decreased responsiveness throughout the day. Despite multiple reports from CNAs, the assigned LPN delayed assessment, did not notify the provider, and failed to document timely interventions. The resident's condition worsened until the evening LPN intervened and sent the resident to the hospital, where a myocardial infarction was diagnosed.
The facility did not provide or document required training in QAPI, compliance and ethics, and infection control for new hires, and failed to ensure annual training for existing staff. Training records were incomplete, and the DON confirmed missing documentation for staff education.
The facility did not ensure that all staff, including new and existing LPNs and CNAs, completed required training on the Quality Assurance and Performance Improvement (QAPI) program. Review of personnel files and training records showed no documentation of QAPI training, and the DON confirmed the lack of such education in staff files.
The facility did not have documentation showing that an LPN and three CNAs completed required infection control training after being hired. Review of personnel files and the in-service attendance calendar showed no evidence of completed training for these staff members, despite the facility's policy that all new hires should receive such training. The DON confirmed that the necessary documentation was missing.
The facility did not have documentation showing that several staff members, including new and existing LPNs and CNAs, completed required compliance and ethics training. Review of personnel files and the in-service attendance calendar revealed that this training was not recorded, and the DON confirmed the lack of evidence for staff education in this area.
Surveyors found that open food items were not consistently dated, covered, or labeled, and food was stored in a manner that could lead to cross-contamination, such as thawing meat above eggs. Additionally, required documentation of dishwasher temperature and sanitizer checks was missing for numerous days, despite facility policies mandating these practices.
A resident without a diagnosis of anxiety or mood disorder received PRN Lorazepam almost daily for several months, exceeding the 14-day limit for PRN psychotropic use. The facility did not respond to pharmacy recommendations to review and discontinue the medication, and failed to ensure a physician's evaluation or appropriate diagnosis, as acknowledged by the DON and Administrator.
A resident receiving daily PRN Lorazepam for anxiety did not have a care plan that addressed the use of anti-anxiety medication, behavior monitoring, or side effect monitoring. Staff and administration confirmed the omission, which was inconsistent with facility policy requiring care plan updates for clinical changes.
A nurse left a cup containing nine oral medications with a resident at a dining table, unsupervised, despite facility policy requiring staff to remain with the resident until all medications are taken. The resident was only approved for unsupervised self-administration of a muscle rub, not oral medications. Interviews confirmed the resident relied on staff for medication administration, and the administrator acknowledged that medications should not be left unattended.
Staff failed to consistently use gloves and perform hand hygiene during perineal care for three incontinent, fully dependent residents. CNAs were observed making direct skin contact with residents' perineal areas after removing gloves or using soiled gloves to touch environmental surfaces, and hand hygiene was not performed as required. Interviews confirmed that glove use is expected throughout perineal care, but the facility could not provide a relevant policy during the survey.
A resident with a severely impaired cognitive status and a history of aggression was involved in multiple altercations with other residents, including grabbing, hitting, and slapping. Despite these incidents, the facility did not adapt the resident's Plan of Care to prevent reoccurrences, as required by care plan instructions. Staff interventions were limited to separating the residents after incidents occurred, and no injuries were noted. Interviews with staff revealed a lack of effective intervention strategies to manage the resident's aggression.
A resident with severe cognitive impairment was subjected to excessive force during a urine sample collection in an LTC facility. Despite exhibiting unusual behavior, the resident's condition was not adequately assessed by the charge nurse. Later, while the assigned nurse was on break, the MDS Coordinator and aides restrained the resident to obtain a urine sample without a physician's order, resulting in distress and bruising. Concerns were raised about the force used and potential re-traumatization, with allegations of documentation being altered.
A LTC facility failed to meet professional standards by falsifying and removing clinical records for two residents. One resident was restrained for a urine sample without a physician's order, leading to bruising, and the documentation was removed. Another resident was pulled from a chair by another resident, resulting in a fall and bruising, but the incident was inaccurately documented as a fall. These actions compromised resident safety and violated regulatory requirements.
The facility failed to adhere to professional standards by falsifying and removing clinical records for two residents. One resident was restrained for a urine sample without a physician's order, resulting in bruising, and the documentation was removed. Another resident was pulled from a chair by another resident, but the incident was inaccurately documented as a fall. The DON denied recollection of the first incident and allegedly instructed staff to misreport the second to avoid police involvement.
A resident with severe cognitive impairment exhibited unusual behavior, including leg shaking and distress. A CNA reported these concerns to an LPN, who dismissed them as normal and did not assess the resident. No assessments were recorded in the clinical records for that day.
The facility inaccurately completed MDS assessments for 77 residents, coding them as having physical restraints due to a misunderstanding by the MDS coordinator. The coordinator believed bed rails on facility beds required coding for physical restraints, despite no residents being physically restrained or having physician orders for such. The facility lacked a policy for MDS coding.
The facility failed to provide adequate staffing in the CCDI unit, leaving only one CNA to supervise residents with severe cognitive impairments during critical times. This led to unsafe situations where residents attempted to ambulate without assistance. Additionally, call light response times were significantly delayed, indicating systemic staffing issues.
A facility failed to conduct a Level 2 PASARR for a resident with severe cognitive impairment and new mental health diagnoses, including anxiety and delusional disorder. Despite the initiation of new psychotropic medications, the facility did not follow its policy to contact the State-designated agency for a Level 2 screen. Staff A confirmed the oversight, citing a lack of a formal process for updating diagnoses or medications.
A resident with arthritis and impaired cognition did not receive recommended restorative exercises, leading to a decline in mobility and increased dependence on staff. Despite therapy recommendations for a restorative nursing program (RNP) to maintain and improve range of motion, strength, and endurance, the resident's participation was inconsistent, as documented in the electronic health record. Staff interviews confirmed the resident's decline and lack of consistent follow-through with the restorative program.
Failure to Provide CPR Due to Code Status Confusion and Staff Errors
Penalty
Summary
Facility staff failed to provide cardiopulmonary resuscitation (CPR) to a resident who was documented as a Full Code in multiple locations, including the care plan, physician orders, Medication Administration Record (MAR), and Electronic Health Record (EHR). Despite clear documentation of the resident's wishes and physician orders to initiate CPR in the event of cardiac arrest, staff did not carry out resuscitative efforts when the resident was found unresponsive. The failure was due to discrepancies in code status indicators, such as incorrect or missing stickers on the resident's door following a room change, and staff misreading the resident's chart. On the day of the incident, several staff members responded to the resident, who was found slumped in a recliner, diaphoretic, unresponsive, and later displaying agonal respirations. Staff were directed to call 911, verify code status, and obtain the crash cart. However, there was confusion and delay in verifying the resident's code status, with staff incorrectly identifying the resident as a Do Not Resuscitate (DNR) based on misinterpretation of chart information and door stickers. During this period, staff did not initiate CPR, and the resident was pronounced deceased. The ARNP was informed of the death and, based on the incorrect report of DNR status, gave an order to release the body. Multiple staff interviews revealed that the confusion was compounded by staff unfamiliarity with the location of the crash cart and failure to promptly call 911. Staff later discovered, upon further review of the resident's records, that the resident was in fact a Full Code. The deficiency was attributed to miscommunication, lack of familiarity with emergency procedures, and errors in identifying the correct code status, resulting in the failure to provide basic life support as required by the resident's wishes and physician orders.
Failure to Timely Assess and Intervene After Resident Chest Pain Complaint
Penalty
Summary
A deficiency occurred when staff failed to provide timely assessment and intervention after a resident with a significant cardiac history complained of chest pain. The resident had diagnoses including hypertension, nonrheumatic aortic stenosis, and a history of cerebrovascular accidents, and was care planned for altered cardiovascular status. The care plan directed staff to assess for chest pain with every interaction and to notify the provider in the event of a change in condition. On the day in question, the resident exhibited symptoms such as chest pain, lethargy, decreased appetite, and was not acting like herself, as reported by multiple CNAs to the assigned LPN. Despite repeated reports from CNAs that the resident was experiencing chest pain, appeared pale, lethargic, and was not her usual self, the LPN did not perform timely or thorough assessments, delayed taking vital signs until later in the day, and did not notify the provider of the resident's change in condition. The LPN administered an inhaler and acetaminophen but did not document provider notification or further assessment between early afternoon and the evening. The resident's condition deteriorated throughout the day, with staff noting she was difficult to arouse and had not eaten, drunk, or voided. When the evening LPN came on shift and was informed of the resident's status, she immediately assessed the resident, found her unresponsive to verbal stimuli, and called for emergency services. The resident was subsequently hospitalized for a myocardial infarction, as confirmed by elevated troponin levels and hospital records. Interviews with staff and review of facility policy confirmed that the required assessments and provider notifications were not completed in a timely manner, leading to a delay in appropriate care for the resident.
Failure to Implement and Document Required Staff Training
Penalty
Summary
The facility failed to implement and document an effective training program for both new and existing staff members. Personnel file reviews and the in-service attendance calendar revealed that newly hired staff, including an LPN and several CNAs, did not have documentation of completed training in Quality Assurance and Performance Improvement (QAPI), compliance and ethics, and infection control upon hire. Additionally, existing staff members lacked documentation of annual training in QAPI and compliance and ethics. The facility's training records only showed infection control as a topic, omitting QAPI and compliance and ethics. During staff interviews, the Director of Nursing confirmed the absence of additional education documentation in staff files and acknowledged the need to build the training program.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that all staff, including both new hires and existing personnel, completed mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. Personnel file reviews and the in-service attendance calendar revealed that six staff members, including LPNs and CNAs, did not have documentation of QAPI training upon hire or annually. The facility's training records did not list QAPI as a training topic, and an undated internal document indicated that training was required for all departments but lacked evidence of compliance. During staff interviews, the Director of Nursing confirmed the absence of additional QAPI education in staff files.
Failure to Document Infection Control Training for New Hires
Penalty
Summary
The facility failed to ensure that newly hired staff members completed mandatory infection control training as part of its infection prevention and control program. Personnel file reviews and the in-service attendance calendar revealed that four staff members, including an LPN and three CNAs, did not have documentation of having completed infection control training after their hire dates. An undated facility document indicated that the training program was intended for all departments, including new hires and existing staff, and the in-service calendar listed infection control as a training topic. However, there was no evidence in the staff files to confirm that these new hires had participated in the required training. The Director of Nursing confirmed the absence of additional education documentation in the staff files.
Failure to Ensure Staff Completion of Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that staff completed required training in compliance and ethics, as evidenced by a lack of documentation for both new hires and existing staff. Personnel file reviews and the in-service attendance calendar showed that six staff members, including LPNs and CNAs, did not have records of completing compliance and ethics training upon hire or annually. The in-service attendance calendar did not list compliance and ethics as a training topic, and an undated facility document indicated that training was intended for all departments but did not provide evidence of completion. During an interview, the DON confirmed the absence of additional education in the staff files.
Deficient Food Storage, Labeling, and Dishwashing Documentation
Penalty
Summary
Surveyors observed multiple deficiencies in food storage and sanitation practices within the facility's dietary department. Open food items, including graham cracker crumbs, powdered sugar, and quick rise soft roll mix, were found undated and uncovered. Additionally, a bag of muffin mix was found with an open date several months prior. During inspection of the refrigerator, a full pan of frozen shredded pork was observed thawing on a shelf above eggs, contrary to facility policy and professional standards for preventing cross-contamination. The Dietary Manager confirmed these practices did not meet expectations for food storage and dating. A review of the facility's dishwasher temperature and sanitization chemical strip test log revealed significant gaps in documentation, with numerous days over a three-month period lacking records of required twice-daily checks. Although an observed test of the dishwasher showed appropriate temperatures and chemical levels, the lack of consistent monitoring and documentation was acknowledged by both the Dietary Manager and the Administrator. Facility policies reviewed required proper thawing of meats, dating and labeling of opened foods, and daily monitoring of dish machine sanitization, all of which were not consistently followed.
Failure to Limit PRN Psychotropic Use and Ensure Appropriate Diagnosis
Penalty
Summary
The facility failed to limit the use of a PRN psychotropic medication, specifically Lorazepam, to the required 14-day period and did not ensure that the resident receiving the medication had an appropriate diagnosis. Clinical record review showed that the resident had intact cognition, no diagnosis of anxiety or other mood disorders, and no behavioral or depressive symptoms, yet received Lorazepam regularly over several months. The medication was administered almost daily, far exceeding the 14-day limit for PRN psychotropic use without documented physician rationale for extension. Additionally, the facility did not respond to repeated recommendations from the consulting pharmacist to review and address the ongoing PRN Lorazepam order in accordance with the 14-day rule. The electronic health record lacked documentation of a physician's evaluation or justification for continued use, and the facility's Medication Regimen Review policy, which requires forwarding pharmacist findings to the physician, was not followed. Both the DON and the Administrator acknowledged the absence of an appropriate diagnosis and the failure to act on pharmacy recommendations.
Failure to Include Anti-Anxiety Medication Management in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed an anti-anxiety medication. The resident, who had intact cognition and multiple medical diagnoses including debility, cardiorespiratory conditions, heart failure, asthma, and respiratory failure, was receiving Lorazepam as needed for anxiety. Despite the ongoing administration of this medication daily since March, the resident's care plan did not include a focus area, goal, or interventions related to the use of anti-anxiety medication, behavior monitoring, or monitoring for possible side effects. This deficiency was identified through clinical record review, staff interviews, and policy review. Both the ADON and the Administrator acknowledged that the care plan was missing required elements related to the resident's anti-anxiety medication. The facility's Clinical Care Management policy requires routine assessment, evaluation, and updating of care plans in response to changes in clinical condition, which was not followed in this case.
Medications Left Unattended During Administration
Penalty
Summary
A deficiency occurred when a nurse failed to follow professional standards during medication administration for a resident with progressive neurological conditions, Parkinson's disease, heart disease, and depression. The resident was assessed as cognitively intact and had a care plan allowing unsupervised self-administration of only a muscle rub, with interventions requiring assessment and documentation of the resident's ability to self-administer. However, during observation, a nurse placed nine oral medications in a cup and left them with the resident at a dining table, unsupervised, before leaving the area. Interviews revealed that the resident's responsible party was unaware of any order for self-administration of pills and stated the resident relied on staff for medication administration. Facility staff confirmed that only the muscle rub was approved for self-administration, and the administrator acknowledged that medications should not be left unattended due to the risk of access by other residents. Facility policy required staff to remain with the resident until all medications were taken, which was not followed in this instance.
Failure to Maintain Hygienic Perineal Care Practices
Penalty
Summary
Surveyors observed that staff failed to perform perineal care in a hygienic manner for three residents who were incontinent and fully dependent on staff for toileting and hygiene. In each case, certified nurse aides (CNAs) either removed gloves and continued care with bare hands, made direct ungloved contact with residents' perineal areas, or used soiled gloves to touch environmental surfaces before continuing care. Specifically, staff were seen disposing of gloves and then making direct contact with residents' buttocks or perineal areas, and in one instance, a privacy curtain was adjusted with soiled gloves before care continued. Hand hygiene was not performed after glove removal and before further resident contact. Interviews with staff, including CNAs and an LPN, confirmed that facility expectations and checklists require glove use throughout the perineal care process. The Director of Nursing acknowledged that bare skin contact during perineal care was inappropriate. Despite requests, the facility was unable to provide a policy regarding perineal care during the survey. The residents involved were all documented as incontinent and fully dependent on staff for hygiene, as reflected in their care plans and Minimum Data Set (MDS) assessments.
Inadequate Supervision Leads to Repeated Resident Aggression Incidents
Penalty
Summary
The facility failed to ensure adequate supervision and prevention of accidents for residents with physical aggression tendencies, leading to multiple incidents involving Resident #3 and other residents. Resident #3, with a severely impaired cognitive status and a history of physical and verbal aggression, was involved in several altercations with other residents, including grabbing, hitting, and slapping. Despite these incidents, the facility did not adapt Resident #3's Plan of Care to prevent reoccurrences, as required by the care plan instructions to keep other residents at arm's length. The incidents involved Resident #3 interacting aggressively with Residents #2, #4, and #7, all of whom also had severely impaired cognitive statuses and required varying levels of assistance with daily activities. These interactions often resulted in physical altercations, such as Resident #3 grabbing Resident #2's arm, backhanding her, and pulling her out of a chair, as well as hitting Resident #4 and striking Resident #7 in the face. Staff interventions were limited to separating the residents after the incidents occurred, and no injuries were noted. However, the facility's failure to implement effective preventive measures and update care plans contributed to the repeated occurrences. Interviews with staff, including the Assistant Director of Nursing and Certified Nurse Aides, revealed a lack of effective intervention strategies to manage Resident #3's aggression. Staff acknowledged the need for increased supervision and potential medication adjustments but did not provide specific interventions to prevent future incidents. The facility's inaction in adapting care plans and implementing adequate supervision measures resulted in ongoing safety risks for residents, as evidenced by the repeated incidents involving Resident #3.
Excessive Force Used in Urine Sample Collection
Penalty
Summary
The facility failed to treat a resident with dignity when excessive force was used to restrain the resident to obtain a urine sample. The resident, who had a severely impaired cognitive status due to non-Alzheimer's dementia, required significant assistance with daily activities and was frequently incontinent. On the day of the incident, the resident exhibited unusual behavior, including leg shaking and signs of distress, which were reported by staff but not adequately addressed by the charge nurse. Later, the resident was taken to the shower room, where further symptoms were noted, and the primary care physician was notified. Despite the physician's instructions to monitor the resident, a urine sample was collected without an order while the assigned nurse was on break. The MDS Coordinator, along with several aides, restrained the resident to obtain the sample, during which the resident was described as erratic and noncompliant, but not combative. The procedure was reportedly distressing for the resident, who was struggling and yelling during the process. Following the incident, staff observed bruising on the resident's arms and legs, raising concerns about the force used during the procedure. The incident was reported to the nurse on the next shift, who documented the bruising and the events leading to it. However, there were allegations of documentation being altered or removed from the resident's record, and concerns were raised about the potential re-traumatization of the resident, who had a history of physical abuse.
Falsification and Removal of Clinical Records in LTC Facility
Penalty
Summary
The facility failed to meet professional standards and practices by falsifying documentation and removing clinical records for two residents. For the first resident, who had severe cognitive impairment and required significant assistance with daily activities, an incident occurred where staff obtained a urine sample without a physician's order. This involved restraining the resident, which led to bruising. A Licensed Practical Nurse (LPN) documented the event thoroughly, but her notes and related incident reports were removed from the resident's clinical record. The Director of Nursing (DON) denied any recollection of the event and claimed no records were removed, despite evidence provided by the LPN. In the second case, a resident with severe cognitive impairment was pulled from a chair by another resident, resulting in a fall and bruising. A Certified Nurse Aide (CNA) witnessed the incident and reported it to a Licensed Practical Nurse (LPN) and a Certified Med Aide (CMA). The LPN documented the incident as a fall, omitting the physical altercation, and later denied being instructed to alter the documentation. The DON was informed of the incident, but the report was inaccurately recorded, potentially to avoid police involvement. Both incidents highlight significant deficiencies in the facility's documentation practices and adherence to professional standards. The removal and alteration of records, as well as the failure to accurately report incidents, demonstrate a lack of integrity in maintaining accurate clinical records and ensuring resident safety. These actions compromise the quality of care and violate regulatory requirements for accurate resident assessments and documentation.
Falsification and Removal of Clinical Records in LTC Facility
Penalty
Summary
The facility failed to meet professional standards and practices by falsifying documentation and removing clinical records for two residents. For the first resident, who had a severely impaired cognitive status and required significant assistance with daily activities, a urine sample was obtained without a physician's order. This was done by restraining the resident to insert a catheter, which resulted in bruising. The Licensed Practical Nurse (LPN) on duty documented the incident thoroughly, but her notes and related reports were removed from the resident's clinical record. The Director of Nursing (DON) denied any recollection of the event and claimed there were no injuries, despite evidence provided by the LPN. In the second case, a resident with severe cognitive impairment was pulled from a chair by another resident, resulting in a fall and a bruise. A Certified Nurse Aide (CNA) witnessed the incident and reported it to other staff members. However, the incident was documented as a fall by a Licensed Practical Nurse (LPN), who later denied being instructed to alter the documentation. The DON was informed of the incident but allegedly instructed staff to document it as a fall to avoid police involvement. Both incidents highlight significant deficiencies in the facility's handling of resident care and documentation. The removal and alteration of records, as well as the failure to accurately report incidents, demonstrate a lack of adherence to professional standards and practices. These actions compromised the integrity of resident care and the facility's accountability in managing resident incidents.
Failure to Assess and Intervene for Resident's Unusual Behavior
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed and provided interventions to maintain their optimal health and well-being. The resident, who had a severely impaired cognitive status with a BIMS score of 0 and required moderate to maximal assistance for daily activities, exhibited unusual behavior, including shaking of the left leg and being very upset. A CNA reported these concerns to an LPN, who dismissed the behavior as normal and instructed the CNA to continue monitoring the resident. Despite repeated reports of concern, the LPN did not assess the resident during the shift, and there were no notes or assessments recorded in the clinical records for the date in question.
Inaccurate MDS Coding for Physical Restraints
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for 77 out of 83 residents, incorrectly coding them as having physical restraints. This error was identified during a facility record review and staff interview. The Resident Matrix document, dated 7/29/24, indicated that 77 residents were recorded as having physical restraints. However, during an interview, the MDS coordinator, Staff K, confirmed that no residents were physically restrained and there were no physician orders for such restraints. Staff K attributed the incorrect coding to her training, which instructed her to code MDS for physical restraints if any facility beds had bed rails. The facility was unable to provide a policy for MDS coding during the survey week.
Inadequate Staffing and Supervision in CCDI Unit
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, particularly in the Chronic Confusion or Dementing Illness Unit (CCDI). Observations revealed that only one Certified Nurses Aide (CNA) was present on the CCDI unit floor during critical times, such as meal services, when resident behaviors were unpredictable and required one-on-one supervision. Staff interviews confirmed that the CCDI unit was frequently understaffed, with CNAs being pulled to assist other units, leaving residents without adequate supervision. This lack of staffing led to situations where residents with severe cognitive impairments and mobility issues attempted to ambulate unsafely without necessary assistance. The report highlighted specific incidents involving residents with severe cognitive impairments who required close supervision and assistance for safe mobility. For instance, one resident with a BIMS score of 3, indicating severe cognitive impairment, attempted to stand and ambulate without her walker, while another resident with unspecified dementia and muscle weakness attempted to leave the dining table without her mobility aid. These incidents occurred while the sole CNA on duty was occupied with other residents, demonstrating the inadequacy of staffing to ensure resident safety and care. Additionally, the facility's call light response times were significantly delayed, with numerous instances of response times exceeding the facility's policy of 15 minutes. The longest recorded response time was over an hour, indicating a systemic issue with staff availability and responsiveness. Interviews with staff and family members further corroborated the concerns about insufficient staffing, with reports of delayed assistance and inadequate supervision contributing to potential safety risks for residents.
Failure to Conduct Level 2 PASARR for Resident with New Diagnoses
Penalty
Summary
The facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASARR) evaluation for a resident with new mental health diagnoses and medication revisions. The resident, identified as having severe cognitive impairment, was documented to have anxiety, depression, and a psychotic disorder. The resident was also on high-risk medications, including antipsychotics, antianxiety, and antidepressants. The last PASARR screening was completed in May 2023, which documented the resident's depression and use of Quetiapine and Sertraline. Despite new diagnoses of anxiety and delusional disorder and the initiation of Risperidone and Lorazepam, the facility did not conduct a Level 2 PASARR. The facility's policy requires contacting the appropriate State-designated agency for a Level 2 screen upon new diagnoses. However, Staff A from social services confirmed that a Level 2 PASARR was not completed, as they believed it was not indicated due to the absence of a status change. There was no formal process in place for updating medical diagnoses or medications.
Failure to Implement Restorative Program for Resident
Penalty
Summary
The facility failed to implement therapy recommendations and provide restorative exercises for a resident with arthritis, weakness, and a history of falling. The resident had moderately impaired cognition and impaired range of motion (ROM) in both upper extremities and one lower extremity. Despite therapy recommendations for a restorative nursing program (RNP) to maintain and improve ROM, strength, and endurance, the resident did not participate in the RNP during the specified periods, as documented in the Minimum Data Set (MDS) assessments. The care plan for the resident, which was revised in March 2024, required assistance with exercises to regain and maintain strength and maximize independence in activities of daily living (ADLs). The plan included a daily RNP with exercises such as active and passive ROM, gait training, and ambulation. However, the electronic health record (EHR) and progress notes revealed inconsistent documentation of the resident's participation in the RNP, with limited instances of group exercise and passive ROM exercises recorded. Observations and staff interviews confirmed the resident's decline in mobility and increased dependence on staff for transfers. Interviews with staff, including the restorative aide and physical therapist, highlighted a lack of consistent follow-through with the restorative program. The resident, who initially ambulated with assistance, experienced a significant decline, requiring a mechanical lift and assistance from two staff members for transfers. The facility's restorative nursing policy emphasized maintaining residents' highest practicable level of functioning, but the documentation and staff reports indicated a failure to adhere to the recommended restorative activities.
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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