Panora Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Panora, Iowa.
- Location
- 805 East Main, Panora, Iowa 50216
- CMS Provider Number
- 165253
- Inspections on file
- 21
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Panora Specialty Care during CMS and state inspections, most recent first.
The facility did not update or revise care plans for three residents to include specific recommendations from PASRR Level II assessments, despite these residents having significant mental health diagnoses and documented needs for specialized services such as psychiatric medication management, therapy, and community placement supports. Instead, care plans contained only general statements about following PASRR recommendations, and staff interviews confirmed a lack of understanding and incomplete integration of these requirements.
The facility did not identify or document individualized target behaviors and side effects for psychotropic medications in care plans or EMARs for multiple residents with psychiatric diagnoses. Staff interviews revealed a lack of awareness about where to find or how to document this information, and records often contained only general orders rather than specific, updated details as required by facility policy.
The facility failed to maintain adequate staffing levels, resulting in prolonged call light response times. Observations showed that call lights were often addressed by a single CNA, with some remaining unanswered for over an hour. Resident interviews confirmed delays, with some experiencing discomfort due to long waits. The facility's staffing was particularly low on weekends, as indicated by a one-star staffing rating and several instances of insufficient CNA coverage.
The facility failed to follow infection control protocols during peri-care and catheter care, as well as during mealtime assistance. A CNA did not use a barrier when emptying a catheter, failed to change gloves or sanitize hands after handling contaminated items, and did not remove PPE before exiting an EBP room. Additionally, the CNA did not perform hand hygiene between assisting different residents during meals, contrary to the facility's policies.
A resident with Parkinson's, diabetes, and dementia was transferred without a gait belt by a CNA, contrary to facility policy. The resident was moved without gripper socks or shoes, and the call light was left out of reach, compromising safety. The DON confirmed the expectation of gait belt use for safety, highlighting a deficiency in transfer practices.
The facility failed to maintain a clean and homelike environment, with observations of unclean bathrooms, damaged walls and ceilings, and stained privacy curtains. Interviews revealed that the bathroom in a resident's room was not cleaned regularly, and the toilet bar had been rusted for about two months. The Administrator acknowledged the issues and mentioned that a contractor was scheduled to fix the damages.
Staff failed to prepare and serve food under sanitary conditions, with a cook and kitchen aide violating glove use and food handling policies. The cook's apron touched serving utensils, and the kitchen aide's shirt touched a piece of cake, both of which were then served to residents.
An RN failed to follow proper infection control practices during a blood glucose reading, including not changing gloves or sanitizing hands between steps, and placing used gloves directly on a resident's bedside table. Both the RN and the DON acknowledged these actions as infection control concerns.
Failure to Incorporate PASRR Level II Recommendations into Resident Care Plans
Penalty
Summary
The facility failed to review and revise the care plans for three out of four residents reviewed, specifically neglecting to incorporate recommendations from the PASRR Level II assessments. Clinical record reviews revealed that for each of these residents, the care plans did not include the specific specialized services and supports recommended by the PASRR Level II, despite the presence of significant mental health diagnoses such as schizophrenia, depression, anxiety, PTSD, and other related conditions. The care plans instead contained general statements about following PASRR recommendations without detailing the individualized interventions required for each resident. For one resident with severe cognitive impairment and multiple mental health diagnoses, the PASRR Level II recommended ongoing psychiatric medication management, individual therapy, rehabilitative services, and community placement supports. However, the care plan only referenced following PASRR recommendations and failed to specify these services. Another resident with normal cognitive function and a history of schizoaffective disorder, depression, and anxiety also had a care plan lacking the detailed interventions outlined in the PASRR Level II, such as psychiatric medication management, rehabilitative services, and community placement supports. The care plan included incomplete interventions and did not address the resident's specific needs as identified in the PASRR. A third resident with normal cognitive function and multiple psychiatric diagnoses similarly had a care plan that did not reflect the individualized recommendations from the PASRR Level II, including psychiatric medication management, individual therapy, and community placement supports. Staff interviews confirmed that the PASRR Level II recommendations were not fully integrated into the care plans, with staff expressing uncertainty about the requirements and acknowledging that the care plans were incomplete. Facility policies required that care plans be comprehensive, person-centered, and revised as resident conditions changed, and that PASRR Level II findings be incorporated, but these standards were not met for the residents reviewed.
Failure to Document Target Behaviors and Side Effects for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not identifying and documenting target behaviors and/or side effects of psychotropic medications for four residents. Clinical record reviews revealed that care plans and electronic medication administration records (EMARs) did not specify the target behaviors for which antianxiety, antidepressant, and antipsychotic medications were prescribed, nor did they consistently document the side effects to be monitored. This deficiency was observed in residents with a range of cognitive abilities and psychiatric diagnoses, including severe cognitive impairment, anxiety, depression, schizophrenia, PTSD, and other mental health conditions. The care plans and EMARs lacked individualized information, often containing only general orders from admission without subsequent updates to reflect specific behaviors or side effects related to each medication. Staff interviews indicated a lack of awareness and understanding among certified nursing assistants (CNAs) and medication aides regarding where to find information about target behaviors and medication side effects. Several staff members reported relying on word of mouth or general knowledge of residents’ usual behavior rather than documented, individualized information. Some staff stated that behaviors would be documented if observed, but there was no clear process for linking specific behaviors or side effects to particular medications in the care plans or EMARs. The care plan coordinator and DON acknowledged that while behaviors were being added to care plans, they were not specifically related to medications, and that the process of updating records to include individualized information was incomplete. The facility’s own policy required the identification and documentation of behavioral symptoms, individualized interventions, and monitoring for medication efficacy and adverse effects. However, the policy was not followed, as evidenced by the lack of detailed documentation in both care plans and EMARs for residents receiving psychotropic medications. This failure to document and monitor target behaviors and side effects as required contributed to the deficiency identified during the survey.
Inadequate Staffing Leads to Prolonged Call Light Response Times
Penalty
Summary
The facility failed to ensure sufficient nursing staff was present during scheduled shifts, leading to prolonged response times to call lights. Observations on the 100 and 300 nursing halls revealed that call lights were primarily addressed by one CNA, with assistance from a CNA from another hallway and a Restorative Aide. During a specific observation period, one call light remained unanswered for over an hour. Interviews with residents indicated that call light response times could range from 30 to 60 minutes, with some residents experiencing discomfort due to prolonged waits. The Director of Nursing acknowledged that meal times posed challenges in maintaining timely responses. The facility's staffing levels were found to be inadequate, particularly on weekends, as evidenced by the Payroll Based Journal report and staffing schedules. The facility had a one-star staffing rating for the fiscal year quarter 4 of 2024, with several instances of low CNA coverage on weekends. The Director of Nursing admitted to low weekend staffing and even personally covered a shift due to insufficient staff, which was not reported to the PBJ. The facility's assessment report indicated that staffing needs were evaluated and adjusted as needed, but the observed deficiencies suggest these measures were not effectively implemented.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during the provision of peri-care and catheter care for residents. Specifically, a Certified Nursing Assistant (CNA) did not use a barrier when emptying a catheter and failed to change gloves or sanitize hands after handling contaminated items. The CNA also did not remove personal protective equipment (PPE) before exiting an Enhanced Barrier Precautions (EBP) room, contrary to the facility's policy. These actions were observed during care for a resident with a multidrug-resistant organism (MDRO) and other serious health conditions, including a pressure ulcer and osteomyelitis. In another instance, the same CNA did not change gloves or perform hand hygiene while providing perineal care to a resident with incontinence. The CNA continued to wear the same gloves while handling clean items and dressing the resident, failing to follow the facility's hand hygiene policy. This oversight occurred despite the resident's care plan requiring assistance with activities of daily living and perineal cleansing. Additionally, during mealtime assistance, the CNA did not perform hand hygiene between assisting different residents, even after handling food and utensils. This lack of hand hygiene was observed while the CNA assisted three residents with their meals, which is against the facility's hand hygiene policy that emphasizes the importance of hand hygiene in preventing the spread of infections.
Failure to Ensure Safe Transfer Practices
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as Resident #39, who had diagnoses of Parkinson's Disease, diabetes, and dementia, and required partial to moderate assistance for transfers. The resident's care plan indicated a need for assistance with activities of daily living and highlighted poor safety awareness due to cognitive impairment. On one occasion, a CNA was observed transferring the resident without using a gait belt, which is contrary to the facility's policy. The CNA moved the resident's feet over the edge of the bed, pulled on the resident's arm, and assisted the resident to stand and transfer to a wheelchair without the use of a gait belt. Additionally, the resident was transferred without wearing gripper socks or shoes, and the call light was left out of reach, further compromising the resident's safety. The Director of Nursing confirmed that the use of a gait belt is expected for safety during transfers, even if not explicitly mentioned in the care plan. The facility's policy on assisting a resident, revised in 2018, outlines the necessary steps for safe transfers, including the use of a gait belt and ensuring the call light is within reach. The failure to adhere to these procedures resulted in a deficiency, as the resident was found on the floor with injuries on a previous occasion, indicating a pattern of inadequate supervision and unsafe transfer practices.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by multiple observations of unclean and damaged areas. On 4/9/24, the bathroom in room [ROOM NUMBER] was found with fecal matter on the toilet rim, inside the bowl, on the wall, and on the floor. Rust was observed around the toilet rim and on the bar attached under the toilet seat. Additionally, wallpaper was peeling, and plaster was coming off the wall by the shower room in the 100 hallway. The dining room ceiling had water damage and was covered by a piece of plastic. On 4/10/24, a resident was seen coming out of the shower room with a staff member, and the door jamb was splintered and broken. Room [ROOM NUMBER] had a section of the ceiling covered with black plastic and blue tape, and the privacy curtain next to a resident's bed was stained with formula from tube feeding. Interviews with residents and staff revealed that the bathroom in room [ROOM NUMBER] was not cleaned regularly, and the toilet bar had been rusted for about two months despite a request for replacement. The Administrator acknowledged the issues, stating that a contractor was scheduled to fix the ceiling and wall damage on April 15th. The Administrator also mentioned that the facility had received a grievance in February regarding the cleanliness of room [ROOM NUMBER] and had added the room to the daily cleaning list. However, the Administrator was unsure about the exact timing of some of the damages and the reasons behind them. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the unclean and damaged areas observed. The Administrator admitted that the rusted toilet handle and the stained privacy curtain were not homelike. The facility had a slow leak in the dining room ceiling, which led to water damage, and a staff member had kicked the shower room door, causing it to splinter. The facility's failure to maintain a clean and homelike environment was evident through these observations and interviews.
Sanitary Food Preparation and Service Deficiency
Penalty
Summary
Staff failed to prepare and serve food under sanitary conditions, increasing the risk of contamination and foodborne illness. During a lunch service, a cook placed serving utensils on the counter attached to the front of the steam table and repeatedly leaned over, causing her apron to touch the utensils. The cook also used the same gloves to open the refrigerator, touch a slice of cheese, and handle buns, violating the facility's policy on glove use. Additionally, a kitchen aide scooped a piece of cake onto a plate and leaned across to scoop another piece, causing her shirt to touch the first piece of cake. Both pieces of cake were then served to residents. The facility's policy on food preparation and service, revised in April 2019, requires gloves to be worn when handling food directly and changed between tasks. The Dietary Manager confirmed that gloves should be single-use and not touch other items when handling food. The 2013 Food Code, considered a standard of practice for the food service industry, also mandates single-use gloves for one task only and prohibits bare hand contact with ready-to-eat food. These observations and policy violations were confirmed through staff interviews and policy reviews.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to perform appropriate infection prevention and control practices during medication administration, specifically during the process of obtaining a blood glucose reading for a resident. An RN, identified as Staff C, did not change gloves or sanitize hands between steps of the procedure. Staff C placed gloves directly on the resident's bedside table, not on the wax barrier, and reused the same gloves after handling the medication cart without sanitizing hands. This occurred multiple times during the observation, leading to potential contamination and infection control concerns. During interviews, Staff C acknowledged the failure to change gloves and sanitize hands as required by the facility's infection control policy. The Director of Nursing also recognized these actions as infection control concerns. The facility's Handwashing/Hand Hygiene policy, revised in August 2019, states that glove use does not replace hand hygiene and that integrating glove use with routine hand hygiene is best practice for preventing healthcare-associated infections.
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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