Park View Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sac City, Iowa.
- Location
- 601 Park Avenue, Sac City, Iowa 50583
- CMS Provider Number
- 165343
- Inspections on file
- 17
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Park View Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively impaired resident with moderate impairment, documented as confused and forgetful, was assisted by the SSD in completing a Medicaid application that involved cashing out a final expense life insurance policy to reduce assets. The SSD communicated with the resident’s POA by email about the need to spend down assets and stated the resident was agreeable if the POA was as well, but the POA questioned the cash-out and reported telling the SSD to wait until she could contact the insurer. Despite this, a cash surrender form was completed with the resident’s signature and the SSD as witness, without documentation of the resident’s cognitive status at the time of signing and without clear documentation of POA consent. The POA later learned the policy had been cancelled and stated the resident did not want it cancelled and was not in a condition to make that decision.
A resident with moderate cognitive impairment and multiple medical conditions, including atrial fibrillation, cirrhosis, arthritis, and a history of repeated falls, was prescribed PRN Lorazepam for anxiety, initially ordered every 4 hours and later changed to every 2 hours PRN without a documented rationale or end date. The MAR showed the PRN Lorazepam was given 19 times in one month, with 11 doses documented as ineffective. The DON reported that the family did not want the resident on psych meds and that staff attempted non-pharmacological interventions first, but acknowledged there was no documented rationale or end date for continuing the PRN Lorazepam beyond 14 days, contrary to facility policy requiring physician documentation for extended PRN psychotropic use.
A resident with moderate cognitive impairment, multiple comorbidities, and a history of repeated falls was care planned as being at risk for falls, with an intervention to wear gripper socks in bed. The resident experienced multiple falls, including being found on the floor between the bed and wall and later on the floor by a dresser with a left arm skin tear, despite only having grippy socks as a relevant intervention at the time. Post-fall Neurological Evaluation Flow Sheets initiated after these events contained multiple missed and incomplete entries over the required 72-hour monitoring period, with several time points left blank or marked only as sleeping, contrary to the facility’s fall occurrence policy that required scheduled neuro checks with vital signs and documentation after each fall.
A resident with severe cognitive impairment and a history of stroke developed worsening pressure ulcers that were not managed according to professional standards. Despite ongoing communication with the PCP and wound center, there was confusion about wound clinic appointments, lack of timely follow-up, and insufficient escalation of care as the wounds deteriorated. The resident was ultimately hospitalized with sepsis and acute respiratory failure, with the wound identified as a likely source of infection. Staff interviews revealed gaps in wound care knowledge and communication.
A resident with cognitive impairment and a high fall risk suffered multiple falls resulting in bilateral elbow fractures and facial lacerations after the pressure alarm intended to alert staff failed to sound on two occasions. Staff did not determine why the alarm malfunctioned, and the resident had a known history of disabling or moving the alarm, but this was not effectively addressed, leading to inadequate supervision and preventable injuries.
A resident with severe cognitive impairment and a history of stroke experienced worsening pressure ulcers. Although the physician was notified of the deterioration, there was no documentation that the resident's representative was informed, as required by facility policy. A family member later reported not being notified about the change.
The facility failed to develop comprehensive care plans for several residents, omitting target behaviors related to psychotropic medication use and non-pharmacological interventions. One resident with moderate cognitive impairment and others with normal cognition had care plans that did not address their specific needs, despite documented behaviors and medication use. The facility acknowledged these deficiencies and was in the process of updating care plans.
The facility failed to update Care Plans for two residents, leading to deficiencies in care. One resident's Care Plan did not reflect changes in weight management and oxygen use, while another resident's Care Plan lacked documentation of a low bed as a fall prevention measure. Staff acknowledged the discrepancies, attributing them to staffing changes and lack of specific policy for Care Plan revisions.
A facility failed to maintain an emergency tracheostomy kit with an obturator at the bedside for a resident with a tracheostomy, as required by the care plan. The kit was instead kept at the nurses' station, and staff communicated its location during reports. The DON cited the resident's independence and tendency to fiddle with items as reasons for not keeping the kit in the room. The facility lacked a tracheostomy policy, contributing to the deficiency.
A CNA failed to perform proper hand hygiene while assisting three residents during meal service, using the same hand to feed multiple residents and not sanitizing hands after wiping mouths or touching straws, contrary to facility policy.
Failure to Involve POA in Financial Decision-Making for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident’s representative/POA to assist a cognitively impaired resident with decision-making regarding a significant financial decision related to Medicaid eligibility. The resident had a BIMS score of 10, indicating moderate cognitive impairment, and progress notes over several days documented that he was alert only to person (and sometimes place) and was confused and forgetful. The Social Services Director (SSD) worked directly with the resident on a Medicaid application and identified a final expense life insurance policy with a cash value of approximately $3,277.81 and a face value of $15,000, which the SSD believed would likely need to be cashed out to reduce the resident’s resources below $2,000. The SSD documented that the resident was okay with cashing out the policy if the POA agreed, and emailed the POA explaining that the resident needed to be below $2,000 in assets and that she could assist the resident with this. The POA questioned what was meant by “cashing out” the policy and indicated she needed to handle this herself, later stating she told the SSD to wait until she could contact the insurance company. Despite this, an insurance company form requesting cash surrender value was completed with the resident’s signature and the SSD as witness. The clinical record did not contain documentation of the resident’s cognitive status at the time he signed the cash surrender form, and the SSD acknowledged she had no documentation of dates or times of her discussions with the POA. The POA later reported that the resident did not want to cancel his life insurance policy, that his mental status had declined and he was not in a condition to make that decision, and that she learned from the insurance company that the policy had been cancelled. The SSD also stated she was not aware of other available options for handling the life insurance policy in the Medicaid spend-down process.
Failure to Obtain Required Rationale and End Date for Extended PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication was only continued beyond 14 days with a provider’s written rationale and end date for one resident. The resident had moderate cognitive impairment, with a BIMS score of 10, and diagnoses including atrial fibrillation, cirrhosis, arthritis, and repeated falls. A new prescription dated 9/25/25 ordered Lorazepam 0.25 mg by mouth every 4 hours PRN for anxiety, and on 10/2/25 the order was changed to every 2 hours PRN without any documented rationale for continuing the PRN psychotropic or specifying an end date. The October MAR showed the PRN Lorazepam was administered 19 times through the 28th, with 11 of those administrations documented as ineffective. In an interview, the DON stated the family did not want the resident on psych medications and that staff tried all non-pharmacological interventions before administering medications per the family’s wishes, and acknowledged she did not think a rationale or end date was provided to continue the PRN Lorazepam, despite facility policy limiting PRN psychotropic use to 14 days unless extended by the physician with documented rationale.
Failure to Implement Fall Interventions and Complete Post-Fall Neuro Assessments
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate fall-prevention interventions and to complete required neurological assessments after falls for one resident. The resident had moderate cognitive impairment, required partial to moderate assistance with multiple ADLs, and had diagnoses including atrial fibrillation, cirrhosis, arthritis, and a history of repeated falls. The care plan identified the resident as at risk for falls related to impaired cognition and recent falls, with an intervention that the resident wear gripper socks in bed. Progress notes documented that on one occasion the resident was found on the floor between the bed and the wall, gripping the curtains, with the bed in the lowest position and grippy socks on, and the resident was only able to answer simple yes/no questions and could not explain what he had attempted to do. On another occasion, the resident was found on the floor by his dresser, leaning on his left arm, reporting left arm pain and having a 4 x 3 cm skin tear near the left elbow, and it required three staff with a gait belt to transfer him to a wheelchair. The facility also failed to complete neurological assessments as required by its fall occurrence policy following these falls. After the first fall, the Neurological Evaluation Flow Sheet initiated that evening lacked completed assessments at several scheduled times, with multiple entries indicating the resident was sleeping and missing vital signs and other required data at specific hours. Some entries documented the resident as sleeping but still included vital signs and pupil assessments, creating inconsistencies. Following a later fall in which the resident was found sitting on the floor with his wheelchair behind him, another neurological flow sheet was initiated, but it lacked completed assessments at additional scheduled times, again marked as sleeping. The facility’s policy required neurological evaluations with vital signs initially, then every 30 minutes times four, every hour times four, and then every eight hours times nine (for a total of 72 hours), with documentation and monitoring for 72 hours post-fall, which was not fully carried out for this resident.
Failure to Provide Timely Wound Care and Follow-Up
Penalty
Summary
A resident with a history of stroke, right-sided hemiplegia, and severe cognitive impairment developed pressure ulcers on both buttocks. The care plan identified the resident as high risk for skin integrity issues and included multiple interventions such as medication administration, wound care per physician orders, use of barrier creams, and regular skin assessments. Despite these interventions, documentation showed that the resident's wounds deteriorated over time, with increasing drainage, foul odor, and the development of eschar. The facility staff communicated with both the primary care provider (PCP) and the wound center physician regarding the resident's condition, but there was confusion and lack of clarity about wound clinic appointments and follow-up care. On several occasions, staff noted worsening wound conditions and communicated these findings via fax to the physicians. However, there was a failure to ensure timely follow-up and coordination between the facility, the PCP, and the wound center. For example, the facility believed the resident had a wound clinic appointment on a certain date, but no such appointment was scheduled, and there was no documentation of follow-up or notification to the wound center physician about the deteriorating wound. Weekly skin assessments continued to show worsening wounds, but the facility did not escalate care or ensure the resident was seen sooner by the wound specialist, even when staff hoped for more urgent intervention. Ultimately, the resident developed severe symptoms including respiratory distress, fever, and a large buttock ulcer, leading to hospital admission. Hospital records indicated the resident was septic with acute respiratory failure, and the wound was identified as a likely source of infection. Staff interviews revealed gaps in wound care knowledge and assessment, as well as uncertainty about wound clinic appointments and communication with providers. The facility's failure to provide treatment and care in accordance with professional standards, including timely follow-up and coordination with wound care specialists, contributed to the resident's decline.
Failure to Ensure Effective Fall Prevention and Supervision
Penalty
Summary
A deficiency occurred when a resident with impaired cognitive function and a known risk for falls experienced multiple falls within a short period, resulting in significant injuries including bilateral elbow fractures and facial lacerations. The resident was equipped with a pressure alarm intended to alert staff when attempting to get up without assistance. However, on two separate occasions, the alarm failed to sound, and staff did not determine the cause of the malfunction. The resident had a documented history of turning off or moving the alarm, but this was not effectively addressed at the time of the incidents. On the first occasion, the resident was found in another room after getting up unassisted, resulting in a right elbow fracture and a laceration near the right eye that required sutures. The alarm did not sound, and staff were unaware of the resident's movement until after the fall. On the following day, the resident fell again, this time fracturing the left elbow and sustaining another facial laceration. Again, the pressure alarm did not activate, and the fall was unwitnessed. Staff interviews confirmed that the alarm was either not turned on, had been disabled by the resident, or was otherwise ineffective, but no investigation into the alarm's failure was conducted at the time. Documentation and staff interviews revealed that the resident's fall risk was known, and interventions such as bed and door alarms were in place or considered. Despite these measures, the lack of adequate supervision and failure to ensure the functionality of the alarm system directly contributed to the resident's repeated falls and injuries. The facility's policy required evaluation and implementation of interventions to minimize fall risk, but these were not effectively executed in this case.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition, specifically the deterioration of pressure ulcers. The resident in question had a history of stroke with right-sided hemiplegia, severe cognitive impairment, and was at risk for skin integrity issues due to immobility and medication use. Documentation showed that the resident developed pressure ulcers on both buttocks, with one area worsening over time as noted in weekly skin assessments. The physician was notified of the changes via fax, but there was no documentation that the resident's representative was informed of the wound deterioration. A family member later reported to the facility that she had not been notified about the worsening of the resident's wounds. Staff interviews confirmed that wound assessments were conducted and physicians were notified, but the clinical record lacked evidence of timely notification to the resident's representative. The facility's policy required immediate notification of significant changes in a resident's status to the resident, their physician, and their representative, but this was not followed in this instance.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, which did not identify target behaviors related to the use of psychotropic, antianxiety, and antidepressant medications, nor did they include non-pharmacological interventions. For Resident #4, the care plan lacked focus areas with goals and interventions related to the diagnosis of dementia, despite the resident's moderate cognitive impairment and use of antipsychotic and antidepressant medications. The care plan also failed to address target behaviors and side effects of the medications. Resident #15, who had normal cognition, was prescribed multiple medications for anxiety and depression. The care plan did not identify target behaviors related to the use of these medications, despite documented behaviors such as complaints, anger, and refusal of care. Similarly, Resident #16, with normal cognition and diagnoses including anxiety disorder and depression, had a care plan that did not identify target behaviors related to the use of psychotropic medications, even though the resident experienced feelings of depression and loneliness. Resident #22, with normal cognition and diagnoses of anxiety, depression, bipolar, and psychotic disorder, also had a care plan that failed to identify target behaviors related to the use of psychotropic medications. The facility's policy required care plans to be reviewed and updated for interventions related to identified behaviors or symptoms of the diagnosis, but this was not done. The facility acknowledged the lack of target behaviors and non-pharmacological interventions in the care plans and was in the process of updating them to provide more individualized focus areas, goals, and interventions.
Care Plan Deficiencies in Resident Interventions
Penalty
Summary
The facility failed to review and revise the Care Plan interventions for two residents, leading to deficiencies in care. For one resident, the Care Plan was not updated to reflect a change from unexpected weight gain to weight loss, despite significant weight loss being documented by the dietitian. Additionally, the Care Plan did not reflect the discontinuation of daily weights, which was ordered by the primary care provider. The resident's oxygen use was also not accurately reflected in the Care Plan, as it did not account for the change from continuous oxygen at 2 liters to a titrated range of 2-4 liters to maintain oxygen saturation levels. Another resident's Care Plan failed to include the use of a low bed as a fall prevention intervention, despite the resident having a history of falls and the low bed being used as a precautionary measure. Observations confirmed the use of a low bed, but this intervention was not documented in the Care Plan. Staff interviews revealed that the low bed had been in use for some time, but the Care Plan had not been updated to reflect this intervention. The Director of Nursing and the Administrator acknowledged the deficiencies in the Care Plans, noting that the Care Plans did not reflect the residents' current needs and interventions. The facility did not have a specific policy for Care Plan revisions, relying instead on the Resident Assessment Instrument manual for guidance. The lack of updates to the Care Plans was attributed to changes in staffing and the Director of Nursing covering multiple areas.
Failure to Maintain Emergency Tracheostomy Kit at Bedside
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy by not having an emergency tracheostomy kit with an obturator at the bedside. The resident, who had diagnoses including coronary artery disease, acute respiratory distress, depression, and pneumonia, was documented to have a tracheostomy and required oxygen. The care plan indicated that a spare tracheostomy should be maintained at the bedside, but observations on two separate occasions revealed the absence of the emergency tracheostomy set in the resident's room. Interviews with staff revealed that the extra tracheostomy set was kept at the nurses' station instead of the resident's room. The LPN stated that the location of the kit was communicated during nurse-to-nurse reports, but there was no policy in place to guide this practice. The Director of Nursing acknowledged the absence of the kit in the room, citing the resident's independence and tendency to fiddle with items as reasons for not keeping it bedside. The facility administrator confirmed the lack of a tracheostomy policy, contributing to the deficiency in care.
Failure to Perform Proper Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to complete proper hand hygiene during meal service, as observed on 4/24/24 at 11:30 AM. A Certified Nursing Assistant (CNA) assisted two residents to eat at the same time, using the same hand to feed both residents without performing hand hygiene in between. The CNA also wiped one resident's mouth with a napkin and then used the same hand to feed another resident, again without performing hand hygiene. Additionally, the CNA assisted a third resident with a drink and straw without performing hand hygiene before or after the task. These actions were observed for three residents during the meal service. The Assistant Director of Nursing (ADON) and infection preventionist confirmed that the facility's policy requires hand hygiene after wiping a resident's mouth or touching straws, but not necessarily after touching a resident's hand unless visibly soiled. The facility's Exposure Control/Hand Hygiene policy, reviewed on 4/24/24, mandates hand hygiene before and after direct resident contact, before and after assisting a resident with meals, and after contact with a resident's mucous membranes and bodily fluids. The observed actions of the CNA were inconsistent with these policy requirements, leading to the identified deficiency.
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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