Parkridge Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Pleasant Hill, Iowa.
- Location
- 5800 Ne 12th Avenue, Pleasant Hill, Iowa 50327
- CMS Provider Number
- 165345
- Inspections on file
- 34
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Parkridge Specialty Care during CMS and state inspections, most recent first.
A resident with sepsis, weakness, urinary incontinence, and intact cognition, who depended on staff for toileting hygiene and transfers, was found at the hospital wearing three pairs of grossly soiled diapers with skin damage. Facility records showed a CNA was assigned to and provided care to the resident on the morning of transfer, and the resident’s care plan, which required staff assistance for toileting and cleansing, did not authorize the use of multiple briefs. One CNA reported being told by the involved CNA to place more than one brief on residents but refused to do so, while another CNA reported seeing the involved CNA apply multiple briefs to this resident and others and had previously told her not to do this. The DON stated that only one brief should be used unless otherwise directed in the care plan, confirming that multiple briefs were not part of this resident’s plan of care.
A resident with sepsis, weakness, and existing moisture-associated skin damage to the buttocks was readmitted from the hospital and refused a full skin check at that time, preferring to remain in a chair for dinner. Facility policy and the care plan required a head-to-toe skin assessment on admission and ongoing monitoring and documentation of skin injuries, but there was no documentation that staff reapproached the resident for a skin assessment, including the buttocks, in the days following readmission. A later skin note identified a new buttocks wound with specific measurements. The Wound Nurse reported there was likely an assumption that the admission nurse had completed the assessment, and the DON stated that admission-day skin assessments and reattempts after refusals were expected but did not occur.
Two residents experienced worsening pressure injuries due to the facility's failure to consistently implement and document required interventions such as turning/repositioning and use of protective devices. Staff were unclear about care plan instructions and documentation procedures, leading to missed treatments and deterioration of skin conditions.
Multiple residents requiring significant assistance with daily living reported that their call lights were not answered within the facility's 15-minute policy, with documented delays ranging from 17 minutes to over two hours. Staff confirmed that call light response times frequently exceeded expectations due to low staffing, and the facility's leadership acknowledged the 15-minute standard was not consistently met.
A resident with hemiplegia, diabetes, and macular degeneration, who required two staff for bed mobility and dressing per the care plan, was assisted by only one CNA. This deviation led to the resident experiencing significant right arm pain, necessitating administration of Tramadol. Both the CNA and the resident confirmed that care plan instructions were not followed, and the DON verified staff are expected to adhere to care plans.
A CNA failed to fully cleanse all required areas during incontinence care for a resident with quadriplegia and severe cognitive impairment, omitting the right and left hips despite facility policy and care plan directives. Staff interviews and policy review confirmed that thigh areas should be included in perineal care.
A resident experienced vomiting and diarrhea, but the facility failed to notify the physician and family as required. CNAs reported the symptoms to an RN, who did not recall being informed and did not document any follow-up actions. The facility's policy mandates prompt notification of changes in a resident's condition, which was not adhered to in this case.
A facility failed to report an abuse allegation within the required 2-hour timeframe after two residents were involved in an altercation, where one admitted to hitting the other. The incident was documented, but the report to the Iowa Department of Inspections, Appeals and Licensing was delayed due to a misinterpretation of the reporting rules by the Administrator.
A resident with intact cognition and multiple diagnoses experienced a delay in the implementation of new physician orders, including changes to their medication regimen. The orders, communicated via email to the DON, were not promptly documented or updated in the MAR, resulting in a delay of several days before the medications were administered. The facility's policy requires immediate recording of verbal orders, which was not followed.
A facility failed to conduct and document necessary assessments for two residents, leading to deficiencies in care. One resident experienced nausea, vomiting, and diarrhea without proper assessments or physician notification, and after falls, lacked vital signs and neurological assessments. Another resident had delayed implementation of new medication orders and lacked monitoring for fluid overload and medication side effects. The DON acknowledged these deficiencies, which violated facility policy.
A resident identified as a fall risk experienced two unwitnessed falls shortly after admission due to the facility's failure to implement necessary interventions, such as using a mechanical stand and assistance of two persons for transfers. The initial care plan did not address the fall risk, and staff did not follow care plan directives during transfers. Incomplete neurological evaluations and lack of proper documentation further contributed to the resident's deteriorating condition, leading to hospitalization where a pelvic fracture was discovered.
The facility failed to maintain sanitary practices in its kitchen, with improperly stored and unlabeled food items, and a dishwasher that did not consistently reach the required rinse temperature. Staff relied on inaccurate temperature readings, lacking proper procedures and equipment for ensuring sanitation standards.
A facility failed to complete a quarterly assessment for a resident as required by the RAI manual. The resident was admitted after a hospital stay, with the last MDS completed on the admission date. A review revealed no subsequent MDS had been completed, violating the requirement to conduct a quarterly assessment 92 days from the prior MDS assessment reference date.
A resident with multiple medical conditions did not receive her scheduled medications on time due to a delay by an LPN. The medications were supposed to be administered via G-Tube at specific times, but during an observation period, no medication was given. The LPN admitted to documenting the administration time incorrectly, and the facility's policy requires medications to be administered within one hour of their prescribed time.
A resident with intact cognition and multiple health conditions did not receive routine scheduled baths as required. Facility records showed only two baths were provided since admission, with no documentation of refusals. Staff interviews indicated that residents should be bathed at least twice a week, but this was not adhered to for the resident.
A facility failed to follow physician orders for a resident with heart failure, neglecting to record daily weights and twice-daily oxygen saturation levels. The resident, who was cognitively intact, was observed with swollen ankles, indicating potential complications. Despite clear orders and protocols, the facility did not consistently adhere to the prescribed care, as acknowledged by the DON.
The facility failed to prevent cross-contamination during G-tube feeding and meal service. An LPN used soiled gloves during G-tube care for a resident, failing to change them after contamination. Additionally, a maintenance staff placed a meal tray on a resident's walker without sanitizing it afterward. The facility's Infection Prevention and Control Program requires adherence to proper techniques.
A male resident with a history of inappropriate behavior kissed a female resident without consent, leading to increased anxiety and depression for the female resident. The male resident's care plan lacked interventions for his behavior, and staff were not informed of his history, resulting in a failure to protect the female resident from abuse.
A male resident with a history of inappropriate sexual behavior kissed a female resident without consent, despite being on 1:1 supervision. The female resident, with dementia and anxiety, reported feeling unsafe. Staff interviews revealed a lack of specific interventions in the male resident's care plan, contributing to the incident.
A facility failed to promptly identify and intervene for a resident's acute change in condition, including chest pain, shortness of breath, cough, and urinary incontinence. Despite staff awareness of the symptoms, the resident's condition was not adequately assessed or communicated to the on-call practitioner, leading to hospitalization with severe health issues.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
The facility failed to honor a resident's right to dignity and respect during incontinence care by applying multiple incontinent briefs at one time. The resident had diagnoses including sepsis, weakness, and required assistance with personal care, with an MDS indicating intact cognition (BIMS 15/15) and dependence on staff for toileting hygiene and transfers. The resident’s care plan required assistance of two staff for toilet transfers, noted urinary incontinence, and directed staff to assist the resident to the bathroom and with cleansing, but did not include the use of more than one incontinent brief. Facility policy on dignity stated that care would be provided in a manner that promoted well-being, satisfaction with life, self-worth, and self-esteem. Documentation showed that on the morning of 11/29/25, CNA Staff C was assigned to and provided care for the resident on the 300 Hall, and the resident was later transferred to the hospital that morning. A hospital shift summary dated 12/2/25 documented that the resident arrived at the hospital in three pairs of grossly soiled diapers with skin damage. An internal investigation witness statement recorded that the DON interviewed Staff C, who stated she had taken care of the resident on that Saturday morning. CNA Staff A reported that when she first started at the facility, Staff C instructed her to place more than one brief on residents, but she chose not to follow this practice. CNA Staff B stated she had observed Staff C placing more than one brief on residents, including this resident, and that she last told Staff C not to do this on 11/28/25, though she did not report it immediately because she was concerned about Staff C’s job. The DON later stated that staff should only apply one brief to residents unless otherwise directed in the care plan, and confirmed that this resident’s care plan did not authorize the use of more than one incontinent brief.
Failure to Complete Timely Post-Readmission Skin Assessment
Penalty
Summary
The deficiency involves the facility’s failure to perform timely and complete skin assessments following a resident’s readmission from the hospital, despite existing policies and care plan directives. The resident had diagnoses including sepsis, weakness, and a need for assistance with personal care, and was cognitively intact with a BIMS score of 15/15. The facility’s pressure ulcer/skin breakdown policy required nursing staff to examine the skin of newly admitted residents for evidence of pressure ulcers or other skin conditions, and the resident’s care plan directed staff to monitor and document the location, size, and treatment of skin injuries and to report abnormalities. Prior to hospitalization, the care plan documented moisture-associated skin damage to the buttocks. Nurses’ notes showed the resident was sent to the hospital for sepsis and later readmitted. On the day of readmission, the resident refused a full skin check because he wanted to remain in his chair for dinner. The record lacked documentation that staff reapproached the resident for a skin check, including assessment of the buttocks, between the date of readmission and several days later. A subsequent skin issues note documented a new buttocks wound with specific measurements and a pink/red wound bed. The Wound Nurse stated that the nurse completing admissions was responsible for head-to-toe skin assessments and acknowledged there was likely an assumption that the admitting nurse had completed the assessment, which contributed to the lack of follow-up. The DON stated that staff should perform skin assessments on the day of admission and, if not done, this should be communicated to subsequent shifts and reattempted if initially refused, which did not occur in this case.
Failure to Prevent and Manage Pressure Injuries Due to Inadequate Interventions and Documentation
Penalty
Summary
The facility failed to provide appropriate interventions to prevent the development and worsening of pressure injuries for two residents. For one resident with a history of diabetes, heart failure, and a recent left great toe amputation, a deep tissue injury developed on the left plantar foot while in the facility. Although the care plan included interventions such as heel suspension devices, a foot cradle, and a turning/repositioning program, there was a lack of consistent implementation and documentation. Staff interviews revealed confusion about when and how to apply these interventions, and the resident reported inconsistent use of protective devices. The clinical record lacked documentation of turning and repositioning, and staff were unclear on where to document these actions or how to verify if a resident was on such a program. Another resident, with diagnoses including diabetes, cerebrovascular accident, and dementia, experienced worsening of a Moisture Associated Skin Damage (MASD) area on the coccyx. The care plan directed staff to perform treatment as ordered and use pressure-reducing devices, but did not specify a turning or repositioning schedule. Documentation showed that wound care treatments were missed on several days, and the MASD area deteriorated before the ARNP was notified. The clinical record and care plan failed to include a positioning schedule, and staff interviews confirmed that they relied on the care plan for such instructions, which were absent. Policy review indicated that staff were expected to assess and document risk factors for pressure ulcers and implement appropriate interventions. However, neither resident had a positioning schedule documented in the Kardex, and there was a lack of documentation and follow-through on required interventions. The deficiencies were identified through observation, record review, and staff and resident interviews, which consistently showed gaps in the implementation and documentation of pressure injury prevention and care.
Failure to Timely Respond to Resident Call Lights
Penalty
Summary
The facility failed to consistently answer resident call lights within the 15-minute timeframe established by its own policy, as confirmed by call light logs, resident interviews, and staff statements. Four residents, all with varying degrees of physical and/or cognitive impairment and requiring significant assistance with activities of daily living, reported that their call lights were not answered promptly. Documentation showed multiple instances where response times ranged from 17 minutes to over two hours. Residents were able to verify these delays by referencing clocks in their rooms, and their statements were corroborated by the facility's call light logs. Staff interviews further confirmed that call lights were often not answered within the expected timeframe, with staff attributing the delays to low staffing levels. The facility's policy, dated March 2021, requires that call lights be answered within 15 minutes to meet residents' needs in an appropriate time frame. The Administrator and DON acknowledged that the facility's expectation is a 15-minute response time, but the documented delays and staff admissions indicate this standard was not consistently met for the residents involved.
Failure to Follow Care Plan for Dependent Resident
Penalty
Summary
The facility failed to follow the comprehensive care plan for a resident who required extensive assistance with activities of daily living (ADLs) due to diagnoses including diabetes mellitus, hemiplegia, and macular degeneration. The resident's care plan, last revised on 1/2/25, specified that two staff members were required to assist with bed mobility and upper and lower body dressing. However, on 4/29/25, only one CNA assisted the resident with rolling and repositioning, contrary to the care plan instructions. This was confirmed by both the CNA involved and the resident, who reported that only one staff member was present during the incident. Following this event, the resident complained of right arm pain, which was documented in the clinical record and required administration of Tramadol for pain management. The pain was significant, with the resident reporting pain levels of 8 and 6 out of 10 at different times throughout the day. The facility's policy required staff to use the care plan in developing daily care routines, and the DON confirmed that staff are expected to follow the resident's plan of care. The failure to adhere to the care plan resulted in the resident experiencing pain and requiring medication.
Incomplete Incontinence Care Provided to Resident with Quadriplegia
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to provide complete and appropriate incontinence care to a resident with quadriplegia, severe cognitive impairment, and bowel incontinence. During observed care, the CNA performed hand hygiene, donned gloves, and used wipes to clean the resident's buttock and front perineal area, wiping from front to back. However, the CNA did not cleanse the resident's right and left hips, which was required by the facility's perineal care policy. The resident's care plan specifically directed staff to assist with perineal cleansing and to observe the skin daily for irritation and redness. Staff interviews confirmed that thigh areas should be cleansed during incontinence care, and policy review indicated that care should extend outward to the thighs.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician and family when a resident experienced a change in condition. The resident, who was newly admitted and had not yet completed a Minimum Data Set (MDS), exhibited symptoms of vomiting and diarrhea over the course of a day. Despite these symptoms, there was no documentation of assessments or interventions related to the nausea, vomiting, and diarrhea, nor was there any record of family or physician notification in the progress notes. Staff interviews revealed that two Certified Nursing Assistants (CNAs) observed and reported the resident's symptoms to a Registered Nurse (RN) throughout the day. However, the RN did not recall being informed of these symptoms and did not document any follow-up actions. The facility's policy required prompt notification of the resident's physician and family in the event of a change in condition, but this protocol was not followed, leading to the deficiency.
Failure to Timely Report Resident Altercation
Penalty
Summary
The facility failed to report an allegation of abuse within the required 2-hour timeframe to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for two residents involved in an altercation. The incident occurred when one resident was observed standing over another resident's bed, and the latter reported being hit on the arm. The resident who was accused admitted to the action. The incident was documented in an Incident Report at 3:30 PM, but the facility did not file the allegation with DIAL until 12:06 AM the following day. The Administrator acknowledged the delay and admitted to misinterpreting the reporting rules, believing there was a 24-hour window for reporting unless there was an injury. The facility's policy requires staff to report any allegations within the timeframes mandated by federal requirements.
Delayed Implementation of Physician Orders for a Resident
Penalty
Summary
The facility failed to implement physician orders in a timely manner for a resident with intact cognition, as indicated by a BIMS score of 14. The resident had diagnoses of hypertension, diabetes mellitus, and hyperlipidemia. New physician orders were communicated to the Director of Nursing (DON) via email from the facility's Advanced Registered Nurse Practitioner (ARNP), which included changes to the resident's medication regimen. These orders were not documented in the resident's progress notes, and there was a delay in updating the Medication Administration Record (MAR) to reflect these changes. The orders included increasing the dosage of Jardiance, Insulin Glargine, starting Cimetidine and Citalopram, and administering Lasix for fluid overload. The implementation of these orders was delayed by several days, with the earliest change occurring three days after the orders were received. The DON acknowledged the delay and stated that the orders should have been implemented immediately. The facility's policy on medication and treatment orders requires that verbal orders be recorded immediately in the resident's electronic medical record, which was not adhered to in this case.
Failure to Provide Necessary Assessments and Interventions
Penalty
Summary
The facility failed to provide necessary assessments and interventions for two residents, leading to deficiencies in their care. Resident #1, who had multiple diagnoses including delirium and acute kidney failure, experienced nausea, vomiting, and diarrhea, but the facility did not complete or document the necessary nursing assessments. Additionally, after two unwitnessed falls, the facility failed to conduct and document vital signs and neurological assessments as required. The lack of timely documentation and communication with the physician and family further exacerbated the situation, as the staff did not notify them of the resident's condition changes. Resident #2, with diagnoses including hypertension and diabetes, experienced a delay in the implementation of new physician orders for medications addressing fluid overload, sexual inhibition, anxiety, and depression. The facility did not document the receipt of these orders or conduct necessary assessments to monitor the efficacy and side effects of the new medications. Furthermore, there was no documentation of assessments related to fluid overload, despite the resident's significant weight gain and increased edema. The Director of Nursing acknowledged the lack of documentation and assessments for both residents. The facility's policy required prompt notification of changes in a resident's condition to the physician and family, as well as detailed observations and relevant information gathering. However, these protocols were not followed, resulting in inadequate care and monitoring of the residents' health conditions.
Failure to Implement Fall Prevention Measures for a High-Risk Resident
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident identified as a fall risk. Upon admission, the resident was known to have a history of falls and required specific interventions, such as the use of a mechanical stand and assistance of two persons for transfers. However, these interventions were not implemented, and the resident experienced two unwitnessed falls within 48 hours of admission. The initial care plan did not address the resident's fall risk, and staff did not follow the care plan directives during transfers. After the first fall, the resident was found on the floor, and although assessed for injuries, the staff did not use the mechanical lift as required by the care plan. The neurological evaluation was incomplete, lacking vital signs and proper documentation. The second fall occurred later the same day, with similar deficiencies in the response, including the absence of a range of motion assessment and failure to use the mechanical lift. The resident's condition deteriorated, leading to a transfer to the hospital, where a pelvic fracture was discovered, though its relation to the falls was uncertain. Interviews with staff revealed inconsistencies in following the care plan and a lack of clarity regarding the resident's transfer status. The Director of Nursing acknowledged the deficiencies in documentation and assessment following the falls. The facility's policies on fall risk management and safe lifting were not adhered to, contributing to the resident's repeated falls and subsequent hospitalization.
Sanitation and Equipment Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary practices in its kitchen, as observed during a survey. Several issues were noted, including improperly stored food items such as undated and unlabeled bags of shredded cheese, light brown disc-shaped items, and various spices. Additionally, there were clear plastic containers with unidentified substances, and food items stored inappropriately, such as macaroni noodles on the floor of the walk-in freezer. These observations indicate a lack of adherence to professional standards for food storage and labeling. The facility also failed to maintain essential kitchen equipment, specifically the dishwasher, which did not consistently reach the required rinse temperature of 180 degrees Fahrenheit. The staff relied solely on the dishwasher's integrated temperature gauge, which was found to be inaccurate when compared to a secondary temperature device. The dishwashing machine's temperature log showed multiple instances where the rinse temperature was not documented or did not meet the required standards, indicating a systemic issue with monitoring and maintaining proper sanitation temperatures. Interviews with staff revealed a lack of proper procedures and equipment for ensuring accurate temperature readings. The Assistant Dietary Service Manager admitted to not using temperature stickers or a reliable thermometer, and the facility's reliance on the dishwasher's gauge was based on incorrect information from the manufacturer. The Regional Dietary Services Manager confirmed the absence of a secondary temping device, which is necessary according to FDA health code. This deficiency in equipment maintenance and monitoring practices contributed to the facility's failure to uphold sanitary standards in food preparation and service.
Failure to Complete Quarterly Assessment
Penalty
Summary
The facility failed to complete a quarterly assessment for one resident, as required by the Resident Assessment Instrument (RAI) manual. The resident in question was admitted to the facility following a hospital stay, with the Admission Minimum Data Set (MDS) documenting an Assessment Reference Date of April 19, 2024. Upon review of the resident's electronic health record on August 26, 2024, it was found that no MDS had been completed since the admission MDS. The RAI manual mandates that a quarterly assessment must be completed 92 days from the prior MDS assessment reference date, which was not adhered to in this case. The facility's policy, revised in July 2017, also requires adherence to federal and state submission timeframes for resident assessments.
Medication Administration Delay for a Resident
Penalty
Summary
The facility failed to administer medication in a timely manner for one resident, identified as Resident #50, who was observed to have not received her scheduled medications during a continuous observation period. Resident #50's medical history included significant conditions such as renal insufficiency, hypertension, aphasia, quadriplegia, seizure disorder, anxiety disorder, depression, and respiratory failure. The resident was prescribed Simethicone and Levetiracetam to be administered via G-Tube twice daily at specific times. However, during an observation on August 26, 2024, from 3:07 PM to 3:57 PM, no medication was administered to the resident, despite the scheduled time being 3:00 PM. Staff E, an LPN responsible for administering the medication, acknowledged the delay and admitted to documenting the medication administration time incorrectly. The Medication Admin Audit Report indicated that the medications were documented as given at 3:20 PM, but the actual documentation occurred at 4:20 PM, which was outside the acceptable one-hour window for medication administration. The Director of Nursing confirmed that the facility's policy requires medications to be administered within one hour of their prescribed time, and deviations should be reported to nurse leadership. The facility's policy emphasizes that medication administration times should be based on resident needs rather than staff convenience.
Failure to Provide Routine Scheduled Baths
Penalty
Summary
The facility failed to provide routine scheduled baths for a resident, identified as Resident #35, who was unable to perform activities of daily living independently. The resident, who had a completely intact cognition with a BIMS score of 15 out of 15, was diagnosed with heart failure, hypertension, diabetes mellitus, cardiogenic shock, a prosthetic heart valve, and shortness of breath. The resident required varying levels of assistance with daily activities, including moderate assistance with bathing. Despite these needs, the facility's records indicated that the resident only received two baths since admission, on 8/12/24 and 8/22/24, with no documentation of any refusals to bathe. Interviews with facility staff revealed that all residents should be bathed at least twice a week, and any refusals should be documented. However, there was no evidence of such documentation for Resident #35. The Infection Preventionist confirmed that the facility did not use a shower log, relying solely on the EHR for documentation. The Director of Nursing stated that staff should reoffer bathing and notify the charge nurse if a resident refuses, but there was no indication that this protocol was followed for Resident #35.
Failure to Follow Physician Orders for Monitoring
Penalty
Summary
The facility failed to adhere to physician orders for a resident with a history of heart failure, hypertension, diabetes mellitus, cardiogenic shock, prosthetic heart valve, and shortness of breath. The resident, who was cognitively intact, required daily weight monitoring and twice-daily oxygen saturation checks as per physician orders. However, the facility did not record the resident's weight on two specific dates and failed to document oxygen saturation levels on two other dates, with only once-daily recordings during a specified period. The resident was observed with swollen ankles, indicating potential complications related to their heart condition. Despite the presence of clear physician orders and facility protocols for monitoring weight and oxygen levels, these were not consistently followed. The Director of Nursing acknowledged that staff should adhere to physician orders, highlighting a lapse in the facility's compliance with prescribed care protocols.
Infection Control Deficiencies in G-Tube Feeding and Meal Service
Penalty
Summary
The facility failed to perform gastric tube (G-tube) feeding in a manner that protects residents from cross-contamination for two residents. During a continuous observation of the G-tube feeding process for one resident, a Licensed Practical Nurse (LPN) was seen using soiled gloves multiple times. The LPN did not use enhanced barrier precautions and placed sanitary supplies directly on a side table. The LPN used disposable gloves to type on a computer and then made direct contact with the resident's G-tube port without changing the contaminated gloves. After performing incontinence care, the LPN continued with the G-tube feeding without changing gloves, again making direct contact with the G-tube port. The Director of Nursing acknowledged that enhanced barrier precautions should be used and gloves should be changed when soiled. Additionally, the facility failed to serve meals in a manner that protects residents from cross-contamination. A maintenance staff member placed a lunch tray on a resident's walker handles without sanitizing them afterward. The administrator confirmed that the staff should have sanitized the walker's handles after placing the serving tray on it. The facility's Infection Prevention and Control Program, last revised in 2018, requires staff to adhere to proper techniques and procedures.
Inadequate Supervision and Care Planning Leads to Resident Abuse
Penalty
Summary
The facility failed to prevent an incident of inappropriate behavior involving a male resident, identified as Resident #1, who kissed a female resident, identified as Resident #2, without her consent. Resident #1, who has a history of heart failure, Non-Alzheimer's Dementia, depression, insomnia, and alcohol abuse, was documented to have no cognitive impairments and was independent with ambulation. Despite this, his care plan noted socially inappropriate behaviors, and he was placed on 1:1 supervision due to these behaviors. The incident occurred when Resident #1 entered Resident #2's room and kissed her on the cheeks, which was against her will. This behavior was consistent with a previous incident at another facility, where Resident #1 was also placed on 1:1 supervision for similar inappropriate conduct. Resident #2, who has diagnoses including Non-Alzheimer's Dementia, anxiety, bipolar disorder, and schizophrenia, was documented to have moderately impaired cognition and required assistance with personal hygiene and transfers. She reported feeling uncomfortable and unsafe after the incident, which led to an increase in her depressive and anxious symptoms. Her care plan indicated that she did not like to be touched and required permission before any physical contact. The incident was reported to the psychiatric provider, and Resident #2 expressed a desire not to be around Resident #1. Interviews with facility staff revealed that the care plan for Resident #1 lacked specific interventions to address his sexual behaviors and that staff were not adequately informed about the reasons for his transfer from the previous facility. The facility's abuse and neglect protocol defined abuse, including sexual abuse, as non-consensual sexual contact of any type with a resident. The deficiency in the facility's handling of Resident #1's behavior and the lack of appropriate interventions in his care plan contributed to the failure to protect Resident #2 from abuse.
Inadequate Supervision Leads to Resident Misconduct
Penalty
Summary
The facility failed to adequately supervise a male resident with known inappropriate sexual behaviors, resulting in an incident where he kissed a female resident without her consent. The male resident, who has a history of heart failure, dementia, depression, insomnia, and alcohol abuse, was documented as having no cognitive impairments and was independent in ambulation. Despite being on a 1:1 supervision plan due to previous inappropriate behaviors, the male resident managed to enter the female resident's room and kiss her on the cheeks, causing her distress and anxiety. The female resident, who has diagnoses including dementia, anxiety, bipolar disorder, and schizophrenia, reported the incident during a psychiatric evaluation. She expressed feeling unsafe and uncomfortable due to the male resident's actions. Her care plan noted that she does not like to be touched and requires permission before any physical contact. The incident led to an increase in her depressive and anxious symptoms, highlighting the facility's failure to provide a safe environment and adequate supervision. Interviews with staff revealed that the care plan for the male resident lacked specific interventions to address his sexual behaviors, and staff were not adequately informed about his history of inappropriate conduct. The facility's oversight in updating and communicating the care plan contributed to the incident, as staff were unaware of the need for heightened supervision when the male resident was outside his room.
Failure to Identify and Intervene for Acute Change in Condition
Penalty
Summary
The facility failed to promptly identify and intervene for an acute change in a resident's condition, which included chest pain, shortness of breath, cough, and urinary incontinence related to fluid volume overload. Despite the resident's symptoms and the family's concerns, the staff did not adequately assess or address the resident's deteriorating condition. The resident's Power of Attorney (POA) reported that the resident was congested and received over-the-counter nasal spray and cough medication. However, the resident's condition worsened, leading the POA to transport the resident to the emergency department, where he was diagnosed with acute hypoxic respiratory failure, pulmonary edema, sinus bradycardia, acute diastolic heart failure, and scrotal swelling due to edema. Interviews with staff revealed that multiple staff members were aware of the resident's symptoms, including a cough, labored breathing, refusal to eat, and refusal to get out of bed. However, these symptoms were not adequately communicated to the on-call practitioner or addressed by the nursing staff. The Advanced Practice Registered Nurse (APRN) reported that she was not informed of the resident's weight gain or difficulty breathing and was only told that the resident had a cold. The Assistant Director of Nursing (ADON) and other staff members also failed to recognize the severity of the resident's condition, leading to a lack of timely intervention. The facility's policies on weight assessment and intervention, as well as acute clinical changes, were not followed. The resident's weight had increased significantly, but this change was not properly documented or communicated to the dietitian or physician. The facility's failure to assess and report the resident's acute change in condition resulted in the resident being admitted to the hospital with severe health issues. The facility initiated an investigation and provided education to the nursing staff after the incident, but these actions were taken after the deficiency occurred.
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A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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