Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkridge Specialty Care during CMS and state inspections, most recent first.
Repeat deficiencies were identified in F812, F880, F725, and F684 after review of the State Agency Website, Federal Provider History Report, QAPI, staff interview, and policy review. The facility had prior citations in each category across multiple surveys, and the Administrator acknowledged the repeated issues and attributed them to staff turnover.
Failure to Report Repeated Missing-Item Grievances: Staff did not consistently escalate repeated resident and family complaints about missing clothing and other belongings to leadership. Multiple residents and representatives reported ongoing losses of clothing, T-shirts, wallets, and purses, and staff interviews showed confusion about when to file grievances or notify management. The facility grievance policy did not include instructions for staff to report complaints or grievances to facility leadership.
A facility failed to provide enough staff to ensure timely call light response, with direct observation showing one resident’s call light left on for 28 minutes before staff entered the room. Multiple residents reported long waits for help, including over an hour, and zone reports documented repeated response times over 15 minutes across several rooms and shifts. Staff interviews confirmed that weekends were especially understaffed and that the call light system had known issues.
Failure to treat residents with dignity and respect occurred when a contracted PT ignored residents’ requests during therapy and used a rude, pushy approach. Two cognitively intact residents with significant medical issues reported that the therapist pushed them too hard, dismissed requests to stop or sit, and made a resident ask for water by saying please while out of breath. An observed therapy session showed the therapist repeatedly telling a resident to keep going despite requests to sit, only providing a wheelchair once the resident began to lose balance.
Unattended Miralax Left Without Self-Administration Orders: Staff left prepared Miralax unattended for two residents without orders allowing self-administration. One resident had intact cognition and the other had severe cognitive impairment, yet both had physician orders for Miralax only. A CMA left a cup at the table for one resident during lunch, and another CMA left unfinished Miralax on a bedside table after the resident took only a few sips and the rest remained in the room.
Two residents lacked required assessments and follow-up documentation. One resident returned from same-day surgery with no documented nursing assessment, post-op orders, or follow-up monitoring in the record, despite staff stating vitals, assessment, and 72-hour monitoring are normally completed. Another resident had an unwitnessed fall and returned from the hospital, but neurochecks were not completed in sequence as expected, and the neuro assessment form was left partially blank or signed late.
A resident with moderately impaired cognition and a documented fall risk was left unattended during an active tornado warning, despite a care plan note that she should not be left unattended during tornadoes. She attempted to self-transfer from a recliner, fell, and was found with facial injuries and a nonreactive pupil. Staff stated cognitively impaired residents should be closely monitored and assigned staff during disasters, and the DON agreed supervision should have been provided; the tornado site plan policy did not address cognitively disabled or wandering residents.
Two residents with feeding tubes and significant medical histories, including CVA, diabetes, dysphagia, and esophageal obstruction, experienced major weight loss without timely follow-up. One resident lost more than 5% in less than a month and the other lost 27.6 lbs. in a very short period, yet reweights and documented nutrition-related follow-up were not completed as required. Staff and the DON acknowledged that reweighs were often delayed or missed, and the facility policy required a next-day recheck for any 5% or greater weight change.
Failure to properly prime an insulin pen before administration. An LPN administered Insulin Lispro to a resident with diabetes without first wasting the required 2 units to prime the KwikPen. The resident’s record showed insulin therapy was ordered, and staff stated priming is standard practice to ensure the pen works correctly and the resident receives the full dose.
Staff failed to follow food handling and hand hygiene practices in two dining rooms. A CNA used bare hands to butter bread for a resident, sneezed into their hand and then assisted a resident with feeding without hand hygiene, and a Dietary Aide used bare hands to touch, cut, and prepare a fresh [NAME] for a resident. The DON and Administrator acknowledged ready-to-eat resident food should not be handled with bare hands.
Infection control failures occurred during resident care and device use. During toileting and hygiene care, two hospice CNAs used the same gloves throughout perineal care and then touched other resident items without changing gloves or performing hand hygiene. EBP was not consistently implemented for residents with a feeding tube and with a wound, PICC line, and wound vac, as room signage was missing and an LPN wore gloves but not a gown during blood sugar testing and insulin administration. The glucometer was also cleaned with a quick alcohol swab instead of the facility’s described cleaning process.
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.
Food service safety standards were not followed when meal temperature logs were frequently left undocumented for breakfast, lunch, and supper across two months. During lunch service, an extension cord on the service table had dried food splatter and grime, cabinet tops above a food prep area had visible dust, and a dietary employee was observed wearing artificial nails with embellishments. The CDM confirmed temperatures should be documented before and after meals and that dietary staff should not have artificial nails.
Failure to offer and communicate alternative menu options to two residents. One resident had COPD, diabetes, malnutrition, and a wound with dehiscence, while the other had diabetes, ESRD, and sarcopenia. Both ate in their rooms, were not reviewed on the day’s menu before meals, and were not aware of how to obtain alternate items; one resident could not read the small print on the tray ticket, and the CDM acknowledged daily menu visits were missed.
A resident with diabetes, osteomyelitis, prior hallux amputation, and severe cognitive impairment developed a worsening left plantar foot wound that later probed to bone. Staff did not document timely podiatrist notification after the open area and infection were found, and interviews showed the resident was still being transferred by standing and pivoting with pressure placed on the left foot despite nonweightbearing status. The DON stated the resident was not changed to a mechanical lift until later, and the facility lacked documentation of an earlier transfer change to maintain nonweightbearing.
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.
Repeat deficiencies not adequately addressed in QAPI/QAA process
Penalty
Summary
The facility failed to adequately address repeat regulatory violations in F812, F880, F725, and F684, despite multiple prior citations in those same categories. A review of the State Agency Website and the Federal Provider History Report showed repeated deficiencies for F684 on 8/11/22, 8/28/24, 10/7/25, and again with the survey ending 5/20/26; for F725 on 8/11/22, 2/26/24, and again with the survey ending 5/20/26; for F812 on 8/11/22, 8/28/24, 10/7/25, and again with the survey ending 5/20/26; and for F880 on 8/11/22, 2/26/24, 8/28/24, and again with the survey ending 5/20/26. The facility’s QAPI and QAA activities, staff interview, and policy review were cited as part of the review, and in an interview on 5/20/26 at 4:05 PM, the Administrator acknowledged the repeat deficiencies and stated the facility would implement performance improvement plans to address the four repeated categories, citing staff turnover as the cause for the repeated issues.
Failure to Report Repeated Missing-Item Grievances
Penalty
Summary
The facility failed to uphold its grievance process when staff members did not consistently report repeated resident and family complaints about missing clothing and other lost items to management. Review of grievance logs from January 2026 through May 2026 documented at least 7 instances of lost or missing resident items, including 3 involving missing clothing. Multiple residents and representatives stated that clothing, T-shirts, wallets, purses, and other belongings had gone missing repeatedly, and several said they had reported the issues to CNAs, CMAs, RNs, or laundry staff but felt the concerns were not addressed or taken seriously. Interviews showed staff were unsure when to escalate complaints to leadership. A CNA stated she sometimes told her supervisor about missing clothing and sometimes did not. A CMA stated she did not know the procedure after laundry could not find missing clothes. An RN stated she tried to resolve complaints by contacting laundry and searching for items before involving leadership, but did not know when leadership should be notified. The laundry supervisor stated the facility kept missing laundry for about 6 months and acknowledged receiving some reports, but could not explain when leadership should be involved. The administrator stated anyone could fill out a grievance form and expected staff to do so when items could not immediately be found, and acknowledged this had not been done in each case. The facility policy dated May 2026 addressed complaints for non-staff members but did not include instructions for staff to report complaints or grievances to facility leadership.
Delayed Call Light Response and Staffing Shortages
Penalty
Summary
The facility failed to provide adequate staffing to meet residents’ needs and ensure timely responses to call lights. During direct observation on 5/12/26, Resident #11’s call light remained continuously engaged from 3:15 PM until 3:43 PM before a staff member entered the room, and the resident confirmed he had pushed the call light. Resident #11 and his representative stated that call lights often take a significant amount of time, sometimes well over 15 minutes, and that during times of high demand no one comes when he presses the call light. Resident #13 also reported on 5/13/26 that she had waited over an hour for assistance and was concerned the facility did not have enough staff, especially on weekends and overnight. Zone Activity Reports for multiple rooms documented repeated call light response times greater than 15 minutes, including waits of 18, 19, 20, 22, 25, 26, 27, 28, 29, 30, 33, 35, and 36 minutes across several dates and shifts. Staff interviews supported the concern: an RN stated the facility standard was 10 minutes for standard call lights and 5 to 7 minutes for bathroom call lights, and noted weekends were “horribly understaffed” with resident complaints about long waits. A CMA stated the facility used 5 minutes for bathroom calls and 15 minutes or less for others, but also said the call light system had issues and sometimes stayed on for a long period after being reset. The DON stated she had provided education on the 15-minute regulatory requirement and acknowledged that such long call light delays were not appropriate.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat residents with dignity and respect when a contracted therapist ignored residents’ wishes during therapy sessions. Resident #13, whose MDS showed a BIMS score of 13 and diagnoses including heart failure, hypertension, orthostatic hypotension, renal insufficiency, malnutrition, asthma, unsteadiness on feet, generalized muscle weakness, and abnormal gait and mobility, stated that Staff J pushed too hard during physical therapy and often ignored requests to stop standing because the resident could not stand any longer. Resident #13 described Staff J as rude and pushy and said other residents had complained about the therapist. Resident #14, whose MDS showed a BIMS score of 15 and diagnoses including renal insufficiency, diabetes, chronic pain, malignant neoplasm of bone, and bilateral lumbago with sciatica, also identified Staff J as rude and pushy. During an observed therapy session, Staff J ignored three separate requests from an unidentified resident to sit down, repeatedly told the resident to keep going, and only placed a wheelchair under the resident once the resident began to lose balance. Resident #14 also reported that Staff J told them they had to say please before getting water while they were out of breath. Staff J described the approach as tough love, while the DON and ADO stated that residents should be treated with respect and that the resident should have been allowed to sit when requested. The facility’s dignity policy stated residents are to be treated with dignity and respect at all times.
Unattended Miralax Left Without Self-Administration Orders
Penalty
Summary
The facility failed to have an order allowing residents to self-administer medications before leaving prepared Miralax unattended for two residents. Resident #10 had a BIMS score of 15, indicating intact cognition, and had a physician order for Miralax once daily for constipation, but no order permitting self-administration. On 5/12/26, a CMA left a cup of prepared Miralax with Resident #10 during lunch service, and by the end of the meal the medication had not been consumed and was left on the table. Dietary staff later discarded the cup during cleanup. The resident's MAR documented the Miralax as taken that day, and the CMA later stated the resident usually takes it but sometimes refuses, and that the resident had taken it on 5/12/26 after the CMA visually confirmed an empty cup. Resident #16 had a BIMS score of 7, indicating severe cognitive impairment, and also had a physician order for Miralax once daily for constipation without an order for self-administration. On 5/14/26, a CMA prepared Miralax mixed with water and brought it into the resident's room with other oral medications. The resident took the oral medications, drank only a few sips of the Miralax, and placed the remaining amount on the bedside table. The CMA left the room with the unfinished Miralax unattended. The DON acknowledged that leaving Miralax unattended in the resident's room was not acceptable, and stated staff administering medications should stay with the resident and watch them to ensure all medications are taken.
Failure to Complete Post-Procedure Assessment and Neurochecks
Penalty
Summary
Resident #4 lacked nursing assessment and follow-up after returning to the facility from a same-day surgical procedure. The resident had a BIMS score of 12, depended on staff for bathing and toileting, used a wheelchair for ambulation, and had diagnoses including acute kidney failure, diabetes, and incontinence. Records showed pre-operative evaluation and surgery-related paperwork, but the clinical record did not contain post-surgical physician orders, a nursing assessment on return, documented care instructions, or additional follow-up assessments related to the procedure. The first nursing entry identified related to the surgery was a progress note dated several weeks later. Staff interviews confirmed the gap in care documentation and follow-up. An RN recalled the resident returning from the procedure and stated that nursing staff would normally take vital signs, complete an assessment, communicate information, and monitor the resident for the next 72 hours, but acknowledged the record lacked a post-procedure nursing assessment. The DON stated staff should review for orders when a resident returns from a procedure, contact the medical provider if none are provided, and complete an assessment including vitals and visualization of the surgical site, with further assessments for the next 3 days. The Medical Director stated urinary stents are typically removed about a week after placement and confirmed staff did not contact them regarding the stent. Resident #3 lacked completion of neurological checks after an unwitnessed fall. The resident had a BIMS score of 9 and diagnoses including difficulty walking, cognitive communications defect, Wernicke's encephalopathy, weakness, need for assistance with personal care, and generalized muscle weakness, with a care plan identifying fall risk. Records showed the resident was found on the floor after an unwitnessed fall, later returned from the hospital after evaluation, and a neurological evaluation form was partially completed with multiple sections left blank or signed late. An RN stated neurochecks should begin immediately after an unwitnessed fall and resume when the resident returns from the hospital, and the DON stated she expected staff to resume neurochecks when the resident returned to the facility.
Failure to Supervise Cognitively Impaired Resident During Tornado Warning
Penalty
Summary
The facility failed to provide adequate resident supervision during a severe weather warning and failed to implement care plan interventions after a series of falls for Resident #16, affecting 1 of 9 residents reviewed for supervision. Resident #3 had a BIMS score of 9, indicating moderately impaired cognition, and the MDS listed difficulty walking, cognitive communication defect, Wernicke's Encephalopathy, weakness, need for assistance with personal cares, and generalized muscle weakness. The care plan identified a fall risk and included interventions noting anxiety during tornadoes and that the resident should not be left unattended, along with UA/C&S-related interventions. During an active tornado warning, Resident #3 was sitting in a recliner with a call light nearby when she attempted to self-transfer and lost her balance. Staff found her on her right side with a cut on her lip, redness on her face, and nonreactive pupils on her right eye. Staff interviews indicated cognitively impaired residents should be kept close, monitored, and assigned staff during disasters, and the DON stated she did not have a good answer for why supervision was not provided and agreed it should have been. The Severe Weather, Tornado Site Plan policy did not include instructions for cognitively disabled residents or residents prone to wandering.
Failure to Reweigh and Follow Up on Significant Weight Loss
Penalty
Summary
The facility failed to follow up after significant weight loss in two residents with feeding tubes and multiple medical conditions. Resident #2 had diagnoses including diabetes, CVA, hemiplegia/hemiparesis, malnutrition, and oropharyngeal dysphagia, and the record showed an enteral feeding tube had been used because of difficulty swallowing. His weight decreased from 220.44 lbs. to 208.2 lbs. in less than a month, and later to 206.1 lbs., with documentation showing 0-100% meal intake, multiple meal refusals, and variable fluid intake. The record also showed dietary recommendations for nutrient-dense intake and supplements, but there was no documentation of a reweigh the next day after the 5% or greater weight change, and no documented intervention related to the weight change over the following weeks. Resident #11 had diagnoses including diabetes, stroke, and esophageal obstruction, and also had a feeding tube. The weight summary showed a loss of 27.6 pounds over a very short period. Staff observed the resident’s enteral feeding tube not functioning, and the resident and representative stated it took a significant amount of time for staff to address feeding tube issues. The dietitian stated reweights should occur no later than 7 days after an initial weight showing a potential issue, and staff acknowledged that reweights did not always happen. Facility staff and leadership confirmed the breakdown in follow-up. A CNA stated reweights were often not done because staff were too busy, and an RN stated the usual practice was to reweigh after notifying the provider when a resident’s weight differed by more than 2 pounds, though this did not always occur. The DON acknowledged the sudden weight loss should have triggered a reweigh but did not have a good explanation for why it did not happen. The facility policy required any weight change of 5% or more to be retaken the next day for confirmation and, if verified, nursing was to immediately notify the dietitian in writing.
Failure to Properly Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to administer insulin correctly when a nurse did not properly prime an Insulin Lispro KwikPen before giving it to Resident #15. During observation on 5/13/26 at 11:21 AM, Staff I, an LPN, pressed the administration button on the insulin autoinjector without first setting any units of insulin to waste in the pen, and then administered the insulin to the resident. Staff I initially stated she had primed the pen, but later said she was not sure whether she had primed it with 2 units of insulin and confirmed that staff should prime the pen with 2 units before administration. Resident #15’s record showed intact cognition with an MDS score of 15 and diagnoses including anemia, hypertension, renal insufficiency, diabetes mellitus, and cellulitis of the right lower limb. The care plan directed staff to administer insulin as ordered, and the May 2026 MAR documented Insulin Lispro KwikPen for diabetes management. Staff H, an RN, stated the facility’s standard practice required priming two units of insulin before administration so the resident receives the full dose and the needle works correctly. The DON stated autoinjector pens require priming, typically with 2 units, before the correct dose is set and administered. The Instructions for Use for Insulin Lispro directed users to prime the pen to remove air from the needle and cartridge and to ensure the pen works correctly.
Improper Hand Contact With Resident Food
Penalty
Summary
The facility failed to ensure appropriate food handling practices were followed in both dining rooms observed. During a continuous lunch service observation in the Assist Dining Room, a CNA used bare hands to touch and butter a slice of bread at a resident’s table, and the resident then ate the bread. Later during the same observation, the CNA sneezed directly into their hand and, without completing hand hygiene, provided feeding assistance to a resident. In the Main Dining Room, a Dietary Aide was observed using bare hands to touch, cut, and prepare a fresh [NAME] at a resident’s table. The Administrator and DON acknowledged staff should not touch ready-to-eat resident food with bare hands, and the DON stated hand hygiene should have been completed after sneezing into the hands and before assisting residents.
Infection Control Failures During Resident Care and Device Cleaning
Penalty
Summary
The facility failed to provide infection prevention and control measures during personal care for a resident with severe cognitive impairment, Alzheimer’s disease, and stroke who depended on staff for transfers, bed mobility, personal hygiene, and toileting hygiene. During observed toileting and hygiene care, two hospice CNAs wore the same gloves throughout the task, cleaned the resident’s perineal area after removal of a soiled brief, and did not perform hand hygiene or change gloves before continuing other resident care. One CNA then touched the resident’s hand, head wrap, glasses, clothing, blankets, and bed remote control with the same gloves used for perineal care before both staff removed their gloves and performed hand hygiene. The facility also failed to implement Enhanced Barrier Precautions for a resident whose care plan identified EBP for tube feedings. The resident had dysphagia, a feeding tube, and a care plan intervention for EBP, but the room did not have signage indicating EBP was required when observed. Staff interviews reflected differing understanding of when EBP applied, with one RN and one CMA describing gowns and gloves for residents with wounds or indwelling devices, and the CMA stating staff did not need EBP if no sign was posted on the door. A third resident had an infected wound, a right foot surgical wound with a wound vac, and a PICC line, and the care plan included EBP. During blood sugar testing and insulin administration, an LPN wore gloves but did not wear a gown as outlined for EBP. After obtaining the blood sugar result, the LPN wiped the glucometer with an alcohol swab rather than following the facility’s described cleaning process using a Sani wipe and maintaining the required wet contact time. The DON stated staff should have followed EBP procedures and proper glucometer cleaning practices.
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.
Food Service Temperature Logs Missing and Dietary Sanitation Standards Not Followed
Penalty
Summary
Food was not served and prepared in accordance with professional standards for food service safety. Review of the August 2025 food temperature logs showed no breakfast temperature documentation for 21 of 31 days, no lunch temperature documentation for 21 of 31 days, and no supper temperature documentation for 10 of 31 days. Review of the September food temperature logs showed no breakfast temperature documentation for 9 of 30 days, no lunch temperature documentation for 11 of 30 days, and no supper temperature documentation for 21 of 30 days. The Certified Dietary Manager stated that food temperatures should be obtained and documented before and after each meal. During a continuous lunch service observation, an electrical extension cord wrapped to a bar on the service table was observed with visible dried food splatter and grime, and the tops of cabinets above a food prep area were observed with a layer of visible dust. A dietary employee was also observed with painted artificial fingernails, including two nails with small embellishments. The CDM acknowledged the condition of the extension cord and cabinet tops and confirmed that dietary staff should not have artificial nails. Facility policies stated that thermometers used to check food temperatures are to be clean, sanitized, and calibrated, that food temperatures held in steam tables are to be monitored throughout the meal, that kitchen and dining room surfaces not in contact with food are to be cleaned regularly to prevent grime accumulation, and that false nails and nail polish are not permitted for dietary team members.
Failure to Offer and Communicate Alternative Menu Options
Penalty
Summary
The facility failed to ensure that residents were aware of and offered alternative menu options for 2 of 3 residents reviewed for food, including Resident #4 and Resident #79. Resident #4 had a BIMS score of 12 and diagnoses including COPD, chronic pain, diabetes, hemiplegia/hemiparesis, malnutrition, and peripheral vascular/arterial disease. The resident was on a physician-prescribed weight loss regimen, had a right above-the-knee amputation surgical incision with dehiscence, and was receiving palliative care. The care plan included interventions to offer meal or snack alternatives as needed, but the resident reported eating in the room, not going to the dining room, and not being aware of how to order alternative menu items if they did not like what was offered. Staff stated menus were reviewed the day prior for some residents, but Resident #4 reported no staff member had reviewed the day's lunch menu with them before the meal. Resident #79 had a BIMS score of 13 and diagnoses including diabetes, hyperkalemia, renal insufficiency/renal failure/end stage renal disease, and sarcopenia. The care plan identified the resident as at risk for altered nutrition status and included interventions to provide meals within the diet and offer meal or snack alternatives as needed. The resident reported eating in the room and stated they were not able to get alternative menu items. During observation, the resident said no staff member had reviewed the day's lunch menu with them before the meal, and the tray ticket listed alternative menu items that the resident could not read because the print was too small. The Certified Dietary Manager acknowledged that they or the assistant dietary manager were supposed to visit residents daily for menu selections, but had not visited Resident #79 that week and may not get to Resident #4 every day; the new dietary menu system also did not print food preferences on individual tray tickets.
Failure to Protect Compromised Foot During Transfers and Delay in Podiatry Notification
Penalty
Summary
Staff failed to transfer a resident in a manner that would avoid pressure on the compromised left foot and failed to notify the podiatrist in a timely manner after an open area was found on the left plantar foot. Resident #6 had diagnoses that included osteomyelitis of the foot, diabetes, and heart failure, and the MDS indicated she required substantial to maximal assistance with chair-to-bed transfers and had severely impaired cognition with a BIMS score of 3 out of 15. Her record also showed a prior left hallux amputation and later documentation of a diabetic ulcer and skin impairment. On 9/5/25, an ARNP documented deterioration of the left plantar foot with malaise and a significant odor in the room, and a culture was obtained. The wound was treated with antibiotics, and subsequent notes described worsening drainage and odor. The facility did not document notification of the podiatrist about the open area and infection from the time it was discovered until the podiatry visit on 9/17/25. At that visit, the podiatrist noted a new opening on the plantar aspect at the subfirst metatarsal head that probed to bone, and the resident was to remain strictly nonweightbearing. Staff interviews showed the resident was still being transferred by standing and pivoting, with staff stating she placed pressure on the left foot during transfers and was not able to avoid weight bearing on that side. The resident also stated she did not wear her shoe unless someone made her and was barefoot during a transfer after a shower. The wound nurse stated she did not notify the podiatrist earlier because there was an upcoming appointment, and the DON stated the resident was only changed to a mechanical lift transfer on 10/6/25. The facility lacked documentation that the transfer status was modified to a mechanical lift before that date to maintain non-weightbearing status.
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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Illustrative
What surveyors actually found near you
We read the 449 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pleasant Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie Vista Village | 2.9 mi | ★★★★★ | 0 | 0 |
| Altoona Nursing And Rehabilitation Center | 3.6 mi | ★★★★★ | 19 | 0 |
| Valley View Village | 3.9 mi | ★★★★★ | 4 | 0 |
| Trinity Center At Luther Park | 5.4 mi | ★★★★★ | 17 | 1 |
| Azria Health Park Place | 6 mi | ★★★★★ | 25 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.