Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Parkview Manor Care Center during CMS and state inspections, most recent first.
The facility failed to respond to call lights within its 15-minute policy for two cognitively intact residents who were dependent on staff for ADLs, toileting, and transfers using a standing mechanical lift. One resident with heart failure and a history of falls reported that staff often took a long time to answer, and call light logs showed a response delay of over 27 minutes. Another resident with bilateral leg impairment, carotid stenosis, dysthymic disorder, and breast cancer reported that call lights were not always answered within 15 minutes and sometimes had to use a cell phone to reach the nurses’ desk; audit data showed multiple call light responses delayed from about 27 minutes to over an hour. The DON stated she was unaware of resident complaints about call light response times and believed corporate audits indicated calls were answered within the required timeframe.
Surveyors observed a dirty kitchen and dining room with limescale and rust on the dishwasher and ice machines, dirty hand-washing stations, and a very dirty dish room floor with leaves under the shelves. A Dietary Aide carried clean cups against his shirt while serving a resident, and staff interviews showed inconsistent cleaning practices, incomplete sign-offs on the monthly cleaning list, and an ongoing problem de-liming the dishwasher and ice machines. The facility sanitation policy did not address cleaning hand-washing stations or de-liming the dishwasher and ice machine.
Detached base board boiler system register covers were observed on the floor in four resident rooms during repeated walkthroughs. A family member said this was typical and reported dust and debris under furniture at times. A CNA, housekeeper, Maintenance Supervisor, and Administrator all acknowledged the condition, and the Administrator stated he had no work order slips for the covers.
Failure to notify the LTC Ombudsman of hospital transfers for two residents. One resident had intact cognition with heart failure, CAD, and depression, and the other had moderately impaired cognition with heart failure, anemia, and depression. Both residents were transferred to the hospital and later readmitted, but the facility’s Ombudsman transfer forms did not document the hospital transfers, and the SW stated she did not always know when someone went to the hospital to update the report.
A resident with moderately impaired cognition and depression had an antidepressant listed in the care plan for major depressive disorder, recurrent, moderate, but the record did not contain an updated PASRR after the resident’s diagnosis changed. The existing Level 1 PASRR did not include major depression, and the facility policy required a follow-up PASRR when a new mental health diagnosis was identified.
Failure to Post Required Daily Nurse Staffing Information: The facility's daily staffing posting did not include the total hours worked for each category or identify whether each nurse on shift was an LPN or RN. Observations over multiple days showed the posting was incomplete, and staff and the DON said the new scheduling software was causing problems with the required posting. The facility also lacked a policy for the daily staff posting.
A staff member accused of physical and verbal abuse against a resident with Alzheimer's was not separated from residents in a timely manner, continuing to work shifts after the incident. The facility's policy for immediate reporting and separation was not followed, leading to a delay in addressing the alleged abuse.
A resident with Alzheimer's and dementia was involved in an incident where a CNA responded with verbal and physical actions after the resident became combative. The incident was not reported to the appropriate authorities in a timely manner, as required by the facility's policy, leading to a delay in investigation and notification to the Department of Inspections, Appeals and Licensing.
A resident with moderately impaired cognition and a history of suicidal ideation attempted to harm himself by wrapping a bed remote cord around his neck. Despite previous incidents and verbal threats, the facility failed to secure potentially harmful cords in the resident's room, leading to an immediate jeopardy situation. The resident's care plan interventions were not fully implemented, and staff interviews revealed inconsistencies in supervision and monitoring.
A resident with a history of diabetes and Alzheimer's was at high risk for pressure ulcers, yet the facility failed to consistently document and provide appropriate care for their stage 2 pressure ulcers. Despite having a care plan, the facility did not complete required assessments or document treatments, leading to fluctuating ulcer conditions. Interviews revealed confusion about treatment application, and the resident's family noted a lack of observed care, resulting in a deficiency in pressure ulcer management.
The facility failed to provide sufficient staff, resulting in delayed call light responses for several residents. A resident with intact cognition reported waiting up to 30 minutes for assistance, leading to accidents. Another resident with impaired cognition experienced distress and self-harm due to delays. Staff confirmed insufficient staffing, particularly on weekends, and Resident Council Minutes highlighted ongoing concerns. The facility's policy required call lights to be answered within 15 minutes, but this was not consistently achieved.
The facility failed to provide adequate clinical rationale for declining gradual dose reductions (GDR) for psychotropic medications in four residents. These residents, with varying levels of cognitive impairment, were on multiple psychotropic medications, including antipsychotics and antidepressants. The physician's notes lacked clinical rationale for denying GDR requests, and no changes were made to the medication orders, contrary to the facility's policy requiring attempts at GDR unless contraindicated.
A resident with Alzheimer's disease, requiring total assistance with toileting, was verbally abused by a CNA during care. The resident became combative and verbally abusive, prompting the CNA to respond with inappropriate language. The incident was witnessed by another staff member and confirmed by the CNA. Facility policy prohibits such abuse, and the CNA was suspended pending investigation.
A facility failed to ensure a resident's code status was available due to missing documentation of the IPOST in the designated binder. Staff acknowledged that the absence of the IPOST would require contacting the DON, potentially delaying CPR. The DON confirmed the IPOST was not in the binder until obtained from Hospice after a delay, despite the facility's policy to consider residents full code without an IPOST.
A resident with severely impaired cognition and multiple medical conditions developed an unstageable pressure ulcer due to a catheter. The facility failed to notify the physician and family about this significant change in condition, as confirmed by the DON. The facility's policy required immediate notification of such changes.
A facility failed to provide the correct Medicare notices to a resident whose skilled stay ended, resulting in a deficiency. The resident, with intact cognition, did not receive the required Advance Beneficiary Notice of Non-Coverage (CMS 10055) or the Notice of Medicare Non-Coverage (CMS 10123 NOMNC) at the end of their skilled stay. Instead, an incorrect form was given, contrary to the facility's policy.
A facility failed to develop a comprehensive Care Plan for a resident using high-risk medications. The resident, with moderately impaired cognition and multiple health conditions, was prescribed Sertraline HCL, Clonazepam, and Ativan for anxiety disorder. However, the Care Plan lacked details on these medications, their side effects, and monitoring requirements. A Corporate Nurse confirmed the expectation for such inclusions, aligning with the facility's care planning policy.
The facility failed to revise care plans for three residents, leading to deficiencies in care. A resident with impaired cognition developed a pressure ulcer due to a catheter, but the care plan lacked interventions. Another resident experienced multiple falls, but the care plan was not updated promptly. A third resident's care plan was not updated after a fall with injury. The facility's policy for comprehensive care plans was not consistently followed.
A resident with a J-tube did not have the tube placement verified as per physician orders. The LPN administered medications without checking placement by auscultation, as required. The DON expected staff to use a stethoscope to verify placement, aligning with facility policy, but this was not followed, leading to a deficiency.
A resident with severe cognitive impairment and multiple health issues did not receive timely face-to-face visits from a physician or NPP as required. The facility's policy mandates visits every 60 days, but there were significant gaps between visits, confirmed by a corporate nurse.
A significant medication error occurred when an agency nurse, unfamiliar with the facility's systems, administered Xanax and morphine to a resident who was not prescribed these medications. The error was due to a lack of proper resident identification and verification, as well as insufficient orientation and training for the nurse. The mistake was identified by another nurse during a narcotic count, highlighting the need for adherence to medication administration policies.
The facility failed to follow infection prevention practices and medication administration guidelines for three residents. A CNA and an LPN did not use enhanced barrier precautions (EBP) for residents with indwelling devices, and a CMA improperly administered a dropped pill. The DON expected adherence to EBP and proper medication handling, as per facility policies.
A CNA inappropriately took over a task from two other CNAs, causing a resident with severe cognitive impairment to become agitated. The CNA responded with foul language and disrespectful remarks. The incident was confirmed by other staff, and the CNA was terminated following an investigation.
Untimely Call Light Responses for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to respond to resident call lights within the 15-minute timeframe required by its April 2019 Call Light Response policy, which directs staff to answer call lights within 15 minutes and to receive notifications via door lights, a call light panel at the nurse’s station, or handheld electronic devices. For one resident with intact cognition, heart failure, a history of falls with fractures, and an ADL self-care performance deficit, the MDS and care plan documented the need for substantial assistance with showers, hygiene, toileting, and transfers using a standing mechanical lift, as well as use of a wheelchair and positioning bar. This resident reported that staff did not respond to her call light within 15 minutes and that she timed responses, noting that about four to five times per week it took staff a long time to answer. An electronic call light log showed that on one occasion her call light, activated at 1:30 PM, was not answered for 27 minutes and 21 seconds. Another cognitively intact resident with bilateral leg impairment, wheelchair use, dependence on staff for toileting and hygiene, frequent urinary incontinence, and diagnoses including carotid stenosis, dysthymic disorder, and breast cancer, also had an ADL self-care performance deficit care plan requiring a standing mechanical lift transfer to the commode with one staff, assistance with repositioning, moderate assistance for dressing, and total dependence for bathing. This resident stated that staff did not always answer her call light within 15 minutes and that when this occurred, she used her cell phone to call the nurses’ desk for assistance, and she felt the facility was short staffed and used a lot of agency staff. Electronic call light audit data for this resident showed multiple delayed responses: one call answered 44 minutes and 50 seconds after activation, another answered 1 hour and 2 minutes after activation, and another answered 27 minutes and 21 seconds after activation. The DON reported she was not aware residents complained about untimely call light responses, believed corporate call light audits were in the “green zone” indicating calls were answered within 15 minutes, and acknowledged only a few family complaints at care conferences that she felt had been addressed.
Sanitation and Dish Handling Deficiencies in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain a sanitary kitchen and dining room and failed to handle dishes in a sanitary manner to reduce the risk of cross contamination and food borne illness. During an initial walk-through of the kitchen on 8/18/25, surveyors observed limescale and rust on the dishwasher, limescale build-up inside and outside the kitchen ice machine, and limescale and rust on the dining room ice/water machine, including rust on the water spout. Dirty hand-washing stations were also observed in the dishwashing room and kitchen, and the dishwashing room floor appeared very dirty with leaves under the shelves. On 8/19/25, the same conditions remained during follow-up observation: limescale was still present on the dishwasher and ice machines, and the hand-washing stations remained dirty. During this observation, a Dietary Aide carried a stack of clean special non-spill cups against his shirt through the kitchen, filled them, and took them to a resident in the dining room. Staff interviews indicated inconsistent cleaning practices and no cleaning schedule for some tasks. The Dietary Manager stated staff followed a monthly cleaning list and daily tasks, but also acknowledged an ongoing problem de-liming the dishwasher and ice machines. The Administrator stated the expectation was to clean the ice machine and dishwasher monthly. The monthly cleaning task list for August 2025 showed incomplete sign-offs for multiple tasks, including only one initial for all PM tasks on 8/14/25. The facility sanitation policy assigned the dining service supervisor responsibility for the cleaning schedule and routine floor cleaning, but it did not include instructions for cleaning hand-washing stations or de-liming the dishwasher and ice machine.
Detached Register Covers Left on Resident Room Floors
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by leaving base board boiler system register covers detached and/or on the floor in Rooms #1, #6, #10, and #18. During walkthroughs on 8/18/25, 8/19/25, and 8/20/25, surveyors observed the register covers on the floor in each of the identified rooms. The facility reported a census of 26 residents. During interviews, an anonymous family member stated it was typical to see the register covers detached and/or on the floor and reported dust, candy wrappers, and a toothbrush under the bed or dressers at times. A CNA stated staff complete maintenance slips for repairs needed in resident rooms and reported observing the register covers detached and/or on the floor in the identified rooms. A housekeeper stated broken items are reported to maintenance and said rooms are cleaned daily, including sweeping under dressers and beds, and acknowledged seeing the register covers detached and/or on the floor. The Maintenance Supervisor stated he did not have work order slips for the register covers and said the covers come off daily when bumped by lifts, beds, or wheelchairs. The Administrator stated he routinely saw the covers off, did not have maintenance work order slips for them, and expected staff to complete work order slips for the detached and/or floor register covers.
Failure to Notify LTC Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the LTC Ombudsman for 2 of 2 residents who transferred to the hospital. Resident #6 had an MDS assessment showing a BIMS score of 15, indicating intact cognition, and diagnoses of heart failure, coronary artery disease, and depression. The clinical census showed the resident was on unpaid hospital leave on 5/19/25 and returned to the facility on 5/22/25. A health status note documented the transfer to the local hospital, and another note indicated the facility received a call reporting the resident had transferred to another hospital. The admission/readmission UDA documented the resident’s return to the facility from the hospital. Resident #24 had an MDS assessment showing a BIMS score of 10, indicating moderately impaired cognition, and diagnoses of heart failure, anemia, and depression. The clinical census showed the resident was admitted to the hospital on 1/22/25 and readmitted to the facility on 1/27/25. A health status note documented that the hospital called and reported the admission, and the admission/readmission UDA reflected the resident’s return to the nursing facility from the hospital. The facility’s Notice of Transfer Form to Long Term Care Ombudsman for May 2025 and January 2025 lacked documentation of these hospital transfers, and the Social Worker stated she did not always know when someone went to the hospital to update the Ombudsman report, though transfers to the hospital should be included.
Failure to Submit Updated PASRR for Resident With New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) evaluation for one resident with a new mental health diagnosis. Resident #24’s MDS assessment identified a BIMS score of 10, indicating moderately impaired cognition, and included a diagnosis of depression. The care plan also reflected use of an antidepressant for major depressive disorder, recurrent, moderate. However, the resident’s Level 1 PASRR dated 10/22/22 did not include a diagnosis of major depression, and the clinical record contained no PASRR after that date. During interview, the Administrator stated that if a resident had a diagnosis change or medication change, the facility should submit a new PASRR. The facility policy on PASRR screens and evaluations directed staff to complete a follow-up PASRR when a resident received a new mental health diagnosis.
Failure to Post Required Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information with the required staffing data for a census of 26 residents. On 8/18/25 at 11:17 AM, 8/19/25 at 9:55 AM, and 8/20/25 at 2:57 PM, observation of the staff posting showed it did not include the total hours worked for each category and did not identify whether the nurse on each shift was an LPN or RN. During an interview on 8/20/25 at 2:58 PM, Staff C, LPN stated the overnight shift posts the daily staffing information and was unsure why the hours per shift were not included. The DON stated on 8/20/25 at 3:10 PM that she places the next day's posting behind the current day posting at the end of the day and explained the new scheduling software did not allow edits to add the hours per shift. The Administrator stated on 8/20/25 at 3:31 PM that the new scheduling software was rolled out at the end of June 2025 and had caused problems getting it to work for the facility's needs. The facility also lacked a policy for the required daily staff posting.
Failure to Separate Alleged Abuser from Residents
Penalty
Summary
The facility failed to separate a staff member accused of alleged physical and verbal abuse from dependent residents in a timely manner. The incident occurred on 8/30/24, involving a resident with Alzheimer's disease and moderately impaired cognition, who required total assistance with toileting and was always incontinent. The staff member continued to work their shifts on subsequent days without being separated from the residents, resulting in an immediate jeopardy situation. The incident was reported by a CNA to a Licensed Practical Nurse (LPN) shortly after it occurred, but the LPN did not notify the Director of Nursing (DON) or the Administrator immediately. The CNA described the staff member's inappropriate behavior, including verbal abuse and physical contact with the resident. Despite the report, the staff member continued to work until the situation was addressed on 9/3/24, when the DON was informed and took action. The facility's policy required immediate reporting of abuse allegations to the charge nurse, who should then inform the Administrator or designated representative. The policy also mandated immediate measures to prevent further potential abuse, such as suspending the accused employee. However, these procedures were not followed, leading to a delay in addressing the alleged abuse and ensuring resident safety.
Removal Plan
- The facility began and completed education for all charge nurses to send the alleged abuser home immediately upon receiving information of alleged abuse. The staff member will remain off work until incident is investigated.
- The facility terminated the alleged abuser/employee.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to notify the Department of Inspections, Appeals and Licensing (DIAL) in a timely manner regarding an alleged incident of physical and verbal abuse involving a resident. The incident occurred on the night of August 30, 2024, when a Certified Nursing Aide (CNA) reported that a resident attempted to hit or slap another CNA, who then responded with verbal and physical actions against the resident. The CNA reported the incident to a Licensed Practical Nurse (LPN) shortly after it occurred, but the facility did not begin its investigation until September 3, 2024, and reported the incident to DIAL later that day. The resident involved in the incident had a history of Alzheimer's disease and dementia with behavioral disturbances, requiring total assistance with toileting and being always incontinent. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition and physical behavioral symptoms. During the incident, the resident became combative, and the CNA involved responded with inappropriate language and physical contact, which was witnessed by another staff member who reported it to the LPN. The delay in reporting the incident was due to a lack of communication and understanding of the reporting protocol among the staff. The LPN who was informed of the incident did not notify the Director of Nursing (DON) or the Administrator immediately, as required by the facility's policy. The DON was unaware of the incident until September 3, 2024, when another staff member brought it to her attention. This delay resulted in the facility being notified of an immediate jeopardy situation by the Department on September 24, 2024.
Removal Plan
- The facility disciplined and educated the nurse about their requirement to separate the employee from the resident and report to the Director of Nursing (DON) and/or Administrator immediately.
- The facility began education to all staff regarding timeliness of reporting potential abuse of a resident by a staff.
- The Director of Nursing (DON) called the remaining staff to review abuse education.
Failure to Prevent Resident Self-Harm Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident who attempted suicide by wrapping a bed remote cord around his neck. The resident, who had a history of moderately impaired cognition and multiple medical diagnoses, was admitted to the facility and had difficulty adjusting to the new environment. Despite the resident's previous incident with a call light necklace cord and verbal threats to harm himself, the facility did not secure the cords in his room, leading to an immediate jeopardy situation. The resident's care plan included interventions to remove or secure potentially harmful items in his room, but these were not fully implemented. After the resident's suicide attempt, the facility staff failed to conduct a thorough assessment or documentation of the resident's mental and physical status before returning unsecured television and cable cords to his room. The resident's wife requested the return of the cords so he could watch television, but the facility did not ensure the cords were properly secured, leaving the resident at risk. Interviews with staff revealed that the resident had expressed suicidal thoughts and had previously wrapped a call light necklace around his neck. Despite these warning signs, the facility did not maintain consistent 15-minute checks or secure the cords in the resident's room. The lack of proper supervision and failure to adhere to the facility's policy for residents at risk of suicide contributed to the deficiency.
Removal Plan
- The Director of Nursing (DON), Provisional Administration and Administrator in training (AIT) entered Resident #21's room, secured the bed electrical cord, the cable cords and television cords with zip ties.
- They repositioned the television, moved Resident #21's recliner across the room away from the television, and removed the bed remote.
Deficiency in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide and document appropriate care for a stage 2 pressure ulcer for a resident, leading to a deficiency in pressure ulcer management. The resident, who had a history of type 1 diabetes, Alzheimer's Disease, and muscle weakness, was identified as being at high risk for pressure ulcers. Despite having a care plan in place that included interventions such as regular skin assessments, use of pressure-reducing devices, and application of ointments, the facility did not consistently follow these protocols. The Braden Scale, which assesses skin health, was not completed quarterly as required, and there was a lack of documentation for the treatment of the resident's pressure ulcers from February to September 2024. The resident's skin condition was documented in various Skin/Wound Notes, which showed fluctuating measurements and conditions of the pressure ulcers on the resident's buttocks and ischium. Despite the presence of a treatment order for Calmoseptine ointment, the Treatment Administration Records (TARs) lacked consistent documentation of its application. Interviews with the Wound Nurse and the Director of Nursing (DON) revealed that the treatment was not being documented as expected, and there was confusion regarding the application of the ointment based on the condition of the skin. The deficiency was further highlighted by the resident's family member, who reported not observing the staff performing the treatment on the resident's pressure ulcers. The facility's failure to adhere to its own policies and procedures for pressure ulcer care, including regular assessments, documentation, and communication with the care team, contributed to the ongoing issues with the resident's skin condition. This lack of consistent care and documentation led to the deficiency identified by the surveyors.
Staffing Deficiency Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, as evidenced by multiple instances of delayed call light responses. Resident #23, with intact cognition, reported experiencing call light response times of up to 30 minutes, particularly on weekends, leading to bowel and bladder accidents. The facility's call light report confirmed two instances where Resident #23's call light was on for more than 15 minutes. The Administrator acknowledged staffing challenges during evenings and weekends, despite efforts to overstaff during these times. Resident #21, with moderately impaired cognition, experienced significant delays in call light responses, leading to distress and a reported incident of self-harm. His wife noted that while call lights were usually answered within 5 minutes, there was an instance where it took 20-25 minutes. The facility's call light report showed four instances of delays exceeding 15 minutes. Staff described Resident #21 as impatient and noted his tendency to yell or put himself on the floor when frustrated by delays. Resident #7 and Resident #10 also reported delays in call light responses, particularly on weekends, with call light durations exceeding 15 minutes on several occasions. Staff members, including CNAs, confirmed insufficient staffing to answer call lights promptly. Resident Council Minutes from August and September reflected ongoing concerns about call light response times, particularly in the afternoons and on weekends. The facility's policy required call lights to be answered within 15 minutes, but this standard was not consistently met.
Lack of Clinical Rationale for Denying GDR in Residents
Penalty
Summary
The facility failed to provide adequate clinical rationale for declining gradual dose reductions (GDR) for psychotropic medications in four out of five residents reviewed. These residents were receiving various psychotropic medications, including antipsychotics, antidepressants, and antianxiety drugs. The facility's policy requires attempts at GDR in two separate quarters unless contraindicated, with clear documentation of any changes or adverse effects. However, the physician's notes for the residents in question lacked clinical rationale for denying GDR requests, and no changes were made to the medication orders. Resident #3, with severely impaired cognition, was on multiple psychotropic medications, including Aripiprazole and Bupropion, without a documented rationale for not attempting GDR. Similarly, Resident #8, also with severely impaired cognition, was on Seroquel and Sertraline, with GDR requests denied without explanation. Resident #9, with moderately impaired cognition, was on Brexpiprazole, Seroquel, and Duloxetine, again with GDR requests denied without rationale. Lastly, Resident #11, with Alzheimer's and anxiety, was on Haloperidol and Alprazolam, with no changes made to the medication orders despite the lack of clinical rationale for denying GDR. The Director of Nursing acknowledged the issue and intended to discuss it with the physician.
Verbal Abuse Incident Involving Resident with Alzheimer's
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member. Resident #9, who has moderately impaired cognition due to Alzheimer's disease and unspecified severity dementia with behavioral disturbances, was involved in the incident. The resident's Minimum Data Set (MDS) indicated they required total assistance with toileting and were always incontinent. During a care episode, Resident #9 became combative and verbally abusive towards Staff A, a Certified Nurse Aide (CNA). In response, Staff A verbally retaliated by using inappropriate language towards the resident. The incident was corroborated by another staff member, Staff B, who witnessed the exchange during the first rounds. Staff A admitted to the verbal abuse during an interview. The facility's policy on abuse prevention clearly states that all residents have the right to be free from abuse, including verbal abuse, which is considered a form of mental abuse. The Director of Nursing confirmed the incident and noted that Staff A was suspended pending investigation.
Failure to Ensure Resident's Code Status Availability
Penalty
Summary
The facility failed to ensure that a resident's current code status was readily available, as evidenced by the absence of a completed Minimum Data Set (MDS) assessment and documentation regarding advance directives for one resident. The resident's Iowa Physician Orders for Scope of Treatment (IPOST) was not found in the designated binder on the crash cart, which was the only location where the facility kept such documents. Staff members, including an LPN, acknowledged that the absence of the IPOST in the binder would necessitate contacting the Director of Nursing (DON) to determine the resident's code status, potentially delaying the initiation of CPR in an emergency. The DON confirmed that the facility's procedure involved completing the IPOST with the resident or their family during the admission process and placing a copy in the binder while sending the original to the physician for signature. However, in this case, the resident's family had retained the IPOST at home, and it was only obtained from Hospice and placed in the binder after a delay. The facility's policy stated that in the absence of an IPOST, the resident should be considered a full code, but the lack of immediate access to the document could hinder timely medical response.
Failure to Notify Physician and Family of New Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician and family regarding the development of a new pressure ulcer for a resident with severely impaired cognition. The resident required substantial assistance with bed mobility, transfers, and toileting, and had an indwelling catheter. The resident's medical history included anemia, hypertension, heart failure, atrial fibrillation, renal disease, and benign prostatic hyperplasia. The resident was identified as being at risk for developing pressure ulcers. A progress note dated 8/21/24 documented the presence of an unstageable pressure ulcer due to a medical device, specifically a catheter, located at the right groin/gluteal fold. The ulcer was described as a large, irregularly shaped open area with yellow and brown slough. The clinical record lacked documentation of notification to the physician or family about the new pressure ulcer. The Director of Nursing confirmed the absence of such notifications and stated that the facility's policy required immediate notification of the physician and family in the event of a significant change in condition. The facility's policy, revised in October 2023, mandated notifying the resident's representative and primary care provider as soon as possible in person or by phone when there is a significant change in condition.
Failure to Provide Correct Medicare Notices
Penalty
Summary
The facility failed to provide the required Medicare notices to a resident whose skilled stay ended, resulting in a deficiency. Specifically, the facility did not issue the Advance Beneficiary Notice of Non-Coverage (CMS 10055) when the resident's skilled stay ended on May 8, 2024, nor did they provide the Notice of Medicare Non-Coverage (CMS 10123 NOMNC) when the skilled stay ended on June 28, 2024. Instead, the resident was given an incorrect form, the CMS R 131, on June 26, 2024, which was not the appropriate document for the situation. The resident involved had intact cognition, as indicated by a BIMs score of 13, and was admitted for a Medicare Part A skilled stay. Despite the facility's policy requiring the provision of these notices two days prior to the end of services, the administrator confirmed that the correct forms were not provided. This oversight occurred even though the facility's policy, revised in January 2024, clearly instructed staff to issue these notices upon admission, when Medicare services end, and periodically during the resident's stay.
Failure to Include High-Risk Medications in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive Care Plan for a resident, identified as Resident #21, who was at risk due to the use of high-risk medications. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition and required partial/moderate assistance with transfers and locomotion. The resident had multiple diagnoses, including atrial fibrillation, hypertension, heart failure, renal disease, benign prostatic hyperplasia, stroke, and non-Alzheimer's dementia. Despite these conditions, the Care Plan lacked information about the usage of antidepressants and antianxiety medications, potential side effects, and monitoring requirements. Physician orders were in place for the administration of Sertraline HCL, Clonazepam, and Ativan for anxiety disorder, with specific dosages and schedules. However, the Care Plan did not reflect these medications or the necessary precautions and monitoring associated with their use. A Corporate Nurse, identified as Staff K, confirmed the expectation that the Care Plan should include high-risk medications and their side effects. The facility's policy on Comprehensive Person-Centered Care Planning, revised in October 2023, instructed that the Care Plan should include services to maintain the resident's highest practicable well-being, which was not adhered to in this case.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plan for three residents, leading to deficiencies in their care. Resident #15, with severely impaired cognition and multiple health issues, including an indwelling catheter, developed an unstageable pressure ulcer due to a medical device. Despite multiple refusals to lie down for treatment, the care plan did not address the new pressure ulcer or provide interventions to prevent catheter-related pressure. The care plan also lacked guidance on managing the resident's refusal to reposition. Resident #21, with moderately impaired cognition and a history of falls, experienced six falls within a short period. The care plan was not updated with interventions for these falls until much later, despite an incident report recommending keeping the bed in the lowest position. Observations revealed that the bed was not consistently kept in the low position, and the care plan was not promptly updated after each fall, as expected by the DON. Resident #6, with intact cognition and a history of hypertension, diabetes, anxiety, and depression, experienced a fall with injury. However, the care plan was not updated with interventions for this fall until over a month later. The facility's policy required comprehensive care plans to be developed and implemented based on the resident's needs, but this was not consistently followed, as noted by the DON, who acknowledged that nurses sometimes failed to update the care plans promptly.
Failure to Follow Physician Orders for J-tube Placement Verification
Penalty
Summary
The facility failed to adhere to physician orders regarding the verification of the placement of a jejunostomy tube (J-tube) for a resident. The resident, who had intact cognition and was diagnosed with cancer, hypertension, renal insufficiency, anxiety, and depression, was using a feeding tube. The physician's order required the position of the J-tube to be verified each shift by auscultating for a swooshing sound of an air bolus or measuring the tube from the abdominal wall to the top edge. However, during observations on two separate occasions, a Licensed Practical Nurse (LPN) administered medications via the J-tube without checking its placement as per the physician's orders. Interviews with the LPN revealed that they checked the placement by checking residual, which was not in accordance with the physician's orders. The Director of Nursing (DON) expected the staff to check placement by using a stethoscope to auscultate while pushing air in and pulling back to check residual. The facility's policy on enteral feedings also directed staff to check the patency of a jejunostomy feeding tube by auscultating the epigastric region and instilling an air bolus. This discrepancy between the expected procedure and the actions taken by the staff led to the deficiency noted in the report.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a physician or non-physician practitioner (NPP) conducted face-to-face visits, including comprehensive assessments, every 60 days for a resident. This deficiency was identified for one of the five residents reviewed for physician services. The resident in question had a severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMs) score of 3, and required substantial assistance with bed mobility, transfers, and toileting. The resident also had an indwelling catheter and multiple diagnoses, including anemia, hypertension, heart failure, atrial fibrillation, renal disease, and benign prostatic hyperplasia. The clinical record showed that the resident was seen by a physician on three specific dates, with significant gaps between visits: 127 days and 96 days, respectively, between the required comprehensive assessments. Staff K, a corporate nurse, confirmed that the resident missed two physician visits in April and August 2024. The facility's policy, in line with OBRA federal guidelines, mandates that residents be seen every 30 days for the first 90 days after admission and once every 60 days thereafter, with visits alternating between a physician and a physician's assistant or nurse practitioner. The failure to adhere to this schedule resulted in the identified deficiency.
Medication Error Due to Lack of Verification and Training
Penalty
Summary
The facility failed to administer medication appropriately, resulting in a significant medication error involving two residents with the same first name. Resident #1, who had moderately impaired cognition and did not have prescriptions for opioid or antianxiety medications, was mistakenly given Xanax and morphine that were prescribed for Resident #6. This error occurred due to a lack of proper identification and verification procedures by Staff L, an agency nurse working at the facility for the first time. Staff L, who had not received orientation or training on the facility's electronic clinical record system, administered the wrong medications to Resident #1. She did not use the computer to verify resident identities with photographs, as she had already given other medications without it. The error was discovered by Staff M, an RN, who noticed discrepancies during a narcotic count and observed Staff L coming from the wrong area of the building. Staff L confirmed the error after reviewing the Medication Administration Record and resident photographs with Staff M. The facility's policy required verification of resident identity before medication administration, which was not followed in this instance. The Director of Nursing and other staff members acknowledged that an orientation checklist was not completed for Staff L, and the expected procedures for medication administration, including using the computer and verifying resident identity, were not adhered to. This oversight contributed to the medication error, as Staff L was not adequately prepared to administer medications safely in the facility.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to appropriate infection prevention practices by not following enhanced barrier precautions (EBP) and medication administration guidelines for three residents. Resident #3, with severely impaired cognition and an indwelling catheter, did not receive proper EBP during catheter care as the certified nursing assistant (CNA) did not wear a gown, mistakenly believing it was optional. Similarly, Resident #10, who had a feeding tube, did not receive care with EBP as the licensed practical nurse (LPN) also did not wear a gown, under the impression that it was unnecessary. The Director of Nursing (DON) expected staff to apply EBP for residents with indwelling medical devices, as per the Centers for Disease Control and Prevention guidelines. Additionally, during a medication pass, a certified medication assistant (CMA) dropped a pill into the medication cart drawer and proceeded to administer it to Resident #1 without discarding it, contrary to the facility's medication administration policy. The policy required that any wasted dose be replaced and documented, but the CMA only considered replacing the pill if it had fallen to the floor. The DON clarified that the expectation was to discard any dropped medication and obtain a new dose, highlighting a lapse in following established procedures.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect. On 3/23/24, a Certified Nursing Assistant (CNA), identified as Staff A, entered the room where two other CNAs, Staff B and Staff C, were assisting a resident with a mechanical lift. Staff A took over the task without informing the resident, causing agitation. When the resident expressed frustration, Staff A responded with foul language and disrespectful remarks. The resident, who had severely impaired cognition and required assistance for transfers, did not recall the incident later. The Care Plan for the resident indicated that staff should be extra patient due to the resident's dementia. Staff B and Staff C confirmed that Staff A used inappropriate language and acted rudely towards the resident. Staff D, an LPN, assessed the resident after the incident and found no physical injury. The Director of Nursing (DON) completed an investigation, during which Staff A was suspended and subsequently terminated for violating the facility's abuse policy. The facility's policy on abuse prevention clearly states that residents have the right to be free from abuse, including verbal abuse, which was defined as using disparaging and derogatory terms within the hearing distance of residents.
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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.
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Nursing homes near Reinbeck
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside | 8 mi | ★★★★★ | 6 | 0 |
| Grundy Care Center | 8.4 mi | ★★★★★ | 15 | 0 |
| Westbrook Acres | 11.3 mi | ★★★★★ | 8 | 0 |
| Sunrise Hill Care Center | 12 mi | ★★★★★ | 7 | 0 |
| Harmony House Health Care Center | 12.7 mi | ★★★★★ | 14 | 0 |
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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.