Parkview Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Reinbeck, Iowa.
- Location
- 1009 Third Street, Reinbeck, Iowa 50669
- CMS Provider Number
- 165522
- Inspections on file
- 21
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 8
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.
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.
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.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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