Parkview Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Wellman, Iowa.
- Location
- 516 13th Street, Wellman, Iowa 52356
- CMS Provider Number
- 165234
- Inspections on file
- 26
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Parkview Manor during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple diagnoses was involved in an incident where they were found unclothed with another resident. Despite an assessment indicating the resident could not identify harmful situations or avoid exploitation, the care plan was not updated to reflect this risk or the inability to provide informed sexual consent. Staff interviews confirmed the care plan should have addressed these findings, but it was not revised accordingly.
A resident with severe cognitive impairment and a history of aggression struck another resident in the face with a walker, causing a nasal fracture. Despite known behavioral risks and care plan interventions requiring close supervision and separation from others during agitation, staff were not present in the dining room at the time, allowing the incident to occur. The injured resident, who also had cognitive impairment, experienced ongoing fear and distress as a result.
Multiple residents did not receive ordered labs, medications, or follow-up care due to failures in transcribing and implementing provider orders. Orders for routine and as-needed labs, medication administration, and specialist referrals were missed or incorrectly documented, and dictated clinic notes were not consistently reviewed by nursing staff. The facility's inconsistent processes and reliance on agency staff contributed to these deficiencies, affecting residents with complex medical needs.
Two residents were not treated with dignity and respect: one was left in stained, inadequate clothing and with unkempt hair despite care plan directives, and another experienced distress after a room search led to the removal and delayed return of personal items important to her well-being. Staff acknowledged the issues, and the facility's assessment highlighted the need for person-centered care.
Surveyors found that two residents with cognitive and physical impairments did not have their call lights within reach during multiple observations. One resident with severe cognitive impairment and multiple diagnoses had the call light on the floor or hanging on the wall, while another resident needing mobility assistance had the call light placed on a chair out of reach. Staff and the DON acknowledged the expectation for call lights to be accessible to all residents.
A resident's code status was inconsistently documented across the EHR, care plan, and IPOST binder, with conflicting indications of DNR and CPR preferences. LPNs relied on both electronic and paper sources for code status information, leading to confusion due to discrepancies. Facility policy required proper validation and documentation, but this was not consistently followed.
Staff did not consistently mop the dining room floor or clean ceiling fans, resulting in persistent sticky floors, dried liquid stains, and thick dust on fans and ceilings. Interviews revealed inconsistent cleaning routines and unclear staff responsibilities, with no formal housekeeping policy in place for common area sanitation.
Medications requiring refrigeration, including insulin pens, were stored in a refrigerator with temperatures consistently above the facility's policy range. Staff were unclear about the correct temperature requirements, and the refrigerator was poorly maintained, with the freezer compartment filled with dried ice. These actions resulted in improper storage of drugs and biologicals.
Two residents reported being treated roughly and without respect during incontinence care by a CNA. One resident with severe cognitive impairment and another with intact cognition both expressed distress over the CNA's behavior. Despite being informed, the CNA continued inappropriate actions. The facility's administrator was unaware of the incidents until reviewing notes and initially perceived the concerns as cultural differences.
A facility failed to report allegations of abuse involving two residents in a timely manner, violating its abuse prevention policy. One resident with severe cognitive impairment reported rough treatment by a CNA, corroborated by her roommate. Another resident with intact cognition also reported similar behavior by the same CNA. Despite these reports, the facility did not document or report the incidents to the State Agency as required.
A facility failed to investigate abuse allegations and separate the alleged perpetrator from residents. A resident with severe cognitive impairment and another with intact cognition reported rough and rude behavior by a CNA. Despite these reports, the facility did not document investigations or ensure the CNA was removed from resident care. The Administrator was unaware of the incidents until days later, highlighting a lack of timely response.
A facility failed to notify a resident, their representative, and the ombudsman of a discharge, as required by policy. The resident, with intact cognition and diagnoses of bipolar disorder, anxiety, and depression, was sent to the hospital for evaluation due to increasing behaviors. The facility did not document the required notifications, and the Administrator confirmed the ombudsman was not informed.
A facility failed to provide a written notice of the bed-hold policy to a resident and/or their representative during a hospital transfer. The resident, with intact cognition and diagnoses including bipolar disorder, was transferred without documented notification of the bed-hold policy, contrary to the facility's policy. The Administrator believed the nurse communicated this information, but no documentation supported this.
A facility failed to document the decision-making process and notify a resident's family about appeal rights after not allowing the resident to return post-hospitalization. The resident, with a history of bipolar disorder, anxiety, and depression, exhibited erratic behavior following ECT treatment. Staff noted the behavior was uncharacteristic, but the facility did not document the clinical decision-making or consult a provider, nor did they provide necessary appeal information to the family.
A resident with a history of bipolar disorder and intact cognition exhibited erratic behaviors after ECT treatment, including undressing in public and urinating on the floor. Despite these changes, the facility failed to notify a physician or conduct an assessment during the night, delaying emergency care until the following morning.
A resident with diabetes was discharged from an LTC facility without a comprehensive plan, resulting in a lack of home health services and medication administration. Miscommunication and inadequate documentation led to the resident going without insulin for over a week. The facility failed to ensure a smooth transition, as required by their discharge planning policy.
The facility failed to respond to call lights promptly, with residents reporting waits of 30 minutes to over an hour. A resident with a chronic wound waited over an hour for assistance, while another with heart failure experienced delays in changing clothes. A resident post-surgery reported inconsistent response times, and another with incontinence faced long waits leading to accidents. Staff acknowledged staffing issues, and the facility lacked a formal call light policy.
A resident with a Stage 4 pressure ulcer did not receive consistent treatment as ordered, with missing entries and illegible initials in the Treatment Administration Records. The resident reported missed treatments, and staff interviews confirmed lapses. An LPN failed to complete a treatment, and an RN was unable to fulfill a treatment due to contract termination. The DON expected all treatment orders to be carried out, but discrepancies in care delivery were noted.
A resident with moderate cognitive impairment and a feeding tube was observed lying flat during enteral feeding, contrary to facility protocols requiring head of bed elevation to prevent aspiration. Additionally, the supplemental formula bag was not labeled with the date and time of initiation, as required by facility procedures. These deficiencies were confirmed by both a CNA and the DON.
The facility exhibited several infection control deficiencies, including improper handling of ice scoops, uncovered transport of clean laundry, and unsanitary conditions in the laundry area. Staff interviews revealed inadequate training and a shortage of PPE, with gloves not readily accessible. The infection preventionist confirmed that glove sizes were on backorder, and policies lacked guidance on PPE management.
A resident with severe mental illness did not receive prescribed medications upon admission, leading to increased agitation and aggressive behavior. Despite having medications available, staff failed to administer them due to software defaults and communication lapses. This resulted in physical altercations with another resident and a staff member, highlighting deficiencies in medication administration and staff coordination.
The facility failed to ensure residents were treated with dignity while being provided care. One resident was observed with their face positioned directly on a catheter bag, and another resident's room had persistent urine odors and stains, indicating a lack of proper hygiene and dignity in care practices.
The facility failed to maintain a clean and odor-free environment for a resident with cognitive impairment and incontinence issues. Observations revealed strong urine odors, urine-stained sheets, and full urinals left on the floor. The Housekeeping Supervisor confirmed frequent issues with odors due to spills and wet briefs left in the room.
The facility failed to complete wound treatments as ordered for two residents. One resident with multiple diagnoses did not receive prescribed treatments for her face, scalp, wrist, and nostrils on several occasions. Another resident with significant assistance needs did not receive treatments for an abrasion and Urea Cream application on specific dates.
The facility failed to ensure adequate personal hygiene services for three residents, including providing at least two bathing opportunities per week and proper catheter care. One resident was not provided scheduled bathing opportunities and refused showers on multiple occasions. Another resident did not receive scheduled bathing opportunities and had improper catheter care. A third resident was not provided scheduled bathing opportunities and refused showers on several occasions.
Failure to Update Care Plan for Resident at Risk of Exploitation
Penalty
Summary
The facility failed to update the care plan for a resident to reflect their risk for exploitation, despite evidence from assessments and staff observations indicating this risk. The resident in question had a BIMS score of 8, indicating moderately impaired cognition, and medical diagnoses including metabolic encephalopathy, non-Alzheimer's dementia, depression, and adjustment disorder. The care plan had previously addressed the resident's tendency to show affection to others, but did not address the risk of exploitation or the resident's inability to provide informed sexual consent. An incident occurred in which the resident was found unclothed in another resident's bed, with both residents unclothed and kissing. Staff intervened, performed a head-to-toe assessment, and separated the residents. The facility completed a verbal informed sexual consent assessment, which revealed that the resident did not demonstrate the ability to identify harmful situations or avoid exploitation. However, the care plan was not updated to reflect these findings or the resident's inability to provide informed consent. Interviews with the Administrator, Social Services, and the DON confirmed that the care plan should have been updated to reflect the resident's risk for exploitation and inability to give informed consent, but this was not done. The facility's policy requires that care plans include measurable objectives and interventions based on comprehensive assessments, but this requirement was not met in this case.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A resident with severe cognitive impairment and a history of sundowning and physical aggression struck another resident in the face with a walker, resulting in a nasal fracture. The aggressor's care plan identified risks for sundowning, poor impulse control, and previous aggressive behaviors, including prior attempts to hit other residents with a walker. Interventions in the care plan included anticipating needs, environmental modifications, and staff interventions to protect others, but these were not effectively implemented at the time of the incident. On the day of the incident, the aggressive resident and the victim were seated next to each other in the dining room before meal service, with no aides present in the room. Staff interviews revealed that the aggressor had previously exhibited similar behaviors, and staff were aware of the need to separate him from other residents and provide close supervision, especially during periods of agitation. Despite these known risks and care plan interventions, the resident was left unsupervised, allowing the incident to occur. Multiple staff members confirmed that the resident had attempted to hit others in the past and that interventions such as seating him near the nurse's station and providing one-on-one care were supposed to be in place. The victim, who had moderate cognitive impairment and a history of behavioral symptoms, sustained a minimally displaced nasal fracture and expressed ongoing fear and distress following the incident. The facility's abuse prevention policy required staff to provide a safe environment and monitor care to ensure residents are free from abuse or mistreatment. However, the lack of staff presence and failure to follow care plan interventions directly contributed to the resident-to-resident altercation and resulting injury.
Failure to Implement Provider Orders and Follow-Up Care
Penalty
Summary
The facility failed to carry out provider orders for multiple residents, as evidenced by missed laboratory draws, failure to administer medications as ordered, and lack of follow-up on diagnostic procedures. For several residents with chronic and acute conditions such as diabetes, heart failure, seizure disorders, and recent fractures, provider orders for routine and as-needed labs, medication administration, and specialist follow-up were not implemented as directed. In many cases, the orders were either not transcribed correctly onto the Medication Administration Record (MAR), were signed off in error, or were not acted upon at all. For example, residents with orders for routine labs every six months did not have labs collected as scheduled, and residents with orders for as-needed diuretics based on weight gain did not receive the medication when indicated by their weight records. Residents with complex medical needs, including those with recent falls and fractures, did not receive timely follow-up with specialists as ordered. In one instance, a resident who sustained a hip fracture and was discharged from the hospital with orders for orthopedic follow-up did not have the appointment scheduled, and there was no documentation of the follow-up visit. Similarly, another resident with a provider order for a sleep study due to insomnia and related symptoms did not have the study scheduled or completed, despite repeated documentation in clinic notes and nursing progress notes indicating the need for this diagnostic test. The facility's process for handling provider orders was inconsistent and lacked clear accountability. Orders communicated during provider rounds were not always transcribed or implemented, and dictated clinic notes containing new orders were not systematically reviewed or acknowledged by nursing staff. The facility's reliance on agency staff and frequent staff changes contributed to lapses in communication and follow-through. The facility's own policy required that provider orders be clearly documented, transcribed, and implemented, but this was not consistently followed, resulting in missed care interventions for multiple residents.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold residents' rights to dignity and respect for two residents. One resident with heart failure, dementia, and anxiety, and moderate cognitive impairment, was observed sitting in a common area wearing a thin, stained shirt without a bra, and with unbrushed hair. The resident reported not feeling well and having a rash on her chest. She indicated she did not have any other short sleeve shirts available. Staff initially responded by addressing the rash and later provided her with clean clothing options after being questioned about her attire. The care plan for this resident included goals to assist with self-care, encourage daily clothing changes, and maintain dignity, but these were not consistently implemented as observed. Another resident, with diagnoses including cancer, renal disease, diabetes, anxiety, and depression, and with intact cognition, reported distress after a room search resulted in the removal and misplacement of personal items, including scissors and tweezers of significant personal value. The resident stated she was told to obtain a lock box, which her family provided, but her items were lost for up to three weeks before being returned. Staff confirmed the room search was conducted for safety reasons and acknowledged the resident's upset over the loss and delay in returning her belongings. The facility assessment emphasized the importance of person-centered care and maintaining dignity, which was not fully observed in these instances.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents with cognitive and physical impairments. For one resident with severe cognitive impairment, dementia, and multiple physical diagnoses, the call light was observed on the floor or hanging on the wall, out of reach, during multiple observations. The resident was unable to access the call light to request assistance and expressed a desire for help. The care plan for this resident addressed communication needs but did not include specific instructions regarding call light accessibility. For another resident with moderate cognitive impairment and a need for assistance with mobility and self-care, the call light was found on a chair next to the resident, not within reach, while the resident was in a recliner and unable to reposition herself. The resident stated she wanted help to lie down in bed. Staff acknowledged the call light was not accessible and assisted the resident upon entering the room. The care plan for this resident did include a directive to keep the call light within reach, but this was not followed during the observed incident. The Director of Nursing confirmed that all residents are expected to have call lights accessible.
Failure to Accurately Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to accurately document and maintain a resident's cardiopulmonary resuscitation (CPR) status. Review of the resident's electronic health record (EHR) showed a profile page indicating Do Not Resuscitate (DNR) status, but the scanned EHR documents included a DNR IPOST for a different resident. Physician orders contained a verbal order for DNR status, while the care plan indicated that the resident and their responsible party requested CPR to be initiated. Additionally, the IPOST in the facility's binder reflected a CPR status, with verbal consent from the legal healthcare representative and physician signature documented. Interviews with LPN staff revealed that code status information was accessed from both the EHR profile page and a physical IPOST binder at the nurses' station, depending on the situation. The facility's policy required validation of code status orders upon admission and quarterly, with appropriate state-approved DNR forms signed before entering a No CPR order in the EHR. The inconsistency and lack of accurate documentation across multiple sources led to confusion regarding the resident's actual code status.
Failure to Maintain Clean and Sanitary Dining Room Environment
Penalty
Summary
Staff failed to thoroughly mop the dining room floor after each meal service and did not routinely clean the ceiling fans in the dining room. Observations revealed sticky floors, dried liquid stains, and a pink stain under a chair near the front entrance of the dining room, which persisted over consecutive days. Additionally, two ceiling fans closest to the entrance were covered in thick dust, with a visible ring of dust on the ceiling around the fans. These conditions were noted both after lunch and breakfast services, indicating a lack of consistent and thorough cleaning. Interviews with housekeeping staff and the Housekeeping Supervisor revealed inconsistencies in cleaning practices and uncertainty about responsibilities for cleaning the dining room and ceiling fans. Staff reported spot mopping due to scheduling conflicts with resident activities, and there was confusion about who was responsible for cleaning after dinner and for cleaning the ceiling fans. The Housekeeping Supervisor confirmed the presence of sticky floors and dusty fans and acknowledged the need for cleaning. The facility did not have a formal housekeeping policy for cleaning and sanitizing common areas, as confirmed by the Administrator.
Improper Refrigeration of Medications
Penalty
Summary
Surveyors observed that medications requiring refrigeration, including multiple insulin pens and other drugs, were stored in a medication refrigerator with temperatures consistently above the facility's policy range of 36 to 46 degrees Fahrenheit. On one occasion, the thermometer inside the refrigerator read 50 degrees. The temperature log for the month showed repeated instances of temperatures ranging from 46 to 50 degrees, with some days missing documentation entirely. Additionally, the freezer compartment was found to be almost completely filled with dried ice, except for two ice bags, indicating poor maintenance of the refrigerator. During interviews, a Registered Nurse was unsure of the exact required temperature but believed it should be around 40 degrees, while the DON stated it should be below 50 degrees but did not know the specific range. The facility's policy clearly stated that medications requiring refrigeration must be kept between 36 and 46 degrees Fahrenheit. The improper storage conditions and lack of staff knowledge regarding correct temperature requirements led to the deficiency in medication storage.
Failure to Ensure Dignity and Respect During Incontinence Care
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect during incontinence care, affecting two residents. Resident #2, who has severe cognitive impairment due to non-Alzheimer's dementia, multiple sclerosis, and diabetes, reported that a CNA was rough and mean during care. The resident's care plan emphasized the need for respectful communication due to past trauma and anxiety. An incident was reported where the CNA entered the room at night, pulled down the resident's pants without warning, and spoke harshly. The resident and her roommate expressed distress and requested that the CNA not return. Despite being informed of the issue, the CNA continued to exhibit inappropriate behavior in the resident's room. Resident #7, who has intact cognition and requires assistance with toileting hygiene, also reported that the same CNA was rude and rough during care. The resident felt that the CNA's manner was as if she was mad. Another CNA confirmed that Resident #7 had complained about being treated roughly. The facility's administrator was unaware of the specific incidents until reviewing progress notes and stated that concerns about the CNA were initially perceived as cultural differences. The administrator acknowledged that if such behavior was reported, it would warrant investigation and suspension of the staff member involved.
Failure to Report Allegations of Abuse in a Timely Manner
Penalty
Summary
The facility failed to report allegations of abuse for two residents, leading to a deficiency in their abuse prevention policy. Resident #2, who has severe cognitive impairment and requires assistance with toileting, reported that a CNA was rough and mean during care. The resident's roommate corroborated the account, stating that the CNA acted without warning and used harsh language. Despite these reports, the facility did not document the incident or report it to the State Agency within the required timeframe. The Director of Nursing was informed via text, but no immediate action was taken to address the situation. Resident #7, who has intact cognition and requires assistance with toileting, also reported that the same CNA was rude and rough during care. This was reported to a nurse by another CNA, but the facility again failed to document or report the incident to the State Agency. The Administrator was unaware of the severity of the situation and attributed the concerns to cultural differences, indicating a lack of communication and proper reporting within the facility. The failure to report these allegations in a timely manner is a clear violation of the facility's abuse prevention policy.
Failure to Investigate Abuse Allegations and Separate Alleged Perpetrator
Penalty
Summary
The facility failed to investigate allegations of abuse and did not ensure the separation of the alleged perpetrator from residents in two cases. Resident #2, who has severe cognitive impairment and requires assistance with toileting, reported that a CNA was rough and mean during care. The resident's roommate corroborated this account, stating that the CNA acted without warning and used harsh language. Despite these allegations, the facility did not document an investigation or ensure the CNA was removed from resident care during the shift when the incident was reported. Similarly, Resident #7, who has intact cognition and requires assistance with mobility and toileting, reported that the same CNA was rude and rough during care. Another staff member confirmed that Resident #7 had complained about the CNA's behavior. However, the facility again failed to document an investigation or separate the CNA from resident care. The Administrator was unaware of these incidents until reviewing progress notes days later, indicating a lack of timely response to abuse allegations.
Failure to Notify Resident and Ombudsman of Discharge
Penalty
Summary
The facility failed to notify a resident, their representative, and the ombudsman of a transfer or discharge, as required by policy. The resident, who had diagnoses including bipolar disorder, anxiety, and depression, was sent to the hospital for evaluation due to increasing behaviors. The Minimum Data Set (MDS) assessment indicated the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Despite the facility's policy requiring written notification in a language and manner understandable to the resident and their representative, and a copy sent to the Office of the State Long-Term Care Ombudsman, the facility did not document such notifications. The Administrator confirmed via email that the ombudsman was not notified of the discharge.
Failure to Provide Bed-Hold Policy Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to a resident and/or the resident's representative during a transfer to the hospital. The resident, who had diagnoses including bipolar disorder, anxiety, and depression, was assessed with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. According to the facility's policy dated 11/15/22, written information regarding the bed-hold policy should be provided prior to transferring a resident to the hospital. However, during the review of the clinical records, it was found that the Health Status note dated 2/4/25, which documented the planned transfer, lacked evidence of family notification or provision of bed-hold information. Additionally, the Discharge Evaluation from the same date did not include documentation regarding the bed-hold policy. The Administrator later stated that it was her understanding that the nurse on duty communicated with the family about the discharge, which should have included bed-hold information, but there was no documentation to support this.
Failure to Document and Notify Regarding Resident's Return Post-Hospitalization
Penalty
Summary
The facility failed to ensure proper documentation and notification procedures were followed when they did not allow a resident to return after hospitalization. The resident, who had diagnoses including bipolar disorder, anxiety, and depression, was noted to have intact cognition with a BIMS score of 14 out of 15. After an electroconvulsive therapy (ECT) treatment, the resident exhibited erratic behaviors such as urinating on the floor and undressing in public areas, which were out of character according to staff interviews. Despite these behaviors, the facility did not document the clinical decision-making process regarding the resident's inability to return, nor did they consult with a provider or specify which needs they could not meet. Additionally, the facility failed to provide the resident's family with necessary information regarding appeal rights, including contact details for the entity handling such requests and assistance in completing appeal forms. Interviews with staff revealed that the resident was generally pleasant and cooperative prior to the incident, and the sudden change in behavior was unexpected. The facility's administrator admitted to lacking documentation related to the decision-making process and mistakenly believed that appeal notices were unnecessary if the resident was out of the facility for more than ten days.
Failure to Provide Timely Emergency Care for Resident with Behavioral Changes
Penalty
Summary
The facility failed to provide timely emergency services for a resident, identified as Resident #8, who exhibited a significant change in behavior following an electroconvulsive therapy (ECT) treatment. The resident, who had diagnoses of bipolar disorder, anxiety, and depression, and was noted to have intact cognition, began displaying erratic behaviors such as urinating on the floor and undressing in public areas. Despite these changes, there was no documentation of an assessment or physician notification during the night when the behaviors were first observed. Staff interviews revealed that the resident's behavior was notably different from his usual demeanor, which was typically calm and sociable. Staff members reported that the resident appeared disoriented and behaved inappropriately, yet the facility did not notify a physician or send the resident for evaluation until the following morning. The Director of Nursing acknowledged that a change in mental status should prompt immediate provider notification, which did not occur in this instance.
Inadequate Discharge Planning Leads to Medication and Service Gaps
Penalty
Summary
The facility failed to develop and implement a comprehensive discharge plan for a resident, leading to a problematic transition to a post-discharge setting. The resident, who had intact cognition and required moderate assistance with daily activities, was discharged without a clear plan for home health services or medication administration. The discharge planning process was inadequately documented, and there was a lack of communication among the facility staff, the resident's managed care organization, and the host home where the resident was placed. The resident's discharge was complicated by a recent hospitalization and a new diagnosis of diabetes mellitus requiring insulin. Despite these complexities, the facility proceeded with the discharge without ensuring that necessary services and supports were in place. The social worker involved in the discharge planning was unaware of who was responsible for setting up a physician appointment necessary for home health services, and there were issues with obtaining the correct insulin and supplies due to pharmacy and insurance complications. The case manager and host home reported significant miscommunication and lack of coordination, resulting in the resident going without insulin and other medications for over a week. The facility's policy on discharge planning was not followed, as evidenced by the absence of a documented discharge plan that addressed the resident's needs and goals. This lack of planning and communication led to a failure in providing a smooth and safe transition for the resident.
Delayed Call Light Response Times in LTC Facility
Penalty
Summary
The facility failed to respond to call lights within a reasonable amount of time, as evidenced by multiple resident reports and call light logs. Residents reported waiting from 30 minutes to over an hour for assistance, which was corroborated by call light logs showing response times ranging from 19 to 40 minutes. Resident #22, who required assistance due to obesity and a chronic wound, reported waiting over an hour on the toilet. Resident #10, with a history of heart failure and falls, experienced delays in receiving help for changing clothes. Resident #50, who needed substantial assistance due to post-surgery conditions, also reported inconsistent response times. Resident #34, with bladder incontinence, experienced long waits leading to incontinent episodes. The facility's staff, including a CNA and the DON, acknowledged that staffing issues contributed to delayed response times, with the expectation being a 15-minute response time. However, the facility lacked a formal policy addressing call light response times. Resident council minutes indicated ongoing concerns about call light response times, with some improvement noted but still dependent on the staff present. The administrator confirmed the absence of a policy and the inability to print call light logs, which were only viewable at the nursing station.
Failure to Administer Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to carry out a treatment as ordered for a resident with a Stage 4 pressure ulcer. The resident, who had diagnoses including diabetes, respiratory failure, and morbid obesity, was noted to have a Stage 4 pressure ulcer on the left ischium. The treatment plan required the application of skin prep once daily for 16 days. However, the Treatment Administration Records (TARs) for July and August showed missing entries and illegible initials, indicating that the treatment was not consistently administered. The resident reported missed treatments, and staff interviews confirmed lapses in the treatment schedule. On one occasion, a Licensed Practical Nurse (LPN) failed to complete the treatment on the specified date, and a Registered Nurse (RN) admitted to signing off on a treatment with the intention of completing it later, but was unable to do so due to termination of her contract. The Director of Nursing (DON) expressed an expectation for staff to carry out all treatment orders, highlighting a discrepancy between expected and actual care delivery. The lack of consistent treatment documentation and administration contributed to the deficiency identified by the surveyors.
Failure to Maintain Proper Tube Feeding Protocols
Penalty
Summary
The facility failed to properly manage the care of a resident with a feeding tube, specifically in maintaining the appropriate head of bed elevation during enteral feeding and labeling the supplemental formula bag with the date and time of initiation. The resident, who had a moderate cognitive impairment and required partial to moderate assistance, was observed lying flat in bed while receiving tube feeding, contrary to the care plan and facility procedures that required the head of bed to be elevated to 45 degrees during and after feeding. This oversight was noted by both a CNA and the DON, who confirmed that the resident should not be flat during feeding due to the risk of aspiration. Additionally, the facility did not adhere to its policy of labeling the enteral feeding set with the date and time it was hung. On two separate occasions, the supplemental formula bag lacked proper labeling, which was confirmed by an LPN and acknowledged by the DON. The facility's procedures for enteral feedings, dated 2019, clearly instructed staff to label the administration set and maintain the head of bed elevation to prevent aspiration, yet these protocols were not followed for the resident in question.
Infection Control Deficiencies in Laundry and PPE Management
Penalty
Summary
The facility failed to implement appropriate infection control measures in several areas, including laundry handling, ice water distribution, and environmental cleaning. Observations revealed that a hospitality aide improperly handled the ice scoop by dropping it back into the ice after filling residents' cups. Additionally, clean laundry was transported in uncovered wire baskets, and the laundry area was found to be unsanitary, with piles of laundry on the floor and dryer lint filters not cleaned as required. A bag of trash with a brown liquid substance was observed leaking onto the floor in a hallway leading to the laundry and kitchen areas, further indicating lapses in environmental cleanliness. Interviews with staff highlighted issues with training and supply management. A laundry aide admitted to separating laundry on the floor and noted that dryer filters were supposed to be cleaned twice daily, but this was not consistently done. The facility was also experiencing a shortage of personal protective equipment (PPE), specifically gloves, which were not readily accessible in all resident areas. The infection preventionist confirmed that certain sizes of gloves were on backorder, and the facility's policies did not adequately address PPE management.
Failure to Administer Medications as Ordered Leads to Resident Agitation and Aggression
Penalty
Summary
The facility failed to administer medications as ordered for a resident, leading to increased agitation and aggressive behaviors. The resident, who had a history of severe mental illness and was admitted from a psychiatric hospital, did not receive prescribed doses of Trazodone and Quetiapine upon arrival at the facility. The Director of Nursing entered the medication orders into the electronic record, but due to a default in the software, the orders were set to start the following day. As a result, the resident did not receive the necessary medications on the day of admission, contributing to his agitation and aggressive behavior. The resident exhibited exit-seeking behavior and aggression, requiring multiple staff interventions. Despite having medications available in the facility's automated dispensing machines and in the resident's supply from the VA pharmacy, the medications were not administered as prescribed. Staff interviews revealed that medication aides did not always administer the medications due to unavailability or resident refusal, and they failed to document these occurrences or notify the nurses. This lack of communication and documentation contributed to the resident's behavioral escalation. The resident's aggressive behavior resulted in physical altercations with another resident and a staff member, leading to injuries. The facility's failure to administer medications as ordered and the lack of coordination and communication among staff members were significant factors in the events that transpired. The facility's policies on medication administration and emergency pharmacy services were not adequately followed, leading to the deficiency identified in the report.
Failure to Ensure Dignity and Proper Hygiene in Resident Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity while being provided care. Resident #14, who had a severely impaired cognitive status and required total dependence for mobility, transfers, dressing, toilet use, and personal hygiene, was observed being transferred into bed with a mechanical lift by two CNAs. During the care, one CNA placed the catheter bag on the bed at head level, causing the resident's face to be positioned directly on the catheter bag. Additionally, the CNA failed to cleanse the supra pubic catheter tubing and the stop valve tubing when emptying the catheter bag. The catheter bag was then placed on the bed frame, and a blanket was placed over the resident before the CNA left the room, indicating a lack of proper hygiene and dignity in care practices for Resident #14. Resident #14's diagnoses included cerebral palsy and obstructive uropathy, which necessitated careful and respectful handling during care procedures. The failure to follow proper protocols and maintain the resident's dignity during care was evident in this incident. Resident #21, who had a minimally impaired cognitive status and required assistance with mobility, transfers, dressing, toilet use, and personal hygiene, was frequently incontinent of bladder and always incontinent of bowel. Multiple observations revealed a strong odor of urine in Resident #21's room, with urine stains on the sheets and floor, and full urinals left on the floor. The housekeeping supervisor confirmed that the room had persistent odor issues due to residents spilling urinals and wet briefs being left in the room. This indicates a failure to maintain a clean and dignified environment for Resident #21, further compromising the resident's dignity and quality of care.
Failure to Maintain Odor-Free Environment
Penalty
Summary
The facility failed to ensure a clean and odor-free environment for Resident #21, who had a minimally impaired cognitive status and required varying levels of assistance with daily activities. Observations on multiple dates revealed a strong odor of urine in Resident #21's room, with specific instances of urine-stained sheets and full urinals left on the floor. The Housekeeping Supervisor confirmed that the room frequently had issues with odors due to residents spilling urinals and leaving wet briefs and pull-ups in the room.
Failure to Complete Wound Treatments as Ordered
Penalty
Summary
The facility failed to complete wound treatments in accordance with physician orders for two residents. Resident #15, who had a moderately impaired cognitive status and multiple diagnoses including Non-Alzheimer's dementia and respiratory failure, did not receive prescribed treatments for her face, scalp, wrist, and nostrils on multiple occasions. Specifically, treatments involving bacitracin, Vaseline, Sulfamylon, and Sodium Chloride Nasal Solution were either not transcribed on the Treatment Administration Record (TAR) or not administered as ordered on several dates in April and May 2024. This resulted in missed treatments on specific dates, including 4/25/24, 4/29/24, 4/30/24, and 5/1/24, among others. Similarly, Resident #12, who had an intact cognitive status but required significant assistance with daily activities and had multiple diagnoses including coronary artery disease and diabetes mellitus, did not receive prescribed treatments for an abrasion on his right inner thigh and for the application of Urea Cream 10% on his lower legs. The TAR indicated that these treatments were not provided on the evenings of 4/3, 4/21, and 4/27 for the abrasion, and on 4/3 and 4/21 for the Urea Cream. These omissions indicate a failure by the facility to adhere to physician orders and maintain professional standards of quality in wound care management for these residents.
Failure to Provide Adequate Personal Hygiene and Catheter Care
Penalty
Summary
The facility failed to ensure adequate personal hygiene services for three residents, including providing at least two bathing opportunities per week and proper catheter care. Resident #12, who had an intact cognitive status and required maximal assistance with daily activities, was not provided bathing opportunities as scheduled on two occasions and refused showers on two other occasions. The care plan for Resident #12 included specific instructions for bathing and skin inspection, which were not consistently followed. Resident #14, who had a severely impaired cognitive status and required total dependence for daily activities, was not provided bathing opportunities as scheduled on six occasions. Additionally, during observations, staff failed to properly cleanse the resident's suprapubic catheter tubing and stop valve, and placed the catheter bag in a position that allowed the resident's face to come into contact with it. The care plan for Resident #14 included specific instructions for bathing and catheter care, which were not consistently followed. Resident #18, who had an intact cognitive status and required moderate to maximal assistance with daily activities, was not provided bathing opportunities as scheduled on five occasions and refused showers on three other occasions. The care plan for Resident #18 included specific instructions for bathing and nail care, which were not consistently followed. The facility's catheter care policy outlined specific procedures for maintaining hygiene standards, which were not adhered to during the observed care of Resident #14.
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A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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