Pine Acres Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Des Moines, Iowa.
- Location
- 1501 Office Park Road, West Des Moines, Iowa 50265
- CMS Provider Number
- 165350
- Inspections on file
- 38
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Pine Acres Rehabilitation And Care Center during CMS and state inspections, most recent first.
Staff failed to maintain resident dignity and respond appropriately to needs in several instances. A resident with chronic pain and a leg fracture was left on the toilet for an extended period after activating the call light, despite multiple staff reportedly walking past without responding, and later reported that an LPN was intimidating and did not provide requested PRN narcotic pain medication for severe pain, leading the resident to cry in pain. Two residents reported that staff routinely entered their rooms without knocking, which was directly observed when staff interrupted interviews without announcing themselves. Another dependent resident with CVA, malnutrition, aphasia, dementia, and severely impaired cognition was observed being fed by a CNA who appeared disengaged, did not interact with the resident, mechanically placed food and a straw into the resident’s mouth, and rubbed her eye before continuing to feed, contrary to expectations for dignified, respectful care.
Surveyors found that the facility failed to fully incorporate key interventions into the comprehensive care plans for two residents. One resident with a history of stroke, unsteadiness, and a recent fall from bed had been instructed by staff to keep the bed in the lowest position while asleep, but this specific fall-prevention measure was not documented in the care plan, which only referenced general mobility assistance and a clutter-free environment. Another resident with severe cognitive impairment, dementia with behavioral disturbances, anxiety, and depression had an active order for antianxiety medication and documented anxiety behaviors, yet the care plan did not list the antianxiety medication, did not describe the target anxiety behaviors for staff to monitor, and did not include non-pharmacologic interventions for anxiety management.
Staff failed to protect a resident’s heels during a mechanical lift transfer and did not provide required supervision for an at-risk smoker. One resident with impaired cognition, bilateral leg weakness, stroke history, and a moderate Braden risk was observed being transferred from bed to wheelchair in a mechanical lift by an OT and a CNA, during which his heels were dragged across the mattress and later noted to be red, contrary to staff statements and facility policy that feet should be elevated and not contact the mattress during active movement. Another resident with hemiplegia, stroke, and other comorbidities had documentation and a care plan stating he was not an independent smoker, lacked spatial and self-awareness, and required supervised smoking, yet he was able on separate early mornings to wheel himself to the enclosed courtyard, cancel or trigger the door alarm, and access the smoking area without staff present, despite a policy requiring supervision per the care plan.
Facility staff did not consistently respond to resident call lights within a reasonable time, especially during evening and night shifts. Several cognitively intact residents reported waiting 30–45 minutes for assistance with toileting and personal care, with one resident left on the toilet for an extended period and another going to bed without proper hygiene. A resident also described a prolonged delay in response while choking on mucous. Resident Council minutes documented concerns about long call light wait times, staff turning off call lights, and staff wearing earbuds during care. Although the DON and CNAs stated that call lights should be answered promptly and the written policy required all staff to respond to activated call lights, these expectations were not consistently met.
A resident with multiple chronic conditions and intact cognition received another resident’s medications after a CMA pre-poured meds for several residents, left them on the med cart, and handed responsibility to a trainee CMA who did not follow the 6 rights of medication administration or verify identity using the MAR. The trainee, unaware that a new resident shared the same room and lacking a photo in the EHR for comparison, administered a muscle relaxant, anticonvulsant, anti-anxiety, and antihypertensive intended for someone else. The resident reported being told the pills were hers despite voicing concern, then blacked out, fell from a scooter, developed hypotension and bradycardia, and required ICU admission with medication and intermittent vasopressor support.
Surveyors found the facility failed to maintain a safe, clean, and comfortable environment, with observations of stained carpets, peeling paint, water damage, dust buildup, and soiled resident equipment. A resident's wheelchair was dirty, had a broken wheel lock, and showed signs of neglect. Facility staff and the DON confirmed these issues, and facility policy required a higher standard of cleanliness and maintenance.
Multiple residents with significant care needs, including those with morbid obesity, heart failure, stroke, and hemiplegia, experienced excessive delays in staff responding to call lights, sometimes waiting over an hour or more. Residents described staff turning off call lights and not returning, and observations confirmed that call lights were not always accessible. The DON stated the expectation was a 15-minute response, but this was not consistently met, resulting in unmet care needs and residents seeking help on their own.
Staff failed to follow infection control protocols during resident care and meal assistance, including not changing gloves or performing hand hygiene between residents, improper handling of catheter drainage equipment, and inadequate use of PPE during care for residents with MDROs. Supplies of gowns for enhanced barrier precautions were also found to be insufficiently stocked.
A resident with stroke, dementia, and hemiplegia who was fully dependent on staff for toilet hygiene did not receive complete incontinence care. During observed care, staff failed to cleanse the inner thighs, outer buttocks, and hips as required by facility policy, despite removing a wet brief and cleansing other areas. The DON confirmed that all areas should have been cleansed.
Staff were observed repeatedly failing to perform hand hygiene while serving food and drinks, handling utensils, and feeding residents by hand, as well as not cleaning shared equipment between resident uses. These actions did not follow facility infection control policies and created unsanitary conditions during meal service and equipment use.
The facility experienced repeated deficiencies in areas such as care plan development, accident prevention, and infection control due to an ineffective QAPI process. Multiple surveys found ongoing failures to update care plans for residents with specific medical needs, ensure proper supervision for those at risk of accidents, and maintain infection prevention standards. Despite having policies in place, the facility did not prevent recurrence of these issues, as evidenced by repeated citations over several years.
A resident with severe cognitive impairment and multiple diagnoses was transferred to the hospital, but the facility failed to document the transfer, notify the physician and family, or provide a bed hold notice as required by policy. Review confirmed these omissions in the resident's electronic health record.
A resident's MDS assessment did not reflect a serious mental illness diagnosis as determined by the state Level II PASRR, despite clinical records and PASRR documentation confirming the condition. The facility's policy required accurate documentation of all medical and psychosocial issues, and staff confirmed the expectation for accuracy.
A resident with multiple mental health diagnoses and prescribed psychotropic medications did not have an updated PASRR evaluation submitted after changes in their condition and care plan. The original PASRR indicated no mental health conditions or related medications, despite subsequent documentation and care plan updates reflecting significant mental health issues and medication use. Facility staff confirmed that no new PASRR was submitted, contrary to policy requirements.
A resident with multiple chronic conditions and incontinence did not have a comprehensive care plan addressing toileting hygiene or assistance. Staff and DON confirmed the absence of toileting interventions in the care plan, and repeated observations noted a strong urine odor in the resident's room, with inconsistent incontinence care documented.
A resident with multiple diagnoses, including dementia and mobility issues, experienced a fall resulting in a right clavicle fracture. Despite new orders for weight bearing as tolerated to the right upper extremity, the care plan was not updated to reflect the fracture or the new mobility status, contrary to facility policy and documentation in the health record.
Nursing staff did not document or implement a pharmacist-recommended gradual dose reduction for a psychotropic medication in a resident with multiple complex diagnoses. Despite agreement from the NP, there was no evidence that the order was processed or clarified, and the resident continued on the same dosage, contrary to facility policy requiring proper documentation and follow-through on medication changes.
Surveyors found that a resident's medications were pre-set and left in a medication cart, and that opened stock medications were not dated as required. A CMA confirmed the practice of setting aside medications for later administration, and the DON acknowledged that this did not follow facility policy, which requires medications to be prepared at the time of administration and opened medications to be dated.
Two residents did not receive adequate supervision or environmental safety as required by facility policy. One resident, with complex medical needs, was allowed to smoke unsupervised and without protective equipment, despite care plan requirements. Another resident with moderate cognitive impairment and mobility issues left the facility without staff knowledge or following the sign-out protocol, leading to a facility-wide search before he was located and returned.
A resident with multiple complex medical conditions, including ESRD and a central venous catheter, was admitted without proper assessment or care planning for the central line. Facility staff failed to obtain treatment orders, monitor the site, or perform dressing changes, despite documentation and resident reports indicating the line was present and the dressing was dirty. The facility did not follow its policy requiring physician notification and treatment orders for wound or line care.
A resident with a history of SUD and multiple behavioral health diagnoses exhibited erratic and escalating behaviors, including agitation and threats, which led to hospitalizations and positive drug screens. Facility staff reported not receiving training specific to SUD, and the resident's care plan lacked risk assessments, monitoring strategies, and interventions for substance use or overdose. The facility's behavioral health training and policies did not address SUD, resulting in inadequate support for the resident's behavioral health needs.
A resident with a history of diabetic foot ulcers did not receive diabetic shoes as ordered, leading to the development of a foot ulcer and subsequent amputations. The facility failed to follow up with the shoe vendor, despite the resident's request and worsening condition. Interviews revealed that the vendor requested additional paperwork, but the facility did not provide it, resulting in a lack of preventative foot care.
The facility failed to update care plans for several residents following changes in advance directives and smoking status. Discrepancies were found between IPOST and care plans, and smoking safety measures were not documented. Staff interviews revealed that established procedures for updating care plans were not consistently followed.
The facility failed to ensure resident safety during smoking activities and wheelchair transfers. A resident was found with smoking materials despite policy requiring them to be stored at the nurses' station. Another resident smoked without a protective apron, and a third resident, who required supervision, was observed smoking unsupervised. Additionally, a resident was transported in a wheelchair without foot pedals, posing a risk of injury.
The facility failed to maintain appropriate food temperatures and ensure sanitary cleaning of dishes and utensils, as evidenced by incomplete food temperature logs and dishmachine quality assurance forms. Despite having the necessary tools, staff did not consistently adhere to the facility's policies on food safety and sanitation.
The facility was found to have unsanitary kitchen conditions, including debris on the walk-in freezer floor, an uncovered fryer full of oil, and unlabeled cereal containers. The Certified Dietary Manager admitted to a lack of required cleaning checklists, and the facility's policies mandate daily and weekly inspections to ensure compliance with sanitation regulations.
A facility failed to complete a criminal record and abuse registry check before rehiring a Registered Nurse. The nurse began working with residents without the necessary clearance, as the background check process was only completed two months later. This oversight was identified during an employee record audit.
The facility failed to address high-risk medications in a resident's care plan and did not follow the smoking protocol for another resident. One resident's care plan lacked guidance on insulin and antidepressants, while another resident was found with smoking materials despite a care plan directive to keep them at the nurses' station. The DON confirmed the need for adherence to care plans.
The facility failed to maintain consistent documentation of code status for two residents, leading to discrepancies between IPOST forms, care plans, and EHRs. Staff interviews revealed reliance on EHR headers for code status, which could result in errors if not accurately updated. Facility policy required clear documentation and communication of code status changes, which was not consistently followed.
A facility failed to consistently perform required pre-dialysis and post-dialysis assessments for a resident with ESRD, despite clear directives in the care plan and physician's orders. The resident, with intact cognition, reported the lack of routine assessments, and the EHR showed missing documentation for several treatments. Staff confirmed the necessity of these assessments, which were also outlined in the facility's hemodialysis policy.
A resident with hemiplegia, anxiety, and diabetes, dependent on staff for toileting, was left unattended despite activating the call light and calling for help. Observations showed staff walking past without assisting, and the resident remained in wet clothing for an extended period. The facility's policy requiring a five-minute response time was not followed, indicating a deficiency in staffing and policy adherence.
A facility failed to implement proper infection control practices for a resident with an indwelling catheter, leading to a urinary tract infection. The resident, with intact cognition and a history of obstructive uropathy, had cloudy urine in the catheter. A CNA lifted the catheter bag above the bladder, causing backflow, and did not perform proper hand hygiene. The facility's policy required the drainage bag to be below the bladder level.
A facility failed to ensure a resident received up-to-date pneumococcal vaccinations. The resident's immunization record lacked documentation of their vaccination status, despite signing a consent form indicating interest in receiving the vaccine. The Provisional Administrator acknowledged the lack of documentation. Facility policies require documentation of vaccination status, but this was not adhered to in this case.
The facility failed to ensure that two residents were provided with up-to-date COVID-19 vaccinations. One resident, admitted in 2014, had their last COVID-19 vaccination in 2022, with no record of an updated vaccine in 2023. Another resident, admitted in 2022, had their last vaccination in 2021, with no documentation of an updated vaccine in 2022 or 2023. The Provisional Administrator acknowledged the lack of documentation for these residents' vaccination status, contrary to the facility's policies.
A resident with severe cognitive impairment and a history of exit-seeking behavior left the facility unsupervised and was found 0.2 miles away after a fall. Despite wearing a wander guard bracelet, the resident was able to exit without staff noticing. The resident's routine was potentially disrupted by a hospice visit and room cleaning, contributing to the elopement.
A resident with severe cognitive impairment and high fall risk experienced multiple falls due to inadequate supervision and failure to wear gripper socks as per their care plan. Despite interventions, the resident fell again, resulting in a hip fracture. The facility's documentation and staff interviews highlighted inconsistencies in following the care plan, particularly regarding the resident's footwear.
The facility failed to obtain ordered laboratory tests for two residents, despite physician orders and existing policies. One resident, with multiple health conditions, did not have INR, CBC, and UA tests completed as ordered. Another resident, with severe cognitive impairment, did not have a UA test sent to the lab. The DON confirmed the absence of these tests, highlighting a failure to meet professional standards of care.
A resident with a history of Alzheimer's and hip fracture, identified as high risk for falls, was found on the floor after a fall, resulting in a hip fracture. Despite care plan revisions requiring assistance for ambulation, the resident was observed walking independently without supervision. Staff acknowledged the resident's independence and refusal of assistance, which was not adequately addressed, leading to the deficiency.
A resident with a history of UTIs was hospitalized for sepsis and a UTI due to inadequate incontinence care. Staff failed to follow proper hygiene protocols, such as changing gloves between tasks and performing hand hygiene, during incontinence care. These actions were against the facility's policies, leading to a deficiency.
A long-term care facility failed to provide oxygen therapy according to physician orders for three residents, leading to deficiencies in respiratory care. One resident with COPD was found with an empty portable oxygen tank, while another with heart failure had their oxygen set incorrectly. A third resident's care plan lacked specific interventions for oxygen therapy. The facility's policy required adherence to physician orders, but staff failed to ensure portable tanks were adequately filled and set correctly.
The facility failed to arrange transportation for two residents to attend medical appointments, resulting in missed cardiology and orthopedic follow-ups. One resident with multiple health issues missed several cardiology appointments due to lack of scheduling, while another with a hip fracture had their orthopedic appointment rescheduled due to a scheduling conflict. The facility's policy on timely transportation scheduling was not followed, leading to these deficiencies.
The facility failed to administer medications as directed by physicians' orders for two residents with severe cognitive impairments. One resident's Lidocaine topical pad was not started until four days after the order, and another resident's urine analysis was delayed, leading to a delay in antibiotic treatment.
The facility failed to provide the required two baths per week for three residents, as documented in their MDS assessments. Interviews and electronic documentation confirmed the lapses in care, with residents expressing a desire for more frequent bathing and the Interim Administrator acknowledging the failure to meet expectations.
Failure to Maintain Resident Dignity, Timely Call Light Response, and Appropriate Pain Management
Penalty
Summary
Facility staff failed to maintain resident dignity and timely response to needs in multiple situations. One cognitively intact resident with osteoarthritis, chronic pain, and a history of a fall with fracture required assistance of one staff for toileting and transfers and was non‑weight bearing to the left lower leg while receiving therapy for a leg fracture. This resident reported that a CNA assisted her onto the toilet and left the room; after activating the call light within about five minutes, no staff responded for approximately 45 minutes, despite her roommate observing several staff walking past the room without answering the call light. The resident stated that the CNA who eventually responded was not assigned to her hall and that being left on the toilet for that length of time made her feel like no one cared about her. The same resident also reported that when she requested PRN pain medication for left leg pain rated at 7, staff told her she could not receive PRNs at that time because they could not locate the assigned LPN. When the LPN did respond, the resident stated the nurse was mean and intimidating, insisted she would receive Tylenol instead of the PRN narcotic ordered for higher levels of pain, and that this behavior caused the resident to avoid requesting narcotics when that nurse was on duty. The resident reported sitting and crying for two hours due to pain and experiencing breakthrough pain related to therapy, and stated she had informed the DON that she endured a lot of pain because the LPN did not administer the requested PRN medication. Additional dignity concerns were identified with other residents. One resident reported that staff frequently entered his room without knocking, and this was observed when a staff member entered during an interview to check his ice without knocking. Another resident reported that staff had been entering his room without knocking for a long time and that he was fed up; this was observed when three staff entered his room without knocking and interrupted an interview. During a lunch observation, a dependent resident with CVA, malnutrition, aphasia, dementia, severely impaired cognition, and total dependence on staff for eating was fed by a CNA who sat with her elbow on the table, head resting on her hand, did not look at or interact with the resident, mechanically placed food and a straw into the resident’s mouth, and rubbed her eye before resuming feeding without apparent hand hygiene. These actions and inactions occurred despite facility policies on promoting/maintaining resident dignity and call light response, and staff and DON statements that expectations included timely call light response, knocking and announcing before entering, and providing appropriate pain control and dignified, engaged feeding assistance.
Failure to Include Fall-Prevention and Antianxiety Interventions in Resident Care Plans
Penalty
Summary
Surveyors identified that the facility did not develop and implement complete, individualized care plans for two residents following changes in condition and treatment. For one resident with a history of stroke, unsteadiness on feet, and muscle weakness, records showed the resident fell from bed while sleeping and was hospitalized. Progress notes documented that new fall prevention interventions would be determined upon the resident’s return and that the care plan was reviewed and updated. The revised care plan referenced the fall and directed staff to assist with mobility and maintain a clutter-free environment, but it did not include the specific intervention that staff had instructed the resident to follow: keeping the bed in the lowest position when asleep. During interviews, the resident confirmed staff had given this instruction, and an LPN and CNA both stated that such a bed-positioning intervention should appear in the care plan, but it was not present. For another resident with severely impaired cognition, non-Alzheimer’s dementia with behavioral disturbances, anxiety, and depression, the MDS and electronic health record documented an order for antianxiety medication and described the behaviors the resident exhibited when anxious. A progress note also described the resident’s anxiety behaviors and indicated they had not been recently observed. However, the resident’s care plan, although it listed an anxiety disorder, did not include the ordered antianxiety medication, did not specify the resident’s anxiety behaviors for staff to monitor, and did not outline any non-pharmacological interventions for staff to attempt. In interviews, an LPN and CNA indicated that the antianxiety medication, target behaviors, and related interventions should be included in the care plan, and the DON stated that care plans should be updated to accurately reflect care based on physician orders, consistent with the facility’s comprehensive care plan policy.
Failure to Protect Resident During Mechanical Lift Transfer and to Supervise At-Risk Smoker
Penalty
Summary
Surveyors identified that staff failed to protect a resident’s heels during a mechanical lift transfer. One resident with moderately impaired cognition, bilateral leg nerve damage causing muscle weakness, a history of stroke, and a documented moderate risk for pressure ulcer development required extensive assistance with ADLs and mobility. His care plan directed staff to follow facility protocols for prevention of skin breakdown. During observation of a bed-to-wheelchair transfer using a mechanical lift, an OT and a CNA repositioned the resident in the sling while his heels dragged across the mattress. After transfer, the OT exposed the resident’s heels and noted redness on the right heel. Multiple CNAs later stated that residents’ feet and bodies should not contact the mattress while being actively moved with a mechanical lift, and the DON stated staff should have lowered the bed or elevated the heels to prevent shearing or rubbing. The facility’s Safe Resident Handling/Transfers policy required safe handling and transfers to prevent or minimize injury and provide a safe, comfortable experience. Surveyors also found that staff failed to provide required supervision for an at-risk smoker who accessed the courtyard alone. Another resident with intact cognition but significant physical impairments, including hemiplegia, stroke, acute respiratory failure, hypertension, and diabetes, required extensive assistance with mobility and ADLs. A progress note and a Safe Smoking Assessment documented that he was not an independent smoker, lacked spatial and self-awareness, and required supervision for smoking. His care plan directed staff to supervise smoking, ensure cigarettes were fully extinguished, and assist him to and from the designated smoking area as needed. On one early morning, the resident wheeled himself through an exit door into the enclosed smoking courtyard by canceling the door alarm and activating the automatic door opener, with no staff present and no audible alarm heard. On another early morning, he opened the courtyard door and triggered the alarm, to which the DON immediately responded and reminded him he needed staff present to smoke. The facility’s Resident Smoking policy required that supervision be provided as indicated on each resident’s care plan.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves facility staff not consistently answering resident call lights within a reasonable amount of time, particularly during evening and night shifts. Multiple residents with intact cognition, as indicated by Brief Interview for Mental Status (BIMS) scores of 15, reported extended waits after activating their call lights for assistance with toileting and personal care. One resident stated that after being assisted to the toilet by a CNA, she activated her call light within five minutes but did not receive help back to bed for approximately 45 minutes. Another resident reported turning on the call light for toileting assistance and waiting about 30–45 minutes without a response, ultimately going to bed without being properly cleaned. A third resident reported experiencing prolonged call light response times for a long period during evenings and overnights, including an incident where he choked on mucous and waited about 15 minutes for staff to respond, during which he feared he was choking to the point of death before clearing it himself. Resident Council minutes from a recent month documented concerns that staff were turning off call lights, wearing earbuds during care, and that there were long wait times for call lights to be answered. The facility census was reported as 81 residents. The DON and CNAs interviewed stated that staff were expected to respond to call lights within an appropriate time and as quickly as possible, and the facility’s call light policy directed all staff who see or hear an activated call light to respond and notify appropriate personnel of the resident’s need.
Significant Medication Error Leading to ICU Admission After Wrong-Resident Administration
Penalty
Summary
A resident with intact cognition and multiple diagnoses including chronic kidney disease, peripheral vascular disease, hypertension, and diabetes was involved in a significant medication error shortly after admission. The resident reported that she was given medications that belonged to her roommate and stated she told the staff member the medications were not hers, but the staff member insisted they were. She took the medications, believing the physician might have changed her regimen upon admission, and subsequently blacked out and fell from her scooter. The clinical record included a progress note documenting that the resident fell as a result of a medication error and that her blood pressure was low, prompting contact with the nurse practitioner and transfer to the hospital. Hospital records showed the resident was admitted to the ICU for accidental ingestion of a muscle relaxant, an anticonvulsant, an anti-anxiety medication, and a blood pressure medication, and was followed for persistent bradycardia and hypotension requiring medications, oxygen, and intermittent vasopressor support. Facility staff interviews revealed that a CMA who was training another CMA removed medications for three residents, placed them in cups on top of the medication cart, and handed the keys to the trainee before going on break. The trainee then administered the medications, believing she was giving them to the intended resident, but was unaware there was a new resident in the same room and did not use the six rights of medication administration. The trainee acknowledged that the new resident did not yet have a photo in the EHR and admitted she did not follow the required resident identification and medication verification process. The facility’s policy required use of the resident photo in the MAR and adherence to the six rights of medication administration, which were not followed in this incident.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance of a safe, clean, and comfortable environment. In one resident room, the carpet was excessively stained with dark and pink spills, and the bathroom shower was used for storage of trash bags filled with empty cans, while personal hygiene items were stored on the floor. The dining room had peeling paint, exposed drywall, and hanging plaster from water leaks, with one damaged area directly above a dining table. Additional findings included a large vent with dust buildup, stained ceiling tiles, windows with residue and tape marks, corroded sink cabinetry, and an actively leaking water line saturating the floor. The nurses' station and main facility areas had heavily stained carpets, and a skylight area had ceiling tiles with brown and black discoloration and powder-like particles falling onto the floor. The entertainment area vent was covered in a fuzzy, black substance, and the main carpeted areas were soiled with various stains. A resident who used a wheelchair was found to have a visibly soiled wheelchair with debris buildup and multiple cigarette burns on the cushion. The wheelchair's left wheel lock was nonfunctional, and the resident reported it had not worked properly for a long time. The DON confirmed that staff were expected to clean wheelchairs at least weekly and as needed, and that carpets had been shampooed multiple times without success in removing stains. Facility policy required housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment, but these standards were not met as evidenced by the observations.
Failure to Provide Timely Response to Call Lights Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights for all residents reviewed, as evidenced by multiple resident interviews, observations, and record reviews. Several residents, all with significant care needs such as morbid obesity, heart failure, stroke, hemiplegia, and cognitive impairments, reported excessive delays in staff responding to their call lights, with some waiting over an hour and, in one case, over two hours. Residents consistently described situations where staff would turn off call lights, promise to return, and then not come back for extended periods, leaving residents without necessary assistance for toileting, transfers, and other essential care needs. Observations confirmed that call lights were not always accessible to residents, with instances where the call light was out of reach, preventing residents from requesting help. One resident was observed with the call light cord draped over the bed footboard and the button out of reach, and another resident confirmed they could not access the call light when needed. The facility's policy required call lights to be within reach and secured as needed, but this was not consistently followed. The Director of Nursing acknowledged that the policy did not specify a required response time but stated her expectation was for call lights to be answered within 15 minutes. Residents reported negative experiences due to these delays, including being left wet for extended periods, which contributed to ongoing skin issues, and having to leave their rooms to seek assistance themselves. The facility census at the time was 79 residents, and the deficiency was identified through a combination of resident interviews, staff interviews, observations, and policy review.
Widespread Infection Control Lapses During Resident Care and Dining
Penalty
Summary
Staff failed to maintain infection control practices for all residents reviewed, as evidenced by multiple observed lapses. During meal assistance, a CNA wore the same pair of gloves while touching multiple residents and their food items, without performing hand hygiene between contacts. In another instance, staff emptied a resident's catheter bag by placing the graduated container directly on the carpeted floor without a barrier and allowed the catheter drain spout to touch the inside of the container, contrary to facility policy. For another resident, although a barrier was used, the catheter spout repeatedly touched the inside of the graduated container during emptying, and the container was left uncovered on the back of the toilet after use. Additionally, a package of perineal wipes used for one resident was placed on another resident's bedside table after care was completed. Further deficiencies included a staff member providing ostomy care to a resident with a multidrug-resistant organism diagnosis without wearing a protective gown, as required by enhanced barrier precautions. It was discovered that PPE supply bins outside resident rooms were inadequately stocked, with only one out of several bins containing gowns. The DON confirmed expectations for proper hand hygiene, use of barriers, and PPE, which were not met during these observed care activities.
Incomplete Incontinence Care Provided
Penalty
Summary
Staff failed to provide complete incontinence care for a resident with a history of stroke, non-Alzheimer's dementia, and hemiplegia, who was dependent on staff for toilet hygiene and was always incontinent of urine and frequently incontinent of bowel. During observed care, staff removed a visibly wet brief and cleansed the area above the penis, the penis, and the scrotum, but did not cleanse the inner thighs. When the resident was turned, staff cleansed between the buttocks and inner buttocks but did not cleanse the outer buttocks and hips. Facility policy required cleansing of the buttocks and anus, and the Director of Nursing confirmed the expectation to cleanse all areas of the buttocks and hips during incontinence care.
Failure to Maintain Infection Control During Meal Service and Equipment Use
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during meal service and equipment use. Dietary staff were observed serving drinks and handling utensils by touching the rims of glasses and the spoon portions, then placing their hands in a trash bag and returning to serve residents without performing hand hygiene. This occurred repeatedly over a 25-minute period, with no hand sanitization between tasks. Additionally, a CNA was seen feeding residents by hand, touching food directly and placing it in residents' mouths without sanitizing hands or wearing gloves. The CNA also sneezed into her shirt, wiped her nose with her hand, and continued to serve food and drinks to residents without washing or sanitizing hands. Further, staff failed to clean and disinfect shared resident-care equipment, specifically an EZ Stand, between uses for different residents. The EZ Stand was moved from one resident room to another and parked in the hallway without being sanitized at any point during the observation. Facility policies require hand hygiene after sneezing, coughing, or handling food, and mandate cleaning and disinfection of reusable resident-care equipment between uses, but these procedures were not followed as observed.
Repeat Deficiencies Due to Ineffective QAPI Process
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies during the current recertification survey. Survey findings revealed that the facility had ongoing issues in several areas, including the development and implementation of comprehensive care plans, care plan timing and revision, accident hazards and supervision, labeling and storage of drugs and biologicals, staff competency, and infection prevention and control. These deficiencies were identified through staff interviews, review of CMS-2567 reports, and facility policy review. Repeated citations were documented across multiple surveys, with deficiencies noted for failing to develop and update care plans for residents prescribed medications such as insulin and antidepressants, as well as for residents with specific needs like smoking assessments and code status updates. There were also failures in ensuring appropriate supervision and interventions for residents at risk for accidents, falls, and elopement, as well as lapses in infection control practices, such as improper gloving and catheter care. The facility's QAPI policy outlined responsibilities for oversight and monitoring, but the recurrence of similar deficiencies indicated that the processes in place were not effective in preventing or correcting these issues. The CASPER report and survey history showed that the same types of deficiencies had been cited repeatedly over several years, including in previous annual recertification surveys. The facility's QAPI and QAA activities, as described in their policy, were intended to systematically identify and address problems, but the persistence of these deficiencies demonstrated that the facility did not adequately implement or sustain effective corrective actions to resolve the underlying issues.
Failure to Document Hospital Transfer, Notifications, and Bed Hold Notice
Penalty
Summary
The facility failed to document a resident's transfer to the hospital, including the required notifications to the physician and family, and did not provide documentation of a bed hold notice for one resident. Clinical record review showed that the resident, who had diagnoses of non-Alzheimer's dementia, stroke, and heart failure and was severely cognitively impaired, was on hospital leave for over two weeks. However, the resident's progress notes during this period lacked documentation of the transfer event, notifications to the physician and family, and completion of a bed hold notice. Further review of facility policy indicated that staff are required to obtain a physician's order for emergency transfers, provide necessary information to the receiving provider, document assessment findings and relevant information in the medical record, and provide a notice of transfer and bed hold policy to the resident and their representative. The Corporate Nurse confirmed that there was no documentation in the electronic health record regarding the assessment prior to transfer, bed hold notice, transfer information, or notifications to the physician and family, which was not in accordance with facility expectations.
Failure to Accurately Complete MDS Assessment for Serious Mental Illness
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident by not identifying that the resident had a serious mental illness as determined by the state Level II Preadmission Screening and Resident Review (PASRR). Clinical record review showed that the resident's MDS, dated 3/22/25, listed diagnoses of psychotic disorder, anxiety disorder, and depression, but did not indicate that the resident was considered to have a serious mental illness by the PASRR process. However, the resident's PASRR Level II outcome, dated 1/20/24, confirmed that the resident met criteria for serious mental illness due to a diagnosis of major depressive disorder. Facility policy required accurate assessment and documentation of residents' medical, functional, and psychosocial problems. The Corporate Nurse confirmed the expectation that the MDS should be completed accurately.
Failure to Update PASRR Evaluation for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to submit an updated Preadmission Screening and Resident Review (PASRR) evaluation for a resident with multiple mental health diagnoses and psychotropic medications. Upon review, the resident's clinical record showed diagnoses including delusional disorders, non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, and a history of substance abuse. The resident was also prescribed antipsychotic, antianxiety, and antidepressant medications, among others. Despite these significant mental health conditions and medication changes, the PASRR on file, dated at the time of admission, indicated no mental health diagnoses, symptoms, or related medications. The care plan for the resident was updated several times to reflect ongoing mental health concerns, behavioral symptoms, and the use of psychotropic medications. However, the PASRR was not updated to reflect these changes, as required by facility policy and federal regulations. Staff interviews confirmed that the PASRR in the electronic health record was the only one available and that no new PASRR had been submitted, even after the resident's diagnoses and medication regimen changed. Administration acknowledged that the PASRR should have been resubmitted when the care plan was updated to include new diagnoses and medications. Facility policy requires prompt referral for a Level II PASRR review when a resident exhibits new or possible serious mental disorders or when new information arises that refutes the original PASRR findings. In this case, despite clear evidence of new and ongoing mental health diagnoses and the use of psychotropic medications, the facility did not coordinate with the PASRR program to ensure an updated evaluation was completed, resulting in a failure to comply with regulatory requirements.
Failure to Develop and Implement Comprehensive Toileting Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including debility, cardiorespiratory issues, heart failure, diabetes mellitus, and respiratory failure. The resident was dependent on staff for personal care, including toileting hygiene, and was frequently incontinent of urine and always incontinent of bowel. Despite these needs, the care plan did not include specific interventions, tasks, or measurable goals related to toileting hygiene, assistance, or care. Staff interviews confirmed that the resident was not on a toileting program, and the Director of Nursing acknowledged that toileting interventions and steps were missing from the care plan. Observations over several days documented a persistent strong odor of urine in the resident's shared room, and staff reported inconsistent checks for incontinence episodes. Soiled clothing and briefs were found in the room, contributing to the odor. The facility's own policy requires comprehensive care plans with measurable objectives and timeframes to address all identified needs, but this was not followed for the resident in question.
Care Plan Not Updated After Resident's Clavicle Fracture
Penalty
Summary
The facility failed to revise the comprehensive care plan to accurately reflect the current status of a resident following a significant change in condition. The resident, who has diagnoses including hypertension, non-Alzheimer's dementia, anxiety disorder, and depression, was found on the floor after self-transferring from a wheelchair and subsequently diagnosed with a right clavicle fracture. The resident's care plan did not include the new diagnosis of a fractured right clavicle or the updated order for weight bearing as tolerated (WBAT) to the right upper extremity, despite documentation in the electronic health record and physician's orders. The resident's care plan continued to list interventions related to fall risk and mobility, but failed to address the specific needs and interventions required following the clavicle fracture and the new WBAT order. Staff interviews and facility policy review confirmed that the care plan should have been updated to reflect these changes in the resident's condition, as required by facility policy and regulatory guidelines.
Failure to Document and Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the necessary knowledge and techniques for timely medication management for a resident with multiple complex diagnoses, including cancer, heart failure, renal insufficiency, psychiatric disorders, and substance abuse. The resident was prescribed several psychotropic medications, and a pharmacist recommended a gradual dose reduction (GDR) for one of these medications, Mirtazapine. The recommendation was agreed upon by the facility's Nurse Practitioner, but there was no documentation indicating that the charge nurse received or processed the order, nor was there evidence of clarification or implementation of the GDR in the resident's medical record or Medication Administration Record (MAR). Interviews and record reviews revealed that the Director of Nursing (DON) was unaware that the recommended GDR had not been clarified or implemented, and the resident continued to receive the same dosage of Mirtazapine. The facility's medication order policy requires clear documentation, clarification, and transcription of medication orders, including changes in dosage, but these procedures were not followed in this case. This lapse resulted in a failure to ensure appropriate medication management and documentation for the resident.
Failure to Properly Store and Label Medications
Penalty
Summary
Surveyors observed a medication cart containing a medicine cup with approximately 12 pills labeled for a specific resident, which had been set aside because the resident preferred to take their medications later. A Certified Medication Aide confirmed this practice. Further inspection of the medication cart revealed unsealed or opened stock medications that were not labeled with the date they were opened. The Director of Nursing acknowledged that medications should not be pre-set and left in the cart, and that opened medications should be dated according to facility policy, which aligns with pharmacy recommendations. The facility's policy requires that the date be indicated on medications when the manufacturer's seal is broken by LTC personnel.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who had multiple complex medical conditions including atrial fibrillation, COPD, and respiratory failure, was assessed as requiring supervision while smoking, the use of a smoking apron, and for his lighter to be kept at the nurses' station. Despite these documented requirements, the resident was observed smoking independently in the outdoor courtyard without staff supervision, not wearing a smoking apron, and keeping his cigarettes and lighter in his wheelchair pouch. The resident confirmed he had not been supervised while smoking for some time, did not use the apron, and always kept his smoking supplies with him, contrary to the care plan and facility policy. Another resident, who had moderate cognitive impairment and significant mobility limitations due to multiple trauma, stroke, and multiple sclerosis, left the facility premises with a friend without notifying staff or signing out, as required by facility protocol. Staff discovered the resident was missing when his wheelchair was found outside by the drive, prompting a facility-wide search and calls to the resident's family and friend. The resident later returned and stated he was unaware of the need to inform staff or sign out when leaving, as this was not required in his previous assisted living setting. The resident's family also confirmed being contacted by the facility during the search. Both incidents demonstrate lapses in the facility's adherence to its own policies and care plans regarding resident safety and supervision. In the first case, the resident's smoking was not properly supervised according to the documented assessment and policy, and in the second case, the resident was able to leave the facility unsupervised despite his cognitive and physical impairments, and without following the required sign-out procedure. These failures resulted in the residents not receiving the level of supervision and environmental safety required to prevent accidents.
Failure to Assess and Manage Central Line for Resident
Penalty
Summary
The facility failed to provide appropriate assessment, obtain treatment orders, or ensure physician follow-up for a resident with a central venous catheter. Upon admission from an acute hospital, the resident, who had diagnoses including end stage renal disease, cirrhosis, and immunodeficiency, was noted to have a central line in the left internal jugular vein. However, the admission assessment and care plan did not identify the presence of the central line or include interventions for its care or infection prevention. Nursing progress notes documented the presence of the central line and a dialysis graft, but there was no evidence of physician notification or treatment orders for the central line, nor were there orders for monitoring, site care, or dressing changes in the medication and treatment administration records. Resident and staff interviews confirmed that the central line dressing had not been changed for an extended period, and staff were unsure of the line's purpose or management responsibility. The resident reported that the dressing appeared dirty and that staff discussed its condition, but no action was taken to address it until much later. The facility's policy required licensed nurses to notify physicians and obtain treatment orders in the absence of such orders, but this was not followed. The deficiency was identified through review of clinical records, staff and resident interviews, and facility policy.
Failure to Provide Competent Staff and Effective Care Planning for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of a resident with a history of Substance Use Disorder (SUD). Direct care staff reported a lack of training specific to SUD, and the facility's behavioral health training did not include education on SUD. The care plan for the resident lacked a risk assessment for substance use, did not identify triggers or signs and symptoms to monitor for, and did not include interventions for suspected or identified substance use or plans for overdose emergencies. The facility's policy required staff to have education to meet the behavioral health needs of residents, including those with SUD, but this was not implemented in practice. A resident with a history of polysubstance abuse, including methamphetamines, marijuana, and alcohol, as well as diagnoses of Bipolar Disorder, Schizophrenia, and anxiety disorder, exhibited erratic and escalating behaviors during their stay. The resident had multiple incidents of agitation, paranoia, and threats of violence, resulting in hospitalizations and positive drug screens for methamphetamines and opioids. Staff interviews revealed that they had not received training on how to care for residents with SUD and were unsure how to respond to allegations or suspicions of substance use within the facility. Documentation showed that the resident's care plan interventions were limited to monitoring lab results, communicating facility rules, and offering information about substance use programs, but did not address specific strategies for prevention, monitoring, or response to substance use or overdose. Staff reported being told to keep the resident within sight but did not provide one-on-one supervision. The lack of targeted training and comprehensive care planning contributed to the facility's failure to effectively address the behavioral health needs of the resident with SUD.
Failure to Provide Diabetic Shoes Leads to Amputation
Penalty
Summary
The facility failed to ensure a resident with a history of bilateral foot diabetic ulcers received diabetic shoes as ordered by the physician. The order for diabetic shoes was placed on 7/10/24, but the facility did not follow up with the shoe vendor to ensure the shoes were ordered and delivered. This oversight continued throughout July, and by 8/30/24, the resident developed a foot ulcer, indicating a lack of preventative foot care measures. The resident, who had a history of Type 2 diabetes with foot ulcers and neuropathy, expressed a desire for diabetic shoes on 8/26/24. Despite this, the facility did not document any communication or follow-up with the shoe vendor between 7/10/24 and 8/30/24. The resident's condition worsened, leading to a wound on the left heel, which eventually required debridement and resulted in a left foot amputation on 10/26/24 and a below-the-knee amputation on 10/31/24. Interviews with facility staff and the shoe vendor revealed that the vendor requested additional paperwork to fulfill the shoe order, but the facility continued to send the same paperwork without addressing the vendor's request. The Director of Nursing stated that follow-up should occur within 24-48 hours, yet there was no evidence of such follow-up. The lack of timely action and communication contributed to the resident's deteriorating condition and subsequent amputations.
Removal Plan
- The DON and designee(s) conducted a full-house audit on diabetic residents to determine at-risk diabetics and ensure proper preventative foot care.
- An audit was conducted to ensure all treatments, supplies, and equipment were readily available for order by the physician and were being followed to ensure residents received the proper preventative foot care.
- DON or designee(s) reviewed the medical records of diabetic residents to ensure that weekly skin assessments were completed and treatment recommendations/orders were in place.
- The DON or designee conducted a care plan audit to ensure that treatment recommendations/orders were included in the care plan and that they were being followed.
- All facility policies and procedures related to podiatry services, skin integrity foot care, and physician orders reviewed and revised as needed.
- Education provided to regional Clinical Manager at Curana to ensure that all practitioners that come to Pine Acres will be collaborating with the IDT team to ensure referrals are made timely and appropriately.
- An audit of orders, interventions, and devices regarding foot care and foot services was conducted by the Nursing Supervisor(s) to ensure proper use.
- The DON/Corporate Nurse/Consultant educated all licensed nurses on facility policies and procedures related to diabetes, foot care, and appropriate wound treatment measures.
- The DON/Corporate Nurse/Consultant educated all licensed nurses on appropriate documentation, which included transcription and entering treatment orders on the physician's order sheet in the EHR and the resident's TAR.
- DON/Corporate Nurse/Consultant educated all nurse aides on preventative diabetic foot care.
- DON/Corporate Nurse/Consultant conducted daily treatment record and nursing documentation audits to ensure accurate and complete documentation of diabetic foot care and preventative measures.
- For residents returning from the hospital, treatment recommendations/orders and wound care appointments will be transcribed and overseen by the DON and Corporate Nurse.
- DON/Corporate Nurse/Consultant Monitoring will continue to monitor/audit the following: Observation of treatments for diabetic foot care prevention and orders, Weekly physician orders, Weekly diabetic skin treatment orders related to diabetics, Treatment recommendations and orders are being added and processed into the EHR and TAR.
- A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue.
Failure to Update Care Plans for Advance Directives and Smoking Status
Penalty
Summary
The facility failed to fully review and revise the comprehensive care plans for several residents following changes in their advance directives and smoking status. Specifically, discrepancies were found between the Iowa Physician Orders for Scope of Treatment (IPOST) and the care plans for multiple residents. For instance, one resident's IPOST indicated a Do Not Attempt Resuscitation (DNR) status, while their care plan listed them as Full Code, requiring emergency measures like CPR. Another resident's care plan did not reflect their Full Code status as indicated in their IPOST. Additionally, the facility did not update care plans to reflect changes in residents' smoking status and safety measures. One resident's care plan failed to include the requirement to wear a smoking apron, despite the smoking assessment indicating this safety measure. Another resident's care plan did not document their approval to use a vape and the prohibition of cigarette smoking due to safety concerns. Furthermore, a resident was observed smoking without a completed smoking assessment or any interventions documented in their care plan. Interviews with facility staff, including the Social Worker, Director of Nursing (DON), and MDS Coordinator, revealed that there were established procedures for updating care plans upon changes in residents' status. However, these procedures were not consistently followed, leading to the deficiencies noted. The facility's policies on residents' rights regarding treatment and advance directives, as well as smoking policies, were not adequately implemented, resulting in incomplete or inaccurate care plans for the affected residents.
Safety Lapses in Smoking Supervision and Wheelchair Transfers
Penalty
Summary
The facility failed to ensure the safety of residents during smoking activities and wheelchair transfers, leading to potential accident hazards. Resident #57, who had intact cognition, was observed with cigarettes and a lighter in his possession, contrary to the care plan that required these items to be kept at the nurses' station. Despite being assessed as safe to smoke without supervision, the facility policy was not followed, as staff did not secure the smoking materials, and there was no documentation of resident refusals. Resident #21, also with intact cognition, was observed smoking without wearing a smoking apron, as required by the facility's smoking policy. Despite being informed of the policy and having previously surrendered smoking materials to staff, the resident was found with a lighter in his room, indicating a lapse in adherence to safety protocols. Staff supervision was inconsistent, as evidenced by unsupervised smoking sessions and the absence of protective gear. Resident #26, who required supervision while smoking due to past incidents and refusal to wear a smoking apron, was observed smoking without the necessary protective gear and supervision. The resident had a history of non-compliance with the smoking policy, including storing smoking materials in his room and smoking outside designated times. Additionally, Resident #20 was transported in a wheelchair without foot pedals, posing a risk of injury, as the resident's feet dangled close to the floor during the transfer. The facility's policy on safe transfers did not specifically address the use of foot pedals, highlighting a gap in safety measures.
Deficiency in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure that food was prepared and maintained at the appropriate temperature and that dishes and utensils were cleaned in a sanitary manner. This deficiency was identified through a review of food temperature logs and dishmachine quality assurance forms. Specifically, from September to November, numerous meals were found to have incomplete or missing food temperature records. Additionally, during October and November, several meals lacked verification that the dishmachine's chemical sanitizer reached the required 50 parts per million (ppm) or greater. These lapses were acknowledged by the Certified Dietary Manager (CDM) during an interview. The facility's policies on Food Safety Requirements and Sanitation Inspection, which were reviewed and revised in November, state that food should be prepared to reach recommended temperatures and that all equipment used in food handling should be cleaned and sanitized to prevent contamination. Despite these policies, the facility did not consistently adhere to the procedures, as evidenced by the gaps in the logs. The presence of a food thermometer, alcohol wipes, and test strips in the food prep area and dishmachine area indicates that the necessary tools were available, but the staff did not consistently use them to ensure compliance with the facility's policies.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an initial tour. The walk-in freezer floor was found with excess debris, including food crumbs, small food items, and packing tape from delivery boxes. Additionally, a fryer that was not in use was left full of oil without a cover, and plastic cereal containers lacked labels or dates, as they were not stored in their original packaging. These conditions indicate a failure to store food in a manner that prevents contamination and foodborne illness. During an interview, the Certified Dietary Manager (CDM) admitted that there were no required daily or weekly cleaning checklists for staff to complete. Instead, a general checklist of cleaning needs was posted on a whiteboard at the kitchen entrance. The CDM acknowledged that the walk-in cooler and freezer floors were only swept as needed and that the fryer should have been covered when not in use. The facility's policies on food safety and sanitation, reviewed and revised in November 2024, require daily inspections of refrigerators, coolers, and freezers, as well as weekly inspections of the food service area by the dietary manager to ensure compliance with sanitation and food service regulations.
Failure to Complete Background Check Before Rehire
Penalty
Summary
The facility failed to complete a criminal record check and dependent adult/child abuse registry check prior to the rehire date of a Registered Nurse, identified as Staff E. Staff E was rehired on 9/9/24, but the updated Single Contact License and Background Check initiated on 9/4/24 indicated that further research was required, and the Division of Criminal Investigation's final response was pending. Despite this, Staff E began working with residents from 9/9/24 to 11/11/24 without the necessary background check clearance. The facility only completed the background check process on 11/11/24. This oversight was acknowledged by the Provisional Administrator during an interview on 12/5/24 and was identified during an employee record audit conducted by the Administrator on 11/11/24. The facility's policy on Background Investigations, revised in November 2024, mandates that the Human Resource department conduct all applicable background investigations for employment applications and current employees as appropriate for their positions.
Care Plan Deficiencies in Medication Management and Smoking Protocol
Penalty
Summary
The facility failed to ensure that the care plan for a resident addressed high-risk medications, specifically insulin and antidepressants. The resident, who had diagnoses of diabetes, anxiety, and depression, was receiving insulin and antidepressant medications. However, the care plan did not include information on these medications or guidance for staff on monitoring for side effects. This oversight was confirmed by the Director of Nursing, who acknowledged that care plans should address high-risk medications. Additionally, the facility did not adhere to the care plan regarding smoking materials for another resident. This resident, who had a history of depression, hypertension, Parkinson's, and other conditions, was observed with cigarettes and a lighter in his possession, contrary to the care plan's directive that these items be kept at the nurses' station. The care plan specified that staff should ensure no smoking materials were at the bedside and that they should be provided during designated smoking times. The Director of Nursing confirmed that staff should follow the care plan or document any noncompliance.
Inconsistent Documentation of Code Status
Penalty
Summary
The facility failed to provide clear and consistent documentation regarding the code status of two residents, leading to potential confusion in emergency situations. For Resident #10, there was a discrepancy between the Iowa Physician Orders for Scope of Treatment (IPOST), which indicated a Do Not Attempt Resuscitation (DNR) status, and the care plan and electronic health record (EHR), which both indicated a Full Code status. Additionally, the care conference attendance record also listed the resident as DNR, further highlighting the inconsistency in documentation. For Resident #34, the IPOST indicated a Full Code/CPR status, but the care plan failed to document the resident's code status. Interviews with staff revealed that they relied on the EHR page header to determine a resident's code status, which could lead to errors if the information was not accurately updated. The facility's policy required that any changes in code status be clearly documented in all relevant sections of the medical record and communicated to social services, but this was not consistently followed, resulting in the identified deficiencies.
Failure to Perform Required Dialysis Assessments
Penalty
Summary
The facility failed to consistently perform required pre-dialysis and post-dialysis assessments for a resident who required such services. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, reported that staff had not routinely conducted these assessments before or after her hemodialysis treatments. The resident's medical history included anemia, hypertension, End-Stage Renal Disease (ESRD), Diabetes Mellitus (DM), epilepsy, psychotic disorder, and Non-Alzheimer's dementia. The care plan specifically directed staff to perform pre/post dialysis assessments, and the physician's order required these assessments on dialysis days. The Electronic Health Record (EHR) revealed missing documentation for pre-dialysis assessments on specific dates and incomplete post-dialysis assessment documentation for several treatments in November 2024. Staff interviews confirmed that pre-dialysis and post-dialysis assessments should be completed and documented in the EHR. The facility's policy on hemodialysis, revised in November 2024, required nurses to check the dialysis access site for patency before and after treatments and every shift. However, the facility did not adhere to these protocols, leading to the deficiency.
Failure to Provide Timely Assistance to Resident
Penalty
Summary
The facility failed to meet the care needs of a resident, identified as Resident #51, who was dependent on staff for toilet transfers and toileting hygiene due to conditions including hemiplegia, anxiety, and diabetes. The resident was observed sitting in the hallway with wet shorts, indicating a need for assistance. Despite activating the call light at 8:39 a.m., the resident did not receive timely help. Staff members walked past the room without entering, and the resident continued to call for help intermittently until 9:07 a.m. when a CNA entered the room briefly. However, the resident was left unattended again until 9:19 a.m. when the CNA returned after the State Agency informed the Administrator of the resident's need for assistance. The facility's policy on call light response, which requires staff to respond within five minutes, was not adhered to in this instance. The Director of Nursing confirmed that ideally, staff should respond promptly and ensure the appropriate personnel is notified if they cannot provide the required assistance. The delay in response and failure to provide timely care to the resident highlights a deficiency in staffing and adherence to facility policies, impacting the resident's care and dignity.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices to prevent urinary tract infections (UTIs) for a resident with an indwelling catheter. The resident, who had intact cognition and required moderate assistance with personal hygiene, was noted to have opaque and cloudy urine in the catheter. The resident had a history of obstructive uropathy, acute renal failure, and anemia, and had previously been hospitalized for a UTI. The care plan directed staff to position the catheter bag below the bladder level to prevent backflow, but this was not adhered to during care. During an observation, a Certified Nurse Aide (CNA) was seen lifting the resident's urine catheter bag above the bladder, causing urine to flow back into the resident. The CNA also failed to perform proper hand hygiene and used the same gloves to handle the catheter and the alcohol swab. The Director of Nursing confirmed that staff should follow the policy, perform hand hygiene, and keep the bag below the bladder level. The facility's catheter care policy, revised in November 2024, instructed staff to ensure the drainage bag is below the bladder level to prevent backflow.
Failure to Document Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to ensure that a resident was provided with up-to-date pneumococcal vaccinations. The resident, who was admitted on December 6, 2022, had an immunization record that lacked documentation of their pneumococcal vaccination status. On July 25, 2023, the resident signed a consent form indicating their interest in receiving the vaccine, but the electronic health record did not document whether the vaccine was administered. During an interview on December 5, 2024, the Provisional Administrator acknowledged the lack of documentation regarding the resident's vaccination status and whether the vaccine was administered in 2023. The facility's Infection Prevention and Control Program, reviewed and revised in July 2024, states that residents will be offered pneumococcal vaccines recommended by the CDC upon admission unless contraindicated or previously received. Additionally, the General Immunization/Vaccination policy, reviewed and revised in November 2024, requires that the resident's medical record include documentation of whether the resident received or did not receive the immunization due to medical contraindication or refusal.
Failure to Provide Up-to-Date COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure that two residents were provided with up-to-date COVID-19 vaccinations. Resident #2, who was admitted on 9/27/14, had their last COVID-19 vaccination documented on 11/29/22, with no record of an updated vaccine being offered or administered in 2023. Similarly, Resident #45, admitted on 12/6/22, had their last COVID-19 vaccination on 12/21/2021, with no documentation of an updated vaccine being offered or administered in 2022 or 2023. During an interview, the Provisional Administrator acknowledged the lack of documentation for these residents' COVID-19 vaccination status. The facility's Infection Prevention and Control Program and General Immunization/Vaccination policy require that residents be offered the COVID-19 vaccine when available and that their medical records include documentation of vaccination status, which was not adhered to in these cases.
Resident Elopement and Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident identified as being at risk for elopement. The resident, who was severely cognitively impaired and wore a wander guard bracelet, left the facility unattended and was found approximately 0.2 miles away after suffering a fall. The resident was last seen by staff at approximately 1:45 PM, and the facility was alerted by EMS at 2:15 PM that the resident had fallen and would be transported to the Emergency Department for evaluation. The facility staff were unaware that the resident had left the facility until informed by EMS. The resident had a history of Alzheimer's disease, dementia, and other medical conditions, and was receiving hospice care. The resident's care plan included interventions for elopement risk, such as wearing a wander guard and checking its function every shift. Despite these measures, the resident was able to exit the facility unsupervised. Progress notes indicated a pattern of exit-seeking behavior, with multiple instances of the resident attempting to leave the facility and being redirected by staff. On the day of the incident, the resident's routine was potentially disrupted by a hospice visit and room cleaning, which may have contributed to the elopement. The facility's investigation revealed that the resident was last seen by housekeeping staff at 1:45 PM, and the wander guard was reported to be functioning properly earlier in the day. However, the facility staff did not notice the resident's absence until EMS arrived to inform them of the fall.
Removal Plan
- Residents at risk for elopement were re-evaluated using Point Click Care (PCC) elopement risk assessment tool, care plans were updated, and wander guards were checked for appropriate functioning.
- All doors were checked for proper functioning, and no concerns were identified. A call was placed to have doors and alarms inspected, with no active issues regarding door functioning and alarm systems.
- Immediate education with all staff provided on the elopement and wander guard policy and will continue to educate until all staff have been thoroughly informed and trained.
- The Minimum Data Set (MDS) coordinator reviewed section E of the MDS and associated Care Area Assessments (CAA). Care plans were reviewed and updated to reflect the audit findings. Concerns were not identified.
- The Director of Nursing (DON) or designee will audit all new admissions for elopement risk and ensure interventions are in place.
- The Interdisciplinary Team (IDT) reviewed the most recent fall risk assessments for all residents identified as potentially at risk for falls. Residents determined to be at risk have completed care plan updates, and the interventions currently in place are appropriate.
- The IDT ensured that all residents identified as at risk for falls had safety measures and resident-specific interventions added to their care plans.
- The IDT ensured that the safety measures and resident-specific interventions added to the care plans were also reflected on the Kardex so the Certified Nurses Assistants (CNAs) had access to this information.
- The DON and designee(s) instructed the CNAs to review the updated Kardex before their next shift.
- 1:1 was placed immediately on the front door until confirmation of proper functioning was obtained by maintenance and all active wander guards were tested to ensure alarm function.
- All new hires will receive education on elopement, wandering and resident safety from the social services designee.
- All exit doors will be checked daily to ensure proper use and function.
- A Quality Assurance Performance Improvement (QAPI) plan was implemented, and all findings will be discussed in the monthly meeting.
- Main entrance was moved to the 1499 door, and a receptionist was placed in front of that door, and the old entrance door is no longer in use as a main entrance door and is locked per fire safety regulations. Visitors are encouraged to use the new entrance to ensure resident safety and monitoring.
Failure to Prevent Falls and Ensure Proper Footwear
Penalty
Summary
The facility failed to ensure that a resident was free from accidents, resulting in multiple falls and a hip fracture. The resident, who had severe cognitive impairment and was at high risk for falls, experienced a fall in the dining room while attempting to stand from his wheelchair. At the time, he was wearing regular socks instead of the gripper socks specified in his care plan. The resident reported tripping over the wheelchair pedals, which were supposed to be removed unless he was being assisted. Following this incident, the interdisciplinary team discussed the resident's falls and noted that he did not have shoes on, only socks. Despite interventions such as removing foot pedals and monitoring, the resident experienced another fall the next day. During this fall, he was again found wearing regular socks, not gripper socks, and complained of hip pain. The resident was sent to the hospital, where he was diagnosed with a right hip fracture. The facility's documentation and staff interviews revealed that the resident had a history of self-transferring and not using the call light for assistance. Despite being at high risk for falls, the resident was not consistently provided with the appropriate footwear as per his care plan. The Director of Nursing and the Administrator acknowledged that the resident should have been wearing gripper socks, especially given his recent history of falls and self-transferring behavior.
Failure to Obtain Ordered Laboratory Tests for Residents
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for two residents. For the first resident, the facility did not obtain laboratory tests as ordered by the physician. The resident had multiple health conditions, including coronary artery disease, heart failure, and end-stage renal disease, and was on Warfarin Sodium, a blood thinner. Despite orders to recheck the INR level and obtain a CBC and UA, the facility did not follow through with these tests. The Director of Nursing (DON) confirmed the absence of these lab results and acknowledged the expectation to obtain labs per physician orders. For the second resident, the facility also failed to obtain a UA as ordered by the physician. The resident had severe cognitive impairment and multiple diagnoses, including anemia and coronary artery disease. A physician order directed staff to obtain a UA and send it to the preferred lab, with results to be faxed to hospice. However, the clinical record lacked documentation of the UA results, and the DON later confirmed that the UA specimen was not sent to the lab. The facility's policy on laboratory services and reporting, reviewed in April 2024, mandates that the facility must provide or obtain laboratory services when ordered by a healthcare provider. The policy also emphasizes the facility's responsibility for the timeliness of these services. Despite this policy, the facility did not meet the required standards, as evidenced by the lack of follow-up on the ordered laboratory tests for both residents.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident who was at high risk for falls. The resident, who had a history of Alzheimer's disease, hip fracture, and other medical conditions, was found on the floor after a fall, resulting in a left hip fracture. Despite being identified as high risk for falls, the resident was observed ambulating independently without the required assistance, which was contrary to the care plan that specified assistance of one staff member for ambulation outside the room. The resident's care plan was revised following the fall to include new interventions such as posterior hip precautions and the use of a wheelchair for long distances. However, staff interviews revealed that the resident continued to walk independently with a walker, both inside and outside the room, without the necessary supervision. Staff members acknowledged the resident's independence in ambulation and noted that the resident often refused assistance, which was not adequately addressed by the facility. The Director of Nursing confirmed that the resident was supposed to receive assistance outside the room but often refused help. Despite therapy recommendations for assistance, the resident continued to ambulate independently, posing a risk of further falls. The facility's policy on accidents and supervision emphasized the need for adequate supervision to prevent accidents, which was not effectively implemented in this case, leading to the deficiency.
Inadequate Incontinence Care and Hygiene Practices
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident, leading to a deficiency. The resident, who had intact cognition and was dependent on staff for toileting hygiene and transfers, was always incontinent of bowel and bladder. The resident had a history of UTIs and pneumonia, and the care plan directed staff to check and change the resident four times per shift and as needed. However, the resident was hospitalized for sepsis and a UTI, indicating a lapse in the care provided. During an observation, staff members were seen performing incontinence care without following proper hygiene protocols. The staff used gloves from their shirt pockets, did not change gloves between dirty and clean tasks, and failed to perform hand hygiene after removing gloves. Additionally, the staff did not cleanse the resident's lower back or hips and applied cream with dirty gloves. These actions were contrary to the facility's policies on perineal care, hand hygiene, and personal protective equipment, which emphasize the importance of hand hygiene and changing gloves between tasks to prevent infection.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide oxygen according to physician orders for three residents, leading to deficiencies in respiratory care. Resident #2, with intact cognition and multiple diagnoses including coronary artery disease and COPD, was found with an empty portable oxygen tank while experiencing shortness of breath. The nurse attending to Resident #2 discovered the empty tank and switched the resident to an oxygen concentrator in the room, but was unsure how long the tank had been empty. The facility lacked a process for checking portable oxygen tanks, contributing to this oversight. Resident #6, with severely impaired cognition and diagnoses including heart failure and atrial fibrillation, was observed with an empty portable oxygen tank set at 2 liters, contrary to the prescribed 3 liters per minute. Staff failed to check the tank's status, and when replaced, the new tank was also set incorrectly at 2 liters. This repeated oversight indicated a failure to adhere to the prescribed oxygen therapy regimen. Resident #7, also with severely impaired cognition and conditions such as COPD and respiratory failure, was observed with an empty portable oxygen tank set at 2 liters. The facility's policy required oxygen to be administered under physician orders, but the care plan for Resident #7 lacked specific interventions for oxygen therapy. The Director of Nursing acknowledged the expectation for staff to check and ensure portable tanks were adequately filled and set according to orders, highlighting a gap in compliance with the facility's oxygen administration policy.
Deficiency in Transportation Arrangements for Medical Appointments
Penalty
Summary
The facility failed to arrange and provide transportation services for two residents to attend their scheduled medical appointments. Resident #2, who had multiple health conditions including coronary artery disease, heart failure, and chronic respiratory failure, missed several cardiology appointments. The clinical records lacked documentation of transportation arrangements, and the hospital notes indicated that Resident #2 was a no-show for appointments on multiple occasions. The facility's administrator and the transportation company confirmed that Resident #2 was not scheduled for transportation on the missed appointment dates. Resident #3, who had a history of severe cognitive impairment and a recent hip fracture, also experienced issues with transportation to a follow-up orthopedic appointment. The appointment was initially scheduled for a specific date but was rescheduled by the transportation aide due to a scheduling conflict with another resident's surgery appointment. The Director of Nursing acknowledged that the transportation form was not filled out in a timely manner, and the provisional administrator was unaware of the rescheduling. The facility's policy on transportation services, which mandates scheduling transportation as soon as appointment details are known, was not adhered to in these cases. The lack of proper scheduling and communication led to missed appointments for both residents, highlighting a deficiency in the facility's transportation arrangements for medical appointments.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as directed by physicians' orders for two residents. Resident #1, who had severe cognitive impairments and required substantial assistance with daily activities, was prescribed a Lidocaine topical pad to be applied daily. However, the Medication Administration Record (MAR) indicated that the medication was not started until four days after the physician's order. The Interim Administrator confirmed that staff are expected to follow physicians' orders, which was not done in this case. Resident #6, who also had severe cognitive impairments and required substantial assistance, was ordered to have a urine analysis (UA) with culture and sensitivity due to increased altered mental status and other symptoms. Despite multiple attempts to obtain the sample, it was not successfully collected and sent to the lab until several days later. Consequently, the resident's antibiotic treatment was delayed. The Regional Director of Operations confirmed that the physicians' orders were not followed, which is against the facility's expectations.
Failure to Provide Required Baths for Residents
Penalty
Summary
The facility failed to provide the required two baths per week for three residents, as documented in their Minimum Data Set (MDS) assessments. Resident #1, who had severe cognitive impairments and required substantial to maximal assistance with bathing, did not receive baths during three separate weeks between December 2023 and February 2024. Resident #2, who had moderate cognitive abilities and was dependent on assistance for bathing, did not receive baths during a week in March 2024. Resident #3, who had moderately impaired decision-making abilities and required substantial to maximum assistance with bathing, did not receive baths during two separate weeks between December 2023 and March 2024. Interviews with the residents and the facility's Interim Administrator confirmed the failure to provide the required baths. Resident #2 expressed a desire to receive showers twice a week, and the Interim Administrator verified that the staff did not meet the expectation of providing two baths per week for the residents. The facility's electronic documentation of task completion corroborated these findings, indicating a lapse in the provision of care as directed by the residents' care plans.
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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