Pioneer Valley Living And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Sergeant Bluff, Iowa.
- Location
- 400 Sergeant Square Drive, Sergeant Bluff, Iowa 51054
- CMS Provider Number
- 165615
- Inspections on file
- 22
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pioneer Valley Living And Rehab during CMS and state inspections, most recent first.
A resident with heart failure, diabetes mellitus, and HTN had a physician order for daily weights with PRN Bumetanide and instructions to notify the physician for specified weight gains. Over multiple months, MAR review showed numerous instances where the daily weights were refused or marked as not applicable, yet the clinical record contained no documentation that the physician was notified of these refusals or missed weights. The ADON acknowledged there was no documentation of such notification, and the facility did not have a policy addressing when to notify the physician in these situations.
The facility did not carry out the required number of weekly audits as outlined in its QAPI Plan of Correction, resulting in repeated deficiencies in areas such as professional standards, quality of care, and infection control. The administrator cited a misunderstanding about audit requirements, and oversight responsibilities were not met according to the facility's QAPI plan.
A resident with a history of hemiplegia, depression, and muscular dystrophy, who was dependent on staff for toileting, was left waiting in the dining room in soiled garments for about 30 minutes after an incontinence episode because staff were occupied feeding other residents. Staff and DON interviews confirmed that assistance should have been provided, and facility policy requires residents to be treated with dignity.
A resident with severe cognitive impairment, total dependence for care, and recent admission to Hospice experienced a significant decline in condition. Despite this, the facility did not complete a Significant Change MDS assessment within the required timeframe after recognizing the change, as confirmed by record review and staff interview.
The facility did not submit comprehensive MDS assessments within the required timeframe for two residents. In both cases, the assessments were completed and accepted late, and staff interviewed were unable to provide a response regarding the delay. Facility policy requires timely initiation, encoding, and transmission of assessments per CMS RAI guidelines.
The facility did not update or individualize care plans for several residents with complex medical needs, including those with skin breakdown, edema, pressure ulcers, and use of pressure-relieving devices. Care plans lacked specific interventions for conditions such as edema, skin wounds, and the use of Prafo boots, despite physician orders and direct observations. Additionally, one resident's care plan contained outdated target dates, showing a lack of regular review by the interdisciplinary team.
The facility did not follow physician orders for two residents, including administering medication despite blood pressure parameters and failing to obtain daily weights or notify the physician after a significant weight gain. The affected residents had complex medical histories, including diabetes, hypertension, and heart disease.
A resident with severe cognitive impairment and total dependence on staff for mobility and toileting did not consistently receive restorative services as outlined in their care plan. Documentation showed that exercise opportunities were frequently missed or marked as not applicable, and staff interviews revealed a lack of training, unclear responsibilities, and staffing shortages. The facility did not have a policy on restorative services, contributing to the deficiency.
A resident with advanced dementia and mobility deficits was not repositioned for over five hours while seated in a Broda Reclining wheelchair, despite being at risk for skin impairment and having a documented pressure area. Multiple staff passed by without providing repositioning or checking personal needs, and staff interviews revealed inconsistent understanding of repositioning requirements.
Two residents experienced inadequate monitoring and intervention for skin issues, including inconsistent wound care application and incomplete documentation of skin assessments. One resident with multiple comorbidities and skin breakdown did not have detailed wound measurements or consistent dressing changes, while another at risk for pressure ulcers did not receive weekly skin assessments as ordered. Facility policies and physician orders for individualized skin care and documentation were not followed.
A resident with severe cognitive impairment and a right heel pressure ulcer was repeatedly observed without the required protective boots and prescribed dressing, despite orders for their continuous use. Staff did not consistently communicate or address the absence of the dressing, and the facility's pressure ulcer prevention protocols were not followed, resulting in inadequate care for the resident.
A resident with moderate cognitive impairment and mobility deficits was observed being pushed in a wheelchair without foot rests by a CNA, contrary to facility policy and staff expectations. Multiple staff interviews confirmed that foot rests are required when transporting residents in wheelchairs, but this protocol was not followed.
Staff did not follow Enhanced Barrier Precautions when providing wound care to a resident with a stage 2 pressure injury, as they failed to wear gowns and did not have appropriate PPE signage posted. The resident was dependent on staff for care and had a care plan indicating skin integrity issues, but EBP protocols were not followed during a dressing change.
A resident at moderate risk for pressure ulcers was repeatedly left sitting in a recliner without a pressure-reducing cushion, despite documented care needs and staff awareness of his inability to reposition himself. The care plan lacked interventions for skin integrity, and staff did not consistently communicate or implement preventive measures, resulting in the development of two open sores on the resident's buttocks.
A resident with diabetes received both long-acting and short-acting insulin from an LPN despite a blood sugar reading below the physician-ordered threshold for notification. The LPN did not contact the physician as required, and the resident was later found unresponsive with severe hypoglycemia, requiring emergency intervention and hospitalization.
Two residents experienced injuries during mechanical lift transfers due to staff failing to follow facility policy and manufacturer guidelines, including using only one staff member for transfers that required two and not ensuring proper use of equipment, resulting in a fractured thumb and a fall.
The facility experienced repeated deficiencies in its QAPI program, including failures in comprehensive assessments, care planning, and infection control. Despite having a QAPI plan and recent performance improvement initiatives for MDS and falls, ongoing staff turnover and reliance on third-party management contributed to the recurrence of these issues.
The facility did not complete or submit required MDS assessments for four residents, including discharge, End of PPS Part A Stay, admission, and death in facility assessments. These failures were confirmed through record review and staff interviews, with the administrator acknowledging that MDS assessments had not been consistently completed.
The facility did not develop or maintain comprehensive care plans for several residents with specialized needs, including those requiring CPAP, catheter care, fall interventions, and hospice services. Observations and staff interviews revealed missing or inaccurately documented care plans, with staff acknowledging gaps in training and documentation practices.
The facility did not develop or update individualized care plans for four residents, resulting in missing interventions for skin integrity, transfer assistance, behavioral management, and use of mechanical lifts. For example, a resident with a history of pressure injuries lacked a care plan for skin protection, another experienced a fall during a transfer not addressed in the care plan, and two residents on psychotropic medications or with behavioral symptoms had incomplete care plans lacking necessary interventions and monitoring.
The facility did not consistently monitor for expired medications or document open dates on insulin pens for multiple residents. Staff relied on general rules for medication expiration and did not verify medication details during shift changes, leading to expired hydrocodone and insulin pens without open dates remaining in use. Facility policy required documentation of open dates and prompt removal of expired medications, but these procedures were not followed.
Surveyors found that required comprehensive MDS assessments were not completed in a timely manner for three residents. In each case, either annual or admission assessments were left incomplete or still in progress, with the administrator citing staff shortages and unclear assignment of responsibilities as contributing factors.
A resident with multiple diagnoses was readmitted from the hospital and admitted to hospice care, but the facility did not complete the required significant change MDS assessment within 14 days of recognizing the change in condition. The assessment was completed 23 days after hospice admission, and the care plan lacked documentation about the hospice provider and services.
Quarterly MDS assessments were not completed within the required timeframe for three residents, with assessments either delayed by several months or not completed at all. The Administrator confirmed that changes in leadership and MDS staffing contributed to the failure to meet CMS requirements for timely resident assessments.
A resident's MDS assessment inaccurately documented the presence of a stage 2 pressure ulcer, despite staff interviews confirming the resident did not have a pressure ulcer but instead had a laceration. The facility also did not have a policy for maintaining accurate resident records.
Three residents with varying medical and cognitive conditions were admitted without receiving a written summary of their baseline care plan, and there was no documentation that staff reviewed the initial care plan with the residents or their representatives. Facility staff used a kardex as the baseline care plan but did not provide it to residents or families, nor retain the original version, resulting in missing required documentation.
A resident with COPD and respiratory failure, dependent on supplemental oxygen, was repeatedly observed wearing oxygen tubing that was not labeled with a date of application. Staff provided inconsistent information about the frequency of tubing changes, and facility records lacked orders or documentation for this care. No facility policy was provided regarding the changing and documentation of oxygen tubing.
Staff failed to follow infection control protocols for two residents with medical devices. An LPN administered tube feeding and medications without wearing a gown and stepped on oxygen tubing, while another resident's urinary catheter bag was found on the floor without a privacy cover. The DON confirmed these were breaches of infection prevention standards.
A resident with multiple chronic conditions and no cognitive impairment reported that a CNA used excessive force while cleaning her face and eyes, causing pain and bruising, and did not stop when asked. The incident was corroborated by nursing and social work staff, who observed the bruising and documented the resident's complaint. The resident described the staff member involved, and the DON confirmed the resident's reliability and the facility's expectation for gentle care.
Staff did not follow physician orders for two residents, including failing to notify the provider of repeated high blood pressure readings for one resident and not documenting non-pharmacological interventions before administering PRN anti-anxiety medication to another. Nursing staff and the DON confirmed that required documentation and interventions were not consistently completed.
Three residents did not receive appropriate care due to missed neurological assessments after a fall, delayed hospital transfer, and repeated missed medication doses because medications were not available. In addition, there was a lack of physician notification regarding missed medications and failure to document or follow family wishes about a resident's medication regimen.
The facility did not maintain accurate records for two residents, including missing documentation of required weekly weights for a resident with a feeding tube and lack of evidence that a provider was contacted after repeated high blood pressure readings for another resident, despite MAR entries indicating otherwise.
Failure to Notify Physician of Repeated Refusal of Ordered Daily Weights
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the physician when a resident repeatedly refused ordered daily weights or when weights were not completed. The resident had diagnoses of heart failure, diabetes mellitus, and hypertension, and an MDS assessment documented a BIMS score of 15, indicating no cognitive impairment. A physician-signed order dated 1/29/26 required daily weights, with PRN Bumetanide and instructions to notify the physician for specified weight gains. Review of the January, February, and March 2026 Medication Administration Records showed multiple days where daily weights were either refused or marked as not applicable, including numerous refusals across all three months. Despite these repeated refusals and missed weights, review of the clinical record showed no documentation that the physician had been notified about the resident’s refusal of daily weights or the failure to complete them. The facility also lacked a policy addressing physician notification in such circumstances. During an interview, the ADON confirmed there was no documentation of physician notification regarding the resident’s refusal of daily weights or incomplete weights, although the ADON stated an expectation that staff notify the physician when orders are not being completed.
Failure to Implement Effective QAPI Program and Audit Processes
Penalty
Summary
The facility failed to implement a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program as required. Repeated deficiencies were identified during annual surveys and complaint investigations, including issues related to services meeting professional standards, quality of care, QAPI program and plan, and infection prevention and control. The facility's Plan of Correction (POC) specified that four files per week would be audited for several areas, but only two files per week were actually audited over multiple weeks, falling short of the stated plan. The administrator acknowledged a misunderstanding regarding the number of files to be audited weekly, which contributed to the failure to meet the POC requirements. The QAPI Facility Plan indicated that the governing body or facility administration was responsible for oversight of QAPI activities, including identifying and prioritizing problems based on performance data and input from residents and staff. However, the facility did not follow through with the planned audits, resulting in noncompliance with QAPI program requirements.
Resident Left in Soiled Garments Due to Delayed Assistance
Penalty
Summary
A deficiency occurred when a resident with normal cognitive function and a history of hemiplegia, depression, and muscular dystrophy was left waiting in the dining room in soiled garments after experiencing an incontinence episode. The resident, who was dependent on staff for toileting and transfers, reported that staff told her she could not be taken back to her room to be changed because they were feeding other residents. The resident stated she waited approximately 30 minutes before being assisted back to her room for care. Staff interviews confirmed that during meal times, most CNAs assist in the dining room, with only one or two available to respond to other needs, such as toileting assistance. The DON stated that staff are expected to assist residents requesting to return to their rooms due to incontinence. Facility policy also affirms residents' rights to adequate care and dignity. The failure to promptly assist the resident resulted in her remaining in soiled garments, which did not honor her right to dignity.
Failure to Complete Significant Change MDS After Resident's Decline and Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (SCMDS) within 14 days after recognizing a significant change in condition for a resident. The resident, who had a severe cognitive deficit as indicated by a BIMS score of 0, was totally dependent on staff for toileting and transfers, and was admitted to Hospice care. Documentation showed that the resident was admitted to Hospice services on January 25, and the care plan was updated to reflect a decline in cognition and physical condition. However, the electronic chart only showed quarterly MDS assessments and lacked a SCMDS following the significant change. The facility administrator acknowledged the omission during an interview.
Failure to Submit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to submit comprehensive Minimum Data Set (MDS) assessments within the required timeframe as directed by the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual for two out of fifteen residents reviewed. Specifically, one resident's quarterly MDS assessment was accepted several days after the assessment date, and another resident's quarterly MDS assessment was completed and accepted well over a month after the assessment date. During interviews, the Director of Nursing and another staff member stated they did not have a response regarding the completion and submission of the MDS documents, as they were not responsible for completing them. Facility policy requires that assessments be initiated, encoded, and transmitted according to CMS RAI guidelines.
Failure to Update and Individualize Resident Care Plans
Penalty
Summary
The facility failed to update and provide individualized care plans for three residents with long-standing conditions. For one resident with moderate cognitive impairment, diabetes, chronic kidney disease, edema, and diabetic neuropathy, the care plan did not include focus areas or interventions for edema or skin breakdown, despite observations of significant swelling, fluid-filled blisters, and open sores on the lower extremities. The resident was dependent on staff for multiple activities of daily living and was being seen by an outside wound clinic, but these specific skin and edema issues were not addressed in the care plan. Another resident with advanced dementia, decreased mobility, and incontinence was at risk for pressure ulcers and had a documented pressure area on the right inner ankle. The care plan identified a general risk for skin impairment and included some interventions, but it was not updated to reflect the specific treatment for the ankle wound or the use of Prafo boots when out of bed, as observed and ordered by the physician. Multiple observations confirmed the resident was consistently wearing Prafo boots both in bed and out of bed, but this was not documented in the care plan. A third resident with a history of stroke, hemiplegia, and depression, who was at risk for pressure ulcers and had a diabetic foot ulcer, also had a care plan that did not include the use of Prafo boots for pressure avoidance, despite physician orders and repeated observations of the resident wearing them. Additionally, another resident's care plan contained outdated target dates for all focus areas, indicating a lack of regular review and updating as required by facility policy.
Failure to Follow Physician Orders for Blood Pressure and Weight Monitoring
Penalty
Summary
The facility failed to follow physician's orders and professional standards of quality for two residents. For one resident with a history of bariatric surgery, diabetes, chronic kidney disease, and adult failure to thrive, staff did not adhere to the medication order for Midodrine, which specified to hold the medication if the systolic blood pressure was over 100. Despite this, the medication was administered multiple times when the resident's systolic blood pressure readings were above the specified threshold. Additionally, the resident was observed with supplemental oxygen tubing not in use as intended, and she reported sometimes forgetting to put it back on. For another resident with hypertension, diabetes, morbid obesity, edema, and heart disease, the facility failed to obtain daily weights as ordered and did not notify the physician when the resident experienced a significant weight gain of 13 pounds in one day. The care plan required daily weights and physician notification for specific weight changes, but documentation showed missed weight recordings and no evidence of physician notification after the rapid weight gain. The facility also lacked policies on edema or blood pressure management.
Failure to Implement Restorative Services for Dependent Resident
Penalty
Summary
The facility failed to implement restorative services for a resident with severe cognitive impairment, who was totally dependent on staff for toileting and transfers, and required substantial assistance with dressing. The resident also had a stage 2 pressure injury and was receiving hospice care. The care plan indicated the need for a program to maintain strength and mobility, including daily use of exercise equipment and range of motion (ROM) exercises as tolerated. However, documentation showed that out of 52 opportunities to assist the resident with exercises over a 26-day period, staff marked half as not applicable, several as refused, and only a few as completed. Interviews with staff revealed a lack of training and clear assignment regarding restorative services. The Director of Rehabilitation confirmed that staff were not trained on restorative services or ROM exercises. Multiple staff members, including CNAs and LPNs, indicated that restorative services were inconsistently provided due to staffing shortages and lack of designated personnel. The Director of Nursing stated that CNAs were expected to offer restorative exercises but there was no special person assigned, and one CNA was unaware of the restorative program. The facility administrator acknowledged the program was not functioning as it should and confirmed the absence of a policy on restorative services.
Failure to Reposition Resident Leading to Prolonged Immobility
Penalty
Summary
Staff failed to reposition a resident with advanced dementia, decreased mobility, and incontinence for over five hours while the resident was seated in a Broda Reclining wheelchair. The resident, who was at risk for skin impairment and had a documented pressure area on the right inner ankle, was observed in the same position from 7:55 AM until 1:22 PM, with only brief movement to and from the dining room. During this period, multiple staff members passed by without repositioning or checking on the resident’s needs, despite the care plan indicating the need for frequent repositioning and the use of pressure-relieving devices. Interviews with staff revealed inconsistent understanding of repositioning requirements, with some staff believing that adjusting the wheelchair’s recline constituted repositioning, while others stated that residents should be laid down or rolled to prevent pressure sores. The facility’s policies referenced frequent repositioning but did not specify the required frequency. The lack of consistent repositioning and unclear policy guidance contributed to the failure to provide necessary care and assistance with activities of daily living for the resident.
Failure to Monitor and Document Skin Issues and Wound Care
Penalty
Summary
The facility failed to adequately monitor and intervene for skin issues in two residents, resulting in deficiencies in wound care and documentation. One resident with a moderate cognitive deficit, multiple comorbidities including diabetes and chronic kidney disease, and a history of moisture-associated skin damage, was dependent on staff for most activities of daily living. The care plan for this resident lacked specific interventions for skin breakdown and edema, despite ongoing issues with fluid retention and visible swelling. Observations revealed that wound treatments were inconsistently applied, with missing or undated dressings, and the resident sometimes had to remind staff to perform wound care. Documentation in the clinical record and on weekly skin assessment tools was incomplete, lacking detailed descriptions and measurements of wounds, and did not consistently reflect the resident's current condition, including new blisters and changes in skin integrity. Another resident, who had normal cognition but was at risk for pressure ulcers due to a history of stroke and hemiplegia, also experienced lapses in required skin monitoring. The care plan identified the resident as being at moderate risk for pressure ulcers and included interventions such as pressure-relieving devices. However, the facility failed to complete the required weekly skin observation tool as ordered by the physician, with the last assessment being overdue by 14 days at the time of review. This omission was confirmed by the Director of Nursing, who was unable to provide an explanation for the missed assessments. Facility policies required individualized assessment and care planning for residents at risk of skin breakdown, including weekly measurement and documentation of ulcers and prompt notification of physicians regarding new skin issues. Despite these policies and specific physician orders, the facility did not ensure that wound care treatments and assessments were consistently implemented or documented for the affected residents.
Failure to Provide Consistent Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide appropriate interventions for pressure ulcer prevention and care for one resident with a known pressure ulcer on the right heel. The resident, who had severe cognitive impairment and was dependent on staff for mobility and personal care, was observed multiple times without the ordered protective boots and without the prescribed dressing on the affected heel. Documentation showed that the resident's wound progressed from a Stage II to a Stage IV ulcer, and treatment orders required the use of a protective boot at all times and regular dressing changes. Despite these orders, the resident was seen in public areas without the protective boots and was later found without a treatment dressing during a transfer for bathing. Staff interviews confirmed that the absence of the dressing was noticed only during care activities, and there was a lack of consistent communication to ensure prompt replacement of the dressing. The facility's policy required staff to implement pressure relief measures and maintain appropriate positioning and protective surfaces, but these measures were not consistently followed. The resident's care plan and treatment orders were not adhered to, resulting in lapses in pressure ulcer prevention and care.
Resident Pushed in Wheelchair Without Foot Rests
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment, non-Alzheimer's dementia, and depression was observed being pushed in a manual wheelchair without foot rests by staff. The resident required partial to moderate assistance for transfers and ambulation, as documented in the Minimum Data Set and care plan. Observations showed the resident self-propelling the wheelchair with feet slightly off the floor and later being pushed by a CNA for a distance of at least 50 feet without foot pedals attached. Multiple staff members, including CNAs, a physical therapist assistant, and the Director of Nursing, confirmed during interviews that facility policy requires foot rests to be in place and residents' feet to be on the foot rests when being pushed in a wheelchair. The facility's own policy also specifies that foot rests must be lowered and the resident's feet placed on them prior to transport. Despite these requirements, the resident was transported without foot rests, constituting a failure to protect the resident from potential accident hazards.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with a stage 2 pressure injury. The resident, who had severe cognitive impairment, was totally dependent on staff for toileting and transfers, and required substantial assistance with dressing. The resident was also on hospice care and had a care plan indicating skin integrity impairment and the need for protective boots. During a wound dressing change to the resident's right foot, three staff members, including a registered nurse and two certified nurse aides, did not wear gowns as required by EBP protocols. Additionally, there was no EBP signage posted on the resident's door to alert staff to the need for full personal protective equipment (PPE) during high-contact care activities. The facility's policy required the use of gowns and gloves for residents with wounds or indwelling medical devices, but this was not followed in the case of the resident with an open wound. The administrator acknowledged the failure to implement EBP during care.
Failure to Provide Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement appropriate interventions to prevent pressure ulcers for a resident who was at moderate risk for skin breakdown. Despite care plan instructions and MDS documentation indicating the need for pressure-reducing devices in both the chair and bed, the resident was repeatedly observed sitting in a recliner for extended periods without any pressure-reducing cushion. Staff interviews and observations confirmed that the resident was unable to shift his weight independently and often waited long periods for assistance, with staff acknowledging the absence of protective padding and the need for such devices. The resident, who had a history of renal insufficiency, peripheral vascular disease, hip fracture, and significant weight loss, developed two open sores on his buttocks. Documentation showed that the care plan lacked any reference to skin conditions or interventions for pressure sore prevention, despite the resident's declining mobility, increased weakness, and previous episodes of skin breakdown. Staff did not consistently apply prescribed creams, and communication lapses were noted between CNAs and licensed nurses regarding new or worsening skin issues. Multiple observations over several days revealed the resident sitting in soiled briefs and on unprotected recliner seats, with staff only intermittently providing absorbent padding and not pressure-reducing cushions. The facility's own assessment indicated a high percentage of residents at risk for skin breakdown, yet individualized preventive measures were not implemented for this resident. The facility's policy required assessment and care planning to prevent pressure sores, but these were not followed in this case.
Failure to Prevent Significant Medication Error in Insulin Administration
Penalty
Summary
A resident with diagnoses of diabetes mellitus, renal insufficiency, and hypertension required insulin injections for diabetes management and had physician orders for blood sugar checks four times daily, with instructions to notify the physician if blood sugar was less than 70 mg/dl or greater than 250 mg/dl. On the morning in question, the resident's blood sugar was recorded at 69 mg/dl, which was below the threshold requiring physician notification. Despite this, the LPN administered both long-acting and short-acting insulin as scheduled, without contacting the physician as required by the order. Following the administration of insulin, the resident was found unresponsive but breathing, with a blood sugar of 34 mg/dl. The nurse administered glucagon and called emergency services, resulting in the resident being transported to the emergency room. The ER record confirmed the resident was treated for hypoglycemia and subsequently admitted for other medical issues. The nurse later acknowledged that the short-acting insulin likely contributed to the further drop in blood sugar and that the physician should have been contacted before administering insulin when the blood sugar was below the specified threshold. The facility's blood glucose monitoring policy did not provide specific direction for diabetes treatment, and only the involved nurse received counseling and education following the incident. The deficiency was identified due to the failure to follow physician orders regarding insulin administration and blood sugar monitoring, resulting in a significant medication error and the resident's hospitalization.
Failure to Prevent Accidents During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents during transfers for two of three residents reviewed. One resident with mild cognitive impairment, Parkinson's disease, and total dependence on two staff for transfers with a mechanical lift was transferred by a single staff member using an EZ stand, contrary to facility policy and the resident's care plan. This resulted in the resident sustaining a fractured right thumb, which was discovered the following morning when the resident was unable to release his hands for a pulse oximeter reading. The staff member responsible for the transfer did not report the incident or injury to the nurse or the oncoming shift, and multiple staff interviews confirmed that mechanical lifts were often used with only one staff member due to staffing shortages or busy shifts, despite the policy requiring two staff for such transfers. Another resident, who had intact cognitive functioning but was experiencing weakness and illness, required partial assistance for transfers and used a walker and wheelchair for mobility. During an episode of increased weakness, two CNAs attempted to transfer the resident to the bathroom using a Sit to Stand (STS) mechanical lift. The resident was unable to support her own weight and slid out of the sling onto the floor. Staff interviews revealed that the resident was not standing well on the machine, her arms were not properly positioned, and there was uncertainty about whether the sling's belt was tightened as required by the manufacturer's instructions. The incident occurred after the nurse instructed staff to use the STS due to the resident's inability to transfer as usual, and the resident was later found to have been septic with a urinary tract infection. Documentation and staff statements indicated a pattern of non-compliance with facility policy and manufacturer guidelines regarding the use of mechanical lifts, including the frequent use of only one staff member for transfers that required two, and improper use of equipment such as not ensuring the sling belt was snug. These actions and inactions directly led to resident injuries, including a fractured thumb and a fall from a mechanical lift.
Repeated Deficiencies in QAPI Program and Resident Care Processes
Penalty
Summary
The facility failed to ensure a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies identified during both annual surveys and complaint investigations. These deficiencies included issues with comprehensive assessments and their timing, assessments after significant changes, quarterly assessments, encoding and transmitting resident assessments, development and implementation of care plans, provision of services meeting professional standards, quality of care, the QAPI program and plan itself, and infection prevention and control. The facility's QAPI plan outlined responsibilities for oversight, resource allocation, problem identification, corrective actions, and staff training, but these measures were not effectively implemented, as shown by the recurrence of the same deficiencies. During an interview, the Administrator acknowledged ongoing performance improvement plans (PIPs) related to MDS (Minimum Data Set) and resident falls, both initiated recently. The Administrator also noted staff turnover, with two staff members previously hired for these areas no longer employed at the facility, and a third-party service now managing MDS and care plans. Despite these efforts, the facility continued to experience repeated deficiencies in key areas of resident assessment, care planning, and infection control, indicating that the QAPI program was not functioning as required at the time of the survey.
Failure to Complete and Submit Required MDS Assessments
Penalty
Summary
The facility failed to complete and/or submit Minimum Data Set (MDS) assessments in a timely manner for four residents. For one resident, after being sent to the emergency room and subsequently admitted to the hospital, the facility did not complete a required discharge assessment. Another resident's End of Prospective Payment System (PPS) Part A Stay MDS assessment remained in progress and was not submitted as required. A third resident's admission MDS assessment was also left in progress and not submitted as completed. Additionally, for a resident who died in the facility, the required Death in Facility MDS tracking record was not completed. The administrator confirmed that these assessments were not completed or submitted as required, noting that MDS assessments were not being completed prior to her tenure. The findings were based on record review, staff interviews, and reference to the MDS 3.0 Resident Assessment Instrument User's Manual.
Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents with specific clinical needs, as required by policy. For one resident with a diagnosis of anemia, coronary artery disease, and heart failure, who experienced shortness of breath when lying flat, a physician order for nightly CPAP use was not reflected in the care plan. Observation confirmed the resident was not using the CPAP, and the resident reported inconsistent use. The Assistant Director of Nursing acknowledged the omission of the CPAP in the care plan. Another resident with COPD, respiratory failure, and a catheter placed during a recent hospitalization did not have a timely or accurately dated care plan for catheter management. The DON admitted to backdating the care plan due to her absence and lack of education on proper care plan documentation. A third resident with hypertension, dementia, and coronary artery disease experienced an unwitnessed fall, but the care plan interventions, such as a reminder sign to wait for staff assistance, were not promptly or accurately documented. Additionally, a resident with a history of stroke, cancer, and hypertension, who was admitted to hospice care, lacked a care plan detailing the hospice provider and services being delivered. Staff interviews revealed ongoing challenges with staff turnover, training, and maintaining up-to-date care plans, contributing to these deficiencies.
Failure to Develop and Update Individualized Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and maintain individualized, resident-specific care plans for four residents, as required by regulation and facility policy. For one resident with renal insufficiency, peripheral vascular disease, and a history of hip fracture, the care plan did not address skin conditions or interventions to prevent pressure sores, despite the resident requiring pressure-reducing devices and later reporting discomfort from a sore. Observation confirmed the absence of a pressure-reducing device in the resident's chair, and the resident was found sitting directly on a vinyl seat. Another resident with multiple diagnoses, including coronary artery disease, diabetes, and limited mobility, experienced a fall from a mechanical lift (Sit to Stand) during a transfer. The care plan did not include the use of the mechanical lift or specific interventions for changes in the resident's status, even though staff used the device when the resident was too weak to stand. Staff interviews revealed uncertainty about whether the use of the mechanical lift should have been included in the care plan and acknowledged that monitoring for changes in status and appropriate steps were not documented. For a resident with seizure disorder, anxiety, depression, and bipolar disorder, the care plan failed to document the behaviors displayed, non-pharmacological interventions, or targeted behaviors for staff to monitor, despite the resident receiving multiple psychotropic medications. Another resident with severe cognitive impairment and behavioral symptoms had a care plan that did not reflect the current use of an EZ Stand mechanical lift for transfers, even though staff and therapy records indicated its use. The care plan also did not address the resident's refusal to use transfer aids or the need for increased staff assistance during transfers. Facility policies required care plans to be based on comprehensive assessments and updated with changes in resident condition, but these requirements were not met for the residents reviewed.
Failure to Monitor Expired Medications and Document Insulin Pen Open Dates
Penalty
Summary
The facility failed to properly monitor and document pharmaceutical services for residents, specifically regarding expired medications and the lack of open dates on insulin pens. During observations, it was found that hydrocodone prescribed to two residents had expired based on the delivery and expiration dates, and several insulin pens for four residents were present in the medication cart without documentation of the dates they were opened. Staff interviews revealed that nurses relied on pharmacy labeling or a general rule of six months from delivery for medication expiration, and did not consistently document or verify medication details during shift changes. Additionally, the process for counting and verifying Schedule II medications was not thorough, as staff did not check the medication names or resident names, only the pill counts. The facility's policies required staff to record open dates on medication containers and promptly return expired medications to the pharmacy, as well as label insulin pens with the date opened. These procedures were not followed, resulting in expired medications remaining in use and insulin pens lacking required documentation.
Failure to Complete Timely Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments as required by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual for three out of four residents reviewed. Specifically, the annual and admission MDS assessments were either incomplete or still in progress for multiple residents. For one resident, the admission assessment was accepted, but all subsequent assessments over a period of more than a year were incomplete. Another resident's annual assessment was overdue and still in progress at the time of the survey. A third resident's admission/Medicare 5-day assessment was also found to be in progress and not completed at the time of review. The administrator acknowledged that there were significant staffing issues which resulted in the failure to complete the required MDS assessments. She indicated that while she was initiating the assessments, the responsibility for completion was not clearly assigned due to her working in a different building and staff shortages, leading to a backlog and missed assessment deadlines. The facility had a census of 47 residents at the time of the survey.
Delayed Completion of Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within the required 14-day timeframe after recognizing a significant change in condition for one resident. The resident, who had diagnoses of stroke, cancer, and hypertension and was cognitively intact, was readmitted to the facility following hospitalization and was admitted to hospice care. Documentation showed that the significant change MDS was initiated seven days after hospice admission and not completed until 23 days after the resident's return, exceeding the regulatory requirement. Additionally, the care plan lacked documentation regarding the hospice provider and services being delivered. Staff interviews confirmed that significant change MDS assessments are triggered automatically upon hospice admission, but the assessment was not completed within the mandated period.
Failure to Complete Required Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete Quarterly Minimum Data Set (MDS) assessments as required by the Centers for Medicare and Medicaid Services (CMS) for three residents. For one resident, a Quarterly MDS assessment was completed five months after the previous assessment, exceeding the required three-month interval. Another resident had a Quarterly MDS assessment completed five months after the Admission MDS, also outside the mandated timeframe. In both cases, the Administrator confirmed that the assessments were not completed within the required period, noting that MDS assessments were not being finished and that staff would enter information for their sections but not complete the process. A third resident's record showed that after the Admission MDS, the facility started but did not complete documentation on subsequent quarterly assessments, with the next accepted MDS not occurring until a significant change assessment much later. The Administrator attributed these failures to changes in facility leadership and MDS staffing, which led to missed MDS requirements, including quarterly assessments. Facility policy and CMS guidelines both require that quarterly MDS assessments be completed at least every 92 days, a standard that was not met for these residents.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to provide an accurate assessment for one resident, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation. The MDS for the resident indicated diagnoses of stroke, cancer, and hypertension, and recorded a Brief Interview for Mental Status (BIMS) score of 15, showing no cognitive impairment. The same MDS documented the presence of a stage 2 pressure ulcer. However, interviews with the Director of Nursing (DON) and another staff member revealed that the resident did not have a pressure ulcer, but rather a laceration, and that the documentation was incorrect. The facility also lacked a policy on maintaining accurate resident records.
Failure to Provide Written Baseline Care Plan to Residents Upon Admission
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to three residents upon admission, as required. For each of these residents, the clinical record review showed that there was no documentation that staff reviewed the initial care plan with the resident or their representative, nor was a copy of the baseline care plan provided. The residents involved had various diagnoses, including chronic obstructive pulmonary disease, respiratory failure, hypertension, non-Alzheimer's dementia, coronary artery disease, anxiety disorder, and insomnia. Cognitive status ranged from no impairment to moderate impairment, with one resident unable to complete the BIMS due to rarely or never being understood. Facility policy required that a preliminary care plan be developed within 24 hours of admission to ensure residents' needs are met. However, staff interviews revealed that the facility considered the kardex sheet placed in the resident's room as the baseline care plan, but did not retain these documents or provide them to residents or their representatives. The Director of Nursing confirmed that the kardex was not offered to residents or families and that the original admission kardex was not kept when updated, resulting in a lack of documentation for the baseline care plan review and provision.
Failure to Change and Label Oxygen Tubing for Resident on Supplemental Oxygen
Penalty
Summary
Facility staff failed to change and label oxygen tubing for a resident with chronic obstructive pulmonary disease (COPD), respiratory failure, and dependence on supplemental oxygen. Multiple observations over several days showed the resident wearing oxygen tubing that lacked a date of application. The resident reported having to argue with staff to use her CPAP machine during naps and sleep. Staff interviews revealed inconsistent information regarding the frequency of oxygen tubing changes, with one staff member stating it was done monthly and another later clarifying it was done weekly. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed no orders for changing oxygen tubing, and the facility was unable to provide a policy regarding the changing and documentation of oxygen tubing. The deficiency was identified through direct observation, resident interview, and review of facility records, which confirmed that the required documentation and labeling of oxygen tubing were not being performed. The lack of clear orders and policy, as well as inconsistent staff statements, contributed to the failure to provide safe and appropriate respiratory care for the resident.
Failure to Implement Infection Control Practices During Care of Residents with Medical Devices
Penalty
Summary
Staff failed to implement proper infection control practices for two residents. For one resident with an abdominal feeding tube and on continuous oxygen, an LPN administered nutrition and medications via the feeding tube while only wearing gloves and not donning a gown as required by the facility's Enhanced Barrier Precautions policy. During the procedure, the LPN also stepped on the resident's oxygen tubing, which was lying on the floor, and placed the tip of the feeding tube inside the bag of nutritional supplement, both of which were identified as infection control concerns. The resident was NPO, at risk for aspiration, and had multiple comorbidities including use of antipsychotic, antidepressant, diuretic, and antiplatelet medications. In a separate incident, another resident's urinary catheter bag was observed lying directly on the floor without a privacy cover. The facility did not provide a policy regarding catheter bags not touching the floor, but the Director of Nursing confirmed that the catheter bag should never be on the floor. These observations indicate lapses in infection prevention and control practices during the care of residents with indwelling medical devices.
Failure to Treat Resident with Dignity During Personal Care
Penalty
Summary
A resident with a history of heart failure, Parkinson's disease, depression, osteoarthritis, and chronic pain, and who was assessed as cognitively intact, required assistance with personal care due to tremors and weakness. The resident reported that during an episode of care, a staff member with braided hair was wiping her face and eyes so forcefully that it caused pain and resulted in bruising around her eye. Despite the resident's request for the staff member to stop due to pain, the staff member continued the action. The resident later reported soreness and visible bruising was documented by nursing staff. Interviews with the resident confirmed that she experienced pain and bruising after the incident, and she stated that she had told the staff member to stop, but her request was ignored. The resident could not recall the staff member's name but described her appearance. Nursing staff and the social worker corroborated the resident's account, noting the presence of bruising and the resident's report of pain. The incident was reported to facility leadership, and the resident indicated that she had not experienced similar issues since that time. Staff interviews revealed that the CNA in question did not recall the incident or being informed by the resident of any pain. The Director of Nursing confirmed that the resident was considered reliable and that the description matched only one staff member on duty at the time. The facility's policy states that residents have the right to be treated with dignity and respect, and the method for washing a resident's eyes should be gentle, starting from the inner to the outer corner with a warm cloth.
Failure to Follow Physician Orders and Document Interventions
Penalty
Summary
Staff failed to follow physician orders for two residents, resulting in deficiencies in care. For one resident with a history of hypertension, renal insufficiency, and peripheral vascular disease, staff were required to monitor blood pressure daily and notify the primary care provider if readings were outside the specified range. Despite multiple instances of elevated blood pressure above the ordered threshold, there was no documentation that the physician was contacted as required. This omission was confirmed by a hand-written physician order noting the lack of notification and subsequent adjustment of hypertension medication. Another resident with severe cognitive impairment, multiple comorbidities, and a history of behavioral symptoms had physician orders for PRN anti-anxiety medication, with instructions to document non-pharmacological interventions prior to administration and to monitor for side effects and effectiveness. Review of the medication administration record and progress notes revealed that staff administered PRN lorazepam on numerous occasions for agitation, restlessness, and aggression, but consistently failed to document any non-pharmacological interventions attempted before medication was given. Progress notes also lacked required behavior documentation associated with each administration. Interviews with nursing staff and the Director of Nursing confirmed that staff were expected to attempt and document non-pharmacological interventions prior to administering PRN medications for behavior, and to record these actions in the resident's chart. However, record review demonstrated that this documentation was not consistently completed, resulting in a failure to meet professional standards of quality and to follow physician orders as required.
Failure to Provide Timely Assessment and Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. One resident with a history of hip fracture and cerebrovascular accident experienced a fall and complained of pain, but staff did not consistently document neurological assessments or ongoing vital signs after the incident. The resident was not sent to the hospital for observation until several hours later, despite continued complaints of pain, and was later found to have a pelvic fracture. Staff interviews revealed uncertainty about the assessments performed, and the Director of Nursing confirmed the absence of a policy for neurological assessments after falls and could not locate the required documentation in the resident's chart. Two other residents missed multiple doses of prescribed medications because the medications were not available at the facility. One resident, with diagnoses including COPD and respiratory failure, did not receive several doses of fexofenadine and Yupelri inhalation solution over multiple days, and there was no documentation that the physician was notified of these omissions. Progress notes indicated repeated attempts to obtain the medications from the pharmacy, but the medications remained unavailable for an extended period. Another resident, with a history of stroke, cancer, and hypertension, experienced a discrepancy between hospice orders and family wishes regarding the continuation of a supplement. Although the hospice nurse agreed to continue the supplement per family request, the facility's records did not show physician notification or clear documentation of the family's wishes being followed. The Director of Nursing stated that staff should have notified the physician about missed medications and honored the family's request regarding the resident's medication regimen.
Inaccurate Documentation of Care and Failure to Record Required Monitoring
Penalty
Summary
The facility failed to ensure that resident records accurately reflected the care provided for two residents. For one resident with a feeding tube and a history of significant weight loss, the care plan required weekly weights following a physician's order. Although the Medication Administration Record (MAR) indicated that weights were taken and documented, the actual weight record lacked any follow-up weights after the initial order, and there was no evidence that the required monitoring was performed as directed. For another resident with hypertension and an order for daily blood pressure (BP) monitoring and physician notification if BP readings were outside specified parameters, the clinical record showed multiple instances where BP readings exceeded the threshold. Despite this, there was no documentation that the physician had been contacted as required. The MAR showed that nurses checked boxes indicating the provider had been contacted, but the Director of Nursing confirmed that there should have been corresponding documentation in the clinical record, which was absent.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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