Pleasant View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Whiting, Iowa.
- Location
- 200 Shannon Drive, Whiting, Iowa 51063
- CMS Provider Number
- 165296
- Inspections on file
- 19
- Latest survey
- July 3, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Pleasant View Care Center during CMS and state inspections, most recent first.
The facility did not consistently serve meals at safe and appetizing temperatures, with observations showing food items such as chicken and pasta being served below required temperatures and in poor condition. Several residents and family members reported that meals were often cold, dry, or overcooked, and staff interviews confirmed that proper reheating procedures were not followed, leading to unsatisfactory meal quality.
Surveyors observed unsanitary conditions in kitchen and dining areas, including food debris in refrigerators, buildup on equipment, and improper food handling by staff. Staff failed to perform hand hygiene after moving between clean and dirty areas, handled food containers inappropriately, and did not discard food dropped on the floor, all in violation of facility policy.
Staff did not follow the planned menu or provide correct portion sizes for pureed diets, resulting in some residents not receiving all required menu items or full servings during meal service. Staff interviews confirmed that insufficient preparation and omissions occurred, and facility leadership acknowledged that menu and portion expectations were not met.
The facility did not maintain food at safe temperatures, with milk served at 44.4°F and lunch items like Salisbury steak and pureed green beans below the required 135°F. A Dietary Aide and the Administrator acknowledged the temperature discrepancies, which violated the facility's policy.
The facility failed to maintain sanitary practices in the kitchen and during meal service. Staff improperly handled food and utensils without cleaning or performing hand hygiene, contrary to the facility's policy. The kitchen was found in unsanitary conditions, with food debris and mold present. Staff shortages contributed to the lack of cleanliness, and cleaning logs were unavailable.
A facility failed to protect resident information when a CMA left a laptop open with EHR data of 10 residents visible and a paper with a resident's narcotic medication time exposed. The CMA was normally assigned different duties. The facility's policy requires securing PHI, as confirmed by the DON.
The facility failed to maintain the dignity of two residents during meal service. A resident was seated at a table labeled as the 'feeder table' by an LPN, and another resident was transported with their briefs and thigh exposed. Staff acknowledged the need for better coverage and language use. The residents had conditions requiring full assistance with ADLs.
The facility failed to serve correct portions and therapeutic diets to residents. A resident on a pureed diet received an incorrect portion of scalloped potatoes due to staff oversight. Additionally, two residents on renal diets did not receive the prescribed parsley noodles, as they were not prepared. The facility's policy requires adherence to physician-ordered diets, which was not followed.
The facility failed to maintain proper infection control practices, as an RN did not perform hand hygiene during medication administration for two residents, and a CNA improperly transported soiled linen. The RN was unclear about hand hygiene protocols, and the CNA did not follow the facility's policy of placing soiled linen in a bag before transport.
The facility failed to develop comprehensive Care Plans to address the side effects of opioid and antidepressant medications for a resident with heart failure, hypertension, and Non-Alzheimer's Dementia. The Care Plan did not include information regarding the side effects of escitalopram and hydrocodone-acetaminophen, despite the facility's policy requiring such details.
A resident with a history of falls and impaired mobility fell in the shower room after a CNA attempted to transfer her without using a gait belt, resulting in a bruise on her right hand. Multiple staff members confirmed the incident, and the DON acknowledged the failure to follow protocol.
The facility failed to ensure proper infection control practices for two residents. An LPN and two CNAs did not change gloves or wash hands between tasks while providing wound and incontinence care, compromising infection control protocols.
Failure to Serve Palatable and Safe Temperature Meals
Penalty
Summary
The facility failed to ensure that food and drink were served at safe, palatable, and appetizing temperatures for several residents. Observations during meal service revealed that food items, such as lemon chicken and garlic parmesan pasta, were served below the expected temperature, with the chicken measuring as low as 117.7°F and the pasta at 98.8°F after tray delivery. The chicken was also observed to be dry, burnt, and difficult to cut, and the pasta was mushy. Staff interviews confirmed that the food did not reach the required temperatures, and the normal reheating process was not followed, as food was placed directly on the hot cart instead of being returned to the oven. Multiple residents and their family members reported dissatisfaction with the food quality and temperature. One resident consistently described the food as cold and dry, while another stated that meals were not always hot and expressed a preference for warmer food. A family member of a resident dependent on renal dialysis reported that the food was often dry, difficult to eat, and that vegetables were overcooked. Another resident's spouse noted inconsistency in food temperature, with meals sometimes arriving hot and other times not. Staff observations and interviews further highlighted procedural lapses, such as food being left on the counter before being placed on room tray carts and difficulties in maintaining appropriate temperatures on the steam table. The Certified Dietary Manager and dietary staff acknowledged that food was not reheated as required and that the chicken appeared dry and tough. The administrator confirmed that the meal service was delayed, and the food was not handled according to standard procedures, resulting in suboptimal food temperatures and quality for residents.
Failure to Maintain Sanitary Food Preparation and Handling Practices
Penalty
Summary
The facility failed to maintain proper sanitary conditions in the kitchen and food preparation areas, as evidenced by multiple observations of unclean equipment and improper food handling practices. During an initial walkthrough, surveyors found dried liquid and scattered food debris in refrigerators and freezers in the east dining room kitchenette, as well as white crust lime buildup on the ice machine, coffee machine, and dishwasher in another dining area. Drawers containing utensils and cupboards with small appliances were also found with food debris and dried liquid. The main kitchen refrigerator was similarly observed to have food debris. During meal service, staff were observed engaging in unsanitary practices. One staff member, after pureeing pasta, entered the dirty side of the kitchen, touched the dishwasher handle and dish carts, and then returned to the clean side without performing hand hygiene. The same staff member dropped a covered pan of pasta on the floor, picked it up, and placed it over an open rack of garlic bread in the oven. Another dietary aide was seen making a salad, stacking containers of vegetables and ham in her arms, and using her face to steady the stack, while a different aide plated food, served it to residents, and returned to the kitchen without hand hygiene. Interviews with staff confirmed awareness of proper procedures, such as the need for handwashing after moving between clean and dirty areas and discarding food dropped on the floor, but these procedures were not followed during the observed incidents. The facility's own policies require kitchen cleanliness, proper food storage, and strict hand hygiene, as well as discarding any food that comes into contact with the floor, but these standards were not met during the survey period.
Failure to Follow Planned Menu and Portion Sizes for Pureed Diets
Penalty
Summary
Facility staff failed to follow the planned menu for residents requiring pureed diets during meal preparation and service. Observations showed that staff did not use the correct number of servings or portion sizes as indicated on the menu and by facility policy. Specifically, during the preparation of pureed lemon chicken, only one piece of garlic bread was used to thicken four servings of chicken, instead of the required four pieces. Staff also did not prepare enough pureed chicken to provide the full portions for each resident, and the correct scoop sizes were not consistently used during service. Staff interviews confirmed that these deviations occurred due to time constraints and oversight. During meal service, residents on pureed diets did not consistently receive all menu items. For example, one resident did not receive the full portion of pureed meat, and nine trays were served without garlic bread. Staff acknowledged that the omission of garlic bread and insufficient portions of pureed meat were due to forgetting and running out of prepared food. The dietary aide relied on the extended menu but did not ensure all items were served as planned, and the cook did not prepare enough pureed food to meet the menu requirements. The Certified Dietary Manager and Administrator both confirmed that the facility's expectation was for staff to follow the menu completely, including serving the correct portions and all menu items to residents on pureed diets. Facility policy required therapeutic diets to be individualized and to coincide with the menu extensions, but these standards were not met during the observed meal service. The deficiency was identified through review of menus, observations, staff interviews, and policy review.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain food at safe and appetizing temperatures, as observed during a survey. On August 13, 2024, a Dietary Aide was seen pouring milk for a resident from a jug that was at 44.4 degrees Fahrenheit, exceeding the facility's policy requirement for cold foods to stay below 41 degrees Fahrenheit. On August 14, 2024, a temperature check of lunch items revealed that the Salisbury steak was at 128 degrees Fahrenheit and the pureed Salisbury steak was at 115 degrees Fahrenheit, both below the required 135 degrees Fahrenheit for hot foods. The pureed green beans were at 134.5 degrees Fahrenheit, also below the required temperature. The facility's policy, dated 2021, mandates that temperatures should be periodically checked to ensure compliance with these standards. The Administrator confirmed that staff should adhere to these temperature guidelines.
Sanitation Deficiencies in Kitchen and Meal Service
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen and during meal service, as observed by surveyors. Staff C, a Dietary Aide, improperly handled food by using the same tongs to remove aluminum foil, plate sandwiches, and pour stew, without cleaning the tongs between uses. Staff D, an Activities Assistant, picked up a cup from the floor with bare hands and handled utensils without performing hand hygiene. Staff F did not change gloves or perform hand hygiene while preparing a resident's meal. Staff E, a cook, used a disher to scoop pureed food into steam pans without cleaning it between uses. These actions were contrary to the facility's General Food Preparation and Handling policy, which requires the use of clean utensils to avoid manual contact with prepared foods. Additionally, the initial kitchen walkthrough revealed unsanitary conditions, including a thick layer of grease and food debris on the shelf above the stove, food debris on a cart with clean dishes, and an accumulation of food debris and dried liquids on the kitchen floor, walk-in fridge, and freezer. Mold was found around the caulk and wall in front of the dishwashing sink. Staff A, the Head, admitted to not having mopped or swept the previous day due to staff shortages and was unable to provide cleaning logs. The facility's policy requires the kitchen to be kept neat and orderly, with surfaces and equipment cleaned and sanitized as appropriate.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to protect resident information from unauthorized access, as observed during a survey. On August 13, 2024, a Certified Medication Aide (CMA), identified as Staff H, left a laptop open with Electronic Health Record (EHR) information of 10 residents visible while attending to a resident in her room. Additionally, a sheet of paper with a resident's narcotic medication administration time was left exposed. Staff H mentioned that she was usually assigned different duties. The facility's policy, effective since November 28, 2016, mandates the protection of Protected Health Information (PHI) in compliance with applicable laws and regulations. On August 15, 2024, the Director of Nursing (DON) confirmed that staff are expected to secure EHR medical records when leaving the cart unattended.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to uphold the dignity of two residents during meal service. One resident, who was seated at a table referred to as the 'feeder table' by a Licensed Practical Nurse (LPN), was not addressed by name. This resident had a history of cerebral palsy, epilepsy, autistic disorder, and was wheelchair-dependent, with a Minimum Data Set (MDS) indicating they were rarely or never understood but had adequate hearing. The use of the term 'feeder table' was noted as inappropriate and not in line with maintaining resident dignity. Another resident was observed being transported to the dining area with their briefs and upper left thigh exposed, as their pants were cut for comfort by a family member. The resident had a BIMS score indicating moderately impaired cognition and required assistance with all Activities of Daily Living (ADLs). Staff acknowledged that they should have used a pad or sheet to cover the resident to maintain dignity, as they had access to such items. The Director of Nursing (DON) confirmed that staff should be mindful of their language and ensure residents are covered appropriately.
Failure to Serve Correct Portions and Therapeutic Diets
Penalty
Summary
The facility failed to serve the appropriate portions and therapeutic diets to residents, as observed during a survey. Specifically, a resident on a pureed diet was served an incorrect portion of pureed scalloped potatoes. The cook, Staff E, prepared the pureed scalloped potatoes using a blender and referenced a pureed disher conversion chart, which directed the use of a #6 (5 1/3 oz) disher and a #8 (4 oz) disher. However, during lunch service, Staff G, a Dietary Aide, only used the #6 disher to plate the pureed scalloped potatoes, forgetting to use the #8 disher as required. This resulted in the resident receiving an incorrect portion size. Additionally, the facility failed to provide the correct therapeutic diet for two residents who were ordered renal diets. The menu review indicated that residents on renal diets should receive 4 oz of parsley noodles, but Staff E admitted to not preparing parsley noodles for the lunch service, citing it as an oversight. The facility's policy, as outlined in a document titled 'Therapeutic Diets' dated 2021, mandates that diets be offered as ordered by the physician or designee. The administrator confirmed that staff should adhere to the scoop diagram and menu items, which was not followed in these instances.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration for two residents. On one occasion, a Registered Nurse (RN) assisted a resident with drinking water during medication administration and then proceeded to handle the medication cart and other items without performing hand hygiene. The RN admitted to not washing her hands after the medication pass and was unclear about the proper hand hygiene protocol. The facility's Medication Pass Policy and Quality Assurance Audit for Medication Pass both emphasized the importance of proper sanitation and hand hygiene, which were not adhered to in this instance. Additionally, the facility did not follow proper procedures for handling soiled linen. A Certified Nurse Aide (CNA) was observed carrying uncontained, soiled linen from a resident's room to the soiled utility room, allowing the linen to come into contact with his uniform and gait belt. The facility's Linen Handling policy required soiled linen to be placed in a plastic bag before transport, which was not followed. The Director of Nursing confirmed that staff should adhere to the policy for linen removal.
Failure to Address Medication Side Effects in Care Plan
Penalty
Summary
The facility failed to develop comprehensive Care Plans to address the side effects of opioid and antidepressant medications for one resident. Resident #13, who has diagnoses of heart failure, hypertension, and Non-Alzheimer's Dementia, was taking escitalopram for depression and hydrocodone-acetaminophen for pain. The Care Plan, revised on 2/10/24, did not include information regarding the side effects of these medications. This deficiency was identified through a clinical record review and staff interview, which confirmed that the side effects should have been listed on the Care Plan as per the facility's policy.
Failure to Use Gait Belt During Transfer
Penalty
Summary
The facility failed to ensure that residents were safe from accidents and hazards, specifically in the case of Resident #33. Resident #33, who had a history of falls, impaired mobility, and impaired cognition, fell in the shower room after a CNA attempted to transfer her from the shower chair to the wheelchair without using a gait belt. The resident sustained a bruise on her right hand as a result of the fall. The CNA admitted to not using a gait belt during the transfer, which is against the facility's protocol for transferring residents. The incident was corroborated by multiple staff members, including the DON and an RN, who confirmed that the resident was found on the wet shower floor, fully clothed and wearing gripper socks. The DON acknowledged that the CNA did not use a gait belt and stated that the CNA would be re-educated and disciplined. The facility's educational checklist clearly states that a gait belt should be used during transfers, which was not followed in this instance, leading to the resident's fall and injury.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to ensure that staff used adequate infection control practices to decrease the transmission of pathogens for two residents. Resident #34, who had multiple wounds requiring daily dressing changes, was observed being treated by an LPN who did not change gloves between different tasks and did not wash hands after completing the care. This resident had a history of urinary tract infections, renal insufficiency, and was at risk for developing pressure ulcers. The LPN applied betadine solution, wrapped the heels, and handled various items without changing gloves or washing hands, thereby compromising infection control protocols. Similarly, Resident #1, who required assistance with incontinence care and had a sore on her upper thigh, was attended to by two CNAs who also failed to follow proper hand hygiene practices. The CNAs did not change gloves between tasks and did not wash hands after completing the care. This resident had diagnoses including heart failure, anxiety disorder, schizophrenia, intellectual disabilities, and Down Syndrome. The CNAs handled the resident's brief, bedpan, and applied barrier cream to an open sore without changing gloves or washing hands, further breaching infection control standards.
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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