Prairie Gate
Inspection history, citations, penalties and survey trends for this long-term care facility in Council Bluffs, Iowa.
- Location
- 16 Valley View Drive, Council Bluffs, Iowa 51503
- CMS Provider Number
- 165794
- Inspections on file
- 20
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Prairie Gate during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of bruising reported to staff and family concerns about rough handling by an overnight CNA. Although the LPN communicated these concerns to the charge nurse, no formal report was made to the state agency, and the incident was not investigated as required by facility policy. The DON and administrator were unaware of the allegations, resulting in a failure to report suspected abuse.
A resident with cognitive impairment and a history of bruising reported to staff, along with her family, concerns about rough handling by an overnight staff member during care. Although an LPN communicated these concerns to the charge nurse, there was no evidence that a formal assessment or investigation was conducted, nor was the incident reported to the state agency, contrary to facility policy.
A resident with a history of multiple bruises and a recent hip hematoma reported to staff and family that an overnight CNA was rough during care, leading to concerns about new bruising. Although the LPN reported the complaint to the charge nurse, no assessment or occurrence report was completed as required by facility policy, and documentation of skin alterations was incomplete.
A CNA did not follow proper hand hygiene protocols while providing catheter care to a resident with severe cognitive impairment and an indwelling catheter on Enhanced Barrier Precautions. Hand hygiene was not performed between glove changes or after glove removal, contrary to facility policy and expectations, resulting in a breach of infection prevention practices.
A resident with severe cognitive impairment and multiple diagnoses was injured after a CNA transferred her in a wheelchair without placing her feet on the foot pedals, causing her to fall and sustain a contusion and abrasion. The care plan required a tilt-in-space wheelchair and proper transfer assistance, but these procedures were not followed, as confirmed by video review and staff interviews.
A resident with impaired mobility and a recent arm injury was handled roughly by an agency CNA during nighttime personal care, resulting in pain and distress. The resident reported being unable to turn herself in bed and that the CNA pulled on her injured arm despite her protests. Multiple staff and the resident's family confirmed the resident's account, noting her upset state and pain following the incident. The facility's policy on resident rights was not followed, as the resident was not treated with dignity and respect during care.
A resident with severe cognitive impairment and an elopement risk exited through alarmed double doors after a staff member, upon hearing the alarm, assumed the individual was someone else and turned off the alarm without verifying the resident's identity or notifying nursing staff, contrary to facility protocol. The resident was later found and returned without injury.
The facility did not post the daily nursing census in a prominent area accessible to residents and visitors. The census was found at the nurse's station without the required posting of nursing and CNA hours. A staff member posted the schedule by the front door, unaware it needed to be visible to residents on the second floor, contrary to the facility's policy.
The facility failed to store food according to safe practices, as observed during a kitchen tour. The DM found several undated and open containers in the refrigerator and dry storage, including fruit cups, soup, raw broccoli, cilantro, potato chips, and cherries. A container of raw chicken was improperly stored above other fresh foods. The DM acknowledged that staff were expected to date packages upon opening, per the facility's 'Safe Food Storage' policy.
A facility failed to provide dignified care and respect resident rights, as evidenced by a CNA's rough handling of residents during transfers and a resident being coerced into a shower despite refusal. Several residents reported feeling anxious and undignified due to the CNA's actions, which included not following care plans and rushing through care. Documentation and communication issues also contributed to the failure to respect a resident's right to refuse care.
A facility failed to provide sufficient nursing staff, resulting in delayed call light responses for several residents. One resident, with no cognitive impairment, reported staff shortages during the evening shift, leading to response times exceeding 15 minutes. Another resident, with moderate cognitive impairment, experienced delays up to 24 minutes, affecting her ability to prevent incontinence. A third resident, dependent on staff for transfers, faced response times up to 80 minutes, while a fourth resident, at risk for falls, reported delays over an hour. The facility's policy required prompt call light responses, but recent times exceeded expectations.
A resident reported that her bed linen had not been changed for two weeks, which was confirmed by observations. The facility's policy requires weekly linen changes, but a CNA admitted to not changing the bedding on the scheduled day and communicated this to the next shift. However, the next shift did not change the bedding, leading to the deficiency.
A facility failed to accurately assess a resident's status in the MDS, incorrectly coding insulin injections despite no orders for insulin. The resident's MAR showed no insulin orders, and the DON confirmed the coding error, contrary to the facility's RAI policy requiring accurate assessments.
A resident with moderate cognitive impairment requiring oxygen was found with undated oxygen tubing and nebulizer mask. Staff provided conflicting information about the schedule for changing respiratory supplies, with no consistent practice or documentation. The DON confirmed the expectation for weekly changes, which was not followed.
A resident with moderate cognitive deficit and multiple health conditions was transferred by a CNA without the required assistance or use of a gait belt, contrary to the care plan. The CNA had a history of not following care plans and being rough with residents, leading to multiple warnings and a suspension. Other staff and residents expressed concerns about his handling, and the facility's policy on using gait belts was not adhered to.
A resident in an LTC facility experienced a significant medication error when staff failed to follow a cardiologist's order for Bumetanide, resulting in the resident receiving an incorrect dosage for an extended period. This error contributed to the resident developing an acute kidney injury, as the facility did not properly process and clarify the medication orders.
A facility failed to ensure an LPN maintained the appropriate licensure to practice in Iowa. The LPN's license changed from a multistate to a single state valid only in Nebraska, which was not communicated to the facility. The Human Resources Manager, who took over in 2023, did not verify the license since 2021, leading to the oversight. The facility's system failed to detect the change during the 2023 renewal process.
A resident with multiple health conditions received incorrect dosages of Bumetanide due to the facility's failure to clarify and accurately transcribe physician orders. The resident was supposed to receive 2 mg once daily after an initial period of 2 mg twice daily, but continued to receive higher doses due to transcription errors and lack of clarification by the staff.
Failure to Report Suspected Abuse Following Resident Allegations
Penalty
Summary
The facility failed to report an incident of possible physical abuse involving one resident, as required by policy and regulation. The resident in question had a history of cognitive impairment, with documented changes in her Brief Interview for Mental Status (BIMS) scores and a diagnosis of dementia. Upon admission, the resident had significant bruising on her legs and hips, reportedly from a fall at home, and continued to have bruising during her stay. The resident and her daughter both expressed concerns to staff about rough treatment by a female staff member during overnight shifts, specifically mentioning that the resident felt the staff was rough when turning her. Staff interviews revealed that the concerns about rough handling were communicated to nursing staff, including an LPN and charge nurses. The LPN reported the resident's statements about rough treatment to the charge nurse and completed an assessment, but it was unclear if this was documented in the resident's record. The charge nurses and other staff interviewed stated that they did not recall receiving reports of rough treatment or abuse regarding this resident, and no formal report was made to the state agency. The facility's policies required that any suspected abuse be reported immediately to supervisors and the appropriate authorities, but this process was not followed in this case. Despite the facility's established policies for occurrence reporting and abuse prevention, the incident was not reported to the state agency, and there was no evidence of a formal investigation or protective measures being initiated. The administrator and DON confirmed that they were unaware of any reports of possible abuse or rough treatment involving this resident, and therefore no report was made to the state agency. This failure to report and investigate the alleged abuse constituted a deficiency in the facility's compliance with regulatory requirements for protecting residents from abuse.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident who had a history of cognitive impairment and multiple bruises upon admission. The resident, who had a diagnosis of unspecified dementia and a fluctuating BIMS score indicating periods of moderate cognitive impairment, was noted to have significant bruising on her legs and hips, reportedly from a fall at home prior to admission. During her stay, the resident and her daughter expressed concerns to staff about rough treatment by an unidentified female staff member during overnight shifts, particularly when the resident was being turned or cleaned due to C-diff-related loose stools. Staff interviews revealed that the concerns about rough handling were communicated to at least one LPN, who reported the information to the charge nurse. However, there was no documentation or evidence that a formal assessment or investigation was initiated in response to these allegations. The charge nurses and other staff interviewed either did not recall receiving such reports or stated that no further action was taken. The facility's policies required that any suspected abuse be reported, investigated, and, if necessary, reported to the state agency, but this process was not followed in this case. Despite the facility's policies and the statements from staff and administration outlining the required procedures for handling abuse allegations, there was no indication that the incident involving the resident's report of rough treatment was investigated or reported to the state agency. The lack of documentation and follow-up on the reported concerns constituted a failure to respond appropriately to an alleged violation, as required by facility policy and regulatory standards.
Failure to Assess and Document After Resident Reported Rough Care and Bruising
Penalty
Summary
The facility failed to complete an assessment when a resident reported bruising related to a staff member being rough during care. The resident, who had a history of a fall at home resulting in a right hip hematoma and multiple bruises, was admitted to the facility with documented bruising on her legs and hips. Despite weekly body audits, the documentation did not include measurements of skin alterations, and there was inconsistency in the recorded location of the hematoma. The resident and her daughter reported concerns to nursing staff about rough handling by an overnight staff member, but the staff could not identify the specific individual involved. Staff interviews revealed that the LPN who received the complaint reported it to the charge nurse but did not document an assessment or complete an occurrence report as required by facility policy. The LPN stated that it was difficult to determine if new bruising was present due to the pre-existing bruises from the resident's fall at home. The Director of Nursing and the Administrator both acknowledged that an assessment should have been completed in response to the report of rough care, but no such assessment was found in the resident's records. Facility policy required that any employee discovering or observing an event report it to a supervisor so that immediate and necessary action could be taken, including completion of an occurrence report. However, the lack of documentation and assessment following the resident's report of rough handling constituted a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Adhere to Hand Hygiene Protocols During Catheter Care
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow appropriate infection prevention and control practices while providing catheter care to a resident with severe cognitive impairment and an indwelling catheter, who was also on Enhanced Barrier Precautions (EBP). During the observed care, the CNA performed hand hygiene and donned gloves and a gown, but did not perform hand hygiene between glove changes or after removing gloves at several points in the procedure. Specifically, after cleansing the catheter tubing and removing gloves, the CNA did not perform hand hygiene before donning new gloves. Additionally, after emptying the catheter bag and removing gloves, hand hygiene was again omitted before proceeding with the next steps. The Director of Nursing (DON) confirmed that the facility's expectation was for staff to perform hand hygiene between glove changes and when moving from one contaminated area to another, in accordance with the facility's infection control policy. The policy also required hand hygiene before and after resident contact, after contact with contaminated surfaces, before donning PPE, and after removing PPE. The observed failure to adhere to these procedures constituted a breach of the facility's infection prevention and control program.
Failure to Ensure Safe Wheelchair Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, vascular dementia, depression, rheumatoid arthritis, and cancer was not properly protected from accident hazards during a wheelchair transfer. The resident required partial to moderate assistance for transfers and used a wheelchair for mobility. During an incident after a meal, a CNA assisted the resident by pulling the wheelchair away from the dining table and began pushing her forward without ensuring her feet were placed on the foot pedals. As a result, the resident's feet were under the foot pedals, and she fell out of the wheelchair, sustaining a contusion to the left forehead and an abrasion with bruising. The care plan for the resident indicated the use of a tilt-in-space wheelchair for mobility due to limited physical mobility and impaired self-care abilities. Despite this, the staff member failed to follow proper transfer procedures, as confirmed by video footage and staff interviews. The DON confirmed that the expectation was for staff to ensure residents' feet are on the foot pedals during transfers, which was not done in this case, directly leading to the resident's fall and injury.
Failure to Provide Dignified and Respectful Care During Personal Assistance
Penalty
Summary
A resident with no cognitive impairment and a history of polyosteoarthritis and thyroid disease required assistance with activities of daily living (ADLs), including bed mobility and toileting, due to physical debility and impaired mobility. The resident's care plan specified the need for one staff member to assist with a gait belt and walker for ambulation and transfers, and to provide assistance as needed for bed mobility. On one occasion, the resident experienced right shoulder pain after being assisted by a staff member during the night. According to interviews and documentation, the resident reported that a staff member on the overnight shift entered her room multiple times, woke her, and instructed her to roll over while she was lying flat in bed. The resident stated she was unable to turn without something to grab onto, but the staff member insisted and ultimately pulled on her right arm to turn her, causing pain in an arm that had recently been injured in a fall. The resident described the staff member's attitude as gruff and lacking compassion, and expressed concern for other residents who might not be able to speak up about similar treatment. The resident's daughter and other staff corroborated the resident's account, noting that the resident was upset and in pain following the incident. Further interviews with staff revealed that the staff member in question, an agency CNA, denied pulling on the resident's arm but acknowledged the bed was flat and that the resident had no side rails to assist with turning. Other staff who cared for the resident after the incident observed that the resident was upset, felt trapped, and complained of being handled roughly. The resident, who was not known to complain about staff, specifically described the care as rough and painful, prompting staff to report the incident. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, which was not upheld in this instance.
Failure to Properly Respond to Door Alarm Allows Resident Exit
Penalty
Summary
A resident with severe cognitive impairment and a history of elopement risk exited the care center through alarmed double doors without proper staff intervention. The resident required partial to moderate assistance for mobility and transfers, and his care plan included specific interventions such as door security systems, closed double doors, and frequent checks. On the day of the incident, the resident left the unit through the double doors, which triggered the alarm. A staff member, upon hearing the alarm, looked down the hall, saw a male resident heading toward the Bistro, and mistakenly assumed it was another resident who would be signed out by independent living. The staff member turned off the alarm without verifying the identity of the individual or notifying nursing staff as required by protocol. The resident was later found outside the care center double doors, attempting to locate his room, and was returned to his room without injury. The facility's policy required staff to respond to door alarms by identifying the cause and notifying the charge nurse if the cause was unknown. The staff member involved admitted to not being certain of the resident's identity and acknowledged that he should have checked on the resident and been more proactive. The administrator confirmed that the staff member did not follow protocol by failing to verify who set off the alarm.
Failure to Post Daily Nursing Census in Accessible Area
Penalty
Summary
The facility failed to post the daily nursing census in a prominent area accessible to visitors and residents, as required by their policy. During an observation on August 13, 2024, it was noted that the daily nursing census was posted at the nurse's station, but there was no posting of the number of nursing and certified nurse aide hours. On the following day, a staff member responsible for scheduling stated that she had printed the daily schedule with hours and posted it by the front door on the first floor. However, she was unaware that it needed to be posted where the residents, who were housed on the second floor, could see it. The facility's policy, modified in October 2022, specified that nursing staff data should be posted in a designated public area by staffing personnel, in a place readily accessible to residents and visitors.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored according to safe practices, as observed during an initial tour of the kitchen. The Dietary Manager (DM) provided the tour, during which several undated and open containers were found in both the walk-in refrigerator and dry storage area. Specifically, the refrigerator contained a tray of individual cups of fruit, a container of soup, a bag of raw broccoli, and a bag of cilantro, all open and undated. Additionally, a container of raw chicken was improperly stored on the top shelf above other fresh foods. In the dry storage area, there were open and undated bags of potato chips, dehydrated cherries, and a container of cherries in juice. The DM acknowledged that staff were expected to date packages as soon as they were opened, in accordance with the facility's policy titled 'Safe Food Storage,' which was updated in May 2019. This policy mandates that staff label, date, and properly cover all food items upon opening. Furthermore, the policy specifies the correct order for storing food products in a refrigerator, from top to bottom: prepared ready-to-eat items, fish and seafood, whole cuts of raw beef, whole cuts of raw pork, ground or processed meats, and raw poultry.
Failure to Provide Dignified Care and Respect Resident Rights
Penalty
Summary
The facility failed to provide care in a dignified manner for several residents, as evidenced by the actions of Staff A, a Certified Nurse Aide (CNA). Resident #21, who had a moderate cognitive deficit and required assistance with transfers, reported being handled roughly by Staff A. The resident and her family member described incidents where Staff A did not use a gait belt or follow the care plan, resulting in painful and undignified transfers. Staff A had a history of disciplinary actions for similar behavior, including rushing through care and not following safe transfer techniques. Resident #11, also with a moderate cognitive deficit, experienced undignified treatment when Staff A grabbed her by the shirt and pushed her back to her room after finding her in another resident's room. This incident left the resident feeling nervous and apprehensive about Staff A's presence. Similarly, Resident #6, who was dependent on staff for transfers, reported that Staff A was in a hurry and did not listen to her requests to slow down, resulting in a fall during a transfer from the toilet. Additionally, the facility failed to respect Resident #17's right to refuse care. Despite expressing that she had already showered the previous day, Resident #17 was coerced into taking another shower by staff, who did not allow her to refuse. This incident left the resident feeling upset and undignified, as she felt she had no choice in the matter. The facility's documentation and communication issues contributed to this situation, as staff were not aware of the resident's previous shower and did not properly document or communicate the care provided.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. This deficiency was identified through electronic health records, document reviews, and interviews with residents and staff. Four residents were specifically noted to have experienced delays in call light responses, with times exceeding the facility's expectation of less than 15 minutes. The facility had a census of 32 residents at the time of the survey. Resident #9, who had no cognitive impairment, reported that the facility was often short-staffed during the evening shift, resulting in call light response times occasionally exceeding 15 minutes. Documentation showed instances where the call light was not answered for up to 34 minutes. Resident #12, with moderate cognitive impairment, also experienced delays, with call light response times reaching up to 24 minutes. She reported having to wait longer than 15 minutes to prevent incontinence, leading her to take herself to the bathroom. Resident #6, with a moderate cognitive deficit and total dependence on staff for toileting and transfers, experienced significant delays, with response times reaching up to 80 minutes. Her family reported that she would sometimes call them for assistance when her call light was out of reach. Resident #8, who was totally dependent on staff for transfers and at risk for falls, reported call light response times exceeding an hour, with one instance taking over two hours. The facility's policy required prompt response to call lights, but the Director of Nursing acknowledged that recent response times had exceeded expectations.
Failure to Change Resident's Bed Linen
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for Resident #9 by not changing the bed linen for two weeks. Resident #9, who has no cognitive impairment as indicated by a BIMS score of 15, reported on August 12, 2024, that her bedding had not been changed in two weeks. Observations on August 13, 2024, confirmed that the same bedding was still on Resident #9's bed. The facility's policy, as stated by the Director of Nursing (DON), requires bed linens to be changed weekly, with a specific schedule posted in the nursing office. Staff G, a CNA, admitted to not changing the bedding on the scheduled day, Monday, and communicated this to the next shift, asking them to change the sheets if they had time. However, Staff H, another CNA, stated that she did not change any bedding on her shift and was not informed by the morning shift that any bedding needed to be changed. This lack of communication and adherence to the facility's bed linen schedule resulted in the deficiency observed by the surveyors.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to complete an accurate assessment for a resident during the observation period of the Minimum Data Set (MDS). The MDS assessment for the resident documented a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. However, the resident stated she did not take insulin, and a review of her Medication Administration Record (MAR) since admission revealed no physician orders for insulin. Despite this, the MDS was incorrectly coded to reflect insulin injections. The Director of Nursing (DON) acknowledged that the MDS should have been coded as an injection, not insulin, indicating an error in the assessment process. The facility's policy on the Resident Assessment Instrument (RAI) Process emphasizes the need for accurate assessments supported by clinical records, which was not adhered to in this case.
Inconsistent Respiratory Care for Resident
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident requiring the use of oxygen. Resident #29, who has moderate cognitive impairment, was observed with undated oxygen tubing and a nebulizer mask. The resident reported not having seen the tubing changed during her stay. Staff interviews revealed inconsistencies and a lack of clarity regarding the schedule and responsibility for changing oxygen supplies. Staff members provided conflicting information about when and how often the oxygen tubing and nebulizer equipment were changed, with some stating it was done weekly, while others were unsure or only changed the equipment when visibly soiled. Further investigation showed that there was no consistent practice or documentation for changing the oxygen tubing. Staff members were unaware of any checklist or specific schedule for changing the equipment, and the tubing was not dated as expected by the facility's policy. The Director of Nursing (DON) confirmed that the facility's expectation was for the oxygen tubing to be changed weekly and dated, but this was not consistently followed or documented in the treatment administration record.
Failure to Follow Safe Transfer Techniques
Penalty
Summary
The facility failed to ensure safe transferring techniques for a resident, leading to a deficiency. Resident #21, who had a moderate cognitive deficit and required substantial assistance with transfers due to conditions such as cancer, anemia, heart failure, and hemiplegia, was transferred by Staff A, a CNA, without the required assistance of a second person or the use of a gait belt. The resident and her family member reported that Staff A was rough during transfers, lifting her under the arms and dropping her into a chair, which caused her pain. The care plan specified that the resident required two staff members for transfers using a sit-to-stand mechanical lift, but Staff A did not adhere to these guidelines. Staff A had a history of not following care plans and being rough with residents, as documented in his personnel file. He had received multiple warnings and a suspension for similar behavior, yet continued to disregard safe transfer techniques. Other staff members and residents expressed concerns about his rough handling and lack of compassion, with several residents requesting not to be cared for by him. The facility's policy required the use of gait belts for all transfers of weight-bearing residents needing assistance, which Staff A failed to follow, contributing to the deficiency.
Medication Error Leads to Acute Kidney Injury
Penalty
Summary
The facility failed to follow a cardiologist's order for a resident's medication, resulting in a significant medication error. The cardiologist had ordered Bumetanide 2 mg to be taken twice daily for three days, followed by a once-daily dosage. However, the facility did not initiate the once-daily order, leaving the resident without Bumetanide from March 10 to March 15. Subsequently, the resident received 2 mg twice daily instead of the prescribed 2 mg once daily, and later received 5 mg daily when only 3 mg was ordered. The resident, who had a BIMS score of 15 indicating no cognitive impairment, had multiple diagnoses including heart failure and hypertension. The care plan directed staff to administer medications as ordered and monitor for side effects. Despite this, the resident experienced a significant medication error that went unnoticed for an extended period, leading to an acute kidney injury. The error was discovered when the resident was sent to the hospital due to abnormal lab results. The facility's documentation revealed discrepancies in the medication orders, with different pages showing conflicting instructions. Staff interviews indicated a lack of clarity and communication regarding the orders, with some staff assuming others had verified the orders. The failure to properly process and clarify the medication orders led to the resident receiving an incorrect dosage of Bumetanide, contributing to the resident's acute kidney injury.
Removal Plan
- the facility educated all nurses on processing, initiating, reconciling, and clarification of orders
- the clinical coordinator/designee will audit orders received to ensure staff initiate and clarify orders when new orders are received
- results of these audits will be reported to the QAPI committee for review and modifications as needed
Failure to Verify LPN Licensure
Penalty
Summary
The facility failed to ensure that one of its employed nurses, specifically an LPN, maintained the appropriate licensure to practice in the state of Iowa. The LPN, identified as Staff A, was initially hired with a multistate license that allowed practice in Iowa, but later transitioned to a single state license valid only in Nebraska. This change in licensure status was not communicated to the facility, and the discrepancy was discovered during a review of employee files. The Human Resources Manager, who assumed her role in May 2023, acknowledged the oversight and confirmed that the facility's system for verifying licenses had not been triggered to catch this change. The facility's internal processes, including the employee handbook and position descriptions, clearly state the requirement for staff to maintain current licensure as a condition of employment. Despite these guidelines, the lapse in monitoring and verification allowed Staff A to continue employment without the necessary Iowa licensure. The Human Resources Manager admitted to not running a verification report for Staff A since 2021, which contributed to the oversight. The facility's administrator also confirmed that the change in licensure status was not detected during the renewal process in 2023, indicating a failure in the facility's system to ensure compliance with state licensure requirements.
Failure to Clarify and Transcribe Medication Orders
Penalty
Summary
The facility failed to clarify and accurately transcribe physician orders for a resident, leading to incorrect administration of the medication Bumetanide. The resident, who had a BIMS score of 15 indicating no cognitive impairment, was diagnosed with multiple conditions including heart failure and hypertension. The care plan required staff to administer medications as ordered and monitor the resident's weight and lab work. However, discrepancies in the medication orders were not clarified, resulting in the resident receiving incorrect dosages. The resident was initially ordered to receive Bumetanide 2 mg twice daily for three days, then once daily. However, the facility did not initiate the once-daily order after the three-day period, leading to a gap in medication administration from March 10 to March 15. During this time, the resident received 4 mg daily instead of the prescribed 2 mg. Further discrepancies occurred when the resident was ordered to receive 3 mg daily starting March 27, but continued to receive 5 mg daily. Interviews with staff revealed that the orders were not properly reviewed and clarified. The Director of Nursing acknowledged that the order was not entered correctly and should have been clarified. Staff members admitted to missing parts of the order and failing to ensure that the orders were accurately transcribed and implemented. The facility's policies on order processing and medication administration were not followed, contributing to the deficiency.
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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