Ramsey Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Moines, Iowa.
- Location
- 1611 27th Street, Des Moines, Iowa 50310
- CMS Provider Number
- 165514
- Inspections on file
- 22
- Latest survey
- October 23, 2025
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Ramsey Village during CMS and state inspections, most recent first.
Surveyors observed multiple instances where staff failed to follow proper procedures for using mechanical lifts and wheelchairs during transfers, including not locking wheelchair wheels, not attaching foot pedals during transport, and inconsistent use of lift wheel locks. These deficiencies involved residents with severe cognitive and physical impairments who required significant assistance, and staff interviews revealed inconsistent understanding of safety protocols.
A resident with severe cognitive impairment and total dependence for ADLs was left in a wheelchair without repositioning or incontinence care for several hours after breakfast. Multiple CNAs and LPNs confirmed no assistance was provided during this period, despite care plan and policy requirements for frequent checks and hourly repositioning.
Staff failed to disinfect a mechanical lift between uses for two residents, did not perform proper hand hygiene during perineal care for a resident with dementia and incontinence, and exited a room on Enhanced Barrier Precautions without removing PPE, all in violation of facility infection control policies.
A resident with multiple comorbidities, including diabetes and functional quadriplegia, was admitted with a wound on the left foot that was identified by the ADON but not assessed or reported to a provider by the nurse for 48 days. The wound was only addressed after a CNA discovered it during a transfer, by which time it had worsened. Facility policy required prompt assessment and intervention for new wounds, but these steps were not followed, resulting in a significant delay in care.
A facility failed to accurately complete an MDS assessment for a resident with coronary artery disease, incorrectly documenting anticoagulant use during the 7-day look-back period. The resident's Care Plan and MAR indicated that the anticoagulant Eliquis was discontinued prior to the assessment period. The MDS Coordinator confirmed the discontinuation, highlighting a deficiency in ensuring accurate resident assessments.
A facility failed to include necessary interventions for a resident's PICC line and Mediport in their care plan, despite the resident receiving IV antibiotic therapy. The care plan lacked details on managing these devices, contrary to the facility's policy for comprehensive care plans.
A resident with a gastrostomy tube did not receive care according to professional standards, as staff failed to verify g-tube placement and did not flush the tube with water between medications. The resident, with multiple diagnoses including sepsis and dysphagia, required tube feedings. Despite facility policy and care plan directives, an LPN administered medications and enteral feeding without checking tube placement or performing necessary water flushes, as confirmed by interviews with facility staff.
A resident with multiple health conditions had a skin lesion that was not assessed or documented by staff, despite being observed for over a week. The facility's policy requires staff to document new wounds, but this was not followed, leading to a deficiency.
The facility failed to implement enhanced barrier precautions (EBP) for two residents with indwelling medical devices, as staff did not use gowns during procedures involving a g-tube and a PICC line. Additionally, the infection control manual was not updated annually, lacking necessary approvals and documentation. The DON acknowledged the absence of a specific EBP policy, relying on CDC guidelines.
A facility failed to complete and submit a discharge MDS assessment for a resident within the required timeframe. The resident was discharged, and the assessment was completed late and not submitted to CMS. The MDS Coordinator did not submit the assessment due to the resident's private insurance status, contrary to facility policy and RAI Manual requirements.
A resident with severe cognitive loss was subjected to undignified treatment by a CMA, who allegedly attempted to place a glove in the resident's mouth and made demeaning comments. The incident was witnessed by a CNA, who reported it to an LPN the following day. The facility's policy emphasizes immediate reporting of such incidents.
A resident with Permanent Atrial Fibrillation did not receive Warfarin as ordered due to unavailability, and the physician was not notified. The MAR showed missed doses, and the Progress Notes lacked documentation of physician notification. The DON confirmed Warfarin is not in the Emergency Kit and expected physician notification, but the facility had no policy for this.
A facility failed to report suspected abuse within the required two-hour timeframe. A resident with severe cognitive loss was involved in an incident where a CMA allegedly attempted to place a glove in the resident's mouth and spoke unkindly. The incident was not reported immediately by the witnessing CNA, leading to a delay in filing with the appropriate authorities.
A resident with Permanent Atrial Fibrillation did not receive Warfarin as prescribed due to transcription errors in the EHR. The initial hospital orders were not administered, and subsequent physician orders were incorrectly transcribed, leading to a lower dosage being given. The DON confirmed the error, which violated the facility's medication policy.
Improper Use of Mechanical Lifts and Wheelchairs During Resident Transfers
Penalty
Summary
Surveyors identified multiple deficiencies related to the improper use of mechanical lifts and wheelchairs during resident transfers. In several observed instances, staff failed to follow manufacturer instructions and facility protocols for safe transfer practices. For example, staff did not consistently lock wheelchair wheels during transfers, and mechanical lift wheels were sometimes locked or unlocked contrary to manufacturer recommendations. In one case, staff raised a resident from a toilet using a sit-to-stand lift without locking the lift's wheels, and staff provided conflicting statements about the correct procedure. Manufacturer documentation specified that the sit-to-stand lift's wheels should be unlocked after the resident is raised, but staff were inconsistent in their application of this guidance. Additionally, staff failed to ensure that wheelchair foot pedals were attached while transporting a resident who was unable to self-propel, and a staff member acknowledged that foot pedals should be used when pushing a resident in a wheelchair. Another observation revealed that a resident was transferred using a total body mechanical lift with the legs closed and the wheelchair unlocked, contrary to manufacturer instructions that require the legs to be open for stability and the wheelchair to be locked during transfer. Staff interviews confirmed a lack of consistent understanding and application of these safety procedures. The residents involved had significant cognitive and physical impairments, including severe dementia, end-stage renal disease, history of stroke, and incontinence, requiring varying levels of assistance with activities of daily living and mobility. Care plans specified the need for mechanical lifts, transfer discs, and assistance from multiple staff members, yet these plans were not always followed as observed. The facility also lacked a policy regarding wheelchair safety, as confirmed by the administrator, contributing to inconsistent practices among staff.
Failure to Provide Timely Repositioning and Incontinence Care
Penalty
Summary
A deficiency was identified when staff failed to provide timely repositioning and incontinence care for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who had diagnoses including renal disease, Alzheimer's disease, and was always incontinent of bowel and bladder, required maximal to total assistance for mobility and personal care. The care plan specified that the resident should be checked and provided incontinence care 2-4 times per shift and as needed, with peri-area cleaning after each episode, and repositioned every hour when in a chair. On the day in question, the resident was observed being placed in a wheelchair in the TV lobby after breakfast and remained in the same position until lunchtime, with no evidence of repositioning or toileting assistance during that period. Multiple staff members confirmed they had not assisted the resident with repositioning or toileting after breakfast. Documentation in the electronic health record indicated care was provided before breakfast, and staff statements conflicted regarding the timing of incontinence care. The facility's policy required hourly repositioning for residents in chairs, which was not followed in this instance.
Infection Control Failures: Equipment Disinfection, Hand Hygiene, and PPE Use
Penalty
Summary
Surveyors observed multiple failures in the facility's infection prevention and control practices. Staff did not disinfect a mechanical lift after use between two residents. Specifically, after transferring one resident from a wheelchair to a bed, the mechanical lift was pushed into the hallway without being sanitized. Later, another staff member used the same lift to transfer a different resident without disinfecting it before or after use. Additionally, during perineal care for a resident with Alzheimer's disease and incontinence, a CNA failed to perform hand hygiene or change gloves after handling a trashcan and before providing direct care, contrary to facility policy. The resident required extensive assistance with personal care and was always incontinent of bowel and bladder. Further, a CNA failed to remove PPE before exiting a room where both residents were on Enhanced Barrier Precautions due to invasive devices. The staff member exited the room wearing a gown and walked to another unit, which was not in accordance with the facility's policy that requires gowns to be discarded in the room. Staff interviews confirmed knowledge of the correct procedures, but the observed actions did not align with established infection control policies.
Delayed Assessment and Intervention for Resident Wound
Penalty
Summary
A deficiency occurred when the facility failed to provide timely assessment and intervention for a wound identified on a resident's left foot. Upon admission, the resident, who had multiple diagnoses including diabetes, Alzheimer's disease, functional quadriplegia, bipolar disorder, and polyneuropathy, was noted by the Assistant Director of Nursing (ADON) to have a wound on the left foot. However, the admitting nurse did not conduct a wound assessment or notify the provider for intervention at that time. The resident's care plan directed staff to check for skin breaks and treat promptly as ordered, but the Medication and Treatment Administration Records for the following months did not reflect any intervention for the wound. For 48 days after admission, there was no documented assessment or provider notification regarding the wound. The wound was only re-identified when a CNA noticed blood on a transfer device and the resident's sock, at which point the wound was found to be black, foul-smelling, and measured 3 cm x 3 cm. The nurse then cleansed the wound, applied a protective foam boot, and notified the physician, who ordered antibiotics. Further assessments and wound care were initiated only after this delayed recognition, and the wound was later determined to be an in-house acquired wound of unknown duration. Interviews with staff revealed that the ADON had expected the nurse to notify the physician and family and initiate treatment upon initial identification of the wound, but this did not occur. The facility's policies required prompt assessment, provider notification, and treatment implementation for new skin areas, but these steps were not followed. The delay in assessment and intervention was attributed in part to communication challenges and the use of agency nurses during the period in question.
Inaccurate MDS Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, identified as Resident #4, who was readmitted to the facility from the hospital with a diagnosis of coronary artery disease. The MDS assessment, completed on September 13, 2024, incorrectly documented that the resident took an anticoagulant medication during the 7-day look-back period. However, the resident's Care Plan indicated that anticoagulant therapy was resolved and removed from the Care Plan on April 30, 2023. The Order Summary showed that the resident's anticoagulant medication, Eliquis (Apixaban), was discontinued on July 9, 2024, and the Medication Administration Record (MAR) confirmed this discontinuation. During an interview, the MDS Coordinator, identified as Staff C, reported that she gathered information from the resident's record, interviews with the resident and family, and her own observations while providing care. Staff C confirmed that Resident #4 no longer took Apixaban, as it was discontinued on July 9, 2024. The RAI Manual Version 3.0 specifies that MDS assessment section N0410E should only be marked when a resident took an anticoagulant during the 7-day look-back period, excluding antiplatelet medications like aspirin. The inaccurate completion of the MDS assessment for Resident #4 represents a deficiency in ensuring accurate resident assessments.
Failure to Include Medical Device Management in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was admitted with diagnoses of cancer and pleural effusion. The resident was receiving IV antibiotic therapy and had both a PICC line and a Mediport for medication administration. However, the care plan did not include information or interventions related to the management and monitoring of these medical devices. This omission was identified through clinical record review, observation, and staff interviews. The resident's care plan was initially created upon admission and revised later, but it still lacked critical details about the resident's PICC line and Mediport. Staff interviews revealed that the MDS Coordinator and the Director of Nursing were responsible for updating care plans based on changes in the resident's status. Despite this, the care plan did not reflect the necessary interventions for the resident's medical devices, which was a deviation from the facility's policy that required comprehensive care plans to include measurable objectives and time-frames.
Failure to Verify G-Tube Placement and Flush Between Medications
Penalty
Summary
The facility failed to adhere to professional standards of quality in the administration of medications and enteral feeding for a resident with a gastrostomy tube (g-tube). The resident, who had diagnoses including sepsis due to e-coli, gastroesophageal reflux disease, diabetes, and dysphagia, required tube feedings as per their care plan. The care plan directed staff to check the g-tube placement and gastric contents before each feeding, but these steps were not followed. During an observation, a Licensed Practical Nurse (LPN) administered medications and enteral feeding through the g-tube without verifying the tube's placement or checking for residuals, as required by the facility's policy and the resident's care plan. Additionally, the LPN did not flush the g-tube with water between each medication administered, which is a necessary step to ensure proper medication delivery and prevent tube blockage. The facility's policy on administering medications through an enteral tube, dated 2001, clearly outlines the need to administer each medication separately and flush the g-tube with at least 15 ml of warm water between medications. Interviews with the MDS Coordinator and the Director of Nursing confirmed the expectation that g-tube placement should be checked before administering medications or feedings, and that water flushes should be performed between medications. These omissions in care represent a failure to meet the professional standards of quality required for safe medication administration in residents with g-tubes.
Failure to Assess and Document Resident's Skin Condition
Penalty
Summary
The facility failed to provide timely assessments and interventions for a resident's skin condition, leading to a deficiency. The resident, who has a history of cancer, heart failure, diabetes, cerebrovascular event, non-Alzheimer's dementia, traumatic brain injury, anxiety disorder, and depression, was observed with a red lesion and a dark scab on her right cheek bone. Despite the care plan requiring staff to check for skin breaks and treat them promptly, the wound was not assessed or documented in the resident's medical records. Staff interviews revealed that the registered nurse was aware of the wound for over a week but had not performed a skin assessment or informed the medical director. The unit manager confirmed that the skin assessment was not completed and emphasized the expectation for staff to document new or reopened wounds. The facility's policy requires all staff to participate in resident assessments, but this was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions and Update Infection Control Manual
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions (EBP) for residents with indwelling medical devices, as observed in two cases. Resident #117, diagnosed with sepsis due to E. coli and requiring tube feeding, did not have EBP directives in their care plan. During a medication and enteral feeding procedure, a Licensed Practical Nurse (LPN) did not use a gown and placed supplies on an over-bed table without a barrier, contrary to EBP guidelines. The Director of Nursing (DON) acknowledged the absence of a specific EBP policy, relying instead on CDC guidelines. Similarly, Resident #54, diagnosed with cancer and undergoing antibiotic therapy via a PICC line and Mediport, lacked EBP information in their care plan. An LPN accessed and flushed the resident's PICC line and port without wearing a gown, despite handling these medical devices. The DON confirmed the facility's lack of a formal EBP policy, expecting staff to follow CDC guidelines for residents with medical devices. Additionally, the facility's infection control manual was not updated annually as required. The manual lacked a cover page indicating annual review and approval, and the Record of Adoption form was incomplete, missing details on approved policies, the medical director's signature, and a date of approval. The DON admitted that the January 2024 QAPI meeting minutes did not reflect the approval of the infection control manual, highlighting a gap in the facility's policy review process.
Failure to Timely Complete and Submit MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) assessment for a resident upon discharge within the required timeframe. Specifically, the MDS assessment for a resident who was discharged on 5/22/24 was not completed until 6/2/24, and it was not submitted to the Centers for Medicare & Medicaid Services (CMS) as required. The Director of Nursing (DON) signed the assessment as completed on 6/2/24, which was beyond the 14-day completion requirement after the discharge date. Additionally, the 5-day MDS assessment completed on 5/15/24 was also not submitted to CMS. During an interview, the MDS Coordinator, who had been in the role since March 2024, reported that the discharge MDS was not submitted because the resident had a private insurance plan and did not have a Medicare Part A policy. The facility's policy, revised in March 2022, and the Resident Assessment Instrument (RAI) Manual Version 3.0, both require that discharge assessments be completed and submitted for all residents, regardless of their insurance status. The failure to submit the discharge MDS assessment was a violation of these requirements.
Resident Dignity Violation by Staff
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident involving a Certified Medication Aide (CMA) and a resident with severe cognitive loss. The resident, who had diagnoses including non-traumatic brain dysfunction, dementia, high blood pressure, and stroke, required maximum assistance for transfers and total dependence for care. During an interaction, the resident became verbally aggressive, and the CMA allegedly attempted to place a glove in the resident's mouth while responding to the resident in an unkind and demeaning manner. This incident was reported by a Certified Nurse Aide (CNA) who witnessed the event. The CNA reported that the CMA made a demeaning comment to the resident about his children not caring for him, which was followed by the CMA's aggressive behavior with the glove. The CNA initially did not report the incident immediately due to a busy shift but informed a Licensed Practical Nurse (LPN) the following day. The facility's policy on abuse prevention and reporting was referenced, highlighting the importance of reporting any allegations of abuse, neglect, or mistreatment immediately to the charge nurse, who is then responsible for notifying the Administrator or designated representative.
Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The facility failed to notify the physician when medication was unavailable and not administered to a resident diagnosed with Permanent Atrial Fibrillation. The resident had specific orders for Warfarin, a blood-thinning medication, to be taken in varying doses throughout the week. However, the Medication Administration Record (MAR) indicated that the resident did not receive Warfarin on the 20th of March as ordered, and it was also not administered on the 23rd and 24th of March. The Progress Notes did not document any notification to the physician regarding the missed doses, and the notes for those dates only mentioned that the medication was on order from the pharmacy. The Director of Nursing (DON) confirmed that Warfarin is not stocked in the facility's Emergency Kit and stated that his expectation is for the physician to be notified when a medication is not administered as ordered. However, the facility lacked a policy regarding physician notification in such situations. This oversight in communication and policy led to the deficiency, as the physician was not informed about the resident not receiving the prescribed medication, which is critical for managing the resident's condition.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to report suspected dependent adult abuse within the required two-hour timeframe for a resident with severe cognitive loss and multiple health conditions, including dementia and stroke. The incident involved a Certified Medication Aide (CMA) who allegedly attempted to place a glove in the resident's mouth during a care interaction, while also responding to the resident in an unkind manner. The incident was initially reported incorrectly and was not filed with the appropriate authorities until the following day, exceeding the mandated reporting timeframe. The incident was reported by a Certified Nurse Aide (CNA) who witnessed the event but did not report it immediately due to a busy shift. The CNA reported the incident the next day to a Licensed Practical Nurse (LPN), who then informed the facility manager. The facility's policy requires that all allegations of abuse be reported to the state agency within two hours, which was not adhered to in this case, leading to the deficiency.
Medication Transcription and Administration Error
Penalty
Summary
The facility failed to transcribe and administer medication as ordered by the physician for a resident diagnosed with Permanent Atrial Fibrillation. The resident's Electronic Health Record (EHR) initially reflected a correct transcription of the hospital's admission orders for Warfarin, a blood-thinning medication. However, the medication was not administered as per the original orders. The physician later adjusted the Warfarin dosage based on an INR test result, but the new orders were incorrectly transcribed into the EHR, leading to a decrease in the prescribed dosage. The Medication Administration Record (MAR) showed that the resident received a lower dose of Warfarin than ordered by the physician, specifically a 1 mg tablet instead of the prescribed 2.5 mg tablet on certain days. This error was confirmed by the Director of Nursing, who acknowledged the incorrect transcription and administration of the medication. The facility's Medication and Treatment Orders Policy, which emphasizes safe and effective order writing, was not adhered to in this instance.
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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