Regency Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, Iowa.
- Location
- 815 High Road, Norwalk, Iowa 50211
- CMS Provider Number
- 165399
- Inspections on file
- 26
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Regency Care Center during CMS and state inspections, most recent first.
A resident was incorrectly documented as discharged on the MDS assessment, despite care plan notes and staff interviews confirming the resident remained in the facility. The error was identified when the DON and ADON verified the resident's continued presence and acknowledged the MDS did not accurately reflect the resident's status.
A resident with severe cognitive impairment and a pressure injury to the heel did not have her care plan updated to include physician-ordered interventions for heel offloading. Although staff provided heel protectors and pressure-reducing boots, the care plan lacked documentation of these measures, contrary to facility policy and assessment findings.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required. Surveyors found gaps in staffing and leadership coverage during their review.
A resident with diabetes, who was receiving insulin and other diabetes medications and had experienced episodes of hyperglycemia requiring emergency care, did not have a comprehensive care plan addressing diabetes management. The care plan lacked focus areas, goals, and interventions for diabetes, and the diagnosis was not promptly entered into the EHR. There was also no documentation or monitoring for signs and symptoms of hyperglycemia or hypoglycemia, contrary to facility policy and staff expectations.
Staff did not complete required elopement risk assessments for a resident with severe cognitive impairment and ongoing wandering and behavioral symptoms. Despite frequent documentation of wandering, agitation, and hallucinations, the necessary evaluations were not performed quarterly or as needed, as confirmed by both the MDS coordinator and DON.
Staff did not clean or sanitize shared mechanical lift equipment after use with multiple residents, including those on EBP or TBP, and failed to disinfect the lift even after contact with bodily fluids. CNAs reported a lack of training and absence of sanitizing wipes on the lifts, and the DON confirmed that facility policy requires cleaning between residents.
A dietary staff member was observed handling glasses incorrectly during meal service by placing fingers inside empty glasses, touching the rims of full glasses, and carrying glasses against their apron. These actions did not follow facility policy, which requires glassware to be held by the handle, middle, bottom, or stem, and not by the rim.
The facility did not update care plans for two residents, resulting in inaccurate documentation of a urinary drainage bag type for one resident and an outdated code status for another. Staff and records confirmed that the care plans did not reflect the residents' current needs or physician orders.
A resident with severe cognitive impairment and respiratory failure did not receive oxygen therapy at the physician-ordered rate of 4 L/min; instead, observations and records showed the oxygen was frequently set at 2 L/min without documented physician approval, and staff were unclear about the correct order.
Two residents experienced medication administration errors when an LPN gave one resident a lower dose of Folic Acid than ordered and failed to administer Atorvastatin to another resident, resulting in a 7% medication error rate during the observed pass, exceeding the required threshold.
The facility failed to provide scheduled showers or bed baths for four residents, as required by their care plans. A resident with quadriplegia received no showers in October and only three in November, with no documentation of refusals or rescheduling. Another resident received only one shower in December, missing several in November. Two other residents also missed scheduled showers, with no rescheduling or documentation. Staff interviews revealed a lack of awareness and accountability in documentation and scheduling.
A resident with cognitive impairment reported that a CNA was rough during repositioning, allegedly putting him in a headlock and causing neck discomfort. The facility did not report the incident to the state survey agency within 24 hours, as required by their policy, because they did not consider it an allegation of abuse. Instead, the CNA received education on proper techniques.
A facility failed to provide routine perineal care for a resident requiring substantial assistance for toileting, as staff did not consistently check and change the resident within the required two-hour timeframe. Interviews revealed that CNAs lacked sufficient time and help to perform these tasks, leading to residents waiting up to 6 hours for care. The facility's policy did not specify the frequency for checking and changing residents, contributing to the inconsistency in care.
The facility failed to store and label food items properly, as observed in the refrigerators and freezers. Unlabeled bags of food and oxidized potato chunks were found, indicating non-compliance with food service safety standards. Staff interviews confirmed awareness of these issues, and the facility's policy requires proper labeling and daily checks.
A resident with Stage III kidney failure was not properly monitored for lab values while receiving medications that could affect kidney function. Despite warnings of potential drug interactions, necessary lab tests were not conducted, leading to severe hyperkalemia and acute renal failure, requiring hospitalization and emergent dialysis.
A facility failed to maintain a medication error rate below 5%, with errors observed during a survey. An LPN improperly primed an insulin pen, leading to potential dosing inaccuracies, and administered Levothyroxine outside the accepted time parameters. The Director of Nursing confirmed the latest acceptable administration time was exceeded.
Inaccurate MDS Assessment Documented Resident Discharge
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. According to the MDS assessment tool, the resident was documented as discharged to home/community on a specific date. However, review of the resident's care plan indicated that the resident and their responsible party had chosen long-term placement, and progress notes from the relevant period did not document any discharge. Direct observation confirmed that the resident was still present in the facility after the reported discharge date, and staff interviews verified that the resident had not been discharged. The Director of Nursing (DON) acknowledged that the MDS inaccurately documented the resident as discharged and confirmed the resident's continued presence in the facility. The Assistant Director of Nursing (ADON) stated there had been discussions about the resident discharging home, but the family ultimately decided against it. Facility policy requires that qualified staff conduct accurate assessments reflective of the resident's status at the time of assessment, and that each assessor certifies the accuracy of their portion of the assessment. In this case, the assessment did not accurately reflect the resident's status.
Failure to Update Care Plan with Heel Offloading Interventions
Penalty
Summary
The facility failed to update the care plan for one resident to include specific interventions for offloading her heels while in bed, despite clinical evidence and physician orders indicating the need for such measures. The resident, who had severe cognitive impairment and was at risk for pressure ulcers due to incontinence, debility, and Alzheimer's disease, returned from the hospital with a pressure injury to her heel. Although wound care orders from the hospital specified that her heels should be floated with heel protectors at all times, the care plan did not reflect this intervention for her right heel, which had a deep tissue injury. Staff interviews confirmed that the resident wore booties or pressure-reducing boots to offload her heels, but also noted that she sometimes removed them. The Director of Nursing acknowledged that the intervention should have been included in the care plan and attributed the oversight to staffing changes affecting care plan completion. Facility policies require that all relevant interventions identified in assessments be documented in the care plan and communicated to staff, but this was not done for the resident's heel offloading intervention.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and the lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Develop and Implement Comprehensive Diabetes Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a diagnosis of Diabetes Mellitus. Clinical record review showed that the resident had intact cognition and was prescribed multiple diabetes medications, including insulin, and had experienced episodes of hyperglycemia resulting in emergency department visits for falls and dizziness. Despite these events and ongoing medication management, the care plan did not include a focus area, goals, or interventions related to diabetes management. Additionally, the diagnosis of Diabetes Mellitus was not entered into the electronic health record (EHR) under the diagnosis section until a month after admission, and there was no documentation or monitoring for signs and symptoms of hyperglycemia or hypoglycemia in the Medication Administration Record (MAR) or EHR. Staff interviews confirmed that the Director of Nursing expected diabetes to be addressed in the care plan from admission, with appropriate monitoring and documentation for related symptoms, but acknowledged these elements were missing. Policy review indicated that the facility's comprehensive person-centered care plan policy required identification of problems, needs, strengths, preferences, and goals, as well as how the interdisciplinary team would provide care, but these requirements were not met for this resident.
Failure to Complete Timely Elopement Risk Assessments for Cognitively Impaired Resident
Penalty
Summary
Staff failed to complete an accurate and timely assessment for a resident identified as being at risk for elopement. The resident, who had severe cognitive impairment and multiple complex medical and psychiatric diagnoses, was documented as exhibiting frequent wandering behaviors and episodes of agitation, hallucinations, and delusions. Despite these ongoing behaviors and the resident's care plan identifying elopement risk, the required Elopement Risk Evaluations were not completed quarterly or as needed, as per facility protocol and standards of practice. The clinical record showed that after an initial Elopement Risk Evaluation was completed in March, no further evaluations were documented until August, despite multiple progress notes indicating continued and escalating wandering and behavioral symptoms. Both the MDS coordinator and the DON acknowledged that the evaluations were overdue and should have been completed in accordance with the facility's policy. The deficiency was identified through clinical record review and staff interviews, confirming that the resident's assessments were not conducted as required.
Failure to Sanitize Mechanical Lift Equipment Between Resident Uses
Penalty
Summary
Staff failed to maintain a sanitary environment by not cleaning or sanitizing mechanical lift equipment after use with residents, including those on Enhanced Barrier Precautions (EBP) or Transmission Based Precautions (TBP). During multiple observed transfers, certified nursing assistants (CNAs) moved the mechanical lift from one resident to another and placed it in the hallway without disinfecting it, even after the equipment had come into contact with bodily fluids such as urine. The mechanical lifts did not have sanitizing agents available in their baskets, and staff reported that they had not been trained to clean the equipment after each use. Interviews with staff confirmed that the shared mechanical lifts were not sanitized between residents, and that sanitizing wipes were not available on the lifts. Staff also stated they had not observed others cleaning the lifts, and had not done so themselves, regardless of the resident's precaution status. The Director of Nursing (DON) stated that the expectation was for lifts to be cleaned and sanitized after each use, and facility policy required disinfection of lift surfaces and cleaning of non-critical medical equipment between residents.
Improper Handling of Glassware During Meal Service
Penalty
Summary
During a lunch service observation, a dietary staff member was seen handling resident glasses improperly by placing fingers inside empty glasses and touching the rims of full glasses on six occasions. Additionally, the staff member carried drinks back to resident tables with the glasses pressed against their apron three times. The Certified Dietary Manager confirmed that dietary staff are expected to carry drinks one at a time and to hold cups or glasses by the bottom, not the rim. Facility policy specifies that glassware should be held by the handle, middle, bottom, or stem, and that fingers should not be inside the glass or touching the rim. These observed actions were not in accordance with the facility's established procedures for handling dinnerware and glassware.
Failure to Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to update and revise care plans for two residents as required. For one resident with moderate cognitive impairment and multiple diagnoses, including a neurogenic bladder and use of an indwelling urinary catheter, the care plan inaccurately documented the use of a leg urinary drainage bag. Observations and staff interviews confirmed that the resident had not used a leg bag for approximately six months due to leakage issues, and instead carried a standard urinary drainage bag. Despite this change, the care plan continued to reference the leg bag and related interventions, which did not reflect the resident's current care needs or preferences. For another resident with intact cognition, the care plan listed the code status as Cardiopulmonary Resuscitation (CPR), with interventions to call an ambulance and transfer to the hospital. However, the physician order summary and the current Iowa Physician Order for Scope of Treatment (IPOST) both indicated a Do Not Resuscitate (DNR) status, which was also confirmed by staff. The care plan was not updated to reflect this change in code status, resulting in a discrepancy between the resident's documented wishes and the care plan interventions.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to provide oxygen therapy as prescribed by the physician for a resident with severe cognitive impairment and multiple diagnoses, including diabetes, heart failure, and respiratory failure. The resident was ordered to receive continuous oxygen at 4 liters per minute, but observations over multiple days showed the oxygen was consistently set at 2 liters, both in the dining room and in bed. Review of the electronic health record and medication administration records revealed discrepancies, with documentation often indicating the oxygen was set at 4 liters, while other records and direct observation showed it was set at 2 or 3 liters. There was no documentation supporting any physician-approved change in the oxygen setting from 4 liters to lower amounts during the review period. Staff interviews revealed confusion regarding the correct oxygen order, with a Certified Medication Aide stating the order was for 2 liters and a Registered Nurse confirming the order was actually for 4 liters. The Assistant Director of Nursing acknowledged the correct order was 4 liters and suggested staff may have missed the order. The Director of Nursing confirmed there was no facility policy related to oxygen therapy, stating that staff follow physician orders and standards of practice.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required. During a medication pass observation, a Licensed Practical Nurse (LPN) prepared and administered 17 medications to one resident, including Folic Acid. However, the resident was ordered to receive 1 mg of Folic Acid but was instead given only 400 mcg. For a second resident, the LPN prepared and administered nine medications, but failed to administer Atorvastatin 20 mg as ordered. Additionally, several of this resident's medications, scheduled for 8:00 am, were not administered until 9:21 am. A total of 28 ordered medications were reviewed during the observation, with two errors identified, resulting in a medication error rate of 7%. The facility's policy requires verification of the five rights of medication administration at three separate points and mandates the use of the medication administration record (MAR) during medication passes. Despite these policies, the observed errors occurred, and the facility's reported census at the time was 76 residents.
Failure to Provide Scheduled Showers or Baths
Penalty
Summary
The facility failed to provide at least two showers or bed baths per week for four residents, as required by their care plans. Resident #1, with moderate cognitive impairment and quadriplegia, was documented to have received no showers in October and only three out of six scheduled showers in November. The facility could not provide progress notes to support refusals or rescheduling, nor evidence of offering bed baths when showers were missed. Resident #2, who had no cognitive impairment, received only one shower between early and mid-December, missing several scheduled showers in November. Again, the facility lacked documentation to support refusals or rescheduling. Resident #5, with moderate cognitive impairment, missed several scheduled showers in November and December, with no rescheduling or documentation of refusals. Similarly, Resident #6, with severe cognitive impairment, was documented as not receiving showers for a period in December, with no alternative dates offered. Interviews with staff revealed a lack of awareness and accountability regarding the documentation and scheduling of showers. The Director of Nursing confirmed the use of a spreadsheet to track bathing, but the Administrator was unaware that CNAs were still using outdated methods for documentation. The facility's policy required nursing staff to be informed of refusals, but there was no evidence this was consistently followed.
Failure to Report Alleged Abuse Within Required Timeframe
Penalty
Summary
The facility failed to report an allegation of abuse to the Department of Inspections, Appeals and Licensing (DIAL) within 24 hours as required by their policy. The incident involved a resident with moderately impaired cognitive skills, who reported that a Certified Nursing Assistant (CNA) was rough while repositioning him, allegedly putting him in a headlock and pulling on his neck. The resident expressed concerns about hearing cracking noises in his neck during the incident. Despite these allegations, the facility did not report the incident to the state survey agency, as they did not consider it an allegation of abuse. The facility's policy on abuse prevention requires immediate reporting of alleged abuse to the state survey office, but the administrator confirmed that this was not done. Instead, the CNA received education on proper positioning techniques and safe handling of residents. The facility's investigation concluded that the abuse could not be substantiated, and the incident was not reported to the state survey agency, contrary to the facility's policy.
Inadequate Incontinent Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide routine perineal care for incontinent residents, specifically for one resident who required substantial assistance for toileting. The resident, who had a BIMS score indicating no cognitive impairment, was diagnosed with malignant neoplasm of the colon and had difficulty walking. The care plan instructed staff to use an EZ stand with the assistance of two staff members for toileting and to observe the resident's incontinence pattern to initiate a toileting schedule if needed. However, a review of the Check and Change Audit forms revealed significant lapses in care, with staff failing to document and complete checks and changes within the required two-hour timeframe for 23 out of 35 days. The resident went up to 8 hours without care on some occasions, and there were instances of false documentation of overnight care. Interviews with staff members, including CNAs and the Director of Nursing, highlighted systemic issues with staffing and time management, which contributed to the deficiency. Staff reported not having enough time or help to consistently check and change residents every two hours, leading to residents waiting as long as 5-6 hours for care. The facility's policy on incontinent care did not specify the required frequency for checking and changing residents, further contributing to the inconsistency in care. The resident involved expressed dissatisfaction with the care received, stating that they were not changed for an extended period, which was corroborated by the lack of documentation for that time frame.
Improper Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by observations of improperly stored food items in the facility's refrigerators and freezers. During a direct observation, surveyors found several bags of food, including broccoli, croissants, an oriental vegetable blend, and cake, stored in clear, unlabeled bags in the refrigerator. Additionally, the freezer contained chunks of oxidized potato frozen to the bottom, which were not contained. These observations indicate a lack of proper labeling and storage practices for food items. Interviews with facility staff, including a dietary cook and the Dietary Manager, revealed awareness of the improper storage practices. The dietary cook acknowledged that food should have been labeled before storage and that improperly stored food should be disposed of immediately. She was unaware of the spilled food in the freezer, which should have been cleaned up according to policy. The Dietary Manager also acknowledged the issues with unlabeled food and the need for immediate cleanup of spilled food. A review of the facility's refrigeration policy confirmed that food should be stored in an organized manner, labeled, and checked daily to ensure proper storage and timely disposal of leftovers.
Failure to Monitor Lab Values in Resident with Kidney Failure
Penalty
Summary
The facility failed to appropriately monitor and manage the laboratory values of a resident with Stage III kidney failure who was receiving medications that could affect kidney function. The resident was prescribed Cozaar, an ARB medication, along with potassium supplements and furosemide, which could potentially lead to hyperkalemia. Despite the presence of a software-generated warning about the risk of high potassium levels, the facility did not conduct necessary lab tests to monitor the resident's kidney function and potassium levels during her stay. The resident's clinical records showed that prior to admission, her potassium levels were within normal range, but her BUN and creatinine levels indicated potential kidney issues. However, no kidney function labs were drawn during her stay at the facility. The ARNP added potassium to the resident's medication regimen without considering the interaction with Cozaar and without ordering lab monitoring. This oversight was compounded by the administration of Bactrim, which further increased the risk of hyperkalemia. The resident eventually experienced symptoms such as nausea, vomiting, and diarrhea, leading to her hospitalization. Upon admission to the hospital, critical lab values indicated severe hyperkalemia and acute renal failure, necessitating emergent dialysis. Interviews with the ARNP and DON revealed a lack of routine lab monitoring and reliance on provider orders for lab tests, which contributed to the oversight in managing the resident's condition.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as observed during a survey. Specifically, two errors were identified out of 35 medications administered, resulting in a 5.7% error rate. One error involved a Licensed Practical Nurse (LPN) administering insulin to a resident without properly priming the insulin pen according to the manufacturer's instructions. The LPN primed the pen before attaching the needle, which is contrary to the correct procedure that requires priming after the needle is attached to ensure accurate dosing. The LPN was unaware that priming was necessary to ensure the pen was working correctly and to avoid administering too much or too little insulin. Another error was observed during the medication pass for a different resident. The LPN administered Levothyroxine, scheduled for 6:00 am, at a later time, which was outside the facility's accepted time parameters of one hour before and after the scheduled time. The Director of Nursing (DON) confirmed that the latest acceptable time for administering a medication scheduled for 6:00 am is 7:00 am. This deviation from the scheduled administration time contributed to the facility's medication error rate exceeding the acceptable threshold.
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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