Rehabilitation Center Of Des Moines
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Moines, Iowa.
- Location
- 701 Riverview, Des Moines, Iowa 50316
- CMS Provider Number
- 165268
- Inspections on file
- 26
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Rehabilitation Center Of Des Moines during CMS and state inspections, most recent first.
A resident who was dependent on staff for personal care was left exposed during care when CNAs failed to close the window blinds, allowing visibility from a nearby parking lot. The resident, who was cognitively intact, reported that this occurred frequently. Facility leadership acknowledged the incident as a violation of dignity and resident rights, and the facility's policy required privacy measures that were not followed.
A resident's code status was inconsistently documented, with an IPOST indicating DNR and a physician's order listing Full Code, leading to staff confusion during a medical emergency. The care plan reflected the resident's DNR wishes, but conflicting orders in the system caused uncertainty about the appropriate response when the resident experienced a health crisis.
A resident with a history of falls and weakness was observed being pushed in a manual wheelchair by a CNA without foot pedals, resulting in her feet skimming the floor. The resident, who is cognitively intact and usually self-propels, had requested to be pushed. Staff interviews revealed uncertainty about the availability of wheelchair pedals and confirmed understanding that residents should not be pushed without their feet on the pedals, in accordance with facility policy.
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures, with staff not wearing gowns and gloves during high-contact care activities. Observations and interviews revealed inconsistencies in following EBP protocols, a lack of signage and PPE supplies, and inadequate hand hygiene practices. Staff expressed a need for further education and training on EBP to ensure compliance and improve infection control practices.
A resident with intact cognition and a history of traumatic brain injury, schizophrenia, and bilateral lower leg amputation was observed being pulled backwards in a wheeled shower chair through the hall by a CNA, covered only with a blanket. This action failed to maintain the resident's dignity, as required by the facility's policy on dignity and privacy.
The facility failed to update comprehensive care plans for two residents, leading to inaccuracies and omissions. One resident's care plan incorrectly documented amputation sites and catheter use, while another's plan lacked current fall prevention measures and mental health services. Staff interviews confirmed these discrepancies, highlighting a lapse in the facility's care planning process.
A resident with multiple health issues, including renal insufficiency and diabetes, experienced a delay in follow-up blood work ordered by their PCP. The facility failed to conduct the lab test within the specified timeframe, resulting in a critical sodium level being identified only after the resident showed symptoms of lethargy. This oversight led to the resident's hospitalization for hypernatremia. Facility staff interviews revealed the missed lab work and lack of PCP notification.
A resident with intact cognition and multiple health conditions reported worsening vision, but the facility failed to ensure a timely referral to an optometrist. Despite documentation of blurry vision by a Nurse Practitioner, the resident's complaints were not addressed promptly, and staff were unaware of the issue until much later, resulting in a delayed appointment.
A facility failed to ensure an emergency tracheostomy kit was available at the bedside for a resident with a tracheostomy, who was dependent on staff for care and required oxygen. The absence of the kit was confirmed by a nurse and the DON, despite the care plan requiring it to be present.
A resident with intact cognition was not properly secured in a van during transport, leading to a fall when the vehicle moved. Despite the facility's policy requiring seat belts, the resident fell forward, resulting in soreness and head pain. The resident was evaluated at the ER and returned to the facility without fractures.
A facility failed to honor a resident's DNR status by initiating CPR when the resident became non-responsive. Despite the resident's advance directive and EHR indicating DNR, staff performed CPR following the resident's daughter's instructions. The facility lacked a signed IPOST and did not have the resident's code status in the nursing station binder, leading to confusion during the emergency.
A facility failed to notify a resident's family about an increase in pain and a new order for Oxycodone. The resident, with a BIMS score of 15, had multiple diagnoses including Alzheimer's and arthritis. Despite the facility's policy to inform families of significant changes, there was no documentation of family notification after the resident's pain increased and Tramadol was ineffective, leading to a new Oxycodone order.
A resident with impaired cognition reported that a CNA grabbed her face and used inappropriate language. The facility failed to report this abuse allegation to the State Agency within the required 2-hour timeframe. Despite the facility's policy to suspend accused staff, the CNA continued working on the floor, separated from the accuser. The delay in reporting and failure to suspend the staff member led to the deficiency.
A resident with impaired cognition reported abuse by a CNA, but the facility failed to suspend the accused staff member as per policy. Instead, the CNA was reassigned within the same floor, and the incident was not reported to the State Agency in a timely manner. Misunderstandings of policy by the DON and Administrator contributed to the deficiency.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
Staff failed to maintain privacy and dignity for a resident who required assistance with personal care, including toileting, bathing, and dressing. During the provision of care while the resident was lying in bed, both upper and lower areas of her body, including her breasts, buttocks, and genitals, were exposed. The window blinds in the resident's room were left open, and the window faced a parking lot, making it possible for people outside to see into the room. This was observed during care by two CNAs, and a car parked nearby with a person exiting, although the person did not approach the window. The resident, who had diagnoses including bipolar disorder and muscle weakness, was cognitively intact and able to communicate her concerns. She reported that staff often left the blinds open during care, which compromised her privacy. Facility leadership, including the LNHA and DON, acknowledged the issue as a violation of dignity and resident rights. The facility's policy required staff to maintain privacy during care, including closing doors or drawing curtains or blinds, but this procedure was not followed in this instance.
Failure to Ensure Consistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure clear and consistent direction regarding the code status of a resident, resulting in conflicting documentation and confusion among staff during a medical emergency. The resident had an IPOST indicating Do Not Resuscitate (DNR) status, while a physician's order in the facility's system listed the resident as Full Code, directing that CPR should be performed if the resident's heart or respirations stopped. The care plan also indicated the resident's desire to be DNR per IPOST, with instructions for regular review and updates. During an incident where the resident exhibited abnormal respirations and changes in color, staff responded by calling a code blue and preparing to send the resident to the hospital. Staff members discovered the discrepancy between the IPOST (DNR) and the physician's order (Full Code) at that time, leading to uncertainty about the appropriate response. Staff interviews revealed that the IPOST was signed after the resident's return from a prior hospitalization, while the Full Code order was entered upon that return, possibly due to hospital requirements for a procedure. The facility's policy required that advance directives be respected and that any such documents be included in the medical record, with periodic review and updates. However, the lack of alignment between the IPOST, physician's order, and care plan resulted in staff confusion during a critical event, as they were unsure which directive to follow. The issue was acknowledged by facility leadership, who noted the discrepancy and began reviewing other residents' records for similar issues.
Failure to Ensure Safe Wheelchair Transport for Resident
Penalty
Summary
A deficiency was identified when a resident with a history of repeated falls, bilateral upper limb carpal tunnel syndrome, and weakness was observed being pushed in her manual wheelchair by a CNA without wheelchair pedals attached. During this incident, the resident's feet were skimming the floor as she was transported down the hall. The resident confirmed she had requested to be pushed, and the CNA acknowledged knowing that wheelchair pedals should be used when pushing residents. The CNA was unsure if the resident even had pedals for her wheelchair, and another staff member, new to the facility, was unaware of the incident. The MDS documented that the resident was cognitively intact and typically propelled herself in the wheelchair or walked behind it. Facility policy, reviewed in October 2024, directs staff to position residents' feet on wheelchair footrests when needed and to ensure a safe environment for wheelchair mobility. The MDS coordinator and other staff interviewed understood that residents should not be pushed in wheelchairs without their feet on the pedals, as this could result in injury. The DON and LNHA acknowledged the concern when informed of the observation, and the nurse practitioner confirmed that the resident should not have been pushed with her feet skimming the ground.
Infection Control Deficiencies in EBP Compliance
Penalty
Summary
The facility failed to maintain infection control standards by not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. Specifically, staff did not wear gowns and gloves during high-contact care activities for three residents who were supposed to be on EBP. Observations revealed that staff only wore gloves and not gowns while providing care, and there was a lack of EBP signage and PPE supplies at the residents' doorways. Interviews with staff and family members confirmed inconsistencies in following EBP protocols, and staff expressed a lack of understanding and training regarding EBP requirements. Additionally, the facility did not ensure proper hand hygiene during care procedures. In one instance, a registered nurse failed to perform hand hygiene after removing gloves and before putting on new gloves while providing wound care to a resident. This lapse in infection control was acknowledged by the Director of Nursing, who admitted that the facility struggled with EBP compliance and had concerns about maintaining resident dignity while implementing these precautions. The report highlights multiple instances where staff did not wear gowns during procedures that required them, such as tracheostomy and wound care. Despite the presence of EBP signs and supplies in some areas, staff did not consistently follow the required protocols. Interviews with staff indicated a need for further education and training on EBP to ensure compliance and improve infection control practices within the facility.
Failure to Maintain Resident Dignity During Transport
Penalty
Summary
The facility failed to ensure the dignity of a resident, who was observed being pulled backwards in a wheeled shower chair through the hall by a Certified Nursing Aide (CNA). The resident was covered with only a blanket, with their head uncovered and lower legs partially exposed, revealing both legs were amputated. This incident involved a resident with intact cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, and who had a history of traumatic brain injury, schizophrenia, and bilateral lower leg amputation. The resident required substantial to maximal assistance with bathing, as documented in their care plan. The facility's policy on dignity and privacy, revised in May 2007, mandates that all residents be treated with dignity, respect, and privacy, and that their bodies be examined and treated in a manner that maintains privacy.
Failure to Update Comprehensive Care Plans for Residents
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Summary
The facility failed to revise and update comprehensive person-centered care plans for two residents, leading to inconsistencies and omissions in their care documentation. Resident #27's care plan contained incorrect information regarding amputation sites and the presence of a urinary catheter. Despite the resident having a left leg amputation and no urinary catheter since a hospital visit in July, the care plan inaccurately documented a right foot amputation and the presence of a Foley catheter. Observations and staff interviews confirmed these discrepancies, highlighting a lack of updates to the care plan following significant changes in the resident's condition. Resident #61's care plan also exhibited deficiencies, as it failed to reflect current fall prevention interventions and mental health services. The care plan included an intervention for a fall mat, which was not in use, and did not document the actual fall prevention measures being implemented, such as increased supervision and keeping the room door open. Additionally, the care plan did not include the resident's ongoing counseling services for depression, despite receiving these services since June. Interviews with staff confirmed these omissions and the need for care plan updates to accurately reflect the resident's current care needs. The facility's policy on care planning requires the interdisciplinary team to develop and update comprehensive care plans within seven days of the resident's MDS assessment and as needed for changes in condition. However, the facility did not adhere to this policy, resulting in outdated and inaccurate care plans for Residents #27 and #61. The Director of Nursing indicated that responsibility for care plan updates shifted to the DON and MDS coordinator in August, but the deficiencies persisted, indicating a lapse in the facility's care planning process.
Failure to Timely Obtain Follow-Up Blood Work Leads to Hospitalization
Penalty
Summary
The facility failed to obtain follow-up blood work for a resident within the timeframe ordered by the Primary Care Provider (PCP), which contributed to the resident's hospitalization. The resident, who had multiple diagnoses including renal insufficiency, diabetes, and respiratory failure, had a low potassium level identified on 8/6/24. The PCP ordered a potassium supplement and a follow-up lab test to be conducted on 8/13/24. However, the facility scheduled the lab for 8/15/24 and did not complete it until 8/20/24, five days after the scheduled date. There was no documentation indicating that the PCP was notified of the missed and delayed lab work. The delay in obtaining the lab work resulted in the resident's critical sodium level being identified only after the resident became tired and lethargic, leading to their hospitalization for hypernatremia. Interviews with facility staff, including a Registered Nurse and the Director of Nursing (DON), revealed that the oversight was noticed on 8/20/24, and the lab work was obtained immediately thereafter. The DON acknowledged the missed lab work and the lack of documentation regarding PCP notification. An Advanced Registered Nurse Practitioner was unable to recall if the facility staff had notified them of the missed lab work and could not determine if the delay would have prevented the hospitalization.
Failure to Ensure Timely Vision Care Referral
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Summary
The facility failed to ensure a specialist referral for a resident who complained of worsening vision. Resident #38, who had intact cognition and a history of heart and respiratory disease, non-Alzheimer's dementia, anxiety, depression, and PTSD, reported difficulty seeing out of the left eye. Despite a progress note from a Nurse Practitioner on 6/27/23 documenting blurry vision in the resident's left eye, no referral to an optometrist was made until much later. The resident continued to express concerns about vision deterioration, which were not addressed in a timely manner by the facility staff. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's vision issues. The Director of Nurses was unaware of the resident's complaints, and the Social Services staff only became aware of the issue shortly before the resident was finally scheduled for an optometrist appointment. The facility's policy required arrangements for services not provided in-house, but this was not followed, leading to a delay in addressing the resident's vision concerns.
Failure to Provide Emergency Tracheostomy Kit at Bedside
Penalty
Summary
The facility failed to ensure an emergency tracheostomy kit was available at the bedside for a resident with a tracheostomy. The resident, who was totally dependent on staff for all care, had diagnoses of anoxic brain damage and respiratory failure, and required oxygen. During an observation, it was noted that the resident was in a wheelchair with a tracheostomy and an oxygen mask, but no emergency tracheostomy kit was present at the bedside. The resident's care plan, initiated previously, required a tracheostomy tube and obturator to be kept at the bedside. Interviews with a registered nurse and the Director of Nursing confirmed the absence of the emergency tracheostomy kit, which was against the facility's expectations for residents with tracheostomies. The facility reported a census of 66 residents, and this deficiency was identified for one of the three residents reviewed during the survey.
Resident Not Secured in Vehicle During Transport
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation, resulting in an accident. The resident, who had intact cognition as indicated by a BIMS score of 15 out of 15, was not properly secured with a seat belt in a van. This oversight occurred despite the facility's Fleet Safety Program policy, which mandates that all occupants must wear safety belts and that the driver is responsible for ensuring passengers are properly secured. As a result, when the vehicle began to move, the resident fell forward, landing on her stomach at the front of the vehicle. The incident report noted that the resident was sore all over but had no visible bruising and could move all extremities without difficulty. Following the incident, the resident was transferred to the ER for evaluation. A subsequent provider encounter note indicated that the resident had hit the right side of her head during the fall and reported persistent head pain, as well as exacerbated chronic shoulder and knee pain. The Director of Nursing confirmed that residents should be securely strapped into vehicles and noted that the resident did not sustain a fracture but was assessed at the hospital.
Failure to Honor Resident's DNR Status
Penalty
Summary
The facility failed to honor a resident's advance directive wish to be a Do Not Resuscitate (DNR) by initiating cardiopulmonary resuscitation (CPR) when the resident became non-responsive. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, had documented advance directives stating DNR status in both the Initial Admission Record and a hospital Discharge Summary. However, the resident's Care Plan and electronic health record (EHR) did not reflect this DNR status, leading to confusion during the emergency. When the resident became non-responsive, a Registered Nurse (RN) initiated CPR despite the EHR indicating DNR status, as the resident's daughter instructed staff to continue CPR. The facility lacked a signed Iowa Physician Orders for Scope of Treatment (IPOST) at the time, which contributed to the confusion. The Director of Nursing acknowledged that the code status paperwork was not completed due to the resident's recent hospital visit. The absence of a clear and accessible record of the resident's DNR status in the facility's binder at the nursing station further compounded the issue.
Failure to Notify Family of Resident's Increased Pain and Medication Change
Penalty
Summary
The facility failed to notify the family of a resident about an increase in pain and the need for additional pain medication. The resident, who had a BIMS score of 15 out of 15, was diagnosed with Alzheimer's disease, anxiety disorder, depression, arthritis, joint contracture, and muscle weakness. According to the facility's policy, the family should be informed of significant changes in the resident's physical status. On November 2, 2023, a nurse reported to the Nurse Practitioner that the resident refused care, refused to get out of bed, and that Tramadol was ineffective. The NP ordered Oxycodone 5 milligrams three times daily. However, there was no documentation of family notification regarding the resident's increased pain level and the new medication order. The Director of Nursing confirmed that such a situation would warrant a call to the family.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required 2-hour timeframe for a resident with moderately impaired cognition, as indicated by a BIMS score of 9 out of 15. The resident, who had diagnoses including anxiety, depression, and psychotic disorder, reported that a CNA grabbed her face and used inappropriate language. This incident was reported to staff on the following day, but the facility did not document the submission of the allegation to the State Agency until later that afternoon. The facility's policy required immediate reporting of abuse allegations to the Administrator and relevant agencies, and the removal of the accused staff member from resident care. However, the accused CNA continued to work on the floor with other residents, although separated from the accuser. The Director of Nursing and Administrator acknowledged the delay in reporting and the failure to suspend the staff member, which contributed to the deficiency.
Failure to Properly Address Allegation of Abuse
Penalty
Summary
The facility failed to appropriately handle an allegation of abuse involving a resident with moderately impaired cognition, as indicated by a BIMS score of 9 out of 15. The resident, who had diagnoses including anxiety, depression, and a psychotic disorder, reported that a CNA grabbed her face and used inappropriate language. Despite the facility's policy requiring immediate removal and suspension of the accused staff member pending investigation, the CNA continued to work on the same floor, albeit separated from the specific resident who made the accusation. The facility did not document the submission of the abuse allegation to the State Agency until the day after the incident was reported. Interviews with the DON and the Administrator revealed a misunderstanding of the facility's policy and regulatory requirements. The DON acknowledged that the usual procedure would involve suspending the accused staff member, but in this case, the staff member was merely reassigned to a different section of the same hall. The Administrator believed that separating the staff member from the specific resident was sufficient, although the staff member continued to have access to other residents. This misinterpretation of policy and failure to act in accordance with established procedures contributed to the deficiency.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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