Ridgecrest Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Davenport, Iowa.
- Location
- 4130 Northwest Boulevard, Davenport, Iowa 52806
- CMS Provider Number
- 165049
- Inspections on file
- 24
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Ridgecrest Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence on staff for dressing and hygiene was left in a heavily soiled shirt for several hours, despite multiple staff interactions and being present in common areas with other residents and visitors. Staff did not assist the resident with a clothing change, failing to uphold the resident's dignity.
The facility failed to assist three residents with eating in a dignified manner. A resident with severe cognitive impairment was fed by staff standing over her, contrary to expectations. Another resident, dependent on staff for eating, was left reclined and asleep during meals, receiving minimal assistance. A third resident was also left asleep in a reclined position before being fed by standing staff. Facility policies require meal assistance to ensure safety, comfort, and dignity.
A resident on anticoagulant therapy experienced a critical health event due to the facility's failure to hold warfarin administration despite high INR levels. The resident was found with bleeding and was hospitalized, revealing systemic communication and procedural lapses in managing medication orders and lab results.
The facility failed to maintain food at safe temperatures during meal service, with observed temperatures falling below the required 135 degrees F. Staff interviews revealed ongoing issues with outdated equipment and resident complaints, particularly from those receiving room trays.
The facility failed to follow standard food handling practices during meal service, as Staff B repeatedly used the same gloves for multiple tasks, risking cross-contamination. Despite the facility's policy requiring glove changes between tasks, Staff B handled food and touched various surfaces without changing gloves. Interviews confirmed the expectation for glove changes, which was not adhered to.
A resident with dementia and impaired balance was transported backwards in a Broda chair by a CNA, who held the resident's feet, violating the facility's dignity policy. Staff interviews confirmed the resident should face forward with foot pedals used during transport.
A facility failed to complete an Admission MDS assessment in a timely manner for a resident, with the assessment being completed nearly a month late. The MDS Coordinator confirmed the delay, and the Administrator acknowledged the absence of a policy addressing MDS completion.
The facility failed to complete quarterly MDS assessments on time for two residents. One resident's assessment was delayed due to waiting for other staff, while the other was delayed due to the MDS Coordinator's workload and lack of backup. The facility also lacked a policy for MDS completion.
The facility failed to submit a resident's MDS assessment within the required timeframe, resulting in a deficiency. The assessment, completed in early April, was not submitted until mid-May. The MDS Coordinator admitted to submitting assessments bi-weekly, and the facility lacked a policy for timely MDS submissions.
A resident's MDS assessment inaccurately documented the use of multiple medication classes, including antianxiety and opioids, when only anticoagulant medication was administered. The error occurred because the MDS Coordinator reviewed the wrong person's information. The facility lacked a policy to ensure MDS accuracy.
The facility failed to complete Baseline Care Plans within 48 hours for two newly admitted residents. One resident, cognitively intact, was admitted with heart failure and diabetes, while another, with moderate cognitive impairment, had atrial fibrillation and respiratory failure. Both lacked documented care plans addressing their needs. Interviews revealed confusion over responsibility for care plan completion, and the facility lacked a policy on Baseline Care Plans.
The facility failed to update care plans for two residents: one whose anticoagulant medication was discontinued and another who required a left hand brace. The care plan for the first resident still indicated anticoagulant therapy despite its discontinuation, while the second resident's care plan lacked instructions for the brace's application and removal. Staff interviews confirmed these oversights, highlighting a lapse in communication and documentation.
A facility failed to coordinate care with hospice services for a resident who was transferred to the hospital without notifying hospice staff. The resident, who was on hospice care, experienced a fall and was found with a head injury and low oxygen levels. Despite the resident's request to go to the hospital, hospice was not informed, which was against protocol. Interviews with staff revealed a lack of communication and the absence of a policy for hospice coordination.
The facility failed to effectively implement QA activities, resulting in the recurrence of deficiencies F550, F641, F657, F812, and F880. Despite staff education, these issues persisted, as noted in both the Recertification and Complaint Surveys. The facility's QA plan, revised in August 2024, includes monitoring and auditing procedures, but these measures did not prevent the recurrence of the cited deficiencies.
The facility failed to ensure proper PPE use and infection control during care for residents with COVID-19, tracheostomy, and wound care. Staff did not consistently use N95 masks, goggles, or change gloves as required, leading to deficiencies in infection prevention protocols.
The facility's QAA committee meetings did not include the required members, as the DON and Infection Preventionist were absent from the February meeting, and the Medical Director was absent from the July meeting. The facility's policy mandates these members' attendance, along with quarterly meetings.
The facility failed to document QAPI program education for an RN and three LPNs. A review of human resources files showed no evidence of such training, and the administrator confirmed the absence of a policy for QAPI training. The facility had 51 residents at the time.
A resident with severe cognitive impairment eloped from the facility, resulting in injuries from a fall. The door alarm was triggered, but staff failed to properly investigate or account for all residents, leading to a delay in recognizing the resident's absence. The resident was found hours later on a neighboring property. Staff interviews revealed inadequate response to the alarm and poor communication during shift changes.
The facility failed to provide appropriate urinary catheter care and adhere to infection control practices for two residents. A CNA and another staff member did not follow Enhanced Barrier Precautions, such as wearing gowns and changing gloves and washcloth surfaces during catheter care. These actions were inconsistent with the facility's policies, as confirmed by the DON.
A resident in an LTC facility was hospitalized due to symptoms of medication withdrawal after not receiving Ingrezza as prescribed. The facility changed pharmacies, and the new pharmacy overlooked the order, leading to a week-long lapse in medication administration. The resident experienced involuntary movements and was treated at the hospital. The DON was unaware of the issue until after the hospitalization.
Failure to Maintain Resident Dignity by Not Assisting with Clothing Change
Penalty
Summary
Staff failed to provide care that promoted a resident's dignity by not assisting a dependent resident to change out of a heavily soiled shirt, which the resident continued to wear throughout the day in the presence of other residents and visitors. The resident, who had severe cognitive impairment, non-Alzheimer's dementia, depression, hypertension, and was always incontinent of urine, required maximum assistance with dressing and personal hygiene. Observations showed the resident wearing a white T-shirt with multiple large and small brown stains on the chest area from early morning through the afternoon, despite being present in common areas and during meals with other residents and visitors. Multiple staff interactions occurred throughout the morning, including the use of mechanical stand lifts for incontinence care, but the resident remained in the same soiled clothing after each care episode. Staff interviews confirmed that the resident was cooperative with care and that staff were expected to assist with clothing changes as needed. Despite these expectations and the resident's dependence on staff for dressing and hygiene, the resident was not changed out of the soiled shirt for several hours.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to ensure that three residents were assisted to eat in a dignified manner, as observed during meal services. Resident #5, who had severe cognitive impairment and was dependent on staff for eating, was observed being fed by staff who stood over her rather than sitting next to her, as expected by the Director of Nursing. This occurred during both lunch and breakfast meals, where staff alternated in feeding the resident without maintaining a consistent presence or interaction. Resident #6, diagnosed with Alzheimer's disease and severe cognitive impairment, was also dependent on staff for eating. During observations, the resident was left reclined and asleep in a Broda Chair while meals were served to others. Staff attempted to wake the resident and repositioned her, but she remained largely unattended and asleep, consuming very little of her meal. Resident #8, with similar diagnoses and total dependence on staff for eating, was observed asleep in a reclined position in a Broda Chair during a lunch meal. The meal was left uncovered for a period before staff repositioned the resident and fed her while standing. The facility's policies required that residents receive meal assistance in a manner that ensures safety, comfort, and dignity, which includes not standing over residents while assisting them with meals.
Failure to Manage Anticoagulant Therapy Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to appropriately manage the administration of warfarin, an anticoagulant medication, for a resident, leading to a significant health risk. The resident, who was on anticoagulant therapy due to a cardiac arrhythmia, had an International Normalized Ratio (INR) of 7.8, which was significantly higher than the standard therapeutic range. Despite receiving orders to hold the medication on specific days, the resident was administered warfarin on those days, resulting in an even higher INR of 9.3. This oversight in medication management was a critical error, as the resident was at increased risk for bleeding. The resident was subsequently found with blood on their arms and legs, indicating bleeding complications, and was sent to the hospital. At the hospital, the resident's INR was recorded at 8.2, and they were treated with Vitamin K, an antidote for warfarin overdose. The resident's hemoglobin levels were also low, further indicating the severity of the bleeding. The facility's failure to adhere to the prescribed medication orders and monitor the resident's condition effectively led to this immediate jeopardy situation. Interviews with staff revealed communication and procedural lapses. The nurse responsible for holding the medication did not have adequate access to the electronic health record system to document and manage lab results and medication orders properly. Additionally, there was a lack of timely communication and coordination between the facility and the anticoagulation clinic managing the resident's warfarin therapy. These systemic issues contributed to the failure in managing the resident's medication regimen safely.
Removal Plan
- The identified resident's Coumadin/warfarin was discontinued
- All other residents with Coumadin/warfarin orders were reviewed for accuracy
- Implemented new procedure regarding Coumadin/warfarin administration
- Enter Coumadin/warfarin order into Electronic Health Record
- Nurse will document order on Coumadin/warfarin log located at each station
- DON/Designee will check all new Coumadin/warfarin orders and the log to ensure dosing and follow-up labs are entered as ordered on the log and in Electronic Health Record
- The Nurse who took the order to hold Coumadin/warfarin is no longer employed at the facility
- All nurses will be educated on the new procedure. Additionally, all nurses will be educated on how to properly enter orders in Electronic Health Records
- New employees and agency staff will be trained on how to complete this procedure including entering orders in Electronic Health Records during their orientation
- Audit tool implemented to ensure nurses are administering Coumadin/warfarin according to physician orders
- Audits will be completed weekly for one month and then monthly ongoing as needed
- The audit results will be brought to the Quarterly QA meeting
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain food at a safe and appetizing temperature during meal service, as observed during a survey. On 9/24/24, temperatures of pureed lasagna and ground meat were recorded at 148.4 degrees F and 153.6 degrees F, respectively, before meal service. However, by the end of the meal service, these temperatures had dropped to 127 degrees F and 130 degrees F. Additionally, a test tray revealed that beans and potato wedges were served at 120.1 degrees F and 114.4 degrees F, respectively, which were described as lukewarm by the State Agency. The facility's policy requires hot food to be held at 135 degrees F or higher, indicating a failure to adhere to these guidelines. Interviews with staff revealed ongoing issues with maintaining appropriate food temperatures. Staff B, a cook, acknowledged past problems with keeping food at required temperatures, attributing some issues to the lack of a heat lamp on the steam table. The Director of Dining Services also confirmed occasional problems with food temperatures and noted that both the steam table and warmers were outdated and scheduled for replacement. Resident complaints about food temperatures were reported, particularly from those receiving room trays, which comprised 40 to 50% of the meals served. Despite these issues, the last resident complaint at a council meeting was reported to have occurred months ago.
Failure to Follow Food Handling Practices
Penalty
Summary
The facility failed to adhere to standard food handling practices during meal service, as observed on 9/24/24. Staff B, while wearing gloves, repeatedly engaged in actions that could lead to cross-contamination. At 11:44 AM, Staff B picked up a bun with gloved hands, touched the edge of a tray, and then handled the bun again without changing gloves. At 11:47 AM, after performing hand hygiene and changing gloves, Staff B touched a tray, picked up a phone, and then handled another plate and bun without changing gloves. At 12:07 PM, Staff B touched multiple surfaces with gloved hands, handled bread, opened a can of soup, and used the microwave, all without changing gloves. Interviews with Staff B and the Director of Dining Services revealed an expectation for gloves to be changed when switching tasks or touching surfaces, which was not followed. The facility's policy, revised in January 2024, requires gloves to be changed between tasks when handling ready-to-eat foods.
Resident Dignity Compromised During Transport
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner, as observed during a survey. The resident, who has a self-care performance deficit related to dementia and impaired balance, was seen being transported backwards down a hallway in a Broda chair by a CNA. The CNA was holding the resident's feet while moving the chair rapidly, which is against the facility's policy for resident dignity and proper transport procedures. Interviews with staff, including a CNA and the Assistant Director of Nursing, confirmed that the resident should have been facing forward and that foot pedals should have been used during transport. The facility's policy on dignity, revised in 2021, emphasizes that residents should be treated with dignity and respect at all times, which was not adhered to in this instance.
Delayed MDS Assessment Completion
Penalty
Summary
The facility failed to ensure the timely completion of an Admission Minimum Data Set (MDS) assessment for a resident. The resident was admitted to the facility on January 16, 2024, and the MDS assessment, which should have been completed in a timely manner, was not completed until February 16, 2024. This delay was confirmed by the MDS Coordinator. Additionally, upon request for a facility policy addressing MDS completion, the Administrator explained that the facility did not have such a policy in place.
Failure to Timely Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of quarterly Minimum Data Set (MDS) assessments for two residents. Resident #13's quarterly MDS assessment, with an Assessment Reference Date (ARD) of June 25, 2024, was completed on July 11, 2024. Similarly, Resident #38's quarterly MDS assessment, with an ARD of April 23, 2024, was completed on May 9, 2024. During an interview, the MDS Coordinator acknowledged issues with completing quarterly assessments on time, citing delays due to waiting for other staff to complete their sections and personal workload without a backup. Additionally, the facility lacked a policy to address MDS completion, as confirmed by the Administrator.
Failure to Submit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely submission of Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. Specifically, the Quarterly MDS assessment for a resident with an Assessment Reference Date (ARD) of April 2, 2024, was completed on April 16, 2024, but was not submitted until May 16, 2024. During an interview on September 26, 2024, the MDS Coordinator admitted that submissions were made every other week on Friday and acknowledged the late submission of this resident's MDS. Furthermore, the facility lacked a policy addressing the timely submission of MDS assessments, as confirmed by the Administrator via email on April 26, 2024.
Inaccurate MDS Medication Coding for a Resident
Penalty
Summary
The facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) assessment for a resident reviewed for unnecessary medications. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status (BIMS) exam, was inaccurately documented as taking antianxiety, opioid, and antiplatelet medications, in addition to the anticoagulant medication they were actually taking. This discrepancy was discovered through a review of the resident's Medication Administration Record (MAR), which showed that the resident only took anticoagulant medication. The MDS Coordinator admitted to looking at the wrong person, which led to the error. Additionally, the facility did not have a policy in place to address MDS accuracy, as confirmed by the Administrator.
Failure to Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to complete a Baseline Care Plan within 48 hours of admission for two newly admitted residents. Resident #32, who was cognitively intact with a BIMS score of 13, was admitted with diagnoses including acute chronic systolic heart failure and type 2 diabetes mellitus. The Clinical Admission Assessment for this resident did not identify Focus Areas, Goals, or Interventions for their risk factors, diagnoses, or care needs. Interviews revealed a lack of clarity regarding responsibility for completing the Baseline Care Plan, with the MDS Coordinator and admitting nurse each assuming the other was responsible. Similarly, Resident #53, who had a moderate cognitive impairment with a BIMS score of 9, was admitted with diagnoses including atrial fibrillation, coronary artery disease, and respiratory failure. The Skilled Evaluation for this resident also lacked identification of Focus Areas, Goals, or Interventions. The Director of Nursing expected the nurses caring for the resident in the first 48 hours to develop the Baseline Care Plan, but this was not done. The facility did not have a policy on Baseline Care Plans, contributing to the oversight.
Care Plan Deficiencies in Medication and Equipment Updates
Penalty
Summary
The facility failed to update the care plan for a resident following the discontinuation of anticoagulant medication. The resident, who had intact cognition, was noted in the Minimum Data Set (MDS) assessment to not be taking anticoagulant medication. However, the care plan, last revised several months prior, still indicated that the resident was on anticoagulant therapy. The MDS Coordinator acknowledged the oversight and noted that the care plan should have been revised to reflect the discontinuation of the medication. The Director of Nursing (DON) confirmed that care plans should be revised whenever there is a change in the resident's condition or treatment. Another deficiency was identified when the facility failed to update the care plan for a resident who required a left hand brace. The resident, who was cognitively intact, had a physician's order for an occupational therapy evaluation for a left hand brace. However, the care plan did not include instructions for the application and removal of the brace. Staff interviews revealed that the brace was to be applied in the morning and removed at night, but this information was not documented in the care plan. The DON stated that any nurse could update the care plan, but it appeared that the MDS Coordinator had not been informed of the order for the brace.
Failure to Coordinate Care with Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination of care between its staff and hospice staff for a resident receiving hospice services. The resident, who had intact cognition, was admitted to hospice care but the facility's electronic health record lacked an order for this admission. An incident occurred where the resident was found on the floor with a head injury and low oxygen saturation. Despite the resident's request to be evaluated at the hospital, hospice staff were not notified of the transfer, which was a breach of protocol. Interviews with facility staff, including the Hospice Case Manager and the Director of Nursing, revealed a lack of communication and coordination with hospice services. The Hospice Case Manager acknowledged that the resident had been sent to the hospital without hospice being informed, which was against the expected procedure. The Director of Nursing confirmed that hospice should have been notified in such situations, and admitted that there was a lapse in communication. The facility did not have a policy in place to address hospice coordination, which contributed to the deficiency.
Recurrent Deficiencies in QA Activities
Penalty
Summary
The facility failed to carry out Quality Assurance (QA) activities effectively, leading to the recurrence of deficiencies identified in both the Recertification Survey and Complaint Survey. The deficiencies cited include F550, F641, F657, F812, and F880. Despite the staff being educated on these issues, the problems persisted, as confirmed by the Administrator during an interview. The facility's Quality Assurance Process Improvement Plan, revised in August 2024, outlines procedures for monitoring adherence to quality standards and performing audits to ensure compliance with clinical and administrative policies. However, the plan's implementation did not prevent the recurrence of the cited deficiencies.
Inadequate PPE Use and Infection Control in Resident Care
Penalty
Summary
The facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when providing care to residents with specific health conditions, including COVID-19, a tracheostomy, and wound care. For Resident #257, who had moderate cognitive impairment and was diagnosed with COVID-19, staff did not consistently use N95 masks or goggles as required. Observations showed that staff entered the resident's room without the necessary PPE, such as N95 masks and goggles, despite the availability of these items outside the room. Interviews with staff revealed a lack of understanding and adherence to the facility's PPE protocols for COVID-19 isolation. For Resident #15, who had a tracheostomy and required respiratory treatments, the facility's staff did not follow proper infection control procedures during tracheostomy care. Staff F, a Registered Nurse, failed to change gloves and perform hand hygiene after removing a soiled dressing before applying a new one. This was contrary to the facility's expectations and infection control policies, which required changing gloves and performing hand hygiene between dressing changes. Resident #53, who had a lesion on her back and required wound care, was not placed under Enhanced Barrier Precautions as needed. During wound care, Staff F did not wear an isolation gown and failed to change gloves after cleansing the wound before applying new dressings. The facility's policy required the use of gowns and gloves during wound care to prevent the transfer of Multi-Drug Resistant Organisms (MDRO). The Director of Nursing confirmed that Enhanced Barrier Precautions should have been in place for residents with certain conditions, including wounds.
QAA Committee Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee meetings included the minimum required members, as specified in their policy. A review of the QAA sign-in sheets revealed that during the February 2024 meeting, both the Director of Nursing (DON) and the Infection Preventionist were absent. Additionally, the Medical Director or an appointed designee did not attend the July 2024 meeting. The facility's policy, revised in March 2020, mandates that the QAA committee should include the Administrator or a designee, the DON, the Medical Director, the Infection Preventionist, and representatives from various departments as needed. The policy also requires the committee to meet at least quarterly. The Administrator confirmed these absences during an interview conducted in September 2024.
Lack of QAPI Training Documentation for Nursing Staff
Penalty
Summary
The facility failed to document nursing education on the Quality Assurance and Performance Improvement (QAPI) program for four staff members, including one RN and three LPNs. A review of the human resources files revealed that there was no documentation indicating these nurses received education on the QAPI program. The facility's administrator confirmed that while the staff had been trained, the QAPI program was not included in their training. Additionally, during an interview, the administrator admitted that the facility did not have a policy in place for training staff on the QAPI program. The facility reported a census of 51 residents at the time of the survey.
Failure to Prevent Resident Elopement and Injury
Penalty
Summary
The facility failed to identify and respond to an elopement incident involving a resident with severe cognitive impairment and a history of non-Alzheimer's dementia. The resident, who was independently mobile but required supervision for safety, eloped from the facility during the early morning hours. The door alarm was triggered, but staff did not adequately assess the situation or account for all residents, leading to a delay in recognizing the resident's absence. The resident was discovered several hours later on a neighboring property, having sustained injuries from a fall. The facility's records indicated that the resident was wearing a WanderGuard bracelet, which should have activated the door alarm system. However, staff failed to check the placement and functionality of the bracelet on the night of the incident, and the door alarm was not properly investigated when it sounded. Interviews with staff revealed a lack of proper response to the door alarm and inadequate shift-to-shift communication regarding the resident's whereabouts. The facility's policy on wandering and elopement was not followed, as staff did not conduct a thorough search or initiate the missing resident emergency procedure promptly. The incident highlighted deficiencies in staff training and adherence to safety protocols, which contributed to the resident's elopement and subsequent injuries.
Failure to Follow Catheter Care and Infection Control Protocols
Penalty
Summary
The facility failed to provide appropriate urinary catheter care and did not adhere to standard infection control practices during observations of catheter care for two residents. Resident #5, who had diagnoses including anxiety and generalized weakness, required extensive staff support for daily activities and used a urinary catheter. During an observation, a CNA did not follow Enhanced Barrier Precautions, as they entered the resident's room without a gown, used the same gloves throughout the procedure, and did not change the surface of the washcloth with each pass, contrary to the facility's urinary catheter care policy. Resident #7, diagnosed with obstructive uropathy and non-Alzheimer's dementia, also required moderate staff assistance and used a urinary catheter. During the observation, there was no Enhanced Barrier Precaution sign or isolation cart near the resident's room. Staff L did not wear a gown, used the same gloves throughout the procedure, and failed to change the surface of the washcloth with each pass, which was inconsistent with the facility's policy. The Director of Nursing later confirmed that staff should follow Enhanced Barrier Precautions and change gloves and washcloth surfaces as needed. Both observations revealed a lack of adherence to the facility's policies for catheter care and Enhanced Barrier Precautions, which are critical for preventing infections and ensuring resident safety. The facility's failure to implement these protocols during high-contact resident care activities, such as catheter care, was evident in the actions of the staff involved.
Medication Administration Failure Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, resulting in the resident's transfer to a hospital emergency department for treatment of symptoms associated with medication withdrawal. The resident, who had diagnoses including anxiety and bipolar disorder, was prescribed Chlorpromazine and Ingrezza. The facility's records showed that Ingrezza was not administered on several days in May 2024. The resident experienced involuntary head movements, a symptom of tardive dyskinesia, which was relieved by medication administered at the hospital. The deficiency occurred due to a change in the facility's pharmacy on May 1, 2024, which led to the oversight of the resident's Ingrezza order. Despite daily requests from the nursing staff, the pharmacy did not send the medication due to its cost and the need for special authorization. The Director of Nursing was not informed of the issue until after the resident was sent to the hospital. The resident's Power of Attorney was notified of the situation and expressed upset over the oversight, which resulted in the resident not receiving the medication for seven days.
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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