Royal Oaks Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Urbandale, Iowa.
- Location
- 4614 Nw 84th Street, Urbandale, Iowa 50322
- CMS Provider Number
- 165580
- Inspections on file
- 32
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Royal Oaks Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with indwelling urinary catheters did not receive care and monitoring as ordered, including incomplete documentation of catheter care, frequent failures to record urine output per shift, and missed doses of prescribed antibiotics for UTI treatment. One resident’s care plan lacked specific catheter-care frequency despite an order for catheter care every shift, and TARs showed multiple days without documented catheter care or urine output. Pharmacy records and MAR review confirmed that a full ordered course of Amoxicillin was never dispensed or administered, and staff interviews revealed inconsistent medication reordering practices, limited use of the E‑kit, and reports that some staff were told not to document when medications were unavailable. These combined failures led to a resident not receiving the full antibiotic course for a UTI and being hospitalized.
Surveyors found persistent pungent odors on two nursing units, especially near a shower room, environmental services area, and an East hallway, with odors recurring over multiple days despite intermittent deodorizing efforts. Staff acknowledged the odors as a daily issue, with the housekeeping director citing possible links to resident personal habits and the maintenance assistant suspecting carpets as a source, while an uncovered trash and linen cart with soiled items was observed contributing to odors. The administrator confirmed the building-wide odor problem, which conflicted with facility policy requiring a homelike environment with pleasant, neutral scents and minimal institutional odors.
Staff failed to follow infection prevention and control practices related to insulin administration, catheter care, and hand hygiene. An LPN reused multi-dose insulin pens from discharged and other residents, contrary to policy requiring pens to be single-resident use and clearly labeled, and administered insulin to cognitively intact residents without an insulin-focused care plan for one of them. CNAs providing care to residents on Enhanced Barrier Precautions did not perform hand hygiene before, during, or after care, did not change gloves between dirty and clean tasks, placed a urine graduate directly on the floor without a barrier, handled the catheter system and room surfaces with contaminated gloves, and did not properly clean or store the graduate, all in violation of facility policies on infection control, catheter care, PPE, and hand hygiene.
A resident with intact cognition and multiple chronic conditions, including A-fib, diabetes, and HTN, was care planned as resistive to care and known to refuse medications, but was not care planned or ordered to self-administer meds. The MAR directed staff to administer three mid-morning pills, and facility policy allowed self-administration only with physician and IDT determination. A CMA placed the medications at the bedside, briefly conversed with the resident, and left the room without administering or confirming ingestion, leaving the meds unattended. The DON and CMAs reported that residents are not permitted to keep meds in their rooms and that staff are expected to remain with residents during administration, while the resident reported that staff periodically leave medications in the room. Facility policy required safe administration as prescribed and restricted self-administration to residents formally assessed and approved to do so.
A resident with atrial fibrillation and other psychiatric and medical diagnoses was discharged from a hospital with a physician order for a 2‑week cardiac event monitor and follow‑up. The LTC facility did not incorporate the monitor into the care plan, and although an order was entered to check the monitor every shift and mail it back, there was no MAR/TAR documentation that monitoring occurred. Staff interviews showed confusion and poor recall about when the monitor was applied, how long it was worn, and who removed it, with reports that it was left on the floor and later reapplied. The facility had no process or policy for tracking or mailing medical devices, and the DON ultimately dropped the boxed monitor in a post office mailbox without knowing it was required to be returned via UPS. The hospital clinic confirmed they never received the monitor or data and were still waiting for results, demonstrating that the facility failed to follow physician orders and professional standards for managing and returning the heart monitor.
The facility failed to consistently offer and provide scheduled showers or baths to multiple cognitively intact residents who were dependent on staff for bathing and had care plans and bath schedules specifying twice‑weekly bathing. One resident with arthritis, chronic pain syndrome, and heart failure reported going more than two weeks between showers, and documentation for two months showed baths recorded on only a minority of scheduled days with no indication whether the remaining scheduled baths were completed, not offered, or refused. Another resident admitted with osteoporosis and major depressive disorder did not receive a first shower for 19 days after admission and then received only two showers over about a month, as confirmed by shower logs and family report. A third resident with pain and impaired mobility had baths scheduled twice weekly, but bath records over three months showed baths documented on only a few of the scheduled days, with one refusal and one hospitalization noted. Staff interviews revealed that CNAs were responsible for baths, relied on room‑based bath lists, and were expected to complete both paper and electronic documentation, but paper bath sheets were often not completed, despite a facility policy requiring assistance with ADLs, including bathing, for residents unable to perform them independently.
A resident with multiple comorbidities, dependence for all care, a history of stroke, and recurrent unwitnessed falls had care plan interventions for neuro-checks after falls and routine full-body skin inspections. Over several months, the resident experienced numerous unwitnessed falls, but neuro-checks were only initiated for some of these events, and many of the completed neuro-check forms were missing required assessment intervals. Full-body skin assessments, previously done regularly, were not documented for an extended period, with only focused diabetic foot evaluations recorded. Documented injuries, including facial bruising, a bruised and torn elbow after a fall, and hand cuts from fingernails, were not subsequently tracked in progress notes or skin assessments, despite staff expectations and facility policy that such assessments and documentation occur.
A nurse left the facility unexpectedly during the night shift, leaving only one nurse on duty who did not assume responsibility for two units. As a result, several residents did not receive scheduled or as-needed medications, including pain management and emergency allergy treatment. One resident experienced severe pain and called 911, while another with a history of anaphylaxis had to self-administer her own epi pen. Staff interviews revealed confusion and lack of action to ensure resident care during this period.
A resident who experienced a fall did not receive documented follow-up assessments, including pain, vital signs, or neurological checks, as required by protocol. The incident was not reported, and necessary documentation was not completed by the nurse on duty, resulting in a lack of post-fall monitoring.
The facility did not maintain complete medical records for three residents who experienced falls, including missing neurological check sheets and incident reports. In one case, neurological monitoring was documented as initiated but the records were lost; in another, an incident report was never completed after a nurse left her position abruptly. These lapses resulted in incomplete documentation of resident care following falls.
A resident suffered two fractures and increased pain after being left unsupported during a transfer without a gait belt or proper footwear, while staff turned away to retrieve equipment. Additional observations showed staff improperly using mechanical lifts with the base in the closed position, causing instability and unsafe transfers for multiple residents. Staff interviews revealed a lack of understanding of safe transfer techniques and failure to follow both facility policy and manufacturer instructions.
A resident with a history of schizoaffective disorder and other chronic conditions did not receive prescribed antipsychotic medications for two weeks after admission due to staff entering orders for a different individual with the same name. The error, which was not identified during medication reconciliation, resulted in the resident experiencing psychosis, agitation, withdrawal symptoms, and hospitalization with a stage 3 sacral pressure ulcer.
Surveyors observed persistent unsanitary kitchen conditions, including standing water, a broken sink, damaged floors and ceilings, and excessive ice buildup in cold storage. Staff were seen handling food with bare hands and serving food with inadequate temperature control and improper covering, resulting in at least one resident refusing a meal. Staff interviews confirmed these issues were ongoing and contrary to facility policy.
Two residents with intact cognition reported that their food was often cold and bland, with one specifically noting issues with room tray service. Observation confirmed that hot foods were served below recommended temperatures and ice cream was not properly frozen, contrary to facility policy requiring food to be served at palatable temperatures.
Staff did not properly secure resident health information, including leaving a document with resident-specific details face-up on a medication cart and an unattended, open laptop displaying multiple residents' EHRs in areas accessible to mobile residents. Staff acknowledged these lapses, and facility policy requires such information to be protected at all times.
Staff failed to follow infection control protocols, including not wearing gloves or discarding contaminated medication, not using gowns or performing hand hygiene during wound and catheter care for residents on Enhanced Barrier Precautions, and not disinfecting mechanical lifts between resident uses, despite facility policy and expectations.
A resident with a history of incontinence and requiring assistance with toileting requested help from an LPN after wetting herself. The LPN did not provide immediate assistance or call for help, instead continuing medication administration and instructing the resident to wait in her room. The CNA was asked to assist but delayed care while attending to other residents, resulting in the resident waiting over 10 minutes for incontinence care and expressing feelings of being disregarded.
A resident with anxiety, depression, and osteoarthritis received psychotropic medications, but the care plan did not specify target behaviors for staff to monitor or include non-pharmacologic interventions. Documentation showed a range of behavioral issues, and staff confirmed that care plans were expected to include these elements, as required by facility policy.
A facility failed to maintain accurate and consistent counts of controlled medications, resulting in a card of Percocet prescribed to a resident becoming unaccounted for, along with missing count sheets. Staff interviews revealed confusion and inconsistencies in the medication counting process, including improper combining of count sheets, conflicting staff accounts, and a discontinued controlled medication remaining in the cart. These failures led to the inability to properly account for controlled substances as required.
A resident admitted with chronic pain, anxiety, and multiple diagnoses did not have a baseline care plan developed within 48 hours as required. The care plan was delayed, lacked documentation of chronic pain and psychotropic medication use, and was missing a date, time, and confirmation signature from the resident or family. Staff confirmed the process was not followed according to policy.
A resident with severe cognitive impairment and a right heel pressure ulcer was repeatedly observed without prescribed Prevalon boots, despite physician orders and care plan directives. Staff interviews confirmed the resident was non-weight bearing, had not refused care, and that the boots could not be located or were not applied as required. Nursing staff were unaware of the omission, and there was no documentation of refusal or notification to the nurse.
Two residents requiring oxygen therapy did not receive care in accordance with professional standards, including failure to change and label oxygen tubing as ordered and lack of access to a prescribed Bi-pap machine due to it being missing. Staff provided inconsistent and inaccurate documentation regarding respiratory care, and facility policy for equipment management was not followed.
The facility allowed non-pharmacist staff to draw up Morphine and Lorazepam in syringes, which were then placed unlabeled in medication carts for residents. Additionally, the facility failed to maintain accurate drug records and reconciliation for controlled substances, with several instances of missing counts for medications like Pregabalin and Morphine. These actions violated the facility's policies on medication storage and handling.
The facility failed to respect residents' dignity and self-determination, with incidents of a CNA forcing a resident to bed and handling her roughly, and another resident experiencing rudeness and disrespect. Staff were also observed entering rooms without waiting for an invitation, despite the facility's policy on treating residents with respect.
The facility failed to ensure call lights were within reach for four residents, as observed and confirmed through staff and resident interviews. Call lights were found on the floor or hanging down the side of the bed, making them inaccessible. Residents reported issues with call light accessibility, and staff acknowledged that call lights were often out of reach, contrary to facility policy.
The facility failed to provide a clean and homelike environment, with observations of dried food and stains in a resident's room, and persistent foul odors in hallways. Staff confirmed these conditions, and the facility's policy on cleaning lifts was not adhered to.
A facility failed to properly transfer a resident requiring an assistive device, neglected oral care for two residents, and did not groom a female resident's facial hair. A resident with dementia was transferred without the necessary lift device, causing distress. Oral hygiene was inadequate, with one resident's dentures uncleaned and another's toothbrush entangled with hair. A resident with MS was observed with unwanted facial hair. Facility policies on resident handling and ADLs were not followed.
Facility staff failed to properly assess and follow up on incidents involving residents, leading to deficiencies in care. A resident with severe cognitive impairments fell and sustained a hematoma, but staff did not conduct required follow-up assessments. Another resident had a skin tear with no documented treatment order or follow-up. Additionally, medications for two residents were administered outside prescribed time frames, violating facility policy.
The facility failed to maintain a pest-free environment, with staff and family members observing cockroaches throughout the facility, including in resident rooms and on medication carts. Despite pest control measures, the infestation persisted, and the exterminator company indicated that more aggressive treatment was needed, which required corporate approval.
A facility failed to implement a care plan for a resident with Multiple Sclerosis who required assistance with personal hygiene. Despite the care plan indicating the need for staff assistance with shaving, observations showed the resident had unshaved whiskers, which she expressed dissatisfaction with. The facility's policy required staff to provide necessary grooming services for residents unable to perform ADLs independently.
A deficiency was found in the treatment administration process when an LPN documented a treatment as completed for a resident with Xeroderma, despite it not being performed. The LPN relied on information from another LPN who claimed to have done the treatment. Facility policy requires accurate documentation in the EMAR system after administering medications.
The facility failed to secure medication carts and provide adequate supervision for a high-risk resident. Unlocked and unattended carts were observed in various locations, contrary to policy. A resident with severe cognitive impairments and a high fall risk was left unattended, resulting in a fall and injury. Staff confirmed the resident should not have been left alone.
The facility failed to properly label and store liquid Morphine and Lorazepam for three residents. Unlabeled syringes were found in medication carts, and staff admitted to pre-drawing these medications without proper labeling. The practice had been ongoing for months, contrary to facility policies requiring pharmacist involvement in pre-setting up such medications. Additionally, a bottle of Morphine was found without proper documentation, highlighting a lack of adherence to storage and labeling protocols.
Facility staff failed to don PPE while providing care to residents with catheters and PICC lines, despite signage indicating the need for enhanced barrier precautions. An RN and an LPN were observed not wearing gowns during procedures, and catheter tubing was found on the floor. Staff interviews confirmed inconsistent PPE usage, indicating lapses in infection control practices.
A resident with multiple diagnoses, including hemiplegia, experienced a fall during a transfer in an LTC facility. The facility failed to conduct and document necessary assessments and interventions following the fall and prior to transferring the resident to a hospital. Despite policies requiring documentation and follow-up assessments, these were not completed, leading to a deficiency in care.
A resident with a complex medical history, including end-stage renal disease and hemiplegia, was admitted with a left heel blister that was not addressed in the care plan until ten days later. The facility delayed initiating treatment for the blister and failed to complete required weekly skin assessments and Braden Scale evaluations. This led to the development of a necrotic area on the resident's heel, highlighting a deficiency in the facility's adherence to its pressure injury surveillance policy.
A resident with multiple medical conditions and non-weight bearing status required two staff for transfers using a sliding board. However, during a transfer, only one CNA was present, leading to the resident losing balance and falling. Despite being aware of the two-person requirement, the CNA proceeded alone after the resident indicated they could manage it together. No injuries were reported, but the incident highlights a failure to follow established care plans and protocols.
The facility failed to follow physician orders for catheter care for two residents, resulting in discrepancies in catheter size and lack of proper documentation. Both residents required maximum assistance and had indwelling catheters, but the care plans were not adhered to, and the interim DON was unaware of the reasons for these deficiencies.
A resident with moderate cognitive impairment reported being handled roughly by a male CNA during a transfer, leading to anxiety and bruising on her ankles. Despite family concerns, the facility did not thoroughly investigate or report the incident, and the staff member continued to provide care. The facility's limited response and lack of disciplinary action highlight a deficiency in ensuring resident dignity and respect.
A facility failed to ensure consistency between a resident's IPOST and Care Plan regarding code status. The resident had a DNR order in the physician's orders and IPOST, but the Care Plan indicated a request for CPR/full code status. The facility's policy required updates to the care plan for any changes in directives, but this was not done, as acknowledged by the Administrator. Staff usually referred to the IPOST for code status, resulting in the inconsistency.
A resident with moderate cognitive impairment reported being handled roughly by a male staff member, resulting in bruising on her ankles. Despite the family's report, the facility did not report the incident to the State agency, failed to conduct a thorough investigation, and allowed the staff member to continue working with residents. The facility's actions were inconsistent with their policy on abuse prevention and investigation.
A resident with moderate cognitive impairment and multiple medical conditions reported being handled roughly by a male staff member during a transfer, resulting in bruising. The facility failed to conduct a thorough investigation, did not interview the staff member involved, and did not report the incident to the Department of Inspections and Appeals and Licensing (DIAL). The staff member continued to work at the facility and provide care to the resident.
A facility failed to notify the LTC Ombudsman of a resident's discharge to the hospital, as required by federal regulation. The resident was discharged and later reentered the facility, but the clinical record lacked documentation of the required notification. The Administrator confirmed the omission, which was contrary to the facility's policy on Transfer and Discharge.
A facility failed to refer a resident with PTSD for a Level II PASARR evaluation despite the diagnosis being known at admission. The resident's MDS indicated severe cognitive impairment and diagnoses of major depressive disorder and PTSD, yet the facility did not complete a Level II PASARR. The administrator noted the absence of a specific PASARR policy, with responsibility assigned to a part-time social worker.
A facility failed to implement a comprehensive care plan for a resident with a urostomy, leading to inadequate care and documentation. The resident, who is cognitively intact and has a neurogenic bladder, reported infrequent emptying of the urostomy bag. The care plan lacked instructions for bag care and monitoring, and documentation was inconsistent. The DON acknowledged these deficiencies, noting the expectation for regular emptying and documentation.
A resident with moderate cognitive impairment was found to have smoking supplies, including cigarettes and a lighter, in her room without a smoking safety assessment conducted by the facility. Despite the resident's need for supervision and a safe environment, the facility lacked a smoking policy and did not evaluate the resident's ability to manage smoking supplies safely. The administrator and DON were unaware of the resident's possession of these items, and family members expressed concern about the resident's safety due to her cognitive impairment.
The facility failed to ensure the presence of required members at quarterly QA meetings, missing key personnel such as the Administrator, Infection Preventionist, and Medical Director on various occasions. This was acknowledged by the Administrator during an interview.
A facility failed to enforce smoking policies for a resident with cognitive impairment, who was found with cigarettes and a lighter in her room. Despite the facility's non-smoking policy, residents were observed smoking on the property. The resident's care plan required supervision due to cognitive decline, but no smoking safety assessment was conducted. The facility lacked a designated smoking area and did not monitor residents who smoked.
A resident with moderate cognitive impairment and multiple medical conditions experienced a significant weight loss of 13.43% within a month of admission. The facility failed to notify the physician of this change, as required by the care plan and facility policy. The dietician acknowledged the oversight, admitting that the necessary notification was not prepared or sent.
The facility failed to follow physician orders and medication administration protocols for several residents. A resident with multiple medical conditions missed several catheter flushes, while another received insulin injections without proper priming of the pens. Additionally, a resident reported inconsistent catheter flushing, with records showing multiple missed flushes. These actions did not meet the facility's professional standards of care.
Failure to Provide Ordered Catheter Care, Monitor Urine Output, and Complete Antibiotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered catheter care, monitor urinary output as directed, and ensure complete administration of prescribed antibiotics for residents with indwelling urinary catheters. For one resident with multiple sclerosis and neurogenic bladder who used an indwelling catheter, the care plan directed staff to empty the catheter bag every shift and as needed, and a physician’s order required staff to record catheter output every shift. However, review of the Treatment Administration Records (TARs) over several months showed numerous missing entries for catheter output, with output not recorded for a significant number of shifts in December, January, and February despite the standing order to monitor output each shift. Another resident with obstructive uropathy and an indwelling catheter had multiple hospitalizations related to urinary issues, including sepsis secondary to UTI, enterococcal bacteremia, and complicated UTI. The care plan for this resident identified the presence of an indwelling catheter and directed staff to encourage fluids and check catheter tubing for kinks each shift, but it lacked specific directives for the provision and frequency of catheter care despite an existing physician order for catheter care every shift and as needed. TAR review showed multiple dates over several months where catheter care was not documented as provided, and there was also an order to record urine output that was not consistently followed, with numerous days lacking recorded output. Additionally, although there was an order to change the catheter as needed for leakage, dislodgement, or occlusion, there was no documentation of any catheter change over a several‑month period. The same resident had an order for Amoxicillin 500 mg PO BID for a total 9‑day course to treat a UTI following hospitalization. The MAR showed missing doses on multiple days, and there was no documentation that the antibiotic was administered for one dose on one day and for all doses on two subsequent days. Pharmacy records from the prior vendor confirmed that only 10 tablets (a 5‑day supply) of Amoxicillin were dispensed, even though the order was for a 9‑day course, and the new pharmacy vendor had no record of dispensing Amoxicillin for this resident. Staff interviews revealed inconsistent practices and instructions regarding reordering medications, use of the E‑kit, and documentation when medications were unavailable, including a CMA’s report that she was told by nursing leadership not to document that a medication was not available or awaiting delivery. The resident ultimately required hospitalization for sepsis secondary to UTI and urinary retention, and later for a complicated UTI, after not receiving the full ordered course of antibiotics and with gaps in ordered catheter care and urine output monitoring. Staff interviews further showed confusion and inconsistency in following and documenting physician orders, including lab orders for urinalysis and culture, and in using the electronic health record to track orders and results. The NP reported that orders were written with the expectation that facility management would enter and ensure they were carried out, but that there were frequent instances where orders, including antibiotics, were not followed. The DON and nursing staff described differing understandings of when to change catheters and how to document unavailable medications, with some staff stating they were told not to document unavailability. Collectively, these actions and inactions led to missed catheter care, incomplete monitoring of urinary output, and failure to administer a complete antibiotic course as ordered for residents with indwelling catheters and UTIs. Resident #1 did not receive a full nine-day course of antibiotics to treat a UTI which resulted in a hospitalization.
Persistent Pungent Odors Compromise Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment due to persistent pungent odors on two of three nursing units (Station 1 and Station 2). Surveyors repeatedly detected strong, unpleasant odors in specific areas, including near the shower room and environmental services door on Station 2, and down the East hallway on Station 1. These odors were present at multiple times over several days, sometimes lingering for hours and recurring after temporary reduction. On one occasion, an uncovered trash and linen cart containing trash, soiled briefs, and soiled linens was observed in the Station 2 hallway, contributing to unpleasant odors. Staff interviews confirmed awareness of the ongoing odor problem. The Housekeeping Director reported using a deodorizing machine about twice weekly and as needed, without a set schedule for specific units, and acknowledged that the odor is present daily, suspecting it may be related to personal habits of several residents. The Housekeeping Director stated staff were instructed to change bedding daily and empty trash in a timely manner. The Maintenance Assistant also acknowledged the odors, particularly on Station 1 East hallway, and suspected the carpets as a source, noting they are shampooed once per month. The Administrator acknowledged the pungent odors throughout the building. Facility policy on Quality of Life–Homelike Environment requires staff and management to maximize a personalized, home-like setting with pleasant, neutral scents and to minimize institutional odors, which was not achieved based on these observations.
Failure to Follow Infection Control Practices for Insulin Administration, Catheter Care, and Hand Hygiene
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices, including improper use of multi-dose insulin pens, inadequate hand hygiene, and incorrect use of personal protective equipment (PPE) and supplies during resident care. For one resident with diabetes mellitus, anxiety disorder, and heart failure, who was cognitively intact and received insulin, the clinical record showed that an LPN administered various types of insulin on multiple dates. Facility policy stated that multi-dose insulin pens were for single-resident use only and that changing the needle did not make it safe to use insulin pens for more than one resident. Despite this, the LPN later reported that she borrowed insulin pens from other residents who used the same type of insulin and did not know which residents the pens originally belonged to. Another cognitively intact resident with diabetes mellitus, muscle weakness, and a cognitive communication deficit also received insulin injections. The resident’s care plan did not address insulin use. The medication administration record documented that the same LPN administered long-acting and fast-acting insulin to this resident on several dates. A corrective action form and staff interviews described that this LPN did not dispose of insulin pens from discharged residents and reused those pens, as well as other current residents’ pens, for multiple residents using the same type of insulin. One LPN reported finding a bag of insulin pens with multiple resident names and a pen with a used, blood-contaminated needle attached, and stated she was instructed by the LPN to use these pens until they were gone. The deficiency also includes failures in basic infection control practices during catheter care and personal care for residents on Enhanced Barrier Precautions (EBP). One resident with benign prostatic hyperplasia, diabetes, a history of stroke, and an indwelling urinary catheter required catheter care every shift and was on EBP. During observed care, a CNA donned a gown and gloves without performing hand hygiene, placed a urine graduate directly on the bathroom floor without a barrier, drained the catheter bag into the graduate, and then used the same contaminated gloves to handle her gown, reach into her uniform pocket for an alcohol swab, cleanse the catheter port, open the bathroom door, and empty the graduate into the toilet. The CNA then placed the graduate on a paper towel by the toilet, removed PPE, and proceeded to other resident care tasks without documented hand hygiene between activities. Facility policies required hand hygiene before, during, and after care, glove changes between dirty and clean tasks, single-use gloves, and proper handling and placement of the graduate, but these steps were not followed. Additional observations of personal care for another resident showed staff not performing hand hygiene or changing gloves between dirty and clean tasks. During incontinence care and dressing, staff used gloved hands to remove a soiled brief, clean the genital area after a bowel movement, reposition the resident, adjust bedding, and then change the resident’s clothing and handle the resident’s head/face area, all without changing gloves or performing hand hygiene until after the care was completed. Facility policies on hand hygiene and glove use required hand hygiene at the start and end of care, and whenever moving from a contaminated task to a clean task, as well as single-use gloves to be discarded after each use. These observed practices did not comply with the facility’s infection prevention and control program, catheter care policy, PPE policy, or hand hygiene policy.
Failure to Supervise Medication Administration and Unauthorized Self-Administration
Penalty
Summary
Surveyors identified a deficiency in medication administration supervision for Resident #4, who had intact cognition with a Brief Interview for Mental Status score of 15 and diagnoses including atrial fibrillation, anxiety, arthritis, depression, diabetes, edema, and hypertension. The resident’s care plan, last revised on 10/20/25, documented that the resident was resistive to cares and had a history of refusing medications if they did not feel the medications were necessary, with interventions directing staff to educate the resident on possible outcomes of noncompliance. The care plan did not document that the resident could self-administer medications. The MAR and current physician orders directed staff to offer two different medications mid-morning for a total of three pills and did not indicate that the resident was allowed to self-administer medications. During an observation, a CMA entered the resident’s room with a small cup containing three pills, placed it on the bedside table in front of the resident, visited briefly, and then left the room without acknowledging or administering the medications, which remained on the bedside table. The DON stated that staff are required to stay with residents when administering medications and should not leave residents alone with medications. CMAs interviewed reported that no residents were independent to keep medications in their rooms and that they would not leave medications with a resident in their room. The resident confirmed that medications were left in their room by staff and reported that this occurred periodically. Facility policy on administering medications stated that medications shall be administered in a safe and timely manner as prescribed, and that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined the resident has the decision-making capacity to do so safely.
Failure to Follow Physician Orders and Track Return of Cardiac Event Monitor
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards related to the use, monitoring, and return of a prescribed cardiac event monitor for one resident. The resident was admitted from an inpatient psychiatric facility with diagnoses including atrial fibrillation, hypertension, catatonic disorder, and major depressive disorder, and had intact cognition. The hospital discharge summary documented that cardiology recommended a 2‑week heart monitor at discharge with electrophysiology follow‑up. Despite this, the resident’s care plan revised on 12/29/25 contained no information about the heart monitor, and the facility lacked documentation that the monitor was applied on admission as expected by the clinic. An order was entered on 1/3/26 by an LPN to monitor the heart monitor for placement every shift and to mail the monitor back on Friday and discontinue the order when done, with an order end date of 1/6/26. However, the Medication Administration Record and Treatment Administration Record for that month contained no documentation that staff monitored the placement of the heart monitor. Progress notes showed the resident arrived on 12/17/25 and that on 12/24/25 a family member requested staff place the monitor, but there were no further notes describing when the monitor was applied, how long it was worn, when it was removed, or who removed it. Multiple CMAs and CNAs interviewed either were unaware of the monitor or could not recall the resident wearing it, while one LPN recalled reapplying the monitor after it came off, and another CNA recalled giving the removed monitor to an LPN who no longer worked at the facility. The facility also failed to have or follow a process for tracking and returning the monitor to the vendor. Staff interviews revealed confusion about who was responsible for entering and managing the monitor orders, handling the device, and arranging its return. One LPN reported removing the monitor, packing it, and taking the box to the DON’s office 3–4 weeks prior to the survey, after calling the vendor’s 800 number and involving an ADON who later left employment. The DON initially stated she did not believe the resident had a monitor and did not know if one was received, later reporting that she mailed a labeled box by dropping it in a downtown post office mailbox without knowing its contents or required shipping method, and acknowledging there was no specific person or department responsible for outgoing mail or package tracking. The University Hospital Clinic confirmed they had not received the monitor or data, that their system still showed they were waiting for data, and that the monitor should have been applied on the admission date and returned via UPS after the 15‑day recording period. The administrator confirmed there was no mail policy, and the facility could only produce a medication order policy rather than a broader physician’s orders policy, while the resident assessment policy required that assessment information be consistent with progress notes and care plans, which did not occur in this case. The deficiency is further supported by the family’s report that the monitor was not placed until about a week after admission, that it had been left on the floor before being reapplied, and that the hospital called about the monitor being three weeks overdue. Facility records lacked any process for tracking the disposition of the monitor or ensuring it was returned to the appropriate vendor or provider facility. The clinic nurse confirmed that, because the monitor had not been received, they were unable to download the information to determine if there was any arrhythmia, and that the computer system still showed they were waiting for data. The NP stated she wrote orders and expected them to be processed and followed, and that she informed facility management when orders were not carried out, noting that this happened frequently. Overall, the documented lack of care plan integration, missing monitoring documentation, unclear responsibility for the device, and absence of a mail/return process led to the monitor not being timely returned, delaying data analysis and physician follow‑up for this resident. The facility’s own documentation and staff statements show that the resident should have had the monitor applied on admission and worn it for the prescribed period, with staff monitoring its placement each shift and returning it promptly per the order. Instead, there were gaps in documentation, inconsistent staff awareness of the monitor, and no clear chain of custody or tracking once the device was removed. The DON and regional leadership acknowledged the absence of a mail policy and the lack of a defined process or tracking system for outgoing packages, including medical devices such as the heart monitor. The University Hospital Clinic’s confirmation that no monitor or data had been received, combined with the facility’s inability to verify when or how the monitor was shipped, demonstrates that the facility did not ensure services were provided in accordance with professional standards and physician orders for this resident.
Failure to Consistently Provide and Document Scheduled Resident Bathing
Penalty
Summary
The deficiency involves the facility’s failure to consistently offer and provide scheduled bathing assistance to dependent residents, despite care plans and schedules indicating the need for regular showers or baths. Resident #5, who had intact cognition with a BIMS score of 15 and diagnoses including arthritis, chronic pain syndrome, and heart failure, required staff assistance with bathing and showers per the care plan. Documentation for December and January showed that bathing was scheduled twice weekly on Tuesdays and Fridays, but in December baths were documented as completed only four out of nine scheduled days, and in January only two out of nine scheduled days. There was no documentation for the remaining scheduled bath days to indicate whether bathing was completed, not offered, or refused. Resident #5 reported going over two weeks between showers, stated that baths or showers were often not offered, and noted having to ask for a shower, particularly during January. Resident #3, admitted with osteoporosis and major depressive disorder and dependent on staff for bathing, also had a BIMS score of 15 indicating no cognitive impairment. According to a family member interview, the resident did not receive a first shower until 19 days after admission, and after that first shower, the family was told the resident would receive showers twice weekly. However, the family member reported the resident went eight days before the next shower and received only two showers in a 30‑day period. Documentation Survey Reports for showers covering December and January confirmed that from 12/17/25 to 1/17/25, the resident received showers only on 12/31/25 and 1/8/26. Resident #1, who had intact cognition with a BIMS score of 15 and was dependent on staff for transfers and bathing, had a care plan identifying an ADL self‑care performance deficit related to pain and impaired balance and mobility, with staff directed to provide assistance of one for bathing. The bath schedule showed this resident’s room was assigned baths on Tuesday and Friday mornings. Review of paper bath sheets and Documentation Survey Reports from November through January revealed that baths were documented as completed on only a small fraction of the scheduled bath days: two of nine in November, one of nine in December, and two of nine in January, with one documented refusal and one missed bath due to hospitalization. Multiple staff interviews confirmed that CNAs were responsible for baths, used room‑based bath schedules, and were expected to document in both paper bath sheets and the computer, but staff acknowledged that paper bath sheets frequently were not completed. The DON and other staff described prior lack of a clear process and issues with scheduling and documentation of baths, while the facility’s ADL policy required that residents unable to carry out ADLs independently receive services necessary to maintain good grooming and personal hygiene, including bathing.
Failure to Complete and Document Neuro-Checks and Full-Body Skin Assessments After Multiple Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to complete and document neurological assessments and full-body skin assessments as ordered and care planned for a resident with multiple risk factors. The resident had intact cognition but significant medical conditions including anxiety, aphasia, diabetes, heart failure, hemiplegia, and a history of stroke, and was dependent on staff for all care and transfers. The resident had two or more falls since the prior MDS assessment, was at risk for pressure injuries, and had a diabetic foot wound and an open foot lesion. The care plan included neuro-checks per facility policy for falls and skin inspections due to self-care deficits. Facility incident reports showed 21 unwitnessed falls over several months, but neuro-checks were initiated and documented for only 13 of these falls, and 8 of those 13 neuro-check forms were incomplete, missing one or more of the scheduled assessments required by the facility’s Falls Management System policy and Neurological Assessment form. The facility also failed to consistently complete and document full-body skin assessments for this resident. Weekly full-body skin reviews were documented from late July through early November, but no full-body skin assessments, either electronic or paper, were identified from mid-November through the end of December. During this period, only focused diabetic/neuropathic foot evaluations were documented, which did not address the rest of the body. Progress notes identified a bruise near the left upper eye area and, later, a bruise and skin tear to the right elbow following a fall, as well as cuts on the resident’s hand from fingernails, with treatment orders initiated. However, there was no further documentation in progress notes or skin assessments tracking these injuries. Staff interviews confirmed that neuro-checks for unwitnessed falls were expected to be completed and documented, and that full-body skin assessments were expected on bath days and during weekly skin assessments, but acknowledged that full-body checks were not consistently performed and documented for this resident.
Failure to Provide Nursing Coverage Results in Missed Medications and Resident Distress
Penalty
Summary
The facility failed to provide adequate nursing coverage for approximately four hours on two nursing units, affecting 53 residents, after one of two on-duty nurses left the facility unexpectedly during the night shift. This left only one nurse in the building, who did not assume responsibility for the other units, did not access the medication cart, and did not call for additional help. As a result, residents did not receive their scheduled or as-needed medications, and there was no licensed nurse in charge on each shift as required. One resident with chronic pain and a history of incomplete paraplegia, renal insufficiency, and chronic pain did not receive her scheduled pain medications, resulting in severe pain. She repeatedly requested her medications, but staff informed her that the nurse had left and no one could access the medication cart. The resident's pain became so severe that she called 911 for assistance. Emergency responders found her in visible distress, crying and screaming in pain, and confirmed that her medications had not been administered for several hours past the scheduled time. Another resident with a documented history of multiple anaphylactic reactions and systemic mastocytosis reported symptoms of an allergic reaction, including itching and facial swelling. She initially received Benadryl from the nurse before the nurse left, but when her symptoms worsened, she was unable to get further assessment or intervention from nursing staff. The resident ultimately self-administered her own epi pen, which she kept in her room, as no nurse responded to her call for help. A third resident also did not receive scheduled pain medication during this period. Staff interviews confirmed that there was confusion among staff regarding who was in charge, and no one took responsibility for the residents' care or medication administration after the nurse left.
Failure to Complete Post-Fall Follow-Up Assessments and Documentation
Penalty
Summary
The facility failed to complete required follow-up assessments after a resident experienced a fall. Clinical record review and staff interviews revealed that, although the interdisciplinary team met to discuss the fall and performed a root cause analysis, there was no documentation of follow-up actions such as pain assessments, vital signs, or neurological checks in the resident's record. Additionally, no incident report was found for the fall, and staff confirmed that the nurse on duty at the time did not initiate the required documentation. The absence of follow-up assessments and documentation occurred despite facility protocol requiring these actions after a fall.
Failure to Maintain Complete Medical Records for Resident Falls
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards for three of four residents reviewed. For one resident, a progress note documented a witnessed fall and initiation of neurological checks, with subsequent notes referencing continued monitoring. However, the facility was unable to produce the neurological check sheets, as they were completed on paper and subsequently lost. Similarly, another resident experienced a fall, with a nursing note indicating neurological checks were started, but the corresponding documentation could not be located. In a separate incident, a progress note indicated that the interdisciplinary team met to discuss a resident's fall and implemented an intervention, but no incident report for the fall could be found. Staff interviews revealed that the nurse on duty at the time of the fall left her position abruptly after the incident, and although she assessed the resident and relayed information to another nurse, the required incident report was never completed. The facility's policy requires that medical records be organized and easily retrievable, but in these cases, essential documentation related to falls and follow-up care was missing.
Failure to Ensure Safe Transfers and Proper Use of Mechanical Lifts
Penalty
Summary
The facility failed to ensure resident safety during transfers, resulting in harm to a resident who was improperly transferred in the shower room. The resident, who had a history of seizure disorder, prior laminectomy, and was assessed as requiring partial/moderate assistance for transfers, was left standing at the grab bars without a gait belt and without proper footwear. The staff member assisting her turned away to retrieve a shower chair, leaving the resident unsupported, which led to the resident losing her grip and falling. The fall resulted in two fractures, increased pain, and a decline in the resident's ability to transfer. Observations of other residents revealed additional failures in the use of full body mechanical lifts. Staff were observed transferring residents with the adjustable base of the mechanical lift in the closed position, contrary to both manufacturer instructions and facility policy, which require the base to be in the open position for stability during transfers. This improper use caused residents to tilt and the lift to wobble during transfers, creating unsafe conditions. Staff interviews confirmed a lack of understanding regarding the correct positioning of the lift base, and some staff believed the lifts could only be moved with the base closed due to the age of the equipment. Facility documentation and staff interviews indicated that the use of gait belts and proper footwear were required for transfers, but these protocols were not followed during the incidents. The facility's own policies and the manufacturer's manual for the mechanical lift both emphasized the importance of these safety measures. Despite these clear guidelines, staff failed to implement them, resulting in unsafe transfers and resident harm.
Failure to Verify Resident Identity Leads to Significant Medication Error
Penalty
Summary
The facility failed to verify the correct identity of a newly admitted resident, resulting in the entry of incorrect medication orders into the Electronic Health Record (EHR). Admission paperwork received by the Director of Admissions and Marketing contained information for a different resident with the same name but a different date of birth. This error was not identified during the medication reconciliation process, and the orders were entered into the EHR without confirming the six rights of medication administration. As a result, the resident did not receive her prescribed antipsychotic medications for approximately two weeks following admission. During this period, the resident, who had a history of schizoaffective disorder, hypothyroidism, and other chronic conditions, exhibited significant changes in behavior and mental status. Progress notes documented medication refusals, emotional distress, agitation, and statements indicating psychosis and withdrawal symptoms. The resident's family noticed a decline and questioned whether the correct medications were being administered. It was later confirmed by the DON that the orders entered were not for the correct resident, and the error was only identified after the family raised concerns. The lack of proper verification and reconciliation led to the resident experiencing exacerbation of psychosis, agitation, and withdrawal symptoms, ultimately resulting in hospitalization. Upon return from the hospital, the resident had developed a stage 3 sacral pressure ulcer. Interviews with staff revealed that the process for verifying resident identity and medication orders was not consistently followed, and the policy for medication reconciliation was not adequately implemented, contributing to the significant medication error and subsequent harm to the resident.
Deficient Food Storage, Preparation, and Service Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations of unsanitary and unsafe kitchen conditions. Surveyors observed significant standing water covering half of the kitchen floor, a broken and leaking sink, uneven and missing floor tiles, and a collapsing ceiling with black spots above food preparation areas. The walk-in freezer had excessive ice buildup on the floor, walls, and food items, while the walk-in cooler contributed to the flooding issue. Staff interviews confirmed these issues were ongoing, had been repeatedly reported to management, and had persisted for months to years without resolution. No maintenance or service logs were available for the walk-in cooler or freezer. During meal service observations, staff were seen directly touching residents' food with ungloved hands on multiple occasions. One resident refused to eat a dessert after reporting that a staff member's finger had been in the food. Staff interviews confirmed that direct hand contact with food was against facility policy and that food should be replaced if touched. Additionally, room trays were observed with ill-fitting covers that did not properly protect the food during transport, and several trays sat uncovered and unserved in the hallway for extended periods, resulting in food being served at unsafe temperatures and melted ice cream. Facility policy documents reviewed by surveyors stated that food must be served at safe and appetizing temperatures, staff must never touch residents' food with bare hands, and food must be covered during transportation. The policies also required timely equipment repairs and regular defrosting of freezers. Despite these policies, the facility failed to maintain a safe and hygienic kitchen environment and did not ensure proper food handling and service practices, as evidenced by the direct observations and staff interviews.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to two residents with intact cognition, as identified through clinical record review, observation, and resident and staff interviews. One resident reported that the food was constantly cold and bland, while another stated that food served on room trays was often cold and bland. Direct observation of a sample tray revealed that the ham and green beans were served at 120.3°F and 119°F, respectively, and the ice cream was soft and not frozen. The facility's policy requires all food items to be served at a palatable temperature, but this standard was not met for the residents reviewed.
Failure to Secure Resident Health Information
Penalty
Summary
Staff failed to properly safeguard resident-identifiable information, resulting in unauthorized access to protected health information. On one occasion, an unsecured document containing resident-specific health information was observed face-up on a medication cart, accessible in a hallway where several residents were independently mobile. A staff LPN acknowledged that the document should have been placed face down but was left exposed when she was called away by a resident. In a separate incident, an unattended, open laptop displaying multiple residents' electronic health records was left visible in an area with several mobile residents present. The RN responsible admitted to leaving the laptop open by mistake. The Director of Nursing confirmed that protected health information is required to be secured at all times. Facility policy states that access to resident personal and medical records is limited to authorized staff and business associates.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols during multiple observed care activities. A registered nurse was observed dropping a resident's medication onto a report sheet, picking it up with ungloved hands, and administering it to the resident without discarding the contaminated pill. The nurse later acknowledged that gloves or a spoon should have been used and that the medication should not have been touched by hand. The Director of Nursing confirmed that the correct procedure would have been to discard the pill and obtain a new one. Additionally, staff did not perform appropriate hand hygiene during medication pass, as observed during the survey. Enhanced Barrier Precautions (EBP) were not utilized as required during wound care and catheter care for two residents. One resident with an indwelling catheter and an order for EBP was cared for by a CNA who did not wear a gown while draining the catheter, contrary to facility expectations. Another resident with a Stage 3 pressure ulcer and on EBP had a dressing change performed by an LPN who did not wear a gown or perform hand hygiene between glove changes. Furthermore, staff failed to disinfect a full body mechanical lift between uses with different residents, despite facility policy and DON expectations that lifts be sanitized between each resident. Staff interviews confirmed that lifts were only cleaned at the end of the day, not between residents.
Delay in Incontinence Care and Resident Dignity
Penalty
Summary
A resident with intact cognition and a history of anemia, hip fracture, muscle weakness, and incontinence requested assistance after wetting her pants. The resident, who required moderate to maximal assistance with personal care and was dependent with toileting, approached an LPN in the hallway and asked for help. The LPN informed the resident that a CNA would assist her but did not call for immediate help or provide assistance herself, instead continuing to administer medications to other residents. The resident repeated her request, but the LPN again deferred action, only activating the resident's call light and instructing the resident to wait in her room. The resident propelled herself to her room and waited. The LPN eventually asked the CNA to assist the resident when available, but the CNA prioritized other tasks and did not immediately respond. The CNA attended to other residents' needs before finally entering the resident's room to provide incontinence care approximately 13 minutes after the initial request. During this time, the resident expressed feeling bad and perceived that the nurse did not want to help her. The resident's care plan directed staff to provide incontinence care as needed, and facility policy required staff to treat residents with dignity and respect.
Failure to Include Target Behaviors and Non-Pharmacologic Interventions in Care Plan
Penalty
Summary
The facility failed to include psychotropic medication target behaviors and non-pharmacologic interventions in the care plan for one resident. Record review showed that the resident had diagnoses of anxiety, depression, and osteoarthritis, and was receiving antianxiety, antidepressant, and antipsychotic medications. The resident's Minimum Data Set (MDS) assessment indicated intact cognition, and the electronic health record (EHR) documented a range of behavioral issues, including physical and verbal aggression, socially inappropriate behaviors, and signs of anxiety and agitation. Progress notes and physician orders referenced the need to monitor the effectiveness of medications but did not specify target behaviors for staff to observe or document. The care plan, initiated upon admission, included the use of psychotropic medications but did not identify the specific target behaviors associated with the resident's conditions or outline non-pharmacological interventions for staff to implement. Staff interviews confirmed that the expectation was for care plans to include these elements. The facility's policy required comprehensive, person-centered care plans with measurable objectives, descriptions of services, and inclusion of recognized standards of practice, but these requirements were not met in this case.
Failure to Accurately Account for Controlled Medications and Maintain Proper Records
Penalty
Summary
The facility failed to maintain a consistent and accurate process for counting and accounting for controlled medications, resulting in a card of Oxycodone/acetaminophen (Percocet) prescribed to a resident becoming unaccounted for. The resident in question had a history of cerebral palsy, stroke, and polyneuropathy, and was receiving both scheduled and as-needed opioid medications for chronic pain. The care plan directed staff to administer analgesics as ordered by the physician. Despite these directives, staff were unable to account for a card of Percocet with 12 administrations remaining, as well as the associated controlled drug record sheet and the total count sheet for the medication cart. Multiple staff interviews revealed inconsistencies and confusion in the medication counting process. The DON confirmed that two cards of Percocet had been combined onto a single count sheet, contrary to facility expectations that each card should have its own record. On the day the discrepancy was discovered, staff noted that the count sheet and the partial card of Percocet were missing, and the count sheet for the cart was also unaccounted for. Staff involved in the medication counts provided conflicting accounts regarding the number of items in the cart and the process for cosigning count sheets. One staff member denied signing a count sheet for the Percocet, noting differences in ink and signature style, while another staff member was reported to have been defensive when questioned about the missing items and left the facility before the DON arrived. Further observations found that a discontinued controlled medication (Nayzilam) remained in the medication cart weeks after its discontinuation, and there was confusion among staff regarding how to count certain medications, such as whether a box of nasal spray should be counted as one or two items. The process for removing discontinued medications was not consistently followed, as staff were unaware that the medication was still present in the cart. These lapses in medication management and documentation contributed to the inability to account for controlled substances as required by professional standards.
Failure to Develop Timely and Complete Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident, as required by policy. The resident, who had intact cognition, was admitted with multiple diagnoses including anxiety, depression, contractures, joint pain, and osteoarthritis, and was prescribed several psychotropic and opioid medications. Documentation showed that the resident regularly received medication for chronic pain and anxiety, and her care plan was not initiated until several days after admission. The baseline care plan that was eventually created did not address the resident's chronic pain or psychotropic medication use, and it lacked a date and time of completion. Further review revealed that the baseline care plan was missing a signature and confirmation from the resident or her family, as required by facility policy. Staff interviews confirmed that the expected process was not followed, and progress notes did not document any confirmation of the care plan. The facility's policy required a baseline plan of care to be developed within 48 hours of admission to address immediate health and safety needs, but this was not completed for the resident in question.
Failure to Follow Physician's Order for Pressure Ulcer Intervention
Penalty
Summary
Staff failed to follow a physician's order for a resident with severe cognitive impairment, congestive heart failure, kidney disease, non-Alzheimer's dementia, and a right heel pressure ulcer. The physician's order and care plan both directed that Prevalon boots be applied at all times as tolerated, except when the resident was weight-bearing, to promote wound healing. Multiple observations on different occasions showed the resident was not wearing the Prevalon boots while in her wheelchair or in bed, and staff were unable to locate the boots in her room. Interviews with various staff members, including CNAs, a CMA, and an LPN, confirmed that the resident was non-weight bearing, required a mechanical lift for transfers, and had not refused care. Staff also indicated that the boots should have been on while the resident was in bed, in a wheelchair, or in a lift sling, and that there was no documentation or notification of refusal. The LPN was unaware the resident was not wearing the boots, and the DON stated the expectation was for this intervention to be included in the care plan rather than as a physician's order.
Failure to Provide Safe and Appropriate Respiratory Care and Accurate Documentation
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for two residents requiring oxygen therapy. For one resident with chronic obstructive pulmonary disease, observations revealed that oxygen tubing was not labeled or dated as required, and the resident reported the tubing had not been changed since admission. Staff interviews showed inconsistent understanding of when and how to change and label oxygen tubing, and the Director of Nursing confirmed the expectation for weekly changes with proper labeling, which was not met. For another resident with heart failure, respiratory failure, and obstructive sleep apnea, there was a lack of documentation in the care plan regarding the use of a Bi-pap machine, despite physician orders and the resident's need for the device. The Bi-pap machine was reported missing for an extended period, and the resident was not provided with the ordered therapy. Progress notes and treatment administration records contained discrepancies, with some staff documenting that the Bi-pap was provided when it was actually unavailable. The resident confirmed the machine had been missing and that he had not refused its use, while staff interviews corroborated the missing equipment and acknowledged inaccurate documentation. Facility policy required weekly changes and labeling of oxygen tubing, which was not consistently followed. The lack of proper respiratory equipment management, failure to provide ordered therapy, and inaccurate documentation contributed to the deficiencies identified for both residents.
Improper Handling and Documentation of Controlled Substances
Penalty
Summary
The facility failed to adhere to professional standards of practice by allowing Unit Managers/Supervisors, who were not licensed pharmacists, to draw up liquid Morphine and Lorazepam in 1 ml syringes. These syringes were then placed, both labeled and unlabeled, in medication carts for three residents. This practice was confirmed by a Licensed Practical Nurse (LPN) who observed nine unlabeled Morphine syringes in a medication cart. The Nurse Manager/Supervisor admitted to pre-drawing the liquid Morphine based on estimated usage over a 24-hour period, without proper labeling. Additionally, the facility failed to maintain accurate reconciliation and drug records for controlled substances. For one resident, the Controlled Drug Record form showed several open spaces where staff did not reconcile Pregabalin tablets, failing to count the medication with two staff members as required by policy. Similarly, for another resident, the Controlled Drug Record form revealed open spaces for Morphine Sulfate Solution and Fentanyl patches, indicating a failure to count these medications with two staff members on multiple occasions. The facility's policies on the storage and handling of medications were not followed. Medications were not stored in their original packaging, and containers with missing or incorrect labels were not returned to the pharmacy for proper labeling. The Controlled Substances policy required that controlled medications be counted at the end of each shift by the on-duty and off-duty nurses, with any discrepancies reported to the Director of Nursing (DON). However, these procedures were not consistently followed, leading to the deficiencies noted in the report.
Removal Plan
- Assessment of all medication carts and treatment carts for assurance all medications and treatment ointments/creams and etc. were appropriately labeled.
- Staff education on appropriate labeling and administration of narcotic and anti-anxiety medications.
- Medication administration education updates.
- Destruction of all liquid narcotic and anti-anxiety medications.
- Pain assessments on all residents completed.
- QAPI meeting conducted.
- Assurance of ongoing monitoring and review.
Failure to Respect Resident Dignity and Self-Determination
Penalty
Summary
The facility failed to honor residents' rights to dignity and self-determination, as evidenced by multiple incidents involving staff interactions with residents. One resident reported that a Certified Nursing Assistant (CNA) forced her to go to bed before she was ready and handled her roughly during care. Another resident described an incident where the same CNA was rude and disrespectful, slapping her on the belly and throwing her call light at her, which landed on her neck. This resident also witnessed the CNA transferring her roommate without the required lift device, despite the roommate's protests. Additionally, staff members were observed entering residents' rooms without waiting for an invitation after knocking, which startled the residents. A Licensed Practical Nurse (LPN) and an Activities staff member were both noted to have entered rooms uninvited, even during sensitive care procedures. Staff interviews confirmed that this was a common practice, with one CNA admitting to being guilty of this behavior herself. The facility's abuse policy, which emphasizes treating residents with respect and dignity, was not adhered to in these instances.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to maintain call lights within reach for four residents, as observed and confirmed through staff and resident interviews. During observations, call lights were found on the floor or hanging down the side of the bed, making them inaccessible to residents. For instance, one resident's call light was positioned on the floor, while another resident's call light was hanging down the side of the bed, preventing the resident from reaching it. Staff interviews confirmed these observations, with one staff member noting that call lights were sometimes hooked to light fixtures or curtains, and another staff member finding call lights under bedspreads. Residents also reported issues with call light accessibility. One resident confirmed that their call light was not always within reach, leading them to yell for assistance. Staff interviews further corroborated these findings, with multiple staff members acknowledging that call lights were often out of reach for residents. The facility's policy, revised in March 2018, directed staff to provide care and services to maintain residents' ability to carry out activities of daily living, which includes ensuring call lights are accessible.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for its residents, as evidenced by multiple observations and staff interviews. A photo taken on November 19th revealed dried and hard oatmeal, other food debris on a bedside stand, and dried food on the floor in a resident's room. Additionally, a brown stain consistent with a bowel movement was observed on the wall beside the resident's bed, and a metal tray under the bed contained a dried black substance resembling dried coffee or a loose bowel movement with a dead bug adhered to it. Staff interviews confirmed the presence of dried food in resident rooms and described the rooms as being in disarray. Furthermore, during facility tours, a persistent foul odor of urine was noted in the Terrace A and Generation C hallways on multiple occasions. Staff confirmed the presence of this odor in the Terrace and Generation neighborhoods. The facility's Safe Resident Handling/Transfers policy, which was not dated, indicated that lifts should be cleansed and disinfected according to the manufacturer's instructions after each resident's use, but the report does not confirm adherence to this policy.
Deficiencies in Resident Care and Hygiene Practices
Penalty
Summary
The facility failed to properly transfer a resident who required an assistive device, provide appropriate oral care for two residents, and groom a female resident's facial hair. Resident #18, diagnosed with Non-Alzheimer's Dementia and Venous Insufficiency, was dependent on staff for transfers using an assistive lift device. Despite this, a staff member was observed transferring the resident independently without the required device, causing the resident to cry out in distress. Interviews with staff confirmed that transfers were often conducted without the necessary equipment and assistance, particularly during busy times such as meal preparation. Additionally, the facility failed to maintain proper oral hygiene for two residents. Resident #11's denture cup contained a partial plate with a significant buildup of food particles, and Resident #4's toothbrush was found entangled with hair, indicating neglect in oral care. Furthermore, Resident #6, who required assistance with personal hygiene due to Multiple Sclerosis, was observed with noticeable facial hair, which she expressed a desire to have removed. The facility's policies on safe resident handling and activities of daily living were not adhered to, contributing to these deficiencies.
Deficiencies in Resident Assessment and Medication Administration
Penalty
Summary
The facility staff failed to properly assess and follow up on incidents involving residents, leading to deficiencies in care. Resident #8, who had severe cognitive impairments and was at risk for falls, fell in her room and sustained a hematoma on her forehead. Despite the facility's Falls Management System policy requiring follow-up assessments every shift for 72 hours post-fall, staff did not properly assess the resident on multiple shifts following the incident. Resident #5 was observed with a bandage on his left elbow, covering a skin tear with dried blood and yellow drainage. There was no treatment order documented for this injury, and the incident report was not initially found in the electronic medical record. The resident was unaware of how the injury occurred, and there was a lack of follow-up assessments documented for the skin tear. Additionally, the facility staff failed to administer medications as prescribed for Residents #2 and #17. Medications were administered outside the prescribed time frames, with some morning medications given in the afternoon. The facility's policy required medications to be administered in a safe and timely manner, but staff did not adhere to these guidelines, leading to further deficiencies in care.
Cockroach Infestation in Facility
Penalty
Summary
The facility failed to maintain a resident environment free of cockroaches, as evidenced by multiple observations and interviews. Staff members, including a CNA/CMA and housekeepers, reported seeing both dead and alive cockroaches throughout the facility, including on medication carts, in resident rooms, and even in a resident's bed. A family member also confirmed seeing a live cockroach in a resident's room. Photographic evidence showed numerous dead cockroaches in traps within a resident's room. These observations indicate a significant infestation problem within the facility. The facility's pest control measures, as documented in extermination invoices, included the use of broad-spectrum insecticides and traps. However, these measures were insufficient to control the infestation. The exterminator's manager noted that the pesticides used had a residual effect rather than a direct kill, which may not be effective in high infestation situations. The exterminator company had communicated with facility management about the need for increased services, but management indicated that corporate approval was required for such actions. The presence of cockroaches in resident sink drains was described as indicative of a severe infestation.
Failure to Implement Care Plan for Resident's Personal Hygiene
Penalty
Summary
The facility failed to implement a care plan for a resident who was dependent on staff for personal hygiene due to Multiple Sclerosis. The Minimum Data Set (MDS) assessment indicated that the resident required assistance with activities of daily living, including shaving. Despite the care plan specifying that the resident preferred one staff member to assist with personal hygiene, observations on two occasions revealed that the resident had 1/4 to 1/2 inch long whiskers on her chin. During an interview, the resident expressed her desire to have the whiskers shaved, indicating dissatisfaction with their presence. The facility's policy on Activities of Daily Living, revised in March 2018, directed staff to provide necessary services for residents unable to carry out ADLs independently, including grooming, in accordance with the plan of care.
Deficiency in Treatment Administration Documentation
Penalty
Summary
A deficiency was identified in the facility's treatment administration process for a resident with a physician's order for Ammonium Lactate Lotion 12% to be applied daily to their bilateral lower extremities for Xeroderma. On November 19, 2024, a Licensed Practical Nurse (LPN), Staff J, documented that the treatment was completed, although it was not performed. During an observation and interview on November 20, 2024, Staff J confirmed that the bandages on the resident's legs were dated November 18, 2024, indicating that the dressing change had not occurred as ordered. Staff J admitted to initialing the treatment order based on information from another LPN, Staff Q, who claimed to have performed the treatment. The facility's policy requires the individual administering medication to document it in the Electronic Medication Administration Record (EMAR) system after administration, ensuring the right resident, medication, dosage, time, and method are verified before administration.
Failure to Secure Medication Carts and Supervise High-Risk Resident
Penalty
Summary
The facility staff failed to maintain a locked and secured treatment cart and provide appropriate nursing supervision, leading to potential safety hazards. Observations revealed multiple instances where treatment and medication carts were left unlocked and unattended in various locations within the facility, including near the nurse's station and in the Terrace and Generation neighborhoods. Staff interviews confirmed that unlocked and unattended carts were a recurring issue, which is contrary to the facility's policy that requires medication carts to be kept closed and locked when out of sight of the nurse or Certified Medication Aide (CMA). Additionally, the facility failed to provide adequate supervision for a resident with severe cognitive impairments and a high risk of falls. The resident, who had diagnoses including Non-Alzheimer's Dementia and muscle weakness, was dependent on staff for transfers and mobility. Despite being identified as a fall risk, the resident was left unattended in her room in a specialized wheelchair, leading to a fall that resulted in a hematoma on her forehead. Staff interviews confirmed that the resident should not have been left unattended, highlighting a lapse in supervision and adherence to the care plan designed to prevent falls.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to properly label and store liquid Morphine and Lorazepam, which are narcotic and anti-anxiety medications, respectively, for three residents. During an observation, it was found that nine unlabeled Morphine syringes were stored in a medication cart. Staff I, an LPN, confirmed that Nurse Managers and Supervisors had been drawing up these medications in unlabeled syringes for two months. Staff A, an LPN/Nurse Manager/Supervisor, admitted to pre-drawing the liquid Morphine based on estimated usage over a 24-hour period, without labeling the syringes. The Interim Director of Nursing (DON) confirmed that the practice of pre-drawing and not labeling the medications had been ongoing since before December 2023. Staff J, an LPN, expressed frustration with this practice and had communicated her concerns to Staff A. Additionally, Staff C, a CNA/CMA, and Staff G, an LPN, confirmed they administered these pre-drawn, unlabeled medications to residents. The facility's policy required that only a pharmacist could pre-set up liquid narcotics and anti-anxiety medications, which was not adhered to in this case. Further investigation revealed that a bottle of liquid Morphine was found in Staff A's office without a Controlled Drug Record form, and it was not dated when opened. The facility's policies on medication storage and controlled substances were not followed, as the medications were not stored in their original containers, and there was a lack of proper labeling and documentation. Staff I and Staff J both confirmed that the practice of pre-drawing and not labeling medications was not acceptable and had been a concern since they began their employment.
Infection Control Lapses in PPE Usage and Catheter Management
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control protocols by not donning Personal Protective Equipment (PPE) while providing direct care to residents with catheters, PICC lines, and open skin treatments. Specifically, a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) were observed not wearing gowns while performing procedures on residents with PICC lines and supra pubic catheters, despite signage indicating the need for enhanced barrier precautions. The RN was seen handling a PICC line without a gown, and the LPN failed to cleanse a catheter port with alcohol before reconnecting it, subsequently touching the resident's skin and bedding with contaminated gloves. Additionally, the facility staff did not maintain proper catheter tubing placement, as evidenced by a photo showing a resident's catheter tubing positioned directly on the floor. Interviews with staff confirmed that some personnel did not consistently don PPE during care involving catheters and PICC lines. These observations and interviews highlight lapses in infection control practices, potentially compromising resident safety.
Failure to Assess and Document Post-Fall Care
Penalty
Summary
The facility failed to provide necessary assessments and interventions for a resident following a fall and prior to transferring the resident to a higher level of care. The resident, who had intact cognition and multiple diagnoses including atrial fibrillation, end-stage renal disease, and hemiplegia, experienced a fall while being transferred from a wheelchair to bed using a sliding board. The incident report noted that the resident lost balance and slid to the floor, but no injuries were observed at the time. Vital signs were within normal limits, and the resident was assisted back into the wheelchair by two staff members. Despite the fall, the facility's progress notes lacked follow-up documentation regarding the fall or the decision to send the resident to the hospital for evaluation. The resident was later returned to the facility from the hospital without any documented assessment or intervention related to the fall. The care plan for the resident included interventions for fall risk and assistance with transfers, but there was no evidence of these being effectively implemented or documented following the incident. The Interim Director of Nursing stated that it was expected for staff to complete an assessment for pain and injury after a fall and document findings every shift for 72 hours. However, this was not done in the case of the resident. The facility's policies on changes in a resident's condition and falls management required documentation of any changes and follow-up assessments, which were not adhered to in this instance.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate treatment and services to promote the healing of a pressure ulcer for a resident, identified as Resident #1. The resident was admitted with a left heel blister measuring 3.5 cm x 3 cm, which was noted on admission but not addressed in the care plan until ten days later. The facility did not initiate treatment for the blister until five days after admission, and the required weekly skin assessments were not completed as ordered. Additionally, the Braden Scale for Predicting Pressure Sore Risk was not conducted on admission or weekly as required, with only one assessment completed on September 21, 2024. Resident #1 had a complex medical history, including atrial fibrillation, end-stage renal disease, diabetes mellitus, seizure disorder, and hemiplegia, which increased the risk for skin breakdown. The resident required substantial assistance for personal care and was dependent on staff for transfers and toileting. Despite these risk factors, the facility did not adhere to its own protocols for skin assessments and treatment, leading to a necrotic area developing on the resident's left heel. The facility's policy on pressure injury surveillance required licensed nurses to assess residents and report changes in condition to physicians and management staff. However, the facility did not follow these protocols, as evidenced by the lack of timely assessments and treatment for the resident's pressure ulcer. The Interim Director of Nursing acknowledged that the facility's expectations for skin assessments and Braden Scale evaluations were not met, contributing to the deficiency in care for Resident #1.
Failure to Adhere to Transfer Protocols Leads to Resident Fall
Penalty
Summary
The facility failed to provide a safe transfer for a resident, resulting in a fall. The resident, who had intact cognition and multiple medical conditions including hemiplegia and non-weight bearing status on the left lower extremity, required two staff members for transfers using a sliding board as per the care plan. However, during a transfer from a wheelchair to a bed, only one staff member was present, leading to the resident losing balance and sliding to the floor. The incident occurred when a Certified Nursing Assistant (CNA) attempted to assist the resident with the transfer. Despite being aware that the transfer required two staff members, the CNA proceeded with the transfer alone after the resident indicated they could manage it together. The resident subsequently lost balance and fell, although no injuries were reported. The Licensed Practical Nurse (LPN) who responded to the call light confirmed that only one staff member was present during the transfer. Interviews with staff revealed that the CNA was aware of the two-person requirement but did not adhere to it, influenced by the resident's assertion of independence. The facility's policy and care plan clearly stated the need for two staff members for such transfers, but this was not followed, leading to the fall. The incident highlights a failure to adhere to established care plans and protocols, resulting in an unsafe transfer situation.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to follow physician orders for catheter care for two residents. The first resident, with a BIMS score indicating intact cognition, required maximum assistance for toileting and was dependent on two-person assistance for bed mobility and transfers. The resident had an indwelling catheter and was always incontinent of bowel. The care plan directed catheter changes as ordered, but the electronic medication administration record (eMAR) lacked documentation on when the catheter was to be changed. An observation revealed a discrepancy in the catheter size, and the interim Director of Nursing (DON) acknowledged the lack of proper documentation and was unaware of the reason for the incorrect catheter size. The second resident, also with intact cognition, required maximum assistance for toileting and had an indwelling catheter. The care plan specified catheter changes as ordered, but the eMAR showed the last documented catheter change was over a month prior, contrary to the physician's order for monthly changes. An observation revealed a different catheter size than ordered, and the interim DON, who had recently joined the facility, was unaware of why the catheter had not been changed according to the schedule or why the incorrect size was used. Facility policies emphasized adherence to physician orders and proper catheter care, but these were not followed in these instances.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a male staff member who allegedly handled the resident roughly during a transfer to bed. The resident, who had moderate cognitive impairment and required assistance with activities of daily living due to a self-care deficit, reported feeling anxious and afraid of the staff member. The resident's family member and a family friend both observed bruising on the resident's ankles, which they attributed to the rough handling by the staff member. The incident was reported to the facility by the resident's family member, who was informed that the staff member would no longer provide care for the resident. However, the facility did not conduct a thorough investigation, as they did not interview the staff member involved or report the incident to the Department of Inspections and Appeals and Licensing (DIAL). The facility's internal documentation was limited to a grievance form, which noted that the staff member was educated on being cautious during transfers but did not include any disciplinary action. Interviews with the resident, family member, family friend, and staff revealed inconsistencies in the facility's handling of the incident. The resident consistently reported feeling anxious and afraid of the staff member, while the staff member denied being rough and stated he was only in a hurry due to another resident's potential fall. The facility's failure to adequately address the resident's concerns and ensure her dignity and respect constitutes a deficiency in care.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure congruence between the Iowa Physician's for Scope of Treatment (IPOST) and the Care Plan regarding the code status for a resident. The resident had a Do Not Resuscitate (DNR) order documented in the physician's orders and the IPOST form. However, the Care Plan indicated that the resident and their responsible party requested a cardiopulmonary resuscitation (CPR)/full code status, which was to be honored until the next review. The facility's policy on Advanced Directives required that any changes or revocations be communicated to the care plan team to update the care plan accordingly. Despite this policy, the discrepancy between the IPOST and the Care Plan was not addressed, as acknowledged by the Administrator during interviews. The staff typically referred to the IPOST for code status, leading to the inconsistency in the resident's documented wishes.
Failure to Report Alleged Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with moderate cognitive impairment, who had a history of hip and knee replacement, cancer, multiple sclerosis, and glaucoma. The incident involved a male staff member who allegedly handled the resident roughly during a transfer, resulting in bruising on the resident's ankles. Despite the family member's report to the facility, the alleged abuser continued to work with residents, including the affected resident. The facility's internal investigation was inadequate, as they did not interview the staff member involved or document the investigation findings properly. The Social Services Director (SSD) and the Director of Nursing (DON) observed the resident and noted bruising on the resident's toe, which the resident attributed to dropping a cell phone. However, the resident and a family friend reported bruising on the ankles, which they believed was caused by the staff member's rough handling. The facility did not report the incident to the State survey and certification agency, as they concluded it was not abuse. Interviews with the resident, family member, and family friend revealed consistent accounts of the staff member's rough handling and the resident's fear of the staff member. The facility's policy required immediate investigation and documentation of such incidents, but the facility failed to comply with these procedures. The staff member continued to work in the facility without any disciplinary action, and the facility did not ensure the resident's safety by preventing further contact with the alleged abuser.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to initiate and complete a thorough investigation of alleged abuse involving a resident with moderate cognitive impairment and multiple medical conditions, including hip and knee replacement, cancer, multiple sclerosis, and glaucoma. The incident involved a male staff member allegedly handling the resident roughly during a transfer to bed, resulting in bruising on the resident's ankles. The family member reported the incident to the facility, and the Social Services Director (SSD) was informed. However, the facility did not conduct a comprehensive investigation, as they did not interview the staff member involved or document the investigation findings adequately. The SSD and the Director of Nursing (DON) both interacted with the resident and observed bruising on her toe, which the resident attributed to dropping her cell phone. The resident expressed anxiety and fear regarding the staff member's actions, describing him as rough and causing injuries. Despite these concerns, the facility did not report the incident to the Department of Inspections and Appeals and Licensing (DIAL) as they did not consider it abuse after their limited investigation. The staff member continued to work at the facility and provide care to the resident. The facility's grievance form documented the family's concerns and the SSD's interview with the resident. However, the investigation was not thorough, as the facility did not take disciplinary action against the staff member or ensure he would not provide care to the resident again. The facility's policy on abuse and neglect prevention requires immediate initiation of an investigation and documentation of findings, which was not adequately followed in this case.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman of the discharge/transfer of a resident as required by federal regulation. Specifically, the clinical record for a resident who was discharged to the hospital on December 25, 2023, and reentered the facility on December 29, 2023, lacked documentation of notification to the LTC Ombudsman. During an interview, the Administrator confirmed that the facility had not notified the Ombudsman when the resident was discharged to the hospital. The facility's policy on Transfer and Discharge, with a copyright date of 2023, requires that notice be provided to the LTC Ombudsman as soon as practicable before the transfer or discharge, and that evidence of the notice being sent should be maintained.
Failure to Conduct Level II PASARR Evaluation for Resident with PTSD
Penalty
Summary
The facility failed to refer a resident with a Level I Preadmission Screening and Resident Review (PASARR) for a Level II PASARR evaluation despite the resident having a diagnosed serious mental disorder. The resident, who was admitted with a diagnosis of PTSD, was not referred for a Level II PASARR evaluation when this diagnosis was known to the facility. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and documented diagnoses including major depressive disorder and PTSD. Despite these diagnoses, the facility did not complete a Level II PASARR, as the initial Level I PASARR did not indicate a need for further evaluation. The facility's administrator acknowledged that there was no specific policy in place for PASARR completion, although the facility followed general guidelines. The responsibility for ensuring PASARR completion was assigned to a part-time social worker. The failure to submit a Level II PASARR was identified during a review of the resident's electronic health records, which showed the PTSD diagnosis was present upon admission. The facility's oversight in not conducting a Level II PASARR evaluation for the resident with a serious mental disorder constitutes the deficiency noted in the report.
Failure to Implement Comprehensive Care Plan for Urostomy Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a urostomy and urostomy bag. The resident, who is cognitively intact and has diagnoses including neurogenic bladder and paraplegia, was admitted with a urostomy tube. The care plan did not include instructions on the care of the urostomy bag or monitoring and documenting intake and output. The resident reported that staff did not empty the bag frequently, leading to it becoming very full, with staff emptying it only once a day when it was very full. The Director of Nursing (DON) confirmed that the care plan lacked instructions for urostomy bag care and acknowledged that the bag should be emptied at least once per shift, ideally three times a day, with output documented. However, a review of the electronic health record showed inconsistent documentation of the bag being emptied, with several days lacking entries. The DON stated that while staff were expected to complete and document this task, it was not being consistently monitored or documented. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan, which was not adhered to in this case.
Failure to Ensure Safe Environment for Resident with Smoking Supplies
Penalty
Summary
The facility failed to ensure a safe environment for a resident with moderate cognitive impairment, who was observed to have smoking supplies, including cigarettes and a lighter, in her room. The resident, who had diagnoses including hip and knee replacement, cancer, multiple sclerosis, and glaucoma, was not assessed for smoking safety despite her cognitive decline. The care plan for the resident indicated a need for a safe environment and supervision due to impaired cognitive function and decision-making capabilities. During observations and interviews, it was revealed that the resident had three packs of cigarettes on her nightstand and a lighter in her fanny pack. The resident stated she needed assistance to go outside to smoke and could not do so independently. The facility's administrator and DON were unaware of the resident having smoking supplies in her room and acknowledged the resident's cognitive impairment. The facility did not have a smoking policy, and the administrator stated that residents were required to sign themselves out to smoke off the property, which the resident was unable to do. Interviews with family members and staff confirmed that the resident had kept cigarettes and a lighter in her room since her admission, and there was concern about her safety due to her cognitive impairment. The facility did not conduct a smoking safety assessment for the resident, and the administrator admitted that there was no evaluation for the resident as she had not requested to go outside on her own. The lack of a smoking policy and the failure to assess the resident's ability to safely manage smoking supplies contributed to the deficiency.
QA Meeting Attendance Deficiency
Penalty
Summary
The facility failed to have the minimum required members present at their quarterly Quality Assurance (QA) meetings as mandated by the Centers for Medicare and Medicaid Services (CMS). The facility, which reported a census of 80 residents, conducted QA meetings on several dates, including 4/20/23, 7/20/23, 9/25/23, 10/12/23, 2/16/24, 5/25/24, and 6/13/24. However, during these meetings, essential members were absent: the Administrator was not present on 4/20/23, the Infection Preventionist was absent on 7/20/23, 9/25/23, and 10/12/23, and the Medical Director was not present on 2/16/24. During an interview on 6/27/24, the Administrator acknowledged that all required members were not present at the quarterly QA meetings as expected, confirming the deficiency in meeting the CMS requirements for QA meeting attendance.
Failure to Enforce Smoking Policies for Cognitively Impaired Resident
Penalty
Summary
The facility failed to establish and enforce policies regarding smoking, smoking areas, and smoking safety for residents, specifically for a resident with moderate cognitive impairment. The resident, who had a history of hip and knee replacement, cancer, multiple sclerosis, and glaucoma, was observed with cigarettes and a lighter in her room, despite the facility's non-smoking policy. The resident's care plan indicated she required supervision and a safe environment due to cognitive impairment and risk of falls, yet no smoking safety assessment was conducted. Observations revealed that residents, including the cognitively impaired resident, were smoking on the property grounds, contrary to the facility's stated policy that smoking is not allowed on the premises. The facility's administrator and DON were aware of the resident's cognitive decline but were not aware she had smoking supplies in her room. The facility did not have a designated smoking area or a smoking schedule, and staff did not monitor residents who smoked. Interviews with staff, family members, and the resident herself confirmed that the resident had been keeping cigarettes and a lighter in her room since her admission. Despite the facility's policy, residents were observed smoking near the main entrance, and the cognitively impaired resident was not on the list of residents who smoke. The facility's lack of a comprehensive smoking policy and failure to assess the resident's ability to smoke safely contributed to the deficiency.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's nutritional status, specifically a substantial weight loss. Resident #6, who has moderate cognitive impairment and multiple medical conditions including renal insufficiency, osteoporosis, and depression, experienced a weight loss of 21.55 pounds, equating to a 13.43% decrease, within a month of admission. The resident's care plan required monitoring of nutritional status and notification of the physician in case of significant weight changes, but this was not adhered to. The dietician, responsible for monitoring the resident's weight, acknowledged the significant weight loss and admitted that the physician was not informed as required by the facility's policy. The facility's policy, revised in September 2017, mandates that staff report significant weight changes to the physician. However, the dietician failed to prepare and send the necessary notification to the physician, resulting in a breach of protocol.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to professional standards of care for several residents, as observed during a survey. Resident #21, who has multiple medical conditions including multiple sclerosis and chronic cystitis, was found to have missed several scheduled catheter flushes over a three-month period, despite having a physician's order for daily flushing with acetic acid. The Treatment Administration Record (TAR) indicated multiple dates where the flush was not completed, and the Director of Nursing confirmed that the expectation was for catheter irrigation to be completed as ordered. Resident #40, diagnosed with diabetes mellitus and other conditions, was observed receiving insulin injections without proper priming of the insulin pens, as per facility policy. The Registered Nurse administering the insulin failed to perform a safety test by priming the pens and did not leave the needle under the skin for the required time to ensure full dose delivery. This was contrary to the facility's insulin administration policy, which outlines specific steps to ensure safe and effective insulin delivery. Resident #61, who has renal insufficiency and obstructive uropathy, reported that staff were not consistently flushing his catheter as ordered. A review of the TAR for June 2024 showed that the catheter flush was missed 20 times. The facility's policy on providing physician-ordered services emphasizes adherence to professional standards, which was not met in this case. The Administrator confirmed that it is expected for physician orders to be followed as prescribed.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
