Salem Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Elk Horn, Iowa.
- Location
- 2027 College Avenue, Elk Horn, Iowa 51531
- CMS Provider Number
- 165155
- Inspections on file
- 27
- Latest survey
- December 15, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Salem Lutheran Home during CMS and state inspections, most recent first.
A nurse failed to provide dignity and respect to a resident during a smoking-related incident, where the resident was yelled at by an LPN for being outside with staff. The resident, who was cognitively intact, felt upset and disrespected by the interaction. Staff interviews revealed confusion about the facility's smoking policy and property boundaries, and administrative staff provided inconsistent information. The incident was not formally investigated or documented, and the facility's policy on resident dignity was not upheld.
Two residents requiring assistance with bathing did not consistently receive opportunities for baths or showers as scheduled, with missed baths often attributed to staffing shortages and inadequate documentation of refusals. Staff interviews confirmed that residents sometimes went several days without bathing, and there was no facility policy specifying bathing frequency.
A resident with significant cognitive and medical impairments was reported by family to be missing valuable personal items, including rings, which were documented on the admission inventory. Despite facility policy requiring updated inventories and replacement of lost items, the property was not found or replaced, and inventory records were not kept current.
A background check for an LPN was not completed before employment, contrary to facility policy requiring such checks to prevent abuse, neglect, and theft. The oversight was confirmed by both Human Resources and the DON during interviews.
Two residents with newly identified or possible serious mental disorders or related conditions were not referred for a Level II PASRR evaluation after initially receiving a negative Level I screen. Both residents had new or existing diagnoses and were receiving psychotropic medications, but the required referral to the state-designated authority for further assessment was not completed, as confirmed by staff and documentation review.
Two residents requiring oxygen therapy did not have their oxygen tubing changed and documented according to facility policy and professional standards. Staff and the DON confirmed tubing should be changed weekly, but observations found outdated or undated tubing and no documentation to verify changes were completed.
Staff failed to follow infection prevention and control protocols during care for two residents with indwelling devices and wounds. A CNA did not perform hand hygiene or clean the catheter drainage port before emptying a drainage bag, while an LPN inconsistently used hand hygiene and PPE during wound care, did not maintain clean technique, and failed to date dressings. Facility policies required hand hygiene and Enhanced Barrier Precautions, but these were not consistently followed, as confirmed by the IP and DON.
A resident with moderate cognitive impairment and significant care needs reported being left on a bed pan for several hours without a call light and later experiencing disrespectful care from a CNA, who was suspected of being under the influence. The incident was not documented in the EHR, not investigated, and not reported to the State Agency as required by facility policy, despite management being aware of the allegation.
A resident with moderate cognitive impairment and total dependence on staff for toileting was left on a bed pan for five hours without a call light, resulting in pain and distress. The event was not documented in the EHR, and no follow-up assessments were performed.
A facility failed to ensure proper medication administration, affecting several residents. One resident did not receive all prescribed medications, while another received clonazepam late. A third resident's pulse was not checked before medication administration due to a pacemaker. An RN improperly disposed of medications in a sharps container, affecting 16 residents. The facility's medication administration policy was not followed.
A resident's Ozempic pen was misappropriated in an LTC facility, leading to a delay in medication administration. The resident, with no cognitive impairment, was on diabetic therapy. An agency RN was seen on camera handling the pen inappropriately, which was not accounted for afterward. Staff interviews confirmed the pen should not have been handled during the overnight shift. The facility's policy on preventing misappropriation of resident property was violated.
A staff member failed to maintain sanitary practices during food service by using the same tongs for multiple tasks, placing butter packets directly on food, and handling food without proper hand hygiene. These actions violated the facility's food handling policy.
The facility failed to properly prepare and serve the appropriate portions of pureed and minced & moist diets for residents. Staff did not adhere to specified portion sizes, using a volume method instead of the required alternate texture conversion chart. This resulted in incorrect portion sizes being served, failing to meet the nutritional needs of residents.
The facility failed to protect resident information from unauthorized access. An open laptop screen with resident EHR information and a sheet with resident details were left visible. A CNA noted this was not usual practice, and an RN used the sheet as a 'cheat sheet.' The facility's policy requires strict adherence to confidentiality and HIPAA regulations.
The facility failed to ensure proper hand hygiene and catheter care for residents. A CNA did not perform hand hygiene during toileting and catheter care, and placed a measuring container directly on the floor. Another CNA failed to perform hand hygiene between feeding two residents. Additionally, a catheter drainage bag was improperly managed, and hand hygiene was not performed during catheter care, violating facility policies.
A facility failed to provide a bed hold notice to a resident or their representative during a hospital transfer. The resident was discharged with return anticipated, but the required documentation was missing. The facility's policy mandates providing a state-specific form at discharge, which was not completed, as confirmed by the Administrator and DON.
A facility failed to complete a PASRR for a resident diagnosed with new mental disorders during their stay. Initially, the resident showed no evidence of serious mental illness, but later developed unspecified paranoia, leading to increased medication. Despite policy requirements, the facility did not conduct a new PASRR, and staff interviews revealed a lack of awareness of PASRR regulations.
The facility failed to create comprehensive care plans for three residents, each with cognitive impairments and on psychotropic medications. The care plans did not include target behaviors for medication monitoring, contrary to facility policy requiring individualized plans with measurable goals.
The facility failed to update care plans for three residents, leading to discrepancies in the documented and actual care provided. One resident required a mechanical lift for transfers post-procedure, but the care plan did not reflect this need. Another resident with Alzheimer's had inconsistent fall intervention documentation, and a third resident's care plan lacked reference to necessary edema wear. Staff were aware of these needs through informal notes, but the care plans were not updated accordingly.
A resident with COPD and other medical conditions was observed receiving oxygen at 4 LPM, contrary to the physician's order of 2 LPM during the day and 3 LPM at night. The facility's policy and care plan directed staff to follow the physician's orders, but this was not adhered to, as confirmed by the MAR and observations. The DON acknowledged the need to follow the physician's orders.
The facility failed to identify target behaviors for psychotropic medication use for two residents with severely impaired cognition and multiple diagnoses. Both residents were prescribed various psychotropic medications without specified target behaviors in the physician orders or care plans. Additionally, the facility lacked a policy on psychotropic medications or Gradual Dose Reductions (GDRs).
The facility failed to provide adequate nursing staff, resulting in delayed call light responses for two residents. One resident experienced a 47-minute delay, while another had a 21-minute delay. Staff and the Administrator confirmed frequent staffing shortages and delayed responses.
The facility failed to follow proper infection prevention practices during blood sugar monitoring for three residents with type 2 diabetes mellitus. Staff did not perform hand hygiene before and after procedures, and one staff member used a dropped lancet.
Failure to Maintain Resident Dignity During Smoking Incident
Penalty
Summary
A deficiency occurred when a nurse failed to provide dignity and respect to a resident during an incident involving smoking outside the facility. The resident, who had no cognitive impairment as indicated by a BIMS score of 15, requested to be taken outside to smoke. Staff members, including CNAs, assisted the resident outside, which led to a confrontation with an LPN. The LPN went outside and yelled at the resident and the staff, telling them that staff were not allowed to take residents outside to smoke. The resident reported feeling upset and stated that the nurse did not treat her with dignity or respect during the incident. The resident also expressed feeling bad for being the reason staff were yelled at and noted that some staff treated her well while others did not. Interviews with staff revealed confusion and inconsistency regarding the facility's smoking policy. Staff A, a CNA, stated that she was written up for taking the resident outside but the write-up was later destroyed due to conflicting policies. Staff B, another CNA, confirmed the incident and described the LPN as using a stern and unfriendly tone, which upset the resident. Both CNAs indicated uncertainty about the rules for staff assisting residents with smoking and whether the sidewalk was considered facility property. The LPN involved admitted to being loud and stern but denied yelling at the resident, stating her intent was to enforce facility rules. Administrative staff, including the DON and Administrator, provided conflicting information about the smoking policy and property boundaries. The DON stated that staff were not to take residents outside to smoke, but acknowledged this was not specified in the written policy. The Administrator confirmed that the sidewalk was not facility property and that only non-employee friends or family could assist the resident with smoking outside. There was no formal written investigation or documentation of the incident, and the DON did not speak directly to the resident about the event. The facility's policy on resident dignity emphasized maintaining respect and self-worth, but the actions during this incident did not align with those standards.
Failure to Consistently Provide Bathing Opportunities Due to Staffing and Documentation Issues
Penalty
Summary
The facility failed to assist residents with activities of daily living by not consistently offering or providing opportunities for bathing to two of three residents reviewed. One resident, with diagnoses including arthritis, anxiety disorder, bipolar disorder, COPD, and fibromyalgia, required moderate to total assistance with personal hygiene and toileting. Despite being cognitively intact, this resident and their family reported that staff would ask about bathing preferences but would not return, later documenting refusals that did not occur. Electronic health records showed inconsistent bathing frequency, with some months showing only a few baths and refusals not always documented in progress notes. Another resident, also cognitively intact and requiring maximal assistance with bathing, reported receiving baths 2-3 times a week but noted that if a bath was missed, it was sometimes not rescheduled promptly. Documentation for this resident also showed irregular bathing schedules and lacked consistent refusal documentation. Staff interviews revealed that residents were expected to be bathed twice a week, but missed baths were common due to staffing shortages, with staff sometimes moving baths to the next day or relying on medication aides for assistance. Staff also indicated that refusals should be documented in progress notes and communicated to nurses, but this was not always done. Multiple staff members acknowledged that it was not uncommon for residents to go several days without bathing due to call-ins and short staffing. Review of facility policy found no written policy regarding the frequency of bathing.
Failure to Protect Resident's Personal Property from Loss
Penalty
Summary
A resident with progressive neurological conditions, cancer, non-Alzheimer's dementia, depression, and altered mental status was found to be missing personal property, specifically a wedding ring and a birthstone ring. The resident was unable to participate in interviews due to cognitive impairment, and the loss was reported by a family member. The facility's records included an inventory of personal effects from admission, which listed a ring and a watch, but there was no evidence that the inventory had been updated or that the missing items were replaced. The family reported the missing items to the facility, and documentation showed that Social Services was informed and discussed the matter with the Administrator. Despite the facility's policy requiring inventories to be completed at admission and updated as new items are acquired, staff interviews revealed that the inventory sheets were not kept current. The Social Services staff confirmed that a grievance was filed and the items were never found or replaced. The DON stated that inventory sheets should be accurate and updated, and that lost items should be replaced, but this did not occur in this case. The facility failed to protect the resident's personal property from loss or theft, as required.
Failure to Complete Background Check Prior to Staff Employment
Penalty
Summary
The facility failed to implement its abuse and neglect policy by not completing a required background check prior to the employment of one staff member, an LPN. Review of the personnel file showed that the background check for this staff member was completed several months after the hire date. During interviews, both the Human Resources staff and the Director of Nursing confirmed that the background check was not performed before the staff member began working. The facility's policy prohibits employing individuals with findings of abuse, neglect, exploitation, or misappropriation of property, and requires background checks prior to employment to ensure compliance.
Failure to Refer Residents for Level II PASRR Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer two residents, who were initially screened as negative for serious mental disorder, intellectual disability, or related conditions through the Level I Pre-admission Screening and Resident Review (PASRR), for a Level II PASRR evaluation after new or possible mental health diagnoses became evident. For one resident, the Minimum Data Set (MDS) indicated the use of multiple high-risk psychotropic medications and documented diagnoses including psychological insomnia, major depressive disorder, schizotypical disorder, and anxiety disorder. Despite these findings, there was no evidence in the electronic health record (EHR) of a Level II PASRR evaluation since admission, which was confirmed by the Director of Nursing (DON). Another resident's MDS showed intact cognition but included diagnoses of progressive neurological conditions, anxiety disorder, depression, psychotic disorder, and non-Alzheimer's dementia. The initial PASRR Level I screen did not identify active psychosis or hallucinations, but subsequent EHR documentation revealed new diagnoses of major depressive disorder, unspecified psychosis, and visual hallucinations. Staff interviews confirmed that a new PASRR should have been completed following these new diagnoses, in accordance with facility policy, but this was not done.
Failure to Change and Document Oxygen Tubing per Policy
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for two residents who required oxygen therapy. For one resident with intact cognition and an order for oxygen at night, the oxygen tubing was observed to be dated over two months prior, and the humidification bottle was also outdated. The resident was unsure how often the tubing was changed. Staff interviews revealed that oxygen tubing was supposed to be changed weekly on Wednesdays, as indicated in a master schedule and facility policy, but there were no sign-off sheets or documentation to confirm that this was being done. The Director of Nursing confirmed the expectation for weekly changes, and the facility policy required disposable equipment to be changed weekly and marked with the date and initials. For another resident with multiple diagnoses including heart failure and shortness of breath, the care plan identified oxygen therapy as needed, but the medication administration record did not include orders or instructions for changing the oxygen tubing. Observations on two consecutive days found the resident's oxygen tubing undated. A physician order to change and label the tubing weekly was only written after these observations. These findings demonstrate that the facility did not ensure oxygen equipment was changed and documented according to policy and professional standards for residents requiring oxygen therapy.
Failure to Implement Infection Control and Hand Hygiene Practices During Resident Care
Penalty
Summary
Staff failed to implement appropriate infection prevention and control practices during care for two residents with indwelling medical devices and wounds. For one resident with an indwelling catheter, a CNA donned gown and gloves without performing hand hygiene, placed a urine graduate on a barrier on the floor, and emptied the catheter drainage bag without cleaning the drainage port beforehand. The drainage port was only cleansed with an alcohol wipe after the bag was emptied, and the CNA left the room without performing hand hygiene. Both the Infection Preventionist and the Director of Nursing confirmed that hand hygiene should be completed and Enhanced Barrier Precautions (EBP) should be used at appropriate times during catheter and wound care, as outlined in facility policy. Another resident with multiple chronic conditions, including venous and arterial ulcers, required frequent wound care to both lower extremities. During wound care, an LPN demonstrated inconsistent hand hygiene, such as removing gloves and donning new ones without hand hygiene, and did not always use a gown when applying dressings to the buttocks. The LPN also failed to maintain a clean and dirty environment, placing opened bandages on her lap and under her arm, and continued to use supplies that had fallen on the floor without changing gloves or performing hand hygiene. Dressings were not dated, and the LPN was observed to request assistance from the Infection Preventionist, who had to don PPE to assist. Facility policies required adherence to the 4 Moments of Hand Hygiene and the use of EBP for residents with indwelling devices or wounds, including the use of gloves and gowns during high-contact care activities. Observations and interviews revealed that staff did not consistently follow these protocols, leading to lapses in infection control practices for both residents. The Director of Nursing and Infection Preventionist acknowledged these deficiencies, noting failures in hand hygiene, PPE use, and maintenance of clean and dirty technique during resident care.
Failure to Investigate and Report Alleged Resident Mistreatment
Penalty
Summary
The facility failed to investigate and report an alleged incident of mistreatment involving a resident with moderate cognitive impairment and significant physical dependencies. The resident, who had a history of cerebrovascular accident, hemiplegia, and diabetes, reported that a CNA left her on a bed pan for five hours without access to a call light and later acted disrespectfully and possibly under the influence while providing care. The resident did not initially report the incident to management due to fear but did inform a nurse, who later became the DON, and was told that steps would be taken. A review of the resident's electronic health record did not show any documentation of the incident or any assessments of the resident's cognitive or physical condition following the alleged event. Additionally, there was no record of the incident being reported to the State Agency as required. The DON, who had recently assumed her position, confirmed that the previous administration was aware of the incident, as it was discussed in management meetings, but no investigation or report to the State Agency was completed. Facility policy requires immediate reporting and investigation of alleged abuse, neglect, or mistreatment, including notification of designated agencies within specified timeframes. Despite these policies, the facility did not follow through with the required investigation or reporting procedures in this case, and the staff member involved was later terminated for unrelated reasons. The lack of timely investigation and reporting constituted a failure to comply with regulatory requirements for protecting residents from abuse and ensuring proper oversight.
Failure to Provide Timely Toileting Assistance and Documentation
Penalty
Summary
A resident with moderate cognitive impairment, a history of cerebrovascular accident, hemiplegia, and diabetes mellitus, was left on a bed pan for five hours without access to a call light. The resident was totally dependent on staff for toilet transfers and hygiene. During this period, the resident experienced significant pain and distress, and no staff checked on her throughout the night. The resident eventually located a call light in a drawer and used it to summon assistance. The incident was not documented in the resident's electronic health record, and there were no assessments recorded regarding the resident's cognitive or physical condition following the event. The Director of Nursing confirmed awareness of the incident and acknowledged the lack of documentation and assessment in the health record.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that staff followed professional standards while administering medications to residents, as evidenced by multiple incidents involving four residents. Resident #3, who had no cognitive impairment, expressed uncertainty about whether her medications were being administered as ordered. She had recently been hospitalized for heart failure and required increased oxygen. Resident #4 reported an incident where she did not receive all her medications as ordered, and Staff A, a registered nurse, failed to provide her with the complete set of medications, including her blood pressure medication. Resident #5, also with no cognitive impairment, stated that she did not receive all her medications on one occasion, specifically mentioning that her clonazepam was administered late. She also heard other residents complaining about similar issues. Resident #6 reported that Staff A did not check her pulse as required before administering her medications, which were given late in the afternoon instead of in the morning. This was particularly concerning due to her pacemaker and the need for accurate pulse readings before starting her day. The facility's investigation revealed that Staff A had disposed of medications improperly by placing them in the sharps container. Staff E, another registered nurse, discovered multiple pills in the sharps container and reported the issue to the Director of Nursing. The investigation identified that 16 residents' medications were found in the sharps container, and Staff A admitted to disposing of medications improperly. The facility's policy on medication administration was not followed, leading to the deficiency in medication management.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to protect a resident from financial exploitation, specifically regarding the misappropriation of an Ozempic pen, which is a medication used for diabetes management. The resident, who had a BIMS score of 15 indicating no cognitive impairment, was diagnosed with several conditions including diabetes mellitus and was on diabetic therapy. The resident's Ozempic pen, which had a significant co-pay cost, was reported missing after being delivered to the facility. The incident involved Staff D, an agency RN, who was captured on facility camera footage handling the Ozempic pen inappropriately. The footage showed Staff D entering the medication room, removing the Ozempic pen from the refrigerator, and placing it in her pocket. Despite her claims of restocking insulin pens as instructed by the off-going nurse, the footage and subsequent investigation revealed that the Ozempic pen was not accounted for, leading to a delay in the resident's medication schedule. Interviews with facility staff and the resident confirmed the misappropriation of the Ozempic pen. Staff members stated that the pen should not have been handled during the overnight shift as it is administered weekly. The resident acknowledged a delay in receiving her medication due to the missing pen but reported no further issues after the incident. The facility's policy on abuse and neglect, which includes the right of residents to be free from misappropriation of property, was not adhered to in this case.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to maintain sanitary practices during food service, leading to potential cross-contamination. During an observation, a staff member used the same tongs to handle both plastic wrap and food items, such as rolls, and also used the tongs to remove aluminum foil from a casserole pan. Additionally, the staff member placed butter packets directly onto residents' plates, allowing them to touch the food. The staff member also placed her hand on the steam table counter and then used food scissors to cut meat for residents without performing hand hygiene. Furthermore, she moved pans around the steam table area and continued serving food without washing her hands. These actions were contrary to the facility's policy on food handling, which requires the use of proper utensils and single-use gloves.
Failure to Properly Prepare and Serve Diet Portions
Penalty
Summary
The facility failed to properly prepare and serve the appropriate portions of pureed and minced & moist diets for residents, as observed during a lunch service. The lunch menu specified certain portion sizes for pureed and minced & moist diets, but staff did not adhere to these specifications. Staff I, the cook, prepared minced & moist diets by mincing pork chops with chicken broth without measuring the contents, and similarly, pureed pork chops were prepared without accurate measurement. Additionally, pureed carrots and minced peaches were also prepared without proper measurement, leading to incorrect portion sizes being served. The facility's dietary staff used a volume method for portioning instead of the alternate texture conversion chart, which was not followed as per the facility's policy. The Dietary Manager confirmed that the staff used the volume method, and Staff I admitted to not measuring the minced & moist meat. The policy on portion control indicated the use of a specific disher size for portioning, which was not adhered to during the preparation and serving of meals. This resulted in the failure to meet the nutritional needs of residents on pureed and minced & moist diets, as the appropriate serving sizes were not determined or provided.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to protect resident information from unauthorized access, as observed during a survey. An open laptop screen displaying resident Electronic Health Record (EHR) information was left unattended, and a sheet containing resident names, room numbers, blood glucose results, and insulin information was found face-up on a cart. Staff D, a Certified Nurse Aide (CNA), acknowledged that the information is usually not left visible and that the screen is typically locked. Staff F, a Registered Nurse (RN), admitted to using the sheet as a 'cheat sheet' to avoid forgetting the information. The facility's confidentiality policy, revised in May 2024, mandates that individuals with access to confidential information must handle it in accordance with legal and regulatory requirements. The Administrator confirmed that staff should adhere to Health Insurance Portability and Accountability Act (HIPAA) policies.
Inadequate Hand Hygiene and Catheter Care
Penalty
Summary
The facility failed to provide proper hand hygiene during toileting and urinary catheter care for two residents. During an observation, a Certified Nursing Assistant (CNA) assisted a resident to the bathroom, removed soiled gloves, and failed to perform hand hygiene before donning new gloves. The CNA also placed a graduated measuring container directly on the floor, contrary to the facility's catheter policy, which requires a barrier between the container and the floor. The facility's Personal Protective Equipment (PPE) policy was not followed, as the CNA did not perform hand hygiene after removing gloves. In another instance, a CNA assisted two residents with eating lunch and failed to perform hand hygiene between feeding the residents. The CNA used the same hand to wipe one resident's mouth and then handled the other resident's utensils without performing hand hygiene. This action was against the facility's hand hygiene policy, which mandates maintaining adequate hand hygiene by adhering to specific infection control practices. Additionally, the facility failed to properly manage an indwelling catheter for a resident. The catheter drainage bag was observed hanging on the side of the resident's trash can, which is not in accordance with proper catheter care procedures. During catheter and peri-care, a CNA did not perform hand hygiene throughout the procedure, despite handling the resident and catheter equipment. The facility's catheter care policy requires hand hygiene between resident contact and catheter care, which was not adhered to in this instance.
Failure to Provide Bed Hold Notice for Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative when the resident was transferred to a hospital. This deficiency was identified during a review of clinical records, resident interviews, and facility policy. Specifically, the Minimum Data Set (MDS) assessment for the resident documented a discharge with return anticipated, but the facility did not complete the required bed hold notice for the hospital admission. The resident was admitted to the hospital and returned to the facility two days later, yet the clinical record lacked documentation of the bed hold notice. The facility's bed hold policy, last reviewed in December 2024, mandates that a state-specific form be provided at the time of discharge, detailing the duration of the bed hold policy. However, this procedure was not followed in this instance, as confirmed by the Administrator and Director of Nursing during an interview.
Failure to Complete PASRR for Resident with New Mental Disorder Diagnoses
Penalty
Summary
The facility failed to complete a Pre-Admission Screening and Resident Review (PASRR) for a resident who was diagnosed with new mental disorder diagnoses since admission. The resident, identified as Resident #20, had a Minimum Data Set (MDS) assessment indicating no cognitive deficit and was diagnosed with anxiety disorder, depression, and psychotic disorder. Initially, a PASRR Level I Screen Outcome indicated no evidence of a serious mental illness or intellectual or developmental disability requiring PASRR intervention. However, during the resident's stay, a psychiatrist added a new diagnosis of unspecified paranoia and increased the resident's medication for hallucinations and paranoia. Despite these changes, the facility did not conduct a new PASRR as required by their policy, which mandates contacting the designated state agency for a Level II screening if a resident is diagnosed with a mental disorder while in the facility. Staff interviews revealed a lack of awareness and understanding of PASRR regulations, with the Social Services staff indicating that a new PASRR would be completed if there were a change in behaviors, and the Administrator admitting limited knowledge of PASRR requirements beyond the initial admission screening.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a resident-centered comprehensive care plan for three residents, as identified during a survey. For Resident #5, the quarterly Minimum Data Set (MDS) assessment indicated moderately impaired cognition and several diagnoses, including cancer and non-Alzheimer's dementia. The resident required varying levels of assistance with activities of daily living (ADLs) and was on antipsychotic and antidepressant medications. However, the care plan did not include the target behaviors for these medications, which are essential for staff monitoring. Similarly, Resident #18, with severely impaired cognition and multiple diagnoses such as anxiety and schizotypal disorder, was on several psychotropic medications. The care plan included some behaviors but failed to specify target behaviors for all medications. Resident #39, also with severely impaired cognition, was on antidepressant and antianxiety medications, but the care plan lacked target behaviors for staff to monitor. The facility's policy required individualized, comprehensive care plans with measurable goals, which were not met in these cases.
Failure to Update Care Plans for Resident Needs
Penalty
Summary
The facility failed to update and revise care plans to reflect the current transfer needs and interventions for three residents. Resident #24, who had undergone a Kyphoplasty procedure due to a compression fracture, required the use of a mechanical lift for transfers. However, the care plan inaccurately instructed staff to use a forward wheeled walker and assist of one person during the day, and a non-mechanical stand aide at night. This discrepancy was noted despite the resident's clear need for a mechanical lift, as observed and reported by the resident and staff. Resident #42, diagnosed with Alzheimer's disease and severe cognitive impairment, required complete dependence on staff for mobility and positioning. Observations showed the resident in a tilt-in-space wheelchair and a low wide bed with fall interventions such as a fall mat and call light. However, staff interviews revealed inconsistencies in awareness and implementation of these interventions, with some staff unaware of all necessary fall precautions, indicating a lack of proper communication and updates in the care plan. Resident #16, with severe cognitive impairment and a diagnosis of unspecified dementia, required the use of a wheelchair and wore edema wear for bilateral lower extremities. Despite this, the care plan did not reference the use of edema wear, although staff were aware of its necessity through quick notes at the nurses' station. The Director of Nursing acknowledged the mismatch between the care plans and the quick notes, indicating a failure to update the care plans to reflect the current interventions required for the resident.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that physician's orders for oxygen therapy were followed for a resident with multiple medical conditions, including COPD, Atrial Fibrillation, Chronic Kidney Disease, Heart Failure, and deep venous thrombosis. The resident, who had intact cognition, was observed receiving oxygen at a flow rate of 4 liters per minute, contrary to the physician's order of 2 liters per minute during the day and 3 liters per minute at night. This discrepancy was noted during an observation on August 9, 2024, and was confirmed by the Medication Administration Record for the same date. The facility's policy on oxygen administration, revised in July 2024, instructed staff to adjust the oxygen concentrator's flow rate according to the physician's orders. However, the resident's care plan, which was revised on August 9, 2024, also directed staff to provide oxygen therapy per the physician's order, yet the correct flow rate was not maintained. The Director of Nursing acknowledged that staff should adhere to the physician's orders, indicating a lapse in following established protocols for oxygen administration.
Failure to Identify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to identify target behaviors for the use of psychotropic medications for two residents, leading to a deficiency. Resident #18, with severely impaired cognition and multiple diagnoses including anxiety, depression, and schizotypal disorder, was prescribed several psychotropic medications such as Abilify, Trazodone, Duloxetine, Seroquel, and Buspirone. However, the physician orders did not specify target behaviors for these medications, and the care plan only mentioned 'hollering out' as a behavior without detailing target behaviors for the other medications. Similarly, Resident #39, also with severely impaired cognition and diagnosed with anxiety, depression, and adjustment disorder, was prescribed medications including Bupropion, Clonazepam, Hydroxyzine, and Venlafaxine. The physician orders for these medications also lacked specified target behaviors, and the care plan did not include target behaviors for staff to monitor. Additionally, the facility did not provide a policy regarding psychotropic medications or Gradual Dose Reductions (GDRs), and the Director of Nursing acknowledged that CMS guidelines should be followed.
Failure to Provide Adequate Nursing Staff for Timely Call Light Response
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely responses to call lights, compromising resident safety. Resident #9, who has no cognitive impairment and is frequently incontinent, reported that staff often took longer than 15 minutes to respond to her call light. On one occasion, the call light log showed a response time of 47 minutes and 59 seconds. Video footage confirmed that no staff entered Resident #9's room for 30 minutes after the call light was activated. Staff interviews corroborated the issue, with multiple staff members stating that they often worked short-staffed and that call lights frequently took longer than 15 minutes to be answered, particularly on the morning in question. Resident #10, who also has intact cognition and requires assistance with toileting, reported that call lights often took longer than 15 minutes to be answered, especially during evening and overnight shifts. The call light log showed a response time of 21 minutes and 7 seconds for Resident #10 on a specific date. The facility's policy mandates that call lights be answered promptly, ideally within 15 minutes. The Administrator acknowledged that call lights had exceeded the 15-minute response time on several occasions over the past month, indicating a systemic issue with staffing levels and response times.
Infection Prevention Deficiency During Blood Sugar Monitoring
Penalty
Summary
The facility failed to provide appropriate infection prevention practices during blood sugar monitoring for three residents. Resident #4, who had a diagnosis of type 2 diabetes mellitus, was observed being pushed into an unoccupied room by Staff C. Staff C applied gloves without completing hand hygiene, handled various items including the blood glucose machine and insulin, and administered insulin without performing hand hygiene before or after the procedure. Staff C also failed to perform hand hygiene before administering medication to another resident immediately afterward. Resident #5, also diagnosed with type 2 diabetes mellitus, was observed by Staff D who applied gloves without hand hygiene before performing blood glucose monitoring. Staff D left the room to complete hand hygiene only after the procedure. Similarly, Resident #6, with the same diagnosis, was attended to by Staff C who did not perform hand hygiene before applying gloves and continued to use a lancet that had been dropped on the ground. Staff C then administered insulin without proper hand hygiene. The facility's policy required hand hygiene before and after entering a resident's room, before clean tasks, after glove removal, and before and after medication administration. The Administrator confirmed that the facility's expectation was for hand hygiene to be completed as per the policy.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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