Southeast Iowa Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Keokuk, Iowa.
- Location
- 3140 Plank Road, Keokuk, Iowa 52632
- CMS Provider Number
- 165797
- Inspections on file
- 16
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Southeast Iowa Healthcare Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, whose personal funds were managed by the facility, did not receive required quarterly trust fund statements. The administrative assistant responsible for resident fund accounts reported that quarterly statements were not routinely provided and were only printed upon request, without tracking which residents received them. Facility records showed dozens of residents had personal accounts managed by the facility, and policy required quarterly trust fund statements to be available to residents or their legal representatives.
The facility failed to ensure accurate MDS assessments for two residents when the MDS Coordinator coded weekly Trulicity (dulaglutide) injections as insulin administration and documented invasive mechanical ventilator use for a resident who only had orders for CPAP therapy. Review of care plans and active orders showed no insulin or invasive ventilator orders, while care plan entries for one resident incorrectly stated that the resident received insulin injections. Staff interviews confirmed that Trulicity is not insulin and that no residents used invasive mechanical ventilators, demonstrating that the MDS documentation did not reflect the residents’ actual treatments or physician orders.
A resident with diabetes receiving daily Admelog insulin via pen was given insulin in a manner inconsistent with manufacturer instructions when an LPN withdrew insulin from the pen using an insulin syringe instead of a pen needle and then injected it subcutaneously. Staff reported they had been trained to draw insulin from the pen with a syringe, citing cost and safety concerns with pen needles. The RN and DON confirmed this practice for the resident’s insulin pen, and the DON stated a preference for vials. Manufacturer directions for the Admelog Solostar pen specifically prohibit using a syringe to remove insulin, and the facility’s insulin policy did not address adherence to manufacturer instructions.
A resident with schizophrenia, DM2, COPD, moderate cognitive impairment, and mobility limitations required assistance with ADLs, including hygiene. Surveyors observed the resident with long, jagged fingernails with debris underneath and long, jagged toenails. The resident reported staff did not trim his nails and that no podiatrist or physician had done so. Although the record contained a physician order for annual podiatry care due to diabetes, there was no documentation that podiatry services were provided. An RN stated nursing staff perform nail care and diabetic residents are usually referred to podiatry, and a CNA reported she typically alerts nurses and marks the shower sheet when nail care is needed but may not have done so for this resident. The DON confirmed the shower sheet indicated no nail care was needed and that the resident had not been scheduled with podiatry, despite facility policy requiring annual podiatry visits for diabetic residents’ toenail and foot care.
Two residents experienced multiple episodes of three or more days without a bowel movement during which staff did not consistently implement the facility’s bowel protocol or PRN constipation orders. One cognitively intact resident with diagnoses including GERD, functional dyspepsia, and constipation reported going several days without a BM, requesting medication, and not receiving it, despite PRN orders for Milk of Magnesia, Miralax, and a bisacodyl suppository and no constipation problem addressed in the care plan. Another resident with severe cognitive impairment and chronic constipation, care planned to follow the bowel protocol and with PRN orders for bisacodyl tablets, suppositories, and enemas, had several days without documented BMs and received an enema without evidence of earlier stepwise interventions, and later had another multi-day period without a BM with no documented PRN use. Staff and DON interviews confirmed the existence of a bowel protocol and tracking process but could not explain the lack of timely interventions.
A resident with severe cognitive impairment, incontinence, and orders for daily coccyx and mid-back wound care received treatment from an RN who did not perform required hand hygiene between glove changes or between care of different wound sites. After providing perineal care for a bowel movement and removing soiled gloves, the RN donned new gloves without hand hygiene to apply Calmoseptine to the coccyx wound and complete brief care, then again changed gloves without hand hygiene before cleansing and redressing a mid-back wound with blood-tinged drainage using wound cleanser, gauze, skin prep, Calcium Alginate, and Mepilex. Facility policies and staff interviews confirmed that hand hygiene is required after removing gloves, after contact with body fluids, and between wounds, which was not followed during this observed procedure.
Failure to Provide Quarterly Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide required quarterly personal account statements to a resident whose funds were managed by the facility. Clinical record review showed that Resident #1 was admitted on 12/30/24 and had a BIMS score of 11/15 on the 12/18/25 MDS, indicating moderate cognitive impairment. During an interview, Resident #1 stated the facility assisted with managing her money and reported she had not received a quarterly statement, nor had she requested one. A review of the facility’s list of resident personal accounts showed 46 residents, including Resident #1, had funds managed by the facility. In an interview, the Administrative Assistant, who was responsible for maintaining resident fund accounts, reported that she did not provide quarterly account statements to residents. She stated she only printed statements when residents or their representatives asked and did not track which residents had received statements. She confirmed that Resident #1 had not received a quarterly statement and would only receive one upon request. Review of the facility’s “Resident Trust Fund” policy, dated 10/17/25, revealed that quarterly statements regarding resident trust funds were to be available to the resident and/or the legal resident representative, which was not being done for Resident #1.
Inaccurate MDS Coding for Ventilator Use and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) quarterly assessments accurately reflected the current clinical status and treatment orders for two residents. For one resident, the MDS dated 10/16/25 documented use of an invasive mechanical ventilator under Section O (Special Treatments, Procedures, and Programs) and receipt of insulin injections on one of seven days in the look-back period under Section N (Medications – Insulin). However, the resident’s active orders as of 1/07/25 showed only a weekly Trulicity (dulaglutide) subcutaneous injection for type 2 diabetes mellitus and nightly CPAP for obstructive sleep apnea, with no orders for an invasive mechanical ventilator or insulin administration. The resident’s care plan, revised on 10/21/25, also lacked any indication of invasive mechanical ventilator use or insulin injections. For the second resident, the MDS quarterly assessment dated 10/23/25 documented insulin injections on one of seven days in the look-back period, and the care plan included a focus area for diabetes mellitus with interventions stating that the resident received insulin injections and that staff could administer insulin and check blood sugars in various locations. Review of active orders as of 1/07/25 showed weekly Trulicity (dulaglutide) injections and daily oral Tradjenta (linagliptin) for type 2 diabetes mellitus, with no orders for insulin administration. Staff interviews confirmed that Trulicity had been incorrectly coded as insulin on the MDS for both residents and that the facility had no residents with invasive mechanical ventilators, indicating that the MDS entries did not follow the facility’s MDS Assessments policy or the RAI guidelines referenced therein.
Improper Insulin Pen Use Contrary to Manufacturer Instructions
Penalty
Summary
Facility nursing staff failed to follow manufacturer instructions for administration of Admelog Solostar insulin, resulting in insulin being withdrawn from an insulin pen using a syringe rather than the manufacturer-approved pen needle. Resident #15, who had intact cognition with a BIMS score of 14 and a diagnosis of diabetes mellitus, had a physician order for Admelog U-100 insulin, 6 units subcutaneously with meals, and received insulin injections daily. During observation, Staff D, an LPN, prepared the resident’s lunch insulin by wiping the insulin pen hub with an alcohol pad and inserting an insulin syringe into the pen to withdraw 6 units, instead of attaching and using a pen needle as directed by the manufacturer. Staff D then checked the resident’s blood glucose, which was 140 mg/dL, and administered the insulin into the resident’s right arm. In interviews, Staff D stated they did not use the pen needles because of cost and reported being trained at hire to draw insulin from the pen with a syringe. Staff A, an RN, reported also drawing insulin from the pen into a syringe, stating it was safer than using the non-safety pen needle and believed this resident was the only one prescribed an insulin pen. The DON confirmed that Resident #15 was the only resident using an insulin pen, expressed a preference for vials due to perceived lower risk of error, and stated they knew the resident received the correct insulin and did not think there was an issue with drawing insulin from the pen using a syringe. Manufacturer instructions for the Admelog Solostar pen explicitly stated not to use a syringe to remove insulin from the pen, and the facility’s Insulin Preparation and Administration Policy did not address following manufacturer instructions for insulin administration.
Failure to Provide Required Nail and Podiatry Care for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary assistance with nail care for a resident who required help with activities of daily living. The resident had moderate cognitive impairment, schizophrenia, diabetes mellitus type 2, and COPD, and used a wheelchair and walker for mobility. The MDS indicated the resident required partial to moderate staff assistance for showering and setup assistance for eating and oral hygiene, and the care plan stated the resident was independent with ADLs but should be assisted as needed. During observation, the resident was seen at the nurse’s station with long, jagged fingernails and a brown-like substance under some nails. In an interview, the resident reported that staff did not trim his fingernails, stated they needed to be done, and further reported that his toenails were worse. When the resident removed his socks, his toenails were observed to be long and jagged. The resident stated nursing staff did not cut or trim his toenails and denied that a podiatrist or other physician had trimmed them. The clinical record contained a physician order for an annual podiatry visit for diabetic foot care, but there was no documentation that podiatry care had been provided. An RN stated that nursing staff trimmed and filed residents’ nails and that diabetic residents were usually referred to a podiatrist for toenail care, and reported having trimmed the resident’s fingernails in the past but never his toenails, with no known refusals. A CNA, who provided the resident’s showers and bed baths, stated she would normally notify nurses and mark the shower sheet if nail care was needed and thought she had indicated this for the resident but may not have due to being busy. The DON reviewed the shower sheet and confirmed it documented that the resident did not need nail care and that the resident, a diabetic, had not been scheduled with the facility’s podiatrist, despite facility policy requiring diabetic residents to see a podiatrist at least annually for toenail and/or foot care.
Failure to Implement Bowel Protocol and PRN Constipation Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide timely constipation interventions according to physician orders, the bowel protocol, and resident preferences for two residents who went three or more days without a bowel movement (BM). One resident with intact cognition, continent bowel status, and diagnoses including gastro-esophageal reflux disease, functional dyspepsia, and constipation reported going three or more days without a BM and not receiving any medication despite requesting help. The resident had PRN orders for Milk of Magnesia, Miralax, and a bisacodyl suppository as part of a bowel management regimen, but the care plan did not address a bowel problem area. Record review showed multiple periods of three or more days without a documented BM, with only one administration of Milk of Magnesia during one such episode and no documented PRN constipation medications during later episodes, despite the facility’s bowel protocol requiring escalating interventions on days three, four, and five without a BM. A second resident with severe cognitive impairment, bowel incontinence, and dependence for all ADLs had a care plan problem for chronic constipation directing staff to follow the bowel protocol and had PRN orders for bisacodyl tablets, bisacodyl suppositories, and enemas. Documentation showed several days without recorded BMs, followed by a BM after an enema, with no evidence of earlier, stepwise interventions per the protocol. In another episode, the resident again went multiple days without a documented BM and there was no documentation of PRN constipation medications being administered. Staff interviews confirmed the existence of a bowel protocol requiring oral laxatives on day three without a BM, suppositories on day four, and enemas on day five with physician notification, and that night shift tracked BMs and day shift was responsible for administering protocol medications. The DON was unable to explain why the required interventions were not provided for either resident.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care as required by its infection prevention and control program. A resident with severe cognitive impairment, bowel and bladder incontinence, dependence for all ADLs, and risk for pressure ulcers had physician orders for daily Calmoseptine application to a coccyx wound and daily cleansing and dressing of a right mid-back wound with Calcium Alginate, skin prep, and Mepilex. During an observed wound care procedure, an RN performed initial hand hygiene, donned PPE, sanitized the over-bed table, and set up a clean field with wound care supplies. While the resident was lying in bed on her right side, the RN loosened the incontinent brief, discovered a bowel movement, and provided perineal care with removal of the soiled brief while the DON assisted with placing a clean brief. After completing perineal care, the RN removed her gloves and donned a new pair without performing hand hygiene, then applied Calmoseptine ointment to the coccyx wound and finished applying the new brief. The RN again removed her gloves and donned another pair without hand hygiene before proceeding to the mid-back wound. With the same pair of gloves on, the RN and DON repositioned the resident, removed a dated dressing with blood-tinged drainage from the mid-back wound, sprayed wound cleanser on the wound bed and surrounding tissue, dabbed the area dry with 4x4 gauze, applied skin prep to the surrounding area, placed Calcium Alginate in the wound bed, and covered it with Mepilex. Interviews with the RN and DON confirmed that facility policy and staff training require hand hygiene with glove changes and after contact with body fluids, and policy documents specify hand hygiene after removing dirty gloves and between cleansing different wounds, which did not occur during this observed treatment.
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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