Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southeast Iowa Regional Medical - Klein Center during CMS and state inspections, most recent first.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility lacked documentation that residents or their representatives were informed of the risks, benefits, and alternatives for psychotropic meds for multiple residents. Several residents had dementia or severe cognitive impairment, while one had intact cognition, and were prescribed meds such as lorazepam, aripiprazole, duloxetine, quetiapine, trazodone, risperidone, and amitriptyline. Staff and the DON stated consents were not obtained in some cases because the meds were started before admission, were home meds, or were missed during an EHR transition.
Delayed Call Light Response Due to Insufficient Staffing: Multiple residents reported long waits for call light assistance, including toileting and transfer needs, and call logs showed response delays from 20 minutes to nearly 3 hours. Residents with intact cognition and significant care needs, including one with MS, one with stroke-related deficits, and others needing toileting or transfer help, described waiting over 15 minutes and sometimes much longer. CNAs and the DON acknowledged heavy care loads, 2-assist residents, and staffing concerns that contributed to delayed responses.
Infection control procedures were not followed when a RN drew blood from a resident at a dining room table with other residents present and then placed the specimen vial directly on the clean table without a barrier. The facility also allowed clean resident clothing to be folded and hung on a public couch in a common area without a clean barrier, with staff stating laundry was handled there for resident supervision.
A resident with severely impaired cognition and vascular dementia had conflicting advance directive documentation: the signed IPOST indicated CPR while the EHR physician order indicated DNR. Staff could not consistently locate the resident’s advance directive paperwork, and interviews showed confusion about where the IPOST was stored, whether the family had provided it, and how the DNR order was established. The facility policy stated residents should be given advance directive information at admission and asked to provide a copy if one already existed.
A resident with intact cognition and diagnoses including CVA, seizure disorder, and anxiety disorder was observed having a Keppra level blood draw performed at a dining room table during breakfast while two other residents were present. The RN drew the specimen from the resident’s forearm and placed the vial on the table without a barrier, while other nursing leadership stated blood draws should be done in a private area or the resident’s room to preserve dignity and for infection control.
Psychotropic medication management deficiencies were identified for multiple residents. The facility lacked GDR documentation for residents receiving antipsychotic, antianxiety, and antidepressant medications, did not document non-pharmacological interventions before PRN quetiapine was given, and had a PRN psychotropic order that exceeded the 14-day limit without physician review. Residents involved had severe cognitive impairment and diagnoses including anxiety, depression, dementia, and delirium.
Unlicensed staff applied a prescribed topical cream to a resident with intact cognition. The resident stated CNAs put the cream on and returned it to the nurses, and CNAs confirmed they applied an antifungal cream provided by the nurse. An RN said CNAs sometimes helped apply prescribed cream, while the unit manager and DON stated only nursing staff should apply prescribed ointments; CNA job duties listed personal care tasks, and RN/LPN job descriptions included administering prescribed medications.
Wheelchairs were pushed without footrests in place for two residents during transport. One resident had Parkinson's disease, moderate cognitive impairment, and a history of falls, and was observed being moved while her feet dragged along the floor. Another resident with intact cognition and gait/mobility impairment was observed being pushed in a wheelchair without footrests while holding her legs up. Staff and the DON stated that footrests were expected to be applied before pushing a wheelchair.
A resident with severe cognitive impairment and multiple comorbidities experienced a choking and aspiration event during a meal. Despite ongoing respiratory distress and difficulty swallowing, the LPN did not perform vital assessments or initiate emergency interventions. The resident was left in bed with CPAP and supplemental oxygen, and her condition deteriorated over several hours, ultimately resulting in death before emergency services arrived.
A resident with moderate cognitive impairment and a history of falls experienced an unwitnessed fall when the bed alarm, intended to alert staff for assistance, failed to sound. Staff and family confirmed the alarm was in place but did not activate, and subsequent testing revealed intermittent function. The resident sustained a lumbar compression fracture, and the deficiency was linked to the malfunctioning alarm.
A resident with severe cognitive impairment and a known risk for elopement exited the facility without staff knowledge by following a contracted dietary worker through a secured area. Despite wearing a functioning wander alert device and the presence of door alarms, the resident was able to leave and was only discovered outside when seen by staff through a window. Staff interviews revealed gaps in supervision and awareness of the resident's movements.
Staff did not follow the approved menu or dietician recommendations for pureed diets, serving incorrect food items and portion sizes due to reliance on an inaccurate scoop size guide and lack of a pre-meal huddle. Additionally, required menu items such as fresh grapes were not served to residents on regular diets.
Multiple residents with intact cognition reported that food was frequently served cold, including items such as fries, scrambled eggs, and spaghetti and meatballs. Direct observation confirmed that food temperatures during meal service were below USDA guidelines, with staff acknowledging the issue and the need for further education. Management cited staff retention and training as ongoing challenges.
Staff failed to prevent verbal abuse of three cognitively impaired residents, with one staff member repeatedly using vulgar and derogatory language, including profanity and insults, despite care plans directing gentle communication and reassurance. Other staff witnessed and reported these incidents, which violated facility policy prohibiting verbal abuse.
Staff did not promptly report three incidents of potential verbal abuse involving residents with severe cognitive impairment. In each case, a CNA used vulgar and aggressive language toward residents, including telling one to sit down and calling others derogatory names. Other staff members who witnessed or were aware of these incidents delayed or failed to report them to administration, contrary to facility policy requiring immediate reporting of suspected abuse.
A CNA was reported for speaking loudly and disrespectfully to a resident and for disregarding a resident's complaint about hot water during a shower. Despite these allegations, the CNA continued to work with residents before being separated, contrary to facility policy requiring immediate removal of alleged abusers during investigations.
A resident with severe cognitive impairment exited a facility without staff knowledge, walking unsupervised for approximately ten minutes. The resident left a group activity and exited through an unlocked, unalarmed door to an unsecured courtyard area. The resident was later observed and escorted back inside without injury. The resident had a low elopement risk score and required supervision when ambulating more than 50 feet.
The facility failed to maintain safe food temperatures and provide palatable meals in two households. A dietary staff member did not check food temperatures before serving, resulting in unsafe temperatures for chicken salad and mechanical soft chicken. A resident with intact cognition reported dissatisfaction with the food quality, noting issues with temperature, texture, and lack of fresh options.
The facility failed to supervise medication administration for two residents, leading to unattended medication. A resident with moderate cognitive impairment had a pill left on a table, which was later returned to her by an RN. Another resident was left with a medication cup and eye drops without supervision. The facility's policy did not support leaving medications at the dining table, yet this practice was observed. The care plan and MAR lacked documentation for self-administration, contributing to the deficiency.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent and provide information about the risks, benefits, and treatment alternatives for psychotropic medications for 5 of 6 residents reviewed. The clinical records for Residents #5, #6, #13, #17, and #109 lacked documentation that the resident or resident representative was informed about the medications so an informed choice could be made. The facility policy stated informed consent applied to all treatments requiring informed consent and that residents had the right to make informed decisions regarding care. Resident #5 had diagnoses including anxiety, depression, and delirium due to a known condition, with a BIMS score of 6 indicating severely impaired cognition. The resident was prescribed psychotropic medications including lorazepam, and the record showed a care plan focused on avoiding side effects from psychotropic medication use. The chart did not include documentation that the facility informed the resident or representative of the risks and benefits, alternatives, or other options for the medication. Resident #6 had diagnoses including non-Alzheimer's dementia, depression, and high blood pressure, with a BIMS score of 3 indicating severe cognitive impairment. The resident was prescribed aripiprazole, bupropion, and duloxetine, and the DON stated the facility did not have psychotropic medication consents because the resident began the medications before the consents began. Resident #13 had vascular dementia with anxiety and a BIMS score of 5, and was prescribed amitriptyline and quetiapine; Staff H stated consent was not obtained for amitriptyline because it had been taken at home and quetiapine was missed during an electronic health record transition. Resident #109 had unspecified dementia and was prescribed trazodone, duloxetine, risperidone, and quetiapine; the DON and Staff H stated consents were not obtained because the medications were already being taken before arrival to the facility. Resident #17 had intact cognition with a BIMS score of 13 and was prescribed quetiapine after delirium with nighttime agitation, but the record lacked informed consent documentation and Staff R stated no informed consent was obtained for the new psychotropic medication.
Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to answer resident call lights in a timely manner for 6 of 7 residents reviewed. The report states the facility had a census of 141 residents. Multiple residents reported waiting extended periods for assistance, and call log entries showed delays ranging from 20 minutes to nearly 3 hours before staff marked that they were taking the call light. Resident #160, admitted for aftercare of a healing traumatic left hip fracture, had orders allowing bed rest with exceptions, up in chair, and ambulation with assistance. The resident reported turning on the call light for toileting assistance at 6:34 AM and not receiving a response until 7:24 AM. The call log showed a toileting call light at 6:37 AM with Staff B, CNA, marking intent to take it 55 minutes later, and another toileting call at 2:20 PM with Staff A, CNA, marking intent to take it 25 minutes later. Staff interviews confirmed that staff often responded only after completing other resident care, and the PTA reported hearing the resident say she had been waiting a long time and needed to use the bathroom. Resident #142, who had multiple sclerosis, a BIMS score of 15, impairments on both sides of the body, and dependence on staff for all ADLs, reported waiting more than 15 minutes for call lights and at times waiting one and one-half hours for transfer assistance with a Hoyer lift. The call log showed delays of 44 minutes, 33 minutes, and 20 minutes for transfer assistance. Resident #7, with stroke-related impairments and partial to moderate assistance needs for toileting and transfers, reported waiting more than 15 minutes and said it had been worse over the last couple weeks; the call log showed delays of 33 minutes, 1 hour and 13 minutes, 24 minutes, and 27 minutes. Resident #8 reported call light waits of a half hour or more, and the call log documented delays of 25 minutes to 2 hours, 56 minutes, and 41 seconds. Resident #23 reported waiting over 15 minutes in the bathroom, and the call log showed delays of 35 minutes and 46 seconds and 44 minutes and 28 seconds. Resident #122 reported waiting over a half hour, and the call log showed delays including 1 hour, 6 minutes, and 45 seconds, 52 minutes and 53 seconds, and other delays over 20 minutes. Staff interviews described heavy care needs, multiple 2-assist residents, and periods when one aide was covering a hall with many residents, with staff stating call lights could take longer when they were with other residents.
Infection Control Lapses During Blood Draw and Laundry Handling
Penalty
Summary
Infection control procedures were not followed during a blood draw for a resident who was seated at a dining room table with two other residents and still had breakfast plates in front of them. A RN collected the blood specimen from the resident’s left forearm at the dining room table, then placed the vial containing the blood specimen directly on the clean table surface without a barrier in place. The RN stated the blood draw was done at the dining room table for a Keppra level, and the DON stated blood draws were expected to be completed in a private area or the resident’s room, not in a common area or at the dining room table, and that a barrier should be placed between clean surfaces and blood draw supplies. The facility also failed to prevent potential cross contamination during the laundry process. A CNA placed a laundry basket with a cloth covering on top of a couch in a common hallway area near the laundry room and folded clean resident clothing directly on the couch seat and armrest without a clean barrier. On another observation, staff again placed resident clothing in a laundry basket on top of the couch and hung shirts on hangers directly on the couch seat without a barrier. Staff stated that resident laundry was washed and folded or hung near the common area to provide resident supervision, while the RN unit manager and the Infection Preventionist stated clean resident clothing should be folded in the laundry room, on a clean surface, or in the resident’s room to avoid contamination.
Mismatch Between IPOST and Physician Orders
Penalty
Summary
The facility failed to have Resident #13’s Iowa Physician Orders for Scope of Treatment (IPOST) and provider orders in the electronic health record match. Resident #13’s MDS showed a BIMS score of 5 out of 15, indicating severely impaired cognition, and listed vascular dementia, unspecified severity, with anxiety. The signed IPOST reviewed for the resident indicated CPR, while the EHR physician orders indicated Do Not Resuscitate (DNR) dated [DATE]. During interviews, staff were unable to consistently locate or explain the resident’s advance directive documentation. An RN looked for the advance directives in a binder at the nurse’s station and could not find a paper form for Resident #13. Another RN stated the resident was DNR and that the previous EMR would indicate if the resident had an IPOST, while the binder would also need to be checked. The Unit Manager stated she did not realize the resident had an IPOST before coming to the facility, said the family did not provide it, and stated the IPOST had been scanned into the record about a year and a half earlier. The DON questioned how the facility came to the DNR order and who had the conversation with the family about advance directives. The facility policy stated that residents should be given advance directive information at admission, asked to provide a copy if one already existed, and Social Services should follow up with family if the resident could not supply a copy.
Blood Draw Performed at Dining Room Table During Meal
Penalty
Summary
The facility failed to provide Resident #17 with privacy during a blood draw when the procedure was performed at a dining room table during breakfast with two other residents present. Resident #17’s MDS assessment dated 5/26/26 showed a BIMS score of 13 out of 15, indicating intact cognition, and the resident’s diagnoses included cerebrovascular accident, seizure disorder, and anxiety disorder. An active order dated 6/18/26 included a routine levetiracetam (Keppra) level with instructions for nursing staff to collect a blood specimen. During observation on 6/16/26 at 8:41 AM, Resident #17 was seated at a dining room table with two other residents, and all three had breakfast plates in front of them. An RN approached the resident at the table and drew blood from the resident’s left forearm, then placed the vial containing the specimen on the dining room table without a barrier to protect the clean surface. In interviews, the RN stated the resident did not mind having care done in the dining room, while another RN stated blood draws would be done in a resident’s room to maintain dignity. The unit manager stated blood draws should not be completed at the dining room table during meals, and the DON stated nursing staff were expected to complete blood draws in a private area or the resident’s room, not in a common area or at the dining room table, due to infection control and resident dignity.
Psychotropic Medication Review and PRN Documentation Deficiencies
Penalty
Summary
The facility failed to complete reviews for gradual dose reduction (GDR) for residents prescribed psychotropic medications, failed to document non-pharmacological interventions before giving as needed anti-anxiety medication, and failed to ensure as needed psychotropic medication orders did not exceed 14 days without physician review for 3 of 6 residents reviewed for unnecessary medications. The facility reported a census of 141 residents. For Resident #5, the MDS dated 4/29/26 listed diagnoses of anxiety, depression, and delirium due to a known condition, with a BIMS score of 6 out of 15 indicating severely impaired cognition. The resident was prescribed lorazepam 0.5 mg twice daily and sertraline 50 mg daily, and the record lacked documentation of a GDR during the period from 6/11/25 to 5/27/26, as well as documentation explaining why a GDR was contraindicated. Staff M, RN Manager, stated the facility did not have GDR information because the resident’s medications had been increased, and when asked about other psychotropic medications without an increase, stated the last GDR located was from 2024. The Administrator stated the facility did not have a policy related to GDRs. For Resident #109, the MDS assessment listed diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood, and anxiety disorder, and documented antipsychotic and antidepressant use. The care plan included psychotropic use interventions to observe and monitor changes in mood, behavior, or mental status and document problems, and to provide medications as ordered and monitor effectiveness. For Resident #13, the active orders included quetiapine 25 mg TID PRN dated 5/19/26 with no end date, and the June 2026 MAR showed multiple PRN doses given without documented interventions under psychotropic medication behavior. Staff stated interventions should be documented before PRN administration, and the DON stated there was no reason for the quetiapine not to be a 14-day order and confirmed staff should document interventions tried before giving PRN medications. Resident #13 also had vascular dementia with anxiety, a BIMS score of 5 out of 15 indicating severe cognitive impairment, psychotropic use on the care plan, and an amitriptyline 10 mg bedtime order dated 5/22/25 with no GDR documentation; the DON stated Resident #13 should have had a GDR completed.
Unlicensed staff applied prescribed topical medication
Penalty
Summary
The facility failed to ensure that only licensed nursing staff applied a prescribed topical medication for one resident reviewed. Resident #23 had intact cognition with a BIMS score of 15 out of 15. The electronic health record showed an order for clotrimazole 1% cream to be applied topically to the groin and breast folds for redness, ordered on 6/6/26 and discontinued on 6/17/26. During interviews, Resident #23 stated that CNAs applied the prescribed cream and then returned the cream to the nurses to place back in the medication cart. A CNA stated that a nurse gave them a cup of cream and that they applied it under the resident’s folds in the mornings and on night shift. Another CNA also stated they had applied an antifungal cream provided by the nurse. An RN stated CNAs are supposed to apply prescribed cream but sometimes helped to get things done, and confirmed asking a CNA to apply prescribed cream. In contrast, a unit manager and the DON stated CNAs should not apply prescribed ointments or prescribed creams and that the nurse should apply them. Facility job descriptions for CNAs listed personal care duties, while RN and LPN job descriptions included administering prescribed medications.
Wheelchairs Transported Without Footrests in Place
Penalty
Summary
The facility failed to maintain an environment free from accident hazards when staff transported residents in wheelchairs without footrests in place. Resident #138 had diagnoses including Parkinson's disease, anxiety disorder, depression, and chronic pain syndrome, a BIMS score of 12 out of 15, used a walker and wheelchair for mobility, independently propelled the wheelchair, and had a history of two or more falls without injury since the prior assessment. During observation, a CNA pushed this resident from the room to the dining room and then into the common living area while the wheelchair had no foot pedals attached, and the resident walked her feet along the floor while being moved. Resident #10 had intact cognition with a BIMS score of 15 out of 15 and diagnoses including osteoarthritis, general anxiety disorder, depression, and abnormalities of gait and mobility. The resident used a walker and wheelchair for mobility and independently propelled the wheelchair. During observation, a CNA pushed this resident from the dining room to the resident's room in a wheelchair without foot pedals applied, while the resident held her legs up above the ground. Staff interviews stated that foot pedals were expected to be applied to wheelchairs and residents' feet placed on them before transportation, and the DON confirmed that this was the expectation anytime a wheelchair was being pushed.
Failure to Assess and Intervene After Choking/Aspiration Event
Penalty
Summary
A resident with severe cognitive impairment, Down syndrome, gastroesophageal reflux disease, and sleep apnea experienced a choking and aspiration event during the evening meal. The resident began coughing and reportedly vomited while eating, which was observed by another resident who alerted nursing staff. Upon assessment, the LPN noted labored respirations and described the resident as choking, but did not perform a full clinical assessment such as checking lung sounds, vital signs, or oxygen saturation. The resident was assisted out of the dining area, encouraged to spit out sputum, and later taken to her room, where she continued to cough and struggle to clear her airway. Despite ongoing symptoms, including persistent coughing and difficulty swallowing, the LPN did not conduct further assessments or initiate emergency interventions. The resident was prepared for bed, placed on CPAP with supplemental oxygen, and left to sleep with her head of bed elevated. No documentation or evidence was found that the nurse monitored the resident's respiratory status or reassessed her condition after the initial event. The resident's condition deteriorated over several hours, with staff later finding her in significant respiratory distress, exhibiting audible crackles, cyanosis, and extremely low oxygen saturation. Multiple staff interviews confirmed that no vital signs, oxygen saturation, or lung assessments were performed by the LPN following the choking episode. The resident was not sent out for emergency care until she was found unresponsive and in severe distress several hours later. The lack of timely assessment and intervention following the aspiration event directly contributed to the resident's decline and subsequent death before emergency services could arrive.
Failure to Ensure Proper Functioning of Bed Alarm Results in Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a bed alarm intervention worked properly for a resident with a history of falls and moderate cognitive impairment. The resident required substantial to maximal assistance with mobility and had a care plan that included the use of bed and chair alarms to alert staff when assistance was needed. Despite these interventions, the resident experienced a fall in the bathroom during the night, and it was discovered that the bed alarm did not sound as intended. Clinical documentation and staff interviews revealed that the bed alarm was in place but failed to activate when the resident left the bed. Staff members, including a CNA and RN, confirmed that the alarm did not sound on their phones or audibly, and the issue was only discovered after the resident was found on the bathroom floor. The alarm was later tested and found to function intermittently, with staff noting that wiggling the cord could restore its function. The resident's husband also confirmed that bed alarms were present but did not prevent the fall. The facility's policy required that fall prevention interventions, such as bed alarms, be in working order and checked regularly. However, the failure to ensure the alarm's functionality directly contributed to the resident's unwitnessed fall. The resident sustained a compression fracture of the lumbar spine, as indicated by radiology reports, although the acuity of the fracture was indeterminate. Staff interviews further confirmed reliance on the alarm system for resident safety, and the deficiency was attributed to the alarm's malfunction at the time of the incident.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A resident with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, was assessed as being at risk for elopement and had a care plan in place for this risk. Despite these precautions, the resident was able to exit the facility without staff knowledge. The resident left their assigned area, traversed an unoccupied wing, and exited the building, ultimately being observed outside by staff and subsequently brought back inside. The resident was wearing a wander alert device, which was reported to be functioning at the time of the incident. Staff interviews revealed that the resident was known to wander and had a history of attempting to leave the facility, often expressing confusion and a desire to go home. On the day of the incident, it was believed that the resident followed a contracted dietary worker out of a secured area while staff were preparing to serve breakfast. The dietary worker did not notice the resident following him and was not aware of the resident's status or risk. Multiple staff members confirmed that alarms on exit doors were sounding, but the resident was still able to leave the building unnoticed for a period of time. The incident was discovered when a nurse saw the resident outside through a window and alerted other staff, who then retrieved the resident. Staff interviews indicated that there was a lack of awareness regarding the resident's whereabouts, and some staff were unsure when or how the resident left the unit. The facility's policy defined elopement as a resident leaving a secured area or the building alone and unwitnessed by staff, which occurred in this case.
Failure to Follow Menu and Dietician Recommendations for Pureed Diets
Penalty
Summary
The facility failed to follow the approved menu and dietician recommendations for residents requiring pureed diets. On the observed date, staff prepared a taco salad instead of the taco casserole specified on the menu, and did not adhere to the portion sizes directed by the Registered Dietician. During food preparation, the kitchen staff used incorrect measurements and did not follow the conversion chart accurately, resulting in residents receiving improper portion sizes of both the pureed taco mixture and rice. Additionally, the dietary staff relied on an inaccurate scoop size guide posted in the kitchen, which led to further errors in serving sizes. The required pre-meal huddle, where menu and portion expectations are reviewed, did not occur on the day of the deficiency. Furthermore, the facility did not serve fresh grapes to residents on a regular diet as required by the menu. Interviews with staff revealed a lack of awareness regarding the correct menu items and portion sizes, and the kitchen manager acknowledged the presence of an incorrect scoop size poster in the kitchen. The dietician confirmed that the menu was not followed and expressed concern about the incorrect scoop sizes used during meal service.
Failure to Maintain Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that food was served at safe and appetizing temperatures, as evidenced by multiple resident and staff interviews, as well as direct observation of meal service. Several residents with intact cognition reported that food was often cold, with specific complaints about cold fries, scrambled eggs, and spaghetti and meatballs. Staff interviews confirmed that food frequently arrived at residents' tables at temperatures below recommended guidelines, and that the distance food traveled before being served contributed to the issue. During a continuous observation of meal service, food temperatures were measured and found to be below the United States Department of Agriculture guidelines, with ground meat/bean mixture dropping from 133°F to 84°F and hamburger patties served at 131°F. Staff acknowledged awareness of the temperature requirements and the need to alert management when food temperatures were not within safe ranges. The kitchen manager and dietician both recognized ongoing concerns with food temperature and identified a need for further staff education, while the general manager noted challenges with staff retention and the necessity for continued training.
Failure to Prevent Verbal Abuse of Cognitively Impaired Residents
Penalty
Summary
Staff at the facility failed to protect residents from verbal abuse, as evidenced by multiple incidents involving three residents with severe cognitive impairments and behavioral symptoms. Staff F was reported to have used vulgar and derogatory language towards residents, including telling one resident to 'sit your f**** a*** down,' calling another a 'b****,' and instructing a resident to 'shut the f*** up and sit down.' These actions were witnessed and documented by other staff members, including a CNA and a housekeeper, who reported that Staff F frequently used a 'filthy mouth' and was very vulgar to residents. The incidents were not reported immediately by all staff, with one CNA stating she delayed reporting due to having to work regularly with Staff F. The residents involved had significant cognitive and behavioral challenges, including diagnoses such as non-Alzheimer's dementia, anxiety disorder, chronic kidney disease, non-traumatic brain dysfunction, irritability, anger, and hypertension. Their care plans specifically directed staff to use gentle communication, reassurance, and emotional support. Despite these directives and facility policy prohibiting verbal abuse, staff failed to adhere to appropriate standards of conduct, resulting in residents being subjected to disparaging and derogatory language.
Failure to Timely Report Suspected Verbal Abuse Incidents
Penalty
Summary
Staff failed to timely report three separate incidents of potential verbal abuse involving residents with severe cognitive impairment. In one incident, a CNA was reported to have used vulgar and aggressive language toward a resident with non-traumatic brain dysfunction, irritability, and severely impaired cognition, telling him to sit down and calling him derogatory names. Another incident involved the same CNA calling a resident with non-Alzheimer's dementia and severe cognitive impairment a derogatory name multiple times. A third incident occurred when the CNA responded to a resident's complaint about hot water during a shower by telling her to 'shut the f*** up,' after which the resident was observed crying and expressing distress. Despite witnessing or being aware of these incidents, staff members did not immediately report the potential abuse to administrative staff. One CNA delayed reporting the incidents involving two residents until a later situation arose, citing the need to work regularly with the alleged perpetrator. Another CNA admitted to not reporting repeated verbal abuse toward a resident, despite recognizing it as inappropriate. The facility's policy required staff to report suspected abuse without fear of reprisal and to refer such concerns to the administrator for action, but this procedure was not followed in these cases.
Failure to Timely Separate Alleged Abuser from Residents
Penalty
Summary
The facility failed to promptly separate residents from an alleged perpetrator of abuse after an incident was reported. On 4/1/25, a staff member from housekeeping reported to the DON that a CNA was speaking loudly and disrespectfully to a resident in the memory care common area. Further investigation revealed that another CNA witnessed the same CNA loudly telling a resident that she knew how to do her job, and also observed the CNA continuing to shower a different resident with water the resident stated was too hot. Despite these reports, the CNA in question continued to work on 4/3/25, and the meeting to address the situation was not scheduled until 4/4/25. Facility policy requires that staff intervene and remove alleged abusers from contact with residents until an investigation is complete. However, the CNA accused of mistreatment was not immediately removed from resident care duties following the initial allegation. The DON confirmed that the CNA worked after the complaint was made and that she was not aware of any prior behaviors. The delay in separating the alleged perpetrator from residents did not align with the facility's stated procedures for protecting residents during abuse investigations.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a resident with severe cognitive impairment did not exit the facility without staff knowledge. On July 26, 2024, a resident left a group while walking from an activity area to the memory care unit without the staff supervising noticing. The resident exited through an unlocked, unalarmed door to an unsecured courtyard area and walked on the sidewalk to a location approximately 100 yards from a large pond. A staff member saw the resident from a window and went outside to assist her back to the building. The resident was estimated to be outside, unsupervised, for approximately ten minutes. The resident involved had a severe cognitive impairment, as indicated by a score of 7 out of 17 on the Brief Interview for Mental Status. The resident was independent with mobility using a walker but required supervision when ambulating more than 50 feet with two turns. The resident's diagnoses included non-Alzheimer's dementia, diabetes mellitus, and renal insufficiency. An Elopement Risk tool dated June 13, 2024, identified the resident with a total score of 52, indicating a low risk for elopement. At the time of the incident, the resident was attending a group activity in the general common area. The activity was conducted by the Administrator and the Activity Director, with several residents, including those from the memory care halls, attending. At the end of the activity, the memory care residents were supposed to be escorted back to their households. However, the Administrator did not realize the resident had left the group and veered back into the front lobby area. The resident was later observed through a window, heading east between the B and C buildings, and was immediately escorted back inside without injury.
Removal Plan
- Exit door where Resident #1 exited is now locked at all times and requires keypad access for egress.
- Memory Care residents have been escorted and supervised by designated employee(s) for all programming outside of the memory care.
- All residents have been evaluated for elopement risk.
- Residents identified to be at risk for elopement living in a non-secured unit have had an electronic wandering protection device placed and care plans have been updated.
- Residents identified to be at risk for elopement living in a secured unit will have an electronic wandering protection device placed.
- Elopement Prevention policy has been developed and approved.
- All staff have been educated on new Elopement Prevention policy.
- Additional electronic wandering protection devices were ordered through RF Technologies.
- Daily checks of resident electronic wandering protection devices to ensure that they are in place and operational are already being completed by nursing staff.
- Weekly door checks to be completed weekly.
- Elopement drills to be completed weekly.
Food Temperature and Quality Deficiencies
Penalty
Summary
The facility failed to provide food at a safe temperature in two of the seven households reviewed, specifically in Heritage House and Cobblestone House. Observations revealed that the Food Service/Dietary Manager did not ensure that food temperatures were checked before serving meals. On one occasion, Staff A, a dietary staff member, began plating the noon meal without checking the food temperatures, which led to the chicken salad being served at 46 degrees and the mechanical soft chicken at 127 degrees, both of which are outside the safe temperature range. The facility's policy requires hot foods to be held above 140 degrees, and cold foods should not exceed 41 degrees, which was not adhered to in this instance. Additionally, Resident #90, who has intact cognition and eats independently, reported dissatisfaction with the quality and temperature of the food. The resident stated that the food often tasted cold, vegetables were overcooked, and meats were difficult to chew. During an observation, the resident expressed displeasure with the taste and texture of the broccoli, describing it as overcooked and water-soaked. The resident also noted that the chicken was dry and the chicken noodle soup lacked substance. The resident expressed a desire for fresh food, indicating that the quality of food had not improved since a new company took over food services.
Medication Administration Supervision Deficiency
Penalty
Summary
The facility failed to ensure proper supervision of medication administration for two residents, leading to medication being left unattended. Resident #7, who had moderately impaired cognition, was observed to have a white pill left on a table in a common area. Staff A, a Dietary Aide, found the pill and informed Staff C, a CNA, who then notified Staff B, an RN. Staff B confirmed that the pill belonged to Resident #7, as she was the only resident sitting at that table. Staff B admitted to feeling frazzled and not following the usual procedure of discarding the pill, instead returning it to Resident #7, who then took it. Interviews revealed that this was not an isolated incident, as pills had been found on tables before, and the practice of leaving medications on tables varied depending on the nurse and the resident's cognitive status. Resident #61, who also had moderate cognitive impairment, was left with a medication cup containing various pills and a bottle of eye drops without direct supervision. Staff D, an LPN, placed the medication in front of Resident #61 and continued to pass medications to other residents. The facility's policy did not support leaving medications with residents at the dining room table, yet it was noted that many residents preferred this practice. The Interim DON stated that nurses were expected to supervise residents while they took their medications, which was not adhered to in this case. The facility's Medication Administration Policy outlined that medications should be administered following specific rights and recorded accurately. Self-administration of drugs required a physician's order and an assessment documented in the EHR. However, the care plan for Resident #61 lacked focus and interventions for self-administration, and the MAR did not document self-administration. These oversights contributed to the deficiencies observed in the medication administration process for both residents.
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Nursing homes near West Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakview Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 0 | 0 |
| Azria Health Prairie Ridge | 13.6 mi | ★★★★★ | 19 | 0 |
| Henderson County Ret Center | 14.2 mi | ★★★★★ | 0 | 0 |
| New London Specialty Care | 14.6 mi | ★★★★★ | 10 | 0 |
| West Point Care Center Inc | 15.9 mi | ★★★★★ | 4 | 0 |
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