Southeast Iowa Regional Medical - Klein Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Burlington, Iowa.
- Location
- 1307 South Gear Avenue, West Burlington, Iowa 52655
- CMS Provider Number
- 165110
- Inspections on file
- 18
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Southeast Iowa Regional Medical - Klein Center during CMS and state inspections, most recent first.
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 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.
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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