Southfield Wellness Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Webster City, Iowa.
- Location
- 2416 Des Moines Street, Webster City, Iowa 50595
- CMS Provider Number
- 165411
- Inspections on file
- 32
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Southfield Wellness Community during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical diagnoses was being positioned for an x-ray when a radiology technician allegedly placed a gloved hand over the resident’s mouth and told or asked the resident to stop coughing, as witnessed by a CNA. The CNA reported the incident to the nurse, and the next morning a day-shift nurse informed the ADON, who then spoke with the resident and reported the information to the DON and Administrator. Although facility policy required that all abuse allegations be reported to the state agency within 2 hours, the self-report was not submitted until later that day, resulting in a failure to meet the required reporting timeframe.
A resident with impaired cognition and frequent bowel incontinence was left in a soiled brief for an extended period after experiencing multiple episodes of diarrhea. Staff were unable to provide timely incontinence care due to staffing availability and communication lapses, resulting in the resident feeling upset and undignified. Facility policy requires residents to be treated with dignity and respect, but this expectation was not met.
The facility failed to address deficiencies in care planning, ADL care, quality of care, accident prevention, dialysis, nursing staff sufficiency, and QAPI program effectiveness. Despite efforts to implement a culture change and support from a Regional Nurse Consultant, the facility continued to struggle with accountability and effective implementation of their QAPI plan.
The facility failed to implement its antibiotic stewardship program, as the Infection Preventionist could not provide evidence of antibiotic initiation, lab data monitoring, or infection evaluation for residents with infections. The DON, also serving as the IP, did not demonstrate an active stewardship program, and the facility's infection tracking map lacked necessary details. The Administrator was unable to provide evidence of the program, citing Quality Assurance restrictions.
The facility failed to provide scheduled bathing assistance to residents, impacting their personal hygiene and choice. Staffing shortages led to missed baths, with residents reporting fewer showers than scheduled. Documentation confirmed inconsistencies, and the facility lacked a formal bathing policy.
A resident with intact cognition reported experiencing incontinence due to insufficient staffing, which delayed assistance when needed. This led to feelings of indignity, as the resident had to wait for help, resulting in bowel incontinence. The facility's policy emphasizes treating residents with dignity and respect, but the resident's experience indicates a failure to adhere to this policy.
A facility failed to develop a comprehensive Care Plan for a resident with diabetes, dementia, depression, and PTSD. The Care Plan lacked directions for managing diabetes, including insulin usage and blood sugar monitoring, and did not address anti-anxiety medication use. A Nurse Consultant confirmed the deficiency, noting the absence of necessary information for high-risk medications, despite the facility's policy requiring comprehensive Care Plans.
The facility failed to provide restorative care for two residents, one with a stable thoracic spine fracture and another with hemiplegia. The first resident's restorative program was delayed for 18 days, while the second resident received inconsistent care due to staff being reassigned to other duties. The DON did not document or evaluate the residents' progress, leading to deficiencies in their care plans.
A facility failed to notify a physician of significant weight gains in a resident with ESRD, as required by the physician's orders. Despite multiple instances of weight gain exceeding the specified parameters, the facility did not document any notifications to the physician. Interviews with the DON and Administrator confirmed the lack of adherence to the physician's orders, and the facility did not have a specific policy in place, relying instead on the standard of care.
A resident with multiple health conditions, including heart failure and acute kidney failure, had abnormal lab and chest x-ray results that were not promptly addressed by the ARNP. The results, indicating potential heart failure, were faxed to the ARNP, but there was no documented follow-up or communication. The resident continued to experience symptoms and eventually expired without timely intervention. The facility's policy for prompt notification of critical results was not followed, leading to this deficiency.
Several residents reported significant delays in call light responses, with one resident waiting up to 2 hours for assistance in the bathroom, leading to distress and incontinence. The facility's call light policy was not consistently followed, resulting in multiple instances of delayed responses across different residents.
A resident with a suprapubic catheter required a gentamicin bladder irrigation flush, but an agency nurse was unfamiliar with the procedure. Consequently, a CNA, who was not trained for this task, performed the flush with the resident's guidance. The DON and Administrator were unaware of the incident, and the facility's job description for CNAs did not include such medical procedures.
The facility failed to provide necessary assessments and interventions for three residents, compromising their well-being. A resident with heart failure did not receive proper monitoring and documentation of weights and lung sounds, leading to missed medication administration and unaddressed critical lab results. Another resident with impaired cognition had undocumented bruises, and a third resident with chronic edema lacked documentation for compression stockings and weight monitoring, despite significant weight gain.
A resident with severely impaired cognition and multiple health issues experienced a fall resulting in injuries due to inadequate supervision and failure to implement a fall intervention. The facility did not complete a thorough root cause analysis or update the care plan with new interventions. Additionally, necessary therapy evaluations and treatments were not ordered, despite recommendations.
A resident with a history of CHF, renal insufficiency, and COPD experienced repeated paraphimosis due to the facility's failure to properly manage foreskin retraction during catheter care. Despite receiving instructions from a Urology Clinic, the staff did not consistently follow orders to ensure the foreskin was not left behind the head of the penis, leading to significant swelling and pain. The facility's documentation was inconsistent, and staff interviews revealed a lack of training in proper care for an uncircumcised penis.
The facility failed to provide appropriate bladder care for two residents, leading to urethral erosion and paraphimosis in one resident due to improper catheter management, and another resident was found in a urine-soaked bed due to inadequate incontinence care. The facility lacked specific policies and documentation, contributing to these deficiencies.
A resident with a history of dementia and behavioral issues did not receive the correct dosage of Seroquel for seven days due to a pharmacy mix-up. The resident's medication was ordered from the wrong pharmacy, resulting in the continued administration of a lower dosage than prescribed. The error was discovered by a CMA during medication rounds, and the resident's family and PMHNP were informed.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) within the required 2-hour timeframe. The involved resident had severe cognitive impairment, with a BIMS score of 5, and diagnoses including heart failure, hypertension, and traumatic brain injury. A CNA reported that while assisting a radiology technician in positioning the resident for an x-ray, she observed the technician place a gloved hand over the resident’s mouth due to coughing and tell or ask the resident to stop coughing. The CNA then reported this observation to the nurse on duty. The RN confirmed that the CNA reported the technician put a hand on the resident’s mouth and told or asked the resident to quit coughing, and that the CNA’s description made it sound shocking. The RN stated she did not consider this an allegation of abuse and did not report it to the Administrator or DON. A late-entry Health Status Note documented that the following morning the day-shift front nurse informed the ADON, upon arrival to the building, that the radiology technician had put a hand over the resident’s mouth and asked the resident not to cough the previous night, and that the CNA had reported this to the evening nurse. When the ADON spoke with the resident and asked if anything had happened since the previous day, the resident replied that they did not think so. The ADON then reported this information to the DON and Administrator. The facility’s abuse prevention, reporting, and investigation policy required that all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation be reported to DIAL and other required agencies, with abuse or abuse resulting in bodily injury to be reported immediately and not later than 2 hours after the allegation is made. Despite this policy, the facility did not submit the self-report related to this incident until later that day, beyond the 2-hour reporting requirement.
Delay in Incontinence Care Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, dependent on staff for toileting hygiene and frequently incontinent of bowel, was not provided timely personal care after experiencing multiple episodes of diarrhea. Documentation showed the resident had several incidents of incontinence over the course of an evening. The resident required assistance from two staff members for incontinence care and transfers, as outlined in their care plan. On the evening in question, the resident activated their call light after soiling their brief. A CNA responded and informed the resident that assistance would be delayed until another staff member returned from break, as two staff were needed for care. The CNA attempted to find another staff member but became occupied with another resident requiring immediate assistance and forgot to notify the returning staff about the resident's need. As a result, the resident remained in a soiled brief for an extended period, which the resident later described as upsetting and undignified. Interviews with staff and the resident confirmed that the resident was left waiting for incontinence care, and staff acknowledged the resident's right to timely assistance and dignified treatment. The facility's policy emphasized the importance of treating residents with dignity and respect, but this expectation was not met in this instance, as the resident was not promptly attended to during repeated episodes of incontinence.
Facility Fails to Correct Deficiencies in Care and Staffing
Penalty
Summary
The facility failed to correct deficiencies in 7 out of 12 areas of concern, as identified in past surveys and the current survey. These deficiencies include issues with the development and implementation of comprehensive care plans, provision of ADL care for dependent residents, quality of care, and ensuring the environment is free of accident hazards. Additionally, there were concerns related to dialysis, sufficient nursing staff, and the effectiveness of the QAPI program. The facility's QAPI plan, reviewed on January 14, 2024, outlined a mission to provide resident-centered healthcare and promote caregiver engagement, but the survey findings indicate that these goals were not met in practice. The Administrator acknowledged the repeated concerns and noted that the facility was undergoing a culture change, which included changes in nursing administration and efforts to replace agency staff members. Despite these efforts, the facility continued to struggle with accountability and effective implementation of their QAPI plan. The Regional Nurse Consultant was assigned to the facility in November to provide support, including training for the DON, but the deficiencies persisted, indicating a need for further improvement in the facility's systems and processes.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship policy, as evidenced by the lack of documentation and monitoring of antibiotic use for residents with infections. The Infection Preventionist (IP) identified residents with infections using a facility map but could not provide evidence of when antibiotics were initiated, the monitoring of laboratory data, or the evaluation of treated infections. Specifically, two residents had active urinary tract infections (UTIs), and one resident had completed an antibiotic course for a methicillin-resistant Staphylococcus aureus (MRSA) infection. The Director of Nursing (DON), who also served as the IP, was unable to demonstrate an active antibiotic stewardship program and failed to provide evidence of monitoring or evaluation of antibiotic effectiveness. The facility's policy on antibiotic stewardship required the DON and the Infection Prevention Program Coordinator to educate staff, monitor residents' conditions, and communicate the results of antibiotic therapy to medical providers. However, the DON did not fulfill these responsibilities, as there was no evidence of adherence to evidence-based criteria during the evaluation and management of treated infections. Additionally, the facility's map, which was supposed to track infections, did not include information on the antibiotics used or the monitoring of lab data. The Administrator also could not provide evidence of an active antibiotic stewardship program, citing the need for permission to share the infection tracking process due to its classification as Quality Assurance material.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to residents who were unable to perform this activity of daily living independently. Four residents were identified as not receiving their scheduled showers or baths, which were necessary for maintaining personal hygiene and respecting personal choice. The facility's documentation and interviews with residents and staff revealed inconsistencies in the provision of scheduled bathing services. Resident #6, who required total assistance for bathing due to progressive neurological conditions, diabetes mellitus, and multiple sclerosis, reported receiving showers only every other day instead of daily as scheduled. Documentation confirmed missed showers on specific dates, and staff interviews indicated that staffing shortages, particularly on weekends, led to the reassignment of bath aides to other duties, resulting in missed baths for residents. Similarly, Resident #27, who required substantial assistance for bathing, did not receive showers on all scheduled days, with documentation showing missed and refused baths. Resident #48, who also required assistance, reported receiving fewer showers than scheduled, particularly on Saturdays. Resident #24, dependent on staff for bathing, received only two baths since admission, with no documentation of refusals or attempts to encourage bathing. The Director of Nursing acknowledged the staffing issues and the impact on bathing schedules, but the facility lacked a formal bathing policy, relying instead on a standard of care.
Failure to Provide Dignified Care
Penalty
Summary
The facility failed to provide care that promotes dignity and respect for one resident, identified as Resident #24, out of 21 residents reviewed. Resident #24, who has intact cognition as indicated by a BIMS score of 14, reported experiencing incontinence of bowel movements on a couple of occasions since being admitted to the facility. The resident attributed these incidents to insufficient staffing, which delayed assistance when she needed help. She expressed feeling like a baby when these incidents occurred. The facility's policy on Resident Rights - Dignity and Respect, revised in April 2024, emphasizes treating residents with dignity and respect, and providing considerate and respectful care with reasonable accommodation of individual needs. However, the resident's experience suggests a failure to adhere to this policy, as she had to wait for assistance, leading to incontinence and a loss of dignity.
Incomplete Care Plan for Resident with Multiple Conditions
Penalty
Summary
The facility failed to develop a comprehensive Care Plan for a resident, identified as Resident #13, who was at risk due to multiple medical conditions including diabetes mellitus, non-Alzheimer's dementia, depression, and PTSD. The resident's Minimum Data Set (MDS) assessment indicated intact cognition and documented the use of anti-anxiety and hypoglycemic medications. Despite these complexities, the Care Plan lacked specific directions for managing type 2 diabetes mellitus, including insulin usage, blood sugar monitoring, and parameters for physician notification. Additionally, the Care Plan did not address the use of anti-anxiety medication, its potential side effects, or monitoring requirements. The deficiency was confirmed by a Nurse Consultant, who acknowledged that the current Care Plan did not include necessary information regarding high-risk medications. The facility's Care Plan Policy, revised in July 2023, mandates that Care Plans be developed in accordance with federal regulations and be reviewed and revised by the Interdisciplinary Team following MDS assessments or any changes that necessitate a revision. However, the facility failed to adhere to this policy, resulting in an incomplete Care Plan for Resident #13.
Failure to Provide Restorative Care for Residents
Penalty
Summary
The facility failed to provide restorative care for two residents, leading to deficiencies in their care plans. Resident #43, who had a stable fracture of the thoracic spine and muscle weakness, was recommended for a restorative maintenance program by the Physical Therapist (PT) on February 7, 2025. However, the facility did not initiate this program for 18 days, and the resident's care plan lacked the necessary restorative program. Despite the PT and Director of Nursing (DON) signing a document indicating the setup of a restorative program, it was not completed, as confirmed by an email from the Administrator. Resident #46, diagnosed with hemiplegia and requiring substantial assistance for transfers and toileting, did not receive the recommended restorative care as prescribed. The Point of Care (POC) Response History showed inconsistent completion of the restorative program, with several instances of zero minutes recorded. Interviews revealed that the Restorative Aide was often pulled to perform CNA duties, limiting the time available for restorative care. The DON, responsible for overseeing the restorative program, admitted to not documenting or evaluating the progress of residents in the program, contributing to the deficiency.
Failure to Notify Physician of Weight Gains in Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease (ESRD) by not notifying the primary care physician (PCP) of significant weight gains as per the physician's orders. The resident, who had intact cognition and was diagnosed with medically complex conditions including heart failure and hyperlipidemia, was supposed to have daily weights monitored, with any weight gain of 2-3 pounds in 24 hours or 5 pounds in 5 days reported to the physician. However, the clinical record lacked documentation of such notifications despite multiple instances of weight gain exceeding these parameters over a period of several months. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility did not notify the physician about the resident's weight changes as ordered. The DON was unable to locate any physician notifications related to the weight gains, and the Administrator acknowledged that the staff did not follow the physician's orders. The facility did not have a specific policy regarding this issue, relying instead on the standard of care, which was not adhered to in this case.
Failure to Ensure Timely Physician Response to Abnormal Lab and X-ray Results
Penalty
Summary
The facility failed to ensure timely response from a physician to abnormal laboratory and chest x-ray results for a resident with multiple health conditions, including heart failure, hypertension, atrial fibrillation, diabetes mellitus, and acute kidney failure. The resident required significant assistance with mobility and had moderately impaired cognition. An Advanced Registered Nurse Practitioner (ARNP) ordered several lab tests and a chest x-ray, which revealed significant abnormalities, including high BNP levels indicating potential heart failure or other serious conditions. The lab results were faxed to the ARNP, but there was no documented follow-up or communication from the ARNP regarding these results. Similarly, the abnormal chest x-ray results were faxed, but again, there was no documented response or follow-up from the ARNP. The resident continued to experience symptoms such as increased weight gain and pitting edema, and eventually expired without the abnormalities being addressed in a timely manner. The ARNP reported not being available over the weekend when the results were received and stated that a hospitalist was covering for her. However, there was no evidence of the hospitalist reviewing the results either. The facility's policy required prompt notification of critical lab and radiology results to the attending physician or an appropriate practitioner, but this protocol was not followed, contributing to the deficiency.
Delayed Call Light Responses Lead to Resident Distress
Penalty
Summary
The facility staff failed to consistently answer call lights within a reasonable amount of time, as evidenced by multiple residents reporting significant delays. Resident #46, who has hemiplegia and requires substantial assistance for transfers and toileting, reported waiting 30 minutes to an hour for call light responses, with documented instances of delays ranging from 18 minutes to over an hour. Additionally, Resident #46 experienced a broken call light pendant that was not promptly replaced, further complicating their ability to request assistance. Resident #6, who requires total assistance for toileting hygiene and lower body dressing due to progressive neurological conditions, reported waiting for 2 hours in the bathroom over a weekend when the facility was understaffed. The call light report for Resident #6 showed 12 instances of waiting over 20 minutes for a response within a 30-day period. Similarly, Resident #24 experienced incontinence due to delayed responses, with call light times exceeding 15 minutes on multiple occasions, including a significant delay in receiving requested medication. Resident #13, who also has intact cognition, reported waiting up to 30 minutes for call light responses, resulting in incontinence and embarrassment. The facility's call light policy, which mandates prompt responses, was not adhered to, as evidenced by numerous documented instances of delayed responses across multiple residents. The facility's administrator acknowledged the expectation for call lights to be answered within 15 minutes, highlighting a systemic issue in meeting this standard.
Inadequate Staff Training Leads to Improper Catheter Flush
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies to perform a catheter flush for a resident, leading to a deficiency. A resident with intact cognition and medical conditions including neurogenic bladder and multiple sclerosis required a suprapubic catheter flush with gentamicin bladder irrigation as ordered. However, on a specific date, an agency nurse on duty was unfamiliar with the procedure and did not perform the flush. Instead, a CNA, who was not trained or qualified to perform this task, conducted the flush with the resident's guidance. The CNA admitted to performing the procedure without proper training and acknowledged that it was beyond her scope of practice. The Director of Nursing (DON) and the Administrator were unaware of the incident until it was reported. The CNA stated she left a note for the DON, but the DON claimed not to have received it. The facility's job description for CNAs did not include performing such medical procedures, and both the DON and Administrator expected staff to adhere to their scope of practice. The incident highlights a lapse in ensuring that only qualified personnel perform specific medical tasks, as well as a communication breakdown within the facility's management.
Failure to Provide Necessary Assessments and Interventions for Residents
Penalty
Summary
The facility failed to provide necessary assessments and interventions for three residents, compromising their highest practical physical well-being. Resident #55, with a history of heart failure, hypertension, and diabetes, did not receive proper monitoring and documentation of daily weights and lung sounds, despite physician orders. The lack of documentation led to missed opportunities to administer additional Lasix when needed, and abnormal lab results and chest x-ray findings were not addressed in a timely manner. Resident #55 ultimately expired, with no evidence that the ARNP addressed the critical lab and x-ray results before the resident's death. Resident #20, who had severely impaired cognition and a history of anemia and heart failure, was found with multiple bruises on her right hand and arm. The clinical record lacked documentation, assessments, or notifications regarding these bruises. Staff interviews revealed that the facility's policy required observation and documentation of new skin areas, but this was not followed. The facility was in the process of implementing weekly skin assessments, but not all residents had these assessments in place at the time of the survey. Resident #27, with intact cognition and a history of hypertension and chronic edema, did not have proper documentation for the use of compression stockings or orders for daily weights. Despite significant weight gain over several months, there was no evidence of physician notification or follow-up. The ARNP expected daily weights and notification of weight changes, but the facility did not have an order for weights and failed to track them consistently. The DON acknowledged the lack of documentation and follow-up, indicating a failure to adhere to standard practices for residents with chronic edema and diuretic use.
Inadequate Supervision and Fall Intervention for Resident
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident with severely impaired cognition, as evidenced by a fall incident. The resident, who required substantial to maximal assistance with bed mobility and transfers, experienced a fall resulting in skin tears to the right elbow and knee. The incident occurred as the resident was being assisted from the bathroom to a wheelchair, where they tripped over their own feet. Despite the presence of a gait belt and walker, the facility did not complete a thorough root cause analysis to determine why the resident lost footing or tripped, nor did they implement a fall intervention following the incident. The facility's documentation was lacking in several areas, including the absence of a physician order for an occupational therapy evaluation and treatment, as initially recommended. Additionally, the root cause analysis did not adequately address the cause of the fall, and the care plan was not updated with a new fall intervention. Interviews with facility staff revealed that the previous Director of Nursing intended to obtain physical therapy orders due to the resident's weakness but failed to follow through. The facility's policy required a comprehensive assessment and intervention plan following a fall, which was not adhered to in this case.
Failure to Manage Paraphimosis in Resident
Penalty
Summary
The facility failed to routinely assess and provide interventions for retracting the foreskin of the penis and returning it to its original position for a resident, leading to repeated instances of paraphimosis. The resident, who had a history of congestive heart failure, renal insufficiency, and chronic obstructive pulmonary disease, required intervention at a Urology Clinic on three separate occasions to reduce paraphimosis. Despite having a catheter in place and orders to ensure the foreskin was not left behind the head of the penis, the facility's staff did not consistently follow these instructions, resulting in significant swelling and pain for the resident. The resident's medical records indicated that the foreskin was not properly managed during catheter care, leading to repeated swelling and paraphimosis. The Urology Clinic provided education to the nursing home staff on the importance of retracting the foreskin back over the head of the penis after catheter care, but the facility failed to implement these instructions effectively. The resident's foreskin was found retracted and swollen on multiple occasions, and the facility's documentation did not consistently reflect the interventions or assessments required to address the issue. Interviews with staff revealed a lack of consistent training and understanding of the proper care for an uncircumcised penis, contributing to the ongoing issue. Despite receiving orders and education from the Urology Clinic, the facility's staff did not consistently apply the necessary care, resulting in the resident experiencing pain and requiring repeated medical interventions. The facility's documentation was also found to be lacking, with discrepancies between reported care and the resident's condition upon examination by external medical providers.
Deficiencies in Bladder and Incontinence Care
Penalty
Summary
The facility failed to provide appropriate bladder care and services for two residents, leading to significant deficiencies. One resident, who had a urinary catheter due to obstructive uropathy, experienced urethral erosion and paraphimosis due to improper catheter management. The facility did not use a secure device to hold the catheter in place, resulting in pulling and tension on the catheter. Additionally, the facility did not document the resident's urinary output during a voiding trial, and the resident retained over 1 liter of urine, indicating a lack of proper monitoring and assessment. Another resident, who was frequently incontinent of bowel and bladder, was found in a urine-soaked bed, indicating a failure to provide timely incontinence care. The resident's care plan lacked specific directions on how often to check for incontinence, and staff did not perform incontinence care as expected. The resident's daughter had instructed staff to let the resident sleep, but staff failed to report the situation to the charge nurse, resulting in the resident remaining in a wet bed for an extended period. The facility's policies and procedures for catheter and incontinence care were inadequate, contributing to the deficiencies. The facility did not have a policy related to urinary incontinence and relied on standard practices, which were not effectively implemented. The lack of documentation, monitoring, and adherence to care plans led to the residents' compromised care and the facility's failure to meet the required standards for bladder and incontinence care.
Medication Administration Error Due to Pharmacy Mix-Up
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for a resident by not following physician orders to administer the correct dose of an antipsychotic medication for seven days. The resident, who had moderately impaired cognition and required assistance with mobility, had a history of hypertension, renal disease, cerebrovascular accident, non-Alzheimer's dementia, Parkinson's disease, and neurocognitive disorder with Lewy bodies. The resident exhibited delusions, hallucinations, and behavioral symptoms that could present a danger to himself and others, necessitating the use of antipsychotic medication. On a specific date, the resident became agitated and attempted to physically harm staff and other residents. Following this incident, a new order was received to increase the resident's Seroquel dosage to 50 mg every morning and to start Ativan as needed. However, the facility's Medication Administration Record (MAR) indicated that the resident continued to receive the previous dosage of Seroquel, 25 mg in the morning, due to a medication error. The error occurred because the medication was ordered from the wrong pharmacy, and the new dosage was not administered as prescribed. The facility's investigation revealed that the medication error was identified by a Certified Medication Aide (CMA) who noticed the discrepancy while passing medications. The error was attributed to the resident's switch in pharmacies with a change in the level of care, and the pharmacy that received the script did not fill the order or notify the facility. The Director of Nursing (DON) confirmed that the staff continued to administer the incorrect dosage for several days, and the resident's family and the Psychiatric Mental Health Nurse Practitioner (PMHNP) were notified of the error.
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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