Spencer Post Acute Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Spencer, Iowa.
- Location
- 711 West 11th Street, Spencer, Iowa 51301
- CMS Provider Number
- 165449
- Inspections on file
- 20
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Spencer Post Acute Rehabilitation Center during CMS and state inspections, most recent first.
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.
The facility did not provide or document required bed hold notifications for residents transferred to the hospital for acute medical issues, including those with cognitive impairment, stroke, respiratory failure, and other serious conditions. Staff interviews and record reviews confirmed that bed hold forms were missing from the medical records, and the notifications were not completed at the time of transfer, contrary to facility policy.
Surveyors observed that staff failed to follow infection prevention protocols, including hand hygiene, proper cleaning of shared medical equipment, and use of PPE during care for residents with wounds, catheters, and enteral tubes on Enhanced Barrier Precautions. Staff used a blood glucose monitor on multiple residents without proper disinfection and did not consistently wear PPE during high-contact care activities, despite facility policies and CDC guidelines requiring these measures.
A resident was unable to access personal funds during weekends and was told to wait for the office manager, while staff and management interviews revealed no process or policy for providing funds outside business hours, resulting in a lack of reasonable access to personal funds.
Two residents prescribed high-risk medications did not have care plans that included required non-pharmacological interventions or targeted behaviors for monitoring. One resident's care plan lacked details for antipsychotic, psychotropic, and opioid medication management, while another resident's record did not show evidence of a required Gradual Dose Reduction for an antidepressant, despite repeated pharmacy requests.
A resident with anemia, cancer, and malnutrition was observed using oxygen, but the care plan, physician orders, and MAR did not reflect an order for oxygen therapy following a hospital discharge. Interviews with the ADON and DON confirmed the omission, which was not in accordance with facility policy requiring timely care plan updates.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
A resident with severe cognitive impairment and multiple medical conditions experienced significant weight loss over one month, but staff did not promptly identify or assess the change as required by facility policy. Although the care plan called for daily monitoring and regular weight checks, the necessary evaluation and intervention were delayed, and staff did not immediately obtain a reweight or initiate further assessment.
A resident with anemia, cancer, and malnutrition, who was cognitively intact, received medications via a feeding tube despite being able to take them orally. An RN failed to check tube placement before administering medications, pushed medications quickly through the tube, and left medication residue in the cup and syringe. Staff interviews and facility policy confirmed that tube placement should be checked prior to administration and medications should not be pushed rapidly.
A resident with severe cognitive impairment and end stage renal disease did not have consistent documentation of pre- and post-dialysis vital signs, and there was no record of communication with the physician regarding a fluid restriction. Facility policy required collection of dialysis run sheets and follow-up, but these were missing for multiple dialysis sessions, as confirmed by staff.
A medication error rate above 5% was found when a nurse failed to prime insulin pens before administering insulin to a resident with diabetes and severe cognitive impairment. The RN stated she had never been told to prime the pens, contrary to facility expectations, resulting in two medication errors during the observed medication pass.
Two residents experienced significant medication errors: one received insulin injections without proper priming of the insulin pen by an RN, and another had a prescribed anticonvulsant dose omitted by an LPN, contrary to facility policy. These errors were identified through observation, record review, and staff interviews.
During a lunch meal service, staff used a 3 oz scoop instead of the required 4 oz scoop to serve peas to 22 residents on regular diets, resulting in the failure to follow the prescribed menu and portion sizes as outlined in facility policy.
Two residents experienced deficiencies in medical record accuracy when physician orders were not properly transcribed into the EHR. One resident's MAR did not match the medication packaging or hospital discharge instructions for potassium chloride, and another resident was observed using oxygen without any corresponding orders or care plan documentation. Staff confirmed these discrepancies, and facility policy for recording orders was not followed.
A resident who was cognitively intact had previously received PCV13 and PPSV23 vaccines, but there was no documentation that the resident was educated about, offered, or provided the opportunity to consent to or refuse the recommended PCV20 or PVC21 vaccination, as required by CDC guidelines and facility policy.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in care. A resident on diuretics lacked a care plan for medication management, another with CHF had no updated care plan post-hospitalization, and a hospice resident's care plan lacked essential details. Additionally, a resident requiring eating assistance was left unsupervised, contrary to their care plan.
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. Observations and interviews revealed that call lights were not answered promptly for several residents, with delays ranging from 15 minutes to over an hour. The facility's policy requires call lights to be answered within a reasonable time, with the expectation set at 15 minutes, though the DON preferred a 5-minute response time. Staff was observed responding to call lights but was unsure of the facility's expectations for response times.
The facility did not post the daily census sheet, which includes resident census and nurse working hours, as required. An LPN found that the census sheet for the current day had not been completed, and previous sheets were stored in the medication room. The Administrator confirmed that the charge nurse should initiate the posting at the start of the day shift.
The facility failed to maintain sanitary practices, with observations of unclean ice makers and improper food handling. Staff were seen transporting milk without a lid, mishandling salt and pepper packets, and failing to change gloves or wash hands after touching non-food surfaces. These actions violated the facility's Food Safety and Sanitation policy.
The facility failed to follow proper infection control practices, including transporting uncovered linen carts, inadequate hand hygiene between resident contacts, and improper disinfection of contaminated equipment. A resident with an indwelling catheter and specific diagnoses required enhanced precautions, which were not followed. The DON confirmed the facility's expectations, but staff did not adhere to policies on hand washing and sanitizing wipes.
The facility failed to provide a call light within reach for a resident under contact precautions and did not address maintenance issues for another resident with a malfunctioning closet door. A resident with moderate cognitive impairment was unable to access their call light, contrary to facility policy. Another resident with severely impaired cognition had a closet door off its track and a misplaced toilet safety rail, with the Maintenance Supervisor unaware of these issues due to inconsistent reporting processes.
A facility failed to include a resident's psychotropic medication in the baseline care plan within 48 hours of admission, as required by policy. The resident, with intact cognition and multiple diagnoses including depression, was taking duloxetine as per the hospital discharge list. The omission was confirmed by the MDS Coordinator and acknowledged by the DON.
A resident's care plan was not updated after the discontinuation of mirtazapine, an antidepressant medication, despite facility policy requiring such updates. The MDS Coordinator admitted that the care plan should have been revised to reflect the medication change, highlighting a lapse in maintaining accurate care plans.
A resident's weight monitoring was not conducted as per physician orders, with discrepancies found between the MAR and EHR. The resident reported being weighed only once, while the MAR indicated multiple entries. An LPN claimed to have entered weights in the EHR, but they were missing, violating facility policy on accurate documentation.
A facility failed to provide a Restorative Exercise Program for a resident with severe cognitive impairment and functional limitations in range of motion. The resident was dependent on staff for daily activities and had contractures in both arms. The initial care plan included a directive for a Restorative Exercise Program, but the current care plan did not. The facility had discontinued all restorative programs following a prior deficiency, and no restorative staff were employed at the time.
The facility failed to attempt Gradual Dose Reductions (GDR) for two residents on psychotropic medications. One resident, with non-Alzheimer's dementia and depression, had their antidepressant reduced but not discontinued despite no symptoms. Another resident with severe cognitive impairment was on mirtazapine and escitalopram without documented GDR attempts. The DON cited difficulties in record organization due to a transition to electronic files and ownership change.
A resident with multiple health conditions, including renal disease, was not served the correct therapeutic diet as prescribed. Instead of the renal diet, the resident received regular diet items, including carrots, which were not on the menu. The facility's policy to ensure the correct tray is served was not followed, and a dietary aide confirmed that carrots were used as a substitution due to the unavailability of green beans.
A resident with a documented request for CPR was found unresponsive with no pulse or respirations. Despite the resident's full code status, the LPN and RN on duty did not initiate CPR. The LPN failed to check the resident's code status and left the room without performing resuscitation efforts. The RN confirmed the absence of vital signs but did not start CPR, as she was unaware of the resident's full code status at the time. The LPN was terminated for gross misconduct.
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 Provide and Document Bed Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to ensure that bed hold notices were provided to and signed by residents or their representatives when residents were transferred out of the facility, as required by facility policy. Clinical record reviews and staff interviews revealed that for four residents who experienced hospitalizations or transfers, there was no documentation of bed hold notifications in their medical records. Specifically, the records for these residents lacked bed hold forms for multiple hospital stays, and staff confirmed that the required notifications were not completed at the time of transfer. The residents involved had various medical conditions, including severe cognitive impairment, stroke, aphasia, hypertension, depression, acute respiratory failure, anemia, cancer, and malnutrition. In each case, the residents were transferred to the hospital for acute medical issues such as fractures, infections, or respiratory problems. Despite these transfers, the facility did not provide or document the required written bed hold notifications, as confirmed by the Director of Nursing, Assistant Director of Nursing, and Medical Records staff during interviews.
Failure to Implement Infection Prevention and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices involving several residents with complex medical needs, including those with catheters, wounds, and enteral tubes who were on Enhanced Barrier Precautions (EBP). Direct observation revealed that a registered nurse (RN) did not perform hand hygiene before donning gloves, failed to clean the blood glucose monitor between residents, and did not prime insulin pens as required. The same blood glucose monitor was used on multiple residents without proper disinfection, and the cleaning process did not adhere to the manufacturer's instructions for contact time with disinfectant wipes. The RN also admitted to not being instructed on priming insulin pens and was unaware of the required wet time for disinfectant wipes. Further observations showed that staff did not consistently use personal protective equipment (PPE) as required under EBP protocols. During wound care and catheter care for a resident, the RN failed to don PPE as mandated by EBP, despite the resident having a pressure ulcer and an indwelling catheter. In another instance, a resident with a feeding tube and an EBP sign on the door received medication and tube feeding from the RN without the use of PPE. The RN entered and exited the room multiple times, performing care activities without donning the necessary gown and gloves, even though PPE was available in the room. Interviews with the RN, Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed that staff were expected to follow EBP protocols, including the use of PPE during high-contact care activities for residents with wounds or indwelling devices. The DON and ADON acknowledged that the observed practices did not meet facility expectations or CDC guidelines. Facility policies reviewed by surveyors also required adherence to hand hygiene, proper cleaning of medical equipment, and the use of PPE as outlined by EBP and manufacturer instructions.
Failure to Provide Residents with Ready Access to Personal Funds
Penalty
Summary
The facility failed to provide residents with ready and reasonable access to their personal funds upon request. One resident reported that she was unable to access her personal funds during weekends and had to plan ahead to obtain money from the office before the weekend. She also stated that when she requested funds, she was told she had to wait for the office manager to be present. Staff interviews confirmed that there was no process in place for residents to access personal funds during non-business hours, and staff members were unaware of any method, such as a locked cash box, to provide funds outside of regular office hours. Further interviews revealed that the Business Office Manager acknowledged the absence of a current process for providing residents with access to their funds and noted that a lock box system had been discontinued about a year prior. The Director of Nursing was also unaware of any available personal funds on site for residents. Additionally, the facility lacked a policy related to personal funds, as confirmed by the Administrator. These actions and inactions resulted in residents not having reasonable access to their personal funds as required.
Failure to Document Non-Pharmacological Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to properly identify and document non-pharmacological interventions and targeted behaviors in the care plans for two residents who were prescribed high-risk medications. For one resident with a history of stroke, aphasia, and anxiety, the care plan did not specify targeted behaviors to monitor in relation to prescribed antipsychotic and psychotropic medications, nor did it include non-pharmacological interventions to be attempted prior to administering opioid medication for chronic pain. The Director of Nursing confirmed that these elements should have been included in the care plan. For another resident with severe cognitive impairment and a diagnosis of senile degeneration of the brain, the care plan noted the use of an antidepressant for insomnia but only included interventions to administer the medication and monitor for side effects and effectiveness. The clinical record did not contain documentation of a Gradual Dose Reduction (GDR) for the antidepressant, despite the pharmacy consultant having requested it multiple times. The facility's policy on psychotropic medications did not specifically address GDRs, and no evidence of a completed GDR was found in the resident's records.
Failure to Update Care Plan and Orders for Oxygen Therapy
Penalty
Summary
The facility failed to revise and update the care plan to include a new order for oxygen usage for one resident following a hospital discharge. Observations showed the resident was using oxygen via nasal cannula on multiple occasions, but a review of the Medication Administration Record and current physician orders did not show any documentation for oxygen usage. Additionally, the resident's care plan did not include information regarding oxygen therapy, despite the resident having a recent hospital discharge order for oxygen. Interviews with the ADON and DON confirmed that the oxygen order from the hospital discharge had been noted but was not entered into the resident's orders or care plan. The facility's policy requires the interdisciplinary team to develop and revise comprehensive care plans to reflect changes in orders or resident condition, but this was not followed in this case. The resident had diagnoses of anemia, cancer, and malnutrition, and was assessed as having no cognitive impairment.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Failure to Timely Identify and Assess Significant Weight Loss
Penalty
Summary
The facility failed to promptly identify and assess a resident who experienced significant weight loss. The resident, who had severe cognitive impairment and multiple diagnoses including senile degeneration of the brain, cancer, and atrial fibrillation, was noted to have lost 6.72% of body weight in one month, dropping from 126.5 pounds to 118 pounds. The care plan in place required daily monitoring and recording of food and fluid intake, as well as regular weight checks and dietary supplements as ordered. Despite these interventions, the significant weight loss was not immediately recognized or addressed by the staff. Staff interviews revealed uncertainty about the accuracy of the resident's weight, and a reweight was not obtained promptly after the initial low measurement. The facility's nutrition policy required evaluation by the Interdisciplinary Team for any resident with a weight change of 5% in 30 days, but this process was not followed in a timely manner. Observations showed that the resident was eating with some assistance and consuming supplements, but the necessary assessment and intervention for the weight loss were delayed.
Failure to Follow Feeding Tube Medication Administration Protocol
Penalty
Summary
A deficiency occurred when a registered nurse administered enteral medications through a feeding tube to a resident who was able to take medications orally, without verifying tube placement prior to administration as required by facility policy. The nurse prepared the medications by crushing them, mixing with water, and using a syringe to push each medication swiftly through the tube, followed by water, without checking for residual or proper tube placement beforehand. During the process, the resident coughed and an orange-like substance was expelled from the tube, prompting the resident to clamp the tube. The nurse later attempted to flush the tube with water and checked lung sounds only after medication administration was completed. Additionally, medication residue was observed left in the medication cup and on the syringe, indicating incomplete administration. The resident involved had diagnoses of anemia, cancer, and malnutrition, and was cognitively intact according to the MDS assessment. Staff interviews confirmed that medications should not be pushed quickly through the tube and that tube placement must be checked prior to administration. The facility's policy required verification of tube placement before administering feedings or medications, which was not followed in this instance. The Director of Nursing acknowledged that the nurse should not have administered medications via the tube when the resident could take them orally, should not have pushed medications swiftly, and should have ensured all medication was administered without leaving residue.
Failure to Ensure Proper Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards of practice, specifically regarding communication with the dialysis center and documentation of vital signs. The resident, who had severe cognitive impairment and diagnoses including end stage renal disease and chronic obstructive pulmonary disease, was scheduled for dialysis three times a week. The care plan indicated the need for dialysis and included a fluid restriction, but the clinical record did not document the fluid restriction or any communication with the physician about it. Review of the resident's dialysis notebook revealed multiple gaps in documentation of pre- and post-dialysis vital signs over several weeks. The facility's policy required collection of dialysis run sheets and follow-up with the provider on recommendations, but these records were missing for numerous dialysis sessions. Staff interviews confirmed the absence of required documentation, and the corporate nurse was unable to locate the missing vital sign records.
Medication Error Rate Exceeds Threshold Due to Improper Insulin Administration
Penalty
Summary
A medication error rate of 6.45% was identified during a review of medication administration practices, exceeding the acceptable threshold of less than 5%. The deficiency involved two of thirty-one medications not being administered as ordered. Specifically, a resident with severe cognitive impairment and a diagnosis of type 2 diabetes mellitus had physician orders for insulin Lispro per sliding scale and insulin Glargine daily. Observation revealed that the registered nurse (RN) did not prime the insulin pens before administration, as required by facility protocol and the physician's orders. During the observed medication pass, the RN prepared and administered both insulin Lispro and insulin Glargine without priming the pens, and later confirmed in an interview that she had never been instructed to prime the insulin pen needles. The Director of Nursing (DON) stated that the facility's expectation was for 2 units to be primed after cleansing the septum and attaching the needle for each insulin pen. This failure to follow proper insulin administration technique resulted in the identified medication errors.
Significant Medication Errors Due to Improper Administration and Omission
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration practices. One resident with severe cognitive impairment and a diagnosis of type 2 diabetes mellitus was prescribed insulin Lispro via sliding scale and insulin Glargine daily. During observed administration, a registered nurse failed to prime the insulin pens before injection, a step required to ensure needle patency and accurate dosing. The nurse admitted to never having been educated on priming insulin pens, and the facility did not provide a policy or procedure for insulin pen administration. Another resident, with no cognitive impairment and a history of traumatic brain injury, aphasia, and bipolar disorder, was prescribed Levetiracetam for seizure prevention. The resident's bedtime medication was omitted by an LPN, who later acknowledged simply missing the administration. The omission was discovered the following morning when the medication was found still in the medication pack. The facility's policy required medications to be administered as ordered and within prescribed time frames, but this was not followed in this instance. Both incidents were confirmed through review of medical records, staff interviews, and direct observation. The facility's policies outlined the correct procedures for medication administration, including the seven rights of medication administration, but these were not adhered to in the cases described, resulting in significant medication errors for the two residents.
Failure to Follow Menu and Portion Sizes for Regular Diets
Penalty
Summary
The facility failed to follow the prescribed menu and provide the correct portion size of peas to residents on regular diets during a lunch meal service. Observation revealed that the Certified Dietary Manager used a 3 oz scoop to serve peas instead of the required 4 oz scoop for all regular diet residents, affecting 22 out of 26 residents reviewed. Staff acknowledged the error during the meal service, and documentation confirmed that 22 regular diets were served with the incorrect portion. The facility's policy requires adherence to planned menus and portion sizes, which was not followed in this instance.
Failure to Accurately Transcribe Physician Orders and Maintain Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents by not properly transcribing physician orders into the electronic health record (EHR). For one resident, the Medication Administration Record (MAR) did not match the medication bubble pack for potassium chloride. The MAR indicated a dosage of 20 mEq twice daily, while the bubble pack and hospital discharge instructions specified 40 mEq daily. Staff interviews confirmed the discrepancy, and the Director of Nursing acknowledged the MAR was incorrect. Facility policy required that verbal orders be recorded immediately and accurately in the resident's chart, but this was not followed in this instance. For another resident, observations showed the individual was using oxygen, but there were no corresponding orders for oxygen use in the MAR, Treatment Administration Record (TAR), or current physician orders. The care plan also lacked information about oxygen usage. Staff interviews revealed that the oxygen order was present in the hospital discharge paperwork but was not transcribed into the facility's records upon the resident's return. The facility did not provide a policy for maintaining accurate resident records in this case.
Failure to Document Pneumococcal Vaccine Offer and Education
Penalty
Summary
The facility failed to properly screen, offer, provide education, and document consent or refusal for the pneumococcal immunization for one resident. Clinical record review showed that the resident, who was cognitively intact, had previously received PCV13 and PPSV23 vaccines, but there was no documentation that the resident was educated about, offered, or provided the opportunity to consent to or refuse the recommended PCV20 or PVC21 vaccination, as per updated CDC guidelines. Staff interviews confirmed that the expectation was for vaccinations to be offered according to resident preference, with education provided if refused. The facility's own policy required offering the pneumococcal immunization unless contraindicated or already administered, and mandated education about benefits and side effects prior to offering the vaccine. However, these steps were not documented for the resident in question.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in their care. Resident #50, who had a diagnosis of essential hypertension and localized edema, was prescribed diuretics but did not have a care plan that included focus, goals, or interventions related to the use of these medications. The MDS Coordinator and the Director of Nursing acknowledged the absence of necessary interventions such as lab work, monitoring blood pressure, and notifying the doctor of adverse reactions. Resident #20, who was transferred to the hospital for a low oxygen saturation and later admitted for congestive heart failure (CHF) exacerbation, did not have a care plan that included CHF focus or diagnosis-related interventions. Although a baseline care plan was created, it was not updated to reflect the resident's current condition after the hospital admission. This oversight was noted during the review of the resident's records. Resident #43, who was receiving hospice care, had a care plan that failed to document the terminal prognosis, the hospice company providing services, or contact information. The MDS Coordinator stated that hospice information was kept in a separate notebook, not included in the facility's comprehensive care plan. Additionally, Resident #3, who required assistance with eating, was observed eating unsupervised on multiple occasions, contrary to the care plan's directive for staff assistance. The facility's policy on comprehensive person-centered care planning was not adhered to, as evidenced by these deficiencies.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. Observations and interviews revealed that call lights were not answered promptly for five residents, with delays ranging from 15 minutes to over an hour. Resident #1, with no cognitive impairment, waited 27 minutes for assistance to use the toilet. Resident #17, with moderate cognitive impairment, experienced a 22-minute delay for help transferring to bed. Resident #37, with no cognitive impairment, reported frequent delays exceeding 15 minutes, while Resident #6, with intact cognition, mentioned waiting up to 45 minutes and being left in the dining room for extended periods. Resident #106, also with intact cognition, reported delays over an hour, with staff sometimes turning off the call light without addressing her needs. The facility's policy requires call lights to be answered within a reasonable time, with the expectation set by the Administrator and Director of Nursing (DON) at 15 minutes, though the DON preferred a 5-minute response time. Staff B, a CNA, was observed responding to call lights but was unsure of the facility's expectations for response times. The facility's failure to adhere to its policy and expectations resulted in significant delays in addressing residents' needs, as evidenced by the experiences of the five residents reviewed.
Failure to Post Daily Census Sheet
Penalty
Summary
The facility failed to post the daily census sheet, which includes the resident census and the actual working hours of nurses and nurse aides on duty for the current date. On the morning of 8/21/24, it was observed that there was no visible census posting in the Longhouse portion of the facility. A Licensed Practical Nurse (LPN) stated that the census sheet for the day had not been completed yet and that the prior day's posting was likely in the medication room. Upon retrieving the keys to the medication room, the LPN found census sheets dated from 8/16/24 to 8/19/24, but was unsure if a sheet for 8/20/24 had been completed, as she was off work that day. A census for 8/21/24 was subsequently filled out and displayed in the dining room. The Administrator later confirmed that the daily census posting should be initiated by the charge nurse for each shift, starting with the day shift at 6:00 am, and that the previous day's census should not be removed until the new one is posted.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain sanitary practices in food handling and storage, as observed during a survey. On two separate occasions, black and pink substances were found on the internal plastic ice cube guard edges in both the north and south building kitchens. Additionally, a Dietary Aide was observed transporting a gallon of milk without a lid, and the Dietary Manager improperly handled salt and pepper packets by placing them directly on a resident's plate after use. Further observations revealed improper glove use and hand hygiene practices by staff members. A cook was seen adjusting gloves and touching non-food preparation surfaces before handling food without changing gloves or performing hand hygiene. Another Dietary Aide handled bread with the same gloves used to open the packaging, again without changing gloves or washing hands. These actions were contrary to the facility's Food Safety and Sanitation policy, which requires staff to handle food safely and wash hands after unsanitary contact.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by several observations and staff interviews. Staff were observed transporting clean linen carts uncovered between buildings and in hallways, contrary to the facility's policy that requires linen to be covered during transport. Additionally, staff did not follow proper hand hygiene protocols, as they failed to wash hands between resident contacts and after handling contaminated items. This was observed during medication administration and feeding of residents, where staff did not perform hand hygiene between tasks or after touching potentially contaminated surfaces. In one instance, a staff member did not properly disinfect a wheelchair after it was contaminated during personal care for a resident with transmission-based precautions. The staff member acknowledged not allowing the sanitizing wipes to remain moist on the surface for the required two minutes, as per the instructions. This resident, who had an indwelling catheter and diagnoses of bullous pemphigoid and herpes viral infection, required enhanced barrier precautions, which were not adequately followed. The Director of Nursing confirmed the facility's expectations for infection control practices, including covering linen carts, performing hand hygiene, and using sanitizing wipes correctly. However, these expectations were not met, as evidenced by the observations and staff admissions. The facility's policies on hand washing and the use of sanitizing wipes were not adhered to, leading to deficiencies in infection prevention and control practices.
Deficiencies in Resident Accommodation and Maintenance Reporting
Penalty
Summary
The facility failed to provide a call light system within reach for a resident under contact precautions, and did not accommodate the needs of another resident with a malfunctioning closet door. Resident #22, who had moderate cognitive impairment and was under transmission-based precautions due to a severe acute respiratory infection related to a COVID diagnosis, was observed without a call light within reach. The call light was found on a recliner on the opposite side of the room, and both the Certified Nursing Assistant and the Director of Nursing acknowledged that the call light should have been within reach while the resident was in bed. The facility's policy required that residents have a means of communication with nursing staff, which was not adhered to in this instance. Resident #9, who had severely impaired cognition and required assistance with dressing, was found to have a closet door that was not attached to the overhead track, making it difficult to open. Additionally, a toilet safety rail was observed on the shower floor. Despite these issues being observed over multiple days, the Maintenance Supervisor was not aware of them and did not have a consistent process for identifying and addressing maintenance needs. The facility's maintenance policy required staff to report issues in a log book, but the Maintenance Supervisor did not maintain a separate log of needed repairs and had not transitioned to a new computer system for tracking maintenance requests.
Failure to Include Psychotropic Medication in Baseline Care Plan
Penalty
Summary
The facility failed to include psychotropic medications in the baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who had intact cognition with a BIMS score of 15 out of 15, was diagnosed with diabetes mellitus, cerebrovascular accident, depression, and metabolic encephalopathy. The resident was taking an antidepressant, duloxetine, as directed by the hospital discharge medication list. However, the baseline care plan did not reflect the use of this psychotropic medication until 10 days after admission. The MDS Coordinator confirmed the omission, and the Director of Nursing acknowledged that medications should be reviewed and included in the baseline care plan promptly.
Failure to Update Care Plan After Medication Change
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident diagnosed with non-Alzheimer's dementia and depression. The resident's Minimum Data Set (MDS) dated June 7, 2024, documented the use of antidepressant medications, including mirtazapine and sertraline. However, the medication history showed that the order for mirtazapine was discontinued on June 11, 2024. Despite this change, the care plan was not updated to reflect the discontinuation of mirtazapine. The MDS Coordinator acknowledged that care plans should be updated with medication changes and that a medication change from June should have been reflected in the care plan. The care plan review for the resident was last completed on February 2, 2024, and the next review was scheduled for May 2, 2024, but was not conducted. The facility's policy on comprehensive person-centered care planning, revised in March 2022, requires the interdisciplinary team to review and revise the resident's comprehensive plan of care after each assessment. The failure to update the care plan following the discontinuation of mirtazapine indicates a lapse in adhering to the facility's policy and ensuring accurate and current care plans for residents.
Failure to Follow Physician Orders for Resident Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders regarding the monitoring of a resident's weight upon admission. Resident #106, who was admitted to the facility with intact cognition, had a physician's order to have their weight taken upon admission, daily for three days, and then weekly for four weeks. However, discrepancies were found between the Medication Administration Record (MAR) and the Electronic Health Record (EHR). The MAR indicated weights were recorded on specific dates, but the EHR only showed weights on two different dates, suggesting a failure to accurately document the resident's weight as ordered. Interviews with staff and the resident further highlighted the inconsistency in weight documentation. Staff A, an LPN, claimed to have entered the weights in the EHR before signing the MAR, yet the weights were not present in the EHR. The resident also reported being weighed only once since admission, contradicting the MAR entries. The facility's policy requires accurate implementation of physician orders, including documentation in the Weight Summary section of the resident's chart, which was not adhered to in this case.
Failure to Provide Restorative Exercise Program
Penalty
Summary
The facility failed to provide a Restorative Exercise Program for a resident with severe cognitive impairment and functional limitations in range of motion affecting all four limbs. The resident was totally dependent on staff for daily activities and had contractures in both arms. The initial care plan included a directive for a Restorative Exercise Program for Functional Maintenance, but the current care plan did not include any such program. The facility had previously discontinued all restorative programs following a deficiency noted in a prior survey. The MDS Coordinator confirmed that residents were being reassessed for restorative programs, but no restorative staff were employed at the time. The facility's administrator stated that there was no policy on Restorative Exercise, and the staff had been directed to discontinue all restorative programs after a change in ownership. Certified Nurse Aides were expected to perform restorative programs, but no range of motion programs were in place for any residents.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) for two residents, which is a requirement under federal regulations for the use of psychotropic medications. Resident #19, diagnosed with non-Alzheimer's dementia and depression, had their antidepressant medication, Sertraline, reduced from 25 mg to 12.5 mg over a year ago. Despite the absence of depressive symptoms since the reduction, there was no documentation of attempts to discontinue the medication entirely to assess if the resident could maintain symptom-free without it. Similarly, Resident #14, who has severe cognitive impairment, was prescribed mirtazapine and escitalopram for recurrent depressive disorders. The facility was unable to provide documentation of GDR recommendations or physician follow-up for these medications over the past 13 months. The Director of Nursing (DON) acknowledged the difficulty in locating GDR records due to a transition from paper to electronic files and a change in facility ownership, which affected the organization of documents. The facility's policy requires GDRs and behavioral interventions unless clinically contraindicated, but these were not completed as expected.
Failure to Serve Correct Therapeutic Diet
Penalty
Summary
The facility failed to serve the correct therapeutic diet to a resident who was ordered a renal diet. The resident, who had intact cognition and diagnoses including anemia, coronary artery disease, heart failure, hypertension, renal disease, and diabetes mellitus, was observed receiving regular diet menu items instead of the prescribed renal diet. The electronic health record showed a physician order for a renal diet dated 10/05/22. During a lunch meal service, the cook served the resident regular diet items, including carrots, which were not on the menu for that day. The dietary manager confirmed that all diets should have included green beans, as indicated on the week 5 menu for modified renal diets. A dietary aide later stated that frozen carrots were used as a substitution due to the unavailability of frozen green beans. The facility's policy directed staff to ensure the correct tray is served to the right resident, which was not followed in this instance.
Failure to Implement CPR for Full Code Resident
Penalty
Summary
The facility staff failed to implement CPR for a resident who was found unresponsive with no pulse or respirations, despite the resident's documented request for CPR. The resident had a history of a fracture of the left wrist and hip and was admitted to the facility from the hospital. The resident's care plan and electronic health record indicated that she was a full code, meaning she desired CPR in the event of cardiopulmonary or respiratory arrest. On the day of the incident, a CNA found the resident unresponsive and summoned an LPN, who verified the absence of vital signs but did not initiate CPR. The LPN did not check the resident's code status and left the room without performing resuscitation efforts. Another RN later confirmed the absence of vital signs but also did not initiate CPR, as she was unaware of the resident's full code status at the time. Interviews with the staff revealed that the CNA noticed the resident's fixed gaze and lack of response, prompting her to call the LPN. The LPN observed the resident's condition, noted the absence of vital signs, and heard the resident take several sharp breaths but did not start CPR. The RN, who was called to confirm the absence of vital signs, found the CNA performing post-mortem care and did not question the LPN about the resident's code status. The Director of Nursing (DON) later confirmed that the resident had a current and active order for CPR and that the LPN had failed to adhere to the facility's CPR policy. The facility's policy required staff to administer CPR according to current national guidelines and to continue CPR until the arrival of rescue personnel or a physician's order to discontinue. The LPN involved was terminated for gross misconduct and failure to perform CPR on a resident with a full code status. The facility identified a total of 13 residents who had requested CPR at the time of cardiopulmonary or respiratory arrest.
Removal Plan
- All staff educated on the importance of CPR policy and protocol and what to do in the event of a non-responsive resident.
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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