Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stone Cottage Care Center during CMS and state inspections, most recent first.
A resident who was cognitively intact, totally dependent for ADLs, and had a suprapubic catheter reported being left in his stool for over an hour on multiple occasions, leaving him embarrassed and feeling stripped of dignity. Staff interviews and the resident’s account also described the DON using profanity and derogatory remarks toward him during an angry, accusatory exchange, which the resident said had happened since his first month at the facility.
A resident who was totally dependent for ADLs and had quadriplegia was observed with visible food residue and later a dry mouth and tooth film, while reporting that staff were not brushing his teeth as directed by the care plan. Staff gave inconsistent accounts of oral care frequency, and the DON and Administrator acknowledged the resident’s oral care was expected to be provided routinely. Another cognitively intact resident with quadriplegia, neurogenic bladder, diabetes, and an indwelling catheter reported not receiving peri care for several days; the resident was observed with reddened groin/scrotal areas, the care log lacked peri-care documentation for multiple days, and staff interviews confirmed the resident’s complaints that peri care was not being completed.
Failure to Separate Residents After Threats and Assault: Staff did not keep two residents apart after one resident threatened to hit the other and was seen with her arm raised as if to strike her. Later, during breakfast, the resident approached the other resident in the dining room and hit her in the head with a cup/mug while staff were nearby. The injured resident sustained a bruise and said she did not feel safe, while the aggressor had documented behavioral issues and required extensive assistance with ADLs and mobility.
Delayed call light response was identified for two residents who were totally dependent on staff for ADLs. One resident with quadriplegia reported waits of 30 minutes or more for help and missed repositioning, while another resident with spinal cord dysfunction, quadriplegia, and a suprapubic catheter reported waits of up to 4.5 hours, delays in being cleaned after BMs, and missed bed baths. Staff and the DON reported frequent call-offs, short staffing on multiple shifts, and response times often far beyond the facility’s expected 15-minute standard.
Failure to Provide Ordered OT Services: A cognitively intact resident with quadriplegia, neurogenic bladder, and total dependence for ADLs did not receive ordered OT services. The resident said he had not been getting OT for ADLs, staff reported therapy had stopped because recertification was not completed, and the OT assistant said she could not continue until the OT completed the recertification.
Two residents with quadriplegia and total dependence on staff were unable to reliably access assistance due to ineffective call light systems. One resident had to use a cell phone and later a motion sensor doorbell, both of which were not consistently accessible or audible to staff, resulting in significant delays in response. Another resident relied on a voice-activated cell phone, but was unable to use it without help during observation. Staff confirmed frequent delays in answering calls due to system limitations and staffing issues, contrary to facility policy requiring prompt and accessible call light response.
A resident with quadriplegia and total dependence on staff experienced repeated delays in call light response, sometimes waiting over an hour for assistance. The resident initially used a cell phone as a call light, which was unreliable, and later received a motion sensor system that staff often could not hear or distinguish from others. Staff interviews confirmed that high acuity and insufficient staffing contributed to the inability to answer call lights promptly, in violation of facility policy.
A resident with severe cognitive impairment and a history of repeated falls experienced multiple unwitnessed falls, resulting in serious injuries and hospitalizations, due to the facility's failure to provide adequate supervision and implement effective fall prevention strategies. Despite documented high fall risk, noncompliance with interventions, and family requests for increased supervision, staff did not increase monitoring or involve the family in care planning, and medications increasing fall risk were reinstated against hospital recommendations.
Unqualified Dietary Manager: The facility failed to employ a qualified Dietary Manager in the absence of a full-time dietitian. Staff E, the DM, had not completed the CDM course and said she was still enrolled and expected to finish later. The Administrator stated the DM should be certified, noted the course had not been completed previously, and said there was no policy for DM qualifications.
Lack of QAPI Documentation for Repeated Deficiencies: The facility failed to maintain documentation showing that QAPI activities were used to develop, implement, and evaluate corrective actions or performance improvement activities for repeated deficient practices cited in prior surveys and investigations, including F658, F695, F801, F865, F887, and F550. QAPI records did not show structured investigation, root cause analysis, or monitoring of whether corrective actions were effective, despite the facility policy requiring systematic identification, reporting, investigation, analysis, and prevention of adverse events.
Delayed Response to Resident Call Lights: Residents reported long waits for call lights to be answered, often 15 minutes to 1.5 hours, despite staff stating lights should be answered within 15 minutes. A resident council summary also noted concerns that weekend aides were too slow responding. Residents with intact cognition and significant assistance needs for toileting, hygiene, bed mobility, and transfers described waiting for help to use the bathroom, get cleaned up, or receive other care, and staff acknowledged that responses could take longer when resident needs increased.
Failure to Supervise Resident Who Went Outside Without Oxygen: A resident with COPD, dementia, and oxygen use was allowed outside in hot, humid weather without her O2 and later walked behind the building unsupervised. Staff documented that she refused to come inside, refused oxygen, and was eventually found walking around the facility with her walker before multiple staff redirected her back inside. Interviews showed staff disagreement about whether she could be outside alone, but several staff stated she needed supervision and oxygen when outside.
Failure to verify hospice oxygen orders for a resident with COPD and moderately impaired cognition. The resident had facility oxygen orders for PRN O2 via NC, while the hospice plan of care included continuous O2 for dyspnea. The DON stated she had not reviewed the hospice oxygen orders and that hospice usually sent orders to the provider before they were sent to the facility; she also stated she wanted a specific oxygen setting instead of a range and that the PRN order remained in place.
A resident with moderately impaired cognition and diagnoses including anxiety disorder, bipolar disorder, and seizure disorder was prescribed Ativan 0.5 mg BID for seizure activity, but nursing documentation and staff interviews showed the resident was given another resident's Oxycodone instead of Ativan on separate occasions. The EMR did not contain an order for Oxycodone for the resident, and the facility's medication administration policy required verification of the resident and medication against the MAR.
Failure to offer a COVID-19 booster to a resident and failure to provide COVID-19 vaccination information to staff. A resident with hemiplegia, mild intellectual disabilities, and muscle weakness had a BIMS score of 14/15 and a prior COVID-19 vaccine documented, but the facility had no documentation of education about an updated booster. Staff in Laundry and Housekeeping stated they were not provided information about COVID-19 vaccination, and HR stated the facility did not offer or provide education to staff regarding the vaccine.
A CMA failed to treat a resident with dignity during inhaler administration. After the resident used her Symbicort inhaler and spit into a tissue, the CMA made a disgusted face, gestured toward the resident, and said "ew loogie" near the dining room where other residents and staff were present. The resident had intact cognition and diagnoses including HF, DM, and hemiplegia, and the DON said the behavior was not appropriate.
A resident with intact cognition and diagnoses including HF, DM, and hemiplegia received Symbicort inhaler treatment, but the CMA only gave her water to swish and swallow instead of ensuring she rinsed and spit as directed. The MAR and medication guidance required mouth rinsing without swallowing after inhalation, and the DON stated staff should have the resident swish and spit after using the inhaler.
A resident with dysphagia, Parkinson's disease, and anxiety disorder was placed on a liquid diet after an endoscopy and later advanced to a pureed diet. The resident refused the pureed diet and wanted mechanical soft foods, which were provided, but the facility did not document notifying the provider of the refusal and did not document initiation of ordered ST services. The DON stated the provider wanted follow-up with ST, and an OTA said an ST order had been received but a therapist had not been able to visit.
Medication Error Rate Exceeded 5%: The facility’s medication administration error rate was calculated at 7%. For a resident with anxiety, hemiplegia, paraplegia, and intact cognition, a CMA administered morning meds but omitted famotidine and did not have the ordered nicotine patch available. The eMar noted the facility waited for the patch to come in, and the DON stated staff should have called the pharmacy if a medication was not available and should have checked the medications better.
A resident with cognitive impairment was administered a suppository against his will on two occasions by an LPN, despite his clear refusal. The LPN justified the action due to the resident's constipation and potential health risks. The facility failed to respect the resident's right to refuse treatment, as acknowledged by the DON.
A facility failed to properly document and communicate the discharge process for a resident with significant cognitive impairments and medical needs. The resident's mother was informed verbally about the discharge due to state requirements but did not receive written notice or information about her right to appeal. The facility relied on verbal communication and progress notes, which were insufficient for a safe transition.
A facility failed to provide a resident with written notice of discharge and information on appeal rights. The resident, with cognitive impairments and requiring significant assistance, was discharged after a six-month process without proper documentation. The resident's mother was informed verbally and was unaware of her rights, as no written notice or appeal information was provided.
The facility was found to have multiple sanitation and food handling deficiencies. Dust and food debris were observed in the kitchen, including on the fire suppression system, microwave, and air conditioning unit. The Dietary Manager handled food without gloves during meal preparation for a resident. Additionally, the ice machine had a buildup of substances, and cleaning policies were not followed.
The facility did not employ a qualified Director of Food and Nutrition Services in the absence of a full-time dietitian. The Dietary Manager, not yet a Certified Dietary Manager, was enrolled in a CDM course but had not completed it due to work commitments. She could contact the dietitian but did not have regular consultations. The Administrator confirmed her enrollment in the course with a year to complete it.
The facility failed to conduct a record check evaluation before hiring an RN, identified as Staff B, despite a Criminal History (CCH) record being found. The Business Office Manager and Administrator acknowledged the oversight, and the Director of Nursing planned to cover Staff B's shifts if the evaluation was not completed. The facility's Abuse Policy required adherence to background check protocols.
A facility failed to include fall interventions in the care plan for a resident with a history of falls, despite multiple incidents. The same resident experienced significant weight fluctuations without appropriate care plan interventions or physician notification. Additionally, another resident's inappropriate sexual behaviors towards staff and other residents were not addressed in the care plan, despite multiple documented incidents.
A facility failed to discard an insulin vial after 28 days, as required by professional standards. An RN administered insulin to a resident with Type II diabetes using a vial without a visible open date, and the medication bottle indicated a change date exceeding the 28-day limit. The RN and DON were uncertain about the correct discard period, and the facility's policy was not followed, leading to the use of insulin beyond the recommended period.
A facility failed to address significant weight fluctuations in a resident with a history of stroke, shortness of breath, and diabetes, who was at risk of impaired nutrition. Despite a 10.7% weight loss and a policy requiring physician notification of significant weight changes, the resident's care plan lacked interventions to prevent further weight loss. The facility's process for addressing weight changes was not followed, as the resident's clinical record did not document physician notification or appropriate care plan adjustments.
A resident with COPD and moderately impaired cognition was observed without her oxygen concentrator on multiple occasions, leading to shortness of breath and wheezing. Staff interviews revealed that the oxygen concentrator was not consistently returned to the resident's room after meals, and the resident was seen pushing it herself, which was unsafe. The facility failed to ensure the resident's oxygen was readily available and safely managed.
A resident with chronic pain and moderately impaired cognition did not receive appropriate pain management, as the facility failed to administer as-needed medications or conduct pain assessments despite the resident's complaints. Staff interviews indicated a lack of awareness and response to the resident's pain, contrary to the care plan directives.
The facility failed to document the pneumococcal vaccination status for three residents, with missing records of consent or declination forms. The DON admitted to not having access to the Iowa Registry Immunization System and not realizing the need for documentation, despite facility policy requiring all residents to be offered the vaccine.
The facility failed to properly document and offer COVID-19 vaccines to three residents. One resident's EMR showed a vaccine refusal without a date, while IRIS indicated they received a vaccine. Another resident's EMR showed a booster was received, but lacked documentation of additional vaccines being offered. A third resident's EMR had no vaccination records, and IRIS confirmed no vaccines were received. The DON admitted to not having access to IRIS and not obtaining signed consent or declination forms.
The facility's ineffective QAPI process resulted in repeat deficiencies related to care plan revision, food procurement, and QAPI good faith, as identified in recent surveys. Despite conducting monthly mock surveys, the facility failed to maintain substantial compliance, with unclear expectations from the Administrator. The QAPI Plan aimed to promote consistent systems and resolve negative outcomes, but it was not effective in preventing these issues.
The facility failed to treat residents with dignity and respect in several instances. A resident with severe intellectual disabilities was mishandled by a CNA, causing red marks on her neck. Another resident reported rough incontinence care and public discussion of her financial situation by the DON. A third resident felt ignored by staff who talked among themselves while providing care. The Administrator acknowledged these issues and the HIPAA violation.
A resident with a history of physical aggression pinched another resident, despite having a care plan that included 30-minute checks and previous 1:1 supervision. Staff were assisting other residents at the time, leaving the aggressive resident unsupervised. The facility's abuse policy was not effectively implemented.
The facility failed to report an allegation of abuse to the State Agency when a staff member mishandled a resident with severe intellectual disabilities, causing choking. Despite multiple witnesses and visible red marks on the resident's neck, the facility did not report the incident and allowed the staff member to continue working without further investigation.
The facility failed to thoroughly investigate and ensure immediate protection for two residents following abuse allegations. One resident was mishandled by a CNA, and another resident repeatedly exhibited inappropriate behavior towards others. The facility did not follow its policies on resident rights and abuse, leading to a failure in maintaining a safe environment.
The facility failed to supervise a resident with a history of inappropriate behavior, leading to a privacy violation of another resident with severe intellectual disabilities. The incident was not reported immediately, and the resident's care plan lacked guidance for staff supervision.
The facility failed to provide sufficient staff with the necessary skills to care for a cognitively impaired resident requiring 1:1 supervision and another resident with behaviors affecting others. Incidents involving improper handling and lack of supervision were documented, and staff training records revealed a lack of education related to resident behavioral health needs.
The facility failed to conduct adequate QA activities to address problem-prone areas and create a plan for improvement. CMS 2567 reports listed concerns under tags F550, F609, F610, and F689. Review of QA activities revealed inadequate documentation, including a lack of data collection, monitoring, audits, staff input, and performance indicators. The QA committee did not systematically identify, report, track, investigate, analyze, or utilize data to develop activities to prevent future adverse events. The Administrator acknowledged that QA activities should be carried out, including monthly coverage of abuse prevention.
Failure to Preserve Resident Dignity and Use Respectful Communication
Penalty
Summary
The facility failed to maintain the dignity of Resident #8 by allowing him to remain in his own stool for extended periods before incontinence care was provided. Resident #8 was cognitively intact with a BIMS score of 15 and had diagnoses including traumatic spinal cord dysfunction, quadriplegia, neurogenic bladder, and diabetes mellitus. He was totally dependent on staff for all activities of daily living and had an indwelling urinary catheter. During an observation, he was seen in bed wearing a hospital gown with red stains near the neckline and stated that when he had to sit in his stool for about 1.5 hours, it made him angry, embarrassed, and stripped of his dignity. He also reported that this happened many times and that he had sat in feces for over an hour on multiple occasions. The facility also failed to treat Resident #8 with dignity and respect during interactions with the DON. Staff interviews and the resident’s statements described the DON using profanity and derogatory language toward him, including calling him an alcoholic narcissist and telling him to leave if he did not like it there. A CNA reported hearing the DON make these statements during a wound care-related encounter, and an RN reported that the resident told her the DON had used similar language. Resident #8 stated the exchange was angry, accusatory, and upsetting, and that the DON had treated him this way since his first month at the facility. The care plan identified the resident as having concerns about staff response times and directed staff to respond promptly and respectfully, but the reported interactions did not reflect that approach.
Failure to Provide Ordered Oral Care and Peri Care
Penalty
Summary
The facility failed to provide oral care to a resident who was totally dependent on staff for all activities of daily living due to quadriplegia and had intact cognition. The resident’s MDS identified severe functional dependence, and the care plan directed staff to explain care, provide personal care in pairs, and brush his teeth/provide oral care daily in the evening. During observation, the resident was found in bed with visible food residue on the front surfaces of his upper and lower teeth and later with a dry mouth and visible residue/film on his teeth. The resident stated he had to ask for oral care and reported that his teeth had not been brushed since the evening of 5/18/26, and later said the last oral care he received was on 5/21/26 and 5/22/26. Staff interviews showed inconsistent understanding of the resident’s oral care needs. A CNA stated oral hygiene should be provided at least once a shift or as directed on the Kardex, while another CNA initially said she used a toothette and was not sure how often oral care was required until she checked the Kardex and saw the care plan directed teeth brushing daily in the evening. The DON stated staff were expected to follow the care plan and brush the resident’s teeth/provide oral care daily in the evening, but also said the resident liked to stay up later and staff would do the care when he called the facility and was ready to lie down. The Administrator stated she expected oral care at least in the morning and evening or as directed, and said there should not have been any reason it was not done. The facility also failed to provide peri care for another resident who was cognitively intact, totally dependent for ADLs, and had diagnoses including traumatic spinal cord dysfunction, quadriplegia, neurogenic bladder, and diabetes mellitus, with an indwelling urinary catheter. The care plan identified the resident’s concerns that staff were not completing cares and directed staff to document care provided in a log when entering the room. Progress notes stated staff documentation should reflect ongoing peri-care assistance and resident-maintained signature logs, but the facility did not provide documentation showing peri-care audits were completed. The log reviewed contained no peri-care documentation for multiple consecutive days in May 2026. During observation, the resident was seen in bed with red stains near the neckline of his gown, and the groin and scrotal area appeared reddened. He reported he usually received peri care once a shift, but said he had gone five days without it before receiving care at 5:00 AM. He later stated that when peri care was done, staff cleaned around the suprapubic catheter area but did not touch his groin area. Staff interviews reflected the resident’s repeated complaints that he had not received peri care for five days, and one CNA stated she could not explain why the care was not being done. The Administrator stated she would expect peri care after every incontinent episode and upon rising and before bed, but also said the resident had just had peri care before he made the statement.
Failure to Separate Residents After Threats and Assault
Penalty
Summary
The facility failed to separate two residents after one resident made verbal threats that she would hit the other resident and was later observed behind her with her arm raised as if to strike her. The report states that staff were aware of the conflict between the two roommates, including repeated verbal exchanges about one resident waking the other during the night, but the residents were not kept apart after the threat was reported. The deficiency involved failure to provide adequate supervision and to prevent an accident hazard in the resident area. Resident #11 had diagnoses including hypertension, diabetes, anxiety, asthma, and insomnia, and her MDS showed intact cognition with a BIMS score of 14 out of 15. She required substantial assistance with transfers, dressing, toileting, bathing, and walking short distances, and used a wheelchair and walker. Her care plan identified behaviors that could interfere with care, socialization, or safety, and later added a problem for episodes of physical aggression toward peers, with interventions to monitor behaviors, remove her from triggering environments, and use de-escalation techniques. Despite these documented behaviors, staff interviews indicated that after Resident #11 said she was going to hit Resident #12, no room change or other separation occurred before the later assault. Resident #12 had diagnoses including hypertension, CVA, diabetes, seizure disorder, anxiety, depression, acute pain due to trauma, fractures, and substance abuse history. Her MDS showed mild cognitive impairment with a BIMS score of 11 out of 15, and she required maximal assistance for repositioning, transfers, dressing, toileting, and hygiene, and was unable to stand or ambulate. During breakfast, Resident #11 approached Resident #12 in the dining room and struck her in the head with a water cup or thermos mug while staff were present in the area. Resident #12 sustained a bruise on her face/head area, voiced that she did not feel safe, and requested transfer to another facility.
Delayed Call Light Response and Staffing Shortages
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift, as shown by delayed responses to call lights for two residents. Resident #6 was admitted with quadriplegia, seizure disorder, anxiety, depression, asthma, skin graft failure, and a stage 4 pressure ulcer. His MDS showed intact cognition, total dependence on staff for all ADLs, and inability to stand or ambulate. He reported that he used a device to activate his call light and often waited 30 minutes or more for staff to respond, with delays occurring 3 to 4 times per week and some repositioning needs going unmet for over 2 hours on the night shift. Resident #8 was also cognitively intact and totally dependent on staff for all ADLs, with diagnoses including traumatic spinal cord dysfunction, quadriplegia, neurogenic bladder, and diabetes mellitus. He had an indwelling suprapubic catheter and reported multiple instances of prolonged waits for call light response, including waits of 1.5 hours, over 2 hours, and up to 4.5 hours. He described delays in being cleaned after bowel movements, including sitting in stool for extended periods, and stated that bed baths were missed on multiple occasions. During observation, he was seen in bed wearing a hospital gown with red stains near the neckline and his catheter drainage bag positioned below bladder level in a dignity bag. Staff interviews supported the residents’ reports of staffing shortages and delayed call light response. The DON stated there were staffing problems, with daily call-ins on second and third shift and management staff working off shifts to fill gaps. CNA staff reported that call lights should be answered within 15 minutes but often took 30 to 45 minutes or longer, and that there were not enough staff to provide needed care, especially because many residents required two-person assistance and mechanical lifts. The Administrator stated she expected call lights to be answered within 15 minutes, and the facility policy directed staff to answer call systems immediately and complete requests within five minutes if possible.
Failure to Provide Ordered OT Services
Penalty
Summary
The facility failed to provide occupational therapy for Resident #8, who was cognitively intact with a BIMS score of 15 and had diagnoses of traumatic spinal cord dysfunction, quadriplegia, neurogenic bladder, and diabetes mellitus. The resident’s MDS identified him as totally dependent on staff for all activities of daily living and having an indwelling urinary catheter. A physician order dated 11/6/25 directed occupational therapy to evaluate and treat as ordered, but the last occupational therapy progress note was dated 4/2/26. The care plan, last revised 3/4/26, identified the resident as quadriplegic but did not address the occupational therapy order. On 5/20/26, the resident stated he had not received occupational therapy for activities of daily living. Staff later reported that the occupational therapy assistant had not worked with him for several weeks, and the assistant stated she had last worked with him about a month earlier because recertification had not been completed. The occupational therapist was behind on recertifications due to a family illness, and the administrator confirmed the therapist needed to complete recertification and that the facility did not have full-time in-house therapy staff.
Failure to Provide Effective Call Light System for Residents with Severe Physical Impairments
Penalty
Summary
The facility failed to provide an effective call light system for two residents with quadriplegia and both upper and lower extremity impairments, resulting in unmet needs for timely assistance. One resident, who was totally dependent on staff for all activities of daily living (ADLs) and had intact cognition, was unable to use standard call bells, bed controls, or other devices due to his condition. Upon admission, this resident had to rely on a cell phone to call for help, but faced difficulties when the phone was not charged or within reach. After eight days, the facility provided a motion sensor doorbell system, but the resident reported that it was not reliably heard by staff, especially when they were in other rooms or away from the common area. The resident documented multiple instances where the call system was activated but not answered for extended periods, sometimes up to an hour or more. Staff interviews confirmed that the call light system was inadequate for residents with severe physical impairments. Staff reported that the motion sensor doorbell used by the resident was difficult to hear, especially when staff were behind closed doors or down another hallway. Additionally, high resident acuity and staffing shortages contributed to delays in responding to call lights, with staff acknowledging that it often took more than 30 minutes to answer calls. The maintenance director was aware of the resident's request for a breath-activated call light system and had attempted to find a compatible solution, but the resident continued to experience delays in receiving assistance. A second resident with quadriplegia, also totally dependent on staff for care, preferred to use a voice-activated cell phone to call the facility for help. However, during an interview, this resident was unable to successfully use the voice command system without assistance, as the phone required a restart before it could be used. The facility's policy required that call lights be accessible and functioning at all times, and that staff respond promptly to residents' requests, but these requirements were not met for residents with significant physical limitations who could not use standard call systems.
Failure to Respond Timely to Call Light for Dependent Resident
Penalty
Summary
The facility failed to provide timely responses to a resident's call light, resulting in significant delays in assistance for a resident who was completely dependent on staff for all activities of daily living due to quadriplegia and other medical conditions. The resident, who had intact cognition, required total staff assistance for hygiene, mobility, toileting, and other care needs. Upon admission, the resident initially had to use a cell phone as a call light, which was unreliable due to battery and accessibility issues. After eight days, the facility provided a motion sensor doorbell system as a call light, but this system only rang once in the common area and was not consistently audible to staff, especially when they were in other rooms or down the hallway. Multiple documented instances showed that the resident's call light went unanswered for periods ranging from 15 minutes to over an hour. Observations confirmed that after activating the motion sensor call system, staff did not respond within a reasonable timeframe. Staff interviews corroborated these findings, with several staff members reporting that high resident acuity and insufficient staffing levels made it difficult to answer call lights promptly. Staff also noted challenges in distinguishing between different residents' doorbell systems and hearing the alerts when not in the immediate area. Facility policies required timely responses to call lights and sufficient staffing based on resident needs and acuity. However, both staff and the resident reported ongoing issues with the call light system's effectiveness and the facility's ability to meet response time expectations. The Director of Nursing and the administrator acknowledged the resident's concerns and the limitations of the current call light system, as well as the challenges posed by staffing levels and resident acuity.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and staff assistance to prevent injuries from falls for a resident with a significant fall history and severe cognitive impairment. The resident had multiple diagnoses, including repeated falls, Wernicke's encephalopathy, alcohol dependence with withdrawal delirium, arthritis, and severe cognitive impairment as indicated by a low BIMS score and symptoms of delirium. The resident required moderate staff assistance for transfers and personal care, was at high risk for falls as documented by repeated high scores on fall risk assessments, and had experienced 20 falls over a four-month period, with half of these occurring unwitnessed in the resident's room. Several of these falls resulted in serious injuries requiring hospitalization, including subdural hematoma, skull fracture, and multiple fractures with hemothorax. The facility's care plan included various interventions such as regular safety rounding, keeping the call light within reach, environmental modifications, and encouraging the resident to request assistance. However, the resident was often noncompliant with these interventions, preferring independence and frequently refusing assistance or environmental cues. Staff interviews confirmed that the resident insisted on keeping his room door closed, making it difficult for staff to monitor him, and that staff were hesitant to disturb him due to his agitation when awakened. Despite the high risk and repeated falls, there was no evidence of increased direct supervision or implementation of additional monitoring strategies, such as the use of a baby monitor, to address the resident's specific behaviors and preferences. Additionally, the facility failed to involve the resident's family or legal representative in required care conferences, despite repeated requests from the family for increased supervision and specific fall prevention interventions. The family and POA reported not being invited to participate in care planning and expressed concerns that their input regarding safety measures was not considered. The facility also reinstated medications that increased the resident's fall risk, contrary to hospital discharge instructions, and did not document any alternative strategies to mitigate these risks. These actions and inactions contributed to the resident's continued falls and serious injuries.
Unqualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified person to serve as the Dietary Manager in the absence of a full-time dietitian. Based on professional certification review and staff interviews, the facility had a census of 30 residents and lacked documentation as of 9/2/25 that Staff E, the Dietary Manager, had completed the Certified Dietary Manager course. On 9/3/25 at 11:00 a.m., Staff E stated she had not completed the CDM course and said she started in August 2025 and expected to finish in December 2025. On 9/4/25 at 12:27 p.m., the Administrator stated the Dietary Manager should be certified, said Staff E had been enrolled last year but did not finish, and was currently in the course again. The Administrator also stated there was no policy regarding Dietary Manager qualifications.
Lack of QAPI Documentation for Repeated Deficiencies
Penalty
Summary
The facility failed to maintain documentation showing that its QAPI activities were carried out to develop, implement, and evaluate corrective actions or performance improvement activities related to repeated deficient practices. Review of QAPI meeting documentation, policy, and staff interview showed no evidence of an ongoing QAPI program addressing the cited concerns from prior surveys and investigations, including F658, F695, F801, F865, F887, and F550. The Administrator, who had been in her position for 2 months, stated that she and the DON had reviewed the prior 2567s, recognized the concerns in QAPI, investigated root causes, and provided staff education. Despite that statement, the facility’s QAPI records since the previous survey did not show documentation of structured, systematic investigation, analysis of underlying causes or contributing factors, or monitoring and evaluation of whether corrective actions or performance improvement activities were effective. The facility policy titled Quality Assurance and Performance Improvement, dated 9/2022, stated that the facility would maintain documentation and evidence of systematic identification, reporting, investigation, analysis, and prevention of adverse events, and would document the development, implementation, and evaluation of corrective action or performance improvement activities through a data-driven QAPI program focused on quality of life and quality of care indicators.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs in a timely manner, and residents reported prolonged waits for call lights to be answered. During the survey, 4 of 5 residents reviewed for call lights reported waiting as long as 90 minutes. The facility had a census of 30 residents, and staff interviews confirmed that call lights were expected to be answered within 15 minutes, but staff also acknowledged that responses could take longer when resident needs increased and that there had been resident complaints about delayed responses. Resident #6 had diagnoses including epilepsy, schizophrenia, PTSD, and repeated falls, with intact cognition and assistance needs for dressing, bathing, toileting, and transfers. The resident stated she sometimes waited a half hour or more for help to use the bathroom or get cleaned up, and reported waiting about a half hour for staff to answer her light so she could use the toilet that morning. Resident #8 had diagnoses including stroke, paraplegia, epilepsy, and bipolar disorder, with intact cognition and substantial to maximal assistance needs for toileting, hygiene, bed mobility, and transfers. That resident reported call lights could take 30 minutes or longer and said staff often did not take the time to make sure she had everything she needed before leaving the room. Resident #11 had diagnoses including chronic kidney disease, anxiety disorder, depression, and unsteadiness on their feet, with intact cognition and dependence on staff for toileting, hygiene, dressing, bed mobility, and transfers. The resident reported call light waits well over 15 minutes, with night shift being the worst, and said waits could be as long as 1.5 hours. Resident #12 had diagnoses including heart failure, recent UTI, and schizoaffective disorder, with intact cognition and substantial to maximal assistance needs for transfers and toileting. That resident reported waiting a half hour or more for help, described a call bell system that sounded the same for all residents, and said staff could see call light indicators but did not always respond right away. Resident council minutes also documented that residents wanted weekend aides to be quicker answering call lights, and the minutes did not include follow-up with residents.
Failure to Supervise Resident Who Went Outside Without Oxygen
Penalty
Summary
The facility failed to adequately supervise a resident after the resident went outside without oxygen and later walked behind the building and around the facility unsupervised. The resident had diagnoses of COPD and dementia, used oxygen therapy, and had care plan interventions for supplemental oxygen and supervision/cueing due to impaired cognitive function. The resident’s cognitive testing in the record varied, including scores showing severe impairment, and the resident was documented as refusing oxygen and refusing to come back inside while outside in hot, humid weather. On the day of the incident, staff documented that the resident wanted to go outside to the back patio, refused to stay indoors because of the heat and humidity, and refused oxygen and water. The resident was allowed to remain outside after staff were notified, and later staff were alerted that the resident was no longer sitting where she had been. CNA staff then found the resident walking behind the facility on the sidewalk with her walker. Staff attempted to redirect the resident back inside, but the resident refused and continued walking until staff were able to bring her back toward the building. Interviews showed staff disagreement and uncertainty about the resident’s supervision needs. Some staff stated the resident should have been with staff when outside and should not have been outside unsupervised, while others stated she might be alright unsupervised except for not having oxygen and the hot weather. The DON stated the resident was cognitively intact and independent, but also acknowledged the resident was not always cognitive and that the resident had been based on her BIMS score at the time of the incident. Staff also reported the resident had been outside by herself for about an hour to an hour and a half and that it took multiple staff to get her back into the building.
Failure to Verify Hospice Oxygen Orders
Penalty
Summary
The facility failed to verify oxygen orders with the hospice provider for one resident who had COPD and used oxygen therapy. The resident’s MDS showed a BIMS score of 8 out of 15, indicating moderately impaired cognition, and the care plan identified a focus area for COPD with risk for shortness of breath, impaired breathing, and respiratory infections, with interventions to administer supplemental oxygen as ordered by the physician. The EMR contained physician orders for oxygen via nasal cannula at 1-5 liters PRN to keep oxygen greater than 89% and later oxygen via nasal cannula at 3 liters PRN to keep oxygen greater than 90%. The hospice team plan included an order for oxygen 2-4 liters continuous for dyspnea, but during interview the DON stated she had not looked at the hospice oxygen orders. The DON stated hospice usually sent orders to the provider and then the orders were sent to the facility, and she requested a specific order for one oxygen setting instead of a variation of liters. The DON stated it was her fault that the PRN oxygen remained on the order. The facility’s oxygen administration policy required verification of a physician order, review of physician orders or facility protocol, and review of the resident’s care plan, and the hospice services policy stated facility staff may administer prescribed therapies when the facility becomes aware of the alleged violation.
Medication Administration Error Involving Controlled Drug
Penalty
Summary
The facility failed to administer a resident their prescribed controlled medication for 1 of 6 residents reviewed for medication administration. Resident #17 had an admission MDS showing a Brief Interview for Mental Status score of 10 out of 15, indicating moderately impaired cognition, and diagnoses including anxiety disorder, bipolar disorder, and seizure disorder or epilepsy. The MDS also indicated the resident was prescribed antipsychotic, antianxiety, and antidepressant medications, and the care plan directed staff to give antianxiety medications as ordered by the physician. The EMR showed an order for Ativan 0.5 mg by mouth twice a day for seizure activity, but it did not show an order for Oxycodone for Resident #17. Nursing documentation stated the resident was given Oxycodone instead of Ativan at bedtime on one occasion, and another incident note documented the resident was given Oxy instead of Ativan on a separate occasion. Staff interviews confirmed the medication error, with the DON stating Resident #17 was given another resident's Oxycodone instead of the resident's Ativan. The facility medication administration policy required staff to identify the resident by photo in the MAR and compare the medication source with the MAR to verify the resident name, medication, form, dose, route, and time.
Failure to Offer COVID-19 Booster and Provide Staff Education
Penalty
Summary
The facility failed to offer a COVID-19 booster to one resident reviewed for immunizations. The resident’s annual MDS dated 6/19/25 listed diagnoses of hemiplegia, mild intellectual disabilities, and muscle weakness, and documented a BIMS score of 14 out of 15, indicating intact cognition. The resident’s Iowa Health and Human Services vaccination list showed a COVID-19 vaccination on 6/27/24, but the facility had no further documentation showing that education was provided to the resident regarding an updated COVID-19 booster. The facility also failed to provide information to staff regarding COVID-19 vaccination. On 9/4/25, a Laundry staff member stated the facility did not provide information to her regarding COVID-19 vaccinations, and a Housekeeping staff member gave the same statement. The DON stated the facility used CDC guidelines for resident vaccinations and should offer residents a COVID booster. HR stated she assisted with staff flu vaccinations but that the facility did not offer or provide education to staff regarding the COVID-19 vaccination. The facility’s Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures policy, revised in 2023, stated the facility would encourage staff and residents to remain up-to-date with all COVID-19 vaccine doses and provide resources and counseling about the importance of receiving the COVID-19 vaccine.
Disrespectful interaction with resident during inhaler administration
Penalty
Summary
The facility failed to interact with a resident in a respectful manner for 1 of 3 residents reviewed for dignity. Resident #26 had diagnoses including heart failure, diabetes, and hemiplegia, and her MDS dated 7/17/25 showed a BIMS score of 15 out of 15, indicating intact cognition. Her care plan directed staff to administer aerosol or bronchodilator medications as ordered for COPD. On 9/4/25, a CMA gave the resident her Symbicort inhaler, provided water afterward, and the resident swished and swallowed the water before stating she had to spit and spitting into a tissue. The CMA then turned to the SA with a disgusted look, gestured toward the resident, and said, "ew loogie," while they were near the dining room where other residents and staff were present. The facility's Resident Rights policy stated employees shall treat residents with kindness, respect, and dignity, and the DON stated the comment and behavior were not appropriate when asked about the incident.
Failure to Follow Mouth-Rinsing Instructions After Inhaler Use
Penalty
Summary
The facility failed to ensure a resident rinsed her mouth in accordance with professional standards of quality after receiving Symbicort inhaler treatment. Resident #26 had diagnoses including heart failure, diabetes, and hemiplegia, and her MDS assessment dated 7/17/25 showed a BIMS score of 15 out of 15, indicating intact cognition. The facility policy on provision of physician ordered services stated that ordered services were to be provided according to professional standards of quality. The September 2025 MAR showed an order for Symbicort Aerosol 160-4.5 mcg, 2 puffs twice daily, with directions to ensure the resident rinsed her mouth with water after inhalation and not to swallow. On 9/4/25 at approximately 8:45 a.m., a CMA administered the inhaler and the resident inhaled 2 puffs. Afterward, the CMA gave the resident a glass of water, and the resident swished and swallowed the water; the CMA did not provide a cup to spit into or encourage her to spit out the water. The DON stated staff should have residents swish and spit after using a Symbicort inhaler and that Resident #26 should be reminded to spit out the water.
Failure to Notify Provider of Diet Refusal and Carry Out Ordered ST Services
Penalty
Summary
The facility failed to notify the physician when a resident refused an ordered pureed diet and failed to carry out ordered Speech Therapy (ST) services for a resident with dysphagia. Resident #10 had diagnoses including dysphagia, Parkinson's disease, and anxiety disorder, and the Quarterly MDS dated 8/16/25 indicated he was on a mechanically altered diet with a BIMS score of 14 out of 15. After the resident reported that roast beef felt stuck in his esophagus, he was transferred to the ER for evaluation and later had an endoscopy completed, after which he was placed on a liquid diet for two weeks and then advanced to a pureed diet. The record showed that the resident later refused the pureed diet and wanted a mechanical soft diet, and the facility provided mechanical soft food despite the ordered pureed diet. A fax to the provider asked how long the resident should remain on pureed before advancing to regular, and the provider asked whether ST was involved and directed ST to advance the diet if able. The facility lacked documentation that ST services were initiated and lacked documentation that the provider was notified of the resident's refusal of the ordered pureed diet. The DON stated the provider wanted the facility to follow up with ST, and an OTA stated she received an order for ST at the end of July or beginning of August but had not been able to get a therapist to visit.
Medication Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed 5%, and the survey calculated the facility’s medication administration error rate at 7% with a census of 30 residents. For Resident #8, whose annual MDS dated 7/10/25 listed anxiety, hemiplegia, paraplegia, and a BIMS score of 14 out of 15, indicating intact cognition, the care plan revised 2/1/24 identified the resident as a smoker. The September 2025 MAR showed orders for famotidine 20 mg twice daily and a nicotine patch 14 mg/hour daily. On 9/3/25 at 8:16 a.m., a CMA administered the resident’s morning medications but did not administer famotidine and did not have the nicotine patch available. An eMar medication administration note stated the facility waited for the resident’s nicotine patch to come in. The DON stated on 9/4/25 that staff should have called the pharmacy if a medication was not available and should have checked the medications better.
Resident's Right to Refuse Treatment Not Respected
Penalty
Summary
The facility failed to respect a resident's right to refuse treatment, specifically regarding the administration of a suppository. The resident, who had a moderately impaired cognitive status due to a stroke and other medical conditions, was subjected to a suppository against his will on two separate occasions. On the first occasion, a CNA and an LPN were involved in administering the suppository despite the resident's clear refusal. The resident became agitated and attempted to resist the procedure. On the second occasion, the same LPN, with the assistance of another CNA, again administered a suppository to the resident despite his refusal. The LPN justified the action by citing the resident's constipation and the potential health risks of not addressing it. The resident expressed his refusal verbally, but the LPN proceeded, believing the resident's agitation was due to discomfort rather than a genuine refusal. The Director of Nursing was informed of the incidents and acknowledged that the resident's choice should have been respected. The facility's protocol for addressing bowel movement issues was not followed, as the resident's refusal should have been addressed by the interdisciplinary team. The report highlights the failure to honor the resident's right to self-determination and choice in his healthcare decisions.
Inadequate Documentation and Communication in Resident Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge of a resident met all documentation requirements necessary for a safe and effective transition of care. The resident in question had significant cognitive impairments, requiring maximal to dependent assistance with daily activities and was diagnosed with conditions such as cerebrovascular accident, hemiplegia, and chronic obstructive pulmonary disease. Despite these needs, the facility did not adequately document the discharge process, relying mostly on verbal communication and progress notes, which were insufficient for a proper transition. The resident's mother, who was also her guardian, was informed by the Director of Nursing that her daughter would be discharged due to having three strikes, as per state requirements. However, the mother was not provided with a written notice or informed of her right to appeal the decision. This lack of proper documentation and communication with the resident's guardian contributed to the deficiency identified during the survey.
Failure to Provide Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide adequate written notice of discharge and proper contents of notice, including a statement of the resident's appeal rights, prior to the discharge of a resident. The resident, who had short- and long-term memory deficits and severely impaired cognitive status, required maximal to dependent assistance with daily activities and was diagnosed with conditions such as cerebrovascular accident, hemiplegia, and chronic obstructive pulmonary disease. Despite the resident's condition, the facility did not issue a written discharge notice or inform the resident or her guardian of the right to appeal the discharge decision. The discharge process for the resident lasted six months, during which the facility identified another facility that could provide a day program. The social worker involved in the process stated that most communication was verbal and not recorded, with only some details noted in progress notes. The resident's mother and guardian were informed verbally by the Director of Nursing about the discharge, citing a requirement to move due to the resident having three strikes. The resident's mother was not initially in agreement with the discharge but cooperated without knowledge of her rights, as she did not receive any written notice or information about appeal rights.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain adequate sanitation in the kitchen and during meal service, as observed during a survey. Dust particles were found hanging from the spigots of the fire suppression system over the stove, and this issue persisted during a subsequent observation. The microwave was found with food splatters and debris both inside and outside, and the exterior was sticky to the touch. Dust was also present between the air conditioning unit and the wall, with food items stored below. A floor fan with heavy dust was noted, and the air conditioner near the dishwasher was blowing air towards clean dishes, with its flaps covered in brown spatters and dust. During meal service, the Dietary Manager was observed handling food without gloves, touching bread slices with bare hands while preparing a sandwich for a resident. Additionally, a spray bottle with glass cleaner was found near a food tub, and the ice machine had a white crusty substance and dark flecks inside. The ice scoop was improperly stored on top of the machine. The facility's policy on cleaning and sanitation was not adhered to, as evidenced by the unclean surfaces and equipment in the kitchen.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a qualified person to serve as the Director of Food and Nutrition Services in the absence of a full-time dietitian, as required by their policy. The policy stated that if a dietitian was not employed full-time, the facility should designate a person to serve as the Director of Food Service who received frequent consultations from a qualified dietitian. Additionally, this person should be a qualified dietitian, a graduate of a dietetic technician or dietetic assistant training program, or a graduate of a state-approved course with 90 or more hours of classroom instruction in food service supervision and have experience as a Food Service Supervisor in a healthcare institution. The Dietary Manager, who was not a Certified Dietary Manager (CDM), was currently enrolled in a CDM course but had not completed it due to her daily work commitments. She mentioned that she could call the dietitian anytime but did not have consultations with the former dietitian. The Administrator confirmed that the Dietary Manager was in the CDM course and had a year to complete it.
Failure to Conduct Pre-Employment Background Check
Penalty
Summary
The facility failed to conduct a record check evaluation prior to the employment of a Registered Nurse (RN), identified as Staff B, which is a requirement to ensure clearance for work. The staff roster indicated that Staff B was hired on 9/11/23. However, an 8/30/23 Single Contact License and Background Check (SING) revealed a Criminal History (CCH) record, and the facility did not have further documentation regarding Staff B's CCH or a completed record check evaluation. The Business Office Manager acknowledged the absence of the record check evaluation and anticipated a citation for this oversight. The Administrator confirmed that background checks should be completed before employment begins, and the Director of Nursing stated that if the evaluation was not completed by a specified date, she would cover Staff B's shifts. The facility's undated Abuse Policy indicated that protocols for conducting employment background checks should be followed.
Deficiencies in Care Planning for Falls, Nutrition, and Behavioral Issues
Penalty
Summary
The facility failed to include fall interventions in the care plan for a resident with a history of falls. This resident, who was admitted with diagnoses of stroke, shortness of breath, and diabetes, had a documented history of falls prior to admission and required substantial assistance for transfers. Despite multiple fall incidents occurring after admission, the care plan did not address these falls or include interventions to prevent further incidents. The Director of Nursing acknowledged that the care plan should have addressed falls. The facility also failed to address the nutritional needs of the same resident, who experienced significant weight fluctuations and a history of inadequate energy intake. The resident's weight loss was documented as a 10.7% decrease over a short period, yet the care plan did not include interventions to prevent further weight loss. Additionally, there was no documentation of physician notification regarding these weight changes, contrary to the facility's policy that required such communication. Furthermore, the facility did not address a resident's history of sexual behaviors toward other residents and staff in the care plan. This resident, with moderately impaired cognition, exhibited inappropriate sexual behaviors and aggression towards staff and other residents. Despite multiple documented incidents, the care plan lacked a focus area for managing these behaviors. The Director of Nursing confirmed that these behaviors needed to be addressed in the care plan.
Failure to Discard Insulin Vial After 28 Days
Penalty
Summary
The facility failed to ensure that an insulin vial was discarded after being opened for more than 28 days, as required by professional standards of quality. This deficiency was identified during an observation where a Registered Nurse (RN) administered insulin to a resident diagnosed with Type II diabetes mellitus. The insulin vial used did not have a visible date indicating when it was opened, and the label on the medication bottle indicated a change date of 8/20/24, which exceeded the 28-day limit for opened insulin vials. The RN was uncertain about the correct discard period for opened insulin vials, initially stating it was either 45 or 30 days. Further investigation revealed that the Director of Nursing (DON) was also unaware of the correct discard date, initially hoping the date on the insulin bottle was for another bottle. The facility's policy required opened vials to be discarded after 30 days, but the GoodRX website, provided by the facility, stated that unused Lantus vials stored at room temperature last for up to 28 days. The DON confirmed that the nurses were supposed to mark the opened date on the vial itself with a permanent marker, which was not done in this case. This oversight led to the use of insulin beyond the recommended period, potentially compromising the quality of care provided to the resident.
Failure to Address Weight Fluctuations in Resident at Risk of Impaired Nutrition
Penalty
Summary
The facility failed to recognize and address significant weight fluctuations for a resident at risk of impaired nutrition. The resident, who had a history of stroke, shortness of breath, and diabetes, was noted to have a moderately impaired cognition with a BIMS score of 9 out of 15. The facility's policy required nursing staff to monitor and document residents' weights and report significant weight losses to the physician. However, the resident's clinical record lacked documentation of physician notification regarding the weight fluctuations. The resident experienced a 10.7% weight loss between 7/23/24 and 8/6/24, dropping from 200 lbs to 178.6 lbs, yet the care plan did not address these fluctuations or include interventions to prevent further weight loss. The facility's process involved the dietician evaluating weights and sending a note to the physician, who would then send orders if the weight loss was concerning. Despite this process, the resident's care plan did not reflect any interventions for the observed weight fluctuations or the history of inadequate energy intake. A Nutrition/Dietary Note from 7/20/24 indicated the resident was at increased risk of altered nutrition, but no actions were taken to address this risk. The Director of Nursing stated that staff should reweigh a resident if there was more than a 3-pound increase or decrease, but this protocol was not followed in this case.
Failure to Ensure Oxygen Availability for Resident with COPD
Penalty
Summary
The facility failed to ensure the availability of a resident's oxygen tank for a resident with chronic obstructive pulmonary disease (COPD), diabetes, and joint pain, who required oxygen therapy. The resident, who had moderately impaired cognition, was observed on multiple occasions without her oxygen concentrator, which was necessary to maintain her oxygen levels above 90%. On one occasion, the resident was seen wheezing and short of breath while walking without her oxygen concentrator, which was left in the dining room. Staff interviews revealed that the resident's oxygen concentrator was not consistently returned to her room after meals, and the resident was observed pushing the concentrator herself, which was deemed unsafe by staff. Staff members, including CNAs and an LPN, acknowledged that the resident needed her oxygen more frequently and that it was unsafe for her to push the concentrator herself. The Director of Nursing also confirmed that the resident required her oxygen more during the day and should not be moving the concentrator on her own. Despite these acknowledgments, the facility's failure to ensure the resident's oxygen was readily available and safely managed led to the deficiency identified in the report.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident with chronic pain, as evidenced by the lack of administration of as-needed pain medications and absence of pain assessments. The resident, who had diagnoses including non-Alzheimer's dementia, diabetes, and hypertension, reported frequent pain over a five-day period, yet did not receive any as-needed pain medication or non-medication interventions during this time. The resident's care plan required staff to evaluate the effectiveness of pain interventions and notify the physician if they were unsuccessful, but this was not adhered to. On multiple occasions, the resident expressed experiencing significant pain, such as stating that his foot hurt and his hip hurt severely. Despite these complaints, there was no documentation of pain assessments or administration of as-needed medications like Acetaminophen or Tramadol on specific dates when the resident reported pain. Staff interviews revealed a lack of awareness and response to the resident's pain complaints, with one nurse stating she did not hear the resident's pain complaint and another indicating she would administer as-needed medication only if the scheduled medication was ineffective, but this was not documented.
Failure to Document Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to properly screen and document the pneumococcal vaccination status for three residents. Resident #5's electronic medical record (EMR) lacked documentation of receiving or being offered the pneumococcal vaccine, despite the Iowa Registry Immunization System (IRIS) indicating they received the PCV13 vaccine in 2015. Similarly, Resident #7's EMR showed they received the PCV13 vaccine, but there was no documentation of being offered or declining additional pneumococcal vaccines, even though IRIS recorded a previous pneumococcal 23 vaccine in 2014. Resident #12's EMR lacked any documentation of past or current pneumococcal vaccinations, and IRIS confirmed no vaccines were received. During interviews, the Director of Nursing (DON) admitted to not having access to IRIS and not realizing the need for residents to sign consent or declination forms for the vaccines. The DON also acknowledged the absence of progress notes or declination forms for the residents in question. The facility's policy, dated August 2016, stated that all residents should be offered pneumococcal vaccines to prevent infections, yet this was not consistently documented or followed for the residents reviewed.
Failure to Document and Offer COVID-19 Vaccines
Penalty
Summary
The facility failed to properly screen and document the COVID-19 vaccination status for three residents. Resident #5's electronic medical record (EMR) indicated a refusal of the COVID-19 vaccine without a documented date, while the Iowa Registry Immunization System (IRIS) showed that the resident received the Pfizer vaccine on a specific date. There was no documentation of any other vaccines being offered, received, or declined. Resident #7's EMR showed receipt of a Moderna booster, but lacked documentation of any additional vaccines being offered or declined. The resident expressed a desire to receive the vaccine at the facility due to transportation difficulties. Resident #12's EMR lacked any documentation of past or current vaccinations, and IRIS confirmed no COVID-19 vaccines were received. The facility did not document any offer, receipt, or declination of vaccines for this resident. During interviews, the Director of Nursing (DON) admitted to not having access to IRIS and not realizing the need for signed consent or declination forms for COVID-19 vaccines. The DON acknowledged speaking with Resident #5, who declined the vaccine, but failed to document this in a progress note or obtain a signed declination. The DON also noted that Resident #12 was not present during the COVID clinic and did not provide any declination forms for this resident. The facility's policy, revised in early 2022, stated that vaccines should be offered and administered according to current guidelines, but this was not adhered to in these cases.
Ineffective QAPI Process Leads to Repeat Deficiencies
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) process to address previously identified quality deficiencies. This resulted in multiple repeat deficiencies identified during the current recertification and complaint survey. The deficiencies were previously identified in surveys conducted over the last 17 months. The facility had a census of 22 residents at the time of the survey. The deficiencies included issues related to care plan revision, food procurement, and QAPI good faith, as noted in the CMS-2567 forms from previous surveys. During an interview, the Administrator explained that the facility conducted monthly mock surveys to maintain substantial compliance. However, the Administrator's expectations for substantial compliance were not clearly articulated, as she mentioned the need for continuous monitoring and having issues brought to her attention. The QAPI Plan for 2023 outlined goals such as promoting consistent facility systems, identifying and resolving negative outcomes in resident care, and coordinating the development and evaluation of action plans to achieve quality goals. Despite these goals, the facility's QAPI process was ineffective in preventing repeat deficiencies.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat residents with dignity and respect in several instances. One resident with severe intellectual disabilities and behavioral issues was mishandled by a CNA who grabbed her by the hood of her shirt, causing red marks on her neck. Multiple staff members confirmed the incident, and it was noted that the CNA lacked proper training. The facility's investigation was incomplete, as it did not include interviews with other residents or staff who witnessed the event. Another resident with anxiety, depression, and obesity reported that the same CNA was rough during incontinence care. Additionally, the Director of Nursing (DON) publicly discussed the resident's financial situation and room assignment in front of other residents and staff, causing the resident distress. This was corroborated by another staff member who witnessed the conversation. A third resident with heart failure, a history of stroke, and anxiety reported feeling ignored by staff who talked among themselves while providing care. The resident felt insignificant and like a number. The Administrator acknowledged that staff should engage with residents and that the comment made to the second resident regarding her finances was inappropriate and a violation of HIPAA.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from being pinched by another resident with a history of physical aggression. Resident #1, who has severe intellectual disabilities and a history of physical aggression, pinched Resident #4 on the leg. At the time of the incident, Resident #1 was not on 1:1 supervision but was supposed to be checked every 30 minutes. This incident occurred despite previous aggressive behaviors by Resident #1, including hitting, biting, and grabbing other residents, which had led to the implementation of 1:1 supervision in the past. Resident #1's care plan included various interventions to manage her aggressive behavior, such as analyzing triggers, providing calming activities, and conducting 30-minute checks. However, these measures were not sufficient to prevent the incident with Resident #4. Staff interviews revealed that Resident #1's behavior had worsened over time, and there were instances where she reached out to other residents despite attempts to adjust her medications. The Director of Nursing (DON) acknowledged that Resident #1's behavior was unpredictable and that the facility had difficulty meeting her needs. On the day of the incident, staff members were assisting other residents, leaving Resident #1 unsupervised, which allowed her to pinch Resident #4. The DON confirmed that Resident #1 was not on 1:1 supervision at the time of the incident because her behavior had improved temporarily. However, after the incident, Resident #1 was placed back on 1:1 supervision. The facility's policy on abuse stated that residents had the right to be free from abuse, including physical abuse, but this policy was not effectively implemented in this case.
Failure to Report Allegation of Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency when a staff member did not treat a resident with dignity and respect during positioning. Resident #1, who has severe intellectual disabilities and other behavioral disorders, was allegedly mishandled by Staff A, a CNA, who yanked the resident back by her hood, causing choking. Multiple staff members and another resident witnessed the incident and reported that Staff A lacked proper training and knowledge on how to handle such situations. Despite the incident, the facility did not report it to the State Agency and allowed Staff A to continue working without immediate removal or further investigation into other potential witnesses or residents' concerns. The Minimum Data Set (MDS) assessment for Resident #1 indicated severe cognitive impairment and frequent physical behavioral symptoms. The resident's care plan noted that she found comfort on the floor and might position herself there. On the day of the incident, Staff A attempted to prevent the resident from falling by grabbing her by the hood and pants, which led to the resident becoming upset and swinging at Staff A. Staff members observed red marks on the resident's neck, which were attributed to the sweatshirt's zipper. Despite these observations, the facility's investigation was limited, and the incident was not reported to the State Agency. The facility's policies on resident rights and abuse reporting were not followed. The Administrator and DON assessed the resident and found no visible signs of abuse, leading them to believe there was no need to report the incident. They provided education to Staff A on proper handling techniques but did not remove him from duty. The facility's failure to report the incident and conduct a thorough investigation, including interviewing other residents and staff, resulted in a deficiency in adhering to state regulations and ensuring resident safety and dignity.
Failure to Investigate and Protect Residents Following Abuse Allegations
Penalty
Summary
The facility failed to complete a thorough investigation and ensure immediate protection for two residents following allegations of abuse. Resident #1, who has severe intellectual disabilities and other behavioral disorders, was allegedly mishandled by a CNA. The CNA reportedly grabbed the resident by the hood of her shirt, causing red marks on her neck. Despite the incident, the CNA continued to work without being removed from the facility, and the investigation lacked documentation of interviews with other residents or staff members who might have witnessed the event. Resident #3, who has intact cognition, was involved in multiple incidents of inappropriate behavior towards other residents, including entering their rooms without permission and attempting to assist them with personal tasks. Despite these repeated behaviors, the resident's care plan did not include any guidance for staff on how to manage his actions. The facility's response to these incidents was inadequate, as they failed to document and address the resident's history of inappropriate behavior. The facility's policies on resident rights and abuse were not followed, as timely and thorough investigations were not conducted, and immediate protection for the residents was not ensured. The DON and Administrator did not take appropriate actions to assess and mitigate the risks, leading to a failure in maintaining a safe and respectful environment for the residents.
Failure to Supervise Resident Leads to Privacy Violation
Penalty
Summary
The facility failed to adequately supervise a resident (Resident #3) to protect another resident's personal privacy (Resident #1). Resident #1, who has severe intellectual disabilities and a history of disrobing, was found naked from the waist up after Resident #3 exited her room. The incident was not reported immediately by the Certified Medication Assistant (CMA) who observed it, leading to a delay in addressing the situation. The Director of Nursing (DON) confirmed that the incident was reported as abuse and the police were involved, resulting in Resident #3's arrest and emergency discharge due to an outstanding warrant in another county. Resident #3, who has intact cognition, had a documented history of inappropriate behavior, including entering other residents' rooms without permission and attempting to feed or provide drinks to other residents. Despite multiple instances of such behavior being documented in nurses' notes, the resident's care plan lacked any documentation or guidance for staff regarding his supervision. This oversight contributed to the incident involving Resident #1. Staff interviews revealed that there was a lack of communication and timely reporting of Resident #3's inappropriate behaviors. The DON was unaware of several incidents involving Resident #3, including him attempting to assist another resident in getting ready for bed and rubbing a female resident's shoulders. The failure to document and communicate these behaviors prevented the facility from implementing appropriate supervision measures to protect other residents' privacy and safety.
Inadequate Staff Training and Supervision for Residents with Behavioral Health Needs
Penalty
Summary
The facility failed to provide sufficient staff with the necessary skills to care for a cognitively impaired resident requiring 1:1 supervision and another resident with behaviors affecting others. Resident #1, diagnosed with severe intellectual disabilities and disruptive mood dysregulation disorder, exhibited physical behavioral symptoms such as hitting and kicking. The care plan for Resident #1 lacked specific instructions on handling her behaviors and assisting her out of her wheelchair. An incident occurred where Staff A, a CNA, improperly handled Resident #1 by grabbing her by the hood of her shirt, causing red marks on her neck. Staff interviews revealed that Staff A and other staff members lacked training on how to manage Resident #1's behaviors effectively. Resident #3, diagnosed with anxiety and depression, exhibited behaviors such as entering other residents' rooms and feeding them without permission. Despite multiple incidents documented in nurses' notes, the care plan for Resident #3 did not include guidance for staff on how to supervise him. An incident occurred where Resident #3 was found exiting Resident #1's room while she was naked, leading to concerns about his behavior. The DON admitted that she was unaware of some of Resident #3's behaviors and stated that she would have care planned for these issues if she had known about them. Review of staff training records revealed that several CNAs, including Staff A, lacked documentation of education related to resident behavioral health needs. The facility's policies stated that staff should receive annual in-service training, including dementia management and care of the cognitively impaired. However, the facility did not provide the necessary training to staff, resulting in inadequate care for residents with behavioral health needs.
Failure to Conduct Adequate QA Activities
Penalty
Summary
The facility failed to carry out quality assurance (QA) activities to address problem-prone areas and create a plan for improvement. The CMS 2567 reports dated 6/29/23, 11/30/23, and 1/25/24 listed concerns under tags F550, F609, F610, and F689. Review of facility QA activities from 1/1/24 to 5/19/24 revealed inadequate documentation related to these concern areas, including a lack of data collection, monitoring, audits, staff input, and performance indicators. The QA committee did not systematically identify, report, track, investigate, analyze, or utilize data to develop activities to prevent future adverse events. The current survey conducted from 5/19/24 to 5/22/24 also identified these concerns. The facility's undated QAPI policy stated that documentation should demonstrate systematic identification, reporting, investigation, analysis, and prevention of adverse events, as well as the development, implementation, and evaluation of corrective actions or performance improvement activities. The Administrator acknowledged that QA activities related to former survey concerns should be carried out, including monthly coverage of abuse prevention.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sigourney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor House Care Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Harvest Acres Nursing And Rehab | 13.8 mi | ★★★★★ | 17 | 0 |
| English Valley Nursing Care Center | 14.8 mi | ★★★★★ | 3 | 0 |
| Parkview Manor | 21.9 mi | ★★★★★ | 13 | 0 |
| Northern Mahaska Specialty Care | 22.6 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.