Stone Cottage Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sigourney, Iowa.
- Location
- 900 South Stone Street, Sigourney, Iowa 52591
- CMS Provider Number
- 165381
- Inspections on file
- 30
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Stone Cottage Care Center during CMS and state inspections, most recent first.
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.
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 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.
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.
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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