Stratford Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Stratford, Iowa.
- Location
- 1200 Highway 175 East, Stratford, Iowa 50249
- CMS Provider Number
- 165270
- Inspections on file
- 29
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Stratford Specialty Care during CMS and state inspections, most recent first.
Two residents with intact cognition were subjected to undignified and disrespectful treatment by an RN, including yelling, belittling language, physical restrictions to prevent standing, and threats to move a resident's bed into the hallway. Staff and resident interviews confirmed these actions, which did not align with facility policy requiring respectful and dignified care.
A resident with severe cognitive impairment and multiple medical conditions was involved in an alleged abuse incident where chairs were placed behind their wheelchair. The facility did not notify the physician immediately as required by policy, and documentation of physician notification was missing until days later due to staff miscommunication.
A resident with severe cognitive impairment and multiple medical conditions was found with two dining room chairs placed behind their wheelchair, restricting movement and preventing them from backing up or standing. Staff interviews confirmed the chairs were used to limit the resident's mobility due to supervision challenges, despite facility policy prohibiting such restraint use except for medical necessity. The use of these chairs was not medically indicated and was implemented for staff convenience, violating the facility's restraint policy.
A resident was found restrained in a wheelchair with chairs placed behind it, and although the situation was addressed by staff, the allegation of abuse was not reported to state authorities or law enforcement in a timely manner as required by facility policy. Delays in communication among staff and failure to recognize the incident as abuse led to late notification and a deficiency finding.
A staff member accused of abuse was not immediately separated from a resident after an incident involving the improper placement of chairs behind a wheelchair. The concern was reported to the ADON, who failed to notify the Administrator or initiate an investigation, allowing the staff member to continue working full shifts with resident contact for nearly two days, contrary to facility policy.
The facility did not resolve ongoing deficiencies related to sufficient nursing staff, as concerns about call light response times continued to be reported by residents during surveyor interviews. Despite the QAPI program and call light audits, the Administrator acknowledged that staff did not recognize or report these issues, and the deficiency persisted based on resident feedback.
The facility did not maintain adequate nursing staff to meet resident needs in a timely manner, as evidenced by reports of long call light response times, low weekend staffing, and staff exhaustion. A resident reported waiting up to 45 minutes for assistance, and staff described frequent understaffing, especially during evenings and weekends, making it difficult to complete essential care tasks and respond promptly to resident needs.
Two residents with severe cognitive impairment were not provided with the required Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) form when their Medicare Part A skilled stay ended and they remained in the facility under private pay. Clinical records lacked documentation of the notice, and staff confirmed the forms could not be located, despite facility policy requiring advance written notification of potential liability for non-covered services.
A resident with a feeding tube did not have physician orders specifying the amount of water to use for flushing the tube during medication administration. Nursing staff relied on facility protocol and outdated policies, which were not readily accessible, and there was no documentation of staff education or physician guidance on the matter. This resulted in inconsistent practices and a deficiency related to proper care for residents with feeding tubes.
A resident with severe cognitive impairment and multiple medical conditions was found with a nebulizer mask and tubing at the bedside that had not been changed or cleaned for several months, despite facility policy requiring weekly replacement and nightly cleaning. The equipment was visibly dirty and had not been removed after nebulizer treatments were discontinued.
Staff failed to follow infection prevention and control protocols during care of a resident with a feeding tube and during medication administration for two residents. An LPN did not wear a gown or change gloves as required by enhanced barrier precautions during a g-tube dressing change, and a CMA did not perform proper hand hygiene or gloving between residents and care tasks. These actions were not in accordance with facility policies and CDC guidelines.
A resident who required maximal assistance with transfers was lowered to the floor by a CNA after attempting to self-transfer, resulting in a back abrasion. Despite visible injury and staff attempts to notify the nurse, there was a significant delay before an RN assessed the resident, and the required head-to-toe assessment and documentation of the injury were not completed until the following day.
Two residents experienced falls due to staff failing to provide required supervision and assistance during transfers, and the facility did not implement new interventions after a fall as required by policy. One resident was left unattended in the bathroom and attempted to self-transfer, resulting in injury, while another resident's care plan was not updated after a fall. Delays in nursing assessment and lack of adherence to care plans contributed to these deficiencies.
A resident with intact cognition reported feeling uncomfortable with a CNA's joking behavior, which included questioning the resident's ability to remove their own socks. The resident expressed a desire for the joking to stop and to be treated with dignity and respect, highlighting a failure by the facility to uphold the resident's rights to a dignified existence.
The facility failed to ensure timely responses to resident call lights, with three residents reporting waits exceeding fifteen minutes. Despite having intact cognition and requiring significant assistance, these residents experienced delays, which they verified using clocks or watches. The DON confirmed the expectation for responses within fifteen minutes, as per facility policy.
The facility failed to maintain sanitary conditions during meal service. A cook did not perform hand hygiene before applying gloves and touched various items without changing gloves. The cook handled food with soiled gloves and continued serving the meal after washing hands and applying new gloves. The facility's policy requires handwashing before serving food and changing gloves between tasks.
A resident with impairments on both sides of his extremities did not receive a restorative nursing program despite therapy recommendations. The facility lacked documentation and an active restorative program, as revealed by interviews with the DON and other staff.
A facility failed to change and label oxygen tubing for a resident, as required for infection control. The resident's MAR/TAR lacked documentation for weekly tubing changes, and the resident reported that the tubing had not been changed since admission. The DON acknowledged the oversight, noting that the facility's practice was to change tubing every Sunday, but this was not documented.
The facility failed to respond to resident call lights within fifteen minutes, affecting three residents with intact cognition who required assistance for daily activities. Interviews with staff revealed inconsistent staffing levels, impacting response times. The ADON confirmed the expectation for timely responses, and the facility's policy outlined procedures to ensure call lights are functional and accessible.
Failure to Promote Resident Dignity and Respect
Penalty
Summary
Staff interviews and resident accounts revealed that two residents with intact cognition were not treated with dignity and respect by a registered nurse (RN) identified as Staff C. For one resident, staff reported that Staff C would yell at him, belittle him by calling him dumb, and state that she would not feel sorry for him if he fell and broke his hip. Staff also described Staff C as engaging in screaming matches with the resident, agitating him with her questions, and using wet floor signs to prevent him from standing at the nurses' station. On one occasion, Staff C reportedly tied a memory blanket to the resident's wheelchair pedals to prevent him from standing, which physically restricted his movement. Another resident reported that Staff C would keep him from returning to his room due to his attempts to use the bathroom independently and threatened to move his bed into the hallway as a form of reprimand. Staff corroborated that Staff C made such statements and described her as loud and smart-alecky, frequently yelling at the resident. The facility's policy requires that residents be treated with dignity and respect at all times, and prohibits demeaning practices, but the actions described by staff and residents indicate that these standards were not upheld for the two residents involved.
Failure to Notify Physician of Abuse Allegation
Penalty
Summary
The facility failed to notify the physician following an allegation of abuse involving a resident with severe cognitive impairment and multiple medical diagnoses, including anemia, hypertension, diabetes mellitus, thyroid disorder, traumatic brain injury, and alcohol-induced mood disorder. The resident was non-ambulatory, required substantial to maximal assistance with mobility, and was dependent on staff for locomotion in a manual wheelchair. An incident report documented that the resident was found with two dining room chairs placed behind his wheelchair in the common area to prevent tipping, which was reported as an allegation of abuse. Despite facility policy requiring immediate notification of the attending physician and medical director in such cases, there was no documentation in the incident report or the clinical record that the physician was notified at the time of the incident. Interviews with the DON and Administrator confirmed that the physician was not notified until several days later due to miscommunication and the suspension of the ADON. The delay in physician notification was acknowledged by facility leadership, and the required documentation was not present until after the incident had already occurred.
Unauthorized Use of Physical Restraints on Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including traumatic brain injury and alcohol-induced mood disorder, was subjected to the use of physical restraints. The resident, who was non-ambulatory and dependent on staff for mobility and transfers, was identified as being at risk for falls and required to be within line of sight of staff at all times. Despite this, staff placed two dining room chairs behind the resident's wheelchair while he was seated at a dining room table in the common area, restricting his ability to move his wheelchair backward. Multiple staff members observed the chairs positioned behind the resident's wheelchair on several occasions, with some staff removing the chairs when they noticed them. Staff interviews revealed that the chairs were placed to prevent the resident from standing up or moving backward, as staff were unable to provide constant supervision. The resident was also pushed up to the table with his chest almost touching it, and the wheelchair was locked, further limiting his movement. Staff acknowledged that the chairs were used as a means to control the resident's mobility due to staffing constraints and the resident's tendency to attempt standing. Facility policy prohibits the use of physical restraints except for medical treatment and only after other alternatives have been tried unsuccessfully. The policy also defines physical restraint as any method that restricts a resident's freedom of movement and cannot be easily removed by the resident. The use of chairs to block the resident's wheelchair was not authorized, not medically indicated, and was implemented for staff convenience rather than the resident's safety or medical need, constituting a violation of the facility's restraint policy.
Failure to Timely Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident who was found in a wheelchair with two dining room chairs placed behind it, preventing backward movement. The Maintenance Supervisor discovered the situation early in the morning and immediately removed the chairs, then notified the Dietary Manager. The concern was brought up at a quality assurance meeting later that morning and reported to the Assistant Director of Nursing (ADON), who acknowledged awareness but did not escalate the issue. The Administrator was not present at the meeting and was not informed until the following day, after which the incident was reported to the Department of Inspection, Appeals and Licensing (DIAL) more than a day after the initial observation. The facility also failed to notify law enforcement of the abuse allegation, as required by policy. Staff interviews revealed that the incident was not recognized or reported as abuse in a timely manner, and the facility's own policy required immediate reporting to state authorities and law enforcement. The delay in reporting and lack of immediate action by responsible staff contributed to the deficiency, as the incident was not addressed according to regulatory and facility policy requirements.
Failure to Immediately Separate Staff Accused of Abuse
Penalty
Summary
The facility failed to immediately separate a staff member accused of alleged abuse from contact with dependent residents. On the morning of 11/19/25, a maintenance supervisor observed a resident in a wheelchair with two dining room chairs placed behind the wheelchair, restricting the resident's ability to move backward. The maintenance supervisor reported the concern to the Assistant Director of Nursing (ADON) during a Quality Assurance meeting later that morning. The ADON acknowledged the concern but did not notify the Administrator, initiate an investigation, or separate the accused staff member from residents. As a result, the staff member continued to work full shifts on both 11/19/25 and 11/20/25. The incident was not reported to the Administrator until the afternoon of 11/20/25, after which the Administrator learned that the staff member had not been suspended or separated from residents. Facility policy requires that any employee accused of resident abuse be placed on leave with no resident contact until the investigation is complete. The failure to follow this policy resulted in the accused staff member maintaining resident contact for nearly two days after the initial allegation was made.
Failure to Correct Deficiency in Sufficient Nursing Staff
Penalty
Summary
The facility failed to correct previously identified deficiencies related to sufficient nursing staff, as evidenced by repeated concerns noted in both the current and past surveys. The QAPI program, revised in March 2020, is overseen by the QAPI committee and ultimately the Administrator, who is responsible for interpreting findings to the governing body. Despite this structure, the facility did not address ongoing issues with call light response times, which were brought up by residents during surveyor interviews but not reported to staff. The Administrator acknowledged that residents communicated their concerns about call lights to surveyors rather than staff, and that staff did not perceive or report these issues themselves. The Administrator indicated that call light audits had been conducted within the last year, but deficiencies related to staffing persisted, primarily based on resident interviews rather than direct observation. The Administrator also expressed the belief that staff would never feel they had enough help, and that increased staffing did not necessarily improve efficiency or outcomes. These statements and the lack of effective corrective action contributed to the facility's failure to resolve the deficiency regarding sufficient nursing staff.
Failure to Provide Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by clinical record reviews, PBJ data, and multiple staff and resident interviews. One resident with intact cognition reported that call light response times could take 30 to 45 minutes or longer, and that staff sometimes turned off the call light without returning. Facility records and resident council documentation confirmed call light response times between 15 and 30 minutes. PBJ data reflected excessively low staffing on weekends, and staff interviews described frequent situations where only one nurse and one CNA were responsible for nearly 40 residents. Staff also reported that management did not assist with direct care during shortages, and that staff were often required to find their own replacements when calling in absent. Staff described being mentally and physically exhausted due to chronic understaffing, particularly during evening and weekend shifts. They reported difficulty completing essential care tasks, such as resident baths, and managing increased resident needs during high-activity periods like bedtime. The DON acknowledged that the facility's policy expected call lights to be answered within 15 minutes, but described ongoing challenges in maintaining adequate staffing levels, especially after hours and on weekends. The facility's own grievance documentation and staff interviews consistently indicated that staffing levels were insufficient to provide timely care to all residents.
Failure to Provide SNFABN Form Upon Discharge from Medicare Coverage
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) form to two residents whose Medicare Part A skilled stay ended and who continued to reside in the facility under private pay. Clinical record reviews for both residents showed no documentation that the SNFABN form was given to either the residents or their representatives at the time of discharge from Medicare coverage. Staff interviews confirmed that the necessary forms could not be located for these residents. Both residents had severely impaired cognition as indicated by their Brief Interview for Mental Status (BIMS) scores. One resident had diagnoses including hypertension, cerebrovascular accident, aphasia, and dysphagia, and was using a feeding tube. The other resident had diagnoses of pneumonia, urinary tract infection, depression, coronary artery disease, and hypertension. Despite facility policy requiring advance written notice of potential liability for non-covered services, the required notification was not documented for either resident.
Lack of Physician Orders for Feeding Tube Water Flushes During Medication Administration
Penalty
Summary
The facility failed to have physician orders specifying the amount of water to flush a feeding tube when administering medications for a resident with a feeding tube. The resident in question had a history of traumatic brain injury, subdural hemorrhage, altered mental status, persistent vegetative state, and dysphasia, and was dependent on staff for mobility and transfers. The resident's care plan indicated tube feeding with specific instructions to check tube placement and gastric residuals per facility protocol, but there was no documented order for the amount of water to use for flushing during medication administration. Observations and interviews revealed that nursing staff administered medications via the resident's feeding tube using water flushes based on facility protocol, but without a specific physician order for the water amount. Staff reported using 30 mL of water to dissolve medications and additional flushes before, between, and after medication administration, following the facility's policy. However, the policies themselves were outdated, and staff could not locate them at the nurses' station or on the medication cart. The Director of Nursing (DON) and Corporate Nurse acknowledged that staff were expected to follow the policy, but there was no documentation of physician orders for water flush amounts or of staff education on the policy. Additionally, there was inconsistency in practice regarding checking for gastric residuals and tube placement, with staff reporting changes to their routine only after being questioned by surveyors. The DON stated that the physician had previously indicated residual checks were not required, but there was no documentation to support this. The lack of clear, accessible policies and specific physician orders for water flushes during medication administration led to the deficiency identified by surveyors.
Failure to Replace and Clean Nebulizer Equipment as Required
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a history of hypertension, cerebrovascular accident, aphasia, and dysphagia was found to have a nebulizer mask and tubing at the bedside that had not been changed since it was dated several months prior. The nebulizer mask was visibly dirty, with dust particles and dried liquid spots present. Observations confirmed that the equipment remained at the bedside over multiple days, and the mask/chamber was still marked with the old date. Record review showed that the resident had not received nebulizer treatments for several months, with the last documented use occurring in January, and the order for nebulizer treatments had been discontinued in February. Despite this, the equipment was not removed or cleaned according to facility policy, which required weekly replacement and nightly cleaning of the nebulizer apparatus. Staff acknowledged the outdated and unclean equipment during the survey and confirmed that the expected practice was not followed.
Failure to Follow Infection Control Protocols During Device Care and Medication Administration
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections, particularly for a resident with a feeding tube and during medication administration for two other residents. For the resident with a feeding tube, staff did not follow enhanced barrier precautions (EBP) as required. During a dressing change to the gastrostomy tube (g-tube) site, the LPN did not wear a gown as directed by EBP protocols, used the same pair of gloves throughout the procedure without changing them between dirty and clean tasks, and did not perform hand hygiene at appropriate intervals. The staff member acknowledged these lapses and confirmed awareness of the correct procedures, including the need to change gloves and perform hand hygiene between steps. Additionally, during medication administration for two residents, a Certified Medication Aide (CMA) failed to perform proper hand hygiene and gloving practices. The CMA did not sanitize hands after glove removal, between residents, or before entering a resident's room. The CMA also placed an eye drop bottle directly on a resident's bedside table without a barrier and carried used gloves from the resident's room to the medication cart before discarding them. These actions were contrary to facility policies and CDC guidelines, which require hand hygiene before and after resident care, after glove removal, and when moving between residents or care tasks. Facility policies reviewed included requirements for EBP, handwashing, and glove use, all of which were not followed during the observed incidents. The Director of Nursing confirmed the expectation that staff adhere to these protocols, including wearing gowns for high-contact activities involving medical devices, changing gloves, and performing hand hygiene at appropriate times. The observed failures represent a breakdown in infection prevention and control practices as outlined in facility policy.
Failure to Timely Assess and Document Resident Injury After Assisted Fall
Penalty
Summary
A deficiency occurred when staff failed to immediately assess and document appropriate interventions for a resident who was lowered to the floor and sustained an abrasion to her back. The resident, who had intact cognition and required substantial to maximal assistance with mobility and transfers, attempted to self-transfer from the toilet to her wheelchair. During this attempt, her knees buckled and a CNA assisted her to the floor to prevent a fall, resulting in a back abrasion. The CNA observed bleeding skin tears and attempted to notify the nurse, but there was a significant delay in the nurse's response. Multiple staff interviews confirmed that the nurse did not promptly respond to the incident, with reports indicating a wait time of 10 to 40 minutes before the nurse arrived to assess the resident. During this period, CNAs moved the resident from the floor to her wheelchair without a nursing assessment. The nurse, when she did arrive, did not immediately assess the resident's back injury and later admitted to forgetting to complete the assessment after the resident was put to bed. The initial documentation and assessment of the abrasion did not occur until the following day, despite the injury being visible and reported at the time of the incident. The resident's clinical record indicated a history of falls and multiple diagnoses, including hypertension, diabetes, and mental health conditions. Despite these risk factors and the facility's policy requiring immediate assessment after incidents or changes in condition, the required head-to-toe assessment and documentation were not completed in a timely manner. The delay in assessment and failure to follow protocol were acknowledged by the Director of Nursing and confirmed through staff interviews and record review.
Failure to Prevent Accidents and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure the safety and adequate supervision of two residents, resulting in deficiencies related to accident hazards and fall prevention. One resident, who had intact cognition but significant physical limitations and a history of falls, required assistance from two staff members and the use of a standing mechanical lift for all transfers, including toileting. Despite these requirements being clearly documented in the care plan and CNA Kardex, a staff member left the resident unattended in the bathroom after assisting with toileting and peri-care, stepping out to seek help for the transfer. During this absence, the resident attempted to self-transfer from the toilet to the wheelchair, resulting in her knees giving out and the staff member having to lower her to the floor. The resident sustained abrasions to her back during this incident. Interviews and documentation revealed that the staff member was aware of the resident's need for two-person assistance but proceeded to stand the resident up alone for peri-care and left her unsupervised in the bathroom. There was also a significant delay in the nurse's response to the incident, as the nurse prioritized completing a medication pass before assessing the resident. The nurse did not immediately assess the resident's injuries, and the required assessment of the resident's back was not completed until the following day. Staff interviews confirmed that the care plan was not followed, and the nurse did not respond promptly to the fall, leaving the resident on the floor for an extended period before being assisted back to her wheelchair. In a separate incident, another resident with moderate cognitive impairment and a history of falls was found on the floor after attempting to transfer from a wheelchair to bed and experiencing dizziness. The care plan for this resident did not include any new interventions following the fall, despite facility policy requiring investigation and implementation of preventive measures after such events. The Director of Nursing acknowledged the lack of intervention and documentation for this incident, which was inconsistent with facility policy and expectations for fall prevention and resident safety.
Resident's Dignity Compromised by Inappropriate Staff Interaction
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as required by regulations, which was identified during a survey. The resident, who had intact cognition and was dependent on staff for certain activities, reported feeling uncomfortable with the behavior of a Certified Nursing Assistant (CNA). The resident expressed that the CNA often joked in a manner that was not appreciated, specifically mentioning an incident where the CNA questioned the resident's ability to remove their own socks. Although the resident did not feel degraded, they expressed a desire for the joking to stop and to be treated with dignity and respect. The facility's Administrator confirmed that staff are expected to treat residents with dignity and respect at all times. The resident's care plan included interventions to support their emotional and social needs, such as conversing with the resident during care and monitoring their feelings of sadness, anxiety, and depression. Despite these measures, the resident's experience with the CNA did not align with the facility's expectations or the resident's rights to a dignified existence and self-determination, as outlined in the Residents' Rights document.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure that staff responded to resident call lights and needs in a timely manner, specifically within fifteen minutes, as required. This deficiency was identified through interviews with three residents, all of whom reported waiting longer than the expected time for assistance. Resident #2, who has intact cognition and requires total assistance for various activities of daily living, frequently experienced delays in response times, which he tracked using his watch. Similarly, Resident #33, also with intact cognition and requiring maximal assistance, reported waiting over fifteen minutes for staff to respond, using a wall clock to verify the delay. Resident #87, with intact cognition and medical conditions including hemiplegia and chronic obstructive pulmonary disease, also reported waiting longer than fifteen minutes for assistance, confirmed by checking his watch. The Director of Nursing acknowledged the expectation for staff to respond within fifteen minutes, aligning with the facility's policy revised in March 2021, which aims to ensure timely responses to residents' requests and needs. Despite this policy, the facility's failure to meet the response time requirement was evident in the experiences of the interviewed residents.
Failure to Maintain Sanitary Conditions During Meal Service
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions, as observed during a noon meal service. Staff A, a cook, did not perform hand hygiene before applying gloves and began preparing and serving the meal. Staff A touched various items, including plates, utensils, serving pans, and paper menus, without changing gloves or completing hand hygiene. Additionally, Staff A reached into a bread sack with the same gloves, placed bread on a plate, added meat, and used a knife to cut the sandwich. The cook continued to handle food with soiled gloves, touching meat and bread to add mashed potatoes. After removing gloves to get a cup of butter and barbeque sauce, Staff A washed hands and applied new gloves but continued to serve the meal while touching various items with gloved hands. The facility's Food Preparation and Service policy, revised in April 2019, requires staff to wash hands before serving food, after collecting soiled plates, and to change gloves between tasks.
Failure to Implement Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to complete necessary assessments for a resident, identified as Resident #26, to determine if his abilities remained unchanged or had declined. Resident #26 had impairments on both sides of his upper and lower extremities, yet did not have a restorative nursing program in place. The Minimum Data Set (MDS) indicated a progression of impairment from one side to both sides of his extremities. Despite recommendations from therapy for a Restorative Nursing Program (RNP), the facility did not implement such a program, and the care plan lacked documentation of restorative nursing interventions. Interviews with the Director of Nursing (DON), MDS Coordinator, and the Administrator revealed that the facility did not have an active restorative program due to low participation. The Occupational Therapist confirmed that an RNP was written upon Resident #26's discharge from therapy, but it was not effectively communicated or documented in the resident's care plan. The facility's policy on Restorative Nursing Services, revised in July 2017, directed the provision of restorative care to promote safety and independence, but this was not adhered to in Resident #26's case.
Failure to Change and Label Oxygen Tubing
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not changing and labeling oxygen tubing as required. Resident #87, who had been admitted to the facility and had a hospitalization before returning, was observed with unlabeled oxygen tubing lying on the floor. The facility's Medication Administration Record/Treatment Administration Record (MAR/TAR) did not include a weekly order to change the oxygen tubing, which was a requirement for infection control. The Director of Nursing (DON) acknowledged that the tubing should have been labeled and documented in the MAR/TAR, but it was not. The DON stated that the facility's practice was to change oxygen tubing every Sunday, but there was no documentation to support that this was done for Resident #87. The resident reported that the tubing had not been changed since their admission. The facility's Oxygen Administration policy required documentation of the procedure, including the date, time, and individual performing the procedure, as well as the rate of oxygen flow and how the resident tolerated the procedure. This documentation was missing, leading to the deficiency noted by the surveyors.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure that resident call lights were answered and resident needs were met in a timely manner, specifically within fifteen minutes, for three residents. Resident #1, with intact cognition and requiring total assistance for transfers, bed mobility, dressing, and toilet use, reported frequent delays in call light responses, which he tracked using his watch. Similarly, Resident #3, also with intact cognition and dependent on staff for similar needs, experienced delays and monitored the time using a wall clock. Resident #7, who required assistance for transfers, bed mobility, dressing, and toilet use, reported waiting longer than fifteen minutes at least once a day, using a wall clock to track the time. Staff interviews revealed inconsistencies in staffing levels, affecting the timeliness of call light responses. Staff I indicated that staffing adequacy varied daily, depending on call-ins. Staff J and K noted improvements in staffing but acknowledged previous shortages on four out of seven days. Staff L expressed concerns about insufficient staffing to meet call light response expectations. The Assistant Director of Nursing (ADON) confirmed the expectation for staff to respond to call lights within fifteen minutes and to seek assistance if unable to fulfill a resident's request. The facility's policy on answering call lights, revised in March 2021, outlined procedures to ensure timely responses, including demonstrating call light use to residents and ensuring call lights are functional and within reach.
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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