Sunny View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ankeny, Iowa.
- Location
- 410 N W Ash Drive, Ankeny, Iowa 50023
- CMS Provider Number
- 165441
- Inspections on file
- 25
- Latest survey
- February 16, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Sunny View Care Center during CMS and state inspections, most recent first.
A resident with MS, functional quadriplegia, anxiety, and depression was transferred to a hospital with a UTI after staff reported multiple prior incidents involving marijuana or THC products and implemented a two-person rule for care. While the resident was hospitalized and reportedly medically ready to return, facility leadership repeatedly hand-delivered emergency involuntary discharge notices without performing an in-person or coordinated assessment for readmission and relied only on existing medical records. There was no contemporaneous documentation from the PCP or MD that the resident was a danger to self or others before the discharge notices, and the facility did not document the required elements of its transfer/discharge policy, such as unmet needs, attempts to meet those needs, and detailed discharge information. The resident, her family, and hospital staff described that she wanted to return, was tearful and anxious about the discharge, and that the facility refused readmission even after an ALJ overturned the discharge. The facility also failed to obtain the resident’s or the correct POA’s signature on the discharge summary, instead having a family member of uncertain legal status sign, and did not ask the medical POA to sign when he retrieved the resident’s belongings.
Multiple residents experienced delays and unsafe conditions during transfers due to malfunctioning stand lifts with dead batteries, a bed that could not be lowered to a safe position, and a mechanical lift that tilted during use. Staff and residents reported these issues as ongoing, and maintenance was often unaware of the problems until they were formally reported, indicating lapses in equipment maintenance and reporting systems.
Two residents dependent on mechanical lifts for transfers experienced repeated delays and discomfort due to ongoing problems with lift batteries not holding a charge. One resident waited an extended period for toileting assistance and was left in soiled clothing, while another was left standing on a lift when the battery died. Staff and leadership acknowledged the persistent battery issues, and residents expressed frustration and discomfort with the situation.
The facility did not follow or document physician orders for two residents: one with heart failure and severe cognitive impairment did not consistently receive or have documentation of PRN oxygen when oxygen saturation was below 90%, and another with diabetes did not have required Hgb A1c lab tests completed or documented every six months as ordered. Staff interviews revealed confusion about orders and documentation, and review of records showed missing assessments and incomplete tracking of required labs.
The facility did not consistently follow physician orders for oxygen therapy for three residents with significant medical needs, resulting in missed or undocumented administration of PRN oxygen, incorrect oxygen flow rates, and incomplete documentation of oxygen titration. Staff were sometimes unaware of specific orders or failed to document interventions as required, and residents were observed with oxygen settings that did not match their prescribed orders.
The facility did not maintain complete and accurate medical records for two residents with moderate cognitive impairment who were involved in discharge planning. Despite family requests and ongoing discussions about transferring to other facilities, the Social Services Representative failed to document these interactions or actions in the EHR, contrary to facility policy requiring such documentation.
A resident with multiple chronic conditions and recent surgery did not receive Pyridostigmine Bromide as directed due to a failure to clarify the medication order upon admission. Despite the resident's repeated requests and pharmacy inquiries, the order was not clarified for several days, resulting in a delay in treatment. Facility staff confirmed that the order should have been clarified according to policy.
A resident's room in the facility was found to have an ammonia odor and a sticky carpet due to frequent urinal spills. Despite the resident's preference for urinal placement, the facility failed to ensure adequate cleaning. Interviews revealed that the facility's cleaning schedule was not being met, with only three rooms deep cleaned daily instead of the required six.
A facility failed to communicate and update a resident's assistance level, leading to inadequate supervision and multiple falls. Despite the resident's medical history and therapy recommendations for staff assistance, the Care Plan inaccurately listed them as independent. Staff interviews revealed confusion and inconsistency in understanding the resident's needs, contributing to the deficiency.
A resident did not receive prescribed doses of Calcium Carbonate and Voltaren External Gel as per physician's orders. The facility's records showed missed doses and delays in administration, with no care plan intervention for the Calcium Carbonate. Staff interviews revealed a lack of adherence to scheduled times and no specific policy for following physician's orders. The resident had a complex medical history and required significant assistance with daily activities.
A facility failed to assist a resident with their CPAP machine due to the absence of a physician order. The resident, who had obstructive sleep apnea, required help with the CPAP's water chamber but did not receive assistance despite requests. Staff were unaware of the equipment, and the facility lacked a policy for personal medical equipment.
The facility failed to ensure a yearly psychotropic medication gradual dose reduction (GDR) was attempted or appropriately declined for three residents. A resident with anxiety and depression was on several psychotropic medications, but the GDRs lacked clinical rationale. Another resident with bipolar disorder and psychotic disorder had GDRs for Sertraline and Risperidone without clinical rationale, and no other GDRs were found. A third resident on Escitalopram had no GDR due to the power of attorney's request, and the facility lacked a specific policy for GDRs.
A resident with complex medical conditions did not have their weight monitored as per physician's orders from March to July 2024. The facility failed to document attempts to weigh the resident, any refusals, or notify the physician of missed weights. This led to a significant weight loss and subsequent hospitalization for a UTI and sepsis. The DON acknowledged the issue and stated the facility was becoming stricter in addressing weight monitoring concerns.
A resident with moderate cognitive impairment and multiple medical conditions did not receive adequate bathing assistance as per their care plan, which required substantial assistance for showering at least twice weekly. Documentation showed only one shower was provided over several weeks, with refusals noted but no further attempts to encourage or offer bathing. Facility records lacked evidence of consistent efforts to re-approach the resident for bathing after refusals, contrary to facility policy.
A resident with severe cognitive impairment and high fall risk potentially hit their head during an unattended transfer by a CNA. Despite a witness reporting the incident, the facility failed to document necessary neurological assessments or notify the physician, focusing instead on verbal abuse allegations. The lack of documentation and follow-up resulted in a deficiency in maintaining the resident's well-being.
A resident with severe cognitive impairment and mobility issues was left unattended during a transfer by a CNA, potentially resulting in a head injury. The care plan required two-person assistance, but the CNA attempted the transfer alone. The incident was reported by a witness, but the facility failed to document or assess the event properly, focusing instead on verbal abuse allegations.
A facility failed to monitor a resident's urinary output after catheter removal, leading to inadequate assessment of urinary retention. The resident, with severe cognitive impairment, was not monitored for a week, and the staff did not document urine output accurately when the catheter was reinserted. The facility lacked a policy on monitoring urine output post-catheter removal.
A facility failed to maintain infection control for two residents with indwelling catheters. One resident's catheter bag was found on the floor, and staff did not use barriers during care. Another resident's care did not follow Enhanced Barrier Precautions, as staff failed to wear gowns. The facility's policies on catheter care and infection prevention were not adhered to, increasing the risk of infection transmission.
The facility failed to provide adequate perineal care for two residents with impaired cognition and incontinence. One resident was left on a soiled sheet despite calling for help, while another received improper perineal care, with staff not following the facility's protocol. These deficiencies highlight a lack of timely assistance and adherence to care standards.
The facility failed to respond to resident call lights within the required timeframe, affecting two residents. One resident with impaired cognition experienced delays of 30 to 45 minutes, while another with intact cognition reported a delay of over 30 minutes, causing agitation. Staff acknowledged that call lights were not answered timely due to staffing issues and individual resident needs, despite facility policy requiring a response within 15 minutes.
A facility failed to maintain a complete Care Plan for a resident with moderately impaired cognition and frequent incontinence. The resident required substantial assistance and had multiple diagnoses, but their Care Plan did not address continence status. This was confirmed by the Director of Clinical Services, despite facility policy requiring comprehensive and individualized Care Plans.
The facility failed to follow physician's orders and nursing standards for medication administration. A resident received medications late, while two others were left unattended with their medications. Staff confirmed this was a common practice, indicating a systemic issue in medication management.
A facility failed to conduct follow-up assessments for a resident with severely impaired cognition after an unwitnessed fall. The resident, who required substantial assistance and had multiple diagnoses, fell in their room without injury. Despite the facility's policy requiring 72-hour follow-up assessments, the clinical record lacked these assessments, as confirmed by the Director of Clinical Services.
Failure to Assess for Readmission and Improper Involuntary Discharge Documentation
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive assessment and evaluation of a resident for readmission after a hospital transfer, and to have appropriate documentation in the medical record before issuing an involuntary discharge. The resident had intact cognition per a recent MDS, with diagnoses including progressive neurological conditions, MS, anxiety, depression, and functional quadriplegia. The MDS documented limited verbal behavioral symptoms that did not endanger the resident or others, did not significantly interfere with care or activities, and were unchanged from prior assessments. The care plan reflected the resident’s intent to remain long term and documented that she had been doing well, attending activities, and without untoward behaviors, although later entries noted her voiced discontent about staying and repeated education regarding the facility’s zero-tolerance policy for illicit substances. The record shows multiple incidents related to marijuana or THC products prior to the hospital transfer. The care plan and staff interviews documented that the resident used medical marijuana off property and that staff found three unidentifiable pills in her bed later identified as Marinol, with the resident being educated not to bring in non-prescribed medications. Another entry documented that the resident had a marijuana vape pen in her bag and admitted giving another resident a few hits, leading to re-education about illicit substances and the risks to other residents. A subsequent incident involved staff observing smoke from the resident’s mouth, a strong marijuana odor, and the resident attempting to hide a vape pen; staff reported she appeared impaired with slurred speech and rolling eyes, and the facility implemented a two-person rule for all care and contact. On a later date, the resident became unresponsive with slurred speech and was transferred to the hospital, where she was diagnosed with a UTI; facility staff reported to surveyors that they believed the UTI was complicated by THC use. After the hospital transfer, the facility did not perform an in-person assessment or evaluation of the resident at the hospital, nor did it conduct an assessment through conversations with hospital staff before serving involuntary discharge paperwork. Progress notes documented that the administrator and various witnesses went to the hospital on three separate occasions to hand-deliver emergency involuntary discharge notices, but there was no documentation of any clinical assessment for readmission or evaluation of the resident’s condition at those times. The facility relied on medical records as its assessment and later obtained a letter from the facility MD stating the resident was a danger to herself and others, but this letter was dated after the discharge notices and there was no prior documentation from the PCP or MD in the record indicating the resident was a danger. The facility also failed to follow its own admission, transfer, and discharge policy requirements for documenting the basis of transfer, specific needs that could not be met, attempts to meet those needs, and detailed discharge information. The resident, her family, and hospital staff reported that the resident was medically ready for discharge from the hospital and wanted to return to the facility, but the facility refused readmission and proceeded with the emergency involuntary discharge. The resident described receiving three separate discharge letters at the hospital, each time becoming tearful, scared, and anxious about her future and belongings, and stated she felt devastated and believed the action was related to a prior complaint she had filed. The hospital SW and coordinator corroborated that the facility declined to take the resident back even after an ALJ overturned the discharge, and that the resident was tearful, afraid, and anxious but without suicidal ideation or changes in appetite or sleep. The facility admitted another resident into the original room and locked the door after the hospital transfer. The facility also failed to obtain proper signatures on the discharge summary. The CNO stated that the resident’s mother signed the discharge summary, but the facility did not verify whether she was the POA or guardian, and the resident’s actual medical POA reported he was not consulted about the involuntary discharge and was only contacted about holding the bed at the time of hospital transfer. The POA stated the facility did not ask him to sign the discharge summary when he came to pick up the resident’s belongings. The administrator acknowledged that the resident herself did not sign the discharge summary. These actions and omissions, including the lack of comprehensive assessment for readmission, lack of required documentation supporting the involuntary discharge, and failure to obtain appropriate signatures, led to the cited deficiency and negatively affected the resident’s psychosocial well-being.
Failure to Maintain Safe and Functional Patient Care Equipment
Penalty
Summary
The facility failed to maintain mechanical and electrical patient care equipment in safe operating condition for multiple residents, resulting in delayed care and unsafe conditions. Several residents who were dependent on staff and equipment for transfers, such as those with multiple sclerosis, Parkinson's disease, and severe cognitive impairment, experienced issues with stand lifts and mechanical lifts. Specifically, two residents reported frequent problems with lift batteries dying during transfers, causing delays and leaving them in uncomfortable or unsafe positions while staff searched for working batteries. Staff and residents both confirmed that these battery issues were ongoing and not isolated incidents. In another instance, a resident's bed was found to be malfunctioning, unable to lower to the required safety position. Multiple staff members acknowledged the bed's malfunction, noting that it had been an issue for at least several days to over a week before a work order was finally submitted. The bed's inability to lower posed a safety concern, especially as the resident was dependent on staff for transfers and had a history of stroke and limited mobility. The maintenance staff only became aware of the issue after the work order was placed, despite several staff being aware of the problem earlier. Additionally, observations of two other residents being transferred with a mechanical lift revealed that one of the lift's wheels would come off the ground during use, causing the lift to tilt and creating an unstable transfer environment. Staff confirmed that this tilting had been occurring for some time, and they sometimes had to physically stabilize the lift during transfers. Maintenance staff were not aware of this issue until it was brought to their attention during the survey. Review of facility work orders indicated a lack of documentation for these recurring equipment problems, suggesting that the reporting and maintenance system was not effectively capturing or addressing all equipment safety concerns.
Failure to Maintain Resident Dignity Due to Stand Lift Battery Issues
Penalty
Summary
The facility failed to promote and maintain resident dignity for two residents who were dependent on staff and mechanical lifts for transfers and toileting. Both residents had intact cognition and required assistance for mobility and toileting due to medical conditions such as Multiple Sclerosis and Parkinson's disease. The deficiency was primarily related to ongoing issues with the batteries of stand lifts, which frequently failed to hold a charge, resulting in significant delays and discomfort for the residents during transfer and toileting activities. One resident experienced a delay of approximately 30 minutes after activating her call light to request toileting assistance. Staff attempted to use a stand lift, but the battery died during the process. After replacing the battery with another that also failed, staff had to retrieve a different lift from another part of the building. During this time, the resident remained in her wheelchair, and when finally transferred, her adult brief was saturated and drooping, indicating she had been left in soiled clothing while waiting. Staff confirmed that battery issues with the lifts had been an ongoing problem for months, causing frustration for both residents and staff. Another resident reported being left in a standing position on the lift when the battery died mid-transfer, requiring staff to leave her in that position while they retrieved a replacement battery. She described feeling uncomfortable and undignified during these episodes, which she stated occurred frequently. Facility leadership acknowledged awareness of the battery and charging issues, and resident council minutes also documented that a lift was out of commission. The facility's own dignity policy emphasized the importance of timely and respectful care, including toileting assistance and privacy, which was not upheld in these instances.
Failure to Follow and Document Physician Orders for Oxygen and Lab Monitoring
Penalty
Summary
The facility failed to follow, document, and/or carry out physician orders for two residents. For one resident with heart failure and severe cognitive impairment, there was a physician order to check oxygen saturation (POx) every shift and to apply oxygen at 2 liters via nasal prongs if the POx was below 90%. Documentation showed that on multiple occasions, the resident's oxygen saturation was below 90%, but there was no corresponding documentation that oxygen was applied as ordered. Staff interviews revealed confusion about the existence of the PRN oxygen order, and staff acknowledged not signing for the administration of oxygen when required. Additionally, there was a lack of nursing assessment documentation on days when low oxygen saturation was recorded. For another resident with diabetes and moderate cognitive impairment, there was a standing order to obtain a Hemoglobin A1c (Hgb A1c) test every six months. Review of the Treatment Administration Records (TARs) and progress notes indicated that the required Hgb A1c tests were not consistently documented as completed according to the order. The only Hgb A1c results found in the records were from a previous year and from a hospitalization, with no evidence that the six-monthly tests were performed as ordered by the physician. Interviews with nursing staff and review of facility procedures revealed that lab orders were supposed to be tracked in a Lab Order Book and on the MAR/TAR, with multiple checks in place to ensure completion. However, the process failed to ensure that the required labs were drawn and documented, and staff were unclear about the status of lab orders and documentation requirements. The facility's policy stated that all medications and treatments should be administered as ordered by a healthcare professional, but this was not followed in these cases.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that physician orders for oxygen therapy were followed for three residents. One resident with heart failure and severe cognitive impairment had a physician order for PRN oxygen to be applied when oxygen saturation fell below 90%. Documentation showed at least two occasions when the resident's oxygen saturation was 89%, but there was no documentation that oxygen was applied. Staff members reported not being aware of the PRN oxygen order, and although they sometimes applied oxygen when low saturations were noted, they did not consistently document its administration. The resident was not observed with oxygen during the survey period, and staff acknowledged not signing for PRN oxygen administration as required. Another resident with cancer, COPD, and severe cognitive impairment had a physician order for oxygen at 2 liters per nasal cannula, later changed to a titration order between 2-4 liters to maintain oxygen saturation above 90%. Observations revealed that the resident was often not wearing oxygen or had the oxygen flow set higher than ordered, sometimes at 3.5 to 4 liters instead of the prescribed 2 liters. Staff reported that the resident frequently removed the oxygen or adjusted the flow rate independently. The facility's documentation did not include a place to record the actual liter flow when titration was ordered, and staff acknowledged this gap in documentation. A third resident with multiple diagnoses, including COPD and heart failure, had an order for oxygen at 2 liters via nasal cannula, titrated to keep oxygen saturation above 90%. Observations found the resident receiving oxygen at 1.5 liters instead of the ordered 2 liters on two separate occasions. Staff present at the time acknowledged the incorrect setting and adjusted it to the correct flow rate. The facility's policy required that oxygen therapy be administered as prescribed and documented in the clinical record, but these requirements were not consistently met for the residents reviewed.
Failure to Document Discharge Planning and Family Communications in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents who were undergoing discharge planning. For one resident with moderate cognitive impairment, the care plan did not reflect a discharge plan, despite documented requests from the resident's family for referrals to other facilities. Although care conference notes indicated these requests, there were no progress notes from the Social Services Representative in the resident's electronic health record (EHR) since admission. The Social Services Representative confirmed that she had not documented any interactions or actions taken regarding the resident's transfer requests, and only provided email correspondence with the family as evidence of communication. For another resident, also with moderate cognitive impairment, care conference notes and interviews confirmed ongoing discussions between the Social Services Representative and the resident's family about transferring to a different facility. However, there were no progress notes in the EHR documenting these interactions or updates on the transfer process, with the last note being unrelated to discharge planning. The Social Services Representative acknowledged not documenting these interactions, and the Chief Nursing Officer confirmed that all such interactions should be recorded in the EHR. Facility policy required documentation of communications with residents and their representatives, as well as referrals and discharge plans, but these were not present in the records reviewed.
Failure to Clarify Medication Order Delays Resident's Treatment
Penalty
Summary
The facility failed to clarify a medication order for a newly admitted resident, resulting in a delay in the resident receiving Pyridostigmine Bromide as directed. Upon admission, the resident had a documented history of anemia, hypertension, benign prostate hyperplasia, and arthritis, and required assistance with activities of daily living following a lumbar spine fusion. The resident was cognitively intact, with no memory impairments, and was able to communicate effectively. The resident's outpatient medication list indicated Pyridostigmine Bromide 60 mg to be taken up to four times daily, but the facility's medication record listed the order as every six hours as needed for muscle spasms, which was flagged as outside the recommended frequency. Progress notes revealed ongoing confusion and concern from the resident regarding the administration of his medication, with repeated requests for clarification and a copy of his medication list. The pharmacy also requested clarification before dispensing the medication. Despite these concerns, the order was not clarified until several days after admission, during which time the resident did not receive the medication as he was accustomed to at home. The delay persisted until the provider clarified the order to match the resident's home regimen. Interviews with facility staff, including the DON and the advanced registered nurse practitioner, confirmed that the medication order should have been clarified upon admission according to facility policy. The lack of timely clarification led to the resident not receiving the prescribed medication as intended, despite multiple opportunities to address the issue and clear communication from the resident regarding his needs.
Failure to Maintain Odor-Free Environment in Resident Room
Penalty
Summary
The facility failed to ensure a homelike environment for Resident #71 by not maintaining a room free of odors. Observations revealed an ammonia odor in the hallway and Resident #71's room, despite the use of an odor diffuser. The carpet in the room felt spongy and sticky, particularly near the bed, indicating a lack of adequate cleaning. Resident #71, who has intact cognition and multiple diagnoses including anxiety, stroke, and Parkinson's, prefers to use a urinal while in bed. The resident expressed a preference for the urinal to hang on the trash can next to the bed, which sometimes results in spills when the urinal is full. Interviews with staff revealed that resident rooms are vacuumed and dusted daily, and carpets are cleaned as needed. However, there was no extra scheduled carpet cleaning for Resident #71's room despite frequent urinal spills. The Environmental Supervisor acknowledged the issue but noted that carpet cleaning relies on staff notification. The facility's Environmental Services Checklist requires each room to be deep cleaned monthly, with six rooms deep cleaned daily. However, the Environmental Supervisor estimated that only three rooms are deep cleaned daily, indicating a shortfall in meeting the facility's cleaning goals.
Inadequate Communication and Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to effectively communicate and update the current staff assistance level for a resident, leading to a deficiency in nursing supervision. The resident, who has a history of multiple medical conditions including stroke, hemiplegia, and Parkinson's, was noted to be independent in transfers and mobility according to the Care Plan. However, the resident experienced seven falls after the Minimum Data Set (MDS) was completed, indicating a potential mismatch between the resident's documented independence and their actual needs for assistance. The facility's documentation, including the Activity Level and Recommendations Form and the Physical Therapy notes, showed inconsistencies regarding the resident's required level of assistance, with some documents recommending staff assistance during transfers. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's current assistance needs. Staff members were unable to consistently explain the resident's assistance level, and there was a discrepancy between the Care Plan and the recommendations from therapy. The Director of Rehab acknowledged that the Bio Worksheet did not reflect the resident's current status, given the increase in falls, and could not provide documentation for when the resident was deemed independent. This lack of communication and documentation led to inadequate supervision and contributed to the resident's repeated falls.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for a resident, leading to missed doses of prescribed medications. Specifically, the resident did not receive several doses of Calcium Carbonate (Tums) during the last week of October 2024, as documented by a Registered Nurse (RN) in the Medication Administration Record (MAR). The facility's progress notes indicated that the medication was not on hand on certain days, and there was no documentation for one of the missed doses. Additionally, the facility did not have a care plan intervention for the administration of Calcium Carbonate, and the Director of Nursing (DON) stated that staff should notify the pharmacy if stock medications are unavailable. Furthermore, the facility did not administer Voltaren External Gel as prescribed. Observations revealed that the resident did not receive the topical gel at the scheduled times, and the Treatment Administration Record (TAR) confirmed the delay. The Administration Record History (ARH) showed that the Voltaren was administered over an hour late on multiple occasions. Staff interviews indicated that there was a lack of adherence to the scheduled administration times, and the facility did not have a specific policy for following physician's orders. The resident involved had a complex medical history, including heart failure, chronic kidney disease, diabetes mellitus, chronic pain, and spinal stenosis, and required significant assistance with activities of daily living.
Failure to Assist Resident with CPAP Machine Due to Lack of Physician Order
Penalty
Summary
The facility failed to provide necessary assistance and follow-up for a resident's personal medical equipment, specifically a CPAP machine, which was needed for respiratory care. Resident #235, who had intact cognition and was admitted with conditions including obstructive sleep apnea, had a CPAP machine brought in by family shortly after admission. The resident expressed the ability to use the CPAP independently but required assistance with the water chamber. Despite the resident's requests for help, staff did not provide assistance or follow-up due to the absence of a physician's order for the CPAP. Interviews with various staff members, including registered nurses and the Director of Nursing, revealed a lack of awareness and action regarding the CPAP machine. Staff working during the day were unaware of the equipment, while a night shift nurse confirmed its presence and the resident's use of it without assistance. The facility lacked a policy addressing personal medical equipment, and the Chief Nursing Officer confirmed this absence. The Assistant Director of Nursing acknowledged the expectation for staff to recognize medical equipment and ensure physician orders are in place, highlighting a gap in the facility's procedures.
Failure to Ensure Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a yearly psychotropic medication gradual dose reduction (GDR) was attempted or appropriately declined for three residents. Resident #32, who had multiple diagnoses including anxiety and depression, was on several psychotropic medications. The care plan directed staff to consult with pharmacy and the MD for dosage reduction quarterly, but the GDRs documented lacked clinical rationale, and no other GDRs were found in the resident's electronic health record (EHR). Additionally, the resident exhibited behaviors on specific dates, but no behaviors were documented after 12/25/24. Resident #44, diagnosed with conditions such as bipolar disorder and psychotic disorder, was also on multiple psychotropic medications. The care plan required quarterly consultation for dosage reduction, but the GDRs for Sertraline and Risperidone lacked clinical rationale, and no other GDRs were found in the EHR. The resident had no documented behaviors since 9/01/24, and the staff stated that target behaviors are documented in the Treatment Administration Record (TAR) if observed. Resident #66, with diagnoses including depression and PTSD, was on Escitalopram. The care plan included antidepressant medication use but did not provide directives for dose reductions. A GDR for Escitalopram was documented with no GDR per the power of attorney's request due to fear of increased symptoms. No other GDRs were located in the resident's EHR, and the staff was unaware of where to document target behaviors other than in progress notes. The facility did not provide a policy specific to Gradual Dose Reductions.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of quality care by not obtaining weights for a resident as per the physician's order. The resident, who had a range of complex medical conditions including neurogenic bladder, septicemia, quadriplegia, and edema, was supposed to have their weight monitored monthly. However, the facility did not record the resident's weight from March to July 2024, despite a physician's order to do so. The Treatment Administration Records (TAR) and Progress Notes lacked documentation of attempts to weigh the resident or any refusals by the resident to be weighed. Additionally, there was no documentation that the resident was educated on the risks of refusing to be weighed or that the physician was notified of the missed weights. The resident's care plan also lacked specific directions regarding weight monitoring and actions to take if the resident refused to be weighed. The facility's failure to document and follow up on the resident's weight monitoring led to a significant weight loss of 13.2% over seven months, as noted in a Dietary Quarterly Review. The resident experienced a mental status change and was hospitalized with a diagnosis of urinary tract infection and sepsis, further complicating their health status. The Director of Nursing (DON) acknowledged the issues with obtaining weights and stated that the facility was becoming more strict in addressing this concern. Despite the resident's refusal to get out of bed and be weighed, the facility's policy required that the physician be informed of any refusals, which was not done. The lack of adherence to the weight monitoring policy and failure to communicate with the physician contributed to the deficiency in care provided to the resident.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to a resident who required substantial assistance due to moderate cognitive impairment and multiple medical conditions, including cancer, anemia, coronary artery disease, hypertension, cirrhosis of the liver, and a right humerus fracture. The resident's care plan specified the need for assistance with showering tasks at least twice weekly. However, documentation revealed that the resident received only one shower from the date of admission to early August, with several refusals noted but no further attempts documented to encourage or offer bathing. The facility's records lacked evidence of consistent efforts to re-approach the resident for bathing after initial refusals, as expected by the facility's policy. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the absence of additional documentation for bathing attempts and highlighted the need for staff education on bathing expectations. The facility's policy required that residents receive care according to their individualized care plans, ensuring that their abilities in activities of daily living, such as showering, do not diminish unless unavoidable due to clinical conditions.
Failure to Document and Follow Up on Potential Head Injury
Penalty
Summary
The facility failed to provide necessary interventions and care for a resident, leading to a deficiency in maintaining the resident's highest practical physical well-being. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was reportedly left unattended by a CNA during a transfer, resulting in the resident potentially hitting their head on a wall. Despite a witness reporting the incident to the Director of Nursing (DON), the facility did not document the necessary neurological assessments or notify the physician as required by their policy. The resident's care plan indicated a high risk for falls due to various health conditions, including dementia and decreased mobility. The incident was reported by a family member of the resident's roommate, who witnessed the CNA verbally abusing the resident and leaving them unsupported during a transfer. The DON conducted a head-to-toe assessment but failed to document it in the clinical record, focusing instead on the verbal abuse allegations. The clinical record lacked any documentation of the incident, neurological assessments, or physician notification. Interviews with the DON and the resident's wife revealed that the facility did not follow its neurological assessment policy, which required monitoring for 72 hours after a suspected head injury. The facility's Advance Registered Nurse Practitioner (ARNP) was informed of rough treatment allegations but not specifically about the potential head injury. The facility's failure to document and follow up on the incident as per their policy resulted in a deficiency in providing adequate care and services to the resident.
Inadequate Supervision Leads to Potential Resident Injury
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident with severe cognitive impairment and multiple health conditions, including dementia and a right hip fracture. The resident required substantial assistance with activities of daily living and was at risk for falls due to confusion and decreased mobility. The care plan specified that the resident needed assistance from two staff members for transfers, but an incident occurred where a CNA attempted to transfer the resident alone, resulting in the resident potentially hitting their head against the wall. The incident was reported by a family member of the resident's roommate, who witnessed the CNA leaving the resident unattended on the bedside, leading to a loud noise that was believed to be the resident's head hitting the wall. Despite the report, the facility's documentation lacked any record of the incident or assessments conducted following the event. The Director of Nursing (DON) did not fill out an incident report, as there were no visible injuries, and focused instead on the verbal abuse reported by the witness. Interviews with staff revealed inconsistencies in the understanding and application of the resident's care plan. The CNA involved in the incident claimed that the care plan allowed for a single-person transfer with a gait belt, contradicting the care plan's requirement for two-person assistance. Other staff members confirmed that the resident had always required two-person assistance for transfers. The facility's policy on accidents and incidents emphasized the importance of reporting and documenting such events, but this was not adhered to in this case.
Failure to Monitor Urinary Output After Catheter Removal
Penalty
Summary
The facility failed to monitor and provide appropriate urinary assessment for a resident after the removal of an indwelling catheter. The resident, who had severe cognitive impairment and was unable to communicate pain or urinary needs, was not monitored for urinary retention from the time the catheter was removed until a week later when it was noted that the resident had not urinated. The facility lacked documentation of urinary assessments during this period, and the resident's condition was not adequately monitored. When the resident's catheter was reinserted, the staff did not document the urine output accurately, as required by the physician's order. The nurse reported that the urine output was close to 200 ml, but the exact amount was not recorded, and the catheter was left in place despite the order to remove it if the residual was less than 200 ml. The facility's Nurse Practitioner later stated that leaving the catheter in was appropriate given the resident's history and symptoms. The facility did not have a policy on monitoring urine output or retention after catheter removal, which contributed to the lack of proper documentation and follow-up. The Director of Nursing expected staff to follow standards of practice, document accurately, and follow physician orders, but these expectations were not met in this case. The Assistant Director of Nursing acknowledged the absence of a policy and mentioned that the Corporate Nurse was working on one.
Inadequate Infection Control for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections for two residents with indwelling catheters. Resident #5, who had a neurogenic bladder, septicemia, and a recent urinary tract infection, was observed with a catheter bag lying on the floor, contrary to the facility's policy. During catheter care, staff placed incontinence wipes directly on the turning pad without a barrier and did not ensure the catheter bag was properly positioned, leading to it lying on the floor. This resident had a history of sepsis and was readmitted to the hospital with a complicated UTI and sepsis. Resident #3, who had renal disease, heart failure, and Alzheimer's disease, was also observed receiving inadequate catheter care. Staff failed to wear gowns as required by the Enhanced Barrier Precautions policy during high-contact care activities. Incontinence wipes were placed directly on the wipe container without a barrier, and staff did not initially wear gowns, which was against the facility's policy for residents with indwelling catheters. The Director of Nursing acknowledged the expectation for staff to use appropriate barriers and wear gowns during the entire catheter care process. The facility's policies on Foley catheter care and Enhanced Barrier Precautions were not followed, contributing to the potential for infection transmission. The facility's policy emphasized the importance of preventing urinary tract infections by avoiding contact of catheter tubing with the floor and using enhanced precautions for residents with indwelling medical devices.
Inadequate Perineal Care for Two Residents
Penalty
Summary
The facility failed to provide adequate perineal care for two residents, leading to deficiencies in their care. Resident #2, with moderately impaired cognition and frequent incontinence, was found lying on a soiled sheet with a removed brief after calling for assistance. Despite her calls, staff did not attend to her needs promptly, as confirmed by her roommate and the observation of dried urine on her sheet. This indicates a failure to provide timely assistance and proper hygiene care for Resident #2, who required substantial assistance due to her cognitive and physical impairments. Resident #3, with severely impaired cognition and always incontinent, also did not receive proper perineal care. Staff members were observed providing inadequate care by not changing the washcloth surface and wiping back and forth, contrary to the facility's perineal care protocol. Additionally, during another care session, staff failed to cleanse the resident's buttocks and hips properly. These actions demonstrate a lack of adherence to the facility's protocol for perineal care, compromising the hygiene and dignity of Resident #3, who required maximal assistance due to her medical conditions.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights within the required 15-minute timeframe for two of the three residents reviewed. Resident #2, who has moderately impaired cognition and requires substantial assistance with daily activities, experienced delays of 30 to 45 minutes in call light response. Family members reported these delays and observed staff sitting at the nurse's station during these times. Resident #11, with intact cognition, also reported a delay of over 30 minutes, which caused her agitation. Staff members acknowledged that call lights were not answered timely due to staffing issues and individual resident needs. The facility's policy mandates that call lights be answered within 15 minutes for bedrooms and 5 minutes for bathrooms. However, interviews with staff and residents, as well as Resident Council Minutes, indicated ongoing concerns with call light response times. An Ombudsman email also highlighted complaints related to call light delays. Staff members admitted that approximately 10% of call lights were not answered within the required timeframe, citing staffing shortages and unexpected circumstances as contributing factors.
Incomplete Care Plan for Resident with Incontinence
Penalty
Summary
The facility failed to maintain a complete and accurate Care Plan for one of the residents reviewed. The resident, identified with a Minimum Data Set (MDS) assessment indicating moderately impaired cognition, required substantial assistance with toilet use, personal hygiene, and ambulation. The resident was frequently incontinent of bowel and bladder and had diagnoses including renal insufficiency, polyneuropathy, anxiety, and non-Alzheimer's dementia. However, the Care Plan for this resident did not address their continence status. This deficiency was confirmed through an email from the Director of Clinical Services, acknowledging the omission in the Care Plan. The facility's policy required that each Care Plan include a summary of specific goals and care needs, developed by the Interdisciplinary Team, and be reviewed and revised according to State rules, Federal regulations, and professional standards of nursing care.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to physician's orders and nursing standards of practice for medication administration, affecting three residents. For Resident #13, medications prescribed to be administered at 6 AM were given at 8:48 AM by a Certified Medication Aide. The medications included critical prescriptions such as Apixaban, Losartan Potassium, and Sotalol, among others, which are essential for managing conditions like blood pressure, heart health, and blood thinning. This delay in medication administration indicates a failure to follow the prescribed schedule, which is crucial for the effectiveness of these treatments. Additionally, the facility did not ensure proper supervision during medication administration for Residents #12 and #11. Resident #12, who has moderately impaired cognition, was left unattended with a medication cup, leading him to take his medications without supervision. Similarly, Resident #11, with intact cognition, confirmed that staff frequently left medications at her bedside unattended. Multiple staff members, including CNAs, corroborated that it was common practice to leave medications unattended, which poses a risk of medication errors or misuse.
Failure to Conduct Follow-Up Assessments After Resident Fall
Penalty
Summary
The facility failed to assess and implement interventions for a resident following a fall. Resident #3, who had a severely impaired cognition with a BIMS score of 4, required substantial assistance with toilet hygiene and was always incontinent of bowel and bladder. The resident had diagnoses of fractures, non-Alzheimer's dementia, Bell's palsy, and weakness. On 5/13/24, a progress note indicated that Resident #3 sustained an unwitnessed fall in her room at 7:30 AM without injury. However, the clinical record lacked follow-up assessments for the resident after the fall, which was expected to be conducted for 72 hours according to the facility's policy, as confirmed by the Director of Clinical Services.
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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