The Alverno Health Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton, Iowa.
- Location
- 849 13th Avenue North, Clinton, Iowa 52732
- CMS Provider Number
- 165509
- Inspections on file
- 24
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at The Alverno Health Care Facility during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls experienced three unwitnessed falls within four days, starting soon after admission. Despite documented risks and repeated incidents, the facility did not complete a root-cause analysis to identify common factors, as required by its falls management policy.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Drugs and biologicals were not labeled according to professional standards, and were not stored in locked compartments as required, with controlled drugs not kept in separately locked compartments.
The facility failed to follow up on pharmacy recommendations for medication monitoring and gradual dose reductions for four residents. Despite recommendations for GDRs and laboratory monitoring, there was no documentation of these actions being taken. The DON admitted to not reviewing or forwarding the pharmacist's recommendations to the PCP, contrary to the facility's policy on Medication Regimen Review.
The facility failed to label and date food items in the kitchen, leading to several items being found without proper labeling or beyond expiration dates. Staff interviews revealed that the facility uses a program to track outdated food, but the deficiency indicates a failure in consistently following these procedures.
A resident with diabetes did not receive properly administered insulin due to a failure to prime the insulin pen and check its expiration date. An LPN administered insulin without priming the pen, and the pen was used beyond its expiration date. The DON confirmed the pen should have been primed and removed after 28 days.
A resident in a LTC facility was transferred unsafely from a Broda chair to a bed by two staff members without using a gait belt, and the chair was not locked. The resident required two-person assistance for transfers, as noted in their summary, but the care plan lacked specific transfer instructions. Interviews with staff confirmed the omission of safety measures, and the facility's policy did not address this concern.
The facility failed to follow proper infection control practices during insulin administration for two residents with diabetes. Insulin pens were used without cleaning the hub before needle attachment, and gloves were not worn during administration. The facility's Infection Preventionist and DON confirmed these actions were against protocol.
The facility failed to ensure safe and secure medication disposal. A CMA disposed of two pills in the garbage can on the medication cart, leaving them accessible to 18 residents. Staff interviews revealed inconsistent disposal practices, and the DON was unaware of these practices. The facility's policy lacked clear guidelines for medication disposal.
The facility failed to ensure hand-washing sinks were present in three laundry rooms used by staff to handle soiled items, including isolation materials for C. diff. Staff had to use hand sanitizer or access a soiled utility room to wash hands, posing a contamination risk.
The facility failed to respond to residents' call lights within the required fifteen-minute time frame, affecting multiple residents who required substantial assistance. Interviews and observations revealed significant delays, with some residents waiting over an hour for help. Staff were unsure of the expected response time, and the facility's policy lacked clear guidelines.
A resident reported missing cash and gift cards, but the facility failed to document the investigation outcome or reimburse the missing property. The Administrator did not interview staff or communicate with family members, and the facility lacked a formal policy for handling missing or stolen items.
The facility failed to update the PASRR for a newly admitted resident to reflect his diagnoses of unspecified psychosis, anxiety, and depression. The resident's care plan noted behavior changes and aggression, and the social worker admitted to missing the update.
A facility failed to ensure a resident's PRN anti-psychotic medication was reviewed by the PCP every 14 days or discontinued as required. The resident received the medication multiple times after the 14-day period without proper review or renewal, despite staff awareness of the requirement.
Failure to Complete Root-Cause Analysis After Multiple Resident Falls
Penalty
Summary
The facility failed to complete a root-cause analysis after a resident experienced three falls within a four-day period, beginning within 48 hours of admission. The resident had severe cognitive impairment, vision and hearing difficulties, and required staff assistance for ambulation, toileting, and other activities of daily living. The care plan identified a risk for injury related to falls, with a history of falls and generalized weakness. Despite these known risks, the facility did not conduct a root-cause analysis to determine if there was a common factor contributing to the repeated falls. Incident reports documented that the resident's falls were unwitnessed and occurred in her room, often after attempting to transfer or ambulate without assistance and without using the call light. The resident was found on the floor multiple times, sometimes with minor injuries, and was noted to be disoriented and confused at the time of the incidents. Although staff implemented some interventions after each fall, such as posting reminder signs and increasing visual checks, the facility did not follow its own policy requiring evaluation of falls to determine appropriate interventions to prevent future occurrences.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper medication labeling and storage protocols as observed by surveyors. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Gradual Dose Reductions and Monitor Medications
Penalty
Summary
The facility failed to follow up on pharmacy recommendations for the monitoring of medications and gradual dose reduction (GDR) for four residents. Resident #20, with intact cognition, was prescribed duloxetine, an antidepressant, but there was no documentation of a GDR despite a recommendation from a consultation report. Resident #2, also with intact cognition, was prescribed lorazepam, an antianxiety medication, but similarly, there was no documentation of a GDR following a recommendation. Resident #45, with severely impaired cognition, was prescribed fluoxetine, an antidepressant, and the consultation report recommended a GDR, but there was no documentation of this being addressed. Resident #60, with intact cognition and diagnoses of anxiety and depression, was prescribed buspirone and venlafaxine, but the pharmacist's recommendations for a GDR and laboratory monitoring were not documented as addressed. The Director of Nursing (DON) admitted to receiving emails from the pharmacist and placing them in a folder without reviewing or forwarding the requests to the primary care provider (PCP). The facility's policy on Medication Regimen Review (MRR) requires that the consultant pharmacist's recommendations be communicated to the attending physician and other necessary staff, and that the attending physician should address these recommendations by their next scheduled visit. The lack of action in addressing the pharmacist's recommendations for GDR and monitoring led to the deficiency identified in the report.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to food storage guidelines, as observed during an initial kitchen tour. Several food items in the refrigerator were found without labels or dates indicating when they were opened or prepared. Additionally, some items were kept beyond their expiration dates. Specific items included a large bag of lettuce, a bag of french fries, melted butter, corned beef, and various other food items, all lacking proper labeling. The walk-in refrigerator also contained items with expired dates, such as sliced ham and homemade ranch dressing. Interviews with staff revealed that the facility uses a program to track and dispose of outdated food, and the expectation is for all food items to be labeled with the name, date opened, and discard date. The Sous Chef and Dietary Manager acknowledged the labeling and dating expectations, noting that the refrigerators are checked three times per week. However, the deficiency indicates a failure in consistently following these procedures, as evidenced by the unlabeled and expired items found during the survey.
Failure to Prime and Check Expiration of Insulin Pen
Penalty
Summary
The facility failed to ensure proper insulin administration for a resident diagnosed with Diabetes Mellitus, who received daily insulin injections. During an observation, a Licensed Practical Nurse (LPN) did not prime the insulin pen before administering 2 units of Insulin Lispro for a blood sugar level of 168. The insulin pen had a handwritten open date, but the LPN was unable to confirm the expiration date or the necessity of priming the pen before use. The Director of Nursing (DON) later confirmed that the insulin pen should have been primed with 2 units to prevent air from remaining in the needle and that the pen expired 28 days after being opened. The insulin pen used for the resident had exceeded this period and should have been removed from the medication cart. The facility's Licensed Nurse Skill Competency Checklist included steps for insulin administration but did not address checking the expiration date of insulin pens.
Unsafe Transfer Procedure for Resident
Penalty
Summary
The facility failed to ensure a safe transfer for a resident from a chair to a bed, which was observed during a survey. The resident, who was unable to complete a mental status interview and was dependent on assistance for various activities of daily living, was transferred by two staff members without the use of a gait belt. The resident's care plan did not specify the level of transfer assistance required, and the resident summary indicated a need for two-person assistance with transfers. During the transfer, the Broda chair was not locked, and the staff lifted the resident without using a gait belt, contrary to the facility's expected procedures. Interviews with staff, including the Therapy Director and the Director of Nursing, confirmed that the proper procedure for transferring the resident should have included the use of a gait belt and locking the chair. Staff members involved in the transfer acknowledged the omission of these safety measures. The facility's policy on accidents and incidents did not address the specific area of concern related to the transfer process, highlighting a gap in the facility's procedural guidelines.
Infection Control Deficiency in Insulin Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during insulin administration for two residents with diabetes mellitus. Resident #11, who has Type 2 Diabetes Mellitus, was observed receiving insulin injections without the hub of the insulin pen being cleaned prior to needle attachment. Additionally, the nurse did not wear gloves during the administration of insulin, which is against the expected protocol. The nurse acknowledged the oversight during an interview, admitting that she should have cleaned the hub and worn gloves. Similarly, Resident #45, who also receives daily insulin injections, was administered insulin by a nurse who did not clean the hub of the insulin pen before attaching the needle. The facility's Infection Preventionist and Director of Nursing both confirmed that the expectation is for nursing staff to clean the hub of insulin pens and wear gloves during insulin administration to prevent infections. The facility's competency checklists and medication pass review documents also highlight the importance of these infection control practices.
Unsafe Medication Disposal Practices
Penalty
Summary
The facility failed to ensure medications were disposed of in a safe and secure manner. During a medication cart observation, a Certified Medication Aide (CMA) disposed of two pills, Pantoprazole 40 mg and Metoprolol 50 mg, in the garbage can on the medication cart after they missed the medication cup. This action left the medications unsecured and accessible to 18 residents on the floor. The medication cart was also left unattended during this process. Interviews with staff revealed inconsistent practices for medication disposal, with some staff using the Sharps container or garbage can, while others used drug buster stored in the locked medication room. The Director of Nursing (DON) was unaware that staff were disposing of medications in the garbage or Sharps container and expected them to use drug buster. The facility's policy on medication administration, dated May 2008, did not include procedures for medication disposal. This lack of clear guidelines contributed to the inconsistent and unsafe disposal practices observed among the staff.
Lack of Hand-Washing Sinks in Laundry Rooms
Penalty
Summary
The facility failed to ensure a hand-washing sink was present in three laundry rooms that contained washers and dryers used by staff to transfer presorted clothes from laundry hampers into the washer. During a continuous walk-through of the facility, it was observed that the laundry rooms on the first, second, and third floors did not have hand-washing sinks. This deficiency was identified despite the facility having a census of 88 residents. The absence of hand-washing sinks in these areas is critical, especially when handling soiled items such as isolation materials for C. diff, which requires stringent infection control measures including hand-washing with soap and water, as hand sanitizer alone is not effective against C. diff spores. During an interview, a staff member from Environmental Services (EVS) revealed that in her years of working at the facility, the laundry rooms have never had hand-washing sinks. She mentioned that staff use gloves and proper PPE and then use hand sanitizer available on the wall in the room. However, if they needed to wash their hands with soap and water, they would have to touch multiple doors to access the soiled utility room, which poses a risk of contamination. At the time of the survey, no residents had C. diff, but the lack of proper hand-washing facilities in the laundry rooms represents a significant infection control deficiency.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to respond to residents' call lights within the required fifteen-minute time frame, as observed in multiple instances. Resident #19, who had intact cognition and required assistance for various activities, had her call light on for over an hour and twenty minutes without receiving the needed help. She reported that staff often turned off call lights without providing assistance, leading her to keep the light on to ensure her request was addressed. Similarly, Resident #4, who also had intact cognition and required substantial assistance, reported that call lights often took a long time to be answered, sometimes forcing her to use the bathroom on her own to avoid incontinence. Resident #5, who required substantial assistance and had chronic pain and anxiety, experienced significant delays in call light responses. On one occasion, her call light was on for over two hours without being answered, causing her to fall asleep while waiting for assistance to use the bathroom and receive pain medication. Resident #15, who had an indwelling catheter and required substantial assistance, had a documented history of long call light response times, with multiple instances exceeding twenty minutes. Resident #61, with moderately impaired cognition and requiring substantial assistance, also experienced delays, with her call light being on for over twenty minutes on two separate occasions. Interviews with staff and the Director of Nursing revealed that there was no clear policy on the required response time for call lights, and staff were unsure of the expected response time. The facility's policy on answering call lights advised staff to respond as soon as possible but did not specify a fifteen-minute requirement. The Director of Nursing acknowledged that call light audits had been conducted due to complaints, but the issue persisted. The facility's inability to run a call light report from their computer system further complicated the situation.
Failure to Implement Policy for Missing Property
Penalty
Summary
The facility failed to implement their policy when the Administrator addressed a grievance regarding missing property and possible theft for a resident. The resident, who had an intact cognitive status, reported that between $60 to $80 in cash and approximately $300 in gift cards were missing from his room. Despite the resident's report and a police investigation, the facility's progress notes lacked documentation regarding the missing property, the outcome of an investigation, and any information regarding reimbursement. The Administrator acknowledged awareness of the missing property and conducted a 5-day investigation, which included searching the resident's room and interviewing other residents. However, the Administrator did not interview staff about the incident or inquire whether staff were aware of the resident's money and gift cards. The facility did not have a plan to replace or reimburse the missing property, and the Administrator did not communicate with any family members who may have assisted the resident in acquiring the gift cards. Several staff members, including CNAs and the DON, were involved in searching the resident's room and reported the incident to the Administrator. However, there was no formal investigation involving staff interviews, and inconsistencies were noted in the amounts of money and gift cards reported missing. The facility's Resident Handbook stated that the community does not accept responsibility for the loss or theft of money or valuables, and residents were encouraged to keep valuables in a locked and safe place or in a resident trust account.
Failure to Update PASRR with Accurate Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) for a newly admitted resident accurately reflected his admitting diagnosis. The resident was admitted with diagnoses of unspecified psychosis, anxiety, and depression, which were not documented in the PASRR dated prior to admission. The resident's care plan noted behavior changes related to dementia, including delusions and aggression. The facility's social worker acknowledged that the PASRR was not updated to reflect the new diagnoses, despite the resident receiving these diagnoses shortly after admission.
Failure to Review PRN Anti-Psychotic Medication Every 14 Days
Penalty
Summary
The facility failed to ensure that a resident's PRN anti-psychotic medication was reviewed by the Primary Care Provider (PCP) every 14 days or discontinued as required. The resident was prescribed Seroquel 12.5 PRN, and although the initial rationale for its use was documented, there was no follow-up documentation within the subsequent 14 days to justify its continued use. The resident received the medication on multiple occasions after the 14-day period had lapsed without a proper review or renewal by the PCP, specifically on 4/18/24, 4/22/24, 4/24/24, 4/25/24, and 4/29/24. This oversight was identified during a record review and staff interviews, revealing a lapse in compliance with CMS requirements for PRN anti-psychotic medications. The facility's Social Worker acknowledged awareness of the 14-day review requirement but noted the family's insistence on having the medication available for the resident. During interviews, staff members, including a Registered Nurse/MDS Coordinator, confirmed their awareness of the requirement for PRN anti-psychotic medications to be reviewed every 14 days. Despite this knowledge, the facility did not ensure compliance, resulting in the resident receiving the medication without the necessary evaluations and renewals. The facility reported a census of 88 residents at the time of the survey, and this deficiency was identified through a combination of record reviews and staff interviews.
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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