The Bridges At Ankeny
Inspection history, citations, penalties and survey trends for this long-term care facility in Ankeny, Iowa.
- Location
- 3510 Northwest Ablilene Road, Ankeny, Iowa 50023
- CMS Provider Number
- 165616
- Inspections on file
- 21
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Bridges At Ankeny during CMS and state inspections, most recent first.
The facility failed to ensure accurate medication administration for three residents, resulting in wrong medications, duplicate dosing, and under-dosing. One resident who had recently changed rooms was given another resident’s full set of medications when an RN pulled drugs from the wrong cart slot and did not verify the name or compare the bubble packs to the MAR, leading to hypotension and bradycardia. A second resident with dementia received a double dose of Donepezil when an RN administered the medication but did not document it or secure it on the cart, and a CMA later found the unsigned dose and administered it again. A third post-surgical resident with rectal cancer and severe pain received only half of the ordered Tramadol dose for several days because staff followed the pharmacy bubble pack labeling instead of the physician’s 100 mg order in the electronic record and failed to reconcile the discrepancy between the pack and the MAR.
Staff failed to administer medications as ordered and on time for several residents, with multiple medications—including pain management, insulin, anticoagulants, and others—being given hours after the scheduled times. Audit reports and staff interviews confirmed the delays, and the DON verified the late administrations.
The facility did not respond to resident call lights within the required 15-minute timeframe, with multiple instances of call lights remaining unanswered for extended periods, including up to three hours. Family members and residents reported repeated delays, and staff confirmed that inadequate staffing contributed to the problem. The administrator was aware of ongoing issues, and Resident Council Notes documented repeated complaints about slow call light responses.
Staff failed to consistently follow infection control protocols during an outbreak and while two residents were on enhanced barrier precautions, including not sanitizing equipment after it fell on the floor, not using barriers when placing items in resident rooms, and not always wearing proper PPE. Leadership and staff interviews confirmed ongoing issues with infection control compliance.
A resident receiving hospice care for brain and lung cancer was prescribed oral inhalers and instructed to rinse her mouth after each use. She refused the oral rinses, resulting in stomatitis, but the care plan did not address either the stomatitis or her continued refusal to rinse.
A resident with multiple health conditions and moderate cognitive impairment did not receive proper perineal care after incontinence. Staff cleaned only a limited area, failed to cleanse the vaginal, buttocks, and thigh regions as required, and did not follow facility policy for perineal hygiene. The resident also reported dissatisfaction with previous care related to toileting assistance.
The facility failed to provide sufficient staff to ensure call lights were answered within 15 minutes, with reports of delays up to 60 minutes. Observations and interviews revealed significant staffing shortages, particularly on weekends and during increased admissions, leading to long wait times for resident assistance. Family members and staff expressed concerns about the impact of reduced staffing levels following a change in ownership.
A facility failed to involve a resident and their representative in regular care conferences, holding only two in the past year despite the resident's preference for family involvement. The resident, with a history of stroke, cancer, and dementia, had severely impaired decision-making skills. The social worker confirmed the last care conference was held months ago and could not explain the lack of subsequent meetings.
The facility failed to provide adequate oral hygiene care for two residents as per their care plans. One resident, with a history of stroke and dementia, was dependent on staff for oral care, but documentation showed significant lapses, especially during evening shifts. Another resident, with anxiety and dementia, required assistance and encouragement for oral hygiene, yet documentation was inconsistent, with no records for February. Staff interviews highlighted issues with documentation and care provision.
A resident with dementia and high fall risk was found in a bed left in a high position without supervision, contrary to the facility's Fall Prevention Policy. The resident's care plan required supervision and a safe environment due to cognitive impairment and fall risk, but staff failed to maintain the bed in a low position, as observed by a surveyor.
A resident with end-stage renal disease and a suprapubic catheter did not receive complete incontinence care as per facility policy. During an observed procedure, staff failed to cleanse the resident's groin, penis, scrotum, and thighs, despite the presence of the Director of Nursing. The facility's Perineal Care policy was not followed, leading to a deficiency in care.
A resident with intact cognition fell over her walker and was assisted by CNAs, but the incident was not documented in a timely manner. The nurse on duty, who was already on a final warning for documentation failures, did not record the fall until instructed by management. The facility's policy requires incidents to be documented in the EHR before the end of the shift, which was not followed, leading to a deficiency in maintaining accurate medical records.
A LTC facility failed to follow professional standards for medication administration in two incidents. In one case, an LPN intended to administer medication found unattended near a resident without proper verification. In another, a resident with intact cognition had medications left on their bedside table, including a discontinued drug. The facility's policy requires safe and timely administration, which was not followed.
The facility failed to provide consistent restorative exercises for three residents with limited ROM and mobility issues due to staffing shortages. Despite therapy recommendations, the prescribed exercises were rarely completed, as the restorative aide was frequently reassigned to other duties. This led to a deficiency in care for residents with conditions such as CVA, hemiplegia, and dementia.
A facility failed to ensure staff used Enhanced Barrier Precautions (EBP's) for a resident with a suprapubic catheter. Despite the presence of an EBP sign and available protective equipment, staff did not wear gowns during high-contact care activities. Interviews confirmed that EBP's were required for residents with catheters, and the facility's policy mandated gowns and gloves to prevent the spread of MDRO's.
The facility failed to ensure safe transfer procedures, resulting in incidents where residents were injured due to improper use of equipment and lack of supervision. A resident fell from a weight chair due to a dislodged wheel, another was transferred without engaging lift stability legs, and a third fell from a mechanical lift due to unsecured straps.
The facility failed to provide sufficient nursing staff, resulting in delayed call light responses and unmet resident needs. Observations showed call lights unanswered for over 30 minutes, and interviews with residents and staff confirmed understaffing issues. Staff reported working short, with inadequate support for residents requiring two-person assistance. Despite management's belief in adequate staffing, the facility's assessment did not align with actual resident needs, leading to prolonged wait times and insufficient care.
The facility failed to accurately assess their resident population and resource needs, leading to inadequate staffing and delayed care. The facility assessment did not reflect the actual resident census, and interviews revealed significant delays in response times and insufficient CNAs to assist with ADLs and meals. The Executive Director acknowledged inaccuracies in the assessment, attributing them to a clerical error by the former Administrator.
A resident with liver cirrhosis and cancer, dependent on staff for toileting, was not assisted in a timely manner after requesting help for a bowel movement. Despite the care plan and facility policy requiring staff assistance, the CNA and CMA did not provide the necessary help, and the resident's need was not communicated during shift handoff, resulting in a deficiency in maintaining the resident's dignity.
The facility failed to maintain a clean and homelike environment in the memory care unit dining hall, with food items left on the floor and tables for several days and an overflowing garbage can. Despite expectations for regular cleaning, these conditions persisted, and a family member noted the room's filthy appearance.
A resident with cognitive impairments and a history of falls was not provided with required protective measures, such as Geri-sleeves and fall mats, as outlined in their care plan. Observations showed the resident without these measures, and staff interviews revealed inconsistencies in care plan implementation. The DON acknowledged the oversight, and the facility's policy lacked specific procedures for assistive devices.
A resident with multiple health conditions, including COPD and respiratory failure, was not administered oxygen therapy as ordered. The resident was observed multiple times without the oxygen mask properly in place, leading to low oxygen saturation levels. Family members reported frequent occurrences of the resident being without oxygen, and staff failed to respond promptly during a shift change. The facility's Director of Nursing expected more frequent assessments, especially for residents recently returned from the hospital.
A facility failed to provide a nourishing diet to a resident who chose to eat in her room, leading to a deficiency. Meal service was delayed and chaotic, with no room trays provided to residents confined to their rooms. Staff interviews revealed systemic issues in meal delivery, with the kitchen often forgetting room trays and nursing staff responsible for serving residents on modified diets. The facility's policy required meals to be served according to residents' needs and preferences, which was not followed.
A CNA failed to follow infection control practices while caring for a resident with a catheter, who was on Enhanced Barrier Precautions. The CNA did not wear gloves when handling a graduate container with urine, contrary to facility policy. The ADON expected staff to wear gloves when handling body fluids and to rinse the container after use.
The facility failed to follow infection control practices, including improper handling of a gait belt, lack of barrier use for medical equipment, and incorrect PPE removal. Additionally, a CNA did not wash hands before peri-care and wiped incorrectly, leaving a mechanical sling under a resident without a barrier.
The facility failed to provide discharge and medical information to the receiving health care institution for a resident transferred to the hospital for G-tube placement. The DON confirmed that no transfer form was completed, and staff did not document sending any transfer paperwork or calling the hospital to give a report on the resident's condition. The Administrator confirmed there was no policy for resident transfers to the hospital.
The facility failed to notify the LTC Ombudsman of a resident transfer to the hospital and reentry on the same day, as required by federal regulation. The Administrator confirmed that the facility did not report ED visits to the Ombudsman and lacked a specific ombudsman policy.
A facility failed to include PASRR Level II service recommendations in a resident's Care Plan. Staff interviews revealed a lack of awareness about the need to incorporate PASRR recommendations, and the facility did not have a PASRR policy in place.
The facility failed to develop and implement comprehensive person-centered care plans for three residents. One resident's care plan lacked interventions for dentures and oral care, another resident's care plan did not document fall risks and interventions despite multiple falls, and a third resident's care plan did not include the use of a scoop mattress for positioning.
The facility failed to update a resident's Care Plan to include catheter care after a catheter was inserted due to urinary retention. The ADON confirmed that the Care Plan should have been revised within 24 hours, as per facility policy.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 6.25%. An LPN did not follow proper procedures for insulin administration, leading to incomplete dosing for a resident with diabetes. The ADON, DON, and Corporate Nurse confirmed the expected procedure, but the LPN's actions did not comply with these standards.
A resident with diabetes experienced significant medication errors when an LPN failed to properly administer insulin according to manufacturer instructions and facility policy. The LPN did not hold the insulin pens in the skin for the required time, resulting in insulin leakage and incomplete dosing. Observations and interviews confirmed the proper procedure was not followed.
A facility failed to accurately complete an MDS assessment for a resident with serious mental illness and/or intellectual disability, as indicated by a Level II PASRR. The care plan acknowledged the PASRR status, but the MDS did not, and the facility lacked a specific PASRR policy.
Failure to Ensure Accurate Medication Administration and Dosing for Multiple Residents
Penalty
Summary
The deficiency involves multiple failures in medication administration that resulted in residents not receiving medications as ordered and, in one case, receiving another resident’s medications. One resident with a history of stroke, cognitive communication deficit, and urinary tract infection was involved in a room change. On the morning of the incident, an RN retrieved medications from the medication cart using the room slot labeled for that room, but did not verify the resident’s name on the medication packs or compare the medications to the MAR. The RN popped, crushed, and administered a full set of medications that belonged to a different resident, including several antihypertensives, an anticoagulant, and other medications not prescribed for this resident. Shortly afterward, the resident appeared pale, with head drooping and unable to speak, and was found to have low blood pressure and heart rate. The facility’s investigation documented that the RN had taken medications from the wrong room spot in the cart after the room change and that the investigation lacked documentation of staff or resident interviews about past or present concerns with medication administration. A second deficiency involved another resident with dementia who was cognitively intact per BIMS. On one occasion, a medication (Donepezil 10 mg) arrived from the pharmacy after the CMA had already passed the resident’s morning medications. The RN administered the newly arrived dose but did not immediately sign it out on the MAR and left the medication at the cart between the computer components instead of securing it. While the RN was away in the DON’s office, the CMA, seeing the unsigned medication and not recognizing it had already been given, administered the same medication again and signed it on the MAR. This resulted in a double dose of the medication due to failure to document administration at the time of giving and failure to secure the medication on the cart. A third deficiency involved a resident admitted after digestive system surgery with rectal cancer, anemia, diabetes, a surgical wound, and significant pain. The resident had orders for Tramadol 100 mg PO every 6 hours for pain management, initially PRN and then scheduled. Due to a discrepancy between the physician’s order and the pharmacy-supplied bubble packs, staff administered only 50 mg every 6 hours over several days instead of the ordered 100 mg dose. Documentation showed that the controlled drug receipt forms and bubble pack labels reflected 50 mg tablets, and staff followed the bubble pack directions rather than the computer order. The MAR documented Tramadol 100 mg as given, but only 50 mg was actually administered on multiple occasions. Staff did not compare the bubble pack contents and labeling to the physician’s order in the computer prior to administration, and the error was discovered only after the resident continued to report significant pain and wound dehiscence was noted. Interviews confirmed that nurses and CMAs were expected to follow the 6 rights of medication administration and compare bubble packs to physician orders, but in this case they relied on the bubble pack directions instead of the actual order.
Failure to Administer Medications According to Physician Orders and Timely Manner
Penalty
Summary
Facility staff failed to administer medications according to physician orders and in a timely manner for four residents. Multiple instances were documented where medications, including pain management, anti-anxiety, anticoagulants, insulin, and other critical drugs, were given significantly later than the times specified in the physician's orders. For example, morphine sulfate, magic mouthwash, and Ativan were administered hours after the ordered times for one resident, while another resident received midodrine, enoxaparin, acetaminophen, and lidocaine patch well past the scheduled administration times. Similar delays were observed for other residents, with medications such as atorvastatin, sucralfate, lidocaine cream, and insulin glargine being administered several hours late. Observations and audit reports confirmed these late administrations, and staff interviews revealed that at least one Certified Medication Aide (CMA) was aware of running behind schedule but did not report the issue. The Director of Nursing (DON) confirmed the accuracy of the documented late medication administrations. The facility had a census of 84 residents at the time, and the deficiencies were identified through record review, observation, and staff interviews.
Failure to Respond to Resident Call Lights in a Timely Manner
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by multiple observations, interviews, and documentation. On several occasions, call lights remained unanswered for extended periods, including instances where a call light was on for 16 to 18 minutes before staff responded, and another instance where a call light was left on for 21 minutes. Family members of two residents reported timing call lights being left unanswered for an average of 32 minutes, with one instance lasting up to three hours. Another family member reported a call light being unanswered for one hour, leading the family to provide care themselves. One resident experienced a fall after attempting to use the bathroom without assistance due to a delayed response to their call light, resulting in feelings of disappointment, sadness, anger, and anxiety. Staff interviews confirmed that call lights were not answered within the facility's 15-minute policy due to insufficient staffing and an inability to meet all residents' needs. Resident Council Notes from several months documented ongoing concerns about delayed call light responses, particularly on the evening shift. The facility's administrator acknowledged awareness of the persistent call light response issues. The facility's policy on answering call lights emphasized the importance of timely responses to residents' requests and needs.
Failure to Follow Infection Control Practices During Outbreak and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow appropriate infection control practices during an outbreak and when residents were on enhanced barrier precautions. Observations revealed that staff did not sanitize items such as name tags, thermometers, and blood pressure devices after they had fallen on the floor or been used in resident care, and these items were placed on surfaces without barriers or cleaning. Staff also failed to use proper personal protective equipment (PPE) consistently, with some entering resident rooms without appropriate PPE during an outbreak period. One resident with multiple diagnoses, including renal insufficiency and chronic respiratory failure, required assistance with activities of daily living and was on enhanced barrier precautions due to a pressure area on the left heel. Staff were observed providing care to this resident without adhering to proper infection control protocols, such as failing to sanitize equipment and not using barriers when placing items in the resident's room. Additionally, staff were seen using the same gloves to handle multiple items and not sanitizing high-touch objects like call lights after they had been on the floor. Interviews with staff and facility leadership confirmed awareness of ongoing infection control issues, including improper mask use and PPE compliance, especially during the outbreak. Facility policy required staff to use gloves and gowns for high-contact care activities and to place barriers under items set down in resident rooms, but these procedures were not consistently followed. The Director of Nursing and Administrator acknowledged continued problems with infection control practices.
Incomplete Care Plan for Hospice Resident with Stomatitis
Penalty
Summary
The facility failed to maintain a complete and accurate care plan for one resident who was admitted under hospice care with diagnoses of malignant neoplasm of the brain and lung. The resident's treatment included the use of oral inhalers, with instructions to rinse her mouth after each dose to prevent complications. Despite the resident's refusal to rinse her mouth after inhaler use, which subsequently led to the development of stomatitis as documented by the physician, the care plan did not address the stomatitis or the resident's ongoing refusal to perform oral rinses. This omission was identified through clinical record review and staff interview.
Failure to Provide Proper Perineal Care for Dependent Resident
Penalty
Summary
Staff failed to provide proper perineal care to a resident who required substantial assistance with activities of daily living due to diagnoses including renal insufficiency, chronic respiratory failure, muscle weakness, and moderately impaired cognitive skills. During an observed care episode, a CNA assisted the resident after use of a bed pan by cleaning only the mid-gluteal region with a single swipe, neglecting to cleanse the vaginal area, buttocks, or thighs. The soiled brief was replaced with a clean one, but the perineal area was not properly cleaned according to facility policy. When questioned, one staff member did not respond regarding the condition of the brief, while another confirmed it was a little wet. After further questioning, the CNA admitted to not cleansing the resident's vaginal area and then attempted to clean the area by pulling back the clean brief and wiping anteriorly, but replaced the same soiled brief. The resident later expressed dissatisfaction with previous care, stating that a staff member had told her to urinate in her brief rather than providing the requested bed pan. Facility policy requires thorough perineal care, including washing from front to back and cleaning all relevant areas, which was not followed in this instance.
Staffing Shortages Lead to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient staff to ensure call lights were answered within a reasonable amount of time, which is defined as within 15 minutes. Observations and reports from residents, family members, and staff indicated that call lights were often left unanswered for periods ranging from 30 to 60 minutes. The Palatium Care Monitor at the nurse's station showed multiple instances where call lights were left on for extended periods, with some exceeding 60 minutes. This issue was compounded by the facility's inability to provide comprehensive call light reports due to a recent change in the management of the call light system. Interviews with staff revealed that the facility was experiencing significant staffing shortages, particularly on weekends and during times of increased admissions. CNAs and LPNs reported being overwhelmed with the number of residents requiring assistance, especially those needing two-person transfers. The facility's change in ownership was noted to have resulted in reduced staffing levels, further exacerbating the problem. Staff members expressed concerns about the lack of support from management and the difficulty in providing timely care to residents. Family members and residents expressed dissatisfaction with the long wait times for assistance, with some family members advising residents to activate their call lights well in advance of needing help. The Director of Nursing acknowledged the expectation for call lights to be answered within 15 minutes, but the facility's current staffing levels and increased resident admissions made it challenging to meet this standard. The facility's assessment from September 2024 indicated a commitment to maintaining sufficient nursing staff, but the current situation demonstrated a failure to uphold this standard.
Failure to Conduct Regular Care Conferences
Penalty
Summary
The facility failed to involve a resident and/or their representative in care conferences and did not ensure that care conferences were held at least quarterly for a resident with a history of cerebrovascular accident, cancer, and dementia. The resident, who was admitted to the facility with severely impaired decision-making skills, had expressed a preference for family involvement in care discussions. Despite this, only two care conferences were held in the past year, with only one occurring since the facility's change in ownership. The social worker responsible for setting up care conferences confirmed that the last care conference for the resident was held several months ago and was unable to explain why no further conferences had been scheduled since then.
Deficiency in Oral Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate oral hygiene care as directed in the care plans for three residents. Resident #63, who had a history of cerebrovascular accident, hemiplegia, cancer, and non-Alzheimer's dementia, was dependent on staff for oral hygiene. Despite the care plan's directive for oral care to be provided multiple times a day, documentation revealed significant lapses in care, particularly during the evening shifts. Interviews with staff indicated that the resident could become combative during care, but staff attempted to manage this by reapproaching and encouraging the resident. However, the family reported concerns about the resident's oral hygiene, noting instances of bad breath. Resident #25, diagnosed with anxiety disorder, depression, and non-Alzheimer's dementia, required partial or moderate assistance for oral hygiene. The care plan specified that oral care should be provided and documented twice daily. However, documentation showed only sporadic instances of oral care being recorded, with no entries for February. Interviews with CNAs revealed that while the resident required encouragement to perform oral hygiene, there was no record of refusal, suggesting a lack of consistent documentation. The Director of Nursing acknowledged the deficiency in documentation and the expectation for regular oral hygiene care.
Failure to Maintain Bed in Low Position for Resident at Risk of Falls
Penalty
Summary
The facility staff failed to ensure the safety of a resident by not maintaining the resident's bed in a low position, as required by the facility's Fall Prevention Program Policy. The resident, who had diagnoses of dementia, osteoporosis, and anxiety disorder, was observed lying in bed with the bed in a high position without any staff present in the room, hallway, or at the nurse's station. This occurred despite the resident's care plan indicating a need for supervision and a safe environment due to impaired cognitive function and a high risk of falls. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition and dependence on staff for bed mobility and transfers. The facility's policy, updated in 2001, emphasized the importance of maintaining beds at the lowest position to prevent falls, especially for cognitively impaired residents at high risk. However, during the surveyor's observation, the bed was left in a high position, and the Assistant Director of Nursing acknowledged that the bed was higher than preferred, suggesting staff might have been preparing the resident for breakfast. This oversight in maintaining the bed's position posed a potential risk to the resident's safety.
Incomplete Incontinence Care for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to provide complete incontinence care for a resident with significant medical conditions, including end-stage renal disease, obstructive uropathy, and diabetes. The resident, who had a suprapubic catheter and was dependent on staff for toileting, was observed by surveyors during an incontinence care procedure. Staff A and Staff B, both CNAs, transferred the resident from a wet Broda chair to the bed using a mechanical lift. During the procedure, it was noted that the suprapubic catheter was disconnected from the leg bag, which was empty. Staff A reconnected the catheter to the leg bag after cleansing both ends with alcohol swabs. However, the staff failed to perform complete perineal care as per the facility's policy. The Director of Nursing (DON) observed the procedure and confirmed that the staff did not cleanse the resident's groin, penis, scrotum, right hip, and thighs, which are essential parts of complete incontinence care. The facility's Perineal Care policy outlines specific steps for cleaning the perineal area, including washing the urethra, penis, scrotum, and inner thighs, which were not followed. The failure to adhere to these procedures was confirmed by the DON during an interview, highlighting a deficiency in the care provided to the resident.
Failure to Document Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate documentation for a resident who experienced a fall. The resident, who had intact cognition as per her MDS, reported that she fell over her walker while ambulating independently in her room. Despite being assisted by CNAs and assessed by a nurse, the fall was not documented in a timely manner, and the facility staff were initially unaware of the incident when questioned by EMS. The resident's daughter was also not informed of the fall until days later when the resident herself reported it. Interviews with facility staff revealed discrepancies in the documentation process. A CNA confirmed witnessing the fall and notifying the nurse on duty, Staff K, who assessed the resident but did not document the incident immediately. Staff K later entered a late entry record of the fall, but only after being instructed by management. She claimed it was not her responsibility to document the fall as it occurred at the end of her shift. Other staff members, including the DON, confirmed that it was the responsibility of the responding nurse to document incidents in the EHR before the end of their shift. The facility's documentation policy requires that all incidents, including falls, be recorded in the resident's medical record. However, Staff K, who was already on a final written warning for previous documentation failures, did not adhere to this policy. The lack of timely documentation and communication regarding the resident's fall led to a deficiency in maintaining accurate medical records, as required by professional standards.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards and practices regarding medication administration, as evidenced by two separate incidents involving medication being left unattended. In the first incident, a medication cup containing two tablets was found on a dining room table near a resident who was rarely or never understood. The staff member who discovered the medication brought it to the attention of an LPN, who initially disputed the medication belonged to the resident. Despite the surveyor's advice to contact a nurse manager, the LPN intended to administer the medication without proper verification. The medication was later confirmed to match the resident's prescribed potassium and probiotic pills, but the LPN did not report the incident to management until several hours later. In the second incident, a resident with intact cognition was found with a bottle of Zyrtec and a medication cup containing two pills on their bedside table. The resident's husband had brought the Zyrtec from home, despite being informed not to do so. The resident was unsure why the medications were left there or how long they had been present. The medications were identified as Diltiazem and Guaifenesin, with the latter having been discontinued days earlier. The facility's policy requires medications to be administered safely and not left unattended, yet the medications were left on the bedside table without supervision. Both incidents highlight a failure to follow the facility's medication administration policy, which mandates verifying resident identity and ensuring medications are administered correctly and at the right time. The Director of Nursing confirmed that staff are expected to monitor residents during medication administration and report any medication errors promptly. The facility's policy, last revised in 2012, emphasizes the importance of safe and timely medication administration, which was not adhered to in these cases.
Inadequate Restorative Care Due to Staffing Issues
Penalty
Summary
The facility failed to implement therapy recommendations and provide restorative exercises for three residents with limited range of motion (ROM) and mobility issues. Resident #36, who had a history of cerebrovascular accident (CVA), hemiplegia, Alzheimer's Disease, and dementia, was supposed to receive restorative exercises 3 to 6 times per week. However, documentation showed that these exercises were performed only a few times over several months. Interviews with staff revealed that the restorative aide was frequently reassigned to other duties due to staffing shortages, leading to inconsistent delivery of the prescribed restorative program. Resident #54, diagnosed with stroke, hemiplegia, arthritis, and Alzheimer's disease, also experienced a lack of consistent restorative care. The resident's care plan included specific exercises to be performed multiple times a week, but records indicated these were rarely completed. The facility's documentation and staff interviews highlighted that the restorative program was not being followed as intended, with the restorative aide often pulled to cover other staffing needs. Similarly, Resident #63, with a history of CVA, hemiplegia, cancer, and non-Alzheimer's dementia, did not receive the prescribed restorative exercises. The resident's care plan called for passive and active ROM exercises several times a week, but documentation showed minimal completion of these activities. Staff interviews confirmed that the facility's staffing issues led to the neglect of the restorative program, contributing to the deficiency in care for these residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff utilized Enhanced Barrier Precautions (EBP's) when providing care to a resident with a suprapubic catheter. The resident, who had diagnoses of end-stage renal disease, obstructive uropathy, and diabetes, was dependent on staff for toileting and required EBP's due to the presence of an indwelling catheter. Observations revealed that staff did not wear gowns while transferring the resident from a Broda chair to a bed, nor during catheter and incontinence care, despite the presence of an EBP sign and available personal protective equipment in the resident's room. Interviews with staff, including a CNA, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that EBP's were required for residents with tubes such as catheters, and that staff were expected to wear gowns and gloves during high-contact care activities. The facility's policy on EBP's, dated March 25, 2024, outlined the necessity of gowns and gloves to prevent the spread of Multi-Drug Resistant Organisms (MDRO's) during high-contact activities, including transferring residents and providing hygiene care.
Deficiencies in Resident Transfer Procedures
Penalty
Summary
The facility failed to ensure the safe transfer of residents, leading to multiple incidents involving improper use of equipment and lack of supervision. Resident #8, who had severe cognitive impairment and required substantial assistance for transfers, fell while being weighed on a weight chair. The incident occurred when a wheel of the weight chair dislodged, causing the resident to fall and sustain a head laceration and a wrist fracture. The staff did not use a gait belt during the transfer, and the malfunction of the weight chair was not previously identified despite routine maintenance checks. Resident #10, who was fully dependent on staff for transfers and required a mechanical lift, was transferred without engaging the stability legs of the lift. This oversight by the staff during the transfer process posed a significant risk to the resident's safety. Additionally, the staff failed to conduct a time-out to ensure the proper placement of straps before initiating the transfer, which is a critical step in ensuring the safety of mechanical lift transfers. Resident #4 experienced a fall during a mechanical lift transfer when a sling strap slipped off the hook, causing the resident to fall and hit her head. The incident report indicated that the staff did not secure the sling straps properly, leading to the fall. The resident expressed fear of future transfers due to this incident. The facility's documentation highlighted the need for staff training on mechanical lift transfers to prevent such occurrences.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, resulting in delayed response times to call lights and insufficient care. Observations and reports indicated that call lights were not answered within the expected 15-minute timeframe, with some instances exceeding 30 minutes. Interviews with residents and family members revealed that the facility was understaffed, leading to prolonged wait times for assistance, particularly during peak times such as meal services. Residents expressed dissatisfaction with the level of care, citing long waits for help and inadequate staffing levels. Staff interviews corroborated the residents' and families' concerns, with several staff members reporting that they were often short-staffed and unable to meet the demands of the residents. The staffing coordinator and Director of Clinical Services believed the staffing levels were adequate, but staff members, including CNAs and nurses, reported that the facility had cut staff since a new company took over, leading to unsafe conditions and concerns about their ability to provide proper care. The facility's staffing levels were not adjusted to accommodate the increased census and resident acuity, resulting in inadequate care and unmet needs. The facility's assessment and staffing policies were not aligned with the actual needs of the residents, as evidenced by the discrepancies in the reported average census and the actual number of residents. The facility's assessment lacked detailed information for certain halls, and the staffing levels did not reflect the acuity and assistance required by the residents. The Executive Director acknowledged the need for improvement in call light response times and was in the process of understanding the systems in place, but the ongoing staffing issues continued to impact the quality of care provided to the residents.
Inadequate Facility Assessment and Staffing Levels
Penalty
Summary
The facility failed to adequately evaluate their resident population and identify the necessary resources and staffing levels required to provide appropriate care and services. The facility assessment, updated in March 2024, did not accurately reflect the current resident census or the acuity levels across all hallways, particularly omitting information for residents on the 100-200 halls. The assessment indicated an average census range of 50-66 residents, while the actual census was reported to be 87 residents at the time of the survey, with a year-to-date average of 92.9. This discrepancy suggests that the facility did not have an accurate understanding of the resident population, which is critical for determining the appropriate staffing levels and resources needed. Interviews with residents and family members revealed significant delays in response times to call lights, with reports of waiting 20 minutes to an hour for assistance. Family members also noted insufficient staffing, particularly CNAs, which affected the timeliness of care, such as assistance with ADLs and meal service. A CNA expressed concerns about being short-staffed, which impacted their ability to get residents up for meals on time. The Executive Director, who started in August 2024, acknowledged the inaccuracies in the facility assessment and attributed them to a clerical error by the former Administrator. These findings highlight the facility's failure to maintain an accurate and comprehensive assessment of their resident population and resource needs, leading to inadequate staffing and delayed care.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide toileting assistance and care for a resident in a manner that maintained or enhanced dignity. Resident #7, who had diagnoses of liver cirrhosis and cancer, was dependent on staff for transfers and toileting hygiene and had frequent bowel incontinence. The resident's care plan required staff assistance for toileting and keeping the call light within reach. On the day of the incident, the resident informed a CNA that he needed to use the bathroom for a bowel movement. However, the CNA and a CMA, who was just starting his shift, did not assist the resident and instead left the area to check assignments. The staff failed to communicate the resident's need for toileting assistance during the shift handoff, and the resident remained in his wheelchair without assistance. The Assistant Director of Nursing later stated that staff were expected to provide toileting assistance as requested. The facility's policy on supporting activities of daily living required providing care and services for residents unable to carry out ADLs, including assistance with elimination. Despite these policies, the resident's request for assistance was not addressed, leading to a deficiency in maintaining the resident's dignity.
Failure to Maintain Clean Dining Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the memory care unit dining hall. Direct observations on multiple occasions revealed food items, including dried eggs and smears of jelly, left on the floor and tables for several days without being cleaned. Additionally, a garbage can was observed overflowing with trash from previous dining services. These conditions persisted despite the Certified Dietary Manager's expectation that staff should clean the dining rooms after every meal and perform a deep cleaning after the evening meal. A family member also noted the room's filthy condition, indicating it is often unclean in appearance.
Failure to Implement Care Plan for Resident Safety
Penalty
Summary
The facility failed to adhere to the care plan for a resident with a history of cerebral infarction, anxiety disorder, and non-Alzheimer's dementia, who also exhibited behaviors such as scratching himself and had a history of falls. The care plan, last revised in early August, required the use of Geri-sleeves to protect the resident's skin and fall mats to prevent injury. However, observations on multiple occasions revealed that the resident was not wearing the Geri-sleeves, and fall mats were not present by the bed. Staff interviews and documentation reviews indicated discrepancies in the implementation of the care plan, with the Medication Administration Record (MAR) showing inconsistencies in the documentation of Geri-sleeve application. During an observation, a CNA noticed the absence of Geri-sleeves and fall mats and attempted to address the issue, but the resident was still found without these protective measures the following day. A family member confirmed that the resident was supposed to wear the sleeves but was rarely seen with them. The Director of Nursing acknowledged the absence of fall mats when the resident was moved to another room and emphasized the expectation for staff to follow the care plan. The facility's policy on assistive devices did not provide specific procedures for the use of such equipment, contributing to the deficiency.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen and other respiratory treatments in accordance with physician orders and resident Care Plans for a resident with multiple health conditions, including cerebral infarction, anxiety disorder, non-Alzheimer's dementia, congestive heart failure, respiratory failure, cerebral vascular event, and COPD. The resident was supposed to be on continuous oxygen therapy via a nasal cannula, but the care plan did not specify the ideal oxygen saturation range. Over a period, there were 98 instances where the resident's oxygen saturation was assessed while on room air instead of the ordered continuous oxygen, with the lowest recorded saturation being 84%. On multiple occasions, the resident was observed without the oxygen mask properly in place, leading to low oxygen saturation levels. During one observation, the resident was found with the oxygen mask around his neck and called for help multiple times without staff response, as they were engaged in a shift change. The resident's oxygen saturation was recorded at 79% while wearing a nasal cannula. Family members reported that the resident was often found without oxygen during visits, and images provided showed the oxygen mask improperly positioned. The Director of Nursing stated that staff are expected to assess residents at shift change and more frequently for those recently returned from the hospital.
Failure to Provide Room Trays for Residents
Penalty
Summary
The facility failed to provide a nourishing, well-balanced diet that considered the preferences of a resident, leading to a deficiency in dietary services. During a meal service observation, it was noted that lunch service was delayed and chaotic, with no assistance provided to residents who chose to eat in their rooms or were confined to their beds. The meal service ended without serving room trays to these residents, including one resident who had refused to get up for lunch but wanted to eat in her room. This resident, with intact cognition, reported not receiving a meal and feeling hungry. Interviews with staff revealed systemic issues in meal service delivery, particularly for residents requiring room trays. The Certified Dietary Manager acknowledged that the kitchen staff was not informed of the resident's request for a meal tray. A Registered Nurse confirmed that it was not uncommon for the kitchen to forget room trays, and nursing staff were responsible for serving and feeding residents on modified diets. Another resident reported avoiding eating in her room due to the likelihood of not receiving a room tray, despite having moderately impaired cognition. The facility's policy required residents to receive meals according to their needs and preferences, which was not adhered to in this instance.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility staff failed to adhere to infection prevention and control practices for a resident with a catheter, who was on Enhanced Barrier Precautions (EBP). The resident had a history of liver cirrhosis, cancer, chronic kidney disease, neurogenic bladder, urinary tract infection, and sepsis. During an observation, a Certified Nursing Assistant (CNA) donned a gown and gloves to drain urine from the resident's catheter bag. However, after cleansing the catheter port and removing her gloves, the CNA handled the graduate container with urine without wearing gloves, which was against the facility's policy. The Assistant Director of Nursing (ADON) was present during the observation and later reported that staff were expected to wear gloves when handling body fluids and to rinse the graduate container after use. The facility's policy required all employees to wear gloves when handling body fluids and during high-contact resident care activities, such as indwelling device care. The CNA's actions did not comply with these policies, leading to a deficiency in infection control practices.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure staff followed infection control practices, leading to potential cross-contamination and spread of infection. One incident involved a Certified Nursing Assistant (CNA) who did not properly handle a gait belt after assisting a resident with a Stage 2 pressure ulcer. The CNA placed the contaminated gait belt in her scrub pocket instead of leaving it in the resident's room, as required by Enhanced Barrier Precautions (EBP). Additionally, a Licensed Practical Nurse (LPN) failed to use a barrier when placing medical equipment on a resident's bed and did not disinfect the plastic bin used to transport medications, which was then placed back on the medication cart and counter without cleaning. Another deficiency was observed when a certified medical assistant exited a resident's room wearing an isolation gown and gloves, which were not removed until reaching the medication cart and nurse's station. This action violated the facility's policy that required PPE to be removed before leaving the resident's room. Furthermore, a CNA did not wash her hands before donning gloves to perform peri-care on a resident and initially wiped from back to front, which is against proper infection control practices. The CNA also left a mechanical sling under the resident without a barrier during the peri-care. The facility's policies on Enhanced Barrier Precautions and Isolation-Transmission Based Precautions were not followed by the staff, leading to these deficiencies. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the lapses in infection control practices during interviews, confirming that the staff did not adhere to the expected procedures for preventing cross-contamination and infection.
Failure to Provide Discharge Information to Hospital
Penalty
Summary
The facility failed to provide discharge and medical information to the receiving health care institution at the time of discharge for a resident who transferred to the hospital. The clinical record review revealed that the resident was transported to the hospital for the placement of a G-tube, but there was no documentation of information sent with the resident. The Director of Nursing (DON) confirmed that no transfer form was completed and that staff did not document sending any transfer paperwork or calling the hospital to give a report on the resident's condition. During an interview, the DON stated that staff should have provided copies of the face sheet, Medication Administration Record (MAR), Physician Orders for Life-Sustaining Treatment (IPOST), and progress notes. Additionally, the DON expected staff to call the hospital to give a report on the resident's condition and document this communication. However, the staff did not follow these procedures, and the Administrator confirmed via email that there was no policy in place for resident transfers to the hospital.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman of a resident transfer as required by federal regulation. Specifically, the clinical record for Resident #76 lacked documentation of notification to the LTC Ombudsman when the resident was transferred to the hospital and reentered the facility on the same day. During an interview, the Administrator and Administrator's Assistant confirmed that the facility did not report to the Ombudsman for Emergency Department (ED) visits. Additionally, the Administrator stated via email that there was no specific ombudsman policy in place, and they followed state and federal regulations.
Failure to Include PASRR Recommendations in Care Plan
Penalty
Summary
The facility failed to develop and update the comprehensive Care Plan with Preadmission Screening and Resident Review (PASRR) Level II service recommendations for a resident with a PASRR Level II determination. The resident, who had diagnoses including non-Alzheimer's dementia, anxiety disorder, depression, and bipolar disorder, was admitted to the facility and had a Care Plan that directed staff to follow any specialized services and specialized rehabilitation services recommended. However, the Care Plan lacked the PASRR recommended services, which included ongoing psychiatric medication management, obtaining psychiatric records, rehabilitative services, and community placement supports. Interviews with staff revealed a lack of awareness and understanding regarding the inclusion of PASRR recommendations in the Care Plan. The Social Services staff reported being in the process of making a psychiatric referral but was unaware that PASRR recommendations needed to be included in the Care Plan. The Director of Nursing and Assistant Director of Nursing both indicated that PASRR-related information should be on the Care Plan. Additionally, the facility did not have a PASRR policy in place, as confirmed by the Administrator. The facility's policies on Behavioral Assessment, Intervention, and Monitoring, and Comprehensive Person-Centered Care Plan, indicated that PASRR evaluation reports should be used in resident assessment and care plan development, but this was not followed in this case.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents. Resident #48 was admitted with lower dentures, but the care plan lacked interventions regarding dentures and oral care. Despite family and staff noting issues with the dentures, these concerns were not addressed in the care plan. Staff interviews confirmed that oral care was performed daily, but the care plan did not reflect this, contrary to the facility's policy on comprehensive care plans. Resident #55, who had severe cognitive impairment and a high risk for falls, experienced multiple falls resulting in injuries. The care plan did not document the resident's fall risk or the interventions put in place after each fall. Staff interviews revealed confusion and inconsistencies in updating the care plan, especially after a new company took over the facility's management. The facility's policy requires care plans to be updated within seven days of the MDS assessment and revised as the resident's condition changes, which was not adhered to in this case. Resident #76, who had hemiplegia and hemiparesis, was observed lying on a scoop mattress, which was not documented in the care plan. The DON stated that orders for scoop mattresses are not typically obtained unless used as a restraint, and the facility is a restraint-free environment. The ADON mentioned that the resident's family had requested side rails, which the facility does not allow, and the scoop mattress was offered as an alternative. This intervention was not reflected in the care plan, indicating a failure to document all aspects of the resident's care accurately.
Failure to Update Care Plan for Catheter Insertion
Penalty
Summary
The facility failed to review and revise a resident's Care Plan to meet the resident's needs for catheter care. Resident #26, who had moderately impaired cognition and multiple complex medical conditions, was admitted from a short-term general hospital. The resident's Admission Minimum Data Set (MDS) documented no urinary catheter initially. However, a subsequent order directed staff to insert a catheter due to urinary retention. Despite this, the Care Plan was not updated to reflect the catheter insertion, and it continued to document the resident as an assist of 1 with toileting without any mention of the catheter. During an interview, the Assistant Director of Nursing (ADON) confirmed that the Care Plan should have been revised within 24 hours after the catheter was placed. The facility's policy on comprehensive person-centered care plans also mandates that care plans be revised as residents' conditions change. The failure to update the Care Plan for Resident #26 was acknowledged by the ADON, indicating a lapse in adhering to the facility's policy and the expected standard of care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 6.25%. During a medication administration observation, an LPN administered insulin to a resident with diabetes but did not follow proper procedures. The LPN administered Glargine insulin and Humalog insulin but did not hold the insulin pens in the resident's skin for the required duration to ensure the full dose was administered. This resulted in visible liquid streaming from the needle and the resident feeling something drip on her. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that staff should hold the insulin pen for several seconds after administration to ensure the full dose is delivered, but the LPN did not adhere to this protocol. The manufacturer's instructions for both Lantus and Humalog insulin pens specify that the needle should be held in the skin for a certain number of seconds after the dose is administered to ensure the full dose is delivered. The facility's policy for insulin administration also aligns with these instructions. However, the LPN did not follow these guidelines, leading to the medication error. Interviews with the ADON, DON, and Corporate Nurse confirmed the expected procedure, but the LPN's actions did not comply with these standards, resulting in a medication error rate above the acceptable threshold.
Improper Insulin Administration Leading to Medication Errors
Penalty
Summary
The facility failed to properly administer insulin to a resident with diabetes, leading to significant medication errors. During an observation, an LPN administered Glargine insulin and Humalog insulin to the resident but did not follow the manufacturer's instructions for proper administration. Specifically, the LPN did not hold the insulin pens in the resident's skin for the required amount of time to ensure the full dose was administered. This resulted in insulin leaking from the needle after removal, and the resident reported feeling something dripping on her. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both confirmed that staff should hold the insulin pen for several seconds after administration to ensure the full dose is delivered. The manufacturer's instructions for both Lantus and Humalog insulin pens specify that the needle should be held in the skin for a certain number of seconds after the dose is administered to ensure the full dose is delivered. The facility's policy for insulin administration also aligns with these instructions. However, the LPN did not adhere to these guidelines, leading to the medication error. Interviews with the ADON, DON, and a Corporate Nurse confirmed the proper procedure and highlighted the discrepancy in the LPN's actions. The facility's failure to follow proper insulin administration procedures resulted in a significant medication error for the resident.
Inaccurate MDS Assessment for Resident with Level II PASRR
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident diagnosed with non-Alzheimer's dementia, anxiety disorder, depression, and bipolar disorder. The MDS assessment did not reflect the resident's Level II PASRR status, which indicated serious mental illness and/or intellectual disability. The resident's care plan, however, did acknowledge the Level II PASRR and associated diagnoses, including major depressive disorder, anxiety, bipolar disorder, traumatic brain injury, and dementia. Interviews with staff revealed that the PASRR was completed by the hospital prior to the resident's admission, and the facility's social worker was aware of the Level II PASRR status. The Assistant Director of Nursing, who completed the MDS assessments, admitted to using various sources of information but failed to update the MDS to reflect the accurate PASRR status. The facility also lacked a specific PASRR policy, as confirmed by the Administrator. The Behavioral Assessment, Intervention, and Monitoring policy indicated the use of the PASRR evaluation report for resident assessment and care plan development, but this was not followed in the MDS assessment for the resident in question.
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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