The Highlands
Inspection history, citations, penalties and survey trends for this long-term care facility in Decorah, Iowa.
- Location
- 607 Highland Drive, Decorah, Iowa 52101
- CMS Provider Number
- 165178
- Inspections on file
- 27
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Highlands during CMS and state inspections, most recent first.
Multiple residents were found in bed with their pants or jeans pulled down to their ankles or knees, exposing their briefs, as confirmed by staff and family interviews. Staff reported this was done to make checking and changing briefs easier, but other CNAs acknowledged the practice was not acceptable.
Staff failed to promptly report and address a non-operational air conditioning unit in the CCDI unit, resulting in excessive heat and humidity, condensation, and wet floors. Multiple staff observed and attempted to manage the situation without notifying management or maintenance, leading to unsafe conditions for residents until the issue was escalated and addressed.
Two residents were not given the required 48-hour advance notice of Medicare non-coverage and potential financial liability before their Skilled Nursing Care ended and they transitioned to private pay. Documentation showed that the necessary NOMNC and SNFABN forms were not reviewed or signed in a timely manner, and staff interviews confirmed lapses in following the established process for providing these notices.
The facility did not ensure that required dependent adult abuse training was completed within six months of hire for an LPN, a Food Service Supervisor, a CNA, and a Cook. Personnel files lacked timely documentation of this training, and the facility had no system in place to track completion, despite policy and assessment requirements.
A resident was discharged to a hospital and later readmitted, but the facility did not complete the required Discharge and Reentry MDS assessments as mandated. Staff interviews and record reviews confirmed the assessments were not initiated or completed until after the deficiency was identified.
A resident with moderate cognitive impairment and supervision needs for eating experienced acute changes in condition, including increased blood pressure, elevated pulse, and mental status changes. Despite these signs, the facility failed to conduct follow-up assessments or notify the physician, leading to severe dehydration and sepsis. The resident was eventually transported to the hospital, where he was diagnosed with sepsis and dehydration, and later passed away.
A facility failed to notify a resident's family and PCP of bruising on the resident's forearm in a timely manner. The bruising was documented, but there was no notification until several days later, contrary to the facility's policy requiring notification by the next morning for non-emergent issues. Staff confirmed the expectation to follow the skin protocol and notify promptly.
A facility failed to assess and document a bruise on a resident's forearm, lacking measurements and photographs. Staff interviews revealed confusion about documentation procedures in the electronic health record system, with no formal policy for skin alterations. An RN provided informal training, but it was not part of the onboarding process.
A resident with cognitive impairment fell from a mechanical lift during a transfer due to an unsecured strap, resulting in a head injury and shoulder pain. Despite training protocols requiring two staff to ensure secure transfers, the incident occurred, and the resident was later sent to the ER for evaluation.
The facility failed to provide 10 residents on pureed diets with adequate portions, as observed during a chicken sandwich puree process. Staff initially did not include enough buns to match the number of chicken patties, risking insufficient caloric intake compared to regular diets. The surveyor intervened to correct the portioning, highlighting a lack of clear instructions in the facility's Therapeutic Diets policy.
The facility did not ensure that dietary staff were qualified and educated, as required by their job descriptions, to provide food service to residents. Meal service was observed to start later than scheduled on two occasions. Despite a cook's claim of training in diet preparation, the RN Supervisor confirmed that no dietary staff had completed the necessary training in safety, sanitization, or modified diets.
The facility failed to ensure proper sanitary conditions during meal service. A staff member, while wearing gloves, touched various surfaces and then handled sandwich buns with the same gloves, leading to contamination of food served to multiple residents. The facility's policy lacked specific instructions on glove use, and an RN Supervisor had instructed staff to remove gloves and wash hands when in doubt, but these instructions were not followed.
The facility failed to submit new PASRRs for two residents with severe cognitive impairments. One resident's PASRR omitted a bipolar disorder diagnosis, and another's omitted post-traumatic stress disorder, both requiring Level II evaluations. Staff interviews revealed a breakdown in the process for advising when PASRR Level II determinations are needed.
A resident with moderate cognitive impairment was found with unsecured medications in their room without physician orders or assessments for self-administration. The facility staff were unaware of any residents authorized to self-medicate, and the DON was unfamiliar with the policy for self-administration. The facility's policy requires a physician order, assessment, and secure storage, which were not followed.
The facility did not have a qualified Dietary Manager, as the current manager had not completed a state-approved food service supervisor's course, despite being employed since early 2024. This was confirmed through a review of the employee file and an interview with an RN Supervisor.
Residents Left in Bed with Pants Pulled Down for Staff Convenience
Penalty
Summary
Surveyors observed that multiple residents were positioned in bed with their pants or jeans pulled down to their ankles or knees, exposing their briefs. This was confirmed for five residents during random observations, with staff present at the time. One resident, diagnosed with Alzheimer's Disease, was found in bed with sweatpants around his ankles. Staff confirmed this positioning and removed the pants upon observation. The resident's wife also reported seeing her husband's pants around his ankles on several occasions and expressed her dissatisfaction with this practice, noting it was not how he was dressed at home. Staff interviews revealed that some CNAs positioned residents in bed with their pants around their ankles or knees to facilitate easier checking and changing of briefs. However, other staff members acknowledged that this practice was not acceptable and had observed it occurring at various times. The report documents that this practice was carried out for at least five residents, and staff were aware of the inappropriate positioning of resident clothing while in bed.
Failure to Address Air Conditioning Malfunction and Resulting Unsafe Conditions
Penalty
Summary
The facility failed to properly monitor and intervene when the air conditioning unit in the Chronic Confusion or Dementing Illness (CCDI) unit became non-operational, resulting in excessively warm and humid conditions. Multiple staff members, including RNs, LPNs, and CNAs, observed that the unit became hot, with significant humidity causing condensation and wet, slippery floors. Staff attempted to manage the moisture by dry mopping the floors, but did not notify management or the maintenance department about the high temperatures and humidity during the evening and night shifts. The lack of timely communication delayed appropriate intervention. Staff interviews confirmed that the issue persisted across several shifts, with reports of extremely hot conditions, condensation on floors in hallways and dining areas, and water observed in resident rooms. The Director of Human Resources/Interim Administrator was eventually notified by housekeeping staff, who reported the ongoing problem. Maintenance was contacted the following morning, at which point fans and dehumidifiers were brought in, and additional equipment was purchased to address the malfunction. The deficiency was further substantiated by climatological data indicating high outdoor temperatures during the incident.
Failure to Provide Timely Medicare Non-Coverage Notices Before End of Skilled Nursing Care
Penalty
Summary
The facility failed to provide the required 48-hour advance notice of Medicare non-coverage and potential financial liability to two residents prior to the end of their Skilled Nursing Care stays. For one resident, documentation showed that Skilled Nursing Care began on 2/28/25 and transitioned to private pay on 3/20/25, but there was no evidence in the electronic health record or progress notes that the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) forms were reviewed with the resident or their Power of Attorney at least 48 hours before the transition. The forms were not signed until 10 days after the transition. For the second resident, Skilled Nursing Care started on 12/1/24 and transitioned to private pay on 1/14/25, but again, there was no documentation that the required notices were provided 48 hours in advance, and the forms were not signed until the day after the transition. Staff interviews confirmed that the process for providing these notices was not consistently followed. The Medical Records staff member stated that she spoke with the Power of Attorney before the resident was discharged from Skilled Nursing Care but admitted she may have forgotten to document it. The Nurse Manager indicated that a process exists to ensure the timely completion of Skilled Nursing Care notice forms, but the records reviewed did not reflect compliance with this process for the two residents in question.
Failure to Provide Timely Dependent Adult Abuse Training to Staff
Penalty
Summary
The facility failed to provide required dependent adult abuse training to staff within six months of hire, as evidenced by personnel file reviews for four out of five employees. Specifically, the files for an LPN, a Food Service Supervisor, a CNA, and a Cook all lacked documentation of the mandatory reporter training within the required timeframe. Although certificates for the training were eventually provided, they were dated after the six-month window had passed. The facility assessment indicated that such training was required for all positions, and the facility's abuse prevention policy mandated staff training on abuse prevention, identification, and reporting, but did not specify the required timeframe for completion. During staff interviews, it was revealed that there was no system in place to track the completion of dependent adult abuse training, and the Personnel Director/Provisional Administrator acknowledged that the required training had not been completed on time for the majority of employees reviewed. The facility had a census of 64 residents at the time of the review.
Failure to Complete Required Discharge and Reentry MDS Assessments
Penalty
Summary
The facility failed to complete a Discharge Minimum Data Set (MDS) and a Reentry MDS for a resident who was hospitalized and subsequently returned to the facility. Record review showed that the resident was discharged to the hospital and then readmitted, but the required Discharge and Reentry MDS assessments were not opened, started, or completed as mandated. Staff interviews confirmed that the assessments were not initially flagged for the MDS Coordinator, and the coordinator was not onsite at the time. The deficiency was identified through review of the resident's electronic health record and staff interviews, which revealed the assessments were only in progress after the issue was discovered.
Failure to Identify and Intervene in Resident's Acute Condition
Penalty
Summary
The facility failed to promptly identify and intervene for an acute change in a resident's condition, leading to severe dehydration and sepsis. The resident, who had moderate impaired cognition and required supervision with eating, exhibited several acute changes in condition, including increased blood pressure, elevated pulse, and mental status changes. Despite these signs, there was a lack of follow-up assessments and notification to the physician, which contributed to the resident being transported to the hospital with severe dehydration and sepsis. The resident's electronic health record documented multiple instances where assessments were either incomplete or not conducted at all. On several occasions, the resident showed signs of deterioration, such as increased blood pressure and pulse, mental status changes, and lethargy, but these were not followed up with appropriate medical intervention or physician notification. The resident's condition continued to decline, culminating in a transfer to the emergency department where he was diagnosed with sepsis and dehydration. Interviews with facility staff revealed that there was a failure to notify the physician or nurse practitioner about the resident's condition changes. The psychiatric-mental health nurse practitioner noted a significant change in the resident's mental status during a telehealth appointment and instructed the nursing staff to notify the primary care physician immediately. However, the resident's advanced registered nurse practitioner reported not being aware of any condition changes until the day the resident was sent to the emergency department. This lack of communication and timely intervention contributed to the resident's severe condition and subsequent death.
Removal Plan
- Immediate in-service for nurses on identifying acute changes in resident conditions, conducting complete assessments, and notification of providers of changes in condition.
- Attestation of these procedures for all shifts prior to caring for the residents.
- Review of all resident documentation to ensure there were no current changes of condition that may require follow-up, further assessment, or provider notification.
- Any identified concerns will be assessed and the proper notifications made prior to clinical leadership leaving.
- Started auditing of all resident records to ensure that there are no current changes of condition that may require follow-up, further assessment, or provider notification.
Failure to Notify Family and PCP of Resident's Bruising
Penalty
Summary
The facility failed to notify the family and primary care provider (PCP) of bruising observed on a resident's right forearm. A progress note dated 9/21/24 documented a larger red/purple area and multiple smaller bruises at various stages of healing on the resident's forearm, but there was no documentation of family or PCP notification. The clinical record also lacked any documentation on 9/22/24 and 9/23/24. It was not until 9/24/24 that a progress note indicated the PCP was notified, and the family was informed during their visit on the same day. The facility's policy, dated 6/29/23, required staff to notify the family and attending or on-call physician for any abnormal skin issues, including bruising, by the next morning for non-emergent issues. Staff D confirmed during an interview that she expected staff to follow the skin protocol and notify the family and PCP no later than the next morning.
Failure to Document and Assess Resident's Bruise
Penalty
Summary
The facility failed to properly assess and document a bruise on a resident's right forearm. A progress note dated 9/21/24 indicated the presence of a larger red/purple area and multiple smaller bruises at various stages of healing on the resident's forearm. However, the documentation lacked measurements or a picture of the bruising. During an observation on 9/24/23, the bruises were noted again, but there was still no documentation of measurements or photographs. Staff interviews revealed that the facility's electronic health record system, Point Click Care (PCC), was used for documenting skin concerns, but there was confusion among staff about how to document non-skin tear issues. Staff interviews further highlighted a lack of standardized procedures for documenting skin concerns. Staff C, an LPN, admitted to identifying the bruise but not taking measurements or a picture, citing uncertainty about documentation procedures for non-skin tears. Staff D, an RN, explained that she provides one-on-one education to nurses on taking pictures and measurements, but this training is not part of the formal onboarding process. Additionally, the RN Supervisor confirmed that the facility did not have a published policy for staff regarding skin alterations, contributing to the inconsistency in documentation and assessment of the resident's bruise.
Failure to Secure Mechanical Lift Leads to Resident Fall
Penalty
Summary
The facility failed to prevent an accident involving a resident who was non-verbal and had a cognitive impairment. The resident, who required assistance from two staff members for transfers and used a mechanical lift, fell from the lift during a transfer. The incident occurred when the left shoulder strap of the sling was not properly secured, causing the resident to fall backward and hit his head on the floor. This resulted in a skin tear on the resident's left elbow and subsequent pain and discomfort in the left shoulder and head. The resident's care plan indicated limited physical mobility and required the use of a mechanical lift at the nurse's discretion. During the transfer, two staff members were present, but the strap was not hooked into the mechanism completely, leading to the fall. The resident exhibited signs of pain and a change in consciousness following the incident, prompting a recommendation for evaluation at the emergency room. However, the resident's family initially declined the ER visit due to financial concerns. The facility's training and competency testing for mechanical lift transfers required two staff members to ensure the straps were secured before moving the resident. Despite this, the incident occurred, highlighting a lapse in following the established procedures. The resident was eventually sent to the ER after further deterioration in his condition, where he was diagnosed with an AC joint separation.
Failure to Provide Adequate Pureed Diet Portions
Penalty
Summary
The facility failed to ensure that 10 out of 10 residents on a pureed diet received a well-balanced diet that met their nutritional needs. During an observation of the puree process for chicken sandwiches, it was noted that Staff F, a cook, initially did not include the correct number of buns in the pureed mixture to match the number of chicken patties, which would have resulted in residents receiving fewer calories than those on a non-pureed diet. The surveyor had to intervene twice to ensure that the correct number of buns was added to the mixture to provide the same caloric intake as a regular diet. Additionally, Staff F was unsure of the process for measuring and ensuring correct portion sizes for the pureed food, which led to the surveyor intervening again to ensure accurate portions were served. The facility's policy on Therapeutic Diets lacked specific instructions on how to complete the puree process and ensure that residents on pureed diets received the same portions as those on regular diets. This oversight in policy and staff training contributed to the deficiency in providing a well-balanced diet to residents on pureed diets.
Deficiency in Dietary Staff Qualifications and Meal Service Timing
Penalty
Summary
The facility failed to provide a qualified and educated dietary staff to deliver food service to its residents, with a reported census of 62 residents. Observations revealed that the noon meal service in the dining room started later than the scheduled time on two separate occasions, indicating a delay in meal service. The facility's job descriptions for dietary staff, updated on 7/24/24, required completion of state-approved safety and sanitation, and modified diet courses. However, during an interview, a cook stated he had been trained on different types of diets and their preparation, but the RN Supervisor confirmed that no dietary staff had completed the necessary food service training for safety, sanitization, or modified diets.
Improper Glove Use During Meal Service
Penalty
Summary
The facility failed to maintain proper sanitary conditions during meal service, as observed on 7/24/24. Staff F, while wearing gloves, touched various surfaces such as handles, trays, countertops, his clothing, his arm, serving utensils, and the exterior of bread bags. He then proceeded to handle sandwich buns with the same contaminated gloves, which were used to prepare chicken sandwiches for multiple residents. The facility's policy on Dietary Sanitary Conditions was undated and lacked specific instructions on when gloves should be worn, although it did instruct staff to perform good hand washing before preparing, serving, and distributing food. During an interview on 7/25/24, Staff J, an RN Supervisor, stated that he had instructed staff to remove gloves and wash their hands when in doubt. However, the observations indicated that these instructions were not followed, leading to the contamination of ready-to-eat food.
Failure to Submit PASRR for Two Residents
Penalty
Summary
The facility staff failed to submit a new Preadmission Screening and Resident Review (PASRR) for two residents, leading to a deficiency. Resident #29, with a Minimum Data Set (MDS) assessment indicating severe cognitive impairment, had a PASRR Level 1 Screening Outcome that did not list a diagnosis of bipolar disorder, which was present in other medical documentation. Interviews with facility staff revealed that the clinical team and MDS nurse are responsible for advising when a PASRR Level II determination is required, but this process was not followed correctly for Resident #29. Similarly, Resident #56, also with severe cognitive impairment, had a PASRR Level 1 Screening Outcome that omitted a diagnosis of post-traumatic stress disorder, which should have triggered a Level II PASRR submission. The diagnosis was documented in the medical records but not reflected in the PASRR screening. The oversight in both cases indicates a failure in the facility's process for coordinating assessments and ensuring accurate PASRR submissions.
Failure to Secure Medication and Assess Resident Safety
Penalty
Summary
The facility failed to properly secure medication and assess resident safety for medication administration for a resident with moderate cognitive loss. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, was observed with a half-full bottle of Pepto Bismol and a bottle of vitamin D in his room without physician orders to self-administer these medications. The resident reported using Pepto Bismol frequently for an upset stomach, but there was no documentation in the electronic health record of an assessment to self-administer medications. Observations revealed that the resident's room door was often left open, and the medications were stored in a cabinet with the sliding glass door open, making them accessible to others. Staff interviews indicated a lack of awareness and proper procedure regarding self-administration of medications. The Licensed Practical Nurse (LPN) and Certified Medication Aide (CMA) were unaware of any residents authorized to self-medicate, and the Registered Nurse (RN) was unsure of the location of the self-administration assessment form. The Director of Nursing (DON) acknowledged that the facility had not encountered a situation where a resident wanted to self-administer medications and was unfamiliar with the facility's policy on the matter. The facility's policy required a physician order, an assessment of the resident's ability to self-administer, and secure storage of medications, none of which were followed in this case. The DON expressed doubt about the resident's ability to safely self-administer medication, highlighting a gap in staff training and awareness regarding medication management in resident rooms.
Deficiency in Dietary Manager Qualifications
Penalty
Summary
The facility failed to employ a qualified professional as the Dietary Manager, as required by regulations. A review of the Dietary Manager's employee file revealed a lack of documentation indicating completion of a state-approved food service supervisor's course. This deficiency was confirmed during an interview with a Registered Nurse Supervisor, who stated that the Dietary Manager had been employed since approximately February 2024 without completing the necessary course. Additionally, the facility's job description for Dietary Managers, updated in July 2024, explicitly required completion of a state-approved food service supervisor's course, which the current Dietary Manager had not fulfilled.
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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