The Village Of Ackley
Inspection history, citations, penalties and survey trends for this long-term care facility in Ackley, Iowa.
- Location
- 502 Butler Street, Ackley, Iowa 50601
- CMS Provider Number
- 165443
- Inspections on file
- 21
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Village Of Ackley during CMS and state inspections, most recent first.
The facility failed to notify the LTC Ombudsman of a resident's transfer to the hospital, as required. A resident was admitted to the hospital and returned to the facility without the necessary notification being sent. The Administrator acknowledged the oversight and admitted that notifications for all residents transferred or discharged in April and May were not submitted. The facility also lacked a policy for required notifications.
A facility failed to submit a Level II PASRR evaluation for a resident with a new PTSD diagnosis. The resident was receiving antipsychotic medication for PTSD-related nightmares, but the PASRR only included a negative Level 1 screening without documentation of the mental health diagnosis. The facility's policy required a Level II PASRR evaluation for new mental health diagnoses, which was not completed. The Administrator acknowledged the oversight.
The facility failed to submit accurate PBJ staffing data for July to September 2024, triggering reports for low weekend staffing and insufficient 24-hour nursing coverage. The facility used outside staffing agencies, but the Administrator did not validate the submitted data against facility records. A switch in time clocks and lack of a submission policy contributed to the inaccuracies.
A resident with severe cognitive impairment was subjected to inappropriate language by a CNA during a transfer, violating the facility's Resident Rights policy. The incident was reported by another CNA, leading to the offending CNA's termination. The facility failed to document the date of the CNA's training on Resident's Rights.
A resident with a history of falls and medical conditions experienced multiple falls due to inadequate supervision and failure to update the care plan with therapy recommendations. Despite requiring two staff members for assistance, the care plan directed only one, leading to falls and injuries. The facility's lack of timely fall risk assessments and failure to include necessary interventions contributed to the resident's risk.
A resident experienced difficulty swallowing, poor oral intake, and mouth pain, leading to weight loss and hospitalization for acute kidney injury, dehydration, and MRSA pharyngitis. The facility failed to conduct timely assessments, interventions, and notify the physician, despite the resident's continued decline. The care plan was not adequately followed, and documentation of meal and fluid intakes was inconsistent, resulting in insufficient fluid intake and lack of timely communication with the physician and family.
The facility failed to notify the physician and family for significant changes in condition for two residents. One resident experienced a fall, confusion, and weight loss without timely notification to her physician or family. Another resident had a fall resulting in a bruise, with no documented notification to her physician or family. These actions violated the facility's policy on notifying resident representatives and physicians of significant changes.
A facility failed to maintain a clean and safe environment for a resident, as observed through unclean conditions in the resident's room. The resident's daughter reported the room was dirty, and an inspection revealed personal items left behind, a dried substance on the wall, and a dirty toilet base. The Housekeeping Supervisor acknowledged the room's unclean state and cited staffing challenges as a contributing factor.
A resident with multiple diagnoses, including Parkinson's disease, did not receive Speech Therapy (ST) as ordered by the physician. Despite being informed of the new orders for PT, OT, and ST, the facility failed to document the provision of ST. The Regional Nurse Consultant confirmed the oversight, and the facility's policy requiring documentation and notification of unfulfilled orders was not followed.
The facility failed to accurately document falls and required assessments for three residents. One resident with intact cognition and mobility assistance needs experienced an unwitnessed fall, but the incident report and progress notes were incomplete. Another resident, also with intact cognition, had an unwitnessed fall with missing details in the incident report. A third resident, independent with mobility but with a history of syncope, had a fall reported by her husband, yet the incident report lacked critical information. The facility did not adhere to its policy of maintaining medical records within accepted professional standards.
The facility failed to ensure residents on Coumadin received their therapeutic monitoring as ordered by the physician. One resident missed their lab draw, leading to an elevated INR level, while another missed eight days of Coumadin due to a missed lab order. A third resident had their lab drawn early for convenience, resulting in a low therapeutic level. The facility lacked a proper system to ensure timely completion of INR labs.
The facility failed to follow the approved diet menu and accurately measure servings for residents on pureed diets. The kitchen staff served unapproved items and did not use a pureed conversion chart, leading to incorrect portion sizes.
The facility failed to maintain safe and appetizing food temperatures. During dining observations, a dietary aide served foods outside acceptable holding temperatures and admitted to not knowing how to check salad temperatures. The dining services manager instructed the aide to use ice for salads, but they were served after checking their temperature. Additionally, a staff member reheated mechanical soft turkey but served pureed turkey without rechecking or reheating it.
The facility failed to maintain sanitary practices in food storage, preparation, and service. Observations revealed improper handling of plates, unlabeled and undated food items, and a malfunctioning dishwasher. Cross-contamination occurred during food service, with staff handling food and utensils improperly, leading to potential contamination.
The facility failed to develop a comprehensive water management program and ensure the availability of hand hygiene supplies. Observations revealed empty soap and sanitizer dispensers, and staff interviews indicated issues with transitioning dispensers and supply. The Maintenance Supervisor was unaware of the need for soap dispensers in each room and could not access prior water testing results or locate the water management control policy. The third-party company responsible for water testing only checked chlorine levels and did not test for other pathogens on a routine basis. The facility's handwashing policy emphasized the importance of hand hygiene, but the lack of soap and sanitizer dispensers hindered compliance.
A facility failed to ensure congruent code status between the facility and hospice for a resident. The resident's clinical records indicated a desire for CPR, while the hospice form directed no resuscitation. The discrepancy was noted by nursing staff, and the necessary Iowa Physician Orders for Scope of Treatment (IPOST) were not received when the resident returned from the hospital on hospice care.
The facility failed to timely notify a resident's family of a significant change in the resident's physical condition, specifically a decline in mobility requiring the use of a wheelchair. Despite the facility's policy to notify families as soon as possible, the family was informed 2 1/2 to 3 weeks later.
The facility failed to transmit a discharge MDS assessment in a timely manner for a resident discharged to home. The assessment was due on 2/16/24 but was completed on 4/8/24 without RN verification. The facility lacked a current policy on MDS completion, relying on staff to follow the RAI process.
The facility failed to invite a resident or the resident's representative to an initial Care Conference. The resident, with intact cognition, reported not being invited since admission. Clinical records lacked documentation of the initial Care Conference, and staff interviews confirmed the oversight.
The facility failed to employ a certified dietary manager, with the Dining Services Manager lacking the required certification and formal training. The facility relied on a contract dietician for monthly consultations.
The facility failed to conduct annual staff evaluations for five employees, as required by regulation. Personnel records showed that Staff B, Staff C, Staff G, Staff H, and Staff I did not receive timely evaluations. The Administrator and Regional Director acknowledged the lapse, and the facility lacked a policy on staff evaluations.
The facility failed to update a resident's Care Plan following their admission to hospice services. Despite being admitted to hospice care, the Care Plan did not include hospice services or related interventions, and the EHR lacked hospice Care Plan documents. The resident had severely impaired cognition and required assistance with ADLs.
The facility failed to ensure the required members were present at quarterly QAPI meetings. Record review revealed that the Administrator, Medical Director, and Director of Nursing were absent from several meetings, contrary to the facility's QAPI policy revised in December 2022. The Administrator acknowledged these absences, and the Regional Director of Quality and Clinical Services confirmed the expectation for compliance with QAPI meeting regulations.
The facility failed to prevent a UTI for a resident with severe cognitive impairment and frequent incontinence. Staff were observed performing incontinence care without proper hand hygiene, including not using soap and using toilet paper sprayed with cleanser. The resident's care plan aimed to prevent UTIs, but the resident was diagnosed with a UTI and prescribed antibiotics. Staff interviews revealed a lack of knowledge about the facility's hand hygiene policy.
A resident with moderately impaired cognition and multiple diagnoses, including Parkinson's disease and dementia, was administered PRN Trazodone for insomnia and restlessness over a 28-day period without the required evaluation or documentation to extend the PRN order beyond 14 days. The facility's policy was not followed, leading to the deficiency.
The facility failed to ensure timely completion of Dependent Adult Abuse Mandatory Training recertification for two staff members, an RN and a Maintenance Supervisor. Personnel records showed that the RN last completed the training on 3/31/21, and the Maintenance Supervisor on 1/4/21. The facility's policy requires a 1-hour recertification training every three years. The Regional Director of Quality and Clinical Services acknowledged the lapse.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman of a resident's transfer to the hospital, as required. This deficiency was identified during a clinical record review and staff interview, which revealed that the facility did not inform the LTC Ombudsman about the hospitalization of a resident, referred to as Resident #9. The resident was admitted to the hospital on May 27, 2024, and returned to the facility on May 30, 2024. The facility lacked documentation of the required notification to the LTC Ombudsman regarding this transfer. During interviews, the Administrator acknowledged the responsibility for sending such notifications and admitted that the notifications for Resident #9 and other residents transferred or discharged in April and May 2024 were not submitted. Additionally, the facility did not provide a policy for the required notification to the LTC Ombudsman for resident transfers and discharges.
Failure to Submit Level II PASRR for New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a new mental health diagnosis. The resident, identified as Resident #19, was diagnosed with post-traumatic stress disorder (PTSD) effective November 10, 2023, and was receiving antipsychotic medication for PTSD-related nightmares. The resident's Minimum Data Set (MDS) assessment and care plan reflected this diagnosis and medication use. However, the PASRR completed on January 20, 2023, only included a negative Level 1 screening and lacked documentation of any mental health diagnosis. The facility's policy required a change in status and a Level II PASRR evaluation submission when a new mental health diagnosis was made, which was not completed in this case. During an interview, the Administrator acknowledged the oversight in not completing the Level II PASRR evaluation for the resident's new PTSD diagnosis.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the CMS Payroll Based Journal (PBJ) Staffing Data Report for the quarter of July 1, 2024, to September 30, 2024. The report triggered for excessively low weekend staffing and for failing to maintain licensed nursing coverage 24 hours a day for 26 days during July and August 2024. The facility's staffing reports and interviews revealed that the facility used outside staffing agencies to cover open nursing shifts not filled by facility employees. However, the Administrator did not validate the PBJ data after submission to ensure it accurately reflected the facility's records. The facility switched time clocks from Matrix to Dayforce during the quarter, which may have contributed to the discrepancies in the reported data. The Administrator acknowledged that the PBJ reporting did not match the daily nursing schedules and confirmed that the verification of outside staffing agency hours was done through email correspondence. Additionally, the facility did not provide a policy for the accurate submission of PBJ Staffing Data, and the Administrator did not follow recommended steps to verify the data submission, such as checking the My Submissions page or running validation reports.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as required by their Resident Rights policy. The incident involved a resident with severe cognitive impairment, who had been admitted following a short-term hospitalization and had a history of stroke, non-Alzheimer's dementia, depression, and a psychotic disorder. During a transfer to a wheelchair, the resident became distressed, screaming and calling for help. In response, a certified nursing assistant (CNA), identified as Staff B, used inappropriate language, telling the resident to "shut the fuck up" and made a distressing comment about the resident's deceased mother. The incident was reported by another CNA, Staff A, to the Director of Nursing (DON), who then assessed the resident and found no physical injuries. Staff B admitted to using inappropriate language and was subsequently removed from the facility and terminated. The facility's failure to document the date Staff B received training on Resident's Rights was also noted. The facility's policy emphasizes treating residents with respect and dignity, which was not upheld in this instance.
Inadequate Supervision Leads to Multiple Falls and Injuries
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident who experienced multiple falls. The resident, who had a history of falls and various medical conditions including Parkinson's, dementia, and fibromyalgia, required partial to moderate assistance with transfers and toilet use. Despite therapy recommendations for two staff members to assist the resident and not leave her alone in the bathroom, the care plan was not updated to reflect these recommendations, leading to inadequate supervision and assistance. In June, the resident experienced four falls, resulting in injuries such as a right ankle injury and a skin tear on the right elbow. The falls were attributed to the facility not adhering to therapy recommendations, as evidenced by the care plan directing only one staff member to assist with transfers and ambulation. The facility's documentation lacked timely fall risk assessments and failed to include necessary fall interventions after each incident, further contributing to the resident's risk of falls. Interviews with staff revealed a lack of communication and adherence to updated care plans, with staff members unaware of the therapy recommendations. The facility's incident/accident prevention policy was not followed, as the care plan did not include updated fall interventions, and the facility did not consistently review and modify interventions after each fall. This oversight resulted in repeated falls and injuries for the resident, highlighting deficiencies in the facility's supervision and care planning processes.
Failure to Address Swallowing Difficulties and Notify Physician
Penalty
Summary
The facility failed to conduct appropriate assessments, interventions, and timely physician notification for a resident who experienced difficulty swallowing, poor oral intake, and mouth pain, resulting in weight loss and hospitalization for acute kidney injury, dehydration, and MRSA pharyngitis. The resident began having difficulty swallowing and was sent to the emergency room but continued to experience these issues upon returning to the facility. Despite the resident's continued decline, the facility did not notify the primary care provider until much later, when an order for speech therapy was given. The resident's care plan included monitoring food and fluid intake, providing adaptive equipment, and recording weight changes, but the facility did not document interventions to assist with self-feeding or improve oral intake. The clinical record lacked documentation of a speech therapy evaluation and treatment, as ordered by the physician. Staff interviews revealed that the resident had very dry lips, difficulty swallowing, and poor intake, but these issues were not adequately addressed or communicated to the physician or family. The facility's hydration program policy outlined steps to ensure adequate fluid intake and prevent dehydration, but the resident's fluid intake was insufficient, and the facility failed to document meal and fluid intakes consistently. The resident's family expressed concerns about the resident's condition, and the facility eventually sent the resident to the hospital, where they were diagnosed with acute renal failure and dehydration. The facility did not notify the physician of the resident's poor meal and fluid intakes or recent weight loss in a timely manner.
Failure to Notify Physician and Family of Significant Changes
Penalty
Summary
The facility failed to notify the physician and family for a significant change in condition for two residents. Resident #1 experienced an unwitnessed fall in her room, which was documented in the Facility Event Report. Despite the fall, the staff delayed notifying Resident #1's family until two days later, when the family inquired about a bruise on her chin. Additionally, Resident #1 exhibited signs of confusion, slurred speech, and difficulty swallowing, which were not promptly communicated to her physician. The facility only notified the physician of these issues a week later, after Resident #1 had been sent to the emergency room and returned without a definitive diagnosis. Resident #1 also experienced significant weight loss over a period of 30, 90, and 180 days, with a noted decline in oral intake following her fall. Despite these concerning changes, the facility did not notify Resident #1's physician or family about her poor meal and fluid intakes and the associated weight loss until much later. The delay in communication and lack of timely intervention contributed to the deficiency in care provided to Resident #1. Resident #4 also experienced an unwitnessed fall in her room, resulting in a bruise to her right flank. The facility failed to document any notification to Resident #4's physician or family regarding the bruise, which was identified after the fall. The facility's policy required notification of the resident's representative and physician for serious injuries or significant changes in condition, which was not adhered to in these cases.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for a resident, as observed through various deficiencies in room cleanliness. The resident, who had intact cognition and required assistance with transfers and toilet use, was reported by her daughter to have lived in a dirty room. The daughter noted that during visits, her son's feet would become black from the floor, indicating a lack of cleanliness. Upon inspection, the room was found to be unclean even after the resident's discharge, with personal hygiene items left behind, a dried splattered substance on the wall, and a dirty toilet base with dust and a dried brown substance. Additionally, spider webs with spiders were found in the bathroom and window area, and the floor and baseboards were dirty with dust and debris. The Housekeeping Supervisor acknowledged the room's unclean state and attributed the issues to challenges with housekeeping staff availability in June. She admitted to having to perform some housekeeping duties herself due to a staff member's injury. The facility's cleaning policy outlined specific procedures for maintaining cleanliness, including daily trash removal, bathroom cleaning, and weekly dusting and mopping. However, these procedures were not adequately followed, as evidenced by the room's condition. The supervisor recognized the need for changes in the room cleaning policy to prevent such deficiencies in the future.
Failure to Provide Ordered Speech Therapy
Penalty
Summary
The facility failed to provide Speech Therapy (ST) as ordered by the physician for a resident. The resident, who had a Minimum Data Set (MDS) assessment indicating intact cognition and required partial/moderate assistance with transfers and toilet use, was diagnosed with conditions including hypertension, non-Alzheimer's dementia, depression, parkinsonism, paroxysmal atrial fibrillation, and fibromyalgia. A physician order dated May 21, 2024, directed the facility to provide evaluations and treatments for Physical Therapy (PT), Occupational Therapy (OT), and ST due to Parkinson's disease and falls. Despite the order, the clinical record lacked documentation that the resident received the ST evaluation and treatment. A progress note confirmed that the resident returned from an appointment with new orders for PT, OT, and ST, and the staff was informed of these orders. However, the Regional Nurse Consultant later confirmed that the resident did not receive the ST as ordered. The facility's policy required the charge nurse to record physician orders in the electronic medical record and notify the Primary Care Physician and Power of Attorney if orders were not followed through, which was not documented in this case.
Incomplete Documentation of Falls and Assessments
Penalty
Summary
The facility failed to accurately document a fall and the required assessment related to a fall in the medical record for one resident. This resident, who had intact cognition and required assistance with mobility, experienced an unwitnessed fall in her room. The incident report was incomplete, lacking details such as event specifics, subjective data, environmental factors, pain and body observations, neurological checks, mental status, and interventions. Additionally, the progress notes did not document the fall, nor did they include a fall assessment, neurological assessment, or a fall risk evaluation. For another resident, who also had intact cognition and required assistance with mobility, the facility failed to complete a thorough incident report following an unwitnessed fall. The progress note documented the fall and the resident's injuries, but the incident report was missing critical information, including event details, subjective data, environmental details, pain and body observations, mental status, possible contributing factors, and immediate interventions. A third resident, who was independent with mobility but had a history of syncope and muscle weakness, experienced a fall that was reported by her husband. The incident report for this event was also incomplete, missing sections such as event details, subjective data, environmental factors, pain and body observations, neurological checks, mental status, possible contributing factors, notification guidelines, and interventions. The facility's policy required maintaining medical records within accepted professional standards, which was not adhered to in these cases.
Failure to Ensure Therapeutic Monitoring for Residents on Coumadin
Penalty
Summary
The facility failed to have a system in place to ensure residents who use Coumadin received their therapeutic monitoring as ordered by the physician. For Resident #13, the facility did not complete the scheduled INR lab draw on time, resulting in an elevated INR level that required holding the medication for two doses. The Director of Nursing (DON) admitted that there was no process in place to ensure INR labs were completed as ordered, and the orders might be lost in a stack of papers on her desk. The Assistant Director of Nursing (ADON) confirmed that the facility only conducted a monthly audit to monitor INR and Coumadin orders, which was insufficient to ensure timely lab draws. Resident #5 missed her lab draw, which led to her missing eight days of Coumadin. An agency nurse failed to enter the lab order into the electronic health record (EHR), causing the lab draw to be missed and the pharmacy to stop sending future warfarin doses. The DON confirmed that the lab was not collected because it did not appear on the lab list, and the facility did not have a follow-up order from the pharmacy. This oversight resulted in Resident #5 having an INR level of 1.02 when it was finally checked. For Resident #16, the facility drew the lab early for their convenience, resulting in a low therapeutic level. The resident had a history of atrial fibrillation, stroke, and long-term use of anticoagulants. The facility did not document subsequent PT/INR lab orders after the initial draw, and the resident's INR level was not monitored as required. The DON and ADON both acknowledged the lack of a proper system to ensure the completion of INR labs, which led to these deficiencies in care.
Removal Plan
- The facility reviewed all 3 residents and ensured each resident received the correct Coumadin dose and completed a lab requisition slip for each resident for their next lab draw.
- The facility developed a new lab order process that involved the use of a lab log and lab requisition order.
- The facility educated the nurses regarding the new processes for lab orders, prothrombin time (PT)/ international normalized ratio (INR) orders tracking and residents on anticoagulants that receive an order for an antibiotic.
Failure to Follow Approved Diet Menu and Measure Pureed Diet Servings
Penalty
Summary
The facility failed to follow the approved diet menu and accurately measure servings for residents on pureed diets. On 4/3/24, the planned pureed textured diet for lunch included roast turkey, stuffing, chicken gravy, vegetables, bread/margarine, and coffee cream dessert. However, the kitchen staff served tater tot casserole, vegetables, and salad instead. The Dining Services Manager (DSM) prepared the pureed diets by placing unmeasured amounts of tater tot casserole and low-fat milk into a blender, checking the consistency, and adding more milk without measuring. The DSM then poured the mixture into bowls, claiming each bowl contained one serving, and instructed the kitchen server to use a black #4 serving scoop for the vegetables. The kitchen did not have a pureed conversion chart to determine the correct serving size for pureed diets. The facility's policy on pureed diets, dated January 2021, directed staff to measure the desired number of servings before pureeing, add necessary liquids to achieve the correct consistency, measure the volume of the pureed food, and divide the total volume by the original number of portions to determine the new portion size. On 4/9/24, the Chief Clinical Officer confirmed that the pureed preparation should use the volume method involving measuring. The facility's failure to follow the approved diet menu and accurately measure servings for pureed diets was identified through observation, staff interviews, and policy review.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to provide food served by a method to maintain a safe and appetizing temperature. During a continuous dining observation, a dietary aide took the temperature of two foods, which measured outside the acceptable holding temperature. The pureed tater tot casserole had a temperature of 133.1°F, and the chef salad measured 52.1°F. The dietary aide admitted to not normally checking the temperature of salads and not knowing how to do so. The dining services manager instructed the dietary aide to put the salads in ice to keep them cold, but the salads were served after checking their temperature. Additionally, a staff member prepared a resident plate containing mechanical soft turkey, which measured 129°F, and reheated it to 190°F before serving it to a resident. However, the pureed turkey was served to a resident without rechecking the temperature or reheating it. The facility's Food Preparation and Service policy, revised in October 2018, directed that food held at temperatures between 41°F and 135°F promoted the rapid growth of pathogenic organisms that cause foodborne illness. The policy instructed to maintain the temperature above 135°F. The Food Temperature/Food Safety policy dated March 2024 instructed cooks to measure temperatures before serving food to ensure they maintained below 41°F and above 135°F. If foods were not at the proper temperature, they were to be reheated to 165°F for 15 seconds or cooled to the proper temperature. Cold foods were to be placed in a pan over a deeper pan of ice to keep them at 41°F or below. The Chief Clinical Officer confirmed that staff should follow the food temperature policy.
Sanitary Practices Deficiency in Food Service
Penalty
Summary
The facility failed to maintain sanitary practices in food storage, preparation, and service. Observations revealed that a dietary server placed thumbs on the food surface side of plates before placing them in the serving plate dispenser. Additionally, the kitchen contained unlabeled and undated bags of food, including a bag of red substance, meat chunks, and pasta. The dishwasher, described as a low temp, chemical appliance, failed to show the presence of sanitizer after multiple tests, even after changing the sanitizer supply jug. Maintenance staff indicated that the actuating device might be worn out and needed replacement. Eventually, a sanitizing strip test reflected the presence of sanitizer after multiple attempts. The facility's policies required proper labeling, dating, and sanitizing practices, which were not followed in these instances. Further observations showed cross-contamination during food service. A dietary server placed wax paper on the steam table serving counter, which came into contact with her abdomen. She also handled a steam table pan lid with an ungloved hand, sorted dietary tickets with a gloved hand, and then touched food surfaces with the same hand. The same tongs were used to remove a steam table pan lid and were placed on wax paper that had been contaminated. Additionally, gloves that fell behind a sink faucet were retrieved and used by another staff member to butter bread. The dietary server continued to handle food and utensils improperly, leading to potential contamination. The Chief Clinical Officer confirmed that all food should be labeled and dated, sanitizing regulations should be followed, and dishes should be handled by the edges to prevent contamination.
Inadequate Water Management and Hand Hygiene Supplies
Penalty
Summary
The facility failed to develop a comprehensive water management program and identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. Observations revealed empty soap dispensers in a resident's bathroom and the visitors' main hall men's bathroom, as well as an empty hand sanitizer dispenser between the Assistant Director of Nursing's office and the food serving area. Follow-up observations confirmed that these dispensers remained empty over several days. Staff interviews indicated that the facility was transitioning dispensers and had issues with supply, but there was no clear plan to ensure all rooms had soap dispensers. The Maintenance Supervisor was unaware of the need for soap dispensers in each room and could not access prior water testing results or locate the water management control policy. The third-party company responsible for water testing only checked chlorine levels and did not test for other pathogens on a routine basis. Additionally, the facility lacked a water flow diagram and system measures to identify or prevent the growth of Legionella and other waterborne pathogens. The facility's handwashing policy emphasized the importance of hand hygiene, but the lack of soap and sanitizer dispensers hindered compliance. The undated Water Management Control Policy outlined steps for managing water systems, but these were not implemented effectively. The Chief Clinical Officer confirmed that hand hygiene should occur between glove changes and include soap and water or sanitizer.
Inconsistent Code Status Between Facility and Hospice
Penalty
Summary
The facility failed to ensure that the code status between the facility and hospice were congruent for a resident. The resident's clinical records indicated a desire for CPR, as documented by a physician's signed directive. However, the hospice form signed by the resident's Power of Attorney directed no resuscitation, and this form lacked a physician's signature. The discrepancy was noted by nursing staff, who found no signed copy of the Do Not Resuscitate (DNR) form and received conflicting information from the hospice provider and the resident's family. The care plan and physician orders continued to reflect a full code status, while the hospice provider indicated a DNR status. The Assistant Director of Nursing (ADON) acknowledged the inconsistency and mentioned that the facility did not receive the necessary Iowa Physician Orders for Scope of Treatment (IPOST) when the resident returned from the hospital on hospice care. The ADON explained that typically, changes to code status would be made by the Director of Nursing (DON) or other nurses, but there was uncertainty about whether all nurses knew how to update the orders. The facility's policy required that any changes to CPR/DNR designation be documented and signed by a physician, but this was not done in this case. The Regional Director of Quality and Clinical Services confirmed that the facility expected the code status between hospice and the facility to match and that nurses should receive an updated IPOST. The failure to ensure congruent code status between the facility and hospice led to a deficiency in honoring the resident's advance directives and code status preferences.
Failure to Timely Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to provide timely family notification when changes occurred in a resident's physical or mental condition. Resident #23, who had severely impaired cognition and required assistance with activities of daily living, experienced a decline in mobility and began using a wheelchair. Despite this significant change, the family was not notified until 2 1/2 to 3 weeks later. The facility's policy required family notification as soon as possible for any significant change of condition, but this was not adhered to in this case. Staff interviews revealed inconsistencies in documentation practices, with one RN stating that family notifications are documented in Progress Notes, but if not documented, it did not necessarily mean the notification was not done. Another RN confirmed that any change in status warrants notification to the family and physician. The Chief Clinical Officer stated that the facility should notify the family within 24 hours of a nonurgent, significant change of condition. However, the documentation showed a delay in notifying the family about Resident #23's mobility decline and need for a wheelchair.
Failure to Timely Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit a discharge Minimum Data Set (MDS) assessment in a timely manner for a resident who was discharged to home. The MDS assessment indicated the resident was discharged on 2/2/24, but the completion date was listed as 4/8/24, and it lacked a signature for the RN verification of completion. The assessment was due on 2/16/24 but was marked as late. The Assistant Director of Nursing acknowledged that the discharge MDS assessment was not completed, and the Administrator reported that the facility did not have a current policy regarding MDS completion, expecting staff to follow the most recent Resident Assessment Instrument (RAI). The Regional Director of Quality and Clinical Services also expected accurate MDS assessments and adherence to the RAI process. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual requires discharge assessments to be completed within 14 days after discharge and transmitted within 14 days of completion.
Failure to Invite Resident to Initial Care Conference
Penalty
Summary
The facility failed to invite a resident or the resident's representative to an initial Care Conference. Resident #38, who was admitted on [DATE] and had a BIMS score of 14 indicating intact cognition, reported not being invited to a Care Conference since admission. The clinical record review for Resident #38 lacked documentation of the completion of an initial Care Conference. Interviews with the Regional Director of Quality and Clinical Services and the Assistant Director of Nursing revealed that the quarterly Care Conference for Resident #38 needed to be rescheduled due to the resident's hospital admission. However, there was no awareness or documentation of an initial Care Conference. The facility's policy, effective March 2024, required the preparation of an interdisciplinary person-centered comprehensive Care Plan and the invitation of residents and their representatives to participate in Care Conferences, which was not followed in this case.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service by not having a certified dietary manager. The facility had a census of 34 residents. On 4/1/24 at 9:50 AM, the Dining Services Manager, identified as Staff A, stated she did not have a certification in nutrition and food service management. She mentioned that the facility had a contract dietician who provided monthly dietary service consultation. A course completion certificate reviewed on 4/1/24 at 10:00 AM confirmed that Staff A did not have the required certification. Staff A further stated on 4/3/24 at 7:06 AM that she had no formal training other than a course completed on 9/11/23 and had been working as a dining manager since 12/22/22 without any other dietary management experience. The facility's policy dated September 2019 indicated that the licensed Dietitian along with the facility staff would ensure compliance with State and Federal regulatory requirements.
Failure to Conduct Annual Staff Evaluations
Penalty
Summary
The facility failed to conduct annual staff evaluations for five employees, as required by regulation 481-58.20(13). The personnel records of Staff B, Staff C, Staff G, Staff H, and Staff I were reviewed, and it was found that none of these staff members had received an annual evaluation within the required timeframe. Specifically, Staff B's last evaluation was on 7/8/21, Staff C's on 3/4/22, Staff G's on 10/11/21, and Staff I's on 2/17/20. Staff H, who was hired on 3/1/23, had not received any evaluation since their hire date. The facility reported a census of 34 residents at the time of the survey. During interviews, the Administrator admitted that the facility did not have a policy regarding staff evaluations. The Regional Director of Quality and Clinical Services also acknowledged that the facility failed to conduct the evaluations as expected. This lack of compliance with the regulation was identified through personnel record reviews and staff interviews, indicating a systemic issue in the facility's management of staff performance evaluations.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to update a resident's Care Plan following their admission to hospice services. Resident #23, who had a severely impaired cognition with a BIMS score of 7, required setup assistance with eating and moderate assistance with all other ADLs. The resident had diagnoses including coronary artery disease, bipolar disorder, asthma, and depression. Despite being admitted to hospice services on 3/20/24, the Care Plan revised on 3/22/24 did not include hospice services or related interventions, and the EHR lacked hospice Care Plan documents. Interviews and record reviews revealed that the resident's family member confirmed the recent admission to hospice care. A progress note dated 3/21/24 also indicated the resident was under hospice care. The Chief Clinical Officer stated that Care Plans should be revised within 14 days of a significant change. The facility's policy on Comprehensive Care Plans, dated March 2024, indicated that Care Plans should be updated when significant changes occur, but this was not followed in the case of Resident #23.
Failure to Ensure Required Members Present at QAPI Meetings
Penalty
Summary
The facility failed to ensure the required members were present at quarterly Quality Assurance Performance Improvement (QAPI) meetings. Record review revealed that the facility held QAPI meetings on six different dates, but the required members were not present for four of these meetings. Specifically, the Administrator and Medical Director were absent on 2/13/23 and 3/14/23, the Director of Nursing and Administrator were absent on 6/13/23, and the Director of Nursing, Administrator, and Medical Director were all absent on 8/21/23. The facility's QAPI policy, revised in December 2022, mandates the presence of these members to ensure compliance with State and Federal regulations. The Administrator acknowledged the absence of required staff members in the meetings prior to January 2024, and the Regional Director of Quality and Clinical Services confirmed the expectation for the facility to follow QAPI meeting regulations.
Failure to Prevent UTI Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a urinary tract infection (UTI) for a resident with severely impaired cognition and frequent incontinence of bowel and bladder. During an observation, it was noted that the soap dispensers in the resident's bathroom were empty. Staff members were observed performing incontinence care without proper hand hygiene, including rinsing hands with water only and not using soap, and using toilet paper sprayed with cleanser for perineal care. The resident's care plan included a goal to prevent UTIs, but the resident was diagnosed with a UTI and prescribed antibiotics, indicating a failure to meet this goal. Staff interviews revealed a lack of knowledge about the facility's hand hygiene policy, which required handwashing with soap and water after handling soiled items, before and after assisting with toileting, and after removing gloves. The Chief Clinical Officer confirmed that hand hygiene should occur between glove changes and should include soap, water, or sanitizer. The facility's failure to adhere to proper hand hygiene protocols during incontinence care contributed to the resident's UTI, as evidenced by the resident's medical records and staff observations.
Failure to Evaluate PRN Psychotropic Medication Use Within 14 Days
Penalty
Summary
The facility failed to evaluate and manage the use of as-needed (PRN) psychotropic medication within fourteen days for a resident with moderately impaired cognition. The resident, who had diagnoses of Parkinson's disease, dementia, and hallucinations, was prescribed Trazodone for insomnia and restlessness. The medication was administered multiple times over a 28-day period without the required evaluation or documentation from the prescribing practitioner to extend the PRN order beyond the initial 14 days. The facility's policy mandates that PRN orders for psychotropic medications be limited to 14 days unless a clinical rationale for extension is documented by the attending physician or prescribing practitioner. This policy was not followed in the case of the resident, leading to the deficiency noted in the report. The resident's care plan was revised to change the Trazodone order from PRN to a scheduled regimen, and the pharmacist recommended discontinuing the PRN Trazodone. However, the facility did not initially know the resident's administration schedule or duration of Trazodone use prior to admission. The Director of Nursing and the Chief Clinical Officer confirmed that PRN psychotropic medications should be canceled after 14 days or clarified by the provider, which did not occur in this instance. This oversight resulted in the resident receiving the medication beyond the allowed period without proper evaluation or documentation.
Failure to Ensure Timely Recertification of Dependent Adult Abuse Training
Penalty
Summary
The facility failed to ensure timely completion of Dependent Adult Abuse Mandatory Training recertification for two staff members, a Registered Nurse (RN) and a Maintenance Supervisor. Personnel records revealed that the RN last completed the required 2-hour training on 3/31/21, and the Maintenance Supervisor last completed it on 1/4/21. According to the facility's policy, revised in November 2023, each employee must complete an initial 2-hour training within 6 months of hire and a 1-hour recertification training every three years thereafter. During an interview on 4/9/24, the Regional Director of Quality and Clinical Services acknowledged that both staff members had not completed the recertification training as required by the regulations.
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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