University Park Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Moines, Iowa.
- Location
- 233 University Avenue, Des Moines, Iowa 50314
- CMS Provider Number
- 165272
- Inspections on file
- 26
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at University Park Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to ensure safe positioning and equipment use during multiple resident transfers. A resident with hemiplegia and stroke history was raised in a mechanical stand lift without the knees positioned against the shin pads. Two other residents with severe cognitive impairment and multiple comorbidities were transferred with mechanical lifts while their wheelchairs or Broda chair were not locked, and one of these residents was transported in a wheelchair without foot pedals. Another resident dependent for all ADLs was also transferred with a mechanical lift into an unlocked wheelchair. CNAs and the DON acknowledged that wheelchairs should be locked during transfers and that residents should not be transported without foot pedals.
A resident with severe cognitive impairment and dysphagia was not served the correct pureed diet portions or all required menu items during a meal service. The dietary aide initially provided an incorrect portion size and omitted several menu items, only serving them after being prompted by the dietary manager, with one item never served. This was not in accordance with the facility's menu and portion control policy.
Staff failed to consistently use required PPE, such as gowns and gloves, and did not always perform hand hygiene during high-contact care activities for residents with wounds on Enhanced Barrier Precautions. Observations included an LPN and CNAs providing wound care and transfers without donning gowns, and one staff member not performing hand hygiene between resident contacts, contrary to facility policy.
The facility failed to document food temperatures consistently, with several meal temperatures missing over a three-month period. This lapse in documentation made it unclear if food reached safe temperatures, violating the facility's policy and FDA guidelines.
The facility failed to employ a certified dietary manager, as the Dietary Director lacked the required certification. Despite being in the position for three weeks, the Dietary Director had not completed the necessary certification, although he was enrolled in coursework. The facility also lacked a policy for having a certified dietary manager, as required by the FDA Food Code 2022.
The facility failed to maintain professional standards in food preparation and service. Observations revealed an unclean ice machine, utensils placed on unclean countertops, and uncovered drinks delivered to residents' rooms. Staff interviews indicated a lack of awareness and adherence to facility policies, contributing to these deficiencies.
Two residents experienced a lack of dignity and timely assistance in a facility. One resident, with intact cognition and requiring assistance due to a stroke, was left exposed and missed an activity due to delayed staff response. Another resident, with severe visual impairment, was not promptly assisted after dropping oatmeal during breakfast, and staff failed to offer a replacement meal. These incidents highlight a failure to adhere to the facility's dignity and respect policy.
The facility failed to maintain a homelike environment, as observed in the shared bathrooms of two pairs of residents, which had significant damage including holes in walls and doors, and splintered wood. The Administrator was unaware of these issues, which were not reported in the facility's tracking system, TELS, used for monitoring repairs.
A resident's cellphone was stolen in an LTC facility, with the theft discovered when the family activated an old phone and received unfamiliar text messages. The facility's investigation pointed to a staff member, who was subsequently terminated for non-cooperation. The resident, with cognitive impairments, was unable to report the theft, highlighting a deficiency in protecting resident property.
A resident with intact cognition and multiple health conditions, including hemiplegia and osteoporosis, was found to have their call light placed over three feet away, making it inaccessible while they were seated in a recliner. The facility's policy requires call lights to be within easy reach, and staff are expected to ensure this, but the expectation was not met in this instance.
Two residents with intact cognition experienced significant delays in receiving assistance after activating their call lights. One resident waited 45 minutes for toileting help, while another was left in an undignified state for nearly an hour. Staff interviews confirmed that call lights should be answered within 15 minutes, but this standard was not met.
The facility failed to notify the Long Term Care Ombudsman of resident discharges or transfers as required by federal regulation. Five residents were transferred to the hospital without proper documentation, and staff interviews revealed the facility lacked a policy for reporting these events.
The facility failed to maintain a sanitary environment, as staff did not follow proper hand hygiene and glove use protocols while providing care to residents, including those with catheters and incontinence. This included not changing gloves between dirty and clean tasks and placing items directly on the floor without a barrier.
A resident with chronic obstructive pulmonary disease received oxygen therapy without a physician's order, and the oxygen tubing was not changed as required. The facility's policy mandated weekly changes of the oxygen cannula and tubing, which was not followed. The Assistant Director of Nursing confirmed these deficiencies.
Improper Mechanical Lift Positioning and Unlocked Wheelchairs During Resident Transfers
Penalty
Summary
Surveyors identified deficiencies related to accident hazards and inadequate supervision during resident transfers and wheelchair use. One resident with hemiplegia, diabetes, stroke history, and intact cognition required maximal assistance for most ADLs and was care planned for transfer with an EZ Stand. During observation of a transfer by two CNAs, the resident’s knees were not positioned against the EZ Stand shin pads as the resident was raised from the wheelchair, contrary to safe positioning expectations. The facility’s mechanical lift policy required a test lift to check sling fit, attachment security, and weight distribution, but the observation focused on improper positioning of the resident’s knees during the lift. Additional deficiencies involved failure to lock wheelchairs during transfers and transporting a resident without wheelchair foot pedals. One resident with severe cognitive impairment, non‑Alzheimer’s dementia, and Down Syndrome, who required extensive assistance and mechanical lift transfers, was transferred twice by CNAs using a mechanical lift while the Broda chair or its rear wheel remained unlocked. Another resident with severe cognitive impairment, dementia, seizure disorder, and mild intellectual disabilities, who used a self‑propelled wheelchair, was transported without foot pedals and then transferred with a mechanical lift while the wheelchair remained unlocked. A further resident with hemiplegia, diabetes, COPD, and intact cognition, who was dependent for all ADLs and required a mechanical lift with two‑person assist, was transferred from bed to wheelchair with the wheelchair unlocked throughout the transfer. Staff involved in these incidents acknowledged that wheelchairs should be locked during transfers and that residents should not be transported without foot pedals, and the DON stated staff should lock wheelchair brakes during transfers and follow transfer policy.
Failure to Follow Prescribed Pureed Diet Menu and Portion Sizes
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dysphagia, requiring a pureed diet, was not served meals according to the prescribed menu and portion sizes. The resident's care plan and physician orders specified a pureed diet, and the facility's menu for the day included specific pureed items and portion sizes. However, during lunch service, the dietary aide initially served only one 4oz scoop of chili instead of the required two 4oz scoops. The dietary manager later clarified that the correct serving size was two 4oz scoops, but this information had not been communicated to the aide prior to service. Further observations revealed that the resident did not receive all menu items as required. The dietary aide failed to serve the pureed cinnamon roll, pureed vegetables, and pureed dessert until prompted by the dietary manager, and the pureed cinnamon roll was never served at all. The facility's portion control policy required food to be served according to standard portion sizes and menu requirements, but this was not followed. The administrator confirmed that the expectation was for meals to be served according to the menu.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Surveyors identified that the facility failed to implement appropriate infection prevention and control practices for residents on Enhanced Barrier Precautions (EBP). Specifically, staff did not consistently use required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities for residents with chronic wounds, pressure ulcers, and surgical wounds. Observations included a Licensed Practical Nurse performing a dressing change for a resident with an unstageable pressure ulcer without donning a gown, despite the resident being on EBP due to the presence of a chronic wound. Further observations revealed that two staff members transferred a resident with pressure and surgical wounds without wearing gowns, as required by EBP protocols. After completing the transfer, one staff member failed to perform hand hygiene before proceeding to care for another resident with a surgical wound and wound vacuum, also on EBP. During this subsequent care, staff again did not don gowns as required, although gloves were used and hand hygiene was performed at certain points. The facility's policies, reviewed by surveyors, clearly stated that gowns and gloves must be worn during high-contact care activities for residents on EBP, and that hand hygiene should be performed before and after resident contact, as well as when moving between contaminated and non-contaminated areas. Interviews with the Director of Nursing and the Administrator confirmed that staff did not follow these protocols during the observed care activities, resulting in a failure to adhere to established infection prevention and control measures.
Failure to Document Food Temperatures
Penalty
Summary
The facility failed to adhere to professional standards in the preparation, serving, and distribution of food, as evidenced by incomplete documentation of food temperatures. Over a three-month period, the kitchen meal temperature logs revealed that several meal temperatures were not recorded: 4 out of 90 meals in November, 8 out of 93 meals in December, and 25 out of 78 meals in January. The Dietary Director acknowledged that all temperatures should be logged both in the kitchen and dining rooms prior to food distribution and serving, but this was not consistently done. This lack of documentation made it unclear whether the food reached the required temperatures to ensure safety. The facility's policy on Food Preparation and Service, revised in October 2017, outlined specific temperature requirements to inactivate pathogenic microorganisms and prevent foodborne illness. However, the failure to document these temperatures as required by the policy and the FDA Food Code 2022, which mandates daily oversight of cooking temperatures, indicates a lapse in following proper food safety practices. The Administrator confirmed the necessity of maintaining current food temperature logs to verify that temperatures were taken before food distribution or serving, highlighting a deficiency in the facility's food safety procedures.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to employ a clinically qualified nutrition professional, as the Dietary Director did not possess the required certification. The personnel document review, staff interviews, and facility policy review revealed that the Dietary Director, who had been in the position for three weeks, had not completed the necessary certification. Although he had previously held a Serve Safe Certification, it had expired, and he was currently enrolled in coursework to complete the certification. The Administrator acknowledged the Dietary Manager's new employment status and ongoing coursework. Additionally, the facility lacked a policy related to having a certified dietary manager, which is a requirement according to the Food and Drug Administration Food Code 2022.
Deficiencies in Food Preparation and Service Standards
Penalty
Summary
The facility failed to adhere to professional standards in food preparation, serving, and distribution, as observed during a survey. On one occasion, the ice machine was found to have a light pink substance throughout, indicating a lack of proper cleaning and maintenance. Staff were observed placing cooking utensils directly on countertops without any barrier, and there was uncertainty about when the countertops were last cleaned. Additionally, drinks were delivered to residents' rooms uncovered, which was against the facility's policy. Interviews with staff and residents revealed further issues. A resident mentioned that drinks are usually served without covers, contrary to the facility's policy. The Dietary Director, who was new to the position, was unaware of the need to monitor and clean the ice machine. The Dietary Manager could not confirm when the countertops were last wiped down. The Administrator expected the ice machine to be clean and utensils to be placed on clean surfaces, but could not ensure this was happening. The facility's policies on ice machine maintenance and food preparation were not being followed, contributing to the deficiencies observed.
Failure to Maintain Resident Dignity and Timely Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the incidents involving two residents. Resident #84, who had intact cognition and required assistance with activities of daily living due to a stroke, was left sitting in his reclining chair with his pants down and his brief exposed for an extended period. Despite having his call light on and expressing a desire to attend an activity, staff did not promptly assist him, resulting in him missing the event. Staff interviews confirmed that the resident was left in an undignified state, contrary to the facility's policy on dignity and respect. Resident #54, who also had intact cognition but suffered from severe visual impairment, experienced a lack of timely assistance during breakfast. After accidentally dropping a bowl of oatmeal, staff did not immediately address the spill or offer a replacement meal. The resident was left without interaction or acknowledgment of the incident, and by the time staff inquired if they were finished with their meal, the resident chose to return to their room instead of receiving another serving. This lack of timely response and interaction did not align with the facility's expectations for maintaining dignity and communication with residents. The facility's policy on Quality of Life-Dignity, revised in August 2009, emphasizes the importance of caring for residents in a manner that promotes dignity, respect, and individuality. However, the incidents involving Residents #84 and #54 demonstrate a failure to adhere to these standards, as staff did not provide the necessary assistance and communication to ensure the residents' dignity and participation in activities.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain resident living areas in good repair and provide a homelike environment, as observed during a survey. Specifically, the shared bathrooms of two pairs of residents were found to have significant damage. One bathroom had wall damage on the floorboard, a hole in the wall, and the border coming off by the floor, creating a large gap and hole. Another bathroom had a hole in the door, with the bottom of the door falling apart, featuring jagged edging and splintered wood, and a hole along the floorboard by the sink. The Administrator, upon observation, was not aware of the condition of these bathrooms and acknowledged that the damage was not reported in the facility's tracking system, TELS, which is used to report, track, and monitor repairs and maintenance issues. The Administrator stated that the damage was not homelike and could be a safety concern, and expressed an expectation that such damage should be reported and repaired. The facility's policy on providing a homelike environment, revised in May 2017, emphasizes the importance of maintaining a safe, clean, and comfortable environment for residents.
Misappropriation of Resident's Property
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property, specifically a cellphone. The resident, who was rarely or never understood due to cognitive impairments and other medical conditions, was unable to communicate the loss of their cellphone. The resident's care plan had noted the potential for diversional activity due to cognitive impairment, and interventions included encouraging family involvement and social interaction. However, the care plan was revised to include an allegation of theft of the resident's cellphone, indicating a failure to protect the resident's belongings. The incident came to light when the resident's daughter, who is the responsible party, attempted to Facetime the resident and discovered the phone was missing. Initially, the family believed the phone was misplaced within the facility, as had happened in the past. However, upon activating an old phone with the same number, they received unfamiliar text messages, leading them to suspect theft. The facility conducted an internal investigation, which included reviewing text messages and interviewing staff. A staff member, identified as Staff F, was suspected of taking the phone, as a text message from her number was found on the resident's phone. Staff F did not admit to the theft and failed to cooperate with the investigation, leading to her termination. The facility's investigation revealed that the phone was last seen approximately two weeks before the family activated the old phone. Despite the facility's efforts to locate the phone and identify the perpetrator, the family chose not to press charges. The facility's policy on abuse prevention and misappropriation of property was not effectively implemented, resulting in the resident's property being stolen. The facility's failure to protect the resident's belongings and ensure a secure environment for their property constitutes a deficiency in care.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the residents, identified as Resident #68. This resident had a Brief Interview for Mental Status score indicating intact cognition and was diagnosed with conditions such as anemia, heart failure, hemiplegia/hemiparesis, hip fracture with an artificial hip joint, and osteoporosis. The resident required moderate assistance with transfers and was assessed as a fall risk. The care plan for Resident #68 included interventions such as keeping the call light within reach and removing wheelchair pedals to prevent self-transfers. During a family interview, it was reported that the call light was out of reach when the resident was sitting in a recliner. An observation confirmed that the call light was placed over three feet away from the resident, on a bedside table, making it inaccessible. The Assistant Director of Nursing stated that staff are expected to ensure call lights are within reach of residents. The facility's policy on answering call lights, revised in March 2021, also required that call lights be within easy reach when a resident is in bed or confined to a chair.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to provide sufficient nursing staff to respond to residents' needs in a timely manner, as evidenced by two separate incidents involving residents with intact cognition who required assistance. Resident #50, who was dependent on staff for toileting hygiene, activated his call light while on the toilet and waited approximately 45 minutes for assistance, despite having called the front desk for help. This delay in response caused the resident discomfort, as he had experienced similar delays in the past. Similarly, Resident #84, who required substantial assistance for transfers and toileting, was left sitting in a reclining chair with his pants partially down for nearly an hour. Despite activating his call light and requesting assistance to transfer to his wheelchair, staff did not return promptly, leaving him in an undignified state. Interviews with staff confirmed that call lights are expected to be answered within 15 minutes, yet these expectations were not met, as documented in the facility's Resident Council meeting minutes.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman of discharge or transfer of residents as required by federal regulation. This deficiency was identified through clinical record review, staff interviews, and policy review. Specifically, the facility did not document the discharge or transfer of five residents to the hospital. Resident #5 had an unplanned discharge to the hospital and reentered the facility, but the Notice of Transfer Form lacked documentation of this event. Similarly, Resident #23 had multiple unplanned discharges to the hospital, none of which were documented in the Notice of Transfer Form. Resident #14, who had a seizure disorder and diabetes, was also transferred to the hospital without proper documentation. Resident #42 and Resident #59 experienced unplanned discharges to the hospital, but their transfers were not reported to the Ombudsman as required. Interviews with staff revealed that the facility did not have a policy for reporting discharges or transfers to the Long Term Care Ombudsman. The Administrator admitted that the reports sent to the Ombudsman were incomplete and did not include all residents who were discharged or transferred. The Administrator also acknowledged that the facility's electronic software program did not generate accurate reports of all discharges and transfers. As a result, the facility failed to comply with federal regulations requiring timely notification to the Ombudsman for all resident discharges and transfers.
Infection Control Deficiencies
Penalty
Summary
The facility failed to provide a sanitary environment to help prevent the spread of communicable diseases and infections. For Resident #51, a CNA did not perform hand hygiene before applying gloves and placed a graduate directly on the floor without a barrier while draining a catheter bag. The facility's policy required placing a paper towel on the floor beneath the drainage bag. Additionally, an Environmental Services staff member wore gloves while pushing a cleaning cart and touching elevator buttons, failing to change gloves between tasks, which could lead to cross-contamination. For Resident #11, two CNAs did not change gloves between dirty and clean tasks while providing peri-care, despite the facility's policy requiring glove changes between such tasks. Similarly, for Resident #61, two CNAs wore the same gloves throughout the entire process of transferring the resident, removing soiled briefs, and cleaning the resident, contrary to the facility's hand hygiene and glove use policies. These actions indicate a failure to adhere to proper infection control practices, as confirmed by the Assistant Director of Nursing.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility failed to ensure that a resident received necessary respiratory care and services in accordance with professional standards of practice. Specifically, the resident was provided with oxygen therapy without a physician's order, and the oxygen tubing was not changed as required. The resident, who had a diagnosis of chronic obstructive pulmonary disease and mild cognitive impairment, was observed on two separate occasions with oxygen administered at 2.5 liters per nasal cannula, but the tubing lacked a date mark. A review of the resident's active orders confirmed the absence of a physician's order for oxygen. The facility's policy required oxygen cannula and tubing to be changed every 7 days, which was not adhered to. The Assistant Director of Nursing confirmed these deficiencies during an interview.
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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