Windmill Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Coralville, Iowa.
- Location
- 2332 Liberty Drive, Coralville, Iowa 52241
- CMS Provider Number
- 165545
- Inspections on file
- 20
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Windmill Manor during CMS and state inspections, most recent first.
A resident with a lung transplant missed four doses of essential antirejection medications when Azathioprine and Tacrolimus were not available in the facility. Medication administration records showed missed doses due to unavailability, and staff interviews revealed delays in reordering, lack of timely follow-up with the pharmacy, and insufficient documentation or physician notification regarding the missed doses.
A CNA failed to use a gait belt while assisting a resident with moderate cognitive impairment and mobility deficits during a bathroom transfer. The resident fell and sustained a left arm and wrist fracture. Facility policy required gait belt use for all transfers, and the CNA had received training on this procedure. The incident occurred because the CNA did not see a gait belt available in the room and did not use one, leading to the resident's injury.
A resident with multiple mental health diagnoses remained in the facility beyond the 60-day limit specified in their PASARR approval, but the required resubmission was not completed. The Social Services Director was unaware of the need to update time-limited PASARRs, and facility policy requiring resubmission for extended stays was not followed.
The facility failed to implement care plans for two residents, resulting in medication errors. A resident with depression and anxiety did not receive Clonazepam as prescribed, leading to increased anxiety and an ER visit. Another resident with chronic pain received an incorrect dosage of Lyrica. The facility's care plan policy was not followed.
The facility failed to follow physician orders for three residents, resulting in medication errors. A resident with anxiety and depression did not receive Clonazepam as prescribed, leading to increased anxiety and an ER transfer. Another resident received an incorrect dosage of Lyrica, and a third resident was given medications meant for someone else. Interviews confirmed the expectation for staff to adhere to physician orders.
A resident with a history of pulmonary embolism and on anticoagulant medication reported blood in her stool and requested a hospital transfer, which was denied by an LPN. Despite clear communication and distress, the resident's request was dismissed, and her family was not informed. The resident was eventually transported to the hospital the next morning for possible gastrointestinal bleeding.
A resident on anti-coagulants experienced diarrhea and rectal bleeding, expressing a desire to go to the hospital. Despite clear symptoms and requests, the LPN did not act promptly, leading to a delay in care. CNAs observed the resident's condition worsening and eventually insisted on calling an ambulance. The resident was later found to have a significant blood clot and decreased hemoglobin levels at the hospital.
A resident with severely impaired cognition experienced multiple falls resulting in serious injuries, including fractures, due to the facility's failure to implement and modify safety interventions. The resident's care plan did not adequately address cognitive status, and there was a lack of documentation for incident reports. The facility's emergency care procedures were not effectively followed, contributing to the deficiency.
The facility was cited for deficiencies in kitchen cleanliness and food handling, including soiled surfaces, improper food storage, and inadequate hand hygiene. Flies were present in the kitchen, and staff failed to follow proper glove use and food handling protocols. Refrigerators were found at incorrect temperatures, and facility policies on sanitation and fly prevention were not followed.
The facility failed to maintain correct temperatures for food and drink during meal service. Observations showed milk, chocolate milk, fortified milk, half-and-half creamer, and potato salad were above the required cold temperature of 41°F. Drinks were not served on ice, and post-meal checks confirmed the temperature issues. The Food Service Supervisor expected cold items to be at 34-35°F, as per the facility's policy.
A resident with severe cognitive impairments was not kept in clean clothes or with a clean face after meals, despite requiring assistance. Observations showed the resident repeatedly left in soiled clothing without staff intervention. Interviews revealed inconsistencies in care, with staff sometimes avoiding attempts to clean the resident due to resistance. The facility's policy on resident rights was not upheld.
The facility failed to provide adequate incontinent care for three residents, as observed during a survey. A resident with severe cognitive impairment did not have a care plan intervention for incontinent care, and a CNA failed to cleanse all necessary areas. Another resident with mild cognitive impairment received care that did not include cleansing the hips. A third resident with intact cognition had a care plan lacking direction for post-incontinence care, and CNAs failed to wash the front peri area. The DON confirmed that expected procedures were not followed.
The facility failed to effectively implement its QAPI process, resulting in repeated deficiencies related to Reporting Alleged Violations, Accidents and Hazards, and Food Procurement, and Store/Prep/Serve-Sanitary. Despite having a QAPI Plan that included monitoring and root cause analysis, the same issues were identified in both current and previous surveys, indicating ineffective resolution of these problems.
Missed Doses of Antirejection Medications Due to Unavailable Medication and Inadequate Follow-Up
Penalty
Summary
A deficiency occurred when a resident with a history of lung transplant and severe protein calorie malnutrition missed four doses of critical medications, specifically Azathioprine and Tacrolimus, due to the medications not being available in the facility. The resident was admitted after hospitalization and required ongoing antirejection medications as part of their care plan. Medication administration records showed that doses were not given on multiple occasions, with the reason documented as 'Drug/Item unavailable.' Nursing documentation and staff interviews revealed that there was a lack of timely reordering and follow-up with the pharmacy to ensure medication availability. The pharmacy confirmed that refills for certain medications were not requested by the facility in time, and when a STAT delivery was requested, there was no documentation of delivery confirmation or further follow-up when the medication did not arrive. Additionally, there was no documentation in the electronic health record of attempts to obtain the unavailable medications or of physician notification regarding the missed doses at the time they occurred. Staff interviews indicated that communication and documentation protocols were not consistently followed. Nurses and medication aides reported notifying each other about the missing medications, but did not always document their actions or notify the physician as required. The Director of Nursing stated that nurses are expected to persistently follow up with the pharmacy and notify leadership if medications are not delivered, but this did not occur in this instance, resulting in missed doses of essential antirejection medications for the resident.
Failure to Use Gait Belt During Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use a gait belt while assisting a resident with a transfer in the bathroom, despite facility policy requiring its use for all transfers unless contraindicated and documented in the care plan. The resident, who had moderate cognitive impairment and required extensive assistance with transfers, was using a front-wheeled walker and was being assisted by the CNA. During the transfer, the resident tripped and fell backward after washing her hands, resulting in both the resident and the CNA landing on the floor. The CNA admitted to not using a gait belt because one was not immediately visible in the room. The incident led to the resident sustaining a closed nondisplaced fracture of the left radius, requiring emergency room evaluation and immobilization with a sling and splint. Review of the resident's care plan confirmed the need for extensive assistance and use of a walker, and facility policy mandated gait belt use for all transfers. Staff interviews and personnel records indicated the CNA had received training on gait belt use, and the expectation to use a gait belt was reiterated by the Director of Nursing. The failure to follow established policy and training directly contributed to the resident's fall and injury.
Failure to Resubmit PASARR for Resident with Extended Stay
Penalty
Summary
The facility failed to re-submit a Pre-Admission Screening and Resident Review (PASARR) for a resident with mental health diagnoses, including anxiety disorder, bipolar disorder, and delusional disorders, who remained in the facility beyond the 60-day limit specified in the original PASARR approval. Clinical record review showed that the resident's PASARR allowed for a stay of up to 60 days, after which a status change Level 1 was required if the resident was not discharged. Interviews with the Social Services Director revealed a lack of awareness regarding the need to resubmit time-limited PASARRs when the resident's stay exceeded the approved period or when there was a new mental health diagnosis. The facility's policy also directed that PASARRs for short-term approvals must be resubmitted if the resident remained after the designated timeframe, but this was not followed.
Failure to Implement Care Plans Leads to Medication Errors
Penalty
Summary
The facility failed to implement care plans for two residents, leading to medication errors and adverse outcomes. Resident #3, who had depression and anxiety, was prescribed Clonazepam 1 mg to be taken three times a day. However, the facility staff failed to administer the medication as ordered on two consecutive days, resulting in increased anxiety for the resident and necessitating a transfer to the emergency room. This oversight was confirmed by the resident during an interview. Resident #2, who suffered from acute and chronic pain due to a traumatic fracture of the T10 vertebrae, was administered an incorrect dosage of Lyrica. The staff gave 150 mg instead of the prescribed 100 mg, as noted in a medication error report. The facility's care plan policy, revised in June 2022, mandates the development and implementation of comprehensive care plans with measurable objectives and time frames to meet residents' needs, which was not adhered to in these cases.
Medication Errors and Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to medication errors and adverse outcomes. Resident #3, diagnosed with anxiety, depression, bipolar disorder, delusional disorders, and alcohol dependence, did not receive the prescribed Clonazepam 1 mg three times a day on two occasions, resulting in increased anxiety and an emergency room transfer. This was confirmed by the resident during an interview. The care plan for Resident #3 indicated the need for Clonazepam to manage depression and anxiety, but the staff did not follow through with the administration as ordered. Resident #2 received an incorrect dosage of Lyrica, being administered 150 mg instead of the prescribed 100 mg, although no side effects were reported. The care plan for Resident #2 highlighted the need for pain management due to chronic back pain and a recent traumatic fracture. Additionally, Resident #1 was mistakenly given medications prescribed for another resident, including Atorvastatin, Senna, and Tamsulosin, with no documented side effects. Interviews with the interim administrator and the resident's provider confirmed the expectation that staff should follow physician orders as written, as per the facility's pharmaceutical procedures policy.
Failure to Respect Resident's Right to Hospital Transfer
Penalty
Summary
The facility failed to respect a resident's right to request a transfer to the emergency room for evaluation of blood in stool. Resident #7, who had a history of pulmonary embolism and was on anticoagulant medication, reported blood in her stool and requested to go to the hospital. Despite having intact cognition and clearly communicating her request, the resident's request was dismissed by a nurse, who told her it was not important and refused to facilitate the transfer. The resident's family was not informed, and the resident experienced distress throughout the night. Multiple staff members, including CNAs, observed the resident's condition, which included multiple bowel movements with blood, weakness, and abdominal pain. They communicated the resident's request to the LPN on duty, who continued to monitor the resident but did not act on the request. The resident was eventually transported to the hospital the following morning, where she was assessed for possible gastrointestinal bleeding. The facility's failure to honor the resident's request for hospital evaluation constitutes a deficiency in respecting the resident's rights.
Failure to Timely Address Resident's Medical Concerns
Penalty
Summary
The facility failed to provide timely assessment and intervention for a resident taking anti-coagulant medication who experienced multiple episodes of diarrhea and blood in an incontinent brief. The resident, who had a history of pulmonary embolism, hypertension, and dysphagia, expressed feeling unwell and requested to be taken to the hospital. Despite the resident's clear communication of her symptoms and desire for hospital evaluation, the attending LPN did not initially act on these requests, instead administering Tylenol and taking vital signs without further intervention. Throughout the night, CNAs observed the resident's condition deteriorating, noting symptoms such as weakness, shakiness, and significant rectal bleeding. The CNAs repeatedly reported these observations to the LPN, who dismissed the severity of the situation and did not notify the resident's family or physician in a timely manner. The resident's niece later confirmed that the resident had been in pain and discomfort throughout the night, and that her requests for hospital transfer were ignored until the CNAs insisted on calling an ambulance. The resident was eventually transported to the hospital, where a CT scan revealed a defect in the urinary bladder and a large blood clot, although no acute gastrointestinal bleeding was found. The hospital's findings indicated a significant drop in hemoglobin levels, necessitating further medical intervention. The facility's policy on emergencies, which requires notifying the physician and calling for an ambulance when necessary, was not followed, leading to a delay in appropriate care for the resident.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to implement and modify interventions to ensure the safety of Resident #67, who experienced multiple falls resulting in serious injuries. Resident #67, with severely impaired cognition and dependent on staff for mobility and hygiene, suffered a right tibia fracture after being found on the bathroom floor. Despite being non-weight bearing and having a cast, the resident later fell again in the library, resulting in a left femur fracture that required surgical repair. Additionally, the resident sustained a fracture to the fifth metacarpal bone of the right hand. Interviews with facility staff revealed a lack of documentation for medical incident reports following Resident #67's falls. The Assistant Administrator acknowledged the absence of documentation to show that the falls were not considered major injuries. The MDS Coordinator noted the challenges in managing Resident #67's care due to fluctuating cognitive awareness. The resident's care plan, which included interventions such as weight-bearing as tolerated and assistance with transfers, failed to address the resident's cognitive status after each fall. The facility's Emergency Care Procedure policy outlined steps for immediate care following falls, including evaluating the resident's condition and stabilizing them if fractures were suspected. However, the facility did not adequately follow these procedures, as evidenced by the repeated falls and injuries sustained by Resident #67. The lack of appropriate interventions and documentation contributed to the deficiency in providing a safe environment for the resident.
Deficiencies in Kitchen Cleanliness and Food Handling
Penalty
Summary
The facility was found to have multiple deficiencies in its kitchen operations, including issues with cleanliness, food storage, and food handling practices. During an initial tour of the kitchen, surveyors observed soiled conditions such as food and paper particles on the floor, sticky substances, and various splatters on kitchen surfaces and equipment. Additionally, several food items were found open and undated, including lunch meat, soup, and various dry goods. The presence of flies in the kitchen was noted, with staff failing to clean surfaces after flies landed on them or to cover garbage cans properly. During meal observations, staff were seen handling glasses and food with bare hands, touching the drinking surfaces of glasses, and failing to change gloves between tasks. This improper use of gloves and lack of hand hygiene was observed multiple times, with staff touching various surfaces and food items without changing gloves. The facility's refrigerators were also found to be at incorrect temperatures, with one refrigerator measuring 46 degrees Fahrenheit and another left open with a temperature of 70 degrees Fahrenheit. Interviews with staff revealed that there were ongoing issues with a broken window allowing flies into the kitchen, and no special cleaning protocols were in place to address areas where flies had landed. The Food Service Supervisor outlined expectations for staff regarding cleanliness and food handling, but these were not being followed. Facility policies on sanitation, food storage, and fly prevention were not adhered to, contributing to the deficiencies observed during the survey.
Deficiency in Maintaining Correct Food and Drink Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at the correct temperatures, resulting in a deficiency. During the noon meal preparation and serving, several items did not meet the required cold temperature of 41 degrees Fahrenheit or less. Specifically, milk, chocolate milk, fortified milk, half-and-half creamer, and potato salad were observed at temperatures above the acceptable limit. Additionally, drinks were not served on ice during the meal. Post-meal temperature checks revealed that these items still did not meet the correct holding temperature. The Food Service Supervisor stated that cold items should be maintained at 34-35 degrees Fahrenheit throughout service, as per the facility's Meal Service Procedure policy, which instructs staff to return food items to the kitchen if cold food is above 41 degrees Fahrenheit.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring they were kept in clean clothes and with a clean face after meals. The resident, who has severe cognitive impairments due to conditions such as Alzheimer's disease and progressive neurological conditions, requires assistance with dressing and personal hygiene. Observations over several days revealed that the resident was repeatedly left in soiled clothing with food stains and drool, without staff intervention to clean or change them. Despite the care plan indicating the need for assistance and the potential for the resident to reject care, staff did not consistently attempt to address the resident's hygiene needs. Interviews with facility staff, including the Memory Lane Coordinator and the Director of Nursing, highlighted inconsistencies in care. The Memory Lane Coordinator noted that the resident is on a behavior plan due to resistance to care and that staff sometimes do not attempt to clean the resident due to fear of physical resistance. The Director of Nursing expressed an expectation that staff should clean residents if they have food matter on them, but this was not consistently practiced. The facility's policy on resident rights emphasizes treating residents with respect and dignity, which was not upheld in this case.
Inadequate Incontinent Care for Residents
Penalty
Summary
The facility failed to provide adequate incontinent care for three residents, as observed during a survey. Resident #74, with severe cognitive impairment and frequent incontinence, did not have a care plan intervention directing staff on providing incontinent care. During an observation, a CNA provided care but failed to cleanse all necessary areas, leaving a strong urine odor in the room. The Director of Nursing (DON) confirmed that the expected procedure was not followed, as the CNA did not wash the front of the perineal area, abdominal folds, buttocks, or hips. Resident #49, with mild cognitive impairment and total dependence on toileting hygiene, received care from two CNAs who failed to cleanse the left or right hip after removing a wet brief. Similarly, Resident #71, with intact cognition and always incontinent of bladder, had a care plan lacking direction for post-incontinence care. During care, CNAs failed to wash the resident's front peri area after an incontinence episode. The Assistant Director of Nursing (ADON) and the DON both confirmed that the expected care procedures were not followed, as the facility's policy required washing all soiled skin areas.
Repeated Deficiencies in QAPI Process
Penalty
Summary
The facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies. This resulted in repeated deficiencies cited during the current survey, which were also noted in previous surveys. The deficiencies identified included issues related to Reporting Alleged Violations, Accidents and Hazards, and Food Procurement, and Store/Prep/Serve-Sanitary. The facility had a census of 94 residents at the time of the survey. The QAPI Plan provided by the facility, dated 6/28/2023, outlined a process for monitoring care and utilizing data from various sources. It included tracking, investigating, and monitoring adverse events using the Plan, Do, Study, Act (PDSA) cycle of improvement. However, despite these measures, the facility continued to experience the same deficiencies, indicating that the QAPI process was not effectively addressing the issues. The plan also mentioned the use of structured root cause analysis approaches to identify and address problems, but the recurrence of deficiencies suggests that these methods were not successfully implemented.
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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