Citations in Iowa
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Iowa.
Statistics for Iowa (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Iowa
A resident with severe cognitive impairment and high physical dependency was injured after staff used an undersized mechanical lift sling not approved for use with the facility's lift. Staff were unaware of the correct sling size, the storage area lacked proper guidance, and the sling's tags were worn, leading to the resident falling from the lift and sustaining a spinal fracture.
Two residents were transferred to other facilities without completed discharge summaries or necessary documentation. Both residents arrived at their new locations without paperwork, causing delays in obtaining admission orders and necessary treatments. Receiving providers had to contact the original facility multiple times to obtain essential information for ongoing care.
Two residents with PICC lines did not have care plans that documented the presence of the device, associated risk factors, or required monitoring, despite receiving IV medications and having relevant medical conditions. This was confirmed through record review, staff interview, and policy review.
The facility did not follow professional standards for assessing and documenting the status of PICC lines for two residents receiving IV medications. For both residents, there was no documentation of PICC site, location, or length assessments in the medical record, and required monitoring per facility policy was not performed or recorded.
A resident with Parkinson's disease and a healing ankle fracture did not receive ordered physical and occupational therapy services upon admission, despite clear physician orders and care plan interventions. Documentation and interviews confirmed the therapies were not provided as required, and facility leadership acknowledged the lapse in following therapy orders.
Staff failed to use wheelchair foot pedals during transport for two residents with severe cognitive and physical impairments, resulting in one resident abruptly stopping the wheelchair with their feet and another being pushed with feet skimming the floor, despite facility policy requiring foot pedals for safety.
Two residents experienced deficiencies in care when staff failed to properly assess and intervene after a fall and during wound development. One resident with cognitive impairment and a history of falls was moved multiple times after a fall without a thorough assessment, and was also given medications intended for another resident. Another resident with multiple comorbidities had a blister that was not assessed for two weeks, leading to infection. Staff interviews and documentation confirmed failures to follow facility policies for assessment and reporting.
Staff failed to adhere to infection control protocols during direct care, including performing wound treatments without changing gloves between tasks, not sanitizing treatment supplies before returning them to storage, and conducting procedures in public areas without proper barriers. Supplies were handled and returned to carts without sanitization, and hand hygiene was not performed between resident contact and touching surfaces or oneself.
Two residents experienced significant delays in call light response, with one waiting over two hours and another reporting frequent extended waits. CNAs confirmed that staff shortages and management wage caps contributed to the inability to consistently meet the facility's 15-minute call light response policy.
Two residents were affected by significant medication errors when a CMA, distracted by interruptions, administered another resident's medications to the wrong individual, and another resident continued to receive an outdated Seroquel regimen due to a failure to update medication orders. These errors were identified through video review, clinical records, and staff interviews.
Failure to Provide Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, significant physical dependencies, and a high body weight was not provided with safe and appropriate mechanical lift transfers. The resident, who was dependent on staff for all activities of daily living and had diagnoses including non-Alzheimer's dementia, anxiety disorder, aphasia, diabetes, and arthritis, required the use of a mechanical lift for transfers. On the day of the incident, staff used a mechanical sling that was too small for the resident's weight, as indicated by the color-coded system provided by the sling manufacturer. The purple sling used was rated for 125-200 pounds, while the resident weighed over 318 pounds and required a blue or black sling rated for higher weights. Staff involved in the transfer were unaware of the correct sling size, and the closet only contained the incorrect size at the time. Additionally, the tags on the slings were worn and difficult to read, and there was no sizing chart available in the storage area to guide staff in selecting the appropriate sling. During the transfer, the sling became dislodged from the mechanical lift at the resident's left shoulder, causing the resident to fall from a height of at least four feet. Staff interviews revealed that one staff member let go of the resident to prepare the bed, and the other was operating the lift, resulting in the resident falling out of the sling. The incident report and staff statements confirmed that the wrong size sling was used and that staff did not verify the compatibility or condition of the sling prior to use. The facility's investigation also found that the slings in use were not approved for use with the specific brand of mechanical lift, and the manufacturer had not tested or approved the combination of sling and lift used during the incident. Following the fall, the resident reported severe back pain and was sent to the emergency room, where imaging revealed a mildly depressed T12 compression fracture. The facility's policies required the use of appropriate equipment and supervision to prevent accidents, but these were not followed in this case. The lack of proper sling availability, absence of clear guidance for staff, and failure to ensure equipment compatibility directly contributed to the resident's fall and injury.
Failure to Provide Discharge Summaries and Documentation During Resident Transfers
Penalty
Summary
The facility failed to complete and provide discharge summaries and necessary documentation to the receiving facilities for two residents who were transferred. For one resident with intact cognition and diagnoses including cellulitis, lymphedema, and hypertension, the electronic health record did not contain a completed discharge summary or evidence of communication with the receiving provider. The receiving facility reported delays in obtaining admission orders, which resulted in delayed medication and treatments, as the resident arrived without any paperwork or discharge summary. The facility's own discharge planning policy requires all relevant information to be provided in a discharge summary to facilitate a smooth transition and avoid unnecessary delays. Another resident, also with intact cognition and diagnoses of depression, anemia, and hypertension, was discharged to another facility without a completed discharge summary or documented communication with the receiving provider. The resident reported that the discharge process was rushed, and no discharge paperwork or orders were sent with her. The receiving facility confirmed that no discharge records accompanied the resident and that they had to repeatedly contact the prior facility to obtain the necessary information for care.
Failure to Address PICC Line Care in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement care plans that addressed the presence of Peripherally Inserted Central Catheters (PICC) and associated risk factors for two residents. For one resident with severely impaired cognition and diagnoses including heart failure, anemia, and hypertension, the care plan did not document the existence of a PICC line or include interventions and monitoring related to the device, despite the resident receiving IV medications through the PICC. The Director of Nursing acknowledged that the care plan lacked this essential information. Similarly, another resident with intact cognition and diagnoses of osteomyelitis, pneumonia, and hypertension was discharged from the hospital with a PICC line and received IV medications in the facility. However, the care plan for this resident also failed to document the presence of the PICC line, associated risk factors, or necessary monitoring. These omissions were identified through clinical record review, staff interview, and policy review, and were inconsistent with the facility's policy requiring comprehensive, person-centered care plans that address all identified needs and services.
Failure to Assess and Document PICC Line Status for Residents Receiving IV Therapy
Penalty
Summary
The facility failed to follow professional standards for the assessment and documentation of Peripherally Inserted Central Catheter (PICC) lines for two residents who required IV medications. For one resident with severe cognitive impairment and diagnoses including heart failure, anemia, and hypertension, there was no documentation in the electronic health record of any assessment of the PICC site, its location, or length during the resident's stay. The admission assessment also did not note the presence of a PICC line, and the discharge summary indicated the central line was removed due to occlusion. The Director of Nursing confirmed that nurses were expected to assess the site when administering medication but acknowledged that there was no documentation to support that these assessments occurred, nor were measurements of the catheter performed to ensure it had not moved out of place. Similarly, another resident with intact cognition and diagnoses of osteomyelitis, pneumonia, and hypertension had a PICC line on admission, but the electronic health record lacked documentation of any assessment of the PICC site, location, or length. The admission assessment also failed to document the presence of a PICC line. Facility policy required nurses to monitor the dressing, line, and resident every shift for signs of infection, malposition, or occlusion, and to document these assessments, but this was not done for either resident.
Failure to Provide Ordered Therapy Services Upon Admission
Penalty
Summary
A deficiency occurred when a resident admitted with diagnoses including Parkinson's disease, a healing left ankle fracture, weakness, and low back pain did not receive ordered physical and occupational therapy services upon admission. The resident's Minimum Data Set (MDS) indicated intact cognition and dependence on staff for mobility and transfers, with care plan interventions specifying the use of a walker, wheelchair, and assistance from staff. Physician orders and the inpatient summary documented the need for both physical and occupational therapy evaluations and treatments, as well as specific mobility aids and weight-bearing instructions. Despite these orders, the clinical record lacked documentation that the resident received the required therapy services on the day of admission. Both the resident and their family confirmed that no therapies were provided at that time. Facility leadership, including the DON and Administrator, acknowledged the absence of therapy documentation and confirmed that the expectation is for physician orders to be followed and therapies to be provided as ordered.
Failure to Use Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
Facility staff failed to ensure safe wheelchair transportation for two residents with severe cognitive impairment and significant physical limitations. In one instance, a resident who was dependent on staff for all transfers and used a wheelchair for mobility was transported out of the dining room without foot pedals attached to the wheelchair. As the staff member pushed the resident over a threshold, the resident abruptly put both feet down on the floor, stopping the wheelchair's forward motion. The staff member then left to retrieve and apply the foot pedals before continuing transport. In another instance, a resident with hemiparesis and traumatic brain injury, who required staff assistance for transfers and used a wheelchair, was observed being pushed by a registered nurse without their feet placed on the foot pedals, even though the pedals were attached but folded away. The resident's feet skimmed over the floor during transport. Both staff and the Nursing Services Director confirmed that facility policy required foot pedals to be used during wheelchair transport to keep residents' feet off the floor, and this expectation was documented in the facility's Standards of Care.
Failure to Assess and Intervene After Falls and Wound Development
Penalty
Summary
Staff failed to properly assess and intervene for two residents, resulting in deficiencies in care. One resident with significant cognitive impairment, visual deficits, and a history of falls was observed via facility video to have fallen after tripping over her catheter tubing. Staff present did not immediately respond to the fall, and when they did, they moved the resident multiple times without performing a thorough assessment as required by facility policy. The resident complained of severe leg pain, but staff continued to move and ambulate her without using a gait belt or completing a full assessment, including vital signs and range of motion. The resident was later sent to the emergency department, where a femur fracture was diagnosed. Interviews confirmed that staff did not follow the facility's fall policy, which required a nurse to assess the resident on the floor before moving her, and that documentation of the incident was delayed and incomplete. Additionally, the same resident was administered medications intended for another resident, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The error was not fully reported to the emergency department, as only one of the four medications was disclosed. Staff interviews revealed confusion and lack of adherence to medication administration and error reporting protocols. The Director of Nursing confirmed that the nurse's assessment after the fall was not as thorough as expected and that vital signs were not taken as required. A second resident, with diagnoses including heart failure, diabetes, and dementia, was readmitted with a right trochanter blister. The facility failed to assess the blistered area for two weeks, with no measurements or detailed assessment documented during that period. When the wound was eventually assessed, it had worsened, showing signs of infection and requiring antibiotic treatment. The Director of Nursing confirmed that staff failed to assess the resident's wound as required.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to follow appropriate infection control practices during direct care for three residents. In one instance, an LPN washed and gloved her hands before removing a supportive boot and wound dressing, then performed physician-ordered treatment to multiple areas of a resident's foot using the same gloves. After completing the treatment, the staff member placed unused and/or prescribed treatment supplies into a plastic bag and returned it to the resident's supply basin without sanitizing the surfaces. The Director of Nursing confirmed these observations. Additionally, another staff member performed a dressing change for a resident in a public dining/lounge area without placing a barrier between the table and treatment supplies, and failed to sanitize the supplies before returning them to the treatment cart. This staff member also palpated another resident's hip with bare hands, then touched the resident, furnishings, and herself without washing her hands. The same staff member later confirmed she did not use a barrier or sanitize items as required.
Failure to Provide Adequate Staffing and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple interviews and policy review. One resident reported waiting 2.5 hours for a response to her call light, using the wall clock to time the delay, and expressed frustration over being left in bed in the morning because there were not enough staff available to assist with her transfer, which required 2-3 staff members. Another resident confirmed experiencing extended wait times for staff to respond to call lights, with no particular time of day being worse than others. Certified Nursing Assistants (CNAs) interviewed acknowledged challenges in responding to call lights within the facility's 15-minute policy, citing being occupied in other resident rooms and overall staffing shortages. Staff attributed these issues to difficulties in hiring and retaining healthcare workers, as well as management decisions such as wage caps. The facility's call light policy, revised in September 2023, emphasizes prompt responses, but staff interviews indicated that timely responses were not consistently achieved.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that two out of three residents were free from significant medication errors. In one instance, a Certified Medication Aide (CMA) administered the correct physician-prescribed medications to a resident, but later, due to interruptions including a phone call and a resident's pressure alarm, the CMA mistakenly gave the same resident medications that were prescribed for another resident. The medications erroneously administered included Melatonin, Mirtazapine, Alprazolam, and Apixaban, which were not intended for the resident who received them. This error was confirmed by a review of video footage, clinical records, and a written statement from the Director of Nursing (DON). In another case, a resident continued to receive both Seroquel 12.5 mg and Seroquel 25 mg in the morning, despite a physician's order changing the regimen to Seroquel 25 mg in the morning and 12.5 mg at noon and supper. This discrepancy was discovered during staff rounds, indicating that the medication order change was not properly implemented, resulting in the resident receiving an incorrect dosage for an extended period.
Some of the Latest Corrective Actions taken by Facilities in Iowa
- Staff education was provided to ensure all staff and departments are aware that oxygen equipment cannot be on residents or in the designated smoking area while residents smoke. (J - F0689 - IA)
- Facility educated Resident #32 and other residents who smoke that oxygen equipment cannot be with them while smoking. (J - F0689 - IA)
- Facility posted signs near the exit to the designated smoking area and the front entrance for visitors, stating that oxygen use is not allowed while smoking. (J - F0689 - IA)
- Facility planned audits for compliance to ensure oxygen equipment is not present in the designated smoking area while residents are smoking, with any concerns to be reported to the Administrator immediately and addressed in the facility Quality Assurance meeting. (J - F0689 - IA)
Safety Lapses in Smoking Area and Resident Transport
Penalty
Summary
The facility failed to ensure the safety of residents in a designated smoking area, particularly concerning Resident #32, who was observed smoking with a portable oxygen tank attached to his wheelchair. Despite the facility's policy prohibiting oxygen use in smoking areas, Resident #32, who had been on oxygen since November 2024, was seen smoking with the oxygen tank present, posing a significant safety risk. The resident, diagnosed with paraplegia, COPD, and asthma, was non-compliant with continuous oxygen orders and required supervision while smoking. However, the supervision provided by housekeeping staff was inadequate, as they did not remove the oxygen tank before the resident smoked. Additionally, the facility failed to ensure the safe transport of Resident #25, who was moved from the dining room to his room in a wheelchair without foot pedals. Resident #25, diagnosed with dementia and severe cognitive impairment, required extensive assistance for mobility. The lack of foot pedals during transport posed a risk to the resident's safety, as confirmed by the Director of Nursing, who stated that the expectation was for staff to use wheelchair pedals when transporting residents. These deficiencies highlight the facility's failure to adhere to safety protocols and provide adequate supervision, resulting in Immediate Jeopardy to the health and safety of the residents. The facility's policies and procedures were not effectively implemented, leading to unsafe conditions for residents who required special care and supervision.
Removal Plan
- Staff education provided to ensure all staff and all departments are aware oxygen equipment cannot be on residents or in the designated smoking area while residents smoked. All staff educated prior to the start of their next shift.
- Facility educated Resident #32, and the other residents who smoke, that oxygen equipment cannot be with them while smoking.
- Facility posted a sign near the exit to the designated smoking area stating that oxygen use is not allowed in the designated area.
- Facility posted a sign near the front entrance for visitors stating that oxygen use is not allowed while smoking.
- Facility planned to audit for compliance to ensure oxygen equipment not present in the designated smoking area while residents are smoking and any concerns to be reported to the Administrator immediately and addressed in facility Quality Assurance meeting.
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