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
The deficiency involves multiple failures in pressure ulcer prevention, assessment, and treatment for several residents. A resident admitted without ulcers developed an in-house Stage 2 sacral pressure injury that was not consistently measured or fully assessed for several weeks, despite documented infection and worsening appearance. Staff did not reliably notify the NP or MD of deterioration, did not change treatment orders in a timely manner, and did not update the care plan with new interventions, while the resident reported not being repositioned every 2 hours and sometimes remaining in a saturated brief overnight. Another resident with incontinence-associated dermatitis and documented skin risk had wound assessments with missing or inconsistent measurements, photos showing apparent Stage 2 sacral/coccygeal ulcers that were not documented as such, and a care plan that did not reflect the specific skin issues or interventions identified on the MDS. Staff interviews and the DON’s statements confirmed gaps in CNA reporting, nurse assessment, physician notification, and overall wound care practices.
Surveyors found that the facility failed to consistently involve residents and their representatives in interdisciplinary care plan conferences and did not keep care plans current with residents’ changing clinical conditions. Several residents and families reported they had not been invited to care conferences since a change in ownership, and the social services director acknowledged many conferences were not completed or documented. Care plans for multiple residents were not revised to reflect new transfer requirements (e.g., need for a full-body mechanical lift), new or discontinued indwelling catheters, new diagnoses such as influenza requiring EBP and droplet precautions, and the development or progression of pressure injuries, including MASD, DTI, Stage 2 ulcers, and a surgically debrided Stage 4 sacral ulcer with a wound vac. Staff interviews showed that the MDS coordinator was largely responsible for care plan updates, floor nurses generally did not revise care plans, and IDT participation and documentation of care conferences were inconsistent, resulting in outdated or incomplete care plans that did not match current orders or resident needs.
Surveyors found that multiple residents who required staff assistance with oral hygiene, toileting, and repositioning did not consistently receive this care and that it was not documented as required. Several residents with cognitive impairment or physical limitations, including those with multiple sclerosis, had care plans specifying staff assistance with oral care, yet their records contained no oral care documentation, and one resident’s room lacked oral care supplies. Residents and family members reported that oral care was rarely provided, that a resident often had food on her face and mouth, and that one resident had to use an alarm to prompt staff to reposition her and reported not being changed overnight despite urinary incontinence. Staff interviews confirmed that oral care was expected twice daily per facility policy, but also revealed frequent findings of residents with unclean faces and hands after meals.
A facility failed to prevent accidents and injuries by allowing a resident with moderate cognitive deficit to be pushed a long distance in a manual w/c without footrests while observed by nursing staff, and another resident with severe cognitive impairment to be pushed with feet dragging on the floor. Two dependent residents who required full body mechanical lifts reported or were described as being transferred either with only one staff or without the lift at all, with multiple CNAs and nurses acknowledging that single-staff lift transfers occurred despite the expectation for two-person assistance. Additionally, monthly hot water temperature logs showed elevated readings in some areas and stopped being recorded, while the plant operations director, DON, and administrator each admitted they did not know the appropriate temperature parameters for resident use and had no policies in place for water temperature, mechanical lift use, or wheelchair transport safety.
The facility failed to provide ongoing, understandable education on Resident Rights to its residents and/or their representatives. During a Resident Council meeting, residents reported they were unaware of having rights, did not know what those rights were, and did not know if they were posted in the facility. Review of several months of Resident Council minutes showed that leadership attended but did not provide Resident Rights education. The Life Enrichment Director acknowledged that staff had not been reviewing or educating residents on their rights during these meetings, and the DON stated that Resident Rights were only given at admission and not reviewed on an ongoing basis. Neither could confirm that Resident Rights were posted and readily available, despite facility policy requiring that residents be informed of their rights and that these rights be posted throughout the facility.
Two residents did not receive appropriate assessment and care according to orders and clinical needs. One resident with intact cognition had a diabetic ulcer on a toe that was present on admission but was not identified on the admission skin assessment, and no wound assessment, physician notification, or treatment occurred for about a week until an RN documented and initiated ordered care. Another resident with near-intact cognition had a head injury first seen as a red mark on the forehead; the LPN obtained vitals but did not initiate neuro checks, fully assess for additional injuries, or promptly notify the DON, physician, or family. Neuro assessments and provider notification were delayed until the area became a hematoma later in the day, and additional bruising on the hip and shoulder was only discovered after transfer to the ED.
A resident with multiple medical conditions and moderate cognitive impairment, seated near the nurses’ station while on the phone, swung his arm back and struck another resident with severe dementia twice in the upper back as she self-propelled her wheelchair past him, following her usual routine. Staff reported that this resident could become irritable when redirected, and he then stood up and hit and pinched a CNA who intervened. The aggressor’s care plan identified mood and behavior issues and directed staff to anticipate needs, provide positive interaction, and intervene to protect others’ safety, while the other resident’s care plan addressed impaired cognition and the need for supervision and consistent routine. The facility’s abuse policy states residents must be protected from abuse by anyone, including other residents.
A resident with multiple chronic conditions, moderate cognitive impairment, and dependence on staff for mobility allowed a CNA to use her EBT food stamp card to buy snacks for her and also to purchase items for the CNA, without specifying a spending limit. The CNA used the card at a grocery store to buy a large volume of items, and later could not clearly recall what she had purchased for herself. When the receipt was reviewed, the resident identified numerous items she had not requested that were believed to be for the CNA, totaling a substantial amount. Other staff reported they understood from dependent adult abuse training that using a resident’s resources or accepting gifts was wrong, and facility policy explicitly prohibited exploitation and misappropriation of resident property, yet the resident’s EBT benefits were used inappropriately by staff.
The facility did not ensure that an RN was on duty for at least eight consecutive hours on multiple days over a multi‑month period, despite having a census of 26 residents. Review of nursing schedules and staff interviews confirmed repeated dates with no RN coverage, and the Administrator acknowledged that RN staffing was an ongoing problem. The facility assessment noted that the facility was working toward meeting minimum staffing requirements.
The facility failed to maintain an effective pest control program, resulting in an ongoing mice infestation affecting resident rooms, staff areas, and common spaces. An LPN reported mice eating food stored in a staff locker, and work orders documented a mouse in a resident room. Surveyors observed mice droppings in multiple drawers of a resident’s clothing dresser and in a vacant room near a heat register. A housekeeping aide reported that mice had chewed and torn stored activity items and that a recliner in a resident’s room contained extensive mice droppings and contaminated soft toys. In the Activity Room, where three residents were present, surveyors observed numerous black and green mice droppings near the entrance and a nightstand, along with debris behind the furniture, despite a facility policy stating it would maintain an effective pest control program for pests and rodents.
Failure to Prevent, Assess, and Manage Pressure Ulcers and Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention, assessment, and treatment, and to prevent the development and worsening of pressure ulcers for multiple residents, most extensively documented for Resident #29. Resident #29 was admitted without pressure ulcers and initially assessed with a Braden score of 20 (not at risk), later decreasing to 16 (at risk) and then to 9 (very high risk). An in-house acquired Stage 2 sacral pressure ulcer was first documented on 11/28/25 with measurements, and again on 12/6/25 with increased size. On 12/16/25, the wound was documented as a Stage 2 ulcer but without any measurements. From 12/16/25 through 1/3/26, there were no complete wound assessments with measurements, descriptions, or photos, despite ongoing skin check entries that noted a pressure injury on the coccyx/sacrum without measurements or detailed description. During this period, the care plan did not reflect new or updated interventions in response to the in-house acquired Stage 2 ulcer or its deterioration. Resident #29’s wound worsened significantly without timely or adequately documented provider notification or changes in treatment. Infection documentation from 1/1/26 through 1/5/26 noted a sacral ulcer infection with odor but lacked measurements, wound description, and MD notification. On 1/3/26, an unstageable sacral pressure ulcer with slough/eschar, strong odor, and a much larger area was documented. A subsequent 1/5/26 skin and wound evaluation described an unstageable ulcer with slough/eschar and large dimensions, again without physician notification. The DON acknowledged that weekly wound assessments with measurements and descriptions were not completed between 12/16/25 and 1/3/26 and that the wound did not change from a Stage 2 to a large unstageable ulcer overnight. Interviews with nursing staff indicated that the wound had gotten larger and worse, that the NP was told it looked worse, and that treatment orders were not changed from 12/16/25 until the resident was seen at a wound clinic on 1/2/26. Hospital records later documented a sacral decubitus ulcer with foul odor, significant necrotic tissue, and debridement down to ligamentous structures and exposed bone. The deficiency also includes failures in basic preventive care such as repositioning and incontinence management for Resident #29. The resident, who had multiple sclerosis and could not reposition herself, reported that staff were not turning her every 2 hours as ordered and that she had to set an alarm on her phone to prompt staff. She stated that some overnight shifts only repositioned her once late in the night and that she had reported these concerns multiple times. Staff interviews corroborated concerns that the resident was not being repositioned appropriately and that CNAs had reported the wound was not improving but were told to apply cream without the nurse assessing the area. There were also reports that a CNA refused to change the resident’s saturated brief, allegedly stating there were no briefs and reapplying the same brief, while another CNA described only “freshening up” the resident and not returning later in the shift. The DON and nursing staff acknowledged that CNAs may not recognize or report early pressure injuries, that CNA reports to nurses were sometimes undocumented, and that “a lot of balls were dropped” regarding wound care. For Resident #2, the deficiency includes incomplete and inaccurate wound assessment and documentation, and failure to align the care plan with identified skin risks and conditions. Resident #2 was admitted with a Braden score of 17 and a documented need for repositioning at least every 2 hours, and had incontinence-associated dermatitis (IAD) on the buttocks present on admission. Wound evaluations showed large fluctuations in the documented size of the IAD over time, including a significant increase in area on 12/5/25 and later a marked decrease by 12/30/25, followed by another large increase on 1/6/26. The 12/12/25 wound evaluation lacked any measurements, and a photo from 1/6/26 showed two areas consistent with Stage 2 pressure ulcers on the sacrum/coccyx that were not documented as such in the record. The MDS identified that the resident was at risk for pressure ulcers and had MASD, and that interventions such as pressure-reducing devices and nutrition/hydration interventions were in place, but the care plan only reflected a generic potential for pressure injury and did not include the specific skin issues or interventions identified on the MDS. Interviews and record reviews further demonstrated systemic issues contributing to the deficiencies. The NP reported that she was shown a picture of Resident #29’s wound on 12/16/25 and then only heard again around Christmas via a text that the wound looked worse and needed a wound care visit; she did not receive updates on the wound clinic’s findings and was not informed when the wound became unstageable or significantly deteriorated. She stated she would have expected notification with such changes and that the wound appeared preventable and should not have progressed to its current state. Nursing staff acknowledged expectations to notify physicians of wound changes, lack of improvement, or deterioration, but also acknowledged that this did not occur consistently for Resident #29. The DON confirmed that physician notifications and wound assessments were missing or incomplete, that CNA reports were sometimes not documented, and that there were multiple failures in wound care practices across the facility. Overall, the documented actions and inactions include failure to perform consistent, measurable weekly wound assessments; failure to document and communicate wound deterioration and infection to providers; failure to update care plans and interventions in response to new or worsening pressure ulcers; failure to ensure regular repositioning and timely incontinence care; and failure to accurately identify and document pressure ulcers versus dermatitis. These failures affected multiple residents, with detailed evidence for Residents #29 and #2, and were acknowledged by the DON and nursing staff as significant lapses in wound care and skin integrity management.
Failure to Involve Residents/Representatives and Update Interdisciplinary Care Plans for Changing Clinical Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop, review, and revise comprehensive care plans with an interdisciplinary team that included residents and/or their representatives, and to update care plans when residents’ conditions changed. Multiple residents and family members reported that care plan conferences had not occurred since a change in facility ownership, despite prior practice of quarterly meetings. For example, one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and diabetes, had a baseline care plan and a signed POA document, but there were no care conference attendance sheets, and the family stated they had not been included in care plan meetings since the new company took over. Another cognitively intact resident and that resident’s son both reported they had never been invited to care conferences since admission, and the social services director acknowledged that many care conferences were not completed and that residents and families had not been part of quarterly assessments. The facility also failed to revise care plans to reflect significant changes in residents’ clinical status and treatment orders. One resident with intact cognition and a right femur fracture was being transferred with a whole body mechanical lift per therapy evaluation and documentation, but the care plan still listed stand-pivot transfers with one staff and a gait belt; staff reported they had not received updated transfer information and expected therapy to update the care plan. Another resident with moderate cognitive impairment and multiple diagnoses had a care plan with 19 focus areas whose interventions had largely not been updated since the prior year, despite the facility no longer offering restorative nursing services; there was no EMR documentation of care conferences or timely updates, and late entries were added to progress notes only after surveyor inquiry. A resident who experienced a fall, hospitalization, and diagnosis of Influenza A had a marked decline in transfer ability and required a full-body mechanical lift and transmission-based precautions, but the care plan was not updated to reflect the new transfer status or the need for PPE until after surveyor review. Additional failures involved skin integrity and catheter-related care planning. One resident admitted with a Stage 2 pressure ulcer and later placed on and then removed from an indwelling urinary catheter had care plan interventions that continued to reference catheter care and Enhanced Barrier Precautions for the catheter after the catheter was discontinued by physician order; the MDS showed the resident as incontinent without a catheter, but the care plan was not revised. Another resident at risk for pressure injuries developed in-house acquired moisture-associated skin damage on the buttocks and a deep tissue injury on the right heel, with multiple wound treatment orders and documentation of a scoop mattress and lack of repositioning aids; however, the care plan did not include MASD, the DTI, or related interventions such as pressure-reducing devices or nutrition/hydration measures. A different resident admitted without pressure injuries developed in-house Stage 2 pressure ulcers on the buttocks and a DTI on the right heel; the care plan contained no prevention focus, goals, or interventions until after the wounds occurred. Further, residents with existing or worsening pressure injuries did not have their care plans revised to reflect new or escalated needs. One cognitively intact resident with an in-house Stage 2 sacral pressure ulcer later required surgical debridement of a Stage 4 sacral ulcer with exposed bone and a wound vacuum; the care plan showed a generic focus on potential for pressure injury and an in-house Stage 2 sacral ulcer but no new interventions after the ulcer progressed and the resident returned from the hospital with a wound vac and more advanced wound status. Another cognitively intact resident at risk for pressure ulcers developed unstageable skin on 12/23, but there was no care plan update or added interventions for this finding. Interviews with the MDS coordinator, DON, RN staff, and social services indicated that the MDS coordinator was primarily responsible for building and updating care plans, floor nurses generally did not update care plans, and care conferences were not consistently scheduled or documented with IDT participation, residents, or families, resulting in multiple care plans that were outdated, incomplete, or not reflective of current clinical orders and conditions.
Failure to Provide and Document Oral Care, Toileting, and Repositioning for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required assistance with oral care, toileting, and repositioning for multiple dependent residents. For Resident #22, the Quarterly MDS dated 10/31/2025 showed a BIMS score of 4, indicating severe cognitive impairment, and documented a need for substantial/maximal assistance with oral hygiene. Her care plan, revised 11/18/2020, identified an ADL self-care performance deficit related to multiple sclerosis and required one staff to assist with daily grooming, including personal hygiene and oral care. A handwritten sign in her room requested that staff brush her teeth every day, and her emergency contact reported that her teeth were sometimes not brushed much when she visited, stating the resident would allow staff to complete oral care. On interview, the resident stated staff had not brushed her teeth that morning. The DON later stated she was unaware of the sign and that oral care should be completed at least twice a day, ideally by CNAs but also by nurses or other clinical staff, and possibly during OT. Resident #2’s MDS documented a BIMS of 15, indicating no cognitive impairment, and a need for supervision or touching assistance for oral hygiene. Her care plan, initiated 12/5/2025, documented that she required assistance of one staff for oral care. Review of her EHR showed no documentation of oral care provided. In interview, she stated she had a toothbrush in her bathroom and that whether oral care was provided depended on the staff. She reported that her husband helped her brush her teeth in the evenings, OT used to help her when she was going to therapy, and that occasionally a CNA would assist her with oral care. Resident #3’s MDS showed a BIMS of 11, indicating moderate cognitive impairment, and a need for partial/moderate assistance with oral hygiene. Her care plan, initiated 4/12/2025, documented that she required assistance of one staff for oral care, yet her EHR contained no documentation of oral care. Observation revealed no toothbrush in her room, and the ADON confirmed there was no equipment available to provide oral care. A CNA stated she had completed oral care that morning, claimed she obtained a new toothbrush for the resident every day, and said the resident only required set-up according to the care plan, which conflicted with the documented need for assistance. Resident #29’s MDS documented a BIMS of 15 and a need for supervision or touching assistance for oral hygiene, and her care plan dated 11/19/2025 indicated she required assistance of one for oral care. Her EHR contained no documentation of oral care. She reported that she had to set an alarm on her phone to ensure staff came to reposition her every two hours as ordered by her doctor, and that prior to a hospital stay staff were not repositioning her every two hours, with some overnight shifts only repositioning her at 3:00 or 4:00 AM. She stated she had multiple sclerosis, could not reposition herself in bed, and required staff assistance. She also reported that staff rarely provided oral care, that she could not sit up in bed on her own, and that she would appreciate staff assistance with oral care. She further stated that on one night a CNA refused to change her brief, that she was out of briefs and remained incontinent of urine without being changed all night, and that this CNA only repositioned her but did not change her. She reported prior concerns about this CNA’s care and described feeling treated without appropriate dignity or respect when requesting to be cleaned and changed. Resident #30’s MDS documented a BIMS of 13, indicating no cognitive impairment, and a need for substantial/maximal assistance with oral hygiene. Her care plan, initiated 12/3/2025, documented that she required assistance of one for oral care, yet her EHR contained no documentation of oral care. Her daughter reported that when she visited at random times, she frequently found food on the resident’s face and mouth and that it appeared her mother’s teeth had not been brushed. Staff interviews confirmed expectations and practices related to oral care: the ADON stated it was an expectation that all residents receive oral care even if they do not have teeth, and that dentures should be cleaned or soaked overnight. The DON stated oral care should be completed or offered and documented if refused, and that the required assistance should be reflected on the care plan. A CNA described asking cognitively intact residents when they wanted their teeth brushed and providing oral care before breakfast for residents who were not cognitively aware, and reported frequently finding residents with food on their faces and hands not cleaned from dinner, which she had brought to management’s attention. Review of the facility’s undated oral care policy showed that the purpose of the procedure was to keep lips and oral tissues moist, cleanse and freshen the mouth, and prevent oral infection. The policy required review of the care plan for special needs, assembly of needed equipment and supplies, and documentation in the medical record of the date and time mouth care was provided, the name and title of the person providing care, assessment data about the mouth, complaints of pain or discomfort, refusals with reasons and interventions, and the signature and title of the person recording the data. The policy also required CNAs to report to the licensed nurse for documentation. Despite these policy requirements and the care plan directives, surveyors found no documentation of oral care for multiple residents who required assistance, observed lack of oral care supplies in at least one resident’s room, and obtained resident and family reports that oral care, toileting, and repositioning were not consistently provided as needed.
Failure to Ensure Wheelchair, Mechanical Lift, and Hot Water Safety
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and injuries related to wheelchair transport, mechanical lift use, and hot water temperature monitoring. For one resident with moderate cognitive deficit who used a manual wheelchair with staff assistance, a CNA pushed the resident approximately 240 feet through two hallways without wheelchair footrests in place. A nurse and another staff member observed and interacted with the CNA during this transport but did not stop the wheelchair movement despite facility expectations that residents must have footrests on before being pushed. Another resident with severe cognitive impairment, who was dependent on staff for manual wheelchair use, was observed being pushed by a CNA from the dining room to the living room with the resident’s feet dragging on the floor for about 75 feet, again without use of footrests. The facility also failed to ensure safe and consistent use of full body mechanical lifts for residents who required dependent transfers. One cognitively intact resident, fully dependent on staff for chair-to-bed transfers and care-planned for a full body mechanical lift with two staff, reported that some staff used only one person during lift transfers, while most used two. The resident, a nurse for 30 years, stated she knew two staff were required and that she had to ask staff to get a second person, expressing worry about ending up on the floor if the sling broke. Another resident with moderate cognitive impairment, also fully dependent for transfers, stated she did not like using the full body mechanical lift and instead grabbed staff around the neck while they placed her in the wheelchair, and that staff sometimes brought the lift into the room but then decided not to use it. Multiple staff interviews confirmed inconsistent and unsafe practices with mechanical lifts. One staff member stated he had been trained that lift use was based on manufacturer recommendations and that it could be used with only one person, and he reported concerns to an LPN without apparent follow-up. An RN reported seeing staff transfer residents requiring full body mechanical lifts with only one staff and stated that “all the staff do it all the time,” naming specific CNAs who frequently did so. Another RN acknowledged having to remind certain staff that two people were needed for full body lift transfers and that she had received reports of staff transferring residents alone. A CNA stated staff were not supposed to transfer residents alone with full body lifts but that when a nurse would not help, she transferred with only one staff. The facility further failed to protect residents from possible scalding injuries by not adequately monitoring and controlling hot water temperatures. Review of water temperature logs showed monthly readings in resident rooms and the laundry area, with some laundry temperatures documented above 140°F, and no temperatures recorded after mid-November. The Director of Plant Operations stated it was probably his job to review the temperatures monthly but admitted he did not do so and did not know what temperatures were too hot for resident rooms or showers, nor the appropriate high or low limits. The DON stated that 124°F for resident room water was “a little too hot” but was unsure of the correct temperature to prevent burns or the timeframe for burns to occur. The Administrator stated he was not a temperature expert, could not state the appropriate water temperature for showers or resident rooms, and was unsure whether the Director of Plant Operations had ever been trained on appropriate water temperatures. No policies were presented for appropriate water temperatures, full body mechanical lift use, or wheelchair transportation safety.
Failure to Provide Ongoing, Understandable Education on Resident Rights
Penalty
Summary
The facility failed to provide ongoing education to residents and/or their representatives on Resident Rights in a format that was understandable to them. During a Resident Council meeting, residents present reported they were unaware that they had rights, did not know what their Resident Rights were, and did not know if these rights were posted within the facility. Review of Resident Council minutes for three consecutive months showed that various facility leaders attended the meetings but did not provide education on Resident Rights. During the same Resident Council meeting, the Life Enrichment Director stated she typically led the council and that an Activity Coordinator filled in when she was unavailable, and she acknowledged that staff had not been reviewing or educating residents on Resident Rights during these meetings. The DON stated that Resident Rights were provided only as part of admission packets and agreed they needed to be reviewed with residents on an ongoing basis, and neither the Life Enrichment Director nor the DON could confirm that Resident Rights were posted and readily available for residents, despite the facility’s Resident Rights policy stating that residents were to be informed of their rights and that these rights were to be posted throughout the facility. No specific resident medical histories or clinical conditions were described in relation to this deficiency, and the census at the time was 28 residents.
Failure to Assess and Treat Diabetic Ulcer and Head Injury for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assessment and treatment for a diabetic foot ulcer for one resident and failure to appropriately assess and monitor a head injury for another resident. For the first resident, the admission/readmission progress note dated 1/5/26 documented no impaired skin integrity, including no diabetic ulcer or open areas, despite the resident later being identified as having a diabetic ulcer on the second digit of the left foot. The resident, who had a BIMS score of 15 indicating no cognitive impairment, reported that she had informed the RN/ADON about the sore on her foot and that nothing was done until another RN intervened. The electronic health record showed that a wound evaluation entered on 1/15/26 documented a diabetic ulcer on the left second toe, present on admission, with specific measurements and description, and physician notification at that time. Further review of the records for this resident showed that the wound was again evaluated on 1/16/26 and 1/23/26 with documented measurements, but there was no documentation of any physician notification or treatment for the wound from the time of admission on 1/5/26 until 1/15/26, when the RN first addressed the area. A physician’s order to cleanse the second toe on the left foot and apply triple antibiotic ointment with a bandage daily had a start date of 1/15/26, indicating that treatment was not initiated until ten days after admission. The DON stated that the initial admission skin assessment was completed by one RN who left without documenting the assessment, and that the evening nurse then completed the assessment again. The DON also stated she did not think the initial nurse observed the resident’s foot or toe, acknowledged that the wound should have been noticed on admission, and confirmed that the resident was in the facility for a week without the wound being assessed or treated. For the second resident, who had a BIMS score of 13 indicating no cognitive impairment, the facility failed to appropriately assess and monitor a head injury and associated bruising. A skin check dated 12/22/25 documented no skin issues. On 1/4/26 in the morning, an LPN observed a scratch or red mark on the right side of the resident’s forehead and obtained an initial set of vital signs and an assessment as part of the daily assessment, but did not initiate neuro checks at that time and did not remove the resident’s clothing to assess hips or buttocks, only pulling pant legs up. The LPN reported conflicting accounts from the resident about how the injury occurred and stated she was not aware of any procedure for injury of unknown origin or for witnessed/unwitnessed head injury. Later that day, when the resident’s daughter arrived, the area on the forehead had progressed to a swollen “goose egg,” at which point neuro checks were started and the on-call provider was notified, with documentation showing neurological assessments beginning at 6:00 PM and a skilled note at 7:49 PM describing a hematoma to the right forehead and notifications made. The resident’s daughter reported finding her mother with a bruise on the knee and a wound on the right side of the head, and stated the resident told her she had fallen in the bathroom that morning. She also reported that additional large bruises on the right hip and right shoulder blade were only discovered and brought to attention when the resident was examined in the emergency department the following day. The DON acknowledged that there had been an injury of unknown origin and that staff had not notified the physician or family appropriately when the injury was first found in the morning, and that neuro assessments should have been initiated at that time but were not. The DON stated she would have expected staff to notify her, the physician, and the family when the head injury was first observed at approximately 7:30 AM, and confirmed that these actions were not completed as expected. The nurse practitioner stated she was notified of the forehead area and conflicting stories but was not made aware of the goose egg or any other bruising, and that she would have expected staff to call with any head injuries and start neuro assessments immediately.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse in the form of a resident-to-resident altercation. On the date of the incident, one resident was seated near the nurses’ station while using the phone, and another resident, who routinely self-propelled her wheelchair around the nurses’ station in the evenings, attempted to pass by. As the second resident tried to pass, the seated resident swung his arm back and struck her twice in the upper back. This event was witnessed by a restorative aide and a registered nurse, and was later documented in nursing progress notes and a facility-reported incident. The resident who initiated the altercation had multiple medical diagnoses, including cerebrovascular accident, hemiplegia, aphasia, adjustment disorder with depressed mood, a history of falls, and diabetes. His most recent MDS prior to the incident showed a BIMS score of 9/15, indicating moderate cognitive impairment, and documented that he was usually able to make himself understood and to understand others. His care plan identified mood and behavior issues, including verbal aggression and a tendency to not want to wear clothes, and directed staff to anticipate and meet his needs, assist with coping and interacting, provide positive interaction, discuss inappropriate behavior when reasonable, and intervene as necessary to protect the rights and safety of others by approaching calmly, redirecting, and removing him from situations as needed. The resident who was struck had diagnoses including non-Alzheimer’s dementia, cognitive communication deficit, and adjustment disorder with mixed anxiety and depressed mood, with a BIMS score of 6/15 indicating severe cognitive impairment. She was sometimes able to make herself understood and to understand others, and used a wheelchair as her primary mode of transport. Her care plan addressed impaired cognitive function and directed staff to ask yes/no questions, cue, reorient, supervise as needed, keep her routine consistent, and provide consistent caregivers. On the day of the incident, she was following her usual routine of self-propelling around the nurses’ station when she was hit. Staff interviews described that the striking resident could become irritable when redirected and that he hit the other resident before staff could intervene, then stood up and subsequently hit and pinched the CNA who attempted to stop him. The facility’s abuse prevention policy states that residents have the right to be free from abuse by anyone, including other residents, and that the facility will protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone.
Failure to Protect Resident From Financial Exploitation of EBT Food Benefits
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from financial exploitation by a staff member. The resident had multiple diagnoses including adult failure to thrive, type 2 diabetes with complications, alcoholic cirrhosis of the liver, anxiety, and depression, and had a BIMS score indicating moderate cognitive impairment, though she was always able to make herself understood and to understand others. She was totally dependent on staff for substantial assistance with repositioning, transfers, and was unable to stand or ambulate. Her care plan identified that she had difficulty coping with lifestyle changes, limitations in functional abilities, and the loss of her husband as caregiver, and that she needed assistance with problem solving and psychosocial support. The events leading to the deficiency began when the resident, who received monthly EBT food stamp benefits, asked a CNA to use her EBT card to purchase snacks for her and told the CNA she could also buy items for herself with the card. The resident did not specify an amount the CNA could spend, did not know exactly what the CNA purchased for herself, and recalled the total purchase being a little over $100. Some purchased items required refrigeration and were placed in a refrigerator outside the resident’s direct control, and the resident later reported she had lost track of those items. The resident stated she did not think she had done anything wrong and was unaware at the time that designated facility staff were available to shop for residents. Interviews and document review showed that the CNA acknowledged using the resident’s EBT card at a grocery store, spending a little over $100, and purchasing food for both the resident and herself, but could not clearly recall all items she bought for herself. A grocery store receipt showed 68 items purchased for a total of $268.93 with the resident’s EBT card. When the receipt was later reviewed with the resident, she identified several items totaling $115.96 that she stated she had not requested and believed were purchased for the CNA. Other staff, including another CNA/Restorative Aide, stated they knew it was wrong to use a resident’s resources or accept gifts from a resident based on dependent adult abuse education. The facility’s abuse, neglect, exploitation, and misappropriation prevention policy required protection of residents from exploitation and misappropriation of property, development of protocols to prevent and identify such incidents, and investigation of possible misappropriation, underscoring that the resident’s funds were wrongfully used by staff despite these policies.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to provide required Registered Nurse (RN) coverage for eight consecutive hours per day on 26 days between November 1, 2025, and January 25, 2026, while reporting a census of 26 residents. Review of nursing schedules showed that in November 2025 there was no RN coverage on the 8th, 9th, 15th, 16th, 22nd, 23rd, 27th, 29th, and 30th; in December 2025 there was no RN coverage on the 6th, 7th, 13th, 14th, 20th, 21st, 25th, 27th, and 28th; and in January 2026 there was no RN coverage on the 1st, 3rd, 4th, 11th, 17th, 18th, 24th, and 25th. Staff interviews and schedule review confirmed that the facility did not have an RN in the building for the required eight hours on these dates. The Administrator acknowledged that RN coverage was an ongoing issue and verified the lack of RN coverage on the identified dates. The facility assessment documented that the facility would continue working toward a staffing level that meets the minimum staffing final rule. No specific resident medical histories or conditions at the time of the deficiency were described in the report.
Failure to Maintain Effective Pest Control Resulting in Mice Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free from vermin infestation. Staff interviews revealed an ongoing mice problem in multiple areas, including the staff break room and resident care areas. An LPN reported that mice had eaten a snack stored in her personal locker in the break room about a week prior, and facility work orders documented a mouse in a resident room that was marked as closed. During observations, surveyors found mice droppings in four of six drawers of a resident’s clothing dresser, where socks, jeans, and personal items were stored, and in the corner of a vacant resident room near the heat register. Additional staff interviews and observations showed that the mice problem extended to common and storage areas. The Maintenance Director acknowledged an ongoing mice issue and reported that staff had recently caught live mice in their work area. A housekeeping aide stated that the mice problem was so severe that multiple items in the Activity Room storage closets, including Christmas decorations, were torn and chewed, and staff saw a live mouse jump out of one of the boxes. She also reported that when a recliner cushion in a resident’s room was pulled out, a large amount of mice droppings and some soft toys had to be discarded. During an observation of the Activity Room with three residents present, multiple mice droppings, both black and green, were noted around the room near the entrance door and a nightstand, with debris behind the nightstand. The Administrator confirmed that mice droppings were first noted at the beginning of the month and that the facility had a pest control policy stating it would maintain an effective pest control program for common household pests and rodents.
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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