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 CNA failed to perform hand hygiene after providing catheter care to a resident, both between glove changes and after removing PPE, despite facility policy requiring proper hand hygiene at these points. The lapse was confirmed by the Unit Manager during staff interviews.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as identified by surveyors.
The facility did not provide or document advance information to residents or their representatives regarding the risks and benefits of prescribed psychotropic medications. Multiple residents with conditions such as dementia, anxiety, depression, and other chronic illnesses received medications like antidepressants and antipsychotics without documented informed consent, as confirmed by staff interviews and record reviews.
Surveyors found 13 cartons of expired Glucerna creamy strawberry nutritional supplement stored with other supplement drinks in the kitchen. The expired product was overlooked during daily checks by dietary staff because no residents were currently using that flavor, despite facility policy requiring expired items to be discarded.
The facility did not notify the State LTC Ombudsman about the hospitalization and discharge of two residents, including one who was hospitalized and returned, and another who was discharged home with hospice. Documentation and staff interviews confirmed the lack of required notifications, and facility leadership was unaware of the notification requirement.
Staff did not consistently wear required PPE, such as gowns and gloves, during wound and personal care for two residents on Enhanced Barrier Precautions, and failed to properly identify and implement Transmission Based Precautions for a resident with a VRE infection. Some staff were unaware of the correct precautions or the resident's status, and signage and documentation did not accurately reflect the required infection control measures.
The facility did not complete federally required MDS assessments for two residents. One resident's quarterly MDS assessment was left incomplete, and another resident who was hospitalized and returned did not have the necessary discharge and reentry MDS assessments completed. The MDS Coordinator and DON acknowledged the lapses in timely completion of these assessments.
Two residents' care plans did not address all identified needs, including the use of diuretic and antidepressant medications and the risk of skin breakdown on the coccyx. One resident's care plan omitted guidance on monitoring for medication side effects, while another's did not include the presence of an open area on the coccyx, despite clinical documentation and facility policy requirements.
A resident with a history of receiving Pneumovax (PPSV23) did not have documentation of being offered a pneumococcal conjugate vaccine as recommended by CDC guidelines. Facility policy required nursing staff to screen, educate, and document immunization status, but this process was not followed for the resident, as confirmed by staff and record review.
A resident's care plan was not developed within 7 days of the comprehensive assessment, and the required team of health professionals did not prepare, review, or revise the plan as mandated.
Failure to Perform Hand Hygiene After Resident Care
Penalty
Summary
Staff H, a Certified Nursing Assistant, was observed performing hand hygiene and donning personal protective equipment (PPE) before providing catheter care to a resident. After completing the care, Staff H removed soiled gloves but did not perform hand hygiene before donning new gloves. Staff H then rearranged the resident's wheelchair, opened the door, and exited the room. Upon doffing PPE, Staff H again failed to perform hand hygiene and proceeded down the hall. The facility's Hand Hygiene policy, last updated in January 2025, requires hand hygiene to be performed in accordance with accepted standards of practice. During an interview, the Unit Manager confirmed that hand hygiene should have been performed between glove changes and after removing PPE.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified by surveyors based on observations or events that demonstrated a lack of appropriate safety measures and supervision in the specified area. No additional details about the specific actions, inactions, or individuals involved are provided in the report.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform residents or their representatives in advance about the risks and benefits of psychotropic medications for five residents who were prescribed such medications. Clinical record reviews, policy review, and staff interviews revealed that, despite facility policy requiring notification and consent for the initiation, increase, or decrease of psychoactive medications, there was no documentation that this information was provided to the residents or their representatives. The affected residents had various diagnoses, including dementia, anxiety, depression, diabetes, osteoarthritis, asthma, chronic obstructive pulmonary disease, hemiplegia, and insomnia, and were prescribed medications such as sertraline, trazodone, olanzapine, alprazolam, duloxetine, buspirone, and Tylenol PM. The review of medical records and order summaries for these residents showed that psychotropic medications were administered without documented evidence that the residents or their responsible parties were informed of the associated risks and benefits prior to administration. Interviews with facility staff, including the DON, confirmed the absence of consent forms for these medications, and there was an acknowledgment that the pharmacist would assist in completing them. This lack of documentation and communication represents a failure to comply with facility policy and regulatory requirements regarding informed consent for psychotropic medication use.
Expired Nutritional Supplements Found in Kitchen Storage
Penalty
Summary
During an initial kitchen tour, surveyors observed 13 individual cartons of Glucerna creamy strawberry nutritional supplement with an expiration date of July 2025 stored on a dry storage shelf alongside other supplement drinks. The Dietary Manager confirmed that these Glucerna drinks were expired and acknowledged their presence in the storage area. Staff interviews revealed that the Dietary Aide responsible for checking supplements daily had overlooked the expired product because no residents were currently prescribed that particular flavor. Facility policy required kitchen staff to discard any food item in storage after its expiration date, but this was not followed in this instance.
Failure to Notify Ombudsman of Resident Hospitalizations and Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of the hospitalization and discharge of two residents. For one resident with chronic obstructive pulmonary disease and diabetes, who was cognitively intact, the clinical record showed a hospitalization and subsequent return to the facility, but there was no documentation of Ombudsman notification. The Minimum Data Set (MDS) and progress notes confirmed the resident's transfer to the hospital and return, yet the required notification was not present in the records. The facility administrator confirmed that staff did not notify the Ombudsman and that there was no policy in place for such notifications. For another resident, the records indicated an admission and later discharge to home with hospice services, with the intent for end-of-life care at home. Again, the clinical record lacked documentation of notification to the State Long-Term Care Ombudsman regarding the discharge. The administrator and DON both stated they were unaware of the requirement to notify the Ombudsman in cases of resident discharges and hospitalizations.
Failure to Implement and Identify Correct Infection Control Precautions
Penalty
Summary
Staff failed to consistently wear appropriate personal protective equipment (PPE) during high-contact care activities for residents on Enhanced Barrier Precautions (EBP) and did not correctly implement or identify the required level of infection control precautions for a resident on Transmission Based Precautions (TBP). For one resident with arthritis, heart failure, hypertension, and unstageable pressure ulcer, staff measured and cared for wounds while wearing gloves but not a gown, despite facility policy requiring both gown and gloves for wound care under EBP. Staff interviews confirmed knowledge of the policy, but the LPN involved did not wear a gown, stating she did not expect drainage from the wound. Another resident with chronic obstructive pulmonary disease, fibromyalgia, and an indwelling urinary catheter required substantial assistance with personal hygiene and had excoriated areas identified as a yeast infection. During personal care and catheter-related activities, one LPN wore only gloves while assisting with intimate care tasks, including repositioning and perineal care, while another LPN wore both gown and gloves. The LPN who did not wear a gown stated she believed it was unnecessary since she was not performing catheter care, despite direct contact with the resident and the presence of open skin areas. For a third resident with chronic obstructive pulmonary disease, diabetes, and an indwelling urinary catheter, the facility failed to clearly identify and implement the correct level of infection control precautions. Although the resident was on TBP for a Vancomycin Resistant Enterococci (VRE) infection, the signage on the door only indicated EBP, and the resident was not listed on the facility's matrix as being on TBP. Staff interviews revealed confusion between EBP and TBP, and some staff were unaware of any residents on contact precautions, despite the resident's status and facility policy requiring contact precautions for VRE.
Failure to Complete Required MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete required Minimum Data Set (MDS) assessments for two residents. For one resident, the quarterly MDS assessment due in July remained incomplete and was still listed as 'in progress' in the electronic health record as of late August. The MDS Coordinator acknowledged that MDS assessments had not been completed in a timely manner, citing insufficient time to complete the required work. The Director of Nursing confirmed that MDS assessments should be completed within the appropriate time frames. Another resident, who had diagnoses of chronic obstructive pulmonary disease and diabetes and was cognitively intact, experienced a hospitalization in July. The clinical record review showed that the required MDS discharge assessment with anticipated return and the reentry MDS assessment were not completed following the resident's transfer to and return from the hospital. Progress notes documented the resident's transfer to the hospital, admission, and subsequent return to the facility, but the necessary MDS assessments were missing. The Director of Nursing confirmed that these assessments should have been completed.
Failure to Address Medication and Skin Breakdown Risks in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with diagnoses including anxiety, osteoarthritis, asthma, and chronic lung disease, the care plan did not include information about the resident's use of diuretic and antidepressant medications, despite documentation in the Medication Administration Record and the facility's policy requiring care plans to address medications and their potential side effects. This omission left staff without guidance on monitoring for possible medication-related side effects. For another resident with hemiplegia, Parkinson's disease, and muscle wasting, the care plan addressed the risk of impaired skin integrity related to a suprapubic catheter but did not address the risk of skin breakdown on the coccyx. Clinical documentation indicated the presence of an open area on the coccyx, but this was not reflected in the care plan. The Director of Nursing confirmed that care plans should address high-risk medications and all risks for skin impairment.
Failure to Offer Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to offer a pneumococcal conjugate vaccine to one of five sampled residents reviewed for immunizations. According to the clinical record, the resident had previously received a dose of Pneumovax (PPSV23) in 2010 and was over the age threshold at the time. The resident's record did not contain documentation that staff had offered or administered a pneumococcal conjugate vaccine (such as Prevnar 20, Prevnar 21, or Vaxneuvance) in accordance with current CDC guidelines. The Infection Preventionist confirmed that the resident should have been offered the vaccine based on their immunization history. Facility policy required nursing staff to screen residents for pneumonia vaccination status upon admission, provide education on the risks and benefits of the pneumococcal vaccine, and document both the education and the resident's consent or declination. However, the review found that this process was not followed for the resident in question, as there was no evidence of an offer, education, or documentation regarding the pneumococcal conjugate vaccine. The deficiency was identified through clinical record review, policy review, CDC guideline comparison, and staff interviews.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
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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