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)
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.
Latest Citations in Iowa
A resident with severe cognitive impairment and chronic pain did not receive scheduled morphine for 11 days after a durational order was not renewed or sent to the pharmacy following a provider review. The medication remained active on the MAR, but no new script was generated, leading to withdrawal symptoms and an ER visit. Staff interviews confirmed the lapse was due to failure to renew the order and lack of follow-up on the provider's documentation.
A resident with a history of falls and recent changes in transfer needs was transferred by only one CNA, despite the care plan requiring two-person assistance. The CNA relied on an outdated care sheet in the room, resulting in the resident sustaining a toe injury during the transfer. The incident was due to a lack of updated and accessible care plan information for staff.
A resident with severe cognitive impairment and a history of weight loss was served a regular diet meal with large, tough meat chunks instead of the prescribed mechanically altered diet with ground meats. Staff identified the inconsistency during feeding, and interviews revealed confusion over dietary orders contributed to the error, as the meal did not meet the requirements for a mechanically soft diet.
A resident with diabetes, stroke, and aphasia experienced persistently high blood glucose and elevated heart rate over several days without timely provider notification or additional insulin administration. Nursing documentation was lacking, and staff did not escalate care until the resident's condition became critical, resulting in hospitalization for DKA, sepsis, and pneumonia.
A resident with severe cognitive impairment and a history of falls, who required substantial assistance with transfers and toileting, was left to ambulate independently from the bathroom, resulting in a fall and injury. Staff were inconsistent in following the care plan, and there was confusion regarding the resident's required level of assistance. The care plan was not updated to reflect the resident's current needs, and staff did not provide the supervision necessary to prevent the accident.
A resident with a history of psychiatric and mood disorders, who was prescribed multiple psychotropic medications and developed new diagnoses including bipolar and paranoid personality disorder, did not have their PASRR updated to reflect these changes. Staff interviews indicated uncertainty about when the new diagnoses were received and acknowledged that PASRR updates were expected but not completed. Facility policy required PASRR updates for residents with mental illness, but this was not followed.
Staff failed to follow infection control protocols during care for three residents, including an LPN who did not change gloves or perform hand hygiene between tracheostomy and gastrostomy care, and left and re-entered a resident's room wearing the same gown. The same LPN also did not sanitize hands between glove changes during a wound dressing change for another resident. Additionally, a CNA did not wear a gown while providing catheter care to a resident with an indwelling device, despite EBP signage and available PPE.
A resident with severe cognitive impairment and a history of falls was found on the bathroom floor by staff and assessed for injuries after a fall. Although the resident's family should have been notified promptly, the nurse did not inform them until the following day, contrary to facility policy requiring timely family notification after such incidents.
A resident with a facial lesion diagnosed as basal cell carcinoma did not receive a timely dermatology appointment after a physician's referral order. Despite the order being signed and the family notified, there was a two-month delay before the appointment was scheduled, with no documentation of efforts or reasons for the delay. Staff later discovered the initial referral was denied by insurance and only then sent a second referral, but the timing of this was not documented. Both the resident and her daughter reported no contact from the dermatology office.
A resident with severe cognitive impairment and a history of falls and skin picking developed multiple undocumented bruises that were not identified or assessed according to care plan directives and facility policy. Despite photographic evidence of bruising, staff failed to document or communicate these findings, resulting in missed interventions and incomplete records.
Failure to Administer Scheduled Morphine Due to Lapsed Order Renewal
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and chronic pain, who was prescribed morphine sulfate 15 mg twice daily for pain management, did not receive her scheduled morphine doses for 11 days. The morphine order was a durational order requiring review every 30 days by the Nurse Practitioner. After the Nurse Practitioner’s visit and documentation to continue the morphine, the order was not renewed or sent to the pharmacy, resulting in the medication not being available for administration. The Medication Administration Record (MAR) still showed the morphine as an active order, but no new script was generated, and the pharmacy did not receive a renewal request. During the period without her scheduled morphine, the resident exhibited withdrawal symptoms and was sent to the emergency room for evaluation. Progress notes indicated that the resident experienced vomiting, diarrhea, hypertension, and nonverbal signs of pain, such as grimacing and trembling. The resident’s daughter and hospice staff later became involved, and it was discovered that the morphine order had lapsed. The resident’s condition continued to decline, and she was unable to swallow medications or food in the days leading up to her death. Interviews with facility staff revealed that the lapse in medication administration was due to a failure to renew the morphine order after the Nurse Practitioner’s review. The Assistant Director of Nursing acknowledged that the order should have been written and sent to the pharmacy, and that nurses should have noticed the absence of the order. The Director of Nursing confirmed that the resident experienced opioid withdrawal as a result of not receiving her scheduled morphine. The facility’s policy required care and services to be provided according to the most recent medical orders, which was not followed in this case.
Failure to Update and Communicate Resident Transfer Requirements Leads to Injury
Penalty
Summary
A deficiency occurred when a resident, who had a history of falls and required the assistance of two staff members for transfers following a recent fall, was transferred by only one staff member. The resident's care plan had been updated to reflect the need for two-person assistance with a gait belt after her knee gave out during a previous transfer. However, the care sheet in the resident's room incorrectly indicated that only one staff member was needed for transfers. As a result, a staff member, relying on the outdated care sheet, attempted to transfer the resident alone using a gait belt and walker, rather than following the updated care plan requirements. During this transfer, the resident sustained an injury to her fourth toe, which became bruised and later developed a blackened toenail. The staff member involved was unaware of the updated transfer requirements in the electronic care plan and used the information from the care sheet in the resident's room. The incident highlighted a failure to ensure that staff had access to and followed the most current care plan information, leading to inadequate supervision and an accident during a transfer.
Failure to Provide Prescribed Mechanically Altered Diet
Penalty
Summary
A deficiency occurred when a resident with significant cognitive impairment, a history of weight loss, and multiple diagnoses including GERD and seizure disorder, was not provided with the prescribed mechanically altered diet. The resident's care plan and diet card specified a mechanically soft diet with ground meats, but during a direct observation, the resident was served a regular diet soup containing large, tough chunks of beef and vegetables. Staff feeding the resident noticed the inconsistency, as the meat could not be easily cut or mashed, and confirmed it was not appropriate for the resident's ordered diet. Interviews with staff revealed that dietary staff were responsible for plating food according to diet cards, while CNAs served the food. Both the CNA and dietary manager confirmed the meal served did not meet the resident's dietary requirements. The dietary manager attributed the error to confusion stemming from a previous hospice provider's order, which had allowed for pleasure feedings of normal textured foods, whereas the current order required only mechanically altered foods. Facility policy required mechanically soft diets to include moist, ground meats and soft foods, which was not followed in this instance.
Failure to Notify Provider of Change in Condition for Resident with Hyperglycemia and Tachycardia
Penalty
Summary
The facility failed to promptly notify a medical provider of a significant change in condition for a resident with multiple complex medical diagnoses, including diabetes, stroke, aphasia, and seizure disorders. The resident, who was nonverbal and received the majority of her nutrition via tube feeding, exhibited persistently elevated blood glucose levels over several days, with readings as high as 437, 413, and 397. Additionally, the resident's heart rate was consistently elevated, reaching up to 126 beats per minute, and her blood pressure was trending below baseline. Despite these abnormal findings, there was no documentation that a medical provider was notified of the resident's high blood sugars or tachycardia prior to her acute deterioration. Nursing documentation was notably lacking, with no progress notes entered for a period of nearly two weeks, and the only note during that time referencing a physician note with no new orders. Staff interviews revealed that while some staff recognized the abnormal blood sugar levels and vital signs, there was inconsistency in when to notify a provider, and no action was taken until the resident's condition became critical. When the resident's blood glucose became unreadable by the glucometer, a provider was contacted but did not give orders for insulin, only for tube feeding to be stopped and labs to be drawn. The resident was ultimately sent to the emergency department after further decline, where she was diagnosed with diabetic ketoacidosis, sepsis, and pneumonia. The lack of timely provider notification and absence of additional insulin administration outside of scheduled doses contributed to a delay in appropriate medical intervention. The facility's documentation and communication practices did not reflect prompt recognition or escalation of the resident's deteriorating condition, despite clear evidence of significant changes in vital signs and blood glucose levels.
Failure to Provide Adequate Supervision and Follow Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and follow the care plan for a resident with severe cognitive impairment, resulting in a fall. The resident had a history of dementia, anxiety disorder, a prior humerus fracture, and required substantial to maximal assistance with transfers and toileting according to the most recent MDS and care plan. Despite these documented needs, the resident was allowed to ambulate independently from the bathroom to her chair, during which she fell and sustained a significant skin tear and bruising, and later complained of pain in her right big toe and left arm. Staff interviews and documentation revealed inconsistencies in the assignment and supervision of care for the resident on the day of the fall. The care plan directed staff to provide assistance with transfers and all toileting tasks, but staff accounts indicated that the resident was often left to use the bathroom independently for privacy, with staff only nearby rather than providing direct assistance. There was also confusion among staff regarding the resident's level of independence, with some believing she was care planned to be independent for transfers and toileting, while others stated she required assistance. The care plan had not been updated to reflect changes in the resident's condition, and staff were not consistently following the documented interventions. Further, the facility's policies required ongoing assessment and adjustment of interventions for residents at risk of falls, as well as accurate documentation and communication among staff. However, the care plan was outdated, and staff were unclear about the resident's needs and the required level of supervision. The lack of direct supervision and failure to adhere to the care plan led to the resident's fall and injury, demonstrating a breakdown in communication, care planning, and implementation of fall prevention strategies.
Failure to Update PASRR Following New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a status change in the Preadmission Screening and Resident Review (PASRR) for a resident who received new mental health diagnoses. Clinical record review showed that the resident had a history of psychiatric and mood disorders, including depression and bipolar disorder, and was prescribed multiple psychotropic medications such as antipsychotics, antianxiety, and antidepressants. The resident's care plan was updated to reflect new diagnoses, including bipolar and paranoid personality disorder, as well as symptoms like tactile hallucinations. However, the PASRR Level I screening on file only documented depression and did not reflect the new mental health diagnoses or recent mental health symptoms, nor did it indicate that the resident was receiving mental health services. Staff interviews revealed that the social services staff was informed of new diagnoses during Quality Assurance meetings but was unsure when the resident received the new diagnoses. The staff member also indicated that managing PASRR updates was a new responsibility and acknowledged that updates are expected with new mental health diagnoses. The facility administrator agreed that the PASRR should have been updated. Facility policy required evaluation of residents on antipsychotic medications and completion of PASRR screenings for those with mental illness, but this process was not followed for the resident in question.
Failure to Follow Infection Control Guidelines During Resident Care
Penalty
Summary
The facility failed to adhere to infection prevention and control guidelines for three residents during direct care activities. In one instance, an LPN provided tracheostomy care to a resident with a history of stroke, quadriplegia, and respiratory failure, and then, without changing gloves or performing hand hygiene, proceeded to remove and clean the resident's gastrostomy tube dressing. The LPN also left the resident's room wearing the same gown, walked down the hall, and returned still wearing the gown to complete the dressing change, contrary to facility policy and infection control protocols. In another case, the same LPN performed a wound dressing change for a resident with cancer, coronary artery disease, and two Stage II pressure ulcers. After removing the old dressing, the LPN failed to sanitize her hands before donning new gloves and continuing with wound care. The LPN acknowledged this lapse immediately after the procedure. There was also no Enhanced Barrier Precautions (EBP) sign outside the resident's room, as required for residents with certain conditions. Additionally, a CNA provided catheter care to a resident with a history of stroke, hemiplegia, and seizure disorder, but did not wear a gown as required by EBP for high-contact care activities involving indwelling medical devices. The resident's room had signage and gowns available, but the CNA stated that gowns were only used when a resident had an active infection. The facility's policies required the use of PPE, including gowns, for such care activities, but these were not followed during the observed care.
Failure to Timely Notify Family After Resident Fall
Penalty
Summary
A resident with severely impaired cognitive functioning, as indicated by a BIMS score of 5, experienced a fall in the facility's bathroom. The resident required substantial to maximal assistance with activities of daily living and had a history of safety concerns, including a risk for falls and skin picking. On the evening of the incident, staff found the resident on the bathroom floor, assessed her for injuries, and noted complaints of hip and knee pain, but no visible injuries or swelling were observed. Neurological checks were initiated and found to be within normal limits. Despite the fall and the resident's condition, the nurse on duty did not notify the resident's family on the day of the incident. The family was informed the following day, after the facility became aware that notification had not occurred as required. Facility policy directs staff to document the date and time of family notification following accidents or incidents, but this was not followed in this case.
Failure to Timely Arrange Dermatology Referral for Resident with Skin Lesion
Penalty
Summary
The facility failed to follow a physician's order to arrange a dermatology appointment within a reasonable timeframe for a resident with an open lesion on the left cheek, which had been biopsied and identified as basal cell carcinoma. The physician's order for a dermatology referral was given and signed off by nursing staff, and both the resident and her family were notified of the referral. However, there was a two-month gap between the order and the actual dermatology appointment, with no documentation in the clinical record of attempts to make the appointment or any rationale for the delay. Staff interviews revealed that the initial dermatology referral was denied by insurance, and no appointment was scheduled as a result. The Assistant Director of Nursing was unaware of whether the dermatology office had contacted the resident or her family regarding the denial. Once it was discovered that no appointment had been made, a second referral was sent, but the clinical record did not specify when this occurred. Both the resident and her daughter confirmed they had not received any calls from the dermatology office. The facility's policy required consistent and effective order management, but this was not followed in this case.
Failure to Identify and Document Resident Bruising
Penalty
Summary
The facility failed to identify, assess, and implement interventions for a resident who exhibited multiple undocumented bruises on her body. The resident had severely impaired cognitive functioning, required substantial to maximal assistance with activities of daily living, and had a history of falls and skin picking. Despite care plan directives for weekly skin assessments and specific interventions for skin concerns, documentation and assessment of new bruises were not completed as required. Photographic evidence showed bruising on the resident's forehead, knees, and buttocks over several days, but these were not recorded in the weekly skin observation tools, which indicated no new skin issues during the same period. Interviews revealed that CNAs did not alert nurses to new skin concerns, assuming nurses were already aware due to prior assessments after a fall. The facility's policy required thorough documentation, including physician and family notification, completion of incident reports, and investigation of causation for any abrasions, skin tears, or bruises. However, these steps were not followed for the resident's bruises, resulting in a lack of appropriate assessment and intervention according to the resident's care plan and facility policy.