Azria Health Prairie Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Mediapolis, Iowa.
- Location
- 608 Prairie Street, Mediapolis, Iowa 52637
- CMS Provider Number
- 165220
- Inspections on file
- 26
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Azria Health Prairie Ridge during CMS and state inspections, most recent first.
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.
Two residents were issued emergency discharges following repeated altercations, with the facility failing to adequately address their needs or properly notify and involve their guardians and families in the process. Both residents were transferred to hospitals for psychiatric evaluation, found not to require admission, and were subsequently refused readmission by the facility, resulting in one resident remaining hospitalized and the other returning to independent living with limited support.
Surveyors identified multiple instances where staff failed to store raw meat on the bottom shelf, handled food with gloved hands without changing gloves between tasks, and left an ice scoop handle in contact with ice. Staff interviews confirmed awareness of proper procedures, but these were not consistently followed, resulting in unsanitary food storage and handling.
Three residents experienced a lack of dignity and respect due to staff actions, including inappropriate verbal and physical cues during feeding, use of personal phones during care, and inadequate supply of properly sized incontinence briefs. These actions were confirmed by resident and staff interviews, observations, and review of facility policies, highlighting failures to follow care plans and maintain resident dignity.
A resident with multiple chronic conditions experienced significant weight loss over several months. Although dietary staff documented the weight loss and implemented interventions, the facility failed to provide evidence that the physician was notified of these changes, as required by policy.
Care plans were not updated for two residents who experienced significant weight loss and for another resident who was no longer receiving dialysis, despite clear evidence of these changes. Staff interviews revealed lapses in responsibility for updating care plans, and the facility's policy requiring timely revisions after significant changes was not followed.
A resident with lower extremity impairment and intact cognition did not consistently receive restorative nursing interventions as recommended by therapy, due to inconsistent staff assignment and lack of dedicated restorative personnel. The care plan outlined specific exercises and activities, but staff interviews revealed that restorative programming was often missed or inadequately implemented when the responsible staff member was reassigned to other duties.
The facility did not ensure that its services met professional standards of quality, as observed through practices that did not align with established care guidelines.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
Three medication errors were observed among twenty-seven opportunities, resulting in a medication error rate of 11.11%. Errors included a resident receiving insulin after eating instead of before meals, another resident receiving the wrong dosage form of Ferrous Sulfate, and a third resident being given a different formulation of Polyethylene Glycol than prescribed. These incidents occurred despite facility policies requiring medications to be administered as ordered and within specified time frames.
Multiple residents experienced significant medication errors involving anticoagulants, insulin, and narcotic pain medications due to failures in documentation, communication, and order transcription. In several cases, residents received double doses of medications or had medications administered at incorrect times, and one resident received an incorrect anticoagulant regimen due to a transcription error that was not clarified with the discharging hospital. These errors were identified through observation, interviews, and record review, and were not consistent with the facility's medication administration policy.
The facility failed to complete quarterly MDS assessments on time for several residents, with delays noted in the completion of assessments beyond the required 14-day period from the ARD. Interviews with staff, including the MDS Coordinator and DON, confirmed these delays, and the facility's policy did not address quarterly MDS requirements.
The facility did not complete annual MDS assessments on time for two residents. One resident's assessment was still in process beyond the required timeframe, while another's was completed late. Staff interviews confirmed the delay, which was against the facility's policy requiring completion within 14 days of the ARD.
A facility failed to update a PASRR for a resident with new mental health diagnoses and medications. The resident had a history of anxiety, depression, and psychotic disorder, and was taking antipsychotic and antidepressant medications. Despite significant changes in diagnoses and medication orders, the PASRR was not resubmitted. The MDS coordinator misunderstood the criteria for significant changes, which was later clarified by the administrator. The facility's policy required a PASRR Level II evaluation for new or changed behaviors indicating a serious mental disorder, but this was not followed.
A facility failed to administer a pneumococcal vaccine to a resident who was eligible for the PCV 20 vaccine. The resident had previously received the Prevnar 13 vaccination and consent for the PCV 20 was obtained. However, due to a lack of communication and clarity among staff regarding responsibility for vaccinations, the vaccine was not administered. The DON relied on the Infection Preventionist, who was unaware of the need to offer the vaccine, resulting in a disconnect in the process.
The facility failed to maintain a clean and hazard-free environment, with observations of debris and trash under beds, cluttered hallways, and inconsistent cleaning practices. A resident reported that their room was not always cleaned thoroughly, contributing to the deficiency.
The facility failed to follow enhanced barrier precautions and hand hygiene practices. A resident on enhanced barrier precautions was assisted by CNAs without protective gowns. Another resident received care without staff sanitizing hands before providing a snack. Observations revealed empty sanitizer dispensers and staff not using them, violating the facility's hand hygiene policy.
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 Meet Resident Needs Prior to Emergency Discharge
Penalty
Summary
The facility failed to make adequate attempts to meet the needs of two residents prior to issuing emergency discharges following a series of resident-to-resident altercations. Both residents had intact cognitive status, as indicated by their BIMS scores, and required varying levels of assistance with activities of daily living. The clinical records showed a pattern of verbal disputes and threats of violence between the residents and their peers, with interventions primarily consisting of moving residents to different rooms and de-escalating situations. On the date of the final altercation, the facility obtained orders for emergency psychiatric evaluations and arranged for both residents to be transferred to local hospitals. The process of discharge was initiated while the residents were at the hospitals, with the facility citing the safety of individuals in the facility as the reason for the emergency discharges. The discharge forms included information about placement and appeal rights, but there were lapses in communication with the residents' guardians and family members. One resident's guardian was not informed about the appeals process and did not receive any forms to sign, while the other resident's family could not be reached prior to the discharge. Both residents were ultimately not admitted to the hospitals for psychiatric reasons, and the facility refused to readmit them upon the hospitals' requests. Interviews with facility staff revealed that the decision to discharge was made due to a perceived lack of available rooms to accommodate residents with behavioral issues. The staff also demonstrated a lack of awareness regarding the proper notification and involvement of guardians in the discharge process. As a result, one resident remained hospitalized while the other was taken to his apartment by family members, with concerns noted about his ability to manage medications and daily living needs.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and handling practices within the facility's kitchen. Raw hamburger was found thawing in a metal basin on an upper shelf above meal trays, and frozen chicken breasts were placed on a refrigerator shelf above containers of fruit, contrary to facility policy requiring raw meat to be stored on the bottom shelf to prevent cross-contamination. Staff interviews confirmed that staff were aware of the correct procedures but did not consistently follow them, with several staff acknowledging the improper placement of raw meat and the risk of contamination. During meal service, staff were seen using tongs to remove buns from packaging and then using their gloved hands to handle the buns and other items without changing gloves between tasks. Additionally, an ice scoop was repeatedly left in the ice container with the handle in contact with the ice, and staff continued to use the scoop without changing gloves after touching other surfaces. Staff interviews revealed knowledge of proper glove use and ice scoop handling, but these practices were not consistently implemented. The facility's policy requires measures to prevent cross-contamination, including proper storage of raw meat, adherence to hygiene and sanitary practices, and changing gloves between tasks, all of which were not followed during the observations.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Staff failed to treat three residents with dignity, as evidenced by multiple interviews, observations, and record reviews. One resident with severe cognitive impairment and a history of stroke and aphasia was repeatedly told by staff to chew and swallow his food, despite care plan instructions to avoid such directives. Staff were observed and reported to have taken away the resident's plate, rubbed his cheek in an aggressive manner, and used a mean tone when instructing him to eat. The speech therapist and physical therapist both confirmed witnessing inappropriate staff interactions, including frustration and aggressive verbal and physical cues, which made the resident feel 'disgusting.' The Director of Nursing acknowledged that telling the resident to swallow was a trigger and that staff should not touch the resident's cheek or plate. Another resident with intact cognition reported that staff on the third shift used their personal phones during work hours, making the resident feel undervalued and uncomfortable asking for help. Multiple staff interviews confirmed that personal phone use occurred during shifts, including during resident care and in hallways. The facility's cell phone policy prohibits personal phone use during working hours and in patient care areas, except for authorized business purposes, but staff and social services confirmed that the policy was not consistently followed, leading to resident dissatisfaction and irritation. A third resident, also with intact cognition and total incontinence, reported that the facility frequently ran out of appropriately sized incontinence briefs, resulting in the resident having to wear briefs that were too large or of a different type. Staff confirmed that supply shortages led to residents wearing incorrect sizes, which caused discomfort and skin issues. The staffing coordinator and Director of Nursing acknowledged the supply issues, with staff sometimes borrowing briefs from other rooms and residents being left without the correct size until new supplies arrived. The facility's policy requires staff to be trained on resident dignity and respect, but these incidents demonstrate a failure to uphold those standards.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss for a resident on two separate occasions, as required by facility policy. The resident, who had intact cognition and multiple comorbidities including CHF, diabetes, COPD, morbid obesity, gout, hypothyroidism, and hyperlipidemia, experienced a weight loss of over 10% in six months and over 5% in one month. Documentation showed that the dietitian identified and documented the significant weight loss and made recommendations, including meal enrichment and weekly weights, and noted that faxes were sent to the clinician. However, the facility was unable to provide documentation that the physician was actually notified or made aware of the weight losses, despite multiple staff interviews and record reviews. The resident's care plan and dietary notes reflected ongoing monitoring and interventions for nutritional risk, including the use of supplements and meal enrichment strategies. The resident herself was aware of her weight loss and attributed it to poor appetite following her husband's death and a recent illness. Despite these interventions and awareness by dietary staff, there was no evidence in the medical record or from staff that the physician was notified of the significant changes in the resident's condition, as required by the facility's policy on change in condition.
Failure to Update Care Plans After Significant Changes in Resident Condition
Penalty
Summary
The facility failed to update care plans in a timely manner for three residents following significant changes in their conditions. One resident experienced a significant weight loss of over 10% in six months, as documented in the weight summary, but the care plan was not updated to reflect this change. Another resident, who was at nutritional risk due to multiple medical conditions and had severely impaired cognition, also experienced a weight loss of nearly 15% over five months, yet the care plan did not reflect this significant change. Staff interviews confirmed that the care plans for both residents should have been updated to address the significant weight loss, but this was not done, partly due to a recent change in dietician staffing and unclear responsibilities for updating care plans. Additionally, a third resident's care plan continued to indicate the need for dialysis, despite the resident no longer receiving dialysis services. The resident and staff interviews confirmed that the resident had not been on dialysis for some time, and the care plan had not been revised to reflect this change. The facility's policy requires care plans to be revised when there is a significant change in a resident's condition, but this was not followed in these cases.
Failure to Implement Restorative Nursing Program for Resident with Mobility Impairment
Penalty
Summary
A deficiency occurred when the facility failed to implement a restorative nursing program as recommended by therapy for a resident with impaired lower extremity mobility. The resident, who was cognitively intact and had no upper extremity impairment but did have lower extremity impairment, reported only participating in restorative exercises once. The care plan indicated a need for restorative programming to maintain functional mobility and prevent decline, with specific interventions outlined, including the use of a seated bike, sit-to-stand activities, and lower extremity strengthening and stretching exercises. Despite these documented interventions, staff interviews revealed inconsistent implementation of the restorative program. The staff member primarily responsible for restorative care was frequently reassigned to other duties, such as providing showers, and could not explain how restorative programming was completed when working on the floor. No other staff were officially assigned to restorative programming, and coverage was sporadic. The Restorative Nurse's involvement was limited to documentation assistance, and the Director of Nursing stated that nurses were expected to fill in if the primary staff was unavailable. The facility's policy allowed for restorative nursing care upon discharge from therapy, but the recommended program was not consistently followed.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. The report notes that the facility did not maintain the expected level of quality in the services rendered, as required by regulatory standards. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident’s medical history or condition at the time of the deficiency were not provided in the report.
Medication Error Rate Exceeds Regulatory Standard
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in an observed error rate of 11.11%. This was identified through observation, interview, and record review, where three medication errors were found among twenty-seven opportunities for three residents. One resident, with intact cognition and a history of insulin use, received insulin after already consuming food, contrary to the prescribed administration of insulin before meals. Another resident, also with intact cognition and a diagnosis of anemia, was administered a 324 mg enteric-coated tablet of Ferrous Sulfate instead of the prescribed 325 mg oral tablet. A third resident, with intact cognition and a prescription for Polyethylene Glycol 1450, was given Clearlax 3350 instead of the ordered medication. The facility's policies require medications to be administered as prescribed, within specified time frames, and in accordance with prescriber orders. However, staff failed to follow these protocols, as evidenced by the administration of medications at incorrect times, incorrect dosages, and substitution of medications. These actions directly contributed to the facility's elevated medication error rate, exceeding regulatory standards.
Significant Medication Errors Due to Documentation and Communication Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving the administration of anticoagulants, insulin, and narcotic pain medications. In one case, a resident with intact cognition and a physician order for Warfarin received a double dose due to a lack of communication and documentation between nursing staff and a medication aide during a shift change. The nurse administered the medication but did not document it, leading the medication aide to administer a second dose. This resulted in the resident receiving 8 mg instead of the prescribed 4 mg of Warfarin. Another incident involved a resident with diabetes who was prescribed sliding scale insulin. The LPN checked the resident's blood sugar and administered insulin after the resident had already eaten, contrary to the physician's order to administer insulin before meals. The blood sugar was recorded at 200 mg/dL, and 2 units of insulin were given, but the timing did not align with the prescribed protocol. A third resident, also with intact cognition, was prescribed oxycodone for chronic pain. Due to a similar breakdown in communication and documentation, both an LPN and a medication aide administered a 5 mg dose of oxycodone, resulting in the resident receiving a double dose. Additionally, a resident with severe pulmonary hypertension was prescribed Apixaban following hospital discharge, but a transcription error led to the incorrect entry of the medication order. The facility failed to clarify the discharge instructions with the hospital, resulting in the resident receiving an incorrect dosing regimen. These incidents were confirmed through interviews, record reviews, and direct observation, and were not in accordance with the facility's medication administration policy.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed in a timely manner for five residents out of nineteen reviewed. Specifically, the assessments for Residents #9, #18, #26, #29, and #34 were not completed within the required timeframe. For instance, Resident #18's assessment had an Assessment Reference Date (ARD) of 4/25/24, but the completion date was 5/20/24. Similarly, Resident #26's assessment with an ARD of 8/9/24 was still in process at the time of the review. Other residents also experienced delays in the completion of their assessments, with completion dates extending beyond the 14-day requirement from the ARD. Interviews with facility staff, including the MDS Coordinator, Director of Nursing (DON), and the Administrator, confirmed the delays in completing the MDS assessments. The MDS Coordinator acknowledged the lateness of the assessments for Residents #18 and #26. Both the DON and the Administrator expressed their expectations for timely completion of the MDS assessments. Additionally, the facility's Comprehensive Assessment Policy, dated December 2023, did not address the requirements for quarterly MDS assessments.
Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure timely completion of annual Minimum Data Set (MDS) assessments for two residents, as required by their policy. Resident #18's MDS assessment, with an assessment reference date (ARD) of July 25, 2024, was still in process at the time of the survey. Resident #26's MDS assessment, with an ARD of May 9, 2024, was completed on June 3, 2024, indicating a delay. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator confirmed the assessments were late and should have been completed within 14 days of the ARD. The facility's Comprehensive Assessments Policy mandates that annual assessments be completed at least every 366 days unless a significant change or correction assessment has been conducted since the last comprehensive assessment.
Failure to Update PASRR for Resident with New Diagnoses and Medications
Penalty
Summary
The facility failed to resubmit a PASRR (Preadmission Screening and Resident Review) for a resident with new mental health diagnoses and psychotropic medications added to their plan of care. The resident, who was reviewed for PASRR, had a history of anxiety disorder, depression, and psychotic disorder, and was taking antipsychotic and antidepressant medications. Despite these changes, the PASRR Level 1 Screen Outcome indicated no Level II was required unless a significant change occurred. However, the resident's care plan and medical records showed significant changes, including new diagnoses of major depressive disorder with psychotic symptoms and delusional disorders, as well as new medication orders for Depakote, Duloxetine, and Seroquel. The MDS coordinator, during an interview, acknowledged a misunderstanding regarding what constituted a significant change, believing it only applied to hospital admissions for mental issues. The administrator later clarified that changes in medications and medical diagnoses also required a new PASRR. The facility's policy stated that new onset or changes in behavior indicating a serious mental disorder should be referred for a PASRR Level II evaluation. Despite this policy, the necessary PASRR update for the resident was not completed, leading to the deficiency.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to Resident #8, who was eligible for the PCV 20 vaccine. The resident had previously received the Prevnar 13 vaccination in 2019 and was noted to be eligible for the PCV 20 as of February 13, 2024. The resident's immunization record was reviewed by the ARNP, and verbal consent for the vaccine was obtained from the resident's daughter, with education provided on the risks and benefits. However, the vaccine was not administered. Interviews with facility staff revealed a lack of clarity and communication regarding responsibility for administering the vaccine. The DON stated that he relied on the Infection Preventionist to manage vaccinations, but the ADON/IP was unaware of the need to offer the vaccine to Resident #8. The DON acknowledged the oversight and expressed an expectation for follow-through, but there was a disconnect in the process, resulting in the resident not receiving the vaccine. The facility's policy indicated that pneumococcal vaccines should be administered per CDC recommendations, but this was not followed in this instance.
Failure to Maintain Clean and Hazard-Free Environment
Penalty
Summary
The facility failed to maintain a clean and hazard-free environment for its residents, as evidenced by multiple observations of unclean conditions in resident rooms and cluttered hallways. On several occasions, debris such as rubber gloves and trash were found under the bed in a resident's room and remained there for multiple days despite housekeeping services being performed. Additionally, a gown and deodorant container were observed on the floor in another room, with the deodorant container remaining even after partial cleaning. Hallways were also noted to be cluttered with mechanical lifts, standing devices, and wheelchairs, posing potential hazards. Interviews with staff and residents further highlighted the deficiency in maintaining cleanliness. The Housekeeping and Laundry Supervisor stated that resident rooms are supposed to be cleaned daily, including sweeping, mopping, and sanitizing, with deep cleaning scheduled for one room per hall each day. However, a resident reported that their room was not consistently cleaned, with housekeeping often neglecting areas under or behind furniture. This inconsistency in cleaning practices contributed to the observed deficiencies in maintaining a safe and clean environment.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions and consistent hand hygiene practices, as observed during a survey. Resident #6, who has intact cognition and requires moderate assistance with daily activities, was on enhanced barrier precautions due to a catheter. However, during personal care, two CNAs, Staff E and Staff F, did not wear protective gowns as required. Both staff members acknowledged the oversight during interviews, with one stating she forgot to wear a gown. Additionally, Resident #5, who is severely cognitively impaired and dependent on staff for assistance, was observed receiving care without proper hand hygiene practices being followed. Staff G and Staff H assisted with transfers and incontinence care but did not sanitize hands before providing a snack to the resident. Furthermore, sanitizer dispensers were found empty, and staff were not observed using them. Other staff members, including a registered nurse and a CNA, were also seen assisting multiple residents without sanitizing their hands between contacts, contrary to the facility's hand hygiene policy.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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