Caring Acres Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anita, Iowa.
- Location
- 1000 Hillcrest Drive, Anita, Iowa 50020
- CMS Provider Number
- 165217
- Inspections on file
- 27
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Caring Acres Nursing And Rehab Center during CMS and state inspections, most recent first.
The facility was repeatedly cited for deficiencies related to its QAPI program, including failures to report and investigate incidents, as documented in multiple complaint investigations. Despite having a QAPI/QAA plan in place, the same types of deficiencies recurred over an extended period, indicating that the facility's processes for identifying and correcting quality issues were not effective.
A resident with significant physical impairments and no cognitive deficits was allegedly handled roughly by a CNA during repositioning, leading to a delay in reporting the incident by another CNA who witnessed the event. The concern was not reported to management or the state agency within the required two-hour timeframe, as mandated by facility policy.
A resident with no cognitive impairment reported missing money from her room. The facility's investigation was incomplete, lacking staff and resident interviews, and the investigative file could not be located. Required documentation and witness statements were not obtained as outlined in facility policy.
Two residents experienced significant changes in condition—one with acute illness and another following a fall with pain—yet staff failed to provide timely assessment, notify providers, administer PRN medications, or follow facility protocols for transfer and pain management. These deficiencies resulted in delayed interventions and inadequate care, as confirmed by staff interviews and record reviews.
Three residents experienced a lack of dignity and respect, including a resident with dementia repeatedly denied bathroom assistance and spoken to harshly, a cognitively intact resident subjected to discriminatory language and neglect by a CNA, and another resident left exposed in a common area until staff intervened. Facility leadership acknowledged these actions did not meet expectations for resident care.
A resident with cognitive impairment and behavioral health needs was subjected to verbal abuse by an LPN following a fall, with the LPN making belittling and derogatory remarks about the resident's actions and appearance. Staff interviews confirmed a pattern of inappropriate and abrasive communication by the LPN toward multiple residents, in violation of the facility's abuse prevention policy.
A resident with cognitive impairment and behavioral health diagnoses was subjected to belittling and derogatory comments by an LPN after a fall, with the incident not being reported to management within the required timeframe. Staff interviews revealed uncertainty about the abuse reporting process, and additional concerns were raised about another CNA's conduct, with staff failing to consistently report resident complaints as required by policy.
A resident with multiple chronic conditions did not have proper documentation for the administration of a PRN medication for constipation, and staff failed to follow up on its effectiveness. Nursing staff were unable to confirm when the medication was given or if it was effective, and the required documentation was missing from the MAR, contrary to facility policy.
A resident with mild cognitive impairment and multiple comorbidities was found on the floor after a fall and complained of hip pain. Despite her inability to move her leg without pain, a CNA and an LPN manually lifted her back to bed instead of using a mechanical lift as required by facility policy. The DON confirmed that the proper transfer procedure was not followed.
The facility inaccurately submitted the 4th quarter 2024 PBJ report, showing low weekend staffing and insufficient RN coverage due to missing agency staff hours. The new Administrator, in place since January, noted the absence of a policy for PBJ submissions, contributing to the deficiency.
The facility's QAPI policy lacked essential descriptions for identifying and analyzing adverse events, obtaining resident feedback, and monitoring performance improvements. The Interim Administrator acknowledged these deficiencies, noting incomplete QAPI activities.
The facility did not maintain records of QAA meetings for three out of four quarters, only documenting meetings in April and June of the same quarter. Despite a policy requiring quarterly meetings, the Interim Administrator confirmed the lack of documentation for the remaining quarters. The facility's QAPI policy indicated that meetings should occur monthly or quarterly.
The facility failed to maintain proper infection control and hygiene practices. Staff did not adhere to hand hygiene protocols after assisting residents with toileting, and laundry was not delivered covered. These deficiencies were acknowledged by the facility's administration.
The facility failed to follow physicians' orders for four residents, resulting in missed wound treatments and medication errors. A resident with pressure ulcers did not receive prescribed treatments due to supply shortages, and another resident received an incorrect dosage of simethicone. Additionally, a resident was left unsupervised with medication, and another was nearly given the wrong medication. The facility lacked a policy for medication administration, contributing to these deficiencies.
The facility failed to ensure the safety of residents by not conducting daily checks on Wander Guard alarms for two residents at risk of elopement and not following proper transfer techniques for two other residents. Staff were not adequately trained in using safety devices, and the facility lacked a policy on Wander Guard checks. These deficiencies put residents at risk of harm.
The facility failed to ensure competent care by relying on inadequately oriented Agency Staff (AS). A significant portion of the nursing staff were AS, and one LPN admitted to not knowing how to check wander guards due to lack of orientation. The facility had recently created an orientation checklist, but there was no evidence of its completion by AS. Residents were upset by late medication administration when only AS were on duty, and AS often sought help from non-nursing staff to find supplies.
The facility failed to employ a staff member with specialized training in infection prevention and control, as required by their job description manual. The ADON claimed to be certified but could not provide documentation, and the Interim Administrator confirmed the absence of certification records. Despite requests, the facility could not produce any certifications for infection prevention and control.
The facility failed to ensure documentation and administration of pneumococcal immunizations for four residents, as their EHRs lacked records of consent, declination, or receipt of the vaccine. Despite the facility's expectation to offer immunizations per federal regulations, interviews revealed that these residents were neither offered nor documented to have received the immunizations.
The facility failed to document COVID-19 vaccination offers and statuses for four residents, including those with moderate cognitive impairment. Despite the facility's policy and federal regulations, there was no record of consent or declination for the COVID-19 vaccine in their EHRs. The oversight was acknowledged by the Regional Nurse Consultant and Interim Administrator.
The facility failed to ensure that all CNAs completed the required 12 hours of continuing education annually. A review of personnel files revealed that two CNAs did not have documentation of the necessary training hours. The Administrator acknowledged the lack of a policy on CNA annual training requirements, despite having an in-service schedule and an Annual In-Service Calendar indicating a plan for monthly education.
The facility failed to provide a homelike environment by not ensuring warm water in resident rooms. Multiple residents reported the issue, and observations confirmed the water remained cool. The maintenance supervisor had not conducted recent temperature checks, and a plumber found that the recirculators were not working properly.
The facility failed to conduct a background check before hiring a DON who was listed on the Child Abuse Registry. Despite the facility's policy against employing individuals with abuse findings, there was no follow-up inquiry into the registry listing. Staff interviews revealed a lack of communication and responsibility in the hiring process, with the current Administrator mistakenly believing the background check was clean.
The facility failed to complete the PASARR process for two residents, leading to deficiencies in their care plans. One resident's antipsychotic medication was not documented in the MDS, and a new PASARR was not completed after updated psychiatric diagnoses. Another resident's care plan did not incorporate PASARR Level II recommendations for Schizophrenia, and the facility lacked a PASARR policy.
A facility failed to identify target behaviors for psychotropic medication use for a resident with bipolar disorder. The resident was prescribed Caplyta and Trazadone for depression, but the Caplyta was intended for bipolar disorder. The physician orders lacked target behaviors, and the facility did not have a policy for identifying them. The ADON and Interim Administrator acknowledged the discrepancies in medication orders and diagnoses.
The facility failed to submit information about four residents who are veterans to the Iowa Department of Veterans Affairs. The facility did not ensure these residents completed the Veteran's Questionnaire, which is necessary for determining eligibility for veteran benefits. The Interim Administrator acknowledged the oversight, and the facility lacked a policy for inquiring about veterans' benefits.
The facility failed to provide dignified care to three residents by not offering timely assistance with toileting and maintaining privacy. A resident waited over 45 minutes for toileting assistance, another soiled herself due to delayed response to call lights, and a third was publicly told she needed to change her wet pants. The facility's policy on abuse prevention was violated, as acknowledged by the Administrator.
The facility failed to provide adequate nurse staffing, resulting in delayed care for residents. A resident reported long waits for call light responses, impacting their rehabilitation and daily care. Another resident, at risk for skin breakdown, experienced delays in incontinence care. An LPN worked excessively long hours due to staffing shortages. The facility's staffing plan was deemed unrealistic, and there was no policy on call light response times.
The facility did not ensure RN coverage for 8 consecutive hours daily, with four days lacking RN presence. The DON acknowledged the issue, and the Nurse Scheduler cited challenges in staffing due to reliance on agency nurses. No policy on RN coverage was in place, despite the facility assessment's requirements.
A resident admitted for rehabilitation did not have a documented care plan, despite a care conference discussing his needs. The resident, who was cognitively intact, was dissatisfied with the lack of planning, inadequate equipment, and delayed physical therapy, which affected his rehabilitation progress. The DON acknowledged the absence of a care plan and noted the facility's lack of a specific care planning policy.
A resident admitted with a knee injury and requiring therapy services was accepted by the facility without considering his bariatric equipment needs. The staff was unaware of the necessary equipment, resulting in the resident being mostly bed-ridden for over two weeks until the equipment arrived. This delay hindered his rehabilitation progress and required his family to purchase a suitable walker.
A resident in a LTC facility reported feeling unsafe and fearful due to alleged rough care and inappropriate language by a CNA. The resident, with a BIMS score of 15 and a history of cerebral palsy, anxiety, and PTSD, expressed discomfort and soreness after care. Despite reports of verbal abuse, the CNA continued working, though not with the resident. The facility's inadequate response to the resident's concerns led to a deficiency finding.
A resident with cerebral palsy and other medical conditions reported verbal abuse by a staff member, which was not promptly reported to the State Agency by the facility. The incident involved inappropriate language and behavior by the staff, leading to the resident feeling unsafe. The Assistant Director of Nursing, related to the accused staff, failed to escalate the matter, resulting in a delay in reporting and an Immediate Jeopardy situation identified by the State Agency.
A resident in an LTC facility experienced psychosocial harm due to an altercation with a CNA, Staff A, who allegedly made inappropriate comments. Despite the resident's grievances and visible distress, Staff A returned to work after completing abuse education, although not allowed to care for the resident directly. The resident continued to feel unsafe and expressed concerns about potential retaliation, highlighting a deficiency in the facility's handling of the incident.
The facility failed to follow physician orders and administer medications correctly for two residents. A resident with severe cognitive impairment did not receive Lidocaine cream as ordered before a wound dressing change, and there was no documented order for physician notification regarding weight gain. Another resident did not receive potassium chloride due to a transcription error upon admission, which was only discovered during a monthly medication review. The DON acknowledged these errors, highlighting lapses in medication administration and order transcription processes.
The facility experienced significant service disruptions due to non-payment to local vendors, including waste removal and transportation services. Staff reported overflowing garbage and missed medical appointments for residents. The administration was aware of the outstanding balances and communicated with the corporate office, but delays in payment persisted, affecting the facility's operations.
The facility failed to notify the Long-Term Care Ombudsman of hospital transfers for two residents. The required notifications were not made, and interviews with staff revealed that the responsibility for these notifications had recently changed hands. The facility's policy mandates that transfer and discharge notices must be sent to the Ombudsman, but this was not adhered to.
The facility failed to obtain bed hold notifications for two residents during their hospital transfers. The EHR confirmed the hospitalizations, but no bed hold forms were found. Interviews with staff revealed that the expectation was to obtain bed hold notifications every time a resident is transferred out of the facility, as stated in the facility's Bed Hold Policy.
The facility failed to review and revise the care plan for a resident receiving anticoagulant therapy for a history of an acute embolism and thrombosis. Despite routine administration of the medication, the care plan did not include directives for the therapy. The DON confirmed that the care plan should be updated within one week after a status change, as per policy.
Repeated QAPI Program Deficiencies and Failure to Report/Investigate
Penalty
Summary
The facility failed to ensure the implementation of a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies identified during multiple complaint investigations. Specifically, the facility was cited for failures to report and investigate incidents, with deficiencies noted on several occasions, including failures to report (Tag 609) and failure to investigate (Tag 610). These repeated deficiencies were documented over a period spanning from August 2023 to June 2025, indicating ongoing issues with the facility's processes for identifying and correcting quality problems. A review of the facility's QAPI/QAA plan revealed that, while a policy document existed with a stated purpose of continuous quality improvement and staff participation, the actual practices did not prevent the recurrence of the same deficiencies. Staff interviews and policy reviews confirmed that the facility's approach was not effective in addressing or preventing the cited issues, as the same types of deficiencies continued to be identified during subsequent complaint investigations.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident who had no cognitive impairment and was dependent on staff for mobility and hygiene due to multiple medical conditions, including cerebral palsy and neurogenic bladder. On the evening of the incident, a CNA witnessed another CNA repositioning the resident in a manner perceived as rough and too quick, which caused the resident to verbally express discomfort and ask the staff member to stop. The witnessing CNA did not immediately report the incident, instead waiting until the following day to notify the provisional administrator, believing she had up to two days to report the concern. Facility policy required that all allegations of abuse, neglect, or mistreatment be reported to the state agency within two hours of the allegation being made. Interviews with staff and review of the investigative file confirmed that the concern was not reported within the required timeframe. The Director of Nursing and the administrator both acknowledged that the reporting should have occurred as soon as possible or within two hours, in accordance with policy and regulatory requirements.
Failure to Complete Thorough Investigation of Missing Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation after a resident reported that $90 was missing from her room. The resident, who had no cognitive impairment and multiple medical diagnoses including cerebral palsy, anxiety, and PTSD, kept her money in a specific location in her dresser. Upon discovering the money was missing, she notified staff and the facility replaced the funds. However, the facility's 5-day investigation only included the resident's statement, a timeline of the incident, and a plan of action, but did not include interviews with staff or other residents. Further review revealed that the Director of Nursing was not present at the time of the incident and deferred to another staff member who completed the investigation, but the investigative file could not be located by the Administrator. The only documentation submitted to the State Agency included the resident's care plan, facesheet, and a 5-day summary. The facility's policy requires obtaining witness statements and thorough documentation, but these steps were not completed or could not be verified due to missing records.
Failure to Assess and Intervene After Change in Condition and Fall
Penalty
Summary
The facility failed to provide proper assessments and interventions following changes in condition for two residents. One resident, with a history of Parkinson's Disease, coronary artery disease, and diabetes mellitus, experienced a significant change in condition, including fever, altered mental status, and abnormal vital signs. Despite staff reporting concerns about the resident's condition, including changes in bowel movements, decreased appetite, confusion, and fever, the nurse on duty did not assess the resident or notify the physician in a timely manner. The only intervention provided was a cold rag for the fever, and no PRN medication was administered. The physician was not notified until the resident's condition deteriorated significantly, at which point the resident was sent to the hospital and subsequently expired from sepsis due to aspiration pneumonia. Another resident, with dementia and multiple psychiatric and medical diagnoses, suffered an unwitnessed fall and complained of left hip pain. Staff failed to call the provider for a PRN pain order or for evaluation after the fall. The resident was not sent to the hospital until approximately 12 hours later, where a left hip fracture was diagnosed. Documentation and staff statements revealed that the resident was moved from the floor to the bed without the use of a mechanical lift, contrary to facility protocol, and that pain complaints were not adequately addressed or managed. The resident did not have a PRN pain medication order until after returning from the hospital. Facility policy required prompt assessment, notification of changes in condition, and appropriate interventions, including contacting the medical provider and documenting all significant changes. In both cases, staff failed to follow these protocols, resulting in delayed assessment, lack of timely intervention, and inadequate communication with medical providers and the DON. These failures were corroborated by staff interviews, clinical record reviews, and facility documentation.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect, as evidenced by multiple incidents involving three residents. One resident with severe cognitive impairment and a history of dementia, anxiety, depression, bipolar disorder, and PTSD was repeatedly denied timely assistance to use the bathroom. Staff instructed the resident to sit down and dismissed her requests, leading to increased anxiety and agitation. Observations showed staff raising their voice and refusing to assist, despite the resident's clear indications of need and distress. Another resident, who was cognitively intact and dependent on staff for all mobility and self-care, reported that a staff member used discriminatory language and was rude, refusing to assist both the resident and other staff members. The resident stated that these actions made her feel bad and that she had reported the concerns to previous facility leadership. A third resident with severe cognitive impairment and dementia was observed sitting in a common area with her shirt pulled up, exposing her breast, while other residents and staff passed by without addressing the situation. The exposure was only corrected after several minutes when a staff member entered the room and assisted the resident. Facility leadership acknowledged that staff are expected to be aware of their surroundings and ensure residents' needs are met, but this expectation was not met in these instances.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with mild cognitive impairment and multiple behavioral and mental health diagnoses was subjected to verbal abuse by a staff member. The resident, who required supervision for mobility and had a history of confusion and dementia, was found on the floor by a CNA after attempting to get a drink of water. During the incident, the LPN on duty made belittling and derogatory comments to the resident, including remarks about the resident's fall, her use of the call light, and her body size. The LPN also made statements that were described as cold, abrasive, and nonchalant, which were witnessed and reported by other staff members present during the incident. Staff interviews and statements corroborated that the LPN's interactions with residents were often rude, unapproachable, and inappropriate, particularly with residents who exhibited behavioral issues or dementia. The LPN was reported to have made dismissive and agitating comments to another resident regarding her pets and family, further demonstrating a pattern of verbal mistreatment. The facility's internal investigation substantiated the verbal abuse allegations, and the LPN's employment was subsequently terminated. The facility's policy clearly prohibits all forms of abuse, including verbal abuse, and defines it as the use of disparaging or derogatory language toward residents. Despite this policy, the LPN's conduct toward the resident after her fall, as well as toward other residents, constituted verbal abuse as defined by the facility. The resident involved was unable to participate in an interview due to cognitive limitations, but multiple staff accounts provided consistent evidence of the inappropriate and abusive language used by the LPN.
Failure to Timely Report Alleged Verbal Abuse and Mistreatment
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse by a staff member toward a resident to the appropriate management staff, as required by facility policy and regulatory requirements. The incident involved a resident with mild cognitive impairment and multiple behavioral and mental health diagnoses, who was found on the floor by a CNA. The LPN on duty responded and made belittling and derogatory comments to the resident during the assessment and transfer back to bed. The CNA present reported that the LPN's tone was inappropriate and that the comments included disparaging remarks about the resident's fall, physical appearance, and decision-making. The CNA did not immediately report the incident, stating he was unsure of the reporting process at the time and waited until the next day to notify management. The facility's policy required that any employee or agent who becomes aware of abuse or neglect immediately report the matter to the Administrator or their designee, and that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to the Administrator and the mandated state agency within two hours. However, the report of the incident was delayed, and the required notification to management and authorities was not made within the specified timeframe. Staff interviews confirmed that there was a lack of clarity among some staff regarding the reporting protocol, and that education on the abuse protocol and reporting timeframes was subsequently provided. Additionally, there were reports from another resident regarding a different staff member, an agency CNA, who was alleged to have used discriminatory language and refused to assist with care. Multiple staff members acknowledged hearing complaints from the resident about this CNA, but did not recall reporting these concerns to administration, often attributing the complaints to the resident's general dissatisfaction. The DON and Administrator both stated that all suspected abuse should be reported for investigation, regardless of the resident's history of complaints.
Failure to Document PRN Medication Administration and Effectiveness
Penalty
Summary
Staff failed to properly document the administration of a PRN medication and did not follow up to assess its effectiveness for a resident with Parkinson's Disease, coronary artery disease, and diabetes mellitus. The resident, who was frequently incontinent and required moderate assistance with activities of daily living, had an active order for milk of magnesia as needed for constipation. Review of the Medication Administration Record (MAR) showed that the medication was not signed out as given during the period it was ordered. Staff interviews revealed uncertainty about when the medication was administered and whether its effectiveness was evaluated, with the nurse responsible unable to recall the specific day or if documentation was completed. Further interviews with CNAs indicated that the resident did not have a bowel movement as expected and exhibited changes in condition, which were reported to the nurse. The facility's bowel policy required nurses to assess residents who had not had a bowel movement, document findings, and follow up on PRN medication effectiveness, but these steps were not followed. The Director of Nursing confirmed that nurses are expected to document administration and effectiveness of PRN medications, but this was not done in this case.
Failure to Use Mechanical Lift During Post-Fall Transfer
Penalty
Summary
Staff failed to properly transfer a resident following a fall in her room. The resident, who had mild cognitive impairment and multiple diagnoses including dementia and PTSD, was found on the floor by a CNA after attempting to reach for water and falling out of bed. The resident complained of significant hip pain and was unable to straighten her leg without pain. Despite these complaints, the CNA and an LPN lifted the resident from the floor back to her bed by placing their arms under her arms, rather than using a mechanical lift as required by facility policy and as later confirmed by the Director of Nursing. Staff statements and interviews confirmed that the resident expressed pain during the transfer and was unable to move her leg, yet the mechanical lift was not used. The facility's policy instructed staff to assess the resident and safely transfer them using appropriate equipment after a fall, but this was not followed. The incident was documented in progress notes and staff statements, and the Director of Nursing acknowledged that the correct procedure was not used in this situation.
Inaccurate PBJ Report Submission Due to Missing Agency Staff Hours
Penalty
Summary
The facility failed to accurately submit the required Payroll Based Journal (PBJ) quarterly report, which is essential for maintaining compliance with staffing regulations. The report for the 4th quarter of 2024 indicated issues such as low weekend staffing, insufficient Registered Nurse (RN) coverage for 8 consecutive hours per day, and concerns regarding 24-hour Licensed Nurses coverage. Additionally, the facility had a 1-star staffing rating. Upon investigation, it was revealed that the previous administration did not include agency staff hours in the PBJ report, leading to the inaccurate submission. The current Administrator, who assumed the role in January, acknowledged the oversight and mentioned the absence of a policy for submitting quarterly PBJ reports, which contributed to the deficiency.
Deficient QAPI Policy Implementation
Penalty
Summary
The facility failed to properly establish and implement written policies and procedures for its Quality Assurance and Performance Improvement (QAPI) plan. The facility's QAPI policy, updated in January, lacked essential descriptions on how to identify, report, track, investigate, and analyze adverse events or problem-prone concerns. Additionally, the policy did not include how feedback from resident representatives would be obtained and used to identify high-risk or problem-prone issues. Furthermore, the policy was missing a description of how the facility monitored the effectiveness of its performance improvement activities to ensure sustained improvements. The Interim Administrator acknowledged these deficiencies, noting that QAPI activities had only been completed for two months in the previous year.
Failure to Maintain QAA Meeting Records
Penalty
Summary
The facility failed to maintain records of Quality Assessment and Assurance (QAA) meetings for three out of four quarters reviewed. The facility, which reported a census of 25 residents, only provided documentation for QAA meetings held in April and June of the same quarter. No further documentation was available for the subsequent three quarters. The Interim Administrator acknowledged that the QAA committee had only met during the months of April and June, despite the facility's policy and expectation that the committee would meet at least quarterly. The facility's Quality Assessment and Performance Improvement (QAPI) policy, updated in January, indicated that the QAPI program should consist of monthly or quarterly meetings.
Inadequate Infection Control and Hygiene Practices
Penalty
Summary
The facility failed to implement adequate infection control measures, as evidenced by multiple instances of staff not adhering to proper hand hygiene protocols. Staff members were observed assisting residents with toileting without changing gloves or washing hands afterward. For instance, two CNAs assisted a resident with severe cognitive impairment in the bathroom, failed to change gloves after checking her brief, and did not wash their hands before leaving the bathroom. Similarly, another resident, who was cognitively intact but dependent on staff for hygiene, was assisted with toileting by staff who did not wash their hands after removing gloves and handling trash. Additionally, the facility's laundry procedures were found to be inadequate. The Laundry Supervisor admitted that laundry was not being delivered covered, as the delivery cart was repurposed for other uses. The Interim Administrator acknowledged the expectation for laundry to be covered during delivery, but there was no policy or procedure in place to ensure this practice. These lapses in infection control and hygiene practices were acknowledged by the facility's administration.
Deficiencies in Treatment and Medication Administration
Penalty
Summary
The facility failed to ensure that staff followed physicians' orders for four residents, leading to deficiencies in care. Resident #18, who was cognitively intact and had a history of paraplegia and pressure ulcers, did not receive the prescribed wound treatments on multiple occasions. The Treatment Administration Record (TAR) showed that treatments were missed without explanation on several days in December and January. Staff P, an LPN, reported that the facility often lacked the necessary supplies to complete the treatments, and there was no documentation of refusals or physician notifications as required by the facility's policy. Resident #14, who had severe cognitive impairment, was given an incorrect dosage of simethicone due to the unavailability of a half tablet. Staff J, an LPN, administered only one tablet instead of the prescribed 1.5 tablets, and the ADON acknowledged the error, stating that the medication should not have been split and that the physician should have been notified for a new order. This incident highlights a failure in medication administration and communication with the pharmacy and physician. Resident #20, who had no cognitive impairment, was left unsupervised with her medication, which she mistook for another drug. The Interim DON confirmed that the nurse should have observed the resident taking the medication. Additionally, Staff J attempted to give Resident #26 the wrong medication, which the resident refused, recognizing the error. The facility lacked a policy for medication administration, and the Interim Administrator and Regional Nurse Consultant acknowledged the need for adherence to the Rights of Medication Administration.
Failure to Ensure Safety and Proper Use of Devices
Penalty
Summary
The facility failed to implement necessary interventions to prevent accidents and hazards for four residents. Two residents identified as elopement risks were equipped with Wander Guard alarm bracelets, but staff did not ensure the alarms were functioning by conducting daily checks. The Maintenance Director only checked the Wander Guard functioning once a week, and the Assistant Director of Nursing assumed nurses were checking the devices, although they were not. Staff J, an LPN, admitted to never checking the Wander Guards and not knowing how to operate the device. The facility lacked a policy on Wander Guard checks, and the device used to check the Wander Guards was not readily available. Additionally, the facility failed to provide safe transfer techniques for two residents. One resident, with severe cognitive impairment and dependent on staff for mobility, was lifted unsafely by two CNAs who did not use a gait belt as expected. Another resident, who was cognitively intact but at high risk for falls, was transferred using an EZ Stand lift without properly securing the safety strap. The staff did not tighten the sling belt as required by the manufacturer's instructions, and the Administrator was unsure of the proper procedure. These deficiencies highlight a lack of adherence to safety protocols and inadequate staff training in the use of safety devices and transfer techniques. The facility's failure to ensure the proper functioning of elopement prevention devices and to follow safe lifting procedures put residents at risk of harm.
Inadequate Orientation and Training of Agency Staff
Penalty
Summary
The facility failed to ensure that competent and trained staff were providing resident care, as evidenced by the reliance on contracted Agency Staff (AS) who were not adequately oriented or trained. The nursing schedule revealed that 5 out of 7 nurses were AS, and one LPN admitted to not knowing how to check wander guards and not completing an orientation checklist. The facility had recently established an orientation checklist and a binder with resources, but there was no evidence of AS completing this checklist. Additionally, it was observed that residents were upset due to late medication administration when only AS were working, and AS frequently asked non-nursing staff for assistance in locating supplies.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to employ a staff member with specialized training in infection prevention and control, as required by their job description manual for the Infection Prevention (IP) Nurse position. The manual specifies that the IP Nurse must have current, specialized training and certification in Infection Control from an approved course. During the survey, the Assistant Director of Nursing (ADON) claimed to be certified in infection prevention but could not provide documentation to verify this. The Interim Administrator also confirmed that the facility did not have a copy of the IP nurse's certification and acknowledged the expectation that the IP nurse should have the appropriate certification. Despite requests for documentation, the facility was unable to produce any certifications or qualifications for any employee in infection prevention and control.
Failure to Document and Administer Pneumococcal Immunizations
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure that residents' medical records included documentation of pneumococcal immunizations. This deficiency was identified for four out of five residents reviewed, specifically Residents #6, #13, #17, and #20. The review of the Electronic Health Records (EHR) for these residents revealed a lack of documentation regarding consent or declination for the pneumococcal immunization, as well as no evidence that the residents had ever received the immunization. The Minimum Data Set (MDS) assessments indicated that Residents #6, #13, and #20 had no cognitive impairment, while Resident #17 had moderate cognitive impairment. During interviews, Staff M, a Regional Nurse Consultant, acknowledged that these residents did not receive or were not offered pneumococcal immunizations at the facility. The Interim Administrator confirmed that the facility's expectation was for pneumococcal immunizations to be offered to residents per federal regulations, or for there to be documentation indicating that the residents had received the immunizations in the past. The facility reported a census of 25 residents at the time of the survey.
Failure to Document COVID-19 Vaccination Offers and Statuses
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure proper documentation of COVID-19 vaccination offers and statuses for residents. Specifically, the medical records of four residents, identified as Resident #3, #6, #13, and #17, lacked documentation indicating whether they were offered the COVID-19 vaccine and whether they consented to or declined the immunization. This deficiency was identified through a review of the Electronic Health Records (EHR), policy review, and staff interviews. The facility had a total census of 25 residents at the time of the survey. Resident #3 and Resident #17 were noted to have moderate cognitive impairment, with Brief Interview of Mental Status (BIMS) scores of 9 and 10, respectively. Resident #6 and Resident #13 had no cognitive impairment, with BIMS scores of 15 and 13. Despite these cognitive assessments, there was no documentation in their EHRs regarding their consent or declination of the COVID-19 vaccine. The Regional Nurse Consultant and the Interim Administrator acknowledged the oversight, confirming that these residents did not receive COVID-19 vaccinations in 2024, contrary to the facility's policy and federal regulations that require offering and documenting COVID-19 immunizations for residents.
Deficiency in CNA Continuing Education Requirements
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs) completed the required 12 hours of continuing education annually, as evidenced by a review of personnel files and staff interviews. Specifically, two out of five CNA files reviewed lacked documentation of the required training hours. Staff E, hired on January 2, 2023, and Staff A, hired on December 27, 2023, did not have evidence of completing the necessary training. The facility's Administrator acknowledged the absence of a policy on CNA annual training requirements and mentioned that an in-service schedule had been established, with each session lasting an hour. However, the facility's Annual In-Service Calendar indicated a plan for monthly education to meet the 12-hour annual training requirement for direct care staff.
Facility Fails to Provide Warm Water in Resident Rooms
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for its residents by not ensuring the availability of warm water in residents' rooms. Multiple residents, including those with no cognitive impairment, reported that the water in their sinks was not hot enough for washing hands. Observations confirmed that the water remained cool to the touch even after being run for several minutes. The facility's maintenance supervisor admitted to not having conducted temperature checks recently due to a broken thermometer and acknowledged the issue with water temperatures in various halls. Further investigation revealed that the water temperatures in some rooms were significantly below the expected levels, with temperatures taking a long time to reach even 90 degrees. The interim administrator was unaware of any complaints but later acknowledged the water temperature concerns. A plumber's assessment indicated that the recirculators responsible for pushing hot water were not functioning properly, suggesting a longstanding issue with the facility's water heating system.
Failure to Conduct Background Check Before Hiring DON
Penalty
Summary
The facility failed to ensure that background checks were completed before hiring staff, as evidenced by the hiring of Staff G, the Director of Nursing (DON), who was listed on the Child Abuse Registry for having abused a child. The facility's policy, dated December 2024, clearly stated that they would not knowingly employ individuals found guilty of abuse, neglect, or mistreatment, and that all employees would undergo a criminal background check. However, the personnel record review revealed that there was no documentation of any follow-up inquiry into the details of why Staff G was listed on the Registry. Interviews with staff revealed a lack of communication and responsibility regarding the hiring process. Staff M, a Nurse Consultant, acknowledged that she interviewed Staff G and may have issued the offer letter but did not conduct the background check, stating it was the responsibility of the Administrator. The current Administrator reported that she contacted her superior about the abuse check results, who then reached out to the previous Administrator, who mistakenly believed the check was clean. An email to the Central Abuse Registry confirmed that no further requests were made regarding this background check, indicating a failure in the facility's hiring process and adherence to their own policies.
Failure to Complete PASARR Process and Update Care Plans
Penalty
Summary
The facility failed to complete the Pre-Admission Screening and Resident Review (PASARR) process for two residents, leading to deficiencies in their care plans. Resident #15, who had a diagnosis of Bipolar Disorder and was prescribed Caplyta, an antipsychotic medication, did not have this medication reflected in their Minimum Data Set (MDS) as required. The Assistant Director of Nursing acknowledged that the medication should have been documented as an antipsychotic on the MDS. Additionally, the Interim Administrator admitted that a new PASARR should have been completed when the resident's psychiatric diagnoses were updated, but this was not done. For Resident #21, the facility failed to incorporate the recommendations from the PASARR Level II Outcome into the resident's care plan. Despite having a diagnosis of Schizophrenia and requiring specialized services, the care plan did not reflect these needs. The Interim Administrator stated that a new PASARR was not completed because the resident was transferred from a sister facility, and she was unaware of the required supports. The facility also lacked a policy related to PASARR, contributing to the oversight.
Failure to Identify Target Behaviors for Psychotropic Medication
Penalty
Summary
The facility failed to identify target behaviors for the use of psychotropic medications for a resident with a diagnosis of bipolar disorder, alcohol-induced acute pancreatitis, and adjustment disorder with anxiety. The resident, who had intact cognition, was prescribed Caplyta and Trazadone for depression, although the Caplyta was intended for bipolar disorder. The physician orders did not specify target behaviors for these medications, and the facility did not correctly identify the purpose of the Caplyta prescription. The Assistant Director of Nursing acknowledged the error in the medication order and the lack of identified target behaviors. The Interim Administrator also recognized that medication orders should align with diagnoses and was unaware of the requirement to identify target behaviors with prescribed medications. The facility did not have a policy in place regarding the identification of target behaviors for psychotropic medication orders.
Failure to Submit Veteran Information
Penalty
Summary
The facility failed to comply with the requirement to submit information about residents who are veterans to the Iowa Department of Veterans Affairs. Specifically, the facility did not ensure that four residents, who were either admitted or discharged during the review period, completed the Veteran's Questionnaire. This questionnaire is necessary to determine eligibility for veteran benefits. The facility's oversight was identified through a review of admissions records and interviews with staff, revealing that the questionnaire was not part of the admission process for these residents. The Interim Administrator acknowledged the failure to ask residents about their veteran status upon admission, which is a requirement for facilities receiving reimbursement through the medical assistance program under Iowa Code chapter 249A. The facility also lacked a policy related to inquiring about veterans' benefits, contributing to the oversight. This deficiency affected four residents, two of whom remained in the facility, while one was discharged, and another's veteran status was not reported despite being identified as a veteran.
Failure to Provide Dignified Care and Timely Assistance
Penalty
Summary
The facility failed to uphold the dignity of three residents by not providing timely assistance with toileting and maintaining privacy. Resident #2, who had normal cognitive functioning and required total assistance for toileting, was observed waiting over 45 minutes to use the bathroom. Despite being seated in her power wheelchair outside the bathroom, staff did not promptly assist her, leading to her having to wait for extended periods, sometimes up to two hours. The Assistant Administrator of Nursing acknowledged that residents should not wait longer than 15 minutes for toileting needs, yet Resident #2 experienced significant delays. Resident #1, who was cognitively intact but dependent on staff for hygiene and toileting, reported that it often took a long time for staff to respond to her call light, resulting in her soiling herself and feeling embarrassed. The Administrator acknowledged the delay in assistance, noting that it required two staff members to help Resident #1 with toileting, which contributed to the prolonged wait times. Resident #10, who had severe cognitive impairment and required assistance with toileting, was publicly told by a CNA in the dining room that she needed to change her wet pants. This announcement was made in front of other residents, compromising her dignity. The Administrator recognized that this was not a dignified way to address the resident's needs. The facility's policy on abuse prevention defines verbal abuse as using disparaging and derogatory terms towards residents, which was violated in this instance.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate nurse staffing to meet the needs of its residents, as evidenced by the experiences of three residents. Resident #1, who was admitted for rehabilitation, reported significant delays in call light responses, often waiting 45 to 90 minutes for assistance. This resident was dependent on staff for various activities, including toileting and transfers, and expressed dissatisfaction with the delay in starting physical therapy due to a lack of proper equipment. Similarly, Resident #4, who had a moderate cognitive deficit and was at risk for skin breakdown, experienced long waits for assistance with incontinence care, which she needed frequently due to being a heavy wetter. She reported that staff would sometimes turn off her call light without providing the necessary care, citing insufficient staffing as the reason. Resident #3, who had intact cognitive ability but was dependent on staff for daily activities, also reported long wait times for call light responses. This resident, who was at risk for skin breakdown, relied on staff for peri-care after incontinence episodes. The staff's inability to respond promptly was attributed to a lack of sufficient help, as reported by the resident. The facility's staffing issues were further highlighted by the experiences of Staff D, an LPN, who worked excessively long hours, including a 23-hour shift, due to a shortage of available nurses. Staff D confirmed that there were times when only one CNA was available, and office staff rarely assisted despite promises to do so. The facility's staffing plan, as documented in their assessment, aimed for 3.00 hours per patient day (PPD) for CNA care, equating to 72 CNA hours per day for their census of 24 residents. However, this goal was not met, as indicated by the Regional Nurse Consultant, who acknowledged that the PPD calculation was unrealistic. The Director of Nursing admitted that there was no policy on call light response times, and the facility operated with minimal staffing, particularly during night shifts. This inadequate staffing led to delays in resident care and unmet needs, as reported by both residents and staff.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for 8 consecutive hours each day, as required. During a 30-day period, there were four days without RN coverage, specifically on the 9th, 10th, 17th, and 23rd of November 2024. The Director of Nursing (DON), who is a Registered Nurse, acknowledged the absence of RN coverage on these dates and mentioned discussing the issue with the Administrator. The Nurse Scheduler, Staff F, indicated difficulties in maintaining RN coverage due to a lack of on-call staff and reliance on agency nurses. Additionally, the facility did not have a policy in place regarding RN coverage, despite the facility assessment stating the need for RN or LPN coverage for each shift to provide competent support and care for the resident population.
Failure to Develop Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan for a resident who was admitted for rehabilitation with the goal of returning home. Despite a care plan conference being held and the resident's needs being discussed, no care plan was documented in the electronic record as of the survey date. The resident, who was cognitively intact, expressed dissatisfaction with the lack of planning related to his admission, including inadequate equipment and delayed physical therapy, which hindered his rehabilitation progress. The resident was admitted with lower extremity impairments and was dependent on staff for various activities of daily living. Observations revealed that the resident was mostly bed-ridden for a period due to inadequate equipment and lack of timely therapy. The Director of Nursing acknowledged the absence of a care plan in the electronic record and noted that the facility did not have a specific policy on care planning, instead following general regulations.
Failure to Provide Necessary Bariatric Equipment for Resident
Penalty
Summary
The facility failed to ensure they had the proper equipment and services to meet the needs of a resident before admission, resulting in a deficiency. The resident, who was admitted with a knee injury and required therapy services, was accepted by the facility without considering his bariatric equipment needs. Upon arrival, the staff was unaware of the necessary equipment, and the resident was left without a suitable bed, commode, walker, or chair, which delayed his physical therapy and rehabilitation progress. The resident, who was cognitively intact, expressed frustration over the lack of planning related to his admission. He was mostly bed-ridden from the time of his admission until the necessary equipment arrived, which was over two weeks later. During this period, he was given bed baths and used a bedpan that was too small, leading to frequent spills. The facility's failure to provide the appropriate equipment in a timely manner resulted in the resident losing progress made in the hospital and relying on his family to purchase a suitable walker. The facility's staff, including the Administrator, DON, and ADON, were involved in the decision to admit the resident but did not adequately prepare for his equipment needs. The facility's assessment indicated that they should have obtained more information before admitting a bariatric patient over 425 pounds, yet they did not start calling for the specialized equipment until after the resident's admission. This oversight led to significant challenges in meeting the resident's care needs and contributed to the deficiency identified in the report.
Failure to Protect Resident from Abuse and Psychological Harm
Penalty
Summary
The facility failed to protect a resident from abuse and psychological harm, as evidenced by an incident involving a Certified Nursing Assistant (CNA), referred to as Staff A, who allegedly provided care in a rough manner and used inappropriate language towards the resident. The resident, who had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairments, reported feeling unsafe and fearful when Staff A was present. The resident's medical history included conditions such as cerebral palsy, anxiety, depression, and post-traumatic stress disorder (PTSD), which may have contributed to her heightened sensitivity to the alleged abuse. The incident occurred when the resident expressed dissatisfaction with the delay in being assisted to bed, leading to a verbal altercation with Staff A. Multiple staff members provided statements indicating that the resident was upset and that Staff A responded inappropriately by using profanity and dismissive language. The resident reported feeling sore after Staff A's care and expressed a desire not to be cared for by her. Despite these reports, Staff A continued to work at the facility, although she was not allowed to provide care to the resident in question. The facility's investigation revealed inconsistencies in the accounts of the incident, with some staff members corroborating the resident's claims of verbal abuse, while others denied hearing inappropriate comments. The resident's fear and discomfort were evident, as she reportedly stayed close to other staff members when Staff A was present. The facility's failure to adequately address the resident's concerns and ensure her safety contributed to the deficiency identified by the surveyors.
Failure to Timely Report Resident Abuse Allegation
Penalty
Summary
The facility failed to report a resident's allegation of abuse to the appropriate authorities in a timely manner. On the evening of 7/23/24, two staff members assisted a resident to bed, during which the resident expressed frustration over the delay in being put to bed. The resident accused one of the staff members of being verbally abusive, using inappropriate language, and making her feel uncomfortable. The incident was reported to the Assistant Director of Nursing (ADON), who is also the mother of the accused staff member. The ADON spoke with the resident and the staff involved but did not report the incident to the Director of Nursing (DON) or the State Agency immediately. The resident, who has a history of cerebral palsy, anxiety, depression, and other medical conditions, reported feeling upset and unsafe due to the staff member's behavior. The resident's mental status was assessed as unimpaired, with a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairments. Despite the resident's grievances and the staff's acknowledgment of the incident, the ADON did not escalate the matter, and the facility only reported the allegation to the State Agency the following day after further prompting from other staff members. The delay in reporting the incident led to the State Agency identifying an Immediate Jeopardy situation, which was not addressed until several days later. The facility's failure to act promptly and follow proper reporting protocols contributed to the deficiency, as the resident's allegations were not taken seriously or addressed in a timely manner, potentially compromising the resident's safety and well-being.
Failure to Protect Resident from Psychosocial Harm
Penalty
Summary
The facility failed to protect a resident from psychosocial harm during and after the investigation of an alleged abuse incident. The resident, who had no cognitive impairments and a history of multiple medical conditions including cerebral palsy and PTSD, reported feeling upset and unsafe due to the behavior of a staff member, Staff A. The incident began when the resident expressed frustration over waiting two hours to be put to bed, leading to a verbal altercation with Staff A, who allegedly responded inappropriately. The facility's investigation revealed conflicting accounts of the incident. Staff A and another CNA, Staff B, were involved in the altercation, with Staff A reportedly making inappropriate comments to the resident. The resident expressed feeling unsafe and fearful of Staff A, especially when she was present in the facility. Despite the resident's grievances and visible distress, Staff A was allowed to return to work after completing education on abuse, although she was not permitted to care for the resident directly. The facility's response to the incident included an investigation and discussions with the resident, but the resident continued to feel unsafe and expressed concerns about potential retaliation. The facility's abuse prevention policy was in place, but the handling of the incident and the return of Staff A to work without adequately addressing the resident's ongoing fear and distress contributed to the deficiency.
Failure to Follow Physician Orders and Medication Administration Errors
Penalty
Summary
The facility failed to adhere to physician orders and properly administer medications for two residents, leading to deficiencies in care. For Resident #2, who has severe cognitive impairment, the facility did not apply Lidocaine cream as ordered before a wound dressing change. The registered nurse, Staff E, conducted the dressing change without applying the Lidocaine cream, which was supposed to be applied 30 minutes prior to the procedure to manage pain. This oversight was acknowledged by both Staff E and the Director of Nursing (DON), who confirmed that the medication should have been administered as per the physician's order. Additionally, the facility did not have a documented order for physician notification regarding weight gain for Resident #2, despite the After Visit Summary indicating the need to monitor for tachycardia and notify the physician if there was a significant weight gain. The resident's care plan also lacked goals or interventions related to this requirement, indicating a failure to incorporate critical physician instructions into the resident's care plan and medication administration records. For Resident #4, who has no cognitive impairment, the facility failed to transcribe an order for potassium chloride upon admission, resulting in the resident not receiving the medication for an extended period. This error was identified during a monthly medication review, and the DON admitted to not entering the potassium order with the admission orders. The facility had procedures requiring two nurses to verify admission orders, but this process failed to catch the error. The oversight was acknowledged by the DON, who noted that physician notification and lab tests were conducted after the error was discovered.
Non-Payment Issues Lead to Service Disruptions
Penalty
Summary
The facility failed to use its resources effectively and efficiently, resulting in a status of non-payment with several local vendors. This deficiency was observed through interviews with staff and vendors, as well as document reviews. Staff members reported that garbage had not been picked up for over two weeks on multiple occasions due to unpaid bills, leading to an overflow of trash. Additionally, the facility was in non-payment status with a transportation provider, causing residents to miss important medical appointments. Staff interviews revealed that the facility's administration was aware of the outstanding balances and had communicated with the corporate office regarding these issues. However, the corporate office was reportedly slow in responding and addressing the overdue payments. The facility's maintenance director and other staff members expressed frustration over the lack of communication and resolution from the corporate office, which affected the facility's ability to maintain necessary services such as waste removal and transportation. The report also highlighted specific instances where residents were directly impacted by the non-payment issues. For example, a resident missed a cardiac follow-up appointment necessary for wound healing due to the transportation provider not being paid. The facility's administrator acknowledged the non-payment status with various vendors, including waste removal, pest control, and bottled water suppliers, and noted that the transition from a third-party payment system to the home office handling payments may have contributed to the delays.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for two residents. Resident #1 was in the hospital from 7/29/23 through 7/31/23 and again from 8/1/23 through 8/10/23. Resident #23 was in the hospital from 1/30/23 through 2/1/23. The facility's Electronic Health Records (EHR) confirmed these hospitalizations, but the required notifications to the Ombudsman were not made. A review of the facility's document titled 'Notice of Transfer Form to Long-Term Care Ombudsman' revealed that Resident #1 was not included in the document for the relevant dates. Additionally, there was no Ombudsman notification for January of the previous year for Resident #23's transfer. Interviews with facility staff indicated that the previous Administrator was responsible for Ombudsman notifications, but this responsibility had since been assumed by Staff A in Social Services. Staff A expected Ombudsman notifications to be completed monthly with a report of residents transferred out of the facility. The current Administrator also confirmed that his expectation was for monthly notifications to include all transferred residents. However, the facility failed to adhere to its policy, as outlined in an undated document titled 'Required Discharge and Transfer Notices,' which mandates that transfer and discharge notices must be sent to the Long-Term Care Ombudsman.
Failure to Obtain Bed Hold Notifications
Penalty
Summary
The facility failed to obtain bed hold notifications for two residents during their hospital transfers. Resident #1 was hospitalized from 7/29/23 to 7/31/23 and again from 8/1/23 to 8/10/23, while Resident #23 was hospitalized from 1/30/23 to 2/1/23. The Electronic Health Records (EHR) confirmed these hospitalizations, but no bed hold forms were found for these dates. Interviews with Staff A from Social Services and the Director of Nursing (DON) revealed that the expectation was to obtain bed hold notifications every time a resident is transferred out of the facility. The facility's undated Bed Hold Policy also stated that bed hold notifications should be provided each time a resident is transferred from the facility.
Failure to Update Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to fully review and revise the comprehensive care plan for one resident. The quarterly Minimum Data Set (MDS) for the resident included diagnoses of cancer, congestive heart failure, pulmonary edema, hypertension, and cellulitis of the bilateral lower legs. The MDS indicated the resident received an anticoagulant medication within the seven-day look-back period and had intact cognition. Despite the resident's routine anticoagulant therapy prescribed for a history of an acute embolism and thrombosis of a deep vein in the right lower extremity, the care plan initiated did not include a focus for the anticoagulant medication therapy nor provide staff directives regarding therapy interventions. The Director of Nursing (DON) confirmed that the care plan should be updated within one week after a resident's status change, as per the facility's 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
