Lantern Park Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Coralville, Iowa.
- Location
- 2200 Oakdale Road, Coralville, Iowa 52241
- CMS Provider Number
- 165214
- Inspections on file
- 26
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Lantern Park Specialty Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple psychiatric diagnoses underwent changes in psychotropic medications without documented education or informed consent from the resident or their representative. The facility's records showed only an attempted phone notification to the family, with no follow-up or signed consent form, and the facility's policy did not address informed consent requirements for such medication changes.
A resident with Alzheimer's dementia was admitted to hospice care, but the facility did not complete the required Minimum Data Set (MDS) assessment for a significant change in status within the mandated timeframe, as confirmed by staff and clinical record review.
Quarterly MDS assessments were not completed within the required 92-day timeframe for three residents, with gaps ranging from 95 to 142 days between assessments. Staffing changes and reliance on a corporate support team contributed to the delays, and the issue was not self-identified by the facility during the survey.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
Staff did not deliver care or services in a manner that was trauma informed or culturally competent, failing to meet required standards for addressing residents' trauma histories or cultural needs.
Multiple residents experienced significant delays in call light response, with staff taking between 17 and 40 minutes to respond to requests for assistance. These delays were confirmed through direct observation and resident interviews, despite the administrator's stated expectation that call lights be answered in under 15 minutes.
Two residents requiring substantial assistance for bathing did not consistently receive the scheduled two showers per week, as confirmed by documentation, resident interviews, and staff observations. Both residents, who were cognitively intact, reported infrequent showers, and one exhibited physical signs of inadequate hygiene. The administrator acknowledged that all residents should receive showers twice weekly.
The facility failed to administer medications as prescribed to several residents due to insufficient staffing. Residents with conditions such as hypertension, diabetes, and heart disease missed critical doses of medications like Metoprolol, Digoxin, and insulin. Staff A, a registered nurse, cited a lack of help as the reason for these omissions, which were documented in the residents' MARs and progress notes.
A resident with intact cognition alleged physical abuse, claiming she was hit in the head, causing her glasses to fall off. The facility's investigation was insufficient, as it did not include interviews with staff present during the incident. The Interim Administrator was informed through hospital notes and notified authorities, but there was uncertainty about the completeness of staff interviews. The facility's policy requires thorough investigations, which was not met.
A facility failed to obtain physician orders for supplemental oxygen for a resident with COPD and asthma, leading to undocumented oxygen use. Additionally, another resident missed multiple medication doses due to staffing shortages, with the nurse failing to report the issue to management. The facility's policies and job descriptions were not followed, resulting in deficiencies in care.
A resident with COPD, respiratory failure, and anxiety, requiring moderate assistance with daily living activities, did not receive scheduled baths as per their care plan. Despite a system in place for assigning bath days, the facility failed to provide the necessary hygiene care, with documentation showing only one bath in August and none in September.
A resident with a fall risk and a periprosthetic fracture was injured due to inadequate supervision during ambulation. A CNA failed to use a gait belt, contrary to the care plan and facility policy, resulting in the resident falling and sustaining a non-operable fracture of the right hip. The incident was witnessed by another CNA in training.
A resident with multiple diagnoses required substantial assistance for transfers, but the facility failed to update their care plan to reflect the use of a sit-to-stand lift instead of a front-wheeled walker. Staff interviews confirmed the use of the lift for four months, but the therapy department was not informed, leading to a deficiency in care planning and communication.
A resident with hemiplegia required a mechanical lift for transfers, but staff failed to secure the shin strap due to a missing buckle, leading to unsafe transfer practices. The resident's leg position during the transfer was concerning, and staff training on the use of the lift was inconsistent.
The facility staff failed to treat residents with respect and dignity, as evidenced by incidents involving four residents. A resident with cancer was told by an LPN that he was going to die, causing distress. Another resident was left on the toilet for 20 minutes, feeling scared and uncertain. A third resident reported poor call light response times, leading to incontinence and feelings of unimportance. Additionally, two CNAs were rude to a resident, refusing to assist with toileting. These incidents highlight a pattern of disrespect and inadequate care.
A resident with intact cognition was not informed about changes to her medications or treatment plan, despite facility policies requiring such communication. Staff confirmed that residents with high BIMS scores should be informed, but notifications were only made to the resident's power of attorney, who was not enacted. This lack of communication deviated from the facility's policies on resident rights and dignity.
The facility did not submit complete PBJ data for agency staff during the second quarter, affecting CMS's staffing information. The PBJ report showed a one-star staff rating and low weekend staffing. The Administrator acknowledged the omission of agency staff data, contrary to the facility's policy requiring inclusion of all direct-care staff.
A facility failed to update the PASRR evaluation for a resident with new diagnoses, including Parkinson's disease with dyskinesia and delusional disorders. The resident's care plan was based on an outdated assessment from 2021, and despite new diagnoses documented in the electronic health record, no updated PASRR evaluation was conducted. The facility lacked a specific policy for PASRR completion, relying instead on general regulations.
A resident with a history of falls and multiple diagnoses fell in the shower room, resulting in a nondisplaced fracture of the proximal right femoral neck. The incident occurred because the CNA did not use a gait belt and the resident was not wearing shoes, contrary to the facility's policy and standard practice.
A resident with hypertension, non-Alzheimer's dementia, and orthostatic hypotension fell in the shower room and complained of significant pain in her right hip and pelvis. Despite the resident's inability to flex her right hip and her complaints of pain, an agency nurse used a mechanical lift to place the resident in a wheelchair and took her to her room instead of seeking immediate medical treatment, resulting in inadequate care.
Failure to Obtain Informed Consent for Psychotropic Medication Changes
Penalty
Summary
The facility failed to educate a resident and/or their representative and obtain informed consent prior to making two changes in psychotropic medications for a resident with severe cognitive impairment. The resident had diagnoses including PTSD, depression, and adjustment disorder, and was being treated with multiple psychotropic medications. The care plan included interventions to educate the resident, family, and caregivers about the risks, benefits, and side effects of antidepressant medications. However, when the physician ordered a decrease in duloxetine and initiation and titration of sertraline, there was no documented evidence that informed consent was obtained from the resident or their representative prior to implementing these changes. Review of the electronic health record showed an attempt to notify the resident's wife by leaving a message, but there was no follow-up communication documented to confirm that the representative was informed about the medication changes. Additionally, the facility's provided policy did not address the need for informed consent prior to changes in psychotropic medications, and the informed consent form for the new antidepressant remained unsigned. Staff interviews confirmed that the expectation was for a signed informed consent document to be present when medication changes occurred, but this was not completed in this case.
Failure to Complete Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment for a significant change in status after a resident was admitted to hospice care. Clinical record review showed that a physician order was entered indicating the resident began receiving hospice services for Alzheimer's dementia. According to the Resident Assessment Instrument (RAI) User's Manual, an MDS assessment for a significant change in status must be completed within 14 days of determining the change, and specifically when a terminally ill resident enrolls in a hospice program. Staff interview confirmed that the resident started hospice services, but the required significant change MDS assessment was not completed as mandated.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required timeframe for three residents. Clinical record reviews showed that for one resident, there was a 142-day gap between the admission MDS assessment and the first quarterly assessment. For another resident, there was a 133-day interval between two quarterly assessments, and for a third resident, the gap between quarterly assessments was 95 days. According to the Resident Assessment Instrument (RAI) User's Manual, assessments must be completed no later than 92 days after the previous assessment. Interviews with the new MDS Coordinator and the Administrator revealed that the facility had experienced staffing changes, with the corporate support team intermittently handling MDS assessments while a new Coordinator was being hired. The MDS Coordinator described the process for completing assessments and acknowledged that quarterly assessments should be completed within 92 days. The Administrator confirmed that the previous Coordinator was responsible for the missed assessments, and the new Coordinator had been working to correct identified errors. The facility did not indicate on the Self Identification form that MDS corrections were an ongoing issue.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide care or services that were trauma informed and/or culturally competent. This deficiency indicates that staff did not consider or incorporate trauma-informed approaches or cultural competence in the delivery of care or services to residents, as required. The report does not specify the number of residents affected or provide details about their medical history or condition at the time of the deficiency.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by multiple observations and resident interviews. Three separate instances were documented where call lights remained unanswered for periods ranging from 17 to 35 minutes. Residents reported that it routinely took staff over 15 minutes, and in some cases up to 40 minutes, to respond to their requests for assistance. These delays were directly observed by surveyors, who noted specific times when call lights were activated and the length of time before staff entered the rooms. The facility census at the time was 86 residents, and the administrator confirmed that the expectation was for call lights to be answered in less than 15 minutes.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide at least two baths per week for two of three residents reviewed, despite both residents being assessed as requiring substantial or maximal assistance for showering. Clinical record reviews showed that both residents were scheduled for showers twice weekly, but documentation revealed that the actual number of showers received was inconsistent and often less than scheduled. One resident, with intact cognition and a care plan indicating the need for one-person assistance, reported not receiving showers very often, and records confirmed missed showers over several months. Another resident, also cognitively intact and requiring similar assistance, stated that staff were slow to provide showers and reported not having had a shower for over a week, with physical signs such as greasy hair and slight body odor observed during the survey. Interviews with both residents corroborated the documentation findings, as they expressed concerns about the infrequency of showers. The administrator confirmed that all residents should be receiving showers twice a week, as per facility policy. The deficiency was identified through a combination of clinical record review, resident interviews, and staff interviews, highlighting a failure to consistently provide scheduled bathing assistance to residents unable to perform activities of daily living independently.
Medication Administration Errors Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting six out of ten residents reviewed for medication administration. The errors were primarily due to missed medication doses, as indicated by the residents' Medication Administration Records (MARs) and progress notes. The MARs for several residents showed multiple morning medications marked with a code indicating they were not administered, and progress notes consistently cited a lack of sufficient help as the reason for these omissions. Resident #3, with severely impaired cognition, missed a dose of Metoprolol Succinate for hypertension. Similarly, Resident #15, who had cardiovascular issues, missed a dose of Digoxin. Both cases were attributed to insufficient staffing, as noted by Staff A, a registered nurse. The facility's daily staffing sheet confirmed that only two nurses and one Certified Medication Aide were scheduled for the shift, which was inadequate to meet the residents' needs. Other residents, including those with diabetes, coronary artery disease, and hypertension, also missed critical medications such as insulin, Metoprolol, Furosemide, and Eliquis. These omissions were documented in the progress notes, with Staff A repeatedly citing a lack of help as the cause. Despite notifying providers of the medication errors, no new orders were received, indicating a lack of immediate corrective action. The facility's policy on administering medications, which requires medications to be given as per prescriber orders, was not adhered to, leading to these significant medication errors.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with intact cognition, as indicated by a BIMS score of 15 out of 15. The resident alleged that during the overnight hours, she was hit in the head, causing her glasses to fall off. The incident was reported several days later due to the resident's illness. The facility conducted interviews with other residents and staff, but the investigation lacked thoroughness as it did not include statements from staff who worked during the time of the alleged incident. Additionally, the facility's documentation did not provide sufficient information related to the alleged abuse. The Interim Facility Administrator was made aware of the allegation through hospital notes and took steps to notify relevant authorities. However, there was uncertainty about whether all necessary staff interviews had been conducted. The facility's investigation summary indicated no concerns were noted from the interviews conducted, but it did not address the specific details of the alleged incident. The facility's policy on abuse and neglect requires a thorough investigation to clarify events and identify possible causes, which was not adequately fulfilled in this case.
Deficiencies in Oxygen Administration and Medication Management
Penalty
Summary
The facility failed to obtain physician orders for the use of supplemental oxygen for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and asthma. Despite the resident experiencing low oxygen saturation levels, the care plan did not include interventions related to oxygen use, and the Medication and Treatment Administration Record (MAR/TAR) lacked orders for supplemental oxygen. Nursing staff applied oxygen based on their judgment, and a verbal order was received but not documented in the MAR/TAR. The facility's policy required a physician's order for oxygen administration, which was not followed. Another deficiency involved the failure to administer medications as ordered for a resident on a specific date. Multiple morning and afternoon medication doses were omitted due to insufficient staffing, as noted by a registered nurse. The resident's MAR indicated missed doses, and progress notes confirmed the omissions were due to a lack of help. The facility's staffing sheet showed that only two nurses and one Certified Medication Aide were scheduled for the shift, and the nurse involved did not report the issue to the Regional Director of Clinical Services or the Regional Director of Operations. The facility's Regional Director of Clinical Services and Regional Director of Operations were present on the day of the medication omissions but were not informed of the staffing issues by the nurse. The nurse acknowledged not completing all tasks and requested to return the following day. The Charge Nurse-RN Job Description required compliance with rules and regulations, ensuring residents received necessary care, which was not adhered to in this instance.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to a resident, identified as Resident #1, who required moderate assistance with activities of daily living, including bathing. The resident, who had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, was diagnosed with chronic obstructive pulmonary disease (COPD), respiratory failure, and anxiety. According to the care plan initiated on August 12, 2024, the resident was to receive assistance with baths twice a week, specifically on Mondays and Thursdays. However, documentation revealed that the resident only received one bath on August 29, 2024, and there was no documentation of baths provided in September. Interviews with facility staff, including registered nurses and certified nurse assistants, confirmed that residents are generally scheduled to receive baths twice a week, with a designated bath aide responsible for this task. If bath aides are unavailable, certified nursing assistants are expected to complete the baths. The staff also mentioned a system of assigning bath days based on room numbers, and a master list is used to track which residents need baths. Despite these procedures, the facility failed to adhere to the care plan for Resident #1, resulting in a deficiency in providing necessary hygiene care.
Failure to Use Gait Belt Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide appropriate supervision during ambulation for a resident, resulting in an injury. The resident, who had no cognitive impairment, was identified as having a fall risk due to a periprosthetic fracture of the left hip joint. The care plan required staff to assist the resident with a front-wheeled walker and a wheelchair for mobility, and to use a gait belt during transfers. However, on the day of the incident, a CNA assisted the resident to the bathroom without using a gait belt, which was against the facility's policy. The CNA, who was responsible for the resident's care, admitted to not using a gait belt because she left it in her locker. Instead, she held onto the resident's pants to assist him. During the transfer, the CNA removed the resident's oxygen and turned away from him, leaving him unsupported. As a result, the resident fell in the bathroom, sustaining a fracture to the right hip, which was confirmed by an x-ray as a non-operable fracture of the greater trochanter. The incident was witnessed by another CNA in training, who observed the resident fall after taking a few steps on his own. The facility's policy required the use of gait belts for safe resident transfers, and the CNA involved in the incident had previously been warned for similar infractions. The failure to adhere to the care plan and facility policies directly contributed to the resident's fall and subsequent injury.
Failure to Update Resident Care Plan for Transfer Method
Penalty
Summary
The facility failed to update the care plan of a resident to reflect their current level of functioning, leading to a deficiency. The resident, who had diagnoses including metabolic encephalopathy, legal blindness, lack of coordination, and muscle weakness, required substantial assistance for transfers and ambulation and was totally dependent on staff for toileting. The care plan, last revised in March 2024, indicated the resident should be transferred using a front-wheeled walker with the assistance of two staff members. However, observations and staff interviews revealed that the resident had been transferred using a sit-to-stand mechanical lift (EZ Stand) for the past four months, contrary to the care plan instructions. Interviews with various staff members, including CNAs and LPNs, confirmed the use of the EZ Stand for transfers, which was not documented in the care plan. The therapy department, responsible for assessing and recommending transfer methods, was not informed of the change in the resident's transfer method and did not receive a request for re-evaluation. The Director of Nurses and MDS Coordinators acknowledged the discrepancy between the care plan and the actual transfer method used, indicating a breakdown in communication and documentation processes within the facility.
Deficiency in Safe Transfer Using Mechanical Lift
Penalty
Summary
The facility failed to safely transfer a resident who required a mechanical lift, resulting in a deficiency. The resident, who had no cognitive impairment and was diagnosed with conditions including cerebrovascular accident, hypertension, and hemiplegia, required total assistance for transfers and toileting. The care plan specified the use of a sit-to-stand mechanical lift (E-Z Stand) with assistance from one staff member. However, during an observation, a CNA used the lift without securing the shin strap, which lacked a buckle, and transferred the resident to the bathroom. The resident's left leg was observed to remain straight and tilted back during the transfer, which was noted by a Physical Therapy Aide as a concern. Staff interviews revealed that one CNA had not been trained to buckle the leg harness, while another CNA was aware of the requirement but noted the strap was missing a buckle. The facility had three E-Z Stand lifts, one of which had a broken shin strap. The Director of Nursing confirmed the necessity of applying the leg strap during transfers. The mechanical lift manual indicated the importance of securing the shin strap to keep the patient's legs on the foot plate, highlighting the deficiency in the transfer process.
Failure to Respect Resident Dignity and Timely Response to Needs
Penalty
Summary
The facility staff failed to treat residents with respect and dignity, as evidenced by multiple incidents involving four residents. Resident #78, who had a diagnosis of cancer, reported being mistreated by a nurse, Staff A, who told him he was going to die from his cancer. This conversation was corroborated by an audio recording and other staff members, leading to the termination of Staff A. The incident left Resident #78 upset and angry, highlighting a lack of sensitivity and respect in communication with residents. Resident #13, who had moderately impaired cognition and was dependent on staff for toileting, reported being left on the toilet for 20 minutes, causing her to feel scared and uncertain about when staff would return. Staff interviews revealed that call lights were not always answered promptly, especially during busy times, indicating a systemic issue with staff availability and response times. This delay in assistance compromised the resident's dignity and sense of security. Resident #86, with intact cognition and a history of fractures, reported poor response times to call lights, particularly during evenings and weekends. She experienced incontinence due to delayed assistance, which made her feel unimportant. Additionally, Resident #4 reported rude behavior from two CNAs who refused to assist him with toileting, telling him to try to wipe himself. This incident was confirmed through interviews and led to a grievance being filed. These events collectively demonstrate a pattern of disrespect and inadequate care, affecting the residents' dignity and well-being.
Failure to Inform Resident of Medication Changes
Penalty
Summary
The facility failed to ensure that residents were fully informed and involved in their treatment plans, specifically in the case of one resident with intact cognition. This resident, who had diagnoses of cancer, anxiety, and heart failure, reported that nurses did not explain changes to her medications or the reasons for these changes. Despite having a high score on the Brief Interview for Mental Status (BIMS), indicating intact cognition, the resident was not informed about new medications or changes to her treatment plan. The facility's documentation showed that notifications about medication changes were made to the resident's power of attorney, even though the resident was decisional and the power of attorney had not been enacted. Interviews with staff and the facility administrator confirmed that residents with high BIMS scores should have medication changes explained to them, and that the resident's brother was involved in care conferences by choice, not necessity. The facility's policies emphasized the importance of informing residents about their health status and respecting their dignity and choices. However, the lack of communication with the resident about her medications and treatment plan was a clear deviation from these policies, as evidenced by the absence of documentation showing the resident's involvement in care plan conferences and medication discussions.
Incomplete PBJ Data Submission for Agency Staff
Penalty
Summary
The facility failed to submit complete payroll data for agency staff during the second quarter of the current fiscal year, impacting the accuracy of staffing information reported to the Centers for Medicare and Medicaid Services (CMS). The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year 2024 Quarter 2 indicated a one-star staff rating and excessively low weekend staffing. Upon review, the Administrator provided staff schedules for March, which included both facility and agency staff. However, during an interview, the Administrator admitted that the PBJ data submitted did not include agency staff, acknowledging the impact on CMS's data for the facility. The facility's policy on Reporting Direct-Care Staffing Information, revised in October 2017, required the inclusion of staff hired directly by the facility, through an agency, and contract employees.
Failure to Update PASRR Evaluation for Resident with New Diagnoses
Penalty
Summary
The facility failed to complete an updated Pre-Admission Screening and Resident Review (PASRR) evaluation for a resident with a new diagnosis. The resident, identified as Resident #13, had a history of Parkinson's disease, psychotic disorder, PTSD, and delirium due to a known physiological condition. The Minimum Data Set (MDS) review revealed that the resident had moderately impaired cognition, scoring 10/15 on the Brief Interview for Mental Status (BIMS). The resident's care plan, which included focus areas and interventions for PASRR, was based on an assessment completed prior to admission on 7/9/21. The PASRR outcome from 7/7/21 indicated no Level II was required at that time, as there were no neurocognitive disorders or recent mental health symptoms noted. However, the resident's electronic health record later documented new diagnoses, including Parkinson's disease with dyskinesia dated 10/1/23, delusional disorders dated 11/3/23, and delirium due to a known physiological condition dated 3/15/24. Despite these new diagnoses, the facility did not conduct an updated PASRR evaluation. An email from the Administrator on 8/1/24 confirmed that the facility lacked a specific policy for PASRR completion and relied solely on following regulations. An interview with the Administrator further revealed that the only documentation of a completed PASRR assessment for this resident was from 2021, indicating a failure to update the evaluation in light of the resident's new diagnoses.
Failure to Provide Appropriate Supervision and Use of Gait Belt
Penalty
Summary
The facility failed to provide appropriate supervision to ensure the safety of a resident, leading to a fall incident. The resident, who had diagnoses including hypertension, non-Alzheimer's dementia, and orthostatic hypotension, was identified as being at risk for falls. The care plan included interventions such as encouraging proper footwear and monitoring for an unsteady gait, as well as requiring assistance from one person for various activities of daily living. However, during a bathing session, the resident fell in the shower room, resulting in a nondisplaced fracture of the proximal right femoral neck. The incident occurred because the Certified Nursing Assistant (CNA) did not use a gait belt and the resident was not wearing shoes, contrary to the facility's policy and standard practice as explained by the Director of Nursing (DON). The CNA admitted that she did not have a gait belt on the resident and that the resident was not wearing shoes at the time of the fall. The facility's policy on safe lifting and movement of residents, which was last revised in July 2017, directed staff to use manual lifting devices such as gait belts. The DON confirmed that it is standard practice to use a gait belt and to have hands on the gait belt at all times when assisting a resident. The failure to adhere to these protocols directly led to the resident's fall and subsequent injury.
Failure to Provide Appropriate Post-Fall Assessment and Intervention
Penalty
Summary
The facility failed to complete an accurate assessment and provide appropriate intervention after a fall for a resident diagnosed with hypertension, non-Alzheimer's dementia, and orthostatic hypotension. The resident, who required assistance with activities of daily living, fell in the shower room and complained of significant pain in her right hip and pelvis. Despite the resident's inability to flex her right hip and her complaints of pain, the agency nurse used a mechanical lift to place the resident in a wheelchair and took her to her room instead of seeking immediate medical treatment as per the facility's policy on assessing falls and their causes. A subsequent CT scan revealed a nondisplaced fracture of the proximal right femoral neck. The facility's policy directs staff to provide first aid and obtain medical treatment immediately if there is evidence of an injury after a fall. However, the agency nurse's decision to use a mechanical lift and place the resident in a wheelchair without seeking immediate medical attention demonstrated poor judgment and a failure to adhere to the facility's policy, resulting in inadequate care for the resident after the fall.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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