Manly Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Manly, Iowa.
- Location
- 601 E South Street, Manly, Iowa 50456
- CMS Provider Number
- 165226
- Inspections on file
- 21
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Manly Specialty Care during CMS and state inspections, most recent first.
Failure to Document Non-Pharmacological Interventions Before PRN Antipsychotic Use: A resident with severe cognitive loss, dementia, depression, and anxiety received PRN Haloperidol for agitation and irritability on multiple occasions, but the MAR, progress notes, and supplemental documentation did not show nonpharmacological interventions tried before administration. Staff and the DON confirmed the chart lacked the required documentation, and the facility policy stated antipsychotics should not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions.
Failure to report resident-to-resident abuse allegations to DIAL. A resident with severe cognitive impairment and diagnoses including dementia, Alzheimer's disease, anxiety, and depression was involved in multiple aggressive incidents with other residents, including pushing one resident, grabbing another resident's arm, and lightly poking a resident in the head. Facility records and staff interviews showed the incidents were not timely reported as required by policy and federal requirements.
Failure to investigate resident-to-resident abuse incidents involving a cognitively impaired resident. A resident with severe cognitive impairment, dementia, anxiety, depression, and a history of aggressive behavior was documented grabbing, pushing, poking, yelling at, and invading the space of other residents. The care plan listed general redirection and monitoring interventions but lacked specific aggression-related protections, and the facility's records did not consistently identify the other residents involved. The DON and Administrator stated they did not complete investigations for some of the incidents, and staff did not assess the affected residents for injury or psychosocial harm.
Failure to prevent resident-to-resident abuse: A resident with severe cognitive impairment and a history of aggression toward others struck another resident while seated near an LPN/CNA. The staff member did not intervene until after the hit, despite knowing the resident had prior behavioral issues, including yelling at others, taking belongings, and placing hands on another resident.
Unsanitary Ice Machine and Inadequate Cleaning Practices: The facility failed to maintain a sanitary kitchen and failed to prepare and serve food in accordance with food safety standards. An ice machine was observed with heavy mineral deposit build-up, streaking inside, and small black particles on the baffle, and it remained unchanged on repeat observation. The Mgr and Dietary Mgr both reported the buildup was an ongoing issue and that they could not fully clean the machine despite routine cleaning efforts and use of different products.
The facility failed to employ a qualified nutrition professional, lacking a Certified Dietary Manager or full-time Registered Dietitian as required. The facility has been without a kitchen manager for six months, with Staff A assisting unofficially. The previous Dietary Manager works part-time, and the Registered Dietitian visits monthly. A traveling Certified Dietary Manager has provided occasional assistance.
A facility failed to prevent significant medication errors, affecting eight residents over several months. Errors included incorrect dosages and administration of discontinued medications. Staff concerns about frequent errors, particularly by an RN, were not adequately addressed. The facility's medication administration policy was not effectively implemented, leading to repeated errors.
The facility failed to follow dietary protocols, resulting in residents not receiving appropriate portions or menu items. Residents on pureed and low sodium diets did not receive the correct meals, and the Nutritional Intervention Program was not properly implemented. Staff were unaware of proper procedures, and the Registered Dietitian's expectations were not met.
The facility failed to maintain safe food temperatures during a lunch service. A cook served cold foods, including chef salad and cottage cheese, at temperatures above the safe limit of 41°F. Despite being aware of the temperature issue, the cook proceeded with serving, contrary to facility policy and FDA guidelines. The Registered Dietitian confirmed the expectation for cold foods to be served at 41°F or colder.
The facility inaccurately coded the MDS assessments for two residents. One resident was incorrectly coded as having no serious mental illness despite a Level II PASRR, due to staff confusion. Another resident's MDS failed to document verbal aggression, despite reports of bullying behavior. The facility lacked a specific MDS policy, relying on the RAI Manual, which was not properly followed.
A resident with cerebral infarction, multiple sclerosis, and dysphagia required one-on-one assistance during meals, as per their care plan. However, observations showed the resident was left to eat independently without the necessary support or reminders from staff. Despite staff presence, including CNAs and the DON, the resident did not receive the prescribed assistance, indicating a failure to adhere to the care plan.
The facility failed to update care plans for two residents, leading to unaddressed conflicts and behavioral issues. A resident with intact cognition reported being bullied by another resident with moderate cognitive impairment, but her care plan did not reflect this conflict. The second resident exhibited negative behaviors, yet her care plan lacked documentation of these behaviors and her psychiatric therapy. The MDS Coordinator, new to the role, had not updated the care plans, contrary to facility policy.
The facility failed to provide Dietitian-approved pureed bread to four residents on a pureed diet. Staff were unaware of how to prepare pureed bread, and the CDM removed it from the menu without informing the Dietitian, altering the nutritional content of the meals served. The issue was acknowledged by the Administrator, DON, and ADON.
The facility failed to notify the State Long Term Care Ombudsman of hospital transfers for two residents. The Administrator acknowledged the oversight and the lack of a specific policy for ombudsman reporting.
The facility failed to complete a new PASRR evaluation as required for a resident with moderate cognitive impairment and multiple diagnoses. The MDS Coordinator submitted the new PASRR after the expiration of the approved short-term period, and the facility did not have a PASRR policy.
The facility failed to properly care for and document a resident's pressure ulcers. Staff did not use a cleanser to clean the sacral/coccyx pressure ulcer and were unaware of specific wound care instructions. Additionally, the facility did not accurately update the stages of the resident's pressure ulcers, leading to improper wound care and documentation.
The facility failed to forward a pharmacy recommendation to the physician for re-evaluation of a 14-day PRN Haloperidol (Haldol) order for a resident. The medication was administered 28 times beyond the 14-day period without physician re-evaluation or a new order being issued. The ADON acknowledged the oversight and admitted that the PRN order should have been discontinued as per the facility's policy.
The facility did not meet the required number of members at QAA meetings for the first four of six quarters, including the Administrator, Medical Director, DON, Infection Preventionist, and one other staff member. The DON misunderstood the regulation, believing only five members were needed.
A facility failed to perform proper hand hygiene and follow PPE guidelines during peri-care for a resident with septicemia, recurrent enterocolitis due to clostridium difficile, and hypertension. A CNA used the same dirty gloves to handle clean items without changing gloves or performing hand hygiene. Interviews with the ADON and DON confirmed the expectation to change gloves after peri-care, but the facility's policy lacked specific instructions.
Failure to Document Non-Pharmacological Interventions Before PRN Antipsychotic Use
Penalty
Summary
The facility failed to document non-pharmacological interventions before administering PRN Haloperidol for agitation and irritability for one sampled resident. Resident #39 had a BIMS score of 4, indicating severe cognitive loss, and was diagnosed with non-Alzheimer's dementia, depression, and anxiety. The resident's February 2026 MAR showed Haloperidol 0.5 mg ordered every 8 hours as needed, and the medication was administered on multiple days in February and again on March 2 and 3, 2026. The supplemental documentation and progress notes did not show what nonpharmacological interventions were tried before the medication was given. The care plan identified that the resident used psychotropic medications and included an intervention to document the number of target behaviors, the behaviors observed, and interventions for antipsychotic medication. However, the record lacked documentation of interventions prior to PRN Haloperidol administration on several occasions. Staff interviews confirmed that nurses should document the interventions tried before giving psychotropic medication, and the MDS coordinator stated the supplemental documentation was completed once per shift, which did not show when behaviors occurred or what interventions were attempted for each dose. The DON acknowledged the chart lacked documentation on several occasions, and the facility policy stated antipsychotic medications should not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to timely report allegations of resident-to-resident abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) for incidents involving Resident #39 and two other residents. Resident #39 had a BIMS score of 4, indicating severe cognitive impairment, and the MDS listed diagnoses of non-Alzheimer's dementia, Alzheimer's disease, anxiety, and depression. The record showed Resident #39 was independent with walking 10 feet and 50 feet with two turns and did not use a wheelchair or scooter. Facility documentation and staff interviews showed that the facility did not report an incident on 1/31/26 when Resident #39 entered Resident #5's room, yelled at her, tried to get her out of bed, and pushed her. The facility also did not report an incident on 2/4/26 when Resident #39 got into another resident's space, dumped supper onto the resident's plate, lightly poked Resident #20 in the head, and then grabbed a staff member's wrist and thumb. The DON later stated the incident was not reported because staff felt it could go either way since the resident was not poked hard, and the identity of the resident involved was initially unclear. In addition, the facility failed to report the 2/17/26 incident when Resident #39 grabbed Resident #5's arm and held it until someone separated them. The facility policy required allegations to be reported within the required timeframe by federal requirements.
Failure to investigate resident-to-resident abuse incidents involving a cognitively impaired resident
Penalty
Summary
The facility failed to investigate and review interventions for resident-to-resident abuse involving a resident with severe cognitive impairment and a history of aggressive and verbally aggressive behaviors. Resident #39 had a BIMS score of 4, diagnoses including non-Alzheimer's dementia, Alzheimer's disease, anxiety, and depression, and care plan entries noting that she could become verbally aggressive, take other residents' belongings, yell at residents, wake them up, and place her hands on another resident. The care plan documented general interventions such as redirecting her, approaching her calmly, diverting attention, and removing her from situations, but it lacked specific interventions addressing her aggression and how to protect her and other residents when she became aggressive. The record documented multiple incidents involving Resident #39 and other residents, but the documentation was incomplete. On 1/31/26, Resident #39 went into Resident #5's room, yelled at Resident #5, tried to get her out of bed, pushed her, and then yelled at a third resident, but the note did not identify the third resident. On 2/4/25, Resident #39 got into another resident's space, slapped the air in front of her, dumped supper onto another resident's plate, and lightly poked another resident in the head; staff intervened, and Resident #39 grabbed a staff member's wrist and thumb and used profanity. The note did not identify the residents involved, and the DON later stated the facility did not report the incident because they felt it could go either way and did not know who the resident was at first. A focused evaluation note on 2/17/26 documented Resident #39 grabbing another resident's arm and holding it until someone separated them, but the note did not identify the other resident. The facility's incident list lacked documentation of resident-to-resident abuse for the 1/31/26, 2/4/25, and 2/17/26 events. The DON and Administrator stated they did not complete investigations for the 1/31/26 and 2/4/25 incidents because there was no incident report, and they confirmed staff did not assess the other residents for injuries or psychosocial harm and did not initiate follow-up after the incidents. The DON later identified Resident #5 as the resident involved in the 2/17/26 incident, but the investigation still lacked documentation of the other resident's identity, and the DON acknowledged there was no follow-up or assessment of Resident #5 at the time.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure staff protected a resident from resident-to-resident abuse when one resident struck another resident on the right upper arm while the second resident was seated with a staff member. The incident report stated that the aggressive resident approached the staff member, attempted to grab belongings, yelled, and then moved to the dining room table where the other resident was sitting. As the other resident talked, the aggressive resident told the resident to shut up and slapped the resident on the shoulder/arm. The staff member did not intervene until after the strike occurred and then sat between the residents to separate them. The resident who struck the other resident had a documented history of behavioral issues and altercations with other residents. The MDS identified severe cognitive impairment with a BIMS score of 4, verbal behavioral symptoms toward others, and diagnoses including non-Alzheimer's dementia, Alzheimer's disease, anxiety, and depression. The care plan documented that the resident could become verbally aggressive, take other residents' food or belongings, yell at or enter other residents' rooms, and had previously placed hands on another resident. The staff member interviewed about the incident stated she was aware of the resident's aggression but believed it was best to let her walk around and do her thing because she was hard to redirect.
Unsanitary Ice Machine and Inadequate Cleaning Practices
Penalty
Summary
The facility failed to maintain a sanitary kitchen and failed to serve and prepare food in accordance with professional standards for food safety to reduce the risk of cross contamination and food borne illness. On 3/2/26, the ice machine was observed covered in mineral deposit build-up on the sides, with mineral deposit streaks inside the machine and small pin point black particles on the white plastic baffle. On 3/3/26, the ice machine remained in the same condition. On 3/4/26, the Maintenance Supervisor stated he deep cleaned and descaled the ice machine every 6 months and that the kitchen cleaned it weekly, but also reported the mineral deposit build-up had been an ongoing issue and that nothing gets it fully cleaned. The Dietary Manager stated the ice machine is cleaned every other week and reported she could not get the buildup off the machine or get the inside clean, despite trying several different products. The facility policy titled Ice Machine and Ice Storage Chests, revised January 2012, states the facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions, but further review of the policy lacked direction if the ice machine could not be cleaned properly.
Deficiency in Nutrition Services Staffing
Penalty
Summary
The facility failed to employ a clinically qualified nutrition professional who met the required qualifications of a Certified Dietary Manager or a full-time Registered Dietitian, as indicated in their Facility Assessment. The facility, with a census of 41 residents, has been without a kitchen manager for approximately six months. Staff A, who has been with the facility for about three years, has been assisting with some duties such as ordering supplies but is not officially the kitchen manager. The previous Certified Dietary Manager still works at the facility but no longer holds that position and works approximately 25 hours a week, occasionally picking up extra shifts. The Registered Dietitian visits the facility about once a month, and a traveling Certified Dietary Manager from the corporation has visited several times to assist. Staff F, a cook, was the prior Dietary Manager for the building.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents where residents received incorrect medications or dosages. Over a period from May 2024 to February 2025, eight residents were affected by these errors. These included instances where residents received medications that were either discontinued or administered at incorrect dosages, such as a resident receiving a double dose of Clozapine and another receiving both AM and MD doses of Gabapentin simultaneously. Staff interviews revealed concerns about frequent medication errors, particularly involving a Registered Nurse (RN), Staff G, who was reported to have made several errors. Despite these concerns, the facility did not adequately investigate or address the issues to prevent further occurrences. The Director of Nursing (DON) acknowledged the errors and mentioned that Staff G was written up for a medication error in August, but no further actions or audits were conducted to monitor medication administration practices. The facility's policy on administering medications, revised in April 2019, directed staff to verify the right resident, medication, dosage, time, and method before administration. However, this policy was not effectively implemented, as evidenced by the repeated medication errors. The DON reported that interruptions during medication passes contributed to these errors, but no immediate corrective measures were taken to address this issue.
Failure to Follow Dietary Protocols and Menu Adherence
Penalty
Summary
The facility failed to adhere to the posted menu and serve appropriate portions for residents on specialized diets. During a lunch observation, it was noted that residents on pureed diets did not receive the full menu as posted, including the omission of dinner rolls. Additionally, residents on low sodium diets were served garden rice instead of the prescribed white rice. The facility also failed to provide requested substitutions, such as grilled cheese sandwiches, due to inadequate preparation and stock. The facility's Nutritional Intervention Program (NIP) was not properly implemented, as 9 out of 19 residents did not receive the additional calories or nutrition indicated on their menu cards. This included the absence of extra food items like ice cream, which was out of stock. Staff A, responsible for meal preparation, did not measure the total volume of pureed food as required, and there was a lack of adherence to the puree process instructions posted in the kitchen. Staff interviews revealed a lack of awareness and adherence to dietary protocols, with some staff unaware of the impact of adding broth to pureed food volume. The Registered Dietitian expressed expectations for proper meal preparation and service, which were not met. The Director of Nursing indicated a misunderstanding of the menu card program, suggesting that residents unable to select their meals should receive the full meal within their dietary restrictions.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to serve food within the acceptable temperature range, as observed during a lunch service. Staff A, a cook, was responsible for preparing and serving meals to residents requiring a pureed diet. While the hot foods were at appropriate temperatures, the cold foods were not. Specifically, chilled pears were at 41.5°F, chef salad and cottage cheese were at 45°F, and milk was at 38.9°F. These temperatures were recorded at 11:23 AM, and the items were left at room temperature until service began at 11:30 AM. Notably, the chef salad was served to a resident 21 minutes after it was initially checked, still at an unsafe temperature. Staff A admitted to serving the cold items regardless of their temperature, believing they were acceptable since they had just been taken out of the refrigerator. The Registered Dietitian later confirmed that cold foods should not be served unless they are at 41°F or colder. The facility's policy, revised in April 2019, and the 2022 FDA Food Code both emphasize that potentially hazardous foods must be maintained below 41°F or above 135°F to prevent the growth of harmful pathogens. This oversight in maintaining proper food temperatures led to the deficiency noted in the report.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their records. Resident #1 was identified as having a Level II Preadmission Screening and Resident Review (PASRR) due to a serious mental illness, but their annual MDS assessment incorrectly coded them as a PASRR Level I, indicating no serious mental illness. This error was attributed to confusion among the staff, as reported by the Assistant Director of Nursing (ADON). The Director of Nursing (DON) acknowledged the absence of a specific policy for MDS coding, relying instead on the Resident Assessment Instrument (RAI) Manual, which clearly directs coding for Level II PASRR if a serious mental illness is determined. Resident #33's MDS assessment failed to document verbal behavioral symptoms towards others, despite reports and grievances indicating such behavior. A fellow resident reported being bullied by Resident #33, and the Administrator confirmed that Resident #33 exhibited annoyance and verbal aggression towards others. However, the MDS assessment did not reflect these behaviors during the 7-day lookback period, as required by the RAI Manual. The manual provides specific instructions for reviewing medical records, interviewing staff, and observing residents to accurately code behavioral symptoms, which were not followed in this case.
Failure to Follow Care Plan for Resident Requiring Meal Assistance
Penalty
Summary
The facility failed to adhere to the comprehensive care plan for a resident who required partial/moderate assistance for eating due to conditions such as cerebral infarction, multiple sclerosis, and dysphagia. The care plan specified that the resident needed one-on-one assistance during meals, encouragement to take small bites, alternate bites with drinks, and remain upright after meals. However, observations on two consecutive days revealed that the resident was left to eat independently without the required one-on-one assistance or reminders to follow the prescribed eating strategies. Staff members were present in the dining area but did not provide the necessary support or cues to the resident, contrary to the care plan directives. During the observations, various staff members, including CNAs and the DON, were present in the dining room but did not engage with the resident as required by the care plan. The resident was seen feeding herself without assistance, and staff members were either engaged in conversations with each other or attending to other residents. The DON later expressed uncertainty about the current need for one-on-one assistance, indicating a possible lack of communication or update regarding the resident's care needs. This lack of adherence to the care plan represents a deficiency in the facility's obligation to provide the necessary care and supervision as outlined in the resident's care plan.
Failure to Update Care Plans for Resident Conflicts and Behaviors
Penalty
Summary
The facility failed to update the care plans for two residents, leading to deficiencies in addressing interpersonal conflicts and behavioral issues. Resident #7, who has intact cognition and diagnoses of anxiety disorder, bipolar disorder, and PTSD, reported being bullied by Resident #33, which made her cry. Despite these interactions being known to the staff and the administrator, Resident #7's care plan did not address any conflict with other residents. The facility's staff were aware of the issues between the two residents and attempted to manage the situation by moving Resident #7 to a different dining table, but no formal updates were made to her care plan to reflect these interventions. Resident #33, with moderate cognitive impairment and a diagnosis of non-Alzheimer's dementia, exhibited negative behaviors towards other residents, including yelling and causing another resident to cry. Despite these incidents, Resident #33's care plan did not document any negative or aggressive behaviors or the psychiatric/mental health therapy she was receiving. The MDS Coordinator, new to the job, was responsible for updating care plans but had not yet addressed these issues. The facility's policy requires the interdisciplinary team to develop individualized comprehensive care plans, which was not adhered to in these cases.
Failure to Provide Dietitian-Approved Pureed Bread
Penalty
Summary
The facility failed to provide the Dietitian-approved menu for four residents on a pureed diet. During a lunch observation, it was noted that these residents did not receive pureed bread as specified in their therapeutic menu. The residents involved had varying levels of cognitive impairment and required different degrees of assistance with eating, as documented in their Minimum Data Set (MDS) assessments and doctor's orders. Despite the menu indicating that pureed bread should be served, it was not provided to the residents on the specified date. Staff interviews revealed that the cook and the Certified Dietary Manager (CDM) had never served pureed bread and were unaware of how to prepare it. The CDM admitted to removing the bread from the menu without informing the Dietitian, citing that the residents did not like it. This deviation from the approved menu altered the nutritional content of the meals served. The Registered Dietitian confirmed that the menu was designed to be nutritionally adequate and that pureed bread should have been included. The Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) acknowledged the issue. The Dietitian, who had recently started at the facility, was unaware that pureed bread was not being served and stated that the kitchen staff should follow the approved menus. The facility's policy on menus, revised in October 2017, directed that any deviations from posted menus should be recorded and archived, which was not done in this case.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to send notice to the State Long Term Care Ombudsman regarding the transfer of two residents to the hospital. For Resident #13, the facility did not document the therapeutic leave in November 2023, nor the hospital admissions in January, February, and March 2024 in the Ombudsman reports. The Administrator acknowledged the oversight but was unsure why these residents were missed in the reports. Additionally, the facility lacked a specific policy for ombudsman reporting, although the Administrator claimed they followed the regulations for reporting. For Resident #26, the facility did not document the hospital transfers in September 2023, November 2023, and March 2024 in the Ombudsman reports. The progress notes indicated multiple instances where the resident was transferred to the emergency room and either admitted to the hospital or returned to the facility, but these events were not reported to the Ombudsman. The Administrator confirmed the absence of a policy for ombudsman reporting and was unaware of the reasons for the missed documentation.
Failure to Complete Timely PASRR Evaluation
Penalty
Summary
The facility failed to complete a new Preadmission and Resident Review (PASRR) evaluation as required for one resident. The resident had a Minimum Data Set (MDS) assessment indicating moderate cognitive impairment and diagnoses of depression, bipolar disorder, and dementia. The resident's PASRR Level II Outcome indicated that the short-term approval ended on 4/13/24. However, the MDS Coordinator did not submit a new PASRR for review until 4/13/24, which was determined on 4/18/24, after the expiration of the approved short-term period. The MDS Coordinator was unaware that a new PASRR needed to be completed and determined before the expiration date. The facility did not have a policy for PASRR and reported following the regulations.
Improper Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to properly care for and accurately document pressure ulcers for a resident. During a pressure ulcer dressing change, staff did not use a cleanser to clean the resident's sacral/coccyx pressure ulcer. Instead, a damp towel was used, which was not in accordance with the doctor's orders. The Director of Nursing (DON) and the Licensed Practical Nurse (LPN) involved were unaware of the specific wound care instructions, leading to improper wound cleaning and dressing application. The Advanced Registered Nurse Practitioner (ARNP) acknowledged the concern and stated that the wound order would be revised to ensure proper cleaning and prevent infection. The facility also failed to update the stages of the resident's pressure ulcers accurately. The Minimum Data Set (MDS) assessment documented the presence of Stage 1 and Stage 3 pressure ulcers, but observations and evaluations revealed discrepancies. The Assistant Director of Nursing (ADON) noted that the coccyx pressure ulcer should be classified as unstageable due to the presence of slough, and the Stage 1 pressure ulcer on the right heel should be coded as Stage 2 after verifying the wound's depth. The DON acknowledged the concerns regarding the improper staging of the pressure ulcers. The facility's Wound Care policy, revised in October 2016, directed staff to verify the physician's order for wound care procedures, assemble necessary equipment and supplies, and clean the tissue around the wound with antiseptic or soap and water. However, the staff did not follow these guidelines, leading to improper wound care and documentation. The facility's failure to adhere to proper wound care protocols and accurately document the stages of pressure ulcers resulted in a deficiency in the care provided to the resident.
Failure to Re-evaluate PRN Antipsychotic Medication
Penalty
Summary
The facility failed to forward a pharmacy recommendation to the physician for re-evaluation of a 14-day PRN Haloperidol (Haldol) order for a resident. The pharmacist had recommended that the PRN order, initially prescribed for anxiety and delusions, be reviewed and potentially renewed by the physician after the mandatory 14-day period. However, the facility did not follow this recommendation, and the PRN Haloperidol was administered 28 times from the 15th day to the 32nd day without physician re-evaluation or a new order being issued. The Assistant Director of Nursing (ADON) acknowledged the oversight and could not provide a rationale for continuing the PRN Haloperidol beyond the 14-day period. The ADON admitted that the information should have been forwarded to the physician for review and that the PRN order should have been discontinued after 14 days as per the facility's PRN Medication Policy. This failure to adhere to the policy resulted in the resident receiving the medication without the necessary re-evaluation by a healthcare practitioner.
Failure to Meet QAA Committee Member Requirements
Penalty
Summary
The facility failed to have the minimum required members at the Quality Assessment and Assurance (QAA) meetings, as mandated by regulations. The review of the facility's QAA sign-in sheets revealed that the meetings for the first four of six quarters included the Administrator, Medical Director, Director of Nursing (DON), Infection Preventionist, and one other staff member, falling short of the required six members. During an interview, the DON admitted to misunderstanding the regulation, believing that only five members were required. The facility's Quality Assurance and Performance Improvement (QAPI) Program indicated that the QAA Committee should meet at least quarterly and include representatives from six other departments, as requested by the Administrator.
Failure to Perform Proper Hand Hygiene and PPE Guidelines During Peri-Care
Penalty
Summary
The facility failed to perform proper hand hygiene and follow personal protective equipment guidelines during peri-care for a resident diagnosed with septicemia, recurrent enterocolitis due to clostridium difficile, and hypertension. During an observation, a CNA assisted the resident off a bedpan, performed hand hygiene, and applied a gown and gloves. After completing the peri-care, the CNA used the same dirty gloves to handle a clean brief and other clean surfaces without performing hand hygiene or changing gloves. Interviews with the ADON and DON confirmed that staff are expected to change gloves after peri-care before touching clean items. The facility's policy on perineal care lacked specific instructions for removing gloves after completing peri-care before touching any clean surface.
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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