Crestview Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in West Branch, Iowa.
- Location
- 451 West Orange Street, West Branch, Iowa 52358
- CMS Provider Number
- 165287
- Inspections on file
- 22
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Crestview Specialty Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple risk factors developed a Stage 3 pressure ulcer after admission. Staff failed to follow physician orders for wound care, did not use infection control techniques, omitted required wound treatments, and did not implement pressure-relieving interventions such as an air mattress or regular repositioning. The resident was left in a wheelchair for hours without assistance, and staff were unaware of the resident's skin breakdown, resulting in the development of a new unstageable pressure ulcer.
Two residents did not receive wound care as ordered, with missed or undocumented treatments, improper dressing application, and lack of provider notification when care was refused. Staff interviews and record reviews confirmed that wound assessments and documentation were incomplete, and facility policy for wound care and communication was not consistently followed.
Several residents with severe cognitive impairment and mobility limitations experienced unsafe transfers and incomplete post-fall assessments. One resident fell from a mechanical lift due to improper sling attachment, resulting in fractures and a head injury. Another resident was assisted without a gait belt and fell, while a third was found on the floor without appropriate neurological evaluation. Additionally, a resident requiring two-person assistance was transferred by one CNA without a gait belt. Staff did not consistently follow care plans, manufacturer instructions, or facility policies, leading to injuries and inadequate supervision.
Surveyors found that mechanical lifts and a wheelchair remained visibly soiled over multiple days, and a soiled incontinence pad was left on a bed. CNAs confirmed responsibility for cleaning and stated that soiled items should be removed immediately, but these tasks were not completed as required by facility policy.
A resident with moderate cognitive impairment who required assistance with bathing and personal hygiene did not receive a bath or shower for 17 days due to insufficient staffing. Multiple staff members, including CNAs, RNs, and LPNs, reported being unable to complete required care tasks, such as wound care and scheduled baths, because of routine understaffing. Staff also described situations where residents received meals in their rooms and feeding assistance was delayed, highlighting ongoing staffing shortages despite facility policies intended to address such issues.
Three residents experienced a lack of dignity and respect in their care, including not being offered meal choices, being left in soiled bedding and rooms with persistent odors, and being left undressed and exposed in bed. Staff failed to maintain a clean environment and did not consistently uphold residents' rights to a dignified existence.
A resident with moderate cognitive impairment and diagnoses of dementia and depression was administered risperidone, an antipsychotic medication, without documented informed consent from the responsible party. Staff interviews and record reviews confirmed that the required consent process was not followed, and the care plan did not reflect the use of the medication, contrary to facility policy.
Several residents, including those with cognitive impairments and incontinence, did not receive required assistance with bathing and personal hygiene, with some going extended periods without baths and one resident not receiving needed incontinence care. Staff interviews indicated that missed care was due in part to short staffing, and documentation did not reflect resident refusals or consistent attempts to provide care.
A resident with severe cognitive impairment and a history of pressure ulcers developed a new Stage 2 ulcer on the left heel due to inconsistent use of prescribed protective boots. Despite a care plan requiring bilateral Prafo boots, the resident was observed wearing tennis shoes, leading to the ulcer's recurrence. Staff confusion and inconsistency regarding footwear contributed to the deficiency.
The facility failed to respond to call lights within 15 minutes for several residents, as observed during the survey. A resident with intact cognition and requiring assistance activated the call light, but personal care was delayed. Another resident with medical conditions also experienced delays in receiving assistance. Staffing levels did not meet the Facility Assessment requirements, contributing to the delays, particularly on weekends. The facility's outdated call light system further complicated the issue.
The facility failed to maintain proper hand hygiene during a meal service, as observed with staff not washing hands after handling food and touching various surfaces. Despite training and policy requirements, staff did not adhere to handwashing protocols, leading to potential cross-contamination.
The facility did not have a certified Infection Preventionist (IP) as required by their policy. The Assistant DON was still completing the necessary training. The DON, who is new and not certified, suggested regional personnel for the IP interview. The Regional Director of Operations, not being a nurse, stated that collaboration with the Regional Nurse Consultant and the DON was needed to decide on the interview process, as no IP was on staff.
A facility failed to notify the OSLTO of two hospital transfers for a resident with intact cognition and multiple diagnoses, including cancer and schizophrenia. The resident was transferred to the hospital four times, but the facility did not report two of these transfers. Staff interviews revealed that the social worker was responsible for notifications, and the decision to report was based on whether the transfer was overnight.
A resident with a history of heart and lung conditions returned from the hospital with new medication orders, which were not entered into the eMAR by the facility staff. This oversight led to the resident not receiving critical medications, resulting in worsening respiratory distress and rehospitalization. The error was discovered by a regional nurse, highlighting a breakdown in communication and procedure within the facility.
A resident with no cognitive impairment reported that staff searched her room without consent while she was away, leaving her belongings unorganized. The search was conducted to find a missing remote belonging to her roommate. The ADON and DON were aware of the incident, which violated the facility's Resident Rights policy emphasizing respect and dignity.
The facility failed to accurately assess and respond to the worsening conditions of two residents, leading to severe outcomes. One resident experienced worsening gastrointestinal symptoms over four days, resulting in death after emergent hospital treatment. Another resident experienced worsening edema and inability to urinate, leading to hospitalization. Additionally, a resident with diabetes missed insulin doses due to incorrect transcription of a physician's order, resulting in hospitalization for Diabetic Ketoacidosis.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, left femur fracture, and malnutrition was admitted to the facility without any pressure ulcers and was assessed as being at risk for developing them. The resident was dependent on staff for all transfers, bed mobility, dressing, and toilet hygiene, and had an indwelling urinary catheter with frequent bowel incontinence. Despite being identified as at risk, the care plan did not address the development of a Stage 3 pressure ulcer that was identified on the resident's sacrum. Physician orders were issued for wound treatments, an air mattress, and repositioning every two hours, but these interventions were not consistently implemented. Observations revealed multiple failures in following physician orders and standard care practices. The resident was found without a dressing on the pressure ulcer, and infection control techniques were not utilized during wound care. The air mattress, which was ordered to reduce pressure, was not in place on several occasions. Staff omitted key components of the wound care treatment, such as the application of calcium alginate, and failed to perform hand hygiene or change gloves during wound care. The resident was also left in a wheelchair for extended periods without repositioning or toileting assistance, and staff were unaware of the resident's skin impairments. Further observations documented that the resident's sacral wound was left without a dressing, and a new open area developed on the coccyx. The air mattress intervention continued to be unimplemented, and the resident was found with incontinent stool on the buttocks. Nursing staff admitted to being behind on treatments and not completing wound care as ordered. The care plan and Braden scale assessments were not updated to reflect the resident's changing condition, and the facility failed to ensure timely and appropriate interventions to prevent further skin breakdown.
Failure to Follow Physician Orders and Document Wound Care
Penalty
Summary
The facility failed to assess and follow physician treatment orders for non-pressure wound care for two residents. For one resident with peripheral vascular disease, traumatic compartment syndrome, diabetes, and atrial fibrillation, there was a lack of documentation regarding wound measurements or assessments for vascular wounds on both heels. The treatment administration record showed missed or undocumented wound care on scheduled days, and there was no evidence that the provider was notified when the resident refused wound care. Additionally, a vascular surgery clinic note indicated that the resident had not received proper wound care at the facility, and the family expressed distress over the lack of care during a medical appointment. For another resident with moderate cognitive impairment, esophageal obstruction, dysphagia, heart failure, and chronic kidney disease, the care plan required regular skin evaluations and specific wound care for a skin tear on the left calf. The treatment administration record revealed missed documentation of scheduled wound care, and during an observation, the dressing applied was not consistent with the physician's order. Staff interviews confirmed that the correct dressing was not used and that wound care was not always performed as ordered. Facility policy required verification of physician orders, adherence to care plans, and notification of supervisors if wound care was refused. However, staff interviews and record reviews demonstrated that these procedures were not consistently followed, resulting in missed or improper wound care and lack of appropriate documentation and communication regarding resident refusals and wound status.
Failure to Use Safe Transfer Techniques and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure safe transfer techniques and adequate supervision to prevent accidents for multiple residents, resulting in significant injuries and incomplete post-fall assessments. One resident with severe cognitive impairment and a history of fractures was transferred using a mechanical lift by a CNA who did not follow manufacturer instructions for sling attachment. The resident fell from the lift, sustaining a sacral fracture, tibial plateau fracture, and head injury. The CNA operated the lift alone, did not cross the sling straps as required, and the incident was not immediately reported to the state agency. The facility's own policy and the lift manufacturer's instructions were not followed during this transfer. Another resident with severe cognitive impairment and a history of falls was assisted from a dining room chair without the use of a gait belt, contrary to care plan requirements. The resident fell, complained of dizziness and back pain, and developed a chin bruise. Staff failed to check the resident's range of motion before moving her from the floor, and neurological assessments were not completed as required by facility protocol. Similarly, a third resident with severe cognitive impairment and a history of crawling on the floor was found on the floor by staff, but the event was not treated as an unwitnessed fall, and a neurological assessment was not initiated as required by policy. Additionally, another resident dependent on two staff for transfers was observed being transferred by a single CNA without a gait belt, in violation of the care plan and facility policy. Staff interviews confirmed that transfers were not performed according to established protocols, and staff were not consistently using required safety equipment. Facility policies on safe lifting, neurological assessment, and fall protocols were not followed, leading to preventable injuries and incomplete post-incident assessments for multiple residents.
Failure to Maintain Clean Resident Equipment and Environment
Penalty
Summary
Surveyors observed multiple instances of unclean resident equipment and environmental surfaces within the facility. A full body mechanical lift in one hallway had a brown smear on its leg that remained uncleaned over two consecutive days. Similarly, a mechanical sit-to-stand lift in another hallway had a heavily soiled foot plate with debris that was not addressed over the same period. Additionally, a high back wheelchair was found in the hallway with a yellow-stained towel on its seat, which was not removed or cleaned throughout the day. In a resident room, brown spots and smears were noted on the bathroom floor near the toilet, and a soiled incontinence pad was left on the bed. Interviews with CNAs confirmed that staff were responsible for cleaning mechanical lifts, changing bed linens, and removing soiled incontinence pads. Both interviewed CNAs stated that soiled incontinence pads should not be left on beds and that cleaning of equipment and surfaces was part of their duties. Review of the facility's cleaning and disinfection policy indicated that environmental surfaces and equipment should be cleaned and disinfected regularly and when visibly soiled, in accordance with CDC and OSHA standards. The observations and staff interviews demonstrated a failure to maintain a clean and safe environment as required by facility policy.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the individualized needs of residents, as evidenced by clinical record review, staff interviews, and facility policy review. One resident with moderate cognitive impairment, requiring moderate assistance for bathing and partial assistance for personal hygiene, did not receive a bath or shower for a period of 17 days. Staff interviews revealed that certified nursing assistants (CNAs) and registered nurses (RNs) were unable to complete all required personal care tasks due to routine understaffing. Staff reported that these concerns had been brought to management multiple times without any observed improvement. Additional interviews with licensed practical nurses (LPNs), RNs, and CNAs indicated that wound care treatments and scheduled baths were often delayed or missed when medication aides were not available or when only one CNA was assigned to a hallway with approximately 25 residents, many of whom required two staff members for mechanical lift transfers. Staff also reported that, due to insufficient staffing, residents sometimes received meals in their rooms instead of the dining room, and feeding assistance was provided one at a time. The facility's assessment stated that staffing was based on resident acuity and that contingency plans existed for staff call-outs, but staff consistently reported that these measures were insufficient to address ongoing staffing shortages.
Failure to Ensure Resident Dignity and Respect in Care and Environment
Penalty
Summary
The facility failed to provide a respectful and dignified environment for three residents, as evidenced by multiple observations and interviews. One resident, who was cognitively intact and dependent on staff for toileting and mobility, was not offered meal choices according to her preferences. Staff delivered an incorrect meal and, without asking the resident for her preference, substituted it with a food item not listed on the menu or alternative menu. The resident reported that she is never asked what she would like to eat and is typically given whatever is available, rather than being provided with options. Another resident with bowel incontinence and frequent diarrhea was observed multiple times in a room with a strong odor of feces and urine, and with visibly soiled sheets and floors. The resident confirmed that his sheets had been soiled since the previous night. Observations over several days revealed persistent dried feces on the bed sheets, floor, and bathroom surfaces. Staff interviews confirmed awareness of the soiled conditions, and the CNA job description included maintaining a clean and pleasant environment, which was not upheld in this case. A third resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was found lying in bed without an incontinence product and with pants pulled down around her ankles. This condition persisted during subsequent observations until the DON intervened to provide care and clothing. The resident expressed feeling cold during this time. Facility policy requires residents to be treated with dignity and respect, which was not observed in these instances.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of an antipsychotic medication, risperidone, for one resident diagnosed with non-Alzheimer's dementia and depression. Clinical record review showed that the resident had moderate cognitive impairment, as indicated by BIMS scores of 9 and 11 on separate assessments. The resident began receiving risperidone on a routine basis, as documented in progress notes and the Minimum Data Set (MDS) assessments. However, there was no documentation of informed consent from the resident's responsible party for the use of this psychotropic medication during the period from when the medication was initiated through the time of the survey. Staff interviews confirmed that the process for obtaining consent was not followed, with the Licensed Practical Nurse stating that the nurse who received the order should have contacted the family or resident to obtain and document consent in the chart. The facility's policy on antipsychotic medication use, dated 12/2016, requires that informed consent be obtained, but review of the resident's evaluations and care plan revealed no such documentation. The care plan also failed to include the use of the antipsychotic medication.
Failure to Provide Required Bathing and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically in the areas of bathing and incontinence care, for several residents. One resident with severe cognitive impairment, non-Alzheimer's dementia, schizophrenia, and congestive heart failure was observed with visibly wet clothing and was not assisted by staff with changing or incontinence care, despite care plan interventions indicating the need for staff assistance. Staff acknowledged the resident's inability to perform self-care after incontinence and confirmed that staff should have reapproached and assisted the resident. Multiple residents did not receive the required twice-weekly bathing. One resident with intact cognition and no documented refusals had no baths recorded during their stay. Another resident with severe cognitive impairment and no history of care refusal went up to 14 days without a bath, with documentation showing missed or unattempted baths and only one recorded refusal. A third resident with intact cognition and no refusal behavior had no documented baths for 27 days, with only one recorded refusal, and staff interviews indicated that the resident rarely refused bathing and liked to be clean. Additionally, a resident with moderate cognitive impairment and frequent incontinence was observed to be unshaven, with greasy hair and dirty clothing on consecutive days, and staff reported that the resident did not refuse bathing. Bathing records for this resident showed missed or unattempted baths due to environmental limitations or lack of staff. Staff interviews revealed that short staffing contributed to missed baths, and the facility's policy required assistance with ADLs to maintain hygiene, which was not consistently provided.
Failure to Prevent Recurrence of Pressure Ulcer
Penalty
Summary
The facility failed to prevent the recurrence of a pressure ulcer for a resident, identified as Resident #27, who had a history of severe cognitive impairment and was dependent on staff for dressing and footwear. The resident had previously healed from a Stage 4 pressure ulcer on the left heel, which was resolved in September. However, a new Stage 2 pressure ulcer developed in the same area by October. The resident was assessed as being at moderate to high risk for pressure injuries, as indicated by the Braden Scale scores. The care plan for the resident included the use of bilateral Protective Relief Ankle Foot Orthosis (Prafo) boots to prevent pressure ulcers. Despite this, observations and interviews revealed that the resident was not consistently wearing the prescribed protective boots. Instead, the resident was found wearing tennis shoes, which were not recommended by the wound care provider. Staff interviews indicated confusion and inconsistency regarding the resident's footwear, with some staff members unsure about when the resident should wear the protective boots. The Family Nurse Practitioner and the Director of Nursing both acknowledged that the recurrence of the pressure ulcer could have been prevented if the resident had consistently worn the protective boots. The facility's policy on wound care emphasized the importance of following physician orders and care plans, but this was not adhered to in the case of Resident #27. The lack of consistent application of the prescribed protective measures contributed to the recurrence of the pressure ulcer on the resident's left heel.
Staffing Shortages Lead to Delayed Call Light Responses
Penalty
Summary
The facility failed to respond to call lights within 15 minutes for four residents, as observed during the survey. Resident #12, who had intact cognition and required assistance for various activities, activated the call light at 12:50 PM. Although an LPN turned off the call light and administered insulin, personal care was not provided, and the resident had to wait until 1:08 PM for a CNA to assist with toileting. Similarly, Resident #204, with intact cognition and medical conditions that required assistance, activated the call light at 9:12 AM. An LPN turned off the light at 9:25 AM, promising to send help, but the resident continued to wait until 9:45 AM for assistance from CNAs. Resident #6, with a history of falls and intact cognition, reported that call lights often took 20-30 minutes to be answered, occurring every other day across all shifts. Resident #50, also with intact cognition and dependent on staff for transfers and personal hygiene, confirmed that call lights took 20 minutes or more to be answered. The facility's policy on answering call lights did not specify a time frame, contributing to the delay in response times. The facility's staffing levels did not meet the requirements outlined in the Facility Assessment for several days. The Daily Staffing Plan required two licensed nurses, two medication aides, and six CNAs on the day shift, but records showed that staffing levels were often below these requirements. Interviews with staff and the Director of Nursing revealed that staffing shortages, particularly on weekends, contributed to the delays in responding to call lights. The facility's call light system was also outdated, preventing the production of call light records or logs, further complicating the issue.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
During a noon meal service, the facility failed to adhere to proper hand hygiene practices, leading to potential cross-contamination of food. Observations revealed that Staff H wiped his hand on his shirt after handling a pan of food from the oven. Staff G, after touching various surfaces and handling food, did not wash her hands before returning to the serving line. She caught a spilled mixture of lettuce and cheese with her bare hand and returned it to the preparation pan. Additionally, Staff G handled meal request slips, disposed of them, and continued plating food without washing her hands. Both Staff G and Staff H were observed leaving and returning to the serving area without washing their hands. The Certified Dietary Manager (CDM) confirmed that handwashing was covered in both orientation and ongoing training, and expressed that staff should wash their hands before serving and after any contamination. The facility's handwashing policy, revised in 2020, mandates handwashing after contact with unclean surfaces and when moving between different areas, which was not followed during the observed meal service.
Lack of Certified Infection Preventionist in Facility
Penalty
Summary
The facility failed to have a qualified Infection Preventionist (IP) who completed specialized training in infection prevention and control, as required by their policy. During an interview, the Director of Nursing (DON) and Regional Nurse Consultant confirmed that the facility did not have a certified IP. The Assistant DON was in the process of completing the necessary training but had not yet finished. The DON, being new to the position and not certified, suggested that the IP interview should be conducted with regional personnel. The Regional Director of Operations, who is not a nurse, indicated that collaboration with the Regional Nurse Consultant and the DON would be necessary to determine the appropriate person to conduct the interview, as no IP was currently on staff. The facility's policy, revised in September 2017, requires the IP to conduct ongoing surveillance for Healthcare-Acquired Infections (HAIs) and other significant infections that may impact resident outcomes and require preventative interventions.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Ombudsman (OSLTO) of two separate hospital transfers for a resident. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status score of 13 out of 15, was diagnosed with cancer, schizophrenia, and an excoriation disorder. The resident's care plan included focus areas for impaired cognitive function, risk for skin and soft tissue infection, mental health support, and diabetic ulcers on eight fingers. The resident was transferred to the hospital on four occasions, but the facility did not include the May and June transfers in the notifications to the OSLTO. Interviews with facility staff revealed that the social worker was responsible for submitting discharge information to the OSLTO. The Administrator stated that the decision to report a transfer depended on whether it was an overnight stay. The Social Services Director confirmed that she did not include transfers if the resident returned the same day. This oversight resulted in the omission of a same-day return transfer and a five-day hospital visit from the required notifications.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medication as ordered by the physician for a resident who had recently returned from the hospital. The resident, who had a history of acute congestive heart failure, chronic kidney disease, atrial fibrillation, and pneumonia, was admitted to the emergency department with acute hypoxic respiratory failure. Upon discharge back to the facility, the resident received new physician orders for medications including albuterol, prednisone, Spiriva, and an increased dose of furosemide. However, these new orders were not entered into the electronic Medication Administration Record (eMAR) by the staff nurse, resulting in the resident not receiving the prescribed medications. The resident's condition worsened due to the lack of medication administration, leading to increased shortness of breath, lethargy, and low oxygen saturation levels. The resident was readmitted to the hospital, where it was discovered that the new medication orders had not been implemented since the resident's return to the facility. The failure to administer the medications as ordered was identified by the corporate regional nurse, prompting a self-report to the state and a subsequent investigation. Interviews with facility staff revealed that the new orders were not entered into the system due to a series of miscommunications and oversights. The agency nurse who assisted with the resident's readmission handed the paperwork to the Director of Nursing (DON), who then left the facility due to illness without ensuring the orders were processed. The Assistant Director of Nursing (ADON) later discovered the oversight but was unable to retrieve the orders in a timely manner, as they were locked in the DON's office. This chain of events led to a significant medication error, contributing to the resident's deterioration and eventual rehospitalization.
Removal Plan
- Education provided to nursing staff
- Charge nurse responsible to complete on any admission or transfer in from the hospital followed by double noting by two nurses
Unauthorized Search of Resident's Belongings
Penalty
Summary
The facility failed to respect the personal property and possessions of a resident when staff searched the resident's room without consent. The incident involved a resident who had no cognitive impairment and used a wheelchair for mobility, with diagnoses including post-polio syndrome, rheumatoid arthritis, and paraplegia. The resident reported that while she was away for a physician's appointment, staff searched her belongings without her knowledge, leaving them unorganized. The search was conducted in an attempt to locate a missing television remote belonging to the resident's roommate. Staff interviews revealed that the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were aware of the incident. The ADON confirmed that the resident reported the unauthorized search, and the DON acknowledged instructing staff not to search residents' belongings without their knowledge. The facility's Resident Rights policy, revised in December 2016, emphasizes treating residents with respect and dignity, and ensuring they are free from misappropriation of property. Despite this policy, the staff's actions violated the resident's rights, as they conducted the search without obtaining the resident's consent.
Failure to Assess and Respond to Resident Conditions
Penalty
Summary
The facility failed to accurately assess and respond to the worsening conditions of two residents, leading to severe outcomes. One resident, with a history of traumatic brain injury, diabetes, and other conditions, experienced worsening gastrointestinal symptoms over four days, including stomach ache, abdominal tenderness, and emesis. Despite these symptoms, the facility staff did not notify the medical provider or seek treatment orders in a timely manner. The resident's condition deteriorated, requiring emergent medical treatment in the hospital emergency room, where they died within six hours of admission due to complications including acute respiratory distress syndrome, small bowel obstruction, and acute pancreatitis. Another resident, admitted with diagnoses including congestive heart failure and diabetes, experienced worsening edema and an inability to urinate over two days. The facility failed to document and assess these symptoms adequately, resulting in the resident's hospitalization for urinary retention, suspected bladder malignancy, and acute kidney injury. The facility also failed to administer the resident's prescribed medications promptly due to a delay in completing the admission assessment and entering medication orders into the system. Additionally, the facility failed to correctly transcribe a physician's order for insulin for a resident with diabetes, leading to missed insulin doses and the resident's hospitalization for Diabetic Ketoacidosis. The resident's care plan lacked focus on insulin administration and blood sugar monitoring, contributing to the oversight. The facility's failure to ensure accurate medication administration and timely medical intervention resulted in significant adverse outcomes for the residents involved.
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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