Citations in Iowa
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Iowa.
Statistics for Iowa (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Iowa
Staff failed to perform proper hand hygiene and follow infection control protocols during medication administration for multiple residents. An LPN and an RN were observed not cleaning hands before applying gloves, handling medications and equipment with soiled gloves, using unclean medication tools, and not disinfecting inhalers before returning them to the medication cart, contrary to facility policy.
Three residents with urinary catheters were observed with uncovered catheter bags visible from the hallway or doorway, with urine clearly seen in the bags. Facility policy requires catheter bags to be covered to maintain resident dignity, and staff confirmed this expectation.
Three residents requiring assistance with bathing did not consistently receive scheduled baths, as confirmed by clinical records, resident interviews, and staff reports. Despite care plans and facility policy mandating regular bathing, documentation showed multiple missed baths, and residents reported not being routinely offered bathing opportunities. Staff shortages and changes in bath scheduling contributed to the deficiency, with day-shift CNAs unable to complete all assigned and missed baths.
A resident with heart failure, hypertension, and coronary artery disease did not receive physician-ordered daily weights on multiple days, and there was no documentation that the physician was notified about the missed weights or that monitoring was occurring as ordered. Facility policy required such monitoring and notification, but interviews confirmed these actions were not taken.
Staff did not follow safe transfer procedures for two residents, including improper manual lifting without a gait belt and failure to lock brakes on a mechanical stand lift during transfers. Both actions were inconsistent with facility policy and equipment instructions, and involved residents requiring significant assistance due to physical or cognitive impairments.
Staff did not follow proper incontinence and catheter care protocols for two residents, including failing to clean the catheter tubing after emptying and using the same side of a wipe multiple times during peri care. Additionally, a CNA handled a resident's clothing and wheelchair with soiled gloves before performing hand hygiene, contrary to expected procedures.
A resident with cognitive impairment and chronic pain was prescribed tramadol, and discrepancies were found in the controlled drug count after a CMA failed to sign the record and two tablets were discovered missing. An LPN identified the issue during a shift change, but the CMA left the facility without explanation. The facility's medication storage policy lacked specific procedures for handling missing narcotics, and the cause of the missing medication could not be determined.
A resident with multiple medical conditions was mistakenly given another resident's medications, including jardiance and gabapentin, which were not prescribed for them. The LPN did not follow facility policy for medication administration or implement specific monitoring, such as blood glucose checks, after the error. The resident later developed new symptoms and was transferred to the emergency room after EMS found them unresponsive and with low blood glucose.
The facility did not document significant incidents in the medical records for two residents, including missing money and missing medication. Despite facility policy requiring documentation of such events, these incidents were not recorded by licensed staff.
A resident with a history of colon cancer and other conditions had a low potassium lab result, prompting a nurse practitioner to order potassium chloride supplementation and a repeat lab. The order was not entered, processed, or administered, and the repeat lab was not completed. Staff interviews confirmed the order should have been implemented within 24 hours, but it was not transcribed or followed according to facility policy.
Failure to Follow Hand Hygiene and Infection Control During Medication Pass
Penalty
Summary
Facility staff failed to perform proper hand hygiene and adhere to infection control guidelines during medication administration for four observed residents. Specifically, a Licensed Practical Nurse (LPN) did not perform hand hygiene before applying gloves, handled insulin and medication packaging with gloved hands, and touched various surfaces, including the computer screen and medication drawer, without changing gloves or performing hand hygiene between tasks. The LPN also picked up a dropped medication from the top of the medication cart with a gloved hand, without prior hand hygiene, and placed it into a medication cup for administration. Additionally, a Registered Nurse (RN) used a visibly soiled pill cutter without cleaning it, handled medications and equipment without performing hand hygiene before or after glove use, and failed to clean or disinfect a resident's inhaler after use, returning it to the medication cart without wiping it down. These actions were inconsistent with the facility's policies on administering medications and hand hygiene, which require hand hygiene before and after handling medications, before applying gloves, and after removing gloves. Interviews confirmed that staff were expected to follow infection control measures at all times.
Failure to Cover Catheter Bags Compromises Resident Dignity
Penalty
Summary
Surveyors observed that three residents with urinary catheters had their catheter bags uncovered and visible from the hallway or doorway while lying in bed. These observations occurred at various times, with urine clearly visible in the bags, and no privacy covers in place. Review of the facility's policy on dignity, revised in February 2021, indicated that staff are expected to help residents keep urinary catheter bags covered to promote dignity and prohibit demeaning practices. An interview with the Regional Nurse Consultant confirmed that all catheter bags should have covers due to dignity concerns.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled bathing assistance to three residents who required help with activities of daily living, specifically bathing. Clinical record reviews, resident interviews, and documentation revealed that these residents did not consistently receive their scheduled baths, despite care plans indicating the need for assistance. For example, one resident with muscle wasting and repeated falls was scheduled for baths twice weekly but only received two baths in November and none in the first 20 days of December. Another resident with dementia and Parkinson's disease, also scheduled for twice-weekly baths, missed several scheduled bathing dates in both November and December. A third resident, requiring substantial assistance due to unsteadiness and repeated falls, similarly missed multiple scheduled baths over the same period. Resident interviews confirmed that baths were not consistently offered as scheduled, with some residents expressing distress or dissatisfaction about missed baths. While some residents occasionally refused bathing, documentation and interviews indicated that refusals were not the primary reason for the missed baths. Instead, residents reported that they were not routinely offered the opportunity to bathe according to their care plans, and in some cases, could not recall being offered a bath at all on certain dates. Staff interviews revealed operational issues contributing to the deficiency. A CNA reported that recent staff resignations and changes in the bathing schedule, including shifting some baths to the night shift, resulted in residents not receiving their scheduled baths. The CNA stated that night-shift baths were often not completed, and day-shift staff were expected to compensate for missed baths in addition to their regular duties, leading to further lapses. The facility's policy required documentation of bathing, including refusals and interventions, but records showed incomplete adherence to these requirements.
Failure to Complete Physician-Ordered Daily Weights and Notify Physician
Penalty
Summary
The facility failed to provide physician-ordered daily weights for a resident with heart failure, hypertension, and coronary artery disease. The resident's Minimum Data Set (MDS) indicated no cognitive impairment, and the physician's order specified daily weights if there was a weight gain of more than 3 pounds in one day or more than 5 pounds in one week, with weekly faxing of weights. However, daily weight records showed multiple missed days over a three-month period, and there was no documentation that the physician had been notified about the missed weights or that the monitoring was occurring as ordered. Facility policy required supervision of medical care, including monitoring changes in residents' medical status and overseeing relevant care plans. Interviews confirmed that daily weights should have been completed and the physician notified if they were not.
Failure to Ensure Safe Resident Transfers and Use of Transfer Equipment
Penalty
Summary
Staff failed to provide safe transfers for two residents, as observed during surveyor visits. In one instance, a CNA assisted a resident with toileting by pulling the resident up to a standing position using her forearm under the resident's armpit, rather than using a gait belt as required by facility policy. The resident's care plan indicated a need for one-person assistance with toileting and personal hygiene, and the MDS assessment showed the resident was dependent on staff for toileting and required partial to moderate assistance with transfers. Facility policy specified that staff should use appropriate techniques and devices, such as gait belts, for lifting and moving residents, and staff were expected to be trained in these procedures. In another case, a CNA used a mechanical stand lift to transfer a resident with severe cognitive impairment and multiple diagnoses, including seizure disorder and COPD. The CNA failed to lock the lift brakes before raising the resident from the toilet and again before lowering the resident into a wheelchair, contrary to the operator's manual instructions. The resident's care plan required the use of a mechanical stand lift with one-person assistance for transfers. The administrator confirmed that staff should follow the operator's manual when using the mechanical stand lift.
Failure to Provide Proper Incontinence and Catheter Care
Penalty
Summary
Staff failed to provide complete and appropriate incontinence and catheter care for two residents. In one instance, a CNA emptied a resident's catheter bag, cleaned the catheter end prior to emptying, but after emptying the urine, closed the end and placed it back into the bag without cleaning it again. The CNA then cleaned up supplies, removed gown and gloves, and performed hand hygiene, but did not follow proper protocol for cleaning the catheter tubing after emptying. In another instance, a CNA assisted a resident with toileting and peri care but used the same side of a disposable wipe multiple times to clean both the perineal area and rectum, increasing the risk of contamination. The CNA also pulled up the resident's brief and clothing and adjusted her sweater while still wearing soiled gloves, only removing gloves and performing hand hygiene after the resident was back in her wheelchair. The Regional Nurse Consultant confirmed that staff are expected to use a clean part of the wipe for each stroke and to use an alcohol swab after emptying catheter tubing.
Failure to Maintain Accurate Controlled Medication Records and Investigate Missing Narcotics
Penalty
Summary
The facility failed to provide and maintain accurate records regarding a controlled medication incident involving a resident with muscle wasting, nerve damage, and moderate cognitive impairment who was prescribed tramadol for pain management. On the date in question, the Controlled Drug Count Record was not signed by a Certified Medication Assistant (CMA) at 6 AM, and a subsequent count revealed that two tramadol tablets were missing. The Individual Narcotic Record and Medication Reconciliation indicated discrepancies in the tramadol tablet count between shifts. Staff interviews confirmed that after the administration of bedtime medications, a Licensed Practical Nurse (LPN) assumed responsibility for the medication cart and discovered the missing tablets during the narcotic count with the CMA, who then refused to sign the count record and left the facility immediately. The facility's policy on the storage of medications did not include specific procedures for narcotic counting, destruction, or actions to be taken in the event of missing medication. The Regional Nurse Consultant confirmed the loss of two tramadol tablets and reported that the facility was unable to determine the cause of the missing medication. The investigation concluded without resolution as the CMA involved did not return to the facility or respond to follow-up attempts.
Significant Medication Error and Inadequate Monitoring After Wrong Medication Administration
Penalty
Summary
A resident with diagnoses of heart failure, renal insufficiency, and stroke, and no cognitive impairment, was administered another resident's medications, specifically jardiance and gabapentin, which were not ordered for them. The error occurred during the morning medication pass, and the resident spat out most of the medications due to swallowing issues but ingested at least two or three pills, including a diabetic medication. The LPN involved did not recall all the medications ingested but identified one as a diabetic medication. The nurse did not receive or implement specific monitoring parameters from the provider, such as checking blood glucose levels, and did not document all assessments performed after the error. Later that day, the resident exhibited increased drowsiness and new stroke-like symptoms, prompting emergency medical services to be called. Upon EMS arrival, the resident was found to be unresponsive to verbal stimuli, diaphoretic, and hot, with a blood glucose level of 64 mg/dL. Facility policy required verification of resident identity and medication checks prior to administration, which were not followed in this instance. The medication error and subsequent lack of thorough monitoring and documentation contributed to the resident's acute change in condition and transfer to the emergency room.
Failure to Document Resident Incidents and Missing Medications
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents in relation to significant incidents. For one resident with diagnoses including muscle wasting, repeated falls, and disorientation, there was no documentation in the medical record regarding the reported disappearance of $105 from a pouch attached to the resident's walker. The resident, who had no cognitive impairment according to the BIMS assessment, reported the missing money to the Administrator after returning from the hospital, but this event was not recorded in the resident's records. For another resident with muscle wasting, wheelchair dependence, nerve damage, and moderate cognitive impairment, staff discovered two missing tramadol tablets during a narcotic count. Despite this, there was no documentation in the resident's medical record regarding the missing medication. The facility's own Charting and Documentation policy requires that all incidents, changes in condition, and events involving residents be documented in the medical record, but this was not followed in these cases.
Failure to Implement Physician Order for Potassium Supplementation
Penalty
Summary
The facility failed to implement a physician order for potassium chloride 10 mEq daily following a low potassium lab result for a resident diagnosed with colon cancer, arthritis, and aphasia, who was cognitively intact and required varying levels of staff assistance for daily activities. The nurse practitioner documented a low potassium result and ordered potassium chloride supplementation and a repeat basic metabolic panel in one week. However, review of the electronic medical record and medication administration record showed no evidence that the potassium chloride order was entered, processed, or administered, nor was the repeat lab completed. Interviews with nursing staff and the nurse practitioner revealed that new orders are typically left with the floor nurse or unit manager, who are responsible for processing and transcribing them into the system and notifying the pharmacy. The nurse practitioner expected the order to be carried out within 24 hours, and the director of nursing confirmed that the order should have been processed and transcribed to the MAR within that timeframe. Facility policy requires prompt entry and follow-through of provider orders, but in this case, the order was not implemented, resulting in a failure to follow physician instructions after an abnormal lab result.
Some of the Latest Corrective Actions taken by Facilities in Iowa
- Staff education was provided to ensure all staff and departments are aware that oxygen equipment cannot be on residents or in the designated smoking area while residents smoke. (J - F0689 - IA)
- Facility educated Resident #32 and other residents who smoke that oxygen equipment cannot be with them while smoking. (J - F0689 - IA)
- Facility posted signs near the exit to the designated smoking area and the front entrance for visitors, stating that oxygen use is not allowed while smoking. (J - F0689 - IA)
- Facility planned audits for compliance to ensure oxygen equipment is not present in the designated smoking area while residents are smoking, with any concerns to be reported to the Administrator immediately and addressed in the facility Quality Assurance meeting. (J - F0689 - IA)
Safety Lapses in Smoking Area and Resident Transport
Penalty
Summary
The facility failed to ensure the safety of residents in a designated smoking area, particularly concerning Resident #32, who was observed smoking with a portable oxygen tank attached to his wheelchair. Despite the facility's policy prohibiting oxygen use in smoking areas, Resident #32, who had been on oxygen since November 2024, was seen smoking with the oxygen tank present, posing a significant safety risk. The resident, diagnosed with paraplegia, COPD, and asthma, was non-compliant with continuous oxygen orders and required supervision while smoking. However, the supervision provided by housekeeping staff was inadequate, as they did not remove the oxygen tank before the resident smoked. Additionally, the facility failed to ensure the safe transport of Resident #25, who was moved from the dining room to his room in a wheelchair without foot pedals. Resident #25, diagnosed with dementia and severe cognitive impairment, required extensive assistance for mobility. The lack of foot pedals during transport posed a risk to the resident's safety, as confirmed by the Director of Nursing, who stated that the expectation was for staff to use wheelchair pedals when transporting residents. These deficiencies highlight the facility's failure to adhere to safety protocols and provide adequate supervision, resulting in Immediate Jeopardy to the health and safety of the residents. The facility's policies and procedures were not effectively implemented, leading to unsafe conditions for residents who required special care and supervision.
Removal Plan
- Staff education provided to ensure all staff and all departments are aware oxygen equipment cannot be on residents or in the designated smoking area while residents smoked. All staff educated prior to the start of their next shift.
- Facility educated Resident #32, and the other residents who smoke, that oxygen equipment cannot be with them while smoking.
- Facility posted a sign near the exit to the designated smoking area stating that oxygen use is not allowed in the designated area.
- Facility posted a sign near the front entrance for visitors stating that oxygen use is not allowed while smoking.
- Facility planned to audit for compliance to ensure oxygen equipment not present in the designated smoking area while residents are smoking and any concerns to be reported to the Administrator immediately and addressed in facility Quality Assurance meeting.
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