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Local News

October 30, 2012

Recently fined nursing home has history of violations

CENTERVILLE — Golden Age Skilled Nursing and Rehab, the nursing home that was recently fined $8,000 by the Iowa Department of Inspections and Appeals – Health Facilities Division for failing to help a dying woman, has a long history of citations and violations.

According to records made available from the Iowa Department of Inspections and Appeals website, and compiled by the Daily Iowegian, the Golden Age has received $56,675.50 in fines and 123 violations since Dec. 3, 1999, the date of the first record available online.

The Daily Iowegian compiled similar numbers from facilities with the same classification as Golden Age in Appanoose, Davis, Monroe and Wayne counties.

A total of seven active facilities were studied via online records, which covered a timeline beginning between June 1999 and June 2000 through today.

The seven nursing homes combined for $141,150.50 in fines, 548 violations and 52 citations. Of those numbers, Golden Age accounts for roughly 40 percent of the fines, 22 percent of violations and 23 percent of citations.

State wide, 254 citations have been issued to nursing homes in the fiscal year 2011-12. The citations carry an average fine of $3,099.60. There have been 33 citations that held a fine of more than $8,000.

The largest fine that has been assessed in the past fiscal year was to Davenport Lutheran Home in Davenport for two violations totaling $26,000. Their fine was tripled from $8,000 to $26,000 due to a repeated offense. The report from the citation states that the nursing home “failed to implement interventions and provide adequate supervision designed to prevent accidents” for one resident, who fell and sustained a fractured left hip and subdural and subarachnoid hemorrhage. The resident subsequently died from the injuries.

So far this year, Golden Age has received $15,000 in citations and inspections have uncovered 27 violations.

A Sept. 11 report penalized the nursing home for failing to “provide an accurate assessment and timely intervention” when a resident, who The Des Moines Register reports was 64 year old Barbara Logsdon, had problems clearing her throat of phlegm that had built up and eventually died, despite a physician ordering regular suctioning of Logsdon’s throat due to a medical condition that caused the phlegm.

The nursing home was fined $8,000 for violating four regulations.

A 106-page report filed approximately two weeks prior to Logsdon’s death fined Golden Age a combined $7,000 for 23 violations.

The report noted Golden Age’s many violations, ranging from failure to notify a physician of a resident’s hour-long grand mal seizure to failure of meeting professional standards.

EDITOR’S NOTE: A summary of the 106-page report is at the end of this article. The full report is available on, as well as several other reports cited in this story.

A report from July 23, 2010, fined Golden Age a total of $20,000, when “the facility failed to plan nursing services with provision of assessments and timely interventions for one of three residents reviewed.”

The fine would have been $10,000, but it was doubled to $20,000 under section code 56.6(2), which states “the director of the department of inspections and appeals shall double the penalties specified in subrule 56.3(1) when the violation is due to an intentional act by the facility in violation of a provision of Iowa Code chapter 135C or rule adopted pursuant thereto.”

A resident who had surgery for spinal fusion of his/her lower back on Feb. 24, 2010 entered Golden Age on May 21, 2010, without any compromised skin areas on his/her left heel, right elbow and middle left toe. The report states that the facility had no assessment or intervention in place to address the pressure areas from the onset to May 21, 2010 and did not accurately assess the resident’s coccyx ulcers.

The report continues to state that the resident began having complaints of shortness of breath and was sent to the emergency room by the nursing home.

EDITOR’S NOTE: The following paragraph recounting an ER nurse’s experience with a resident of Golden Age admitted to the ER may be graphic to some.

Upon admittance to the ER on May 21, 2010, an ER nurse told surveyors “she took photographs and attended to [the resident] upon admission… The ER nurse stated she removed the resident’s socks after she noticed a foul odor on the resident. The ER nurse stated she noticed a small scab [black area] on the resident’s toe with soft, red mushy skin on the right heel. The ER nurse asked the resident if s(he) move[s] around a lot and the resident stated ‘no.’  The ER nurse stated she rolled the resident to his/her side due to him/her complaining of his/her bottom being sore. The ER nurse stated she observed a large excoriated area with necrotic and red open sores on the coccyx/buttocks. The ER nurse stated she smelled a foul odor and noticed yellow drainage with dry fecal matter. The ER nurse stated the resident’s loved one was present at the bedside and stated the resident had been living at the nursing home for the last couple of months.”

According to the report, the ulcer found on the resident after the ER nurse removed the sock was approximately the size of a 50-cent piece.

An interview with the resident’s physician uncovered that the physician had no knowledge of open areas on the resident other than the coccyx, and also that no staff at Golden Age had notified him of an open area on the resident’s right elbow, left heel or left middle toe.

A surgeon that was on duty when the resident was admitted said, according to the report, “it would take 2-3 weeks, most likely a month for the area on the resident’s heel to develop. The surgeon stated it would be hard to deny the area was present much of the time the resident was in the care center since the resident [was] admitted to the facility on [March 11, 2010] and admitted to the hospital on [May 21, 2010].”

During interviews, one staff member said she did not see the resident’s heels being open, but did notice the area on the middle toe and failed to report it to a nurse.

Golden Age received a total fine of $7,500 in April 2010 for several violations.

A $6,000 fine was assessed because the facility failed to ensure residents received safety provisions, a resident was able to elope when staff failed to respond to an alarmed door, a resident suffered a left clavicle fracture when straps on a lift broke during a transfer, a resident was not properly supervised from potential hazards in the environment and failing to provide safe transfer for three residents.

In the same report, Golden Age was fined $500 for not alerting the Director of Nurses of the elopement of the resident. Another $500 fine was assessed when Golden Age failed to obtain a state required abuse background, to check for past abuse on children and dependent adult records, before an employee is hired to work at a facility such as Golden Age.

Other large fines assessed to Golden Age include a May 2007 fine of $2,500 and a $2,540 fine in March 2007.

David Werning from the Iowa Department of Inspections and Appeals said the department performs annual inspections of all facilities in the state. They also investigate every complaint received either through their website, or via their toll-free complaint hotline at 1 (877) 686-0027.

Werning said that many violations go without fines. He said via telephone Monday afternoon that a “very good facility” could receive a large fine for an isolated incident. He continued to say that people looking to judge a facility should be sure to view reports, accessible by the department’s health division’s website, in totality.

There are three classes of violations, Class I, II and III. Class I violations are the most severe and generally result from an action that dangers the health of a resident. Class II violations are generally ones that could possible danger residents if left uncorrected. Class III violations generally don’t fine nursing homes and are typically for things like incorrect paperwork.

If a nursing home violates a rule or regulation is had already been cited for in the past 12 months, the department as the ability to triple to fine amount.

Werning said the department has the ability to suspend a facility’s license, however it’s typically done as a last resort due to the hardships of suspending a license would have on residents and their families. Werning said it is a very rare occurrence with only 1-2 facilities having their licenses pulled.

• Summary of June 2012 violations:


A staff member was hired in the social service position on Aug. 11. However, they had not been trained on how to fill out proper forms until Feb. 2012. According to the investigation, "By failing to provide training to 'Staff J' to ensure she understood the intent of the letters, the facility did not ensure the resident's rights to request a standard review claim appeal or an expedited claim appeal (done within 72 hours) for financial liability."

Law requires that facilities inform each resident who is entitled to Medicaid benefits in writing at the time of admission to the nursing facility or when the resident becomes eligible for Medicaid of the items and services that are included in the nursing facility under the state plan. The facility must also inform each resident when they are admitted, and throughout the resident's stay of available services from the facilities, the charges for those services not covered under Medicare or by the facility's per diem rate.

A facility must also furnish a written description of legal rights and also a description of the requirements and procedures for establishing eligibility for Medicaid.

A review of records from Oct. 3, 2011 through March 2, 2012 showed that 20 residents were discharged from skilled care at Golden Age. Of those 20 forms, six were signed by the residents themselves and the other 14 signed by the resident's Power of Attorney. However all 20 forms had a field blank, regarding the resident's continuation or discontinuation of services.

"Twenty out of twenty forms did not have either Option A, or "Yes", or Option B, or "No", checked. Option A gives the resident or responsible party the right to have the services continued and the bill submitted to Medicare for a decision. Option B gives the resident or responsible party the right to not receive services and not submit a claim to Medicare for a review," the Iowa Department of Inspections and Appeals report said.

The report continues to say that from Aug. 9 to Sept. 15, 2011, the facility discharged eleven residents from a skilled level of care and provided the Notice of Medicare Provider Non-Coverage or "generic letter" form. Six of those were signed by the residents and four were signed by the responsible party and one was not signed or dated.


State law requires a facility to immediately inform the resident, consult with the resident's physician and (if known) notify the resident's legal representative or an interested family member when one of the following situations occur: an accident involving the resident which results in injury and has the potential of requiring physician intervention; a significant change in the resident's physical, mental or psychosocial status; a need to alter treatment significantly; or a decision to transfer or discharged the resident from the facility as specified in Iowa section 483.12(a).

The facility must also notify the resident and (if known) the resident's legal representative or interested family member if: there is a change in room or roommate assignment, or a change in the resident's rights under Federal or State law or regulations.

Facilities must also record and periodically update the address and phone number of the resident's legal representative or interested family member.

The report from the Iowa Department of Inspections and Appeals says the requirement was not met after record review and staff interview, the facility staff failed to notify the physician for one of 15 residents that were sampled. One resident, labeled as Resident No. 5 in the report, had a seizure lasting one hour. The resident was identified with a diagnosis of traumatic brain injury and a seizure disorder.

Nurses' notes dated May 9, 2012 at 6:30 p.m. indicated the resident began revealing seizure activity while at the dining room table. The resident was given medication per physician's orders.

Nurses' notes at 7 p.m. on the same day noted that the seizure activity had progressed into a grand mal seizure. The resident was put to bed and given 10 milligrams of Valium, a medication used for the treatment of seizures.

Seizure activity was ongoing in the nurse's notes dated at 7:15 p.m. before seizure activity had stopped, as noted in the nurse's notes at 7:30 p.m.

During an interview on May 23, 2012, "Staff I", who is the Assistant Director of Nursing, "reported the medical record should have the seizure protocol and that physician notification is expected for a seizure. Staff I confirmed the medical record contained no documentation of physician notification for the seizure on May 9, 2012."


State law says a resident has the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health and safety of the individual or other residents would be endangered.

The report states this requirement was not met after the facility failed to complete routine treatments during waking hours for three out of the 15 residents reviewed.

One resident, named Resident No. 13 in the report, was diagnosed with multiple sclerosis, anxiety and neurogenic bladder. The Minimum Data Set (MDS) documented that the resident was fully dependent on staff for transfers and did not walk. The MDS also documented that the resident had a suprapubic catheter and that the resident scored a five out of 15 on the brief interview for mental status, which indicates a poor memory and poor recall.

The physician for the resident instructed the staff to change the catheter monthly. Three of those changes were indicated in nurse's notes with time stamps of 11 p.m., 4:45 a.m. and 3:30 a.m.

The report says that while the care plan directed staff to change the catheter per orders and it did not reveal that the resident benefited in anyway from having the catheter change done during the night hours. "A reasonable person would prefer not to have a catheter change performed during times of sleep," the report continued.

Another patient with the identity of Resident No. 14 also had a diagnosis of neurogenic bladder and multiple sclerosis. The MDS documented that the resident was fully dependent on staff for all cares, had a catheter and also had short and long term memory impairment as well as moderately impaired decision making abilities.

Physician's instructions stated to change the catheter twice a month.

Several nurse’s notes indicated the catheter was changed at times throughout the night and early morning hours, from 12 a.m. to 5 a.m.

During a May interview with investigators, Staff I, who is a licensed practical nurse, stated that all routine treatments and catheter changes will be done during the day shift starting May 1, 2012.


State law says facilities must provide activity programs that are designed to meet the interests and the physical, mental and psychosocial well being of each resident, in accordance with the comprehensive assessment.

The report cites several cases of one or more residents not participating or being engaged with activities other residents were participating in.

In the interview, Staff L, who is identified as an activity director, stated, "she did not have knowledge that the resident needed a resident centered goal and to document the specific activity the resident attended."


State law says that a facility must provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.

The report indicates that through observation and record review, "the facility failed to maintain resident equipment in good condition, free of rips and tears, to ensure safety and comfort and maintain a sanitizable surface for one of 15 resident observed.

Observation of a resident's wheelchair noted that the chest/shoulder harness that was required by the care plan of Resident No. 5, who was diagnosed with cerebral palsy and seizure disorder, had multiple horizontal rips and tears with areas of vinyl missing and also areas with rolled up sharp edges.


The facility is responsible for developing a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment.

The report says that, based on clinical record review, observation and staff interviews, the facility failed to create and update the care plan for eight of 15 residents reviewed.

One resident made repeated comments about death and wanting to harm themselves, according the report. The comments were often triggered when another resident in the facility would pass away.

While a social service staff member met with the resident and the resident's daughter, the care plan failed to provide interventions to monitor the resident's mood or to provide support to the resident at times a death occurs.

The report stated three other instances to prove that the facility failed to meet the regulations.


Any services that are provided or arranged by the facility must meet professional standards of quality, according to state law. However, the report states that the nursing home failed to follow professional standards regarding medication administration for four of the 15 residents reviewed and orders for discharge for two residents.

One example of evidence was the facility staff failing to increase a resident's dosage of Coumadin from 2 milligrams to 2.5 milligrams, per the physician's request. Another example noted that an antibiotic for a urinary tract infection was to be given twice a day from April 29 through May 3. However, doses were still be recorded in the nurse's notes on May 5 and 6.


State law requires that services provided by a nursing home or services arranged by the facility must be provided by qualified persons in accordance with each resident’s written plan of care. The report reviewed 15 residents and reviewed that the facility failed to follow the care plan for four of those 15 residents.

One example of the nursing home’s failure to meet the requirement, according to the report, was with a resident’s care plan that “instructed staff to perform range of motion and splint to the right hand per restorative’s directive.” The restorative nursing flow sheet directed staff to perform range of motion to the right hand and apply the splint in the morning and remove at bedtime. A state surveyor observed the resident was positioned in a bed without their right hand splint on four occasions: May 14 at 5 p.m., May 15 at 8:42 a.m., May 16 at 7:58 a.m. and May 16 at 11:38 a.m.


The report states that “each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.”

The report goes on to say that “the facility failed to provide adequate assessments and interventions for a resident with leg contractures and the inability to move legs for bowel incontinent skin cleansing and failed to assess and provide interventions for bowel management and pain management” in four separate residents.


According to the report, the facility failed to provide showers for resident and failed to provide complete incontinence care for another resident in the facility. State law requires that a resident who is unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.


Facilities, under state law, must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the resident’s clinical condition demonstrates that they were unavailable. If a resident has pressure sores, facilities are to provide necessary treatment and services to promote healing and prevent infection and new sores from developing.

The report states, “the facility failed to ensure one resident received appropriate interventions for repositioning of pressure ulcers and provide complete and accurate assessments of ulcers.” Through record review, observation and review of the “Quick Reference Guide for Clinicians,” surveyors found that the interventions were ineffective or were not implemented as directed on the care plan to prevent the occurrence of an avoidable additional pressure ulcer.


For residents that have a limited range of motion, state law requires that the facility provides appropriate treatment and services so that range of motion either decreases or stays the same. A combination of clinical record review, observation, facility flow sheets and staff interviews found that motion exercises for five of 16 residents were not provided by the facility, the report said.

One of the five examples given showed where there was no documentation that the staff had walked a resident as instructed in the care plan. The restorative nursing record for March 2012 showed no documentation that one particular resident was walked to and from breakfast nine times, was not walked to and from lunch 12 times and was not walked to and from supper 22 times.


Facilities must ensure that the resident environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistance to prevent accidents from happening.

Observations from surveyors, record review and staff interviews indicated Golden Age failed in this regard, as water temperatures were above the 120 degree temperature mark deemed safe by the state and that three of the 15 residents reviewed did not receive adequate supervision.

On May 14, observations showed that hot water temperatures were between 126.9 degrees at a nurse’s station to 132.9 degrees at a hall shower room sink.

A staff member present for the highest reading of 132.9 degrees turned the hot water heater down by one notch and subsequent readings ranged between 107.2 degrees to 113.9 degrees.

In another example, a resident that had a history of falls, was observed on two separate days laying in bed without an accessible call light.

Another resident who also had a history of falling, and a care plan stating not to leave resident alone in wheelchair in their room as they will attempt to self transfer themselves from wheelchair to bed, was observed being left unattended in their room on May 15.


Facilities must ensure that a resident maintains acceptable parameters of nutritional status, unless a resident’s clinical condition demonstrates that it is not possible, and receives a therapeutic diet when there is a nutritional problem, based on the resident’s comprehensive assessment.

According to the report, “the facility failed to follow all interventions on the care to ensure the resident received the nutrition recommended by the dietitian to prevent weight loss for one of three residents reviewed with weight loss.

The resident weighed 237 pounds on March 3 but had decreased weight to 223 pounds on May 8.

Staff interviews stated that the resident often refused snacks. However, the facility had no formal way of tracking the resident’s bedtime snack.


The report found “that facility staff failed to encourage or offer fluids during observed cares for three of four residents at risk of hydration. The facility failed to have consistent tracking methods for one of one residents reviewed on fluid restrictions.” State law says facilities must provide each resident with sufficient fluid intake to maintain proper hydration and health.

Two residents who were at a risk for malnutrition/weight loss because they could not feed themselves or make their needs known were not offered fluids by staff. Another resident who required total dependence of one staff member for eating and had an approach stated in resident’s care plan to offer fluids frequently throughout the day as noted in the care plan, was observed not being offered fluids by staff.

Another resident had a 1,500-milliliter fluid restriction, equating to approximately 50.7 ounces. The facility’s fluid restriction guidelines for the 1,500-milliliters revealed nursing was allowed 18 ounces of fluid per day and 32 ounces allowed for dietary. Oral intake records revealed oral fluid intakes varied from May 6-16.


Facilities must ensure that each resident’s drug regimen is free from unnecessary drugs. Based on a surveyor’s comprehensive assessment of a resident, the report stated, “the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless” therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record.

Clinical record review and staff interview showed that Golden Age failed to document an appropriate diagnosis for a psychotropic medication for one of 17 residents reviewed.

A licensed practical nurse stated during an interview that the medical record did not record a diagnosis for hypnotic medication given to a resident. “Staff I” notified the physician and obtained a diagnosis of insomnia for the hypnotic use.


According to the report, facilities must develop policies and procedures that: ensure residents or their legal representatives are educated on the benefits and side effects of influenza and pneumococcal immunizations, each resident or legal representative is offered an immunization (unless immunization is medically contraindicated or resident has already received immunization) and that the resident or legal representative can refuse immunizations.

The report says “based on clinical review, facility policy review and staff interview, the facility failed to document influenza and pneumococcal education prior to administration for 13 of 15 residents reviewed.”


All facilities must have an infection control program designed to provide a safe, sanitary and comfortable environment while also helping to prevent the spreading of disease and infection.

The report states that “based on clinical record review, observation, facility policy review and staff interview, the facility failed to follow infection control measures for seven of 15 residents reviewed.”

During observations, surveyors noted that on three separate occasions equipment used by residents were not sanitized before being used by another resident.

Another observation noted a staff member that did not change gloves between cleansing a suprapubic catheter site and cleansing a gastronomy tube site.

Review of the housekeeping closet revealed there were no cleaning supplies for cleaning blood spills.

In the report’s sixth example of Golden Age failing to provide an infection control program, a staff member was observed washing her hands and applying gloves. However, before beginning incontinence care to a resident, a staff member walked across the room and picked up the trash can with her right gloved hand without changing gloves.

Two weeks after a resident admitted for pneumonia was discharged from a hospital and received care at Golden Age, they began reporting increased diarrhea. A stool sample verified the resident had an infection of the bowel.

The report says that the resident was “started on Flagyl 500 milligrams intravenously every eight hours and Vancomycin 125 milligrams by mouth four times a day.”

Facility admission orders told staff to administer 250 milligrams of Vancomycin every six hours for 10 days and checking stool sample for C-diff once.

Medical records, according to the report, showed “the facility failed to obtain test samples in a timely manner or implement infection control practices until a confirmed negative test result was obtained.”

Surveyor observations revealed the facility had no isolation precautions or identification of type of isolation of the resident’s room.

Surveyors also found that monthly infection control logs had incomplete tracking methods, lacking information such as whether a culture was an obtain, an organism, an isolated or a nosocomial infection.

An eighth report from surveyors said a staff member put on gloves without first washing her hands when preparing to provide incontinence cares.


According to the report, a “facility must operate and provide services in compliance with all applicable federal, state, and local laws, regulations and codes and with accepted professional standards and principals that apply to professionals providing services in such a facility.”

Findings concluded that the facility failed to provide all employees access to the policy and procedural manual.

In an interview by surveyors with a licensed practical nurse, she stated “she kept the policy and procedural manual in a locked cabinet in her office.” She continued to say that “if an employee needed the policy and procedural manual, they would need to ask” her for the manual.



Facilities must designate a physician to serve as medical director. The responsibilities of a medical director include implementation of resident care policies and the coordination of medical care in the facility.

The report says, “Based on quality assurance meeting documentation and medical director interview, the facility failed to include the medical director in the creation and implementation of facility policies and procedures.”

The report continues to say that during an interview “the medical director stated she did not assist the facility with the policies and procedures. The medical director stated the facility held a quality assurance meeting on [May 24, 2012] after the survey team had informed the facility of concerns areas. The medical director stated the facility did not communicate the concerns and did not ask for her input in correcting the concerns. The medical director had no knowledge of the state operation manual or the regulation that stipulates the duties of the medical director.


Clinical records must be maintained by facilities, and must be complete, accurate and accessible. Records must contain sufficient information to identify the resident, such as: a record of the resident’s assessments, the plan of care and services provided, the results of any preadmission screening conducted by the state, and progress notes.

The facility, based on record review, observation and staff interviews, “failed to provide complete documentation of the resident’s participation in activities to ensure consideration of each resident[‘s] activity interests.

The report states the concern was noted for seven residents.


“The facility must train all employees in emergency procedures when they begin to work in the facility, periodically review the procedures with existing staff and carry out unannounced staff drills using those procedures,” the report stated.

The report continues, “Based on record review and staff interview, the facility failed to ensure the staff knew the facility’s policy and procedures for disaster preparedness.

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