Inspection Reports for Accura HealthCare of Carlisle
680 Cole Street, Carlisle, IA, 500478733
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 10, 2025 found the facility to be in substantial compliance with no deficiencies noted. Prior inspections showed multiple deficiencies related to resident care, including issues with assessments, care planning, infection control, medication administration, and accident prevention. Several complaint investigations were substantiated over time, involving concerns such as failure to treat residents with dignity, inadequate supervision, and improper handling of medications and infection control. Enforcement actions such as immediate jeopardy findings related to fire safety and resident harm were noted in earlier reports, but no fines or license suspensions were listed in the available reports. The facility appears to have made improvements recently, as the latest revisit confirmed correction of prior deficiencies and substantial compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
134% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
70 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 10, 2025
Visit Reason
A revisit for the survey ending July 31, 2025, and complaint investigation for complaints #2579334-C and #2600834-C was conducted from September 8, 2025 to September 10, 2025.
Complaint Details
Complaint investigation for complaints #2579334-C and #2600834-C was conducted; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 8
Date: Jul 28, 2025
Visit Reason
The inspection was conducted as an annual recertification survey and investigation of multiple complaints and facility reported incidents from July 28, 2025 to July 31, 2025.
Complaint Details
The inspection included investigation of complaints #1673874-C and #1674423-C which resulted in deficiencies. Facility reported incidents #1674171-I and 2568030-I also resulted in deficiencies.
Findings
The facility was found to have multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments, incomplete comprehensive care plans, failure to ensure quality of care related to resident assessments and treatments, inadequate infection prevention and control, medication administration errors, and improper handling of resident transfers and catheter care. The facility failed to meet several federal requirements as evidenced by clinical record reviews, staff interviews, and policy reviews.
Deficiencies (8)
Facility failed to accurately complete Minimum Data Set (MDS) assessments for four residents.
Facility failed to develop comprehensive care plans for residents #5 and #23.
Facility failed to ensure quality of care by timely and appropriate interventions for residents with lymphedema and oxygen needs.
Facility failed to maintain a safe environment free of accident hazards, contributing to a fracture for resident #45.
Facility failed to secure catheter bags below the bladder level for residents with catheters.
Facility failed to ensure residents were free of significant medication errors related to insulin administration.
Facility failed to submit accurate Payroll Based Journal (PBJ) staffing data.
Facility failed to establish and maintain an effective infection prevention and control program.
Report Facts
Residents reviewed for MDS accuracy: 4
Facility census: 70
Residents reviewed for comprehensive care plans: 5
Frequency of MDS audits: 3
Frequency of audits for lymphedema wraps: 3
Frequency of catheter bag placement audits: 3
Frequency of insulin administration audits: 3
Frequency of PBJ submission audits: 3
Frequency of infection control education: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | MDS Coordinator | Interviewed regarding MDS assessments and use of RAI Manual |
| Director of Nursing | DON | Educated staff on MDS accuracy, lymphedema wraps, catheter care, insulin administration, and infection control; involved in quality assurance process |
| Staff A | Registered Nurse | Interviewed regarding lymphedema wrap documentation and resident care |
| Staff C | Occupational Therapist | Interviewed regarding resident #55 discharge and wrap use |
| Staff G | Regional Corporate Nurse | Interviewed regarding therapy communication and oxygen orders |
| Staff E | Licensed Practical Nurse | Notified restorative aides about resident injury and assisted with resident care |
| Staff K | Restorative Aide | Interviewed regarding resident transfers and injury |
| Staff L | Certified Nurses Aide | Interviewed regarding resident transfers and injury |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 19, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance, and certification in compliance is effective as of April 19, 2025.
Inspection Report
Re-Inspection
Census: 75
Capacity: 75
Deficiencies: 4
Date: Apr 3, 2025
Visit Reason
This inspection was a revisit of the survey ending March 3, 2025, and an investigation of substantiated complaints #127128-C, #127363-C, and facility reported incident #127380-I conducted from March 31, 2025 to April 3, 2025.
Complaint Details
Complaints #127363-C and facility reported incident #127380-I were substantiated.
Findings
The facility was found to have deficiencies related to ADL care for dependent residents, prevention and treatment of pressure ulcers, range of motion and mobility services, and infection prevention and control. The facility submitted plans of correction and committed to staff education and ongoing quality assurance to ensure compliance.
Deficiencies (4)
Failure to provide necessary services to maintain personal cares of oral hygiene for 1 of 3 residents reviewed (#11).
Failure to provide treatment and services to prevent development of pressure ulcers for 2 of 3 residents reviewed (#4 and #11).
Failure to use ordered Durable Medical Equipment (DME) to prevent further decrease in Range-of-Motion (ROM) for 2 of 3 residents reviewed (#4 and #11).
Failure to don appropriate Personal Protective Equipment (PPE) when providing care to residents on Enhanced Barrier Precautions (#11 and #15).
Report Facts
Census: 75
Residents reviewed: 3
Residents reviewed: 3
Residents on Enhanced Barrier Precautions: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Mentioned in relation to oral hygiene and DME use deficiencies |
| Staff B | Certified Nurse Aide (CNA) | Mentioned in relation to pressure ulcer prevention and PPE use |
| Staff C | Certified Nurse Aide (CNA) | Mentioned in relation to pressure ulcer prevention and PPE use |
| Staff D | Certified Nurse Aide (CNA) | Mentioned in relation to pressure ulcer prevention and PPE use |
| Staff E | Certified Nurse Aide (CNA) | Mentioned in relation to pressure ulcer prevention and PPE use |
| Staff F | Licensed Practical Nurse (LPN) | Mentioned in relation to pressure ulcer prevention and PPE use |
| Staff G | Certified Nurse Aide (CNA) | Mentioned in relation to PPE use and infection control |
| Director of Nursing (DON) | Director of Nursing | Mentioned in relation to staff education and quality assurance |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 3
Date: Mar 4, 2025
Visit Reason
The inspection was conducted as a result of investigations into Complaints #126799-C and #126873-C and Facility Reported Incident #126931-I, conducted from February 25, 2025 to March 3, 2025.
Complaint Details
Complaints #126799-C and #126873-C were substantiated. Facility Reported Incident #126931-I was also substantiated.
Findings
The facility was found to have substantiated complaints related to resident rights, quality of care, and treatment to prevent pressure ulcers. Deficiencies included failure to ensure staff treated residents with dignity and respect, failure to carry out medication interventions, and failure to prevent and treat pressure ulcers in residents.
Deficiencies (3)
Facility failed to ensure staff treated residents with dignity and respect for 3 of 7 residents reviewed.
Facility failed to carry out a medication intervention for 1 of 3 residents reviewed for a change in condition.
Facility failed to prevent the development and worsening of pressure ulcers for 3 of 3 residents reviewed.
Report Facts
Residents reviewed for dignity and respect: 7
Residents reviewed for medication intervention: 3
Residents reviewed for pressure ulcers: 3
Facility census: 75
Facility capacity: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant (CNA) | Named in resident dignity and respect deficiency for calling Resident #2 whiny and causing distress |
| Staff B | Registered Nurse (RN) | Reported observations related to Staff C and resident dignity issues |
| Staff D | Certified Nursing Assistant (CNA) | Reported statements regarding resident dignity issues and submitted statement to Director of Nursing |
| Director of Nursing (DON) | Director of Nursing | Educated staff on treatment expectations and resident rights; involved in corrective actions |
| Administrator | Administrator | Provided statements regarding expectations for staff to treat residents with dignity and respect |
| Staff F | Quality Assurance (QA) Nurse | Measured wound and participated in quality assurance activities |
| Staff A | Wound Nurse Practitioner (NP) | Provided wound treatment plans and assessments |
| Staff Q | Quality Assurance (QA) Nurse | Measured wound and participated in quality assurance activities |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 13, 2025
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and certify the facility in compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective February 13, 2025.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 4
Date: Jan 15, 2025
Visit Reason
The inspection resulted from investigation of Complaints #123586-C, #124707-C, and #124709-C conducted January 13, 2025 to January 15, 2025.
Complaint Details
Complaints #123586-C, #124707-C, and #124709-C were substantiated.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, improper medication cart security, failure to protect resident records, inadequate infection prevention and control practices, and failure to maintain proper cleaning supplies for shared equipment. The facility implemented corrective actions including staff education, audits, and quality assurance reporting.
Deficiencies (4)
Failure to treat residents with dignity by not providing alternate toileting assistance, resulting in resident walking to hallway and yelling for help.
Medication cart was found unlocked and unattended, risking unauthorized access.
Resident records were not properly secured; an unattended laptop displayed multiple residents' EHR information.
Failure to implement infection control policies to prevent cross-contamination, including lack of sanitizing wipes for shared equipment and improper handling of PPE.
Report Facts
Census: 73
Deficiencies cited: 4
Audit frequency: 3
Audit duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Observed locking medication cart and accessing EHR; involved in medication and record security findings |
| Staff B | Certified Nursing Aide (CNA) | Observed interacting with Resident #8 during toileting assistance deficiency |
| Staff D | Housekeeping Aide (HA) | Reported lack of sanitizing wipes and observed infection control deficiencies |
| Staff E | Certified Nurse Aide (CNA) | Observed using shared equipment without sanitizing wipes |
| Staff F | Registered Nurse (RN) | Provided statements about PPE goggles use and infection control |
| Staff G | Certified Nurse Aide (CNA) | Observed handling PPE and reporting shortage of sanitizing wipes |
| Staff H | Housekeeping Aide (HA) | Unable to locate sanitizing wipes, directed to medication rooms |
| Staff J | Licensed Practical Nurse (LPN) | Reported restocking nurses' carts with sanitizing wipes |
| Staff K | Certified Medication Aide (CMA) | Observed handling utensils without hand hygiene |
| Director of Nursing | Director of Nursing (DON) | Provided statements on staff education, rounding expectations, medication cart security, and infection control |
| Director of Operations | Director of Operations (RDO) | Reported vendor change and supply issues related to sanitizing wipes |
| Administrator | Administrator | Reported lack of policy on securing resident records |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction and will be certified in compliance effective September 20, 2024.
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 7
Date: Aug 28, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and investigation of multiple substantiated complaints.
Complaint Details
Complaints #121792-C, #122641-C, #122407-C, and #122260-C were investigated and all were substantiated.
Findings
The facility was found deficient in multiple areas including failure to provide dignity by leaving a catheter bag uncovered, inaccurate resident assessments, failure to implement comprehensive care plans, improper tube feeding management, insufficient nursing staff and RN coverage, delayed call light responses, and inadequate infection prevention and control practices including improper use of PPE.
Deficiencies (7)
Failure to provide dignity by leaving a catheter bag uncovered for 1 of 8 residents reviewed (Resident #2).
Inaccurate assessments of residents' status related to restraints and catheter use for 2 of 18 residents (Residents #2 and #38).
Failure to implement a comprehensive care plan for supervision during meals for 1 of 5 residents (Resident #60).
Failure to verify gastrostomy tube placement and residuals prior to feeding for 1 resident (Resident #7).
Failure to provide sufficient nursing staff and timely response to call lights for 4 residents (Residents #2, #35, #38, and #41).
Failure to ensure RN coverage for at least 8 consecutive hours 7 days a week.
Failure to follow infection prevention and control practices including improper use of gowns and eye protection for residents with MDRO and COVID-19.
Report Facts
Deficiencies cited: 7
Census: 71
Days without 8-hour RN coverage: 9
Residents reviewed: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in catheter care and infection control deficiencies. |
| Staff C | Licensed Practical Nurse (LPN) | Named in tube feeding management and infection control deficiencies. |
| Staff F | Certified Nursing Assistant (CNA) | Named in supervision during meals and infection control deficiencies. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for dignity bags, MDS accuracy, staffing, and infection control. |
| Executive Director | Executive Director | Responsible for education and auditing corrective actions. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 31, 2024
Visit Reason
The document serves as a Plan of Correction following a credible allegation of substantial compliance, leading to certification of the facility in compliance effective May 31, 2024.
Findings
The facility was found to be in substantial compliance based on the accepted allegation and Plan of Correction, resulting in certification of compliance.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 3
Date: May 8, 2024
Visit Reason
The inspection was conducted based on facility complaints #118264-C, #118774-C, #119864-C, and #120185-C from April 26, 2024 through May 8, 2024 to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Complaint Details
The visit was complaint-related based on four facility complaints conducted from April 26, 2024 through May 8, 2024. The complaints involved resident rights violations, quality of care issues including medication administration, and food temperature concerns.
Findings
The facility was found not in substantial compliance due to failure to treat a resident with dignity and respect regarding vaping rights, failure to follow physician orders for insulin administration for one resident, and failure to maintain hot food temperatures above 140 degrees Fahrenheit during meal service.
Deficiencies (3)
Failure to treat 1 of 3 residents with dignity and respect while preserving her rights related to vaping policy enforcement.
Failure to follow physician orders for insulin administration for 1 of 3 residents with acute and chronic illness.
Failure to maintain hot food served at a temperature greater than 140 degrees Fahrenheit during meal service.
Report Facts
Resident census: 65
Medication administration date range: 31
Food temperature measurements: 135
Food temperature measurements: 137
Food temperature measurements: 120
Food temperature measurements: 164
Food temperature measurements: 151
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Practical Nurse (LPN) | Named in insulin administration deficiency observation |
| Staff E | Certified Nursing Assistant (CNA) | Documented resident meal intake related to insulin administration deficiency |
| Staff A | Cook | Named in food temperature deficiency observation |
| Staff B | Dietary Manager | Confirmed incomplete food temperature logs |
| Staff C | Certified Nursing Assistant (CNA) and Certified Medication Aide (CMA) | Confirmed resident food trays served cold |
| Staff D | Certified Nursing Assistant (CNA) and Certified Medication Aide (CMA) | Confirmed resident food trays served cold |
| Staff F | Certified Nursing Assistant (CNA) and Certified Medication Aide (CMA) | Confirmed resident food trays served cold |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 31, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance by the facility.
Findings
The facility was certified in compliance effective August 31, 2023, based on acceptance of the credible allegation and Plan of Correction.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Aug 10, 2023
Visit Reason
The inspection was conducted as a result of investigation of complaint #113801-C and facility reported incident #113815-I from August 9 to August 10, 2023.
Complaint Details
Complaint #113801-C was substantiated. Facility reported incident #113815-I was substantiated.
Findings
The facility failed to properly destroy Resident #6's narcotic medication upon discharge to the hospital, violating drug storage and destruction protocols. The complaint was substantiated and deficiencies were identified related to narcotic handling and destruction procedures.
Deficiencies (1)
Failure to properly destroy Resident #6's narcotic (pain) medication when discharged to the hospital.
Report Facts
Resident census: 67
Medication tablets remaining: 12
Medication tablets delivered: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | CNA (Certified Nursing Assistant) | Interviewed and confirmed medication handling and destruction procedures. |
| Staff C | CMA (Certified Medication Aide) | Interviewed and confirmed policy/procedure for destroying narcotic medications. |
| Staff D | CMA (Certified Medication Aide) | Interviewed and confirmed policy/procedure for destroying narcotic medications. |
| Staff B | LPN (Licensed Practical Nurse) | Interviewed and stated policy/procedure for destroying narcotics. |
| Staff E | Director of Nursing | Confirmed and verified failure to follow facility protocol for narcotic disposal. |
| Staff F | Facility Administrator | Confirmed and verified failure to follow facility protocol for narcotic disposal. |
| Staff G | Facility Owner | Confirmed and verified failure to follow facility protocol for narcotic disposal. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 8, 2023
Visit Reason
A revisit of the survey ending June 15, 2023 was conducted on August 7, 2023 to August 8, 2023 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective July 7, 2023.
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 10
Date: Jun 15, 2023
Visit Reason
An annual recertification survey and investigation of complaints #113349-C, #112889-C, #112316-C, #111921-C and facility reported incident #113224-I were conducted from June 12, 2023 to June 15, 2023.
Complaint Details
Complaints #113349-C and #112889-C were substantiated. Incident #113224-I was substantiated.
Findings
The facility was found to have multiple deficiencies including failure to provide required Medicaid Liability Notices timely, incomplete comprehensive care plans for residents, failure to obtain physician orders for oxygen therapy, inadequate supervision leading to resident injury, pain management deficiencies, medication errors, infection control lapses, and pest control issues. The facility reported a census of 71 residents throughout the survey.
Deficiencies (10)
Failed to provide Medicaid Liability Notices and Beneficiary Appeals within 48 hours of skilled services ending for Resident #12.
Care plan for Resident #9 failed to address use of C-Pap, oxygen saturation monitoring, and oxygen therapy.
Failed to obtain physician order for oxygen therapy for Resident #9.
Failed to ensure resident environment was free of accident hazards; Resident #56 was injured when bumped by laundry cart.
Pain management deficient for Resident #24; lacked documentation and policy.
Medication error rate exceeded 5% with 2 errors out of 26 opportunities for Residents #19 and #28.
Failed to assist residents in obtaining routine and emergency dental care; Resident #24 had untreated tooth abscess.
Failed to properly handle and serve food and drinkware; multiple observations of improper handling of beverage glasses.
Failed to establish and maintain effective infection prevention and control program; lapses in glove use and disinfection of glucometers.
Failed to maintain effective pest control program; vermin evidence found in common areas and resident room.
Report Facts
Census: 71
Medication error rate: 7.69
Medication administration opportunities observed: 26
Date survey completed: Jun 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Practical Nurse (LPN) | Identified Resident #9 receiving oxygen therapy and use of C-Pap |
| Staff F | Laundry staff involved in incident with Resident #56 | |
| Staff L | Licensed Practical Nurse (LPN) | Reported Resident #24 sent to hospital due to facial swelling and pain |
| Staff H | Certified Medication Aide (CMA) | Observed medication administration and glucometer use |
| Staff J | Certified Medication Aide (CMA) | Reported glucometer disinfection procedures |
| Staff K | Licensed Practical Nurse (LPN) | Discussed pain management for Resident #24 |
| Staff M | Advanced Registered Nurse Practitioner (ARNP) | Provided orders for Resident #24's tooth abscess |
| Director of Nursing | Provided statements regarding nursing expectations and dental referrals | |
| Administrator | Responsible for staffing, policies, and pest control vendor |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 16, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance of the facility.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction effective April 16, 2023.
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Date: Mar 29, 2023
Visit Reason
The inspection was conducted as an investigation of complaint #111791-C from March 23, 2023 to March 29, 2023. The complaint was substantiated.
Complaint Details
Complaint #111791-C was substantiated based on interviews, observations, and record review. The complaint involved Resident #2 sustaining a large bruise from sliding down in her wheelchair and improper staff handling.
Findings
The facility failed to revise a care plan to reflect the ongoing needs of Resident #2, who sustained a large bruise related to sliding down in her wheelchair and being hoisted improperly by staff. The facility also failed to provide adequate supervision to prevent accidents, resulting in the resident sliding out of her chair and sustaining bruises. Unsafe repositioning techniques were used by staff.
Deficiencies (2)
Failure to revise care plan to reflect ongoing needs of Resident #2 related to wheelchair cushion and seat adjustments.
Failure to provide adequate supervision and assistance devices to prevent accidents for Resident #2.
Report Facts
Resident census: 64
BIMS score: 3
Bruise size: 42
Bruise size: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Medication Aide (CMA) | Interviewed about bruising on Resident #2 and staff handling |
| Director of Nursing | DON | Acknowledged bruise and staff lifting technique; involved in care plan revision |
| Therapy Manager | Interviewed regarding repositioning technique and care plan interventions | |
| Staff A | Certified Nurse Aide (CNA) | Reported to have done Resident #2's cares on inspection day |
| Staff B | Certified Nurse Aide (CNA) | Assisted with transfer using hoyer lift |
| Administrator | Involved in investigation and acknowledged bruise and staff lifting technique |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 21, 2023
Visit Reason
A second revisit was conducted regarding multiple complaints and a facility reported incident to verify correction of previous deficiencies.
Complaint Details
The revisit was related to complaints #104936-C, #104971-C, #106818-C, #108588-C, #108807-C, #109355-C and facility reported incident #107507-I.
Findings
The revisit identified that all deficiencies were corrected and the facility was in substantial compliance effective March 15, 2023.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 28, 2023
Visit Reason
The inspection was conducted to investigate Complaint 111174.
Complaint Details
Complaint 111174 was investigated and not substantiated on February 23 - 28, 2023.
Findings
The complaint was investigated and found to be not substantiated during the visit from February 23 to 28, 2023.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 3
Date: Feb 13, 2023
Visit Reason
The inspection was a revisit conducted on February 13-15, 2023, related to the investigation of multiple complaints and a facility-reported incident.
Complaint Details
The revisit was related to complaints #104936-C, #104971-C, #106818-C, #108588-C, #108807-C, #109355-C and a facility-reported incident #107507-1. The investigation found substantiated issues with accident hazards and environmental safety.
Findings
The facility failed to ensure a safe environment free of accident hazards, including electrical outlet overheating and discolored outlets posing fire risks. Additionally, staff qualifications and maintenance of a safe, functional environment were inadequate, with issues found in call light functionality and environmental conditions.
Deficiencies (3)
Facility failed to take mitigating measures to prevent accidents related to electrical outlets overheating and discoloration, posing fire hazards.
Facility failed to ensure maintenance staff were adequately oriented and trained to identify and maintain electrical needs.
Facility failed to maintain a safe, functional, home-like environment; call lights were not functioning in multiple rooms and bathroom repairs were needed.
Report Facts
Census: 63
Training hours: 2
BIMS scores: 15
BIMS scores: 3
BIMS scores: 10
BIMS scores: 5
BIMS scores: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff N | Corporate Maintenance Staff | Responsible for training maintenance staff and changing receptacle in room #328 |
| Staff M | Maintenance Staff | Reported absence during electrician visit and lack of follow-up knowledge |
| Staff G | Maintenance Staff | Received 2 hours of fire safety and emergency preparedness training |
| Administrator | Facility Administrator | Provided statements regarding electrical inspections and policy implementation |
| Staff A | CNA | Observed call light issues and resident interactions |
| Staff B | Licensed Practical Nurse (LPN) | Checked call lights and conducted audits |
| Staff D | CNA | Checked bathroom call light functionality |
| Staff J | CNA | Reported resident use of call lights and related issues |
| Staff K | CNA | Reported resident use of call lights |
| Staff F | CNA | Observed intermittent call light functionality |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 4
Date: Dec 15, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints (#104936-C, #104971-C, #106818-C, #108588-C, #108807-C, #109355-C, and facility reported incident #107507-I) regarding resident rights, quality of care, and safety concerns.
Complaint Details
Complaints #104971-C, #106818-C, #108588-C, #108807-C, and #109355-C were substantiated. Facility reported incident #107507-I was substantiated. Complaint #104936-C was not substantiated.
Findings
The facility was found to have failed to respect resident rights, including dignity and freedom from abuse, with substantiated complaints involving staff misconduct and improper restraint. Quality of care deficiencies included inadequate assessment and intervention for a resident's fall, failure to ensure accident-free environment due to electrical hazards, and insufficient in-service training for nurse aides. Immediate jeopardy related to fire safety was identified and removed after corrective actions.
Deficiencies (4)
Failure to respect resident dignity and rights, including improper restraint and verbal abuse by staff.
Failure to provide adequate assessment and timely intervention for a resident's fall.
Failure to ensure resident environment free of accident hazards, including electrical outlet fire hazard.
Failure to provide required in-service training for nurse aides, including dementia training.
Report Facts
Census: 59
Number of residents reviewed: 7
Number of residents reviewed: 6
Number of nurse aides sampled: 4
Hours of dementia training documented: 4.25
Hours of dementia training documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nursing Assistant (CNA) | Named in resident restraint and abuse findings; terminated due to incident |
| Staff F | Certified Medication Aide (CMA) | Witnessed restraint incident and reported discomfort |
| Staff A | Licensed Practical Nurse (LPN) | Involved in resident restraint and abuse allegations |
| Staff B | Certified Nursing Assistant (CNA) | Witnessed abuse and reported concerns |
| Staff D | Dietary Aide (DA) | Reported witnessing resident neglect and verbal abuse |
| Staff C | Certified Nursing Assistant (CNA) | Witnessed abuse and reported concerns |
| Staff H | Certified Nursing Assistant (CNA) | Responded to resident fall and reported on incident |
| Staff I | Certified Nursing Assistant (CNA) | Reported on smoke and electrical hazard incident |
| Staff J | Licensed Practical Nurse (LPN) | Responded to electrical hazard and smoke incident |
| Staff K | Certified Nursing Assistant (CNA) | Reported on call light cover and ceiling tile issues |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse allegations and fall incident; provided education |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 5, 2022
Visit Reason
The document serves as a plan of correction following a survey, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility will be certified in compliance effective 05/05/22 based on acceptance of the plan of correction; no specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 5
Date: Apr 11, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of multiple complaints and a facility reported incident.
Complaint Details
Complaints #101528-C and 101788-C were substantiated. Facility reported incident #101778-I was substantiated.
Findings
The facility was found deficient in multiple areas including failure to update care plans timely, inadequate nursing supervision to prevent accidents, improper use and assessment of bed rails, lapses in infection prevention and control practices, and failure to notify residents and families timely about COVID-19 infections.
Deficiencies (5)
Failed to update the plan of care for 1 of 17 residents reviewed.
Failed to ensure staff provided adequate nursing supervision to protect residents against hazards when transporting residents in wheelchairs without foot pedals.
Failed to assess bed rails for risk of entrapment and obtain consent for use of side rails for 6 of 6 residents reviewed.
Failed to ensure proper hand hygiene, barrier use with glucometer, and covering clean laundry during transport.
Failed to inform residents and their representatives/families of confirmed COVID-19 infections by the next calendar day for 2 of 3 staff members reviewed.
Report Facts
Residents reviewed: 17
Facility census: 60
Residents reviewed for bed rail safety: 6
Residents with side rails: 6
Distance wheelchair pushed without foot pedals: 34
Distance wheelchair pushed without foot pedals: 86
BIMS scores: 3
BIMS scores: 6
BIMS scores: 7
BIMS scores: 12
BIMS scores: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Named in infection control deficiency for improper hand hygiene |
| Staff E | Certified Nurse Assistant (CNA) | Named in infection control deficiency for improper hand hygiene and side rail use |
| Staff B | Certified Nurse Assistant (CNA) | Named in wheelchair supervision and infection control deficiencies |
| Staff F | Laundry Staff | Named in infection control deficiency for transporting uncovered clean laundry |
| Staff J | Licensed Practical Nurse (LPN) | Named in infection control deficiency for glucometer use without barrier |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan updates, wheelchair supervision, side rail policies, infection control, and COVID-19 notification |
| Maintenance Director | Maintenance Director | Interviewed regarding bed rail entrapment assessments |
| MDS Coordinator | MDS Coordinator | Interviewed regarding side rail assessments and care plans |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 3
Date: Dec 20, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 10/28 to 12/20/21, including investigation of multiple complaints and facility-reported incidents.
Complaint Details
Investigation of complaints #97617-C, #100008-C, and facility-reported incident #97427-M resulted in deficiencies. Complaints #98116-C, #99474-C, #99901-C, #100096-C, #100542-C and facility-reported incidents #96772-I and #96777-I did not result in deficiency. Complaint #100067-C was substantiated without deficiency.
Findings
The facility was found to be in compliance with CDC recommended COVID-19 practices. Deficiencies were identified related to bed-hold policy notification, failure to follow physician orders for 1 of 19 residents, and failure to maintain accurate narcotic medication records for 2 of 5 residents reviewed.
Deficiencies (3)
Failed to provide required notification of bed-hold policy and procedure upon transfer or discharge for 1 of 4 residents reviewed (Resident #13).
Failed to follow physician orders for 1 of 19 residents reviewed (Resident #12) related to compression interventions.
Failed to establish a system of records for receipt and disposition of all controlled drugs to enable accurate reconciliation for 2 of 5 residents reviewed (Residents #3 and #17).
Report Facts
Residents reviewed: 19
Residents reviewed: 5
Residents reviewed: 4
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Authored Health Status Notes and facility bed-hold policy form; recorded notification to resident's guardian |
| Staff A | Registered Nurse (RN) | Documented resident's support hose status and nursing progress notes |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding physician orders and narcotic medication investigations |
| Administrator | Involved in notification and corrective actions related to narcotic medication discrepancies | |
| Pharmacist | Investigated missing narcotics and medication discrepancies |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Mar 8, 2021
Visit Reason
The inspection was conducted as part of the facility's investigation of multiple complaints, including complaint 94932-C which was substantiated, while others were not substantiated.
Complaint Details
The visit was complaint-related involving multiple complaints (94932-C, 95787-C, 95189-C, 95072-C, 95056-C, 94740-C, 94616-C, and 94439-C). Complaint 94932-C was substantiated; the others were not substantiated.
Findings
The facility failed to provide a timely involuntary discharge notice for one of four discharged residents reviewed (Resident #5). The resident had diagnoses including Alzheimer's disease and dementia, required long term care placement, and was discharged following a hospital stay. The facility had no policy or procedures related to discharge planning and notice.
Deficiencies (1)
Failure to provide a timely involuntary discharge notice for Resident #5.
Report Facts
Census: 47
Discharged residents reviewed: 4
Discharge date: Nov 25, 2020
Involuntary Discharge Notice date: Jan 8, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Provided information about Resident #5's billing and discharge dates. | |
| Social Worker | Provided the involuntary discharge notice for Resident #5. | |
| Director of Nursing | Stated the facility had no policy and procedures related to discharge planning and notice. |
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 3
Date: Nov 24, 2020
Visit Reason
The inspection was conducted as part of the facility's annual health survey and included investigation of multiple substantiated and unsubstantiated complaints and facility reported incidents, along with a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaints 94369-C, 86987-C, 88314-C, 93050-C, 94033-C, 94373-C, and 94439-C were substantiated. Complaint 94496-C was not substantiated. Facility reported incidents 87328-I, 92585-I, and 93739-I were substantiated. Facility reported incidents 87605-I and 88566-I were not substantiated.
Findings
The facility was found in compliance with COVID-19 infection control practices but had deficiencies related to medication administration, restorative care, and accident prevention. Specifically, staff failed to follow professional medication administration standards for one resident, failed to provide appropriate restorative treatment for a resident with limited range of motion, and failed to provide adequate supervision and assistive devices to prevent accidents for two residents, resulting in a fall with injury.
Deficiencies (3)
Failed to ensure staff followed professional standards of medication administration for 1 of 4 residents reviewed (Resident #157).
Failed to assure a resident with limited range of motion received appropriate treatment and services related to restorative plan for 1 of 3 residents reviewed (Resident #47).
Failed to ensure staff provided adequate nursing supervision and assistive devices to prevent accidents for 2 of 4 residents reviewed (Residents #45 and #158), resulting in a fall with fractured hip and head laceration.
Report Facts
Total residents: 52
Medication administration audit: 169
Missed restorative brace applications: 12
Morse Fall Risk Assessment score: 55
BIMS score: 15
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Named in fall incident involving Resident #45 |
| Staff B | Director of Nursing (previous) | Provided information about care guides and fall prevention |
| Staff C | Administrator (previous) | Recalled fall incident and staff reports |
| Staff D | Licensed Practical Nurse | Observed transferring Resident #158 without gait belt |
| Staff E | Certified Nurse Aide | Observed transferring Resident #158 without gait belt |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and fall policy |
| Administrator | Administrator | Interviewed regarding gait belt use policy |
Inspection Report
Abbreviated Survey
Census: 50
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/23/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 50
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Date: Apr 15, 2020
Visit Reason
Investigation of a facility self-reported incident involving Resident #1 ingesting non-food items, including puzzle pieces, resulting in immediate jeopardy to the resident's health and safety.
Complaint Details
The visit was triggered by a complaint related to Resident #1 ingesting foreign objects, including puzzle pieces, toilet paper, and cotton balls, resulting in immediate jeopardy to the resident's health and safety.
Findings
The facility failed to provide adequate nursing supervision to prevent Resident #1 from ingesting non-food items, including puzzle pieces, toilet paper, and cotton, despite known cognitive impairments and prior incidents. The resident required hospitalization and surgery to remove puzzle pieces from his esophagus. The facility lacked adequate staff education and communication regarding the resident's risk behaviors and failed to remove all choking hazards from the unit.
Deficiencies (1)
Failed to provide adequate nursing supervision to prevent Resident #1 from ingesting non-food items.
Report Facts
Resident census: 63
BIMS score: 3
Wandering Risk Scale score: 14
Number of puzzle pieces removed: 4
Heart rate: 114
Blood pressure: 149
Temperature: 100.3
Staff signatures: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Found puzzle pieces in Resident #1's mouth on 3/24/20 and involved in emergency response |
| Staff B | Certified Nurse Aide (CNA) | Assisted Staff A during puzzle piece incident and provided resident supervision |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Responded to choking incident, stayed with resident until EMTs arrived, and provided staff education |
| Staff C | Licensed Practical Nurse (LPN) | Charge nurse on CCDI unit on 3/20/20, unaware of prior incidents, and involved in resident supervision |
| Staff D | Licensed Practical Nurse (LPN) | Provided care to Resident #1, aware of pocketing behavior, but not of all incidents |
| Staff E | Licensed Practical Nurse (LPN) | Worked night shift, unaware of incidents, and lacked education on resident's risk |
| Staff F | Certified Medication Aide (CMA) | Aware of resident's pocketing behavior, but not of puzzle piece ingestion incident |
| Staff G | Licensed Practical Nurse (LPN) | Aware of resident chewing on tissues/paper, but not of all incidents or formal education |
| Staff H | Licensed Practical Nurse (LPN) | Provided direct supervision to Resident #1 during observation |
| Staff I | Certified Medication Aide (CMA) | Heard about puzzle ingestion incident after it occurred, aware of new activity policy |
| Staff J | Registered Nurse (RN) | New staff, aware of resident needing close monitoring, but not of all incidents or formal education |
| Administrator | Facility Administrator | Responsible for staff education and policy implementation after incidents |
| Admissions and Marketing Coordinator | Admissions and Marketing Coordinator | Conducted sweep of CCDI unit removing small items and puzzles |
| Activities Director | Activities Director | Implemented new activity policy restricting small items on CCDI unit |
| Social Service Designee | Social Service Designee | Revised Resident #1's care plan to include non-food/foreign object ingestion risk |
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