Inspection Reports for Altoona Nursing and Rehabilitation Center
200 Seventh Avenue SW, Altoona, IA, 500091630
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, found the facility in substantial compliance with no deficiencies cited. Earlier inspections showed a mixed pattern, with several complaint investigations substantiating deficiencies related to resident-to-resident abuse, insufficient staffing, medication administration, infection control, and maintaining a safe environment. Notable issues included failure to prevent and document abuse incidents, inadequate nursing staff response, medication errors, and environmental concerns such as unsafe temperatures and unsecured treatment carts. Several complaint investigations were substantiated, particularly involving resident care and abuse prevention, while others were found unsubstantiated. The facility appears to have made some improvements over time, with the most recent report indicating compliance following prior citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
248% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
97 residents
Based on a October 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective November 20, 2025.
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 3
Date: Oct 30, 2025
Visit Reason
The inspection was conducted as a result of complaints #2626082-C and #2639275-C, and a facility reported incident #2652318-I, to investigate allegations of resident-to-resident abuse and ensure compliance with abuse prevention regulations.
Complaint Details
Complaint #2639275-C was substantiated. Facility reported incident #2652318-I was substantiated. The investigation found multiple resident-to-resident altercations involving Resident #6 and Resident #7, with staff failing to prevent harm and properly document incidents.
Findings
The facility was found not to have met requirements related to freedom from abuse, neglect, and exploitation, specifically failing to prevent resident-to-resident abuse incidents involving Resident #6 and Resident #7. Additionally, the facility lacked sufficient nursing staff to respond timely to call lights and failed to complete incident reports for some resident altercations. Resident records were also incomplete regarding incident documentation.
Deficiencies (3)
Failure to ensure residents were free from abuse, neglect, and exploitation, including resident-to-resident physical and verbal abuse incidents.
Insufficient nursing staff to provide timely response to call lights and resident needs.
Failure to maintain resident records with complete incident reports and timely documentation of allegations of abuse.
Report Facts
Census: 97
Deficiencies cited: 3
Call light response time: 15
Audit frequency: 2
Audit duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Malori Mayfield | Administrator | Named as Abuse Coordinator and responsible person for corrective actions |
| Staff A | Registered Nurse (RN) | Observed resident altercation and reported incident |
| Staff B | Licensed Practical Nurse (LPN) | Reported inability to recall incident details and incomplete documentation |
| Staff F | Certified Medication Aide (CMA) | Reported resident behaviors and staff challenges |
| Director of Nursing (DON) | Reported on incident investigations and staffing issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 23, 2025
Visit Reason
A complaint investigation was conducted for complaints #2590075, #2590618, #2590631, and #25904914 from September 22, 2025 to September 23, 2025.
Complaint Details
Complaint investigation for complaints #2590075, #2590618, #2590631, and #25904914; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 18, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction indicating acceptance of a credible allegation of substantial compliance and certification of the facility in compliance effective July 18, 2025.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction, leading to certification in compliance effective July 18, 2025. No specific deficiencies are detailed in the report.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Date: Jun 23, 2025
Visit Reason
The inspection was conducted as a result of complaints #127066-C, #129029-C, and #129628-C which resulted in deficiencies. The investigation focused on issues related to the facility environment and medication administration.
Complaint Details
Complaints #127066-C, #129029-C, and #129628-C triggered the investigation. Complaints #127066-C, #129029-C, and #129628-C resulted in deficiencies.
Findings
The facility failed to maintain comfortable and safe temperature levels in one of two dining rooms, with temperatures reaching the high 80s to low 90s due to a malfunctioning air conditioning unit. Additionally, the facility failed to prepare or administer medications as prescribed for 2 of 3 residents reviewed, including missed insulin doses and unavailable eye drops.
Deficiencies (2)
Failed to provide comfortable and safe temperature levels in the building for one of two dining rooms.
Failed to prepare or administer medication as prescribed and ordered by the physician for 2 of 3 residents reviewed.
Report Facts
Temperature reading: 83
Resident census: 90
Missed insulin doses: 6
Missed eye drop administrations: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported air conditioning unit issues and temperature discomfort in dining room |
| Staff B | Dietary Staff | Reported temperature issues in back dining room on Sunday |
| Staff C | Maintenance Staff | Reported and coordinated repair of air conditioning unit |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed about medication administration and facility temperature issues |
| Staff E | Certified Medical Assistant (CMA) | Reported resident discomfort due to heat in dining room |
| Staff F | Registered Nurse (RN) | Interviewed about medication administration policies |
| Director of Nursing | Director of Nursing (DON) | Acknowledged temperature issues and medication administration concerns |
| Administrator | Administrator | Acknowledged temperature issues in back dining room |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
The document reflects acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, resulting in certification of compliance effective March 20, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction; no specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 10
Date: Feb 27, 2025
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey and investigation of multiple complaints and a facility reported incident.
Complaint Details
Complaint numbers #125984-C, 126083-C, 126227-C, 126583-C and 126938-C were substantiated.
Findings
The facility was found deficient in multiple areas including resident dignity, safe and homelike environment, activities of daily living, accident prevention, infection control, sufficient staffing, hospice services coordination, and quality assurance performance improvement. Several residents were observed with unmet care needs, unsafe transfer practices, cluttered hallways, loud alarms, and improper infection control practices.
Deficiencies (10)
Failure to ensure residents' dignity by providing dressing assistance prior to meals and maintaining privacy during toileting.
Failure to provide a safe, clean, comfortable, and homelike environment including reducing noise, odors, and clutter in hallways.
Failure to provide rehabilitative services as ordered for a resident.
Failure to provide assistance with activities of daily living including bathing, grooming, and nail care for dependent residents.
Failure to ensure safe transfer techniques, clear hallways, and secure smoking supplies.
Failure to provide appropriate catheter care to prevent complications.
Failure to provide sufficient nursing staff to meet resident needs safely and timely.
Failure to effectively coordinate hospice medication management to assist with symptom management.
Failure to maintain an effective Quality Assurance Performance Improvement (QAPI) program to address repeat deficiencies.
Failure to utilize enhanced barrier precautions and infection control practices to prevent spread of infection.
Report Facts
Residents present: 94
Deficiency counts: 10
CMS Payroll Based Journal staffing triggers: 13
CMS Payroll Based Journal staffing triggers: 9
CMS Payroll Based Journal staffing triggers: 2
CMS Payroll Based Journal staffing triggers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Assistant Director of Nursing | Acknowledged dignity concerns, equipment storage issues, and expected staff to use gait belts and gowns for precautions |
| Staff A | Registered Nurse | Assisted resident with feeding and pushed wheelchair without foot pedals |
| Staff E | Certified Nursing Assistant | Reported loud alarms and insufficient staffing |
| Staff F | Certified Nursing Assistant | Observed transferring resident with mechanical lift |
| Staff G | Certified Nursing Assistant | Reported expectations for gait belt use and smoking supply security |
| Staff O | Advanced Practice Registered Nurse | Managed hospice medication and collaborated with hospice staff |
| Staff Q | Hospice Registered Nurse | Collaborated with facility staff on medication management |
| Staff T | Hospice Registered Nurse | Communicated with facility and family regarding resident behaviors and medication changes |
| Staff U | Hospice Medical Director | Discussed medication management and resident comfort |
| Staff V | Certified Nursing Assistant | Reported staffing shortages and hallway clutter |
| Staff W | Registered Nurse | Reported hallway clutter and staffing concerns |
| Staff X | Certified Nursing Assistant | Reported staffing shortages and alarm issues |
| Staff Y | Scheduling Coordinator | Reported staffing expectations and frequent call-ins/no shows |
| Staff Z | Activities Director | Observed pushing resident in wheelchair without foot pedals |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 4, 2024
Visit Reason
An investigation for Complaints #125102-C, #122852-C, #122853-C, #122551-C and Facility Reported Incident #123392-I was conducted from December 02, 2024 to December 04, 2024.
Complaint Details
Investigation was complaint-related involving multiple complaints and a facility-reported incident; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 22, 2024
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 the credible allegation of compliance and plan of correction, effective August 22, 2024.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 4
Date: Aug 7, 2024
Visit Reason
The inspection was conducted from July 30, 2024 to August 7, 2024, resulting from investigations of multiple complaints (#120211-C, #120762-C, #121569-C, #121575-C) and facility reported incidents (#121619-I, #121862-I). Several complaints and one incident were substantiated.
Complaint Details
The investigation was triggered by multiple complaints and facility reported incidents. Complaints #120762-C, #121569-C, and #121575-C were substantiated, as was Facility Reported Incident #121862-I.
Findings
The facility failed to provide adequate perineal care and bathing according to residents' needs, failed to provide restorative exercises as per care plans, did not maintain a safe environment for residents at elopement risk, and failed to secure medication and treatment carts properly.
Deficiencies (4)
Failed to properly provide perineal care and baths/showers according to residents' individual needs and desires.
Failed to provide restorative exercises according to individual plans of care for residents.
Failed to ensure a safe and secure environment for a resident at elopement risk, including non-functional wander guard system and lack of staff orientation on elopement risks.
Failed to maintain locked treatment carts on two separate occasions.
Report Facts
Resident census: 87
Bathing missed dates: 13
Restorative exercise missed dates for Resident #2: 18
Restorative exercise missed dates for Resident #5: 20
Residents identified as wanderers: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Confirmed residents found in soiled bedding and assisted in identifying resident who eloped |
| Staff M | Certified Nursing Assistant (CNA)/Shower aide | Confirmed inability to shower residents as scheduled due to staffing issues |
| Staff N | Certified Nursing Assistant (CNA) | Confirmed residents found soiled in disposable undergarments and bedding |
| Staff E | Certified Nursing Assistant (CNA) | Observed resident elopement and described circumstances |
| Staff H | Licensed Practical Nurse (LPN) | Responded to resident elopement, found wander guard device cut and misplaced |
| Staff G | Maintenance | Reported no electricity to wander guard device door alarm |
| Staff A | Certified Nursing Assistant (CNA) | Confirmed lack of orientation on elopement risk residents |
| Staff B | Certified Nursing Assistant (CNA) | Confirmed lack of orientation on elopement risk residents |
| Staff C | Housekeeping | Unaware which residents posed elopement risk |
| Staff D | Registered Nurse (RN) | Not educated on elopement policy or residents at risk |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 2, 2024
Visit Reason
The document is a Plan of Correction submitted following an inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective May 2, 2024.
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 11
Date: Apr 11, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and investigation of substantiated complaints #119171-C and #120061-C.
Complaint Details
Complaint #119171-C and #120061-C were substantiated.
Findings
The facility was found deficient in multiple areas including failure to promptly notify resident representatives of room changes, failure to maintain a safe, clean, and homelike environment, failure to notify the state ombudsman of resident transfers, inaccurate Minimum Data Set (MDS) assessments, failure to update care plans to reflect therapy recommendations, failure to properly transcribe and implement provider orders, insufficient nursing staff to meet resident needs, failure to provide routine dental services, failure to maintain kitchen freezer in satisfactory condition, failure to follow infection control practices, and failure to provide pneumococcal immunizations to eligible residents.
Deficiencies (11)
Failure to promptly notify resident representative when there was a room change with resident health changes for 1 of 1 residents reviewed.
Failure to contain odors, wipe soiled surfaces and clear cluttered hallways to promote a homelike environment.
Failure to notify the long term care ombudsman for resident transfers to an acute care hospital for 1 of 4 residents reviewed.
Failure to accurately code resident MDS assessments to reflect accurate resident conditions for 2 of 18 sampled residents.
Failure to update and revise the Care Plan to reflect therapy recommendations of resident restorative activities program for three of three sampled residents.
Failure to properly transcribe and implement provider orders for 1 of 7 residents reviewed for medication orders.
Failure to provide restorative activities for three of three sampled residents in order to maintain a functional range of motion and prevent a decline in activities of daily living.
Failure to provide sufficient and competent staff to meet resident needs with bathroom cares and answering call lights timely for 1 of 10 group resident interview and 2 of 18 sampled residents.
Failure to maintain the combination walk-in freezer and refrigerator in a clean and satisfactory condition.
Failure to follow infection control practices including not removing soiled gloves and performing hand hygiene, failure to disinfect resident care devices when soiled, and failure to prevent cross contamination during incontinence cares.
Failure to ensure residents eligible for pneumococcal immunization were offered and documented as receiving or refusing the vaccine.
Report Facts
Residents on census: 89
Length of icicle: 6
Residents reviewed for pneumonia vaccine: 5
Residents eligible for pneumococcal vaccine: 28
Residents reviewed for medication orders: 7
Residents reviewed for dental services: 1
Residents sampled for MDS accuracy: 18
Residents sampled for restorative activities: 3
Residents sampled for nursing staff adequacy: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nursing Assistant | Observed providing incontinence care without proper glove and hand hygiene |
| Staff G | Certified Nursing Assistant | Observed sitting with eyes closed during shift and failing to sanitize equipment |
| Staff I | Certified Medication Aide | Observed providing incontinence care without proper glove and hand hygiene |
| Staff T | Certified Medication Aide | Responsible for dental scheduling, reported resident refused dental care |
| Staff J | Certified Nursing Assistant | Reported staffing shortages and residents not getting showers |
| Staff K | Certified Nursing Assistant | Reported staffing shortages and delays in call light response |
| Staff L | Therapy Staff | Reported therapy recommendations and restorative programs |
| Staff M | Social Worker | Reported receiving restorative therapy recommendations |
| Staff O | Certified Nurse Aide and Restorative Aide | Reported restorative program charting practices |
| Staff P | Maintenance Supervisor | Reported no knowledge of freezer frost and drip issue |
| Staff Q | Dietary Supervisor | Reported frost and drip issue in freezer has existed for years |
| Staff R | Dietary Supervisor | Reported awareness of freezer frost and drip issue |
| Director of Nursing | Director of Nursing | Provided multiple clarifications on restorative programs, infection control, and staffing |
| Administrator | Administrator | Confirmed staff member was found sleeping on duty and terminated |
| Director of Therapy | Director of Therapy | Reported resident therapy caseload and restorative program status |
| Social Services Director | Social Services Director | Reported ombudsman notification and restorative program information |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 11, 2024
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, resulting in certification of compliance effective March 11, 2024.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, with no specific deficiencies detailed in this report.
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 7
Date: Feb 13, 2024
Visit Reason
The inspection was conducted following a Facility Reported Incident and investigation of multiple complaints regarding resident care and facility conditions.
Complaint Details
The visit was complaint-related, triggered by multiple complaints and a facility reported incident. Substantiation status is not explicitly stated.
Findings
The facility failed to treat residents with dignity and respect, maintain a safe and clean environment, provide proper perineal care, adequately treat a pressure ulcer, answer call lights timely, reconcile narcotic counts, and follow infection control procedures including proper glove use.
Deficiencies (7)
Facility staff failed to treat 2 of 3 residents with dignity and respect during personal cares, including failure to knock before entering rooms and leaving residents exposed.
Facility failed to maintain a clean, safe, and homelike environment, including unrepaired holes in walls, damaged flooring, and soiled walls.
Facility failed to properly provide perineal care for 2 of 3 residents, including failure to change gloves and cleanse all required areas.
Facility failed to properly provide care and treatment to a pressure ulcer for 1 of 3 residents.
Facility failed to have sufficient nursing staff to answer resident call lights within 15 minutes for 2 of 4 residents.
Facility failed to reconcile narcotic/controlled substance counts at the beginning and ending of every shift for four medication carts.
Facility staff failed to remove soiled gloves during personal cares for 2 of 3 residents, risking infection transmission.
Report Facts
Deficiency count: 7
Resident census: 94
Call light response time: 30
Call light response time: 180
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nursing Assistant | Named in dignity and perineal care deficiencies. |
| Staff I | Certified Nursing Assistant | Named in dignity and perineal care deficiencies. |
| Staff C | Certified Nursing Assistant | Named in perineal care and infection control deficiencies. |
| Staff D | Certified Nursing Assistant | Named in perineal care and infection control deficiencies. |
| Staff J | Certified Nursing Assistant | Confirmed failure to close doors and change gloves during cares. |
| Staff K | Registered Nurse | Confirmed dignity and call light response issues. |
| Staff G | Registered Nurse | Observed wound care without dressing. |
| Staff A | Licensed Practical Nurse | Confirmed call light response issues. |
| Director of Nursing | Director of Nursing | Provided statements on resident room move-in and narcotic count expectations. |
| Corporate Duality Assurance Nurse | Corporate Duality Assurance Nurse | Confirmed narcotic count deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective December 15, 2023, based on acceptance of the credible allegation of substantial compliance and the Plan of Correction.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 5
Date: Nov 28, 2023
Visit Reason
The inspection was conducted as a result of complaints #114490-C, #114548-C, #116061-C, and #116711-C, which were substantiated. The investigation focused on resident rights, safe environment, professional standards of care, quality of care, and sufficient nursing staff.
Complaint Details
Complaints #114490, #114548, #116061, and #116711 were substantiated following the investigation conducted from November 8 to November 28, 2023.
Findings
The facility failed to treat residents with dignity and respect during showering, maintain privacy, properly clean oxygen concentrators, follow physician orders for medication administration, conduct necessary assessments after falls, and respond timely to resident call lights. Multiple deficiencies were identified based on observations, clinical record reviews, staff and resident interviews, and resident council minutes.
Deficiencies (5)
Facility staff failed to treat 2 of 4 residents with dignity and respect during showering, including lack of privacy curtains.
Facility failed to maintain a safe, clean, comfortable, and homelike environment, including failure to properly clean oxygen concentrators.
Facility failed to follow physician's orders for medication administration for 2 of 3 residents reviewed.
Facility failed to provide necessary assessments for 1 of 3 residents reviewed following a fall.
Facility failed to ensure sufficient nursing staff responded timely to resident call lights within the allotted professional standards of 15 minutes.
Report Facts
Resident census: 90
Medication Administration Record dates: 11
Medication Administration Record dates: 16
Assessment dates: 72
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
A complaint investigation was conducted for complaints #113123-C, #112543-C, #112231-C, #110853-C and facility reported incidents #112623-I, #111375-I from July 3, 2023 to July 6, 2023.
Complaint Details
Investigation involved multiple complaints and facility reported incidents; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 8, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Altoona Nursing and Rehabilitation Center, certifying compliance based on acceptance of the credible allegation of compliance and plan of correction.
Findings
The facility was certified in compliance effective February 8, 2023, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in the document.
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 22
Date: Dec 29, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of multiple complaint and self-reported incident intakes between December 18 and December 29, 2022.
Complaint Details
Complaints #108019, #108029, and #109251 were substantiated. Complaints #108270 and #109503 were not substantiated. Self-reported incidents #108270 and #109650 were substantiated.
Findings
The facility was found deficient in multiple areas including resident rights, dignity in catheter care, reasonable accommodations, notice requirements before transfer/discharge, PASRR coordination, professional standards in care, quality of care, dialysis monitoring, medication error rates, medication administration, drug storage, infection prevention and control, bowel/bladder incontinence, respiratory care, nurse aide performance reviews, licensure compliance, and in-service training for nurse aides. The facility submitted a plan of correction with compliance dates of February 9, 2023.
Deficiencies (22)
Failure to treat residents with respect and dignity regarding catheter dignity bags for residents #15 and #74.
Failure to provide reasonable accommodations and coordinate resident appointments, including dermatology for resident #72.
Failure to notify the Long Term Care Ombudsman of transfers and discharges for residents #19 and #84.
Failure to coordinate PASRR Level II assessments and submit updated diagnoses for residents #22 and #44.
Failure to ensure infection prevention and control program compliance, including PPE usage and staff education.
Failure to ensure proper bowel/bladder incontinence care and catheter bag placement for residents #15 and #74.
Failure to provide proper respiratory/tracheostomy care including humidification and oxygen tubing for resident #76.
Failure to complete dialysis assessments before and after treatment for resident #46.
Medication error rate exceeded 5%, with errors in insulin administration for residents #92 and #32.
Failure to administer medications as prescribed, including priming insulin pens and IV tubing for residents #92 and #32.
Failure to properly label and store drugs and biologicals, including expired medications and flu vaccine storage.
Failure to provide catheter dignity bags to residents with catheters and educate staff on their use.
Failure to provide reasonable accommodations for resident needs and preferences, including appointment management.
Failure to notify ombudsman of transfers and discharges in a timely manner.
Failure to coordinate PASRR assessments and submit required documentation for residents with serious mental disorders.
Failure to maintain an effective infection prevention and control program, including PPE compliance and staff education.
Failure to ensure proper bowel/bladder incontinence care and secure catheter drainage bags.
Failure to provide proper respiratory and tracheostomy care, including humidification and oxygen tubing maintenance.
Failure to complete dialysis assessments and monitoring for residents receiving dialysis treatments.
Failure to perform nurse aide performance reviews timely and maintain documentation.
Failure to comply with licensure requirements and report veteran status for new admissions.
Failure to provide required in-service training for nurse aides to ensure competency.
Report Facts
Census: 87
Deficiencies cited: 22
Medication error rate: 6.9
Weight gain: 20.8
Weight gain: 30
Shingrix vaccine cost: 205
Insulin flexpen units: 35
PICC line placement audits: 6
Compliance date: Feb 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Aide (CMA) | Observed failing to offer dignity bag for urinary catheter drainage |
| Staff B | Certified Nurses Aide (CNA) | Observed failing to offer dignity bag for urinary catheter drainage |
| Staff C | Certified Medication Aide (CMA) | Observed failing to offer dignity bag for urinary catheter drainage |
| Staff J | Unit Manager | Recorded new orders and managed appointments |
| Staff P | Assistant Director of Nursing (ADON) | Documented dermatology appointment and planned follow-up |
| Staff S | Assistant Director of Nursing (ADON) | Planned follow-up for dermatology appointment rescheduling |
| Staff I | Licensed Practical Nurse (LPN) | Reviewed dermatology appointment calendar and interviewed |
| Staff O | Registered Nurse (RN) | Reported on dermatology appointment and IV medication administration |
| Staff K | Assistant Director of Nursing (ADON) | Reported on appointment scheduling and PICC line placement |
| Staff F | Certified Nurses Aide (CNA) | Employee file reviewed for nurse aide performance |
| Staff G | Certified Nurses Aide (CNA) | Employee file reviewed for nurse aide performance |
| Staff H | Certified Nurses Aide (CNA) | Employee file reviewed for nurse aide performance |
| Staff V | Pharmacist | Reported on insulin flexpen preparation and medication administration |
| Staff M | Nurse | Reported IV tubing issues and medication administration |
| Staff E | Licensed Practical Nurse (LPN) | Prepared and administered insulin and oxygen tubing care |
| Staff BB | Licensed Practical Nurse (LPN) | Prepared IV medication for Resident #32 |
| Staff Q | Certified Nursing Assistant (CNA) | Observed mask use and assisted resident |
| Staff T | Certified Nursing Assistant (CNA) | Observed mask use and resident interaction |
| Staff R | Registered Nurse (RN) | Observed mask use and resident interaction |
| Staff U | Medication Aide | Checked medication storage rooms |
| Staff W | Licensed Practical Nurse (LPN) | Observed vaccine storage |
| Staff J | Unit Manager | Reported on medication storage and vaccine handling |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 31, 2022
Visit Reason
The document reports acceptance of the facility's credible allegation of compliance and plan of correction following an investigation ending August 31, 2022, leading to certification in compliance effective October 31, 2022.
Findings
The facility was found to be in compliance based on the accepted plan of correction and credible allegation of compliance following the investigation.
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 4
Date: Aug 31, 2022
Visit Reason
The inspection was conducted in response to complaints and facility-reported incidents between August 3, 2022, and August 31, 2022, including allegations of abuse, neglect, and failure to report incidents timely.
Complaint Details
The investigation included complaints #103681-C, #104018-C, #104039-C, #104926-C, #104980-C, #106617-C and facility-reported incidents #102956-I, #106323-M, #106524-I, and #106805-I. Some complaints were substantiated (e.g., #104018-C, #104039-C, #102956-I), while others were not. The facility failed to report allegations of abuse timely as required by state law.
Findings
The facility failed to report allegations of abuse in a timely manner and did not follow physician orders for some residents. Deficiencies were found related to abuse reporting, comprehensive care plans, medication administration, pharmacy services, and food safety standards.
Deficiencies (4)
Facility failed to report allegations of abuse to the Department of Inspections and Appeals in a timely manner.
Facility failed to follow physician orders for 2 of 5 residents reviewed.
Facility failed to reconcile narcotic/controlled substance counts at the beginning and ending of every shift for one of four residents reviewed.
Facility failed to provide hot food items at or above 140 degrees Fahrenheit to prevent potential foodborne illness.
Report Facts
Facility census: 93
Residents reviewed: 5
Residents reviewed: 4
Residents reviewed: 2
Medication administration errors: 1
Food temperature: 140
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 14, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
Based on acceptance of the credible allegation of compliance and plan of correction, the facility will be certified in compliance effective April 14, 2022.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 5
Date: Mar 23, 2022
Visit Reason
An investigation of Facility Reported Incidents (FRIs) and Complaints was conducted from 3/1 to 3/23/22, triggered by multiple complaints and incidents reported at the facility.
Complaint Details
Multiple complaints were investigated, with most substantiated except complaint #100341. Facility Reported Incidents #102811 and #102381 were substantiated. The investigation included resident and staff interviews, clinical record reviews, and policy reviews.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity and respect, inadequate coordination of care and services, unsafe medication administration practices, and insufficient infection control measures. Several residents experienced neglect and improper care, and staff failed to follow policies and procedures.
Deficiencies (5)
Failure to maintain resident dignity and respect, including inappropriate staff behavior toward Resident #2.
Failure to ensure residents receive treatment and care in accordance with professional standards, including inadequate coordination of services for Residents #6 and #12.
Failure to maintain a safe environment free of accident hazards and provide adequate supervision, including insulin administration errors for Resident #13.
Failure to ensure residents are free of significant medication errors, including insulin administration issues for Residents #10 and #13.
Failure to establish and maintain an infection prevention and control program, including improper hand hygiene and glove use for Resident #14.
Report Facts
Resident census: 87
Deficiency count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nursing Assistant (CNA) | Named in resident dignity and respect deficiency involving Resident #2 |
| Staff F | Licensed Practical Nurse (LPN) | Reported incidents involving Resident #2 and Staff H |
| Staff G | Licensed Practical Nurse (LPN) | Involved in obtaining statements and reporting incidents related to Resident #2 |
| Director of Nursing (DON) | Director of Nursing | Reported on multiple findings including medication administration and infection control |
| Staff E | Registered Nurse (RN) | Observed insulin administration errors and medication pass issues |
| Staff A | Registered Nurse (RN) | Reported on documentation of resident appointments and procedures |
| Staff D | Registered Nurse (RN) | Reported on medication administration timing and insulin administration |
| Staff I | Pharmacist | Reported on insulin medication details and administration |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 95
Deficiencies: 11
Date: Jun 30, 2021
Visit Reason
The inspection was conducted as part of the Recertification Survey and a complaint investigation related to Facility Reported Incident #97422 and Complaint #97849 conducted June 15-30, 2021.
Complaint Details
Complaint #97849-C was substantiated. Facility Reported Incident #97422-1 was substantiated.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident privacy and confidentiality, failure to develop and implement abuse/neglect policies, failure to complete criminal background checks for staff, failure to coordinate PASARR assessments, failure to develop baseline and comprehensive care plans, failure to provide adequate ADL care, failure to ensure CPR certification for staff, failure to maintain infection control, and failure to provide adequate supervision and accident prevention.
Deficiencies (11)
Failure to secure resident medical records and maintain privacy and confidentiality.
Failure to develop and implement abuse/neglect policies and procedures.
Failure to complete criminal background checks and evaluations for staff.
Failure to coordinate PASARR assessments and refer residents appropriately.
Failure to develop and implement baseline and comprehensive care plans for residents.
Failure to provide adequate assistance with activities of daily living including showers.
Failure to ensure staff CPR certification and training.
Failure to maintain infection prevention and control program and procedures.
Failure to provide adequate supervision and accident prevention for residents.
Failure to provide appropriate incontinence care and bladder control.
Failure to properly label, store, and secure drugs and biologicals.
Report Facts
Census: 95
Residents reviewed: 22
Residents with deficiencies: 19
Residents with CPR certification: 26
Residents requiring assistance: 54
Staff CPR certification expiration date: 2021
Residents with ADL deficiencies: 4
Residents with incontinence: 5
Residents with cognitive impairment: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nurse Assistant | Named in deficiency related to criminal background check and timecard review. |
| Staff K | Certified Nurse Assistant | Named in deficiency related to criminal background check. |
| Staff L | Certified Nurse Assistant | Named in deficiency related to criminal background check. |
| Staff M | Certified Nurse Assistant | Named in deficiency related to criminal background check. |
| Director of Nursing | Named as responsible party for multiple deficiencies including privacy, care planning, CPR training, and infection control. | |
| Human Resource Director | Named as responsible party for criminal background check deficiencies. | |
| Social Services Director | Named as responsible party for PASARR coordination deficiencies. | |
| MDS Coordinator | Named as responsible party for care plan deficiencies. | |
| Staff AA | Registered Nurse | Involved in CPR event and care provision. |
| Staff DD | Certified Nurse Aide | Involved in CPR event and care provision. |
| Staff Z | Registered Nurse | Involved in CPR event and care provision. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 14, 2021
Visit Reason
Investigation of a Facility Reported Incident #97396 was conducted on May 14, 2021.
Complaint Details
Facility Reported Incident #97396-I was not substantiated.
Findings
The Facility Reported Incident #97396-I was not substantiated. The report references compliance with Code of Federal Regulations (42CFR) Part 483, Subpart B-C.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Date: Apr 6, 2021
Visit Reason
The inspection was a Centers for Medicare and Medicaid Services (CMS) Focused Concern Survey conducted on 4/6/21 following an Iowa Department of Inspections and Appeals Complaint Survey on 3/11/21.
Complaint Details
The complaint investigation was triggered by complaints investigated under IA00094975, IA00096117, IA00096129, IA00095430, and IA00096267. The Administrator was notified of an immediate jeopardy (IJ) related to the unsupervised steam table on 4/5/21 at 6:30 pm. The IJ was removed on 4/6/21 after corrective actions were implemented.
Findings
The facility failed to prevent resident access to a steam table turned on to the highest setting, posing a burn hazard to cognitively impaired residents. Additionally, the facility failed to secure a cabinet containing resident smoking materials, which were left unlocked and accessible.
Deficiencies (2)
Failure to prevent resident access to the steam table in the dining room which was turned on to the highest setting, posing a burn hazard.
Failure to secure a cabinet containing resident smoking materials including cigarettes and lighters, which were left unlocked and accessible.
Report Facts
Resident census: 92
Number of cognitively impaired residents affected: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenny O'Brien | Administrator | Named in relation to notification of immediate jeopardy and providing education on corrective actions |
| Dietary Aide (D1) | Interviewed regarding steam table operation and safety | |
| Activity Director (AD) | Responsible for overseeing resident smoking activities and securing smoking materials |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 3
Date: Mar 11, 2021
Visit Reason
The inspection was conducted to investigate multiple complaints (#94975-C, #86117-C, #86129-A, and #95430) regarding resident abuse and neglect at Toona Nursing and Rehabilitation Center between March 1 and March 11, 2021.
Complaint Details
Complaints #94975-C, #86117-C, #86129-A, and #95430 were investigated. Complaint #94975-C was substantiated without a deficiency. Complaint #86117-C was substantiated. The investigation focused on abuse and neglect allegations involving Resident #5 and staff members.
Findings
The facility was found to have substantiated complaints of resident abuse and neglect involving staff behavior toward residents, including inappropriate touching and verbal abuse. The facility failed to provide mandatory abuse training for staff and failed to report allegations of abuse timely. Resident #5 was involved in multiple incidents of inappropriate behavior and staff responses were inadequate.
Deficiencies (3)
Facility failed to treat residents with dignity and respect; resident #5 was inappropriately touched and staff used foul language.
Facility failed to develop and implement abuse/neglect policies including mandatory training for staff.
Facility failed to report allegations of abuse immediately and failed to investigate thoroughly.
Report Facts
Census: 91
Complaint IDs: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Named in findings related to inappropriate touching and verbal abuse of Resident #5 |
| Staff F | Certified Nurse Aide | Reported Staff A's inappropriate behavior and involved in investigation |
| Staff G | Certified Nurse Aide | Reported Staff A's cursing and involved in investigation |
| Staff D | Licensed Practical Nurse | Witnessed events and reported to DON |
| Staff E | Certified Nurse Aide | Reported abuse allegations and signed suspension notice |
| Staff K | Certified Nurse Aide | Failed to complete mandatory abuse training within required timeframe |
| Director of Nursing | DON | Investigated abuse allegations and involved in staff disciplinary actions |
| Staff L | Human Resource Manager | Reported staff overhearing and abuse reporting expectations |
| Staff B | Dietary Manager | Reported overhearing abusive language |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 3
Date: Jan 13, 2021
Visit Reason
The inspection was a focused infection control survey and complaint investigation conducted from November 23, 2020 to January 13, 2021, triggered by multiple complaints and a facility reported incident.
Complaint Details
Complaint #94041-C was not substantiated. Complaints #93877, #94429-C, #94684-C, #94665-C, #94686-C, #94673-C, #94674-C, #94675-C, #94678-C, #94680-C, #94681-C, #94882-C, #94683-C, #94684-C, #94685-C, #94688-C, #94687-C, #94689-C, #94690-C, #94894-C, #94695-C, #94001-C, #94929-C, and #94971-C were substantiated. Facility Report Incident #94841-I was substantiated.
Findings
The facility was found to have deficiencies related to quality of care, medication errors, and infection prevention and control. Specific issues included failure to provide treatment and care according to professional standards for Resident #12, significant medication errors affecting Resident #3, and inadequate infection control practices during a COVID-19 outbreak.
Deficiencies (3)
Failure to provide treatment and care in accordance with professional standards for Resident #12, resulting in osteomyelitis and hospitalization.
Failure to ensure residents are free from significant medication errors, including improper insulin administration for Resident #3.
Failure to establish and maintain an effective infection prevention and control program, including inadequate hand hygiene, PPE use, and outbreak management.
Report Facts
Census: 98
COVID positive residents: 30
COVID negative residents: 10
Blood glucose level: 34
Blood glucose level: 69
Blood glucose level: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Documented care and treatment for Resident #12, notified Physician Assistant of infection. |
| Staff B | Licensed Practical Nurse | Documented Resident #12's move from skilled care and appointment with Podiatrist. |
| Staff C | Assistant Director of Nurses | Documented Resident #12's hospital admission and follow-up, confirmed treatment orders. |
| Staff D | Registered Nurse | Administered insulin to Resident #3, confirmed triple check process issues. |
| Staff E | Registered Nurse | Assisted Resident #3 during hypoglycemic episode, called 911. |
| Staff F | Registered Nurse | Prepared medications during observation, failed to sanitize hands properly. |
| Staff G | Nurse Aide | Entered COVID positive room with improper PPE handling. |
| Staff H | Dietary Aide | Observed failing to remove gown and gloves properly in COVID positive area. |
| Staff I | Nurse Aide | Reported Staff J's respiratory problems and mask issues. |
| Staff J | Registered Nurse | Reported respiratory problems and difficulty breathing with mask on. |
| Staff K | Prior Director of Nursing | Confirmed Staff J failed to wear mask properly and provided education. |
| Facility Physician's Assistant | Ordered antibiotic treatment for Resident #12's infection. | |
| Administrator | Confirmed treatment issues and triple check process problems. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 5, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and investigation of complaints #89547, #91115, #91108, #92289, and #92380 was conducted by the Department of Inspections and Appeals.
Complaint Details
Complaints #89547-C, #91115-C, #91108-C, #92289-C, and #92380-C were investigated and all were not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. All complaints investigated were not substantiated.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint #90351 were conducted by the Department of Inspection and Appeals on June 15, 2020.
Complaint Details
Complaint #90351-C was not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #90351-C was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 13, 2020
Visit Reason
The inspection was conducted to investigate complaints #86001, #86914, #87538, and #88020.
Complaint Details
Complaints #86001, #86914, #87538 and #88020 were investigated and found to be not substantiated.
Findings
The complaints investigated during the survey were not substantiated according to the Code of Federal Regulations (42CFR) Part 483, Subpart B-C.
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