Inspection Reports for
AMS Memorial-Greene
108 South High Street, Greene, IA, 506360617
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
61% occupied
Based on a March 2022 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
The document serves as a plan of correction following a prior inspection, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility was certified in compliance effective April 13, 2022, based on acceptance of the plan of correction and credible allegation of compliance.
Inspection Report
Re-Inspection
Census: 19
Deficiencies: 2
Date: Mar 31, 2022
Visit Reason
The visit was an onsite revisit conducted on 3/30/22 - 3/31/22 regarding the recertification survey conducted on 2/14/22 - 2/21/22.
Findings
The facility failed to develop a comprehensive person-centered care plan related to the use of a high-risk medication for 1 of 5 residents reviewed and failed to ensure a PRN medication order for an anti-anxiety drug was limited to 14 days with proper physician documentation for continuation for 1 of 4 residents reviewed.
Deficiencies (2)
Failed to develop a comprehensive person-centered care plan related to the use of a high-risk medication (Coumadin) for Resident #1.
Failed to ensure a PRN medication order for an anti-anxiety drug (Lorazepam) was limited to 14 days and lacked physician documentation for continuation for Resident #2.
Report Facts
Resident census: 19
Residents reviewed for care plan deficiency: 5
Residents reviewed for PRN medication deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged deficiencies related to Resident #1's anticoagulant care plan and Resident #2's PRN Lorazepam order |
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 8
Date: Feb 21, 2022
Visit Reason
The inspection was a recertification health survey conducted from 2/14/22 to 2/21/22 to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including failure to complete background checks prior to hire, incomplete and untimely comprehensive care plans, lack of 24-hour CPR certified staff, failure to provide restorative services as required, insufficient RN coverage, improper use and monitoring of psychotropic medications, and failure to timely notify residents and families of COVID-19 positive cases.
Deficiencies (8)
Failed to complete a background check for 1 of 5 employees prior to hire.
Failed to develop and implement comprehensive person-centered care plans for 2 of 12 residents reviewed.
Failed to review and revise care plans timely for 2 of 12 residents, including after falls and medication changes.
Failed to ensure properly trained personnel certified in CPR were available 24 hours per day.
Failed to ensure staff provided and followed individualized restorative programs for 2 of 3 residents reviewed.
Failed to provide RN coverage for at least 8 consecutive hours a day, 7 days a week on 3 days in a 4 week period.
Failed to ensure PRN psychotropic medication order was limited to 14 days and lacked documented rationale for extension; failed to routinely monitor residents for adverse effects of antipsychotic medications.
Failed to notify residents, representatives, and families by 5 p.m. the next calendar day following occurrence of COVID-19 positive staff cases for 7 of 8 positive cases in January 2022.
Report Facts
Census: 22
Deficiency count: 8
RN coverage days missed: 3
COVID-19 positive staff cases: 8
COVID-19 positive staff cases not timely notified: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Certified Nurse Aide | Named in deficiency for lack of background check prior to hire |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan deficiencies, CPR certification, restorative services, and psychotropic medication monitoring |
| Nursing Home Administrator | Administrator | Interviewed regarding background check policy, CPR certification, and RN coverage |
| Staff J | Registered Nurse, Restorative | Interviewed regarding restorative care services and documentation |
| Office Manager | Office Manager | Interviewed regarding background checks and COVID-19 family notification |
Inspection Report
Routine
Census: 22
Deficiencies: 8
Date: Feb 21, 2022
Visit Reason
Routine inspection of Ams Memorial-Greene nursing home to assess compliance with regulatory requirements including staff background checks, care planning, CPR certification, restorative care, RN coverage, psychotropic medication monitoring, and COVID-19 reporting.
Findings
The facility had multiple deficiencies including failure to complete background checks prior to hire, incomplete and overdue care plans, lack of CPR certified staff on some shifts, failure to provide restorative care as directed, insufficient RN coverage, inadequate monitoring of psychotropic medications, and failure to timely notify residents and families of COVID-19 positive staff cases.
Deficiencies (8)
F0606: The facility failed to complete a background check for 1 of 5 employees prior to hire as required by policy and Iowa Administrative Code.
F0656: The facility failed to develop and implement comprehensive person-centered care plans for 2 of 12 residents, including missing anticoagulant care planning and overdue care plan reviews.
F0657: The facility failed to review and revise care plans after each fall for Resident #15 and failed to care plan antipsychotic medication for Resident #18.
F0678: The facility failed to ensure CPR certified personnel were available 24 hours per day, with 2 shifts lacking CPR certified staff in a 4 week period.
F0688: The facility failed to provide and document restorative care as directed for 2 of 3 residents, including lack of documentation and missed restorative services after staff retirement.
F0727: The facility failed to provide a registered nurse on duty for at least eight consecutive hours a day on 3 days in a 4 week period.
F0758: The facility failed to limit PRN psychotropic medication orders to 14 days without documented rationale and failed to routinely monitor residents for adverse effects of antipsychotic medications.
F0885: The facility failed to document notification to residents and families by 5:00 PM the next calendar day following confirmed COVID-19 positive staff cases for 7 of 8 cases in January 2022.
Report Facts
Residents present: 22
Positive COVID-19 staff cases: 8
Days without RN coverage: 3
Shifts without CPR certified staff: 2
Residents reviewed for care plans: 12
Residents reviewed for restorative care: 3
Residents reviewed for psychotropic medication monitoring: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Certified Nurse Aide | Named in background check deficiency for failure to complete prior to hire |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan deficiencies, CPR certification, restorative care, and medication monitoring |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding background checks, RN coverage, and CPR certification |
| Staff J | Registered Nurse, Restorative | Interviewed regarding restorative care provision and documentation |
Inspection Report
Abbreviated Survey
Census: 19
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 12/7/20-12/8/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Abbreviated Survey
Census: 19
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 12/7/20-12/8/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Abbreviated Survey
Census: 22
Deficiencies: 0
Date: Jun 11, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals 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.
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 6
Date: Mar 5, 2020
Visit Reason
The inspection was conducted as the facility's annual health survey to assess compliance with federal regulations.
Findings
The facility was found deficient in several areas including grievance policy communication, dependent adult abuse training, safe resident transfers, provision of nourishing bedtime snacks, food service safety and sanitation, infection prevention and control, and catheter care practices.
Deficiencies (6)
Failed to make information on how to file a grievance and the grievance officer's contact information available to residents.
Failed to provide current dependent adult abuse training for one of five employees reviewed.
Failed to ensure one resident had a safe transfer using a gait belt as planned.
Failed to offer nourishing snacks to residents at bedtime consistently.
Failed to maintain a clean and sanitary kitchen and failed to ensure all dietary staff wore proper hair and beard restraints.
Failed to follow proper infection control practices for a resident with an indwelling catheter, including inadequate hand hygiene during catheter care.
Report Facts
Facility census: 27
Employees reviewed: 5
Residents referenced: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Named in deficiency related to lack of current dependent adult abuse training. |
| Staff B | Certified Nurse Aide | Named in deficiency related to improper catheter care and hand hygiene. |
| Staff C | Dietary Aide | Named in deficiency related to improper beard restraint during food service. |
| Staff D | Cook | Named in deficiency related to kitchen sanitation and cleaning practices. |
| Staff E | Named in deficiency related to inconsistent offering of bedtime snacks. | |
| Debra Haugen | Administrator | Signed the inspection report and acknowledged grievance officer information was not posted. |
| Director of Nursing | Acknowledged lack of knowledge about expired dependent adult abuse training and improper catheter care practices. | |
| Business Office Manager | Monitors dependent adult abuse training compliance. |
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 6
Date: Mar 5, 2020
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including grievance policy posting, dependent adult abuse training, safe resident transfer, provision of bedtime snacks, kitchen sanitation and food handling, and infection control practices related to catheter care. All deficiencies were assessed as minimal harm or potential for actual harm affecting few or some residents.
Deficiencies (6)
F 0585: The facility failed to post information about the designated grievance officer and residents were unaware of grievance procedures.
F 0607: The facility failed to provide current dependent adult abuse training for one of five employees reviewed.
F 0689: The facility failed to ensure safe transfer of a resident by not using a gait belt as required by the care plan.
F 0809: The facility failed to offer bedtime snacks consistently to residents as documented and reported by residents and staff.
F 0812: The facility failed to maintain a clean kitchen environment and did not ensure proper hair and beard coverings for food service staff.
F 0880: The facility failed to follow proper infection control practices during catheter care for one resident, including inadequate hand hygiene.
Report Facts
Residents census: 27
Employees reviewed for abuse training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Named in deficiency related to expired dependent adult abuse training |
| Staff B | Certified Nurse Aide | Named in deficiencies related to unsafe resident transfer and improper infection control during catheter care |
| Staff C | Dietary Aide | Named in deficiency related to improper beard covering during food service |
| Staff D | Cook | Named in deficiency related to kitchen sanitation and cleaning |
| Staff E | Named in deficiency related to inconsistent snack service | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including abuse training, safe transfer, snack service, and infection control |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen sanitation and hair/beard restraint policies |
| Business Office Manager | Business Office Manager | Interviewed regarding dependent adult abuse training status of Staff A |
Inspection Report
Routine
Census: 25
Deficiencies: 2
Date: Mar 21, 2019
Visit Reason
The inspection was conducted to assess compliance with infection prevention and control programs, including proper sanitization of resident equipment and monitoring of antibiotic use.
Findings
The facility failed to ensure staff followed manufacturer guidelines for sanitizing resident equipment and did not follow their antibiotic stewardship policy, specifically the use of the SBAR tool for residents prescribed antibiotics.
Deficiencies (2)
F 0880: The facility failed to ensure staff followed manufacturers guidelines for sanitizing resident equipment. Staff sprayed disinfectant on a wheelchair cushion but wiped it immediately instead of allowing it to remain wet for 3 minutes as required.
F 0881: The facility failed to follow their antibiotic stewardship program by not completing the SBAR tool for residents prescribed antibiotics, despite policy requirements and staff direction.
Report Facts
Residents present: 25
Antibiotic prescriptions reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Named in sanitizing equipment deficiency |
| Staff B | Certified Nurse Aide | Named in sanitizing equipment deficiency |
| Director of Nursing | Director of Nursing (DON) | Verified sanitizing and antibiotic stewardship deficiencies |
| Director of Resident Services | Licensed Practical Nurse (LPN) | Verified lack of SBAR tool completion for antibiotic orders |
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