Inspection Reports for
Arbor Court
701 East Mapleleaf Drive, Mount Pleasant, IA, 526411402
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
20.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
366% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
51 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 28, 2025
Visit Reason
A complaint investigation for complaint #1775203-C was conducted from August 26, 2025 to August 28, 2025.
Complaint Details
Complaint #1775203-C was investigated and the facility was found to be 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: Apr 28, 2025
Visit Reason
The document serves as a Plan of Correction following a survey ending on April 9, 2025, addressing the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification effective April 18, 2025.
Inspection Report
Routine
Census: 51
Deficiencies: 2
Date: Apr 9, 2025
Visit Reason
The inspection was conducted to assess compliance with resident rights regarding advanced directives and to ensure safety in wheelchair transport for residents.
Findings
The facility failed to accurately obtain and implement advance directives for one resident and failed to ensure proper use of two foot pedals on a wheelchair for another resident, posing potential safety risks. The facility lacked a policy for wheelchair transports.
Deficiencies (2)
Failed to accurately obtain and implement advanced directives per resident and family directives upon admission for Resident #202.
Failed to ensure two foot pedals were used when pushing Resident #17 in a wheelchair, resulting in inadequate support and potential accident hazard.
Report Facts
Residents affected: 1
Residents affected: 1
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding advanced directives and wheelchair foot pedal issues |
| Social Services Director | Social Services Director | Interviewed regarding attempts to contact resident's family about advanced directives |
| Staff C | Certified Nursing Assistant | Interviewed about wheelchair foot pedal usage and condition |
| Staff D | Certified Nursing Assistant | Interviewed about wheelchair foot pedal usage and attempts to fix broken pedal |
| Staff A | Certified Nursing Assistant | Interviewed about wheelchair foot pedal usage |
| Staff B | Certified Nursing Assistant | Interviewed about wheelchair foot pedal usage |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 2
Date: Apr 9, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from April 6 to April 9, 2025.
Findings
The facility was found deficient in accurately obtaining and implementing advance directives for residents and ensuring wheelchair safety by providing proper foot pedals during transport. Two specific deficiencies were cited related to advance directives and accident hazards.
Deficiencies (2)
Facility failed to accurately obtain and implement advanced directives per resident and family directives upon admission for 1 of 1 residents reviewed (Resident #202).
Facility failed to ensure 2 foot pedals were used when staff pushed a resident in a wheelchair, leading to potential accident hazards for 1 of 7 residents reviewed (Resident #17).
Report Facts
Census: 51
Residents reviewed for deficiencies: 7
Residents reviewed for advance directives deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Hanson | Administrator | Signed the report and involved in education and monitoring for plan of correction |
| Director of Nursing | Director of Nursing | Interviewed during inspection, involved in findings and education related to advance directives and wheelchair safety |
| Social Services Director | Social Services Director | Interviewed during inspection, involved in findings and education related to advance directives |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 18, 2025
Visit Reason
A complaint investigation for complaints #125605-C and #126667-C was conducted from February 17, 2025 to February 18, 2025.
Complaint Details
Complaint investigation for complaints #125605-C and #126667-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
The document serves as a Plan of Correction following a survey ending on November 14, 2024, indicating acceptance of credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the Plan of Correction submitted, leading to certification effective November 16, 2024.
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 5
Date: Nov 14, 2024
Visit Reason
The inspection was conducted as part of the annual recertification survey of Arbor Court nursing home to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found deficient in multiple areas including failure to notify the legal guardian of resident condition changes and lab refusals, inaccurate resident assessments regarding tobacco use, failure to submit updated PASRR after mental health diagnosis changes, and incomplete post dialysis assessments. The facility also lacked effective quality assurance measures to correct ongoing deficiencies.
Deficiencies (5)
Failure to notify legal guardian of laboratory refusals and resident change in condition for Resident #7.
Failure to accurately complete Minimum Data Set to reflect tobacco use for Residents #49 and #18.
Failure to ensure resubmission of PASRR after change in mental health diagnoses for Resident #21.
Failure to complete post dialysis assessments for Resident #12 on multiple dates.
Failure to implement effective Quality Assurance Performance Improvement (QAPI) measures to correct ongoing deficiencies.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Provided information about Resident #7's condition and decision-making capacity |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding notification procedures and dialysis assessment documentation |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Reported on Resident #7's refusal of blood draws |
| Staff A | MDS Coordinator | Acknowledged errors in tobacco use coding and planned MDS corrections |
| Staff B | Certified Nursing Assistant (CNA) | Reported on Resident #49's smoking habits |
| Staff C | Certified Nursing Assistant (CNA) | Reported on Resident #49 and Resident #18 smoking habits |
| Staff D | Registered Nurse (RN) | Reported on dialysis assessment procedures and documentation |
| Social Services Director | Social Services Director (SSD) | Responsible for PASRR submissions and acknowledged failure to submit updated PASRR |
| Administrator | Facility Administrator | Provided information on guardianship process, MDS audits, and QAPI activities |
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 5
Date: Nov 12, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of complaints #123942-C and #124692-C.
Complaint Details
The inspection included investigation of complaints #123942-C and #124692-C.
Findings
The facility was found deficient in several areas including failure to notify legal guardians of resident condition changes and lab refusals, inaccuracies in resident assessments, incomplete coordination of PASRR and assessments, failure to complete post dialysis assessments, and deficiencies in the Quality Assurance and Performance Improvement (QAPI) program.
Deficiencies (5)
Failure to notify the legal guardian of laboratory refusals and resident condition changes for Resident #7.
Inaccuracy in Minimum Data Set (MDS) assessments related to tobacco use for Residents #49 and #18.
Failure to ensure resubmission of Preadmission Screening and Resident Review (PASRR) after a change in mental health diagnoses for Resident #21.
Failure to complete post dialysis assessments for Resident #12 receiving dialysis.
Deficiencies in the Quality Assurance and Performance Improvement (QAPI) program including monitoring and corrective actions.
Report Facts
Resident census: 50
Survey dates: November 12 to November 14, 2024
Correction date: November 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasey Thompson | Administrator | Signed the statement of deficiencies and plan of correction. |
| Director of Nursing | Director of Nursing | Provided education to nursing staff and monitored compliance with notification and dialysis assessment requirements. |
| Social Services Director | Social Services Director | Completed updated PASRR for Resident #21 and monitored PASRR compliance. |
| MDS Coordinator | MDS Coordinator | Responsible for accuracy of assessments and monitoring tobacco use coding. |
| Administrator | Administrator | Educated staff on QAPI process and monitored corrective actions. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
A revisit of the survey ending July 3, 2024 and investigation of complaints #123118-C was conducted on September 3-4, 2024.
Complaint Details
Complaint #123118-C was investigated and found not substantiated.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective July 19, 2024. Complaints #123118-C was not substantiated.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: Jul 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation involving an elopement incident of Resident #25 and an accident involving Resident #53 who sustained skin tears and bruising from improper use of a non-mechanical lift.
Complaint Details
The complaint investigation was triggered by an elopement incident on 4/30/24 involving Resident #25, who exited the facility through an unsecured door and was found outside on facility property. The facility also investigated an accident involving Resident #53 on 6/28/24, where improper use of a non-mechanical lift caused skin tears and bruising. The immediate jeopardy was identified and removed after the facility implemented corrective actions including audits, door lock changes, staff education, and policy reviews.
Findings
The facility failed to prevent elopement of a severely cognitively impaired resident (Resident #25) who exited through an unsecured door leading outside, resulting in immediate jeopardy. The facility also failed to adhere to the plan of care for Resident #53, who was dependent on a mechanical lift but was raised using a non-mechanical lift, causing skin tears and bruising to the left forearm. The facility implemented corrective actions including audits, education, and door lock changes to remove immediate jeopardy.
Deficiencies (2)
Failure to ensure a severely cognitively impaired resident was free from elopement due to unsecured doors and alarm system failures.
Failure to adhere to the plan of care for a resident dependent on a mechanical lift, resulting in skin tears and bruising from use of a non-mechanical lift.
Report Facts
Resident census: 55
Skin tear wound measurement length: 2.5
Skin tear wound measurement width: 2.1
Skin tear wound measurement depth: 0
Resident BIMS score: 3
Resident BIMS score: 12
Elopement risk assessment score: 4
Date of incident: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse Aide (CNA) | Involved in the incident with Resident #53 using non-mechanical lift |
| Staff D | Certified Nurse Aide (CNA) | Involved in the incident with Resident #53 using non-mechanical lift |
| Staff H | Certified Nurse Aide (CNA) | Involved in the incident with Resident #53 using non-mechanical lift |
| Staff E | Licensed Practical Nurse (LPN) | Responded to Resident #53's injury and notified ARNP |
| Staff F | Licensed Practical Nurse (LPN) | Performed wound care on Resident #53 |
| Staff I | Physical Therapy Assistant | Provided therapy to Resident #53 and commented on lift use |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding transfer procedures and incident with Resident #53 |
| Staff M | Certified Nurse Aide (CNA) | Worked the night Resident #25 eloped and provided statements |
| Staff J | Certified Nurse Aide (CNA) | Worked the night Resident #25 eloped and provided statements |
| Staff K | Registered Nurse (RN) | Responded to Resident #25 elopement incident |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 6
Date: Jul 3, 2024
Visit Reason
The inspection was conducted to investigate complaints related to failure to provide bed hold notices, inaccurate medication coding on Minimum Data Sets, failure to update care plans, inadequate supervision leading to resident injury, and elopement risk management.
Complaint Details
The complaint investigation was substantiated with findings including failure to provide bed hold notices, inaccurate medication coding, failure to update care plans, inadequate supervision causing injury, and failure to prevent elopement of a cognitively impaired resident. Immediate Jeopardy was identified related to elopement and resident injury but was removed after corrective actions.
Findings
The facility failed to provide bed hold notices to residents upon hospital transfer, properly code medications on Minimum Data Sets, update care plans for smoking residents, ensure safe transfers resulting in skin tears, and prevent elopement of a cognitively impaired resident. Additionally, there was a failure to follow infection control hand hygiene protocols when handling soiled laundry.
Deficiencies (6)
Failed to provide resident or representative written bed hold notice upon hospital transfer for 1 of 2 residents reviewed.
Failed to properly code diuretic, hypnotic, and anticoagulant medications on Minimum Data Sets for 2 of 4 residents reviewed.
Failed to update care plan for smoking resident to include focus area and interventions.
Failed to ensure adequate supervision and safe transfer techniques, resulting in skin tears and bruising to resident's left forearm.
Failed to prevent elopement of a severely cognitively impaired resident who exited the facility through unsecured doors, resulting in Immediate Jeopardy to resident health and safety.
Failed to utilize standard hand hygiene precautions when handling soiled laundry, including failure to wear gloves and wash hands after handling soiled items.
Report Facts
Residents present: 55
Skin tear wound measurement length: 2.5
Skin tear wound measurement width: 2.1
Skin tear wound measurement depth: 0
Resident elopement time: 5.1
Resident elopement last seen time: 4.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) | Named in bed hold policy and medication coding findings |
| Administrator | Named in bed hold policy, care plan, and elopement findings | |
| Director of Nursing (DON) | Director of Nursing | Named in bed hold policy, medication coding, care plan, and elopement findings |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Named in medication coding and care plan findings |
| Staff B | Certified Nursing Assistant (CNA) | Named in resident injury investigation |
| Staff D | Certified Nurse Aide (CNA) | Named in resident injury investigation |
| Staff H | Certified Nurse Aide (CNA) | Named in resident injury investigation |
| Staff E | Licensed Practical Nurse (LPN) | Named in resident injury investigation |
| Staff F | Infection Control and Preventionist | Named in infection control hand hygiene finding |
| Staff O | Housekeeping | Named in infection control hand hygiene finding |
| Staff J | Certified Nursing Assistant (CNA) | Named in elopement investigation |
| Staff K | Registered Nurse (RN) | Named in elopement investigation |
| Staff M | Certified Nursing Assistant (CNA) | Named in elopement investigation |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 5
Date: Jul 3, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of reported incidents.
Findings
The facility was found deficient in multiple areas including failure to provide bed hold notice upon transfer, inaccuracies in resident assessments, incomplete care plan revisions, failure to ensure a safe environment free of accident hazards, and deficiencies in infection prevention and control practices.
Deficiencies (5)
Failure to provide bed hold notice to resident or representative upon transfer to hospital or therapeutic leave.
Inaccurate coding of diuretic, hypnotic, and anticoagulant medications on Minimum Data Sets for residents.
Failure to update care plan timely and include smoking interventions for residents who smoke.
Failure to ensure resident environment free of accident hazards including elopement risk and mechanical lift use.
Failure to establish and maintain an effective infection prevention and control program including hand hygiene and handling of soiled linens.
Report Facts
Census: 55
Deficiencies cited: 5
Elopement drills: 3
MDS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) | Interviewed regarding bed hold policy and MDS updates |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding bed hold policy, MDS coding, and care plan updates |
| Staff G | Certified Nursing Assistant (CNA) | Observed supervising resident in smoking area |
| Staff K | Registered Nurse (RN) | Involved in resident #25 elopement incident and investigation |
| Staff J | Registered Nurse (RN) | Involved in resident #25 elopement incident and investigation |
| Staff M | Certified Nursing Assistant (CNA) | Involved in resident #25 elopement incident and investigation |
| Staff N | Certified Nursing Assistant (CNA) | Involved in resident #25 elopement incident and investigation |
| Staff F | Infection Control and Preventionist | Interviewed regarding infection control practices |
| Staff O | Educated on handling soiled linens and hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 8, 2024
Visit Reason
A complaint survey was conducted for complaints #118910-C and #119532-C from April 3, 2024 to April 8, 2024.
Complaint Details
Complaint survey for complaints #118910-C and #119532-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 9, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on March 9, 2024, related to facility certification compliance.
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 March 9, 2024.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 6
Date: Feb 8, 2024
Visit Reason
A Special Focused Recertification survey and investigation of Complaint #118588-C was conducted from February 5, 2024 to February 8, 2024.
Complaint Details
The inspection was triggered by Complaint #118588-C and included a Special Focused Recertification survey.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity by allowing a resident to remain in soiled clothing for over an hour, failure to follow professional standards in insulin administration for residents with diabetes, improper use of Hoyer lift causing discomfort and risk of injury, failure to intervene when a resident consumed food that was too hot, failure to maintain proper hot water temperature in the kitchen for hand hygiene, failure to properly empty indwelling catheter bags, and failure to maintain an effective Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (6)
Failure to promote a dignified environment by allowing a resident to sit in urine soaked pants and Hoyer sling for over an hour before being changed.
Failure to ensure insulin was held per physician ordered parameters and failure to recheck blood glucose when readings were below 70 mg/dL for 2 of 3 residents reviewed.
Failure to utilize proper transfer techniques when using a Hoyer lift resulting in increased pressure to the back of the neck for one resident and failure to intervene when a resident consumed food that was too hot.
Failure to ensure proper hot water temperature for appropriate hand washing hygiene in the kitchen hand sink.
Failure to ensure effective measures had been taken to correct deficiencies that continue, specifically related to professional standards of care.
Failure to utilize proper infection prevention techniques when emptying an indwelling urinary catheter bag.
Report Facts
Resident census: 55
Insulin administration errors: 13
Blood glucose readings below 70 mg/dL: 11
Staff trained in Hoyer lift: 62
Staff trained via phone: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse (LPN) | Interviewed regarding insulin administration and blood glucose rechecks |
| Staff F | Certified Medication Aide (CMA) | Interviewed regarding incident of resident left in soiled clothing |
| Staff G | Certified Nurse Aide (CNA) | Interviewed regarding incident of resident left in soiled clothing |
| Staff H | Certified Nurse Aide (CNA) | Interviewed regarding incident of resident left in soiled clothing |
| Staff I | Certified Nurse Aide (CNA) | Interviewed regarding incident of resident left in soiled clothing |
| Staff J | Certified Nurse Aide (CNA) | Interviewed regarding Hoyer lift training and use |
| Administrator | Interviewed regarding QAPI program and facility policies | |
| Director of Nursing | Interviewed regarding insulin administration, Hoyer lift procedures, and expectations for resident care | |
| Dietitian | Interviewed regarding feeding practices and resident safety | |
| Maintenance Supervisor | Interviewed regarding hot water temperature issues and maintenance logs | |
| Staff A | Certified Nurse Aide (CNA) | Observed emptying indwelling catheter bag with improper infection prevention technique |
| Staff B | Certified Nurse Aide (CNA) | Interviewed regarding catheter bag emptying procedures |
| Staff C | Certified Nurse Aide (CNA) | Interviewed regarding catheter bag emptying procedures |
| Infection Preventionist | Interviewed regarding expectations for catheter bag emptying |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 30, 2023
Visit Reason
A revisit of the Recertification Survey and investigation of Complaints #114723-C, #114549-C, and #116714-C was conducted from November 13, 2023 to November 30, 2023.
Complaint Details
Complaint #116714-C was investigated and found not substantiated.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective October 5, 2023. Complaint #116714-C was not substantiated.
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 5
Date: Sep 7, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements, including resident rights, protection from abuse and misappropriation, medication administration, and care standards.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity, prevent misappropriation of resident funds, timely report and investigate suspected abuse, ensure proper medication administration, provide appropriate treatment and care according to orders, and implement time limits and interventions for psychotropic medication use.
Deficiencies (5)
Failure to ensure the dignity of a resident by leaving him on a bedpan for prolonged periods causing skin breakdown.
Failure to prevent misappropriation of resident money and failure to timely report and investigate the incident.
Failure to ensure resident received prescribed antibiotic medication consistently and medication error where resident received another resident's medications.
Failure to provide appropriate treatment and care according to orders, resulting in resident developing severe sepsis and requiring hospitalization.
Failure to time limit use of PRN anti-anxiety medication to 14 days and failure to implement and document interventions prior to administration.
Report Facts
Resident census: 54
Medication doses administered after 14 days: 8
Urinary output: 179
Vancomycin doses missed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Certified Nurses Aid (CNA) | Named in misappropriation of resident funds finding |
| Staff M | Hospitality Aid (HA) | Named in misappropriation of resident funds finding and investigation |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding dignity, medication administration, and abuse investigation |
| Staff H | Registered Nurse (RN) | Interviewed regarding medication administration error |
| Staff R | Licensed Practical Nurse (LPN) | Involved in medication administration error |
| Assistant Director of Nursing (ADON) | Licensed Practical Nurse (LPN) | Interviewed regarding resident condition and care |
| Regional Director of Operations | Interviewed regarding psychotropic medication use | |
| Staff I | Licensed Practical Nurse (LPN) | Interviewed regarding PRN medication policies and documentation |
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 17
Date: Sep 7, 2023
Visit Reason
The inspection was conducted as a re-inspection and complaint investigation to assess compliance with previously cited deficiencies and to evaluate the facility's response to complaints and regulatory requirements.
Complaint Details
The complaint investigation included allegations of dignity violations, misappropriation of resident funds, failure to report and investigate abuse, medication errors, and unsafe mechanical lift use. Several allegations were substantiated including misappropriation of funds by a staff member, failure to report abuse timely, and unsafe lift use resulting in resident falls.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, misappropriation of resident funds, failure to timely report and investigate alleged violations, incomplete significant change assessments, untimely care plan updates, medication administration errors, failure to provide quality care including proper weight monitoring and infection management, pressure ulcer prevention and treatment, accident prevention related to mechanical lifts, catheter care, call light response times, nursing staff competency, psychotropic medication management, menu compliance, food safety, and quality assurance program effectiveness.
Deficiencies (17)
Failure to ensure dignity of residents including timely toileting and bedpan use.
Failure to prevent misappropriation of resident funds and failure to timely report allegations.
Failure to timely report alleged violations of abuse, neglect, exploitation, or mistreatment.
Failure to complete thorough investigations of alleged abuse and neglect.
Failure to complete significant change Minimum Data Set (MDS) assessments within required timeframe.
Failure to update care plans timely after significant changes such as falls and transfers.
Failure to ensure residents receive prescribed medications correctly and timely, including documentation of administration and monitoring for side effects.
Failure to provide quality care including consistent weight monitoring and assessment for residents with congestive heart failure and infection management.
Failure to provide appropriate treatment and prevention of pressure ulcers including timely wound care and repositioning.
Failure to ensure safe use and maintenance of mechanical lifts resulting in multiple resident falls and injuries.
Failure to ensure urinary catheter bags are maintained off the floor and contained in dignity bags.
Failure to answer call lights in a timely manner, with documented delays up to over 100 minutes.
Failure to ensure nursing staff demonstrate competency in skills and timely reporting of abuse and changes in resident condition.
Failure to time limit PRN psychotropic medication use to 14 days and failure to document interventions prior to administration.
Failure to follow appropriate portion sizes for ground meat for residents on altered diets.
Failure to ensure food items are properly labeled, dated, and covered in the kitchen.
Failure to maintain an effective and comprehensive QAPI program to address repeat deficiencies and ensure corrective actions are effective.
Report Facts
Facility census: 54
Resident #37 call light delay: 45
Call light delays: 63
Call light delays on day shift: 33
Call light delays on evening shift: 23
Call light delays on night shift: 7
Resident #39 weight: 422.8
Resident #39 weight gain: 29
Resident #18 missed medication doses: 8
Resident #49 PRN alprazolam doses: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Hospitality Aid | Failed to report resident's missing money allegation timely |
| Staff O | Certified Nurse Aide | Misappropriated resident funds |
| Staff V | Registered Nurse | Failed to document pressure ulcer prevention and assessments completely |
| Staff R | Licensed Practical Nurse | Medication administration error giving wrong resident's medication |
| Staff I | Licensed Practical Nurse | Described expectations for weight monitoring and notification |
| Staff E | Licensed Practical Nurse | Described pressure ulcer prevention interventions and resident chair issues |
| Staff H | Registered Nurse | Described call light system and resident complaints |
| Staff D | Hospitality Aide | Witnessed resident fall from Hoyer sling |
| Staff J | Certified Nursing Assistant | Witnessed resident fall from Hoyer sling |
| Staff L | Certified Nursing Assistant | Witnessed Hoyer lift tipping incident |
| Maintenance Supervisor | Responsible for lift maintenance and inspections | |
| Administrator | Provided plan of correction and interview responses | |
| Director of Nursing | Provided plan of correction and interview responses | |
| Regional Director of Operations | Interviewed about psychotropic medication documentation |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
A revisit of the survey ending May 15, 2023 and investigation of facility reported incident #112991-I was conducted from July 10, 2023 to July 13, 2023.
Complaint Details
Facility reported incident #112991-I was investigated and found not substantiated.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective June 14, 2023. Facility reported incident #112991-I was not substantiated.
Report Facts
Facility reported incident number: 112991
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 4
Date: May 15, 2023
Visit Reason
The inspection was conducted as an On-Site Revisit of the Survey ending March 2, 2023, the On-Site Revisit Complaint Survey ending March 15, 2023, and investigation of Complaint #112801-C and Facility Reported Incident #112439-I conducted May 8 to May 15, 2023.
Complaint Details
Complaint #112801-C was substantiated based on failure to assess and monitor a resident after a fall with head injury and failure to provide a safe environment leading to a preventable fall.
Findings
The facility failed to assess a resident after a fall with head injury, did not complete required neurological checks, and failed to provide a safe environment leading to a fall on a wet floor. Additionally, the facility failed to follow physician orders to prevent weight loss for a resident and did not serve mechanically altered texture diets as ordered.
Deficiencies (4)
Facility failed to assess a resident upon return from hospital after a head injury fall and failed to document neurological assessments as required.
Facility failed to provide a safe environment and adequate supervision, resulting in a resident falling on a wet floor and sustaining head injuries.
Facility failed to follow physician orders and interventions to prevent further weight loss for a resident with significant weight loss.
Facility failed to follow and serve the planned mechanically altered texture food menu to residents requiring such diets.
Report Facts
Resident census: 53
Weight loss percentage: 13.9
Weight loss percentage: 5
Number of residents on mechanical soft diet: 7
Number of servings prepared: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Notified of resident fall, started assessment and neurological checks, sent resident to ER |
| Staff B | Licensed Practical Nurse (LPN) | Was across the hall during resident fall, attempted to warn resident of wet floor |
| Staff C | Certified Nursing Assistant (CNA) | Reported resident found on floor after fall |
| Staff F | Housekeeper | Mopped floor where resident fell |
| Director of Nursing | Director of Nursing (DON) | Provided expectations for post-hospital assessments and monitoring |
| Physician | Cared for resident in ER, provided discharge instructions | |
| Staff G | Cook | Prepared and served meals, acknowledged missing menu items |
| Registered and Licensed Dietician | RDLD | Reviewed menus, acknowledged errors in serving sizes, educated staff on volume method |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 4
Date: May 15, 2023
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to properly assess and document a resident's condition after a fall with head injury and to ensure a safe environment to prevent accidents.
Complaint Details
The complaint investigation focused on Resident #4's fall and head injury, the facility's failure to assess and document neurological status post-fall, and the failure to maintain a safe environment to prevent accidents. The investigation also included review of Resident #5's weight loss and dietary issues affecting multiple residents.
Findings
The facility failed to assess and document neurological status post-fall for Resident #4, resulting in minimal harm. The facility also failed to provide a safe environment, leading to a preventable fall causing actual harm. Additionally, the facility failed to follow physician orders to prevent further weight loss for Resident #5 and failed to serve the correct mechanically altered texture diet to seven residents.
Deficiencies (4)
Failed to assess and document neurological assessments post-fall for Resident #4 with head injury.
Failed to provide a safe environment and adequate supervision, resulting in Resident #4 sustaining injuries from a preventable fall.
Failed to follow physician orders and interventions to prevent further weight loss for Resident #5.
Failed to follow and serve the planned mechanically altered texture food menu to 7 residents requiring such diets.
Report Facts
Resident census: 53
Weight loss percentage: 13.9
Weight loss percentage: 5
Number of residents on mechanical soft diet: 7
Number of neurological assessment intervals: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Started neurological assessments post-fall and documented nursing progress notes |
| Staff B | Licensed Practical Nurse (LPN) | Witnessed fall and provided immediate assistance |
| Staff C | Certified Nursing Assistant (CNA) | Reported resident found on floor after fall |
| Staff E | Certified Nursing Assistant (CNA) | Provided care to resident prior to fall |
| Staff F | Housekeeper | Mopped floor where resident fell |
| Director of Nursing (DON) | Director of Nursing | Provided statements on expected nursing assessments and monitoring |
| Physician | Provided orders and statements regarding resident care post-ER visit | |
| Corporate Nurse | Acknowledged failure to document neuro checks and initiated staff education | |
| Staff G | Cook | Prepared meals and acknowledged failure to serve ordered dietary items |
| Registered and Licensed Dietician (RDLD) | Dietician | Approved menus and acknowledged errors in portion sizes for mechanically altered diets |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
The inspection was conducted as a result of complaints #111273-C and #111374-C and a facility self-report #111590-1, focusing on quality of care issues related to a resident who had fallen.
Complaint Details
Complaint #111374-C was substantiated.
Findings
The facility failed to record and complete an assessment on a resident who had fallen, with substantiated complaint #111374-C. The resident had significant cognitive impairments and required extensive assistance, but staff did not complete the necessary post-fall assessment or incident report.
Deficiencies (1)
Failure to record and complete an assessment on a resident who had fallen.
Report Facts
Facility census: 54
Complaint numbers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | licensed practical nurse | Interviewed regarding failure to complete assessment and incident report for Resident #6 |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
The inspection was conducted due to a complaint related to the facility's failure to properly assess and document a resident's fall incident.
Complaint Details
The visit was complaint-related due to failure to assess and document a fall incident involving Resident #6. The complaint was substantiated by staff interview and record review.
Findings
The facility failed to record and complete an assessment on Resident #6 who was found on the floor after a fall. Staff admitted to forgetting to complete the incident report and assessment, and no progress notes documented the fall event.
Deficiencies (1)
Failed to record and complete an assessment on a resident who had fallen.
Report Facts
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Licensed Practical Nurse | Named in relation to failure to complete incident report and assessment for Resident #6 |
Inspection Report
Routine
Census: 54
Deficiencies: 7
Date: Mar 2, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards including care planning, medication administration, resident bathing, call light response, medication error rates, and dietary orders.
Findings
The facility was found deficient in multiple areas including failure to include diuretic medication in care plans for some residents, medication administration errors, inadequate bathing frequency for a resident, delayed call light responses, significant medication errors exceeding 5%, failure to document insulin administration, and failure to provide a physician-ordered therapeutic diet.
Deficiencies (7)
Failure to include use of diuretic medication on comprehensive Care Plans for three residents.
Failure to carry out medication and treatment orders according to professional standards for 5 residents.
Failure to ensure adequate frequency of baths for 1 resident.
Failure to respond to call lights in a timely manner for 5 of 6 residents reviewed.
Medication error rate of 11.11% observed for 3 residents with 5 errors out of 45 medications administered.
Failure to ensure residents were free from significant medication errors for 1 resident due to missing documentation of blood sugar checks and insulin administration.
Failure to provide a physician-ordered therapeutic high protein diet for 1 resident.
Report Facts
Census: 54
Medication error rate: 11.11
Call light response delays: 15
Call light response delays: 11
Call light response delays: 8
Call light response delays: 7
Call light response delays: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Director of Rehab | Stated necessity of using hoyer lift with Resident #107 |
| DON | Director of Nursing | Provided explanations regarding care plans, medication administration, call light response expectations, and medication policies |
| Staff C | Licensed Practical Nurse | Observed administering insulin incorrectly and unaware of priming insulin pens |
| Staff B | Licensed Practical Nurse | Interviewed regarding medication administration and IV tubing capping |
| Staff E | Certified Nursing Assistant | Reported inability to complete baths due to staffing |
| Staff F | Certified Nursing Assistant | Reported missed baths and difficulty responding to call lights due to staffing |
| Staff A | Certified Medication Aide | Observed administering incorrect medication doses |
| Certified Dietary Manager | Certified Dietary Manager | Unaware of high protein diet order for Resident #107 |
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 13
Date: Feb 20, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #109959-C and #110046-C.
Complaint Details
Complaints #109959-C and #110046-C were substantiated as part of this inspection.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, coordination of PASARR and assessments, baseline care plans, professional standards, discharge summaries, nutritional and hydration status maintenance, physician visits, sufficient staffing, medication errors, menus meeting resident needs, and therapeutic diets prescribed by physicians. Several residents' care plans and assessments lacked required documentation and updates.
Deficiencies (13)
Accuracy of Assessments - Facility failed to ensure use of a diuretic medication was accurately coded on the Minimum Data Set (MDS) assessment for one of five residents reviewed.
Coordination of PASARR and Assessments - Facility failed to update care plans to reflect PASARR recommendations for specialized services for residents reviewed.
Baseline Care Plan - Facility failed to ensure insulin and psychotropic medication use was reflected in baseline care plans for residents reviewed.
Professional Standards - Facility failed to ensure medications including ear drops were administered per physician orders and current standards of practice.
Discharge Summary - Facility failed to complete discharge summary for resident reviewed.
Nutritional/Hydration Status Maintenance - Facility failed to maintain acceptable nutritional parameters and hydration for residents reviewed.
Physician Visits - Facility failed to ensure in-person physician visits per guidance for residents reviewed.
Sufficient Staffing - Facility failed to respond to call lights in a timely manner for residents reviewed.
Free of Medication Errors - Facility failed to ensure medication error rate was less than 5% for residents reviewed.
Significant Medication Errors - Facility failed to ensure medication administration errors were prevented for residents reviewed.
Menus Meet Resident Needs/Preparation - Facility failed to serve adequate portions and appropriate diets for residents reviewed.
Therapeutic Diet Prescribed by Physician - Facility failed to ensure therapeutic diets were prescribed by attending physician for residents reviewed.
Resident Records Identifiable Information - Facility failed to maintain complete, accurate, and accessible medical records for residents reviewed.
Report Facts
Residents reviewed: 19
Residents reviewed for medication administration: 12
Medication error rate: 11.11
Residents reviewed for call light response: 6
Residents reviewed for physician visits: 4
Residents reviewed for menus: 6
Residents reviewed for nutritional status: 2
Facility census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Harini Menhe | Administrator | Signed the report and confirmed MDS medication accuracy on 2/28/23. |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans, medication administration, and call light response. |
| Staff D | Director of Rehab | Interviewed regarding use of hoyer lift with resident. |
| Staff E | Certified Nursing Assistant | Observed and interviewed regarding shower sheets and skin monitoring. |
| Staff G Cook | Staff | Observed during meal service and food preparation. |
| Staff A | Certified Medication Aide | Observed administering medications and interviewed regarding medication errors. |
| Staff B | Licensed Practical Nurse | Interviewed regarding medication administration and call light response. |
| Staff C | Licensed Practical Nurse | Observed and interviewed regarding insulin administration. |
| Registered Dietitian | Registered Dietitian | Interviewed regarding nutritional assessments and food service. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 8, 2023
Visit Reason
A revisit of the Complaint Survey ending December 19, 2022 was conducted on February 7, 2023 to February 8, 2023 to verify correction of previous deficiencies.
Complaint Details
This visit was a follow-up to a complaint survey ending December 19, 2022. All deficiencies identified in the complaint survey were corrected.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective 12/20/22.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Dec 14, 2022
Visit Reason
The inspection was conducted as an investigation of complaints #109546-C from December 14, 2022 to December 19, 2022. The complaint was substantiated.
Complaint Details
Complaint #109546-C was substantiated. The investigation found failure to intervene appropriately for a resident on anticoagulant therapy who developed bruising and a gastrointestinal bleed.
Findings
The facility failed to respond appropriately to a warning about a possible interaction between an antibiotic and anticoagulant medication, resulting in adverse effects including bruising and a gastrointestinal bleed in one resident. An Immediate Jeopardy was identified but later removed after corrective actions were implemented.
Deficiencies (1)
Failure to respond to a warning for possible interaction between an antibiotic and anticoagulant medication and failure to intervene appropriately after bruising was observed in a resident on anticoagulant therapy.
Report Facts
Resident census: 56
Medication dosage: 5
Units of blood lost: 4
Date of compliance: Dec 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Mente | Administrator | Signed the report and involved in corrective action plan |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 22, 2022
Visit Reason
A revisit of the survey ending October 5, 2022 was conducted from November 21, 2022 to November 22, 2022 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 11, 2022.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 5
Date: Oct 5, 2022
Visit Reason
Investigation of multiple substantiated complaints and a facility reported incident regarding resident care and medication management.
Complaint Details
Complaints #102502-C, #104816-C, #104861-C, and #104902-C were substantiated following investigation from September 20, 2022 to October 5, 2022.
Findings
The facility failed to provide ongoing re-evaluation of psychotropic medications for Resident #4, resulting in overmedication and hospitalization. The facility also failed to complete timely and accurate Minimum Data Set (MDS) assessments and develop comprehensive care plans timely for several residents. Additionally, the facility did not adequately assess or intervene for significant declines in residents' conditions, including nutritional status and changes in vital signs.
Deficiencies (5)
Failed to provide ongoing re-evaluation of psychotropic medications to ensure least restrictive regimen for Resident #4.
Failed to complete comprehensive Minimum Data Set (MDS) assessments accurately and within 14 calendar days following admission for multiple residents.
Failed to develop and implement comprehensive care plans timely following admission for Residents #1 and #4.
Failed to assess, update providers, and obtain interventions when Resident #4 had significant decline in ADLs and decreased blood pressure, and Resident #10 had pending abdominal x-ray with abdominal distension.
Failed to maintain nutritional and hydration status or place interventions when Resident #4's intakes and ability to feed himself declined.
Report Facts
Resident census: 56
Weight loss percentage: 11.5
Blood pressure reading: 60
Blood pressure reading: 22
Medication doses: 3
Medication doses: 3
Meal intake percentages: 26.8
Meal intake percentages: 83.4
Meal intake percentages: 90.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Reported Resident #4 punched her in the face causing a concussion and described resident behaviors. |
| Staff C | Registered Nurse | Described Resident #4's physical behaviors and medication effects. |
| Staff D | Certified Medication Aide | Described Resident #4's wild behaviors and medication calming effects. |
| Staff E | Licensed Practical Nurse | Reported Resident #4's violent behavior and medication administration. |
| Director of Nursing | Administrator | Reported concerns about psychotropic medication use and oversight. |
| Physician Assistant (PA-C) | Provided clinical assessments and medication adjustments for Resident #4. | |
| Social Services Director | Reported on MDS completion and facility staffing. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Feb 4, 2022
Visit Reason
This inspection was a first revisit of surveys ending 9/13/21, 11/3/21, and 1/3/22, and an investigation of complaints #101625-C and #101940-C, which were substantiated.
Complaint Details
Complaints #101625-C and #101940-C were substantiated.
Findings
The facility failed to identify and properly treat a pressure sore on Resident #4, resulting in deterioration and hospital readmission. Deficiencies were found in assessment, treatment orders, documentation, and staff training related to pressure ulcer care.
Deficiencies (1)
Failure to identify a pressure sore upon admission, complete routine assessments, initiate treatment orders timely, and complete treatments as ordered for Resident #4.
Report Facts
Census: 47
Dates of surveys: Surveys ending 9/13/21, 11/3/21, and 1/3/22
Correction date: Correction date noted as 2/5/22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Assistant Director of Nursing | Interviewed regarding Resident #4's admission skin assessment and wound treatment orders |
| Staff B | Licensed Practical Nurse | Wrote Skin Observation Tool and Progress Note related to Resident #4's wound |
| Staff C | Licensed Practical Nurse | Wrote Progress Note documenting nurse's conversation with wound physician |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 8
Date: Jan 3, 2022
Visit Reason
Investigation of multiple complaints and a focused infection control survey conducted from December 8, 2021 to January 3, 2022, related to COVID-19 practices and notification failures.
Complaint Details
The investigation was triggered by complaints #100850, #100851, #100924, #101167, #101176, #101272, #101301 and a facility reported incident #101275. All complaints and the facility reported incident were substantiated.
Findings
The facility was found not in compliance with CMS and CDC recommended COVID-19 practices. All complaints and the facility reported incident were substantiated, including failures to notify residents' primary care providers and families of COVID-19 diagnoses, failure to administer medications as ordered, inadequate assessments, and failure to prevent and treat pressure ulcers and falls.
Deficiencies (8)
Failure to notify resident's primary care provider and families of COVID-19 diagnosis.
Failure to provide required Medicare Liability Notices when skilled services ended.
Failure to administer over-the-counter medications and ordered medications as prescribed.
Failure to increase assessments and monitor residents diagnosed with COVID-19 and neurological status after falls.
Failure to complete neurological assessments and document fall injuries properly.
Failure to complete wound assessments, document pressure ulcers, and provide ordered treatments.
Failure to ensure resident environment is free from accident hazards and provide adequate supervision during transfers.
Failure to maintain infection prevention and control program including PPE use and monitoring COVID-19 symptoms.
Report Facts
Census: 45
Number of residents reviewed for COVID-19 notification: 4
Number of residents reviewed for medication errors: 3
Number of residents reviewed for pressure ulcers: 3
Number of residents reviewed for accident hazards: 3
Number of residents reviewed for falls: 3
Number of Hoyer lifts in facility: 3
Number of full body slings observed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Henry County | Administrator | Mentioned in relation to high community transmission and facility COVID-19 status. |
| Staff H | Licensed Practical Nurse (LPN) | Reported nurses responsible for notifying PCP of residents testing positive for COVID-19. |
| Staff G | Advanced Registered Nurse Practitioner (ARNP) | Reported testing all residents during COVID-19 outbreak and assessing residents. |
| Staff D | Registered Nurse (RN) | Reported uncertainty about family notifications and responsible for wound treatments. |
| Staff N | Interim Director of Nursing (DON) | Reported expectation for neurological assessments and wound treatments. |
| Staff O | Registered Nurse (RN) | Provided wound treatments and assessed wounds. |
| Staff J | Certified Medication Aide (CMA) | Reported medication administration and resident care. |
| Staff E | Licensed Practical Nurse (LPN) | Reported monitoring residents for COVID-19 symptoms and vital signs. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 4
Date: Nov 3, 2021
Visit Reason
The survey was conducted from October 19, 2021 through November 3, 2021 investigating Complaints #99663, #100359, #100350, and #100358.
Complaint Details
Complaints #99663 and #100358 were not substantiated. Complaints #100350 and #100359 were substantiated.
Findings
The facility was found deficient in respecting residents' dignity and personal property, notification of changes related to residents' conditions, skin integrity and pressure ulcer care, and infection prevention and control. Two complaints were substantiated and two were not substantiated. The facility failed to provide adequate clothing for residents during appointments and failed to notify the wound care specialist physician of changes in a resident's pressure ulcer condition.
Deficiencies (4)
Facility failed to provide adequate clothing for two residents leaving for appointments, violating respect and dignity rights.
Facility failed to notify resident, physician, and representative of changes in resident's condition including injury and psychosocial status.
Facility failed to provide necessary treatment and services to prevent and heal pressure ulcers for residents, including failure to notify wound care physician of changes.
Facility failed to establish and maintain an infection prevention and control program.
Report Facts
Residents reviewed: 5
Census: 44
Deficiency counts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Menke | Administrator | Signed the initial comments section of the report. |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 5
Date: Sep 13, 2021
Visit Reason
The inspection was conducted as an investigation of complaints #99149, #99407, #99468, and #99494 from August 30, 2021 to September 13, 2021. Complaints #99149-C, #99407, and #99468 were substantiated, while complaint #99494-C was not substantiated.
Complaint Details
Complaints #99149-C, #99407, and #99468 were substantiated. Complaint #99494-C was not substantiated.
Findings
The facility failed to notify family members of changes in resident condition for 2 out of 3 residents reviewed, failed to provide adequate supervision for a resident with cognitive impairment who eloped, and failed to ensure nurse staffing data was posted daily and accessible. The facility also failed to maintain proper documentation and policies related to resident elopement and wandering risks.
Deficiencies (5)
Failure to notify family of changes in resident condition for 2 out of 3 residents reviewed.
Failure to provide adequate supervision for Resident #1 who eloped, including malfunctioning door alarms and inadequate investigation of the elopement.
Failure to post nurse staffing data daily in a clear, accessible format for residents and visitors for 4 of 6 days of the survey.
Failure to maintain accurate and complete medical records and documentation related to resident wandering and elopement.
Failure to report elopement to the State Agency within required timeframes.
Report Facts
Resident census: 50
Residents reviewed: 3
Residents with cognitive impairments: 5
Days staffing data not posted: 2
Date range of survey: August 30, 2021 through September 13, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Interviewed regarding notification failures and elopement supervision |
| Staff C | Licensed Practical Nurse | Interviewed regarding elopement and door alarm malfunctions |
| Staff E | Certified Nurse Aide | Interviewed regarding last sighting of Resident #1 prior to elopement |
| Staff D | Certified Nurse Aide | Interviewed regarding alarm sounds and resident elopement |
| Director of Nursing | Director of Nursing | Interviewed regarding notification expectations and elopement supervision |
| Maintenance Director | Maintenance Director | Interviewed regarding door alarm malfunctions and repairs |
| Administrator | Administrator | Interviewed regarding notification procedures and elopement reporting |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 14
Date: Jun 3, 2021
Visit Reason
The annual survey and investigation of Complaint #97366-C and Facility Reported Incident #97639-I were conducted from 05/23/2021 to 06/03/2021.
Complaint Details
Complaint #97366-C was substantiated. Facility Reported Incident #97639-I was not substantiated.
Findings
The facility was found to have multiple deficiencies including failure to complete resident assessments for self-administration of medications, incomplete abuse and criminal background checks for staff, failure to develop comprehensive care plans for residents, inadequate medication administration documentation, failure to provide treatment for pressure ulcers, insufficient nursing staff competencies and training, and lack of proper documentation for respiratory care and advance directives.
Deficiencies (14)
Failure to complete resident assessment for self-administration of medications.
Failure to develop and implement abuse and neglect policies including background checks for staff.
Failure to develop comprehensive care plans for residents.
Failure to meet professional standards in medication administration documentation.
Failure to provide basic life support including CPR and document residents' advance directives.
Failure to provide treatment and services to prevent and treat pressure ulcers.
Failure to provide restorative services to residents with limited range of motion.
Failure to provide respiratory care consistent with professional standards.
Failure to maintain sufficient nursing staff competencies and skills.
Failure to provide regular in-service education and performance reviews for nurse aides.
Failure to post daily nurse staffing data as required.
Failure to conduct monthly drug regimen reviews by a licensed pharmacist.
Failure to maintain a quality assessment and assurance committee and conduct regular QAPI meetings.
Failure to provide psychotropic drug management and documentation.
Report Facts
Census: 41
Residents reviewed: 12
Residents reviewed: 7
Residents reviewed: 16
Residents reviewed: 4
Residents reviewed: 3
Residents reviewed: 4
Residents reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nurse Aide (CNA) | Named in abuse and criminal background check deficiency. |
| Staff I | Licensed Practical Nurse (LPN) | Named in abuse and criminal background check deficiency. |
| Staff L | Certified Nurse Aide (CNA) | Named in abuse and criminal background check deficiency. |
| Staff F | Registered Nurse (RN) | Named in medication administration and oxygen administration deficiencies. |
| Staff E | Licensed Practical Nurse (LPN) | Named in medication administration and oxygen administration deficiencies. |
| Staff J | Certified Nursing Assistant (CNA) | Named in oxygen use and care plan deficiencies. |
| Staff C | Social Services Supervisor | Named in CPR and advance directives deficiencies. |
| Staff G | Restorative Aide | Named in restorative services deficiency. |
| Staff B | Licensed Practical Nurse (LPN) | Named in medication administration deficiency. |
| Staff A | Licensed Practical Nurse (LPN) | Named in wound care and restorative services deficiencies. |
| Staff D | Admissions Coordinator | Named in advance directives deficiency. |
| DON | Director of Nursing | Named in multiple deficiencies related to care plans, medication administration, and follow-up. |
Inspection Report
Abbreviated Survey
Census: 38
Deficiencies: 0
Date: Oct 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted 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 the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 38
Inspection Report
Routine
Census: 42
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B.
Report Facts
Sample Size: 5
Supplemental: 0
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