Inspection Report
Annual Inspection
Census: 51
Deficiencies: 11
Dec 4, 2025
Visit Reason
Annual recertification survey and investigation of complaints #2625141-C, #2671743-C, and #2678226-C conducted December 1, 2025 through December 4, 2025.
Findings
Multiple deficiencies were cited including failure to limit PRN psychotropic drugs to 14 days, failure to coordinate PASARR assessments, failure to implement dietary interventions timely for weight loss, failure to perform pre/post dialysis assessments, failure to act on pharmacist drug regimen review recommendations, failure to serve pureed diets in correct portions, failure to maintain sanitary food handling practices, failure to offer and document influenza, pneumococcal, and COVID-19 vaccinations, and failure to maintain an effective QAPI program.
Complaint Details
The inspection included investigation of complaints #2625141-C, #2671743-C, and #2678226-C. Deficiencies were cited for complaints #2671743-C and #2678226-C. No deficiency was cited for complaint #2625141-C.
Severity Breakdown
SS = D: 7
SS = E: 4
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to limit PRN psychotropic drug to 14 days for 1 of 5 residents (Resident #21). | SS = D |
| Failed to refer a resident (Resident #3) for Level II PASARR evaluation following newly diagnosed mental disorder. | SS = D |
| Failed to fully submit Level I PASRR evaluation within 30 days for 1 of 4 residents (Resident #50). | SS = D |
| Failed to implement dietary interventions timely for significant weight loss (Resident #44). | SS = D |
| Failed to perform pre and post dialysis assessments for 1 of 1 resident reviewed for dialysis (Resident #6). | SS = D |
| Failed to follow through on pharmacist recommendations to complete Abnormal Involuntary Movement Scale (AIMS) assessment for 1 of 5 residents (Resident #21). | SS = D |
| Failed to serve pureed diet residents correct portion sizes and serving sizes (Residents #24, #38, #40, #42). | SS = E |
| Failed to ensure proper food handling, hair covering, kitchen cleanliness, food coverage on trays, and proper hand placement on glassware, risking food contamination. | SS = E |
| Failed to correct repeated deficiencies related to food procurement, storage, preparation, and serving sanitary practices. | SS = E |
| Failed to offer and properly document influenza and pneumococcal vaccinations for 4 of 5 residents reviewed (Residents #14, #33, #41, #50). | SS = E |
| Failed to offer and properly document COVID-19 vaccinations for 3 of 5 residents reviewed (Residents #14, #41, #50). | SS = D |
Report Facts
Residents reviewed for PRN psychotropic drug use: 5
Facility census: 51
Weight loss percentage: 11.91
Number of pre/post dialysis assessments logged: 10
Residents reviewed for vaccinations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Social Services Director | Acknowledged delayed PASRR submission for Resident #50. |
| Staff A | Infection Preventionist | Responsible for vaccination tracking and acknowledged missed vaccinations. |
| Staff E | Cook | Observed serving incorrect pureed food portions and improper food handling. |
| Staff D | Dietary Aide | Observed improper hand placement on cups and lack of beard net. |
| Staff G | Registered Nurse | Described dialysis pre/post assessments process. |
| Director of Nursing | Director of Nursing | Acknowledged deficiencies in AIMS assessments and dialysis assessments. |
| Certified Dietary Manager | Certified Dietary Manager | Acknowledged pureed diet portion size and food handling deficiencies. |
| Chief Operating Officer | Chief Operating Officer | Acknowledged responsibility for following RD recommendations and QAPI deficiencies. |
| Administrator | Administrator | Acknowledged PASRR screening deficiencies. |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 12, 2025
Visit Reason
A revisit of the survey ending September 11, 2025 was conducted from November 6, 2025 to November 12, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in compliance effective October 3, 2025. DPNA will not be effectuated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 23, 2025
Visit Reason
A complaint investigation for Complaint #2636145-C was conducted on October 23, 2025.
Findings
No deficiencies were cited with investigation of the complaint. However, due to a previous visit ending on September 11, 2025, the facility is not in compliance and an onsite visit will be scheduled at a later date.
Complaint Details
Complaint #2636145-C was investigated and no deficiencies were cited; the complaint was not substantiated.
Report Facts
Complaint number: 2636145
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 31, 2024
Visit Reason
A revisit of the survey ending November 26, 2024 and investigation of Complaint #125479-C was conducted on December 30, 2024 to December 31, 2024.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 27, 2024. Complaints #125479-C was not substantiated.
Complaint Details
Complaint #125479-C was investigated and found not substantiated.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 13
Nov 26, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and investigation of reported incidents #122246-I-I, 124480-I, and 125064-I.
Findings
The facility was found to have multiple deficiencies including failure to provide required Medicaid Liability Notices timely, failure to report allegations of abuse promptly, inadequate investigation and reporting of abuse, incomplete and inaccurate resident assessments, insufficient nursing staff response to call lights, and unsafe food storage and handling practices.
Severity Breakdown
SS=E: 3
SS=D: 4
SS=F: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to provide properly filled Medicaid Liability Notices and Beneficiary Appeals within 48 hours for sampled residents. | SS=D |
| Failure to report allegations of abuse timely to the Department of Inspections, Appeals and Licensing (DIAL). | SS=E |
| Failure to ensure all allegations of abuse including verbal threats and rough treatment were reported to facility administration timely. | SS=E |
| Failure to accurately complete Minimum Data Set (MDS) assessments for residents. | SS=D |
| Failure to submit a new readmission screening and resident review (PASRR) level 1 screening for resident. | SS=D |
| Failure to ensure the resident environment remains free of accident hazards including cluttered hallways and improperly stored equipment. | SS=F |
| Failure to maintain sufficient nursing staff with appropriate competencies and skills to assure resident safety and care. | SS=E |
| Failure to respond to call lights in a timely manner and failure to document call light response times accurately. | — |
| Failure to ensure residents are free of significant medication errors including insulin administration errors. | SS=D |
| Failure to ensure safe and effective use of the Lispro Kwikpen injector system for insulin administration. | — |
| Failure to procure, store, prepare, distribute and serve food in accordance with professional standards for food service safety. | SS=F |
| Failure to maintain food storage areas clean, free of debris, and properly labeled with use-by dates. | — |
| Failure to ensure staff wore gloves and practiced hand sanitation when handling resident food. | — |
Report Facts
Facility census: 49
Number of residents reviewed for Medicaid Liability Notices: 3
Number of residents reviewed for abuse allegations: 4
Number of residents with incomplete MDS assessments: 1
Number of residents screened for PASRR: 20
Number of call lights documented on Staff A's disciplinary action: 7
Number of call lights response times documented: 20
Number of residents receiving psychotropic medication: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in abuse and neglect findings related to Resident #10 and Resident #38 |
| Staff B | Certified Nursing Assistant (CNA) | Named in abuse and neglect findings related to Resident #38 |
| Staff G | Licensed Practical Nurse (LPN) | Reported abuse concerns and participated in investigation |
| Staff J | Licensed Practical Nurse (LPN) | Reported observations related to Resident #10 and abuse investigation |
| Staff K | Registered Nurse (RN) | Reported observations of staff behavior and resident agitation |
| Staff P | Licensed Practical Nurse (LPN) | Observed insulin administration and medication handling |
| Staff Q | Regional Corporate Nurse Consultant | Interviewed regarding medication administration and staff hygiene |
| Staff C | Dietary Cook | Observed during dinner service with food handling deficiencies |
| Staff D | Dietary Aide | Observed during dinner service with food handling deficiencies |
| Staff E | Dietary Cook | Observed food storage and sanitation deficiencies |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding abuse investigation and staff education |
| Regional Director of Operations | Regional Director of Operations | Reported on call light response times and staff disciplinary actions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 25, 2024
Visit Reason
A complaint investigation for Facility Reported Incident #119950-I was conducted from April 22, 2024 to April 25, 2024, including a revisit of a prior survey ending March 14, 2024.
Findings
The facility was found to be in substantial compliance. All deficiencies from the prior survey were corrected as of April 8, 2024.
Complaint Details
Complaint investigation for Facility Reported Incident #119950-I was conducted and the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 11
Mar 14, 2024
Visit Reason
The inspection resulted from investigation of multiple complaints (#118497-C, #118591-C, #118561-C, #119063-C, #119122-C) and facility reported incidents (#117735-I, #119404-I, #119445-I) conducted from February 26, 2024 to March 14, 2024.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, inadequate linen supplies, failure to meet professional standards in medication administration, insufficient supervision and assistance for residents, inadequate infection control practices, and failure to maintain a safe and homelike environment. Several residents were affected by these deficiencies.
Complaint Details
Complaints #118497-C, #118591-C, #118561-C, #119063-C, and #119122-C were substantiated. Facility reported incident #119404-I was substantiated.
Severity Breakdown
SS=D: 6
SS=E: 3
SS=G: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to treat residents with respect and dignity, including incidents involving Resident #6 and Resident #17. | SS=D |
| Failure to provide a safe, clean, comfortable, and homelike environment, including inadequate linen supplies and maintenance issues. | SS=E |
| Failure to meet professional standards in medication administration, including failure to give medications as ordered and failure to follow physician orders. | SS=E |
| Failure to provide adequate ADL care for dependent residents, including failure to assist with incontinence care. | SS=D |
| Failure to provide quality care, including failure to promptly identify and intervene for residents at risk for pressure ulcers. | SS=D |
| Failure to provide treatment and services to prevent and heal pressure ulcers, including inadequate wound care and skin assessments. | SS=G |
| Failure to ensure a free of accident hazards environment, including failure to supervise residents and secure medication carts. | SS=D |
| Failure to maintain sufficient nursing staff to meet residents' needs and to answer call lights timely. | SS=D |
| Failure to maintain resident records accurately and confidentially, including incomplete medical records and lack of documentation. | SS=E |
| Failure to maintain infection prevention and control program, including inadequate catheter care and hand hygiene. | SS=D |
| Failure to ensure physician visits are timely and documented. | SS=D |
Report Facts
Facility census: 48
Number of residents reviewed: 20
Number of deficiencies cited: 11
Frequency of staff audits: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nurses Assistant (CNA) | Named in dignity violation involving Resident #6 |
| Staff H | Certified Nurses Assistant (CNA) | Named in dignity violation involving Resident #6 |
| Staff A | Certified Nurses Assistant (CNA) | Interviewed regarding dignity and care for Resident #17 |
| Staff F | Certified Medication Aide (CMA) | Named in medication administration deficiencies |
| Staff E | Certified Nursing Assistant (CNA) | Reported linen supply issues |
| Staff C | Housekeeper | Named in housekeeping and environment deficiencies |
| Staff J | Registered Nurse (RN) | Named in wound care and pressure ulcer deficiencies |
| Interim Director of Nursing | Interviewed regarding multiple deficiencies and care expectations | |
| Maintenance Director | Named in environment and housekeeping deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 21, 2023
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective December 21, 2023.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 23
Nov 21, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of multiple substantiated complaints and a reported incident.
Findings
The facility was found to have multiple deficiencies including failure to provide privacy and dignity during care, unsafe and unclean environment, inadequate abuse and neglect policies implementation, failure to notify the Long-Term Care Ombudsman of hospital transfers, incomplete comprehensive care plans, insufficient assistance with activities of daily living, inadequate dental and dietary services, insufficient nursing staff, medication regimen review irregularities, infection control lapses, and resident call system malfunctions. The facility reported a census of 49 residents.
Complaint Details
Complaints #114233-C, #115667-C, #115918-C, #116408-C, #116528-C, #116916-C, #116940-C were substantiated. Facility reported incident #116113-I was not substantiated.
Severity Breakdown
SS=D: 18
SS=E: 6
Deficiencies (23)
| Description | Severity |
|---|---|
| Failure to provide privacy and dignity during care for residents requiring assistance with gown change and enteral feeding. | SS=D |
| Failure to maintain a safe, clean, comfortable, homelike environment with issues such as unpainted walls, water puddles, and misaligned door magnets. | SS=D |
| Failure to develop and implement abuse and neglect policies including background checks for staff. | SS=E |
| Failure to provide required notice before transfer or discharge to residents and representatives. | SS=D |
| Failure to implement comprehensive care plans consistent with resident rights and needs. | SS=D |
| Failure to provide adequate assistance with activities of daily living including oral hygiene. | SS=D |
| Failure to ensure quality of care including dental services and weight monitoring. | SS=D |
| Failure to provide restorative therapy as ordered and document therapy sessions. | SS=D |
| Failure to ensure proper tube feeding management and labeling. | SS=D |
| Failure to complete dialysis evaluations and treatments as required. | SS=D |
| Failure to maintain sufficient nursing staff and post staffing information. | SS=D |
| Failure to complete monthly drug regimen reviews and report irregularities. | SS=E |
| Failure to provide psychotropic medication reviews and monitor PRN use. | SS=D |
| Failure to label and store drugs and biologicals properly and secure medication carts. | SS=D |
| Failure to provide routine and emergency dental services. | SS=D |
| Failure to provide adequate food and nutrition services including correct portion sizes and food temperatures. | SS=E |
| Failure to employ a qualified dietary staff and certified dietary manager. | — |
| Failure to maintain food safety and sanitation including proper hand hygiene and chemical levels in dishwashers. | SS=E |
| Failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program. | SS=D |
| Failure to maintain an infection prevention and control program including COVID-19 protocols. | SS=E |
| Failure to maintain a functional resident call system. | — |
| Failure to provide abuse, neglect, and exploitation training for staff. | SS=E |
| Failure to provide required in-service training for nurse aides. | SS=E |
Report Facts
Resident census: 49
Call light responses: 120
Call light responses exceeding 15 minutes: 13
Residents reviewed for medication regimen: 5
Residents reviewed for restorative therapy: 3
Residents reviewed for dialysis: 1
Residents reviewed for oral hygiene assistance: 1
Residents reviewed for dental services: 5
Residents reviewed for food portion accuracy: 18
Residents reviewed for infection control: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Danilson | Administrator | Signed the initial comments and plan of correction on 12/21/23. |
| Staff B | Licensed Practical Nurse (LPN) | Named in deficiency related to failure to provide privacy during enteral feeding. |
| Staff P | Interviewed regarding privacy and dignity expectations. | |
| Director of Nursing (DON) | Interviewed multiple times regarding expectations for privacy, grooming, restorative therapy, infection control, and other care practices. | |
| Staff C | Named in deficiency related to failure to complete background checks prior to employment. | |
| Staff A | Interviewed regarding hospital transfer notifications and dental services. | |
| Staff D | Interviewed regarding background checks and dependent adult abuse training. | |
| Staff F | Interviewed regarding dependent adult abuse training. | |
| Staff G | Interviewed regarding dependent adult abuse training. | |
| Staff H | Interviewed regarding medication regimen reviews and infection control. | |
| Staff I | Cook | Interviewed regarding food portion sizes and meal service. |
| Staff J | Interviewed regarding food portion sizes. | |
| Staff K | Dietitian | Interviewed regarding food safety and hand hygiene. |
| Staff L | Interviewed regarding dishwasher chemical levels. | |
| Staff N | Dietary Aide | Interviewed regarding dishwasher chemical levels. |
| Staff O | Interviewed regarding COVID testing and infection control. | |
| Staff Q | Registered Nurse (RN) | Interviewed regarding wound care and infection control. |
| Staff R | Regional Director of Operations | Interviewed regarding QAPI program and infection control. |
| Staff S | Interviewed regarding COVID testing. | |
| Staff T | Certified Nurse Aide (CNA) | Interviewed regarding catheter care. |
| Staff U | Certified Nurse Aide (CNA) | Interviewed regarding catheter care and restorative therapy. |
| Staff W | Registered Nurse (RN) | Interviewed regarding wound care and infection control. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 27, 2023
Visit Reason
The document is a plan of correction submitted following a deficiency statement, indicating the facility's acceptance of compliance and corrective actions.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective July 27, 2023.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 4
Jul 6, 2023
Visit Reason
Investigation of complaints #109332-C and #112985-C and facility reported incidents #112544-I and #112625-I conducted from July 3 to July 6, 2023, including substantiated complaint #112985-C.
Findings
The facility failed to report an allegation of abuse within 24 hours for one resident, Resident #1, involving inappropriate medication administration and holding the resident's nose to force medication intake. Additional findings included incomplete comprehensive care plans for two residents and failure to provide routine showers for two residents. The facility also failed to respond to call lights within 15 minutes for three residents.
Complaint Details
Complaint #112985-C was substantiated. The complaint involved failure to report abuse allegations timely and improper medication administration to Resident #1.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals within 24 hours for Resident #1 involving inappropriate medication administration. | SS=D |
| Failed to fully develop a comprehensive care plan within the required time frame for two residents (Resident #7 and Resident #8). | SS=D |
| Failed to provide showers on a routine basis for two residents (Resident #2 and Resident #4). | SS=D |
| Failed to answer residents' call lights in less than 15 minutes for three residents (Resident #3, #4, and #5). | SS=D |
Report Facts
Census: 47
Call light uses: 55
Call light response time >15 minutes: 14
Call light uses: 48
Call light response time >15 minutes: 8
Call light uses: 86
Call light response time >15 minutes: 23
Baths received: 1
Baths received: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Agency Registered Nurse (RN) | Named in abuse allegation involving holding resident's nose to administer medication |
| Staff B | Certified Medication Aide (CMA) | Witnessed and reported abuse allegation involving Staff A |
| Staff C | Licensed Practical Nurse (LPN) | Reported abuse allegation to HR Director |
| Staff G | Former Director of Nursing (DON) | Not reachable for interview regarding abuse allegation |
| Staff H | Licensed Practical Nurse (LPN), Unit Manager | Reported knowledge of narcotic medication spill and abuse reporting |
| Staff J | Certified Nurse Aide (CNA) | Interviewed regarding resident bathing refusal and care |
| Staff K | Certified Nurse Aide (CNA) | Reported documentation of baths and care |
| Administrator | Provided statements on call light response education and staffing | |
| Regional Director of Operations (RDO) | Interviewed about abuse allegation investigation and reporting | |
| Human Resources Director | Received abuse reports and coordinated investigation |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 12, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, effective December 29, 2022.
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 8
Nov 1, 2022
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaint #108668-C and facility-reported incident #108224-I from November 1 to November 9, 2022.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, incomplete background checks for staff, inadequate referral for PASARR Level II residents, insufficient comprehensive care plans, failure to implement abuse and neglect policies, inadequate medication administration and pain management, and failure to maintain adequate staffing and timely response to call lights. The complaint and facility-reported incident were substantiated.
Complaint Details
Complaint #108668-C was substantiated. Facility-reported incident #108224-I was substantiated but not specific to the allegation.
Severity Breakdown
SS=D: 7
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to treat Resident #5 with respect and dignity, including rude staff behavior and ignoring resident requests. | SS=D |
| Failure to complete Single Contact Repository (SING) background checks prior to hire for two staff members and failure to ensure dependent adult abuse training for one staff member. | SS=D |
| Failure to refer one resident with a negative Level I PASARR result for Pre-Admission Screening and Resident Review (PASARR) Level II evaluation. | SS=D |
| Failure to develop and implement comprehensive care plans for residents, including measurable objectives and timeframes. | SS=D |
| Failure to develop and implement abuse, neglect, and exploitation prevention policies and procedures. | SS=D |
| Failure to provide sufficient in-service training for nurse aides, including dementia management and abuse prevention. | SS=D |
| Failure to ensure staff cardiopulmonary resuscitation (CPR) certification for all shifts reviewed. | SS=E |
| Failure to provide adequate pain management for residents. | SS=D |
Report Facts
Census: 46
Residents reviewed: 16
Residents reviewed: 6
Residents reviewed: 5
Residents reviewed: 2
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Staff reviewed: 6
Staff reviewed: 31
Residents with CPR requested: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant (CNA) | Failed to complete background check prior to hire; involved in abuse prevention training deficiency. |
| Staff F | Certified Nursing Assistant (CNA) | Failed to complete background check prior to hire; involved in abuse prevention training deficiency; disciplinary action for phone use during resident care. |
| Staff L | Dietary Aide | Lacked documentation of dependent adult abuse training. |
| Staff H | Licensed Practical Nurse (LPN) | Reported on resident care plans, medication administration, and pain management deficiencies. |
| Staff M | Registered Nurse (RN) Consultant | Reported on medication administration and call light response time deficiencies. |
| Staff G | Licensed Practical Nurse (LPN) | Reported on medication administration and order processing deficiencies. |
| Staff I | Agency Registered Nurse (RN) | Reported medication error and training deficiencies. |
| Staff K | Agency Registered Nurse (RN) | Reported medication administration and resident monitoring deficiencies. |
| Staff J | Certified Medication Aide (CMA) | Reported on medication administration deficiencies. |
| Staff P | Certified Nursing Assistant (CNA) | Reported on resident care and medication administration deficiencies. |
| Staff O | Temporary Nurse Aide (TNA) | Assisted with resident care during pressure ulcer treatment. |
| Staff A | Registered Nurse (RN) | Reported on resident rights and dining assistance. |
| Staff N | Clinical Services | Reported on Quality Assessment and Assurance (QAA) committee deficiencies. |
| Staff Q | Licensed Practical Nurse (LPN) | Reported on medication administration deficiencies. |
| Staff E | Certified Nursing Assistant (CNA) | Involved in resident dignity and respect deficiency. |
| Staff B | Certified Nursing Assistant (CNA) | Observed ignoring resident requests and lack of door knock prior to entering rooms. |
| Staff F | Certified Nursing Assistant (CNA) | Disciplinary action for phone use during resident care. |
| Staff M | Registered Nurse (RN) Consultant | Reported on call light response time and medication administration. |
| Staff L | Dietary Aide | Lacked dependent adult abuse training documentation. |
| Staff D | Certified Nursing Assistant (CNA) | Failed to complete background check prior to hire. |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 8
Nov 1, 2022
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaint #108668-C and facility-reported incident #108224-I from November 1 to November 9, 2022.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, incomplete background checks for staff, failure to refer residents for PASARR Level II reviews, inadequate comprehensive care plans, insufficient pain management, and failure to maintain adequate staffing and timely response to call lights. Several residents had documented health issues such as pressure ulcers and mental health diagnoses that were not fully addressed.
Complaint Details
Complaint #108668-C was substantiated. Facility-reported incident #108224-I was substantiated but not specific to the allegation.
Severity Breakdown
Level D: 7
Level E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to treat Resident #5 with respect and dignity, including rude behavior by staff and ignoring resident requests. | Level D |
| Failure to complete Single Contact Repository (SING) background checks prior to hire for two staff members and failure to ensure training for one staff member. | Level D |
| Failure to refer Resident #39 for PASARR Level II review despite negative Level I result. | Level D |
| Failure to develop and implement comprehensive care plans for residents, including measurable objectives and timeframes. | Level D |
| Failure to provide adequate pain management for Resident #19, including lack of assessment and documentation. | Level D |
| Failure to maintain sufficient nursing staff and timely response to call lights for multiple residents. | Level D |
| Failure to ensure staff had completed required in-service training for nurse aides. | Level D |
| Failure to ensure staff on duty had current CPR certification. | Level E |
Report Facts
Census: 46
Residents reviewed: 16
Residents reviewed: 6
Residents reviewed: 2
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 2
Residents reviewed: 3
Residents reviewed: 5
Staff background checks: 2
Staff CPR certification: 7
Residents with pressure ulcers: 1
Residents with pain management issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Named in findings related to rude behavior and disciplinary action for phone use during resident care. |
| Staff D | Certified Nursing Assistant (CNA) | Named in findings related to incomplete background check prior to hire. |
| Staff L | Dietary Aide | Named in findings related to lack of required Dependent Adult Abuse training. |
| Staff H | Licensed Practical Nurse (LPN) | Reported on resident care and medication administration issues. |
| Staff M | Registered Nurse (RN) Consultant | Reported on medication administration and call light response findings. |
| Staff G | Licensed Practical Nurse (LPN) | Reported on advanced directives and medication administration policies. |
| Staff P | Certified Nursing Assistant (CNA) | Reported on resident care and medication administration. |
| Staff K | Agency RN | Reported on medication administration incident. |
| Staff I | Agency RN | Reported on medication error and training deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 26, 2022
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 October 26, 2022.
Inspection Report
Complaint Investigation
Deficiencies: 5
Sep 30, 2022
Visit Reason
The inspection was conducted as an investigation of complaints #105658-C, #106355-C, #107830-C and a facility reported incident #107885-I from September 23, 2022 to September 28, 2022.
Findings
The investigation substantiated complaints #106355-C, #107830-C and the facility reported incident #107885-I, while complaint #105658-C was not substantiated. Deficiencies were found related to failure to notify physicians of resident condition changes, failure to follow physician orders for care plans and medication administration, insufficient nursing staff, and delayed call light responses.
Complaint Details
Complaints #106355-C, #107830-C and facility reported incident #107885-I were substantiated. Complaint #105658-C was not substantiated.
Deficiencies (5)
| Description |
|---|
| Failure to notify the physician for 1 of 3 residents reviewed regarding weight change notifications. |
| Failure to follow physician's orders for 1 of 3 residents reviewed related to comprehensive care plans and medication administration. |
| Failure to follow physician orders for weights for 3 of 5 residents reviewed. |
| Insufficient nursing staff to assure resident safety and care. |
| Delayed response to call lights for 2 of 7 residents reviewed. |
Report Facts
Complaints investigated: 3
Complaints not substantiated: 1
Residents reviewed for physician notification: 3
Residents reviewed for care plan compliance: 3
Residents reviewed for weight order compliance: 5
Residents reviewed for call light response: 7
Dates of complaint investigation: September 23, 2022 to September 28, 2022
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 9
Jul 13, 2022
Visit Reason
An investigation of multiple complaints and facility-reported incidents was conducted from May 31 to July 13, 2022, to determine compliance with federal regulations.
Findings
The facility was found to have multiple deficiencies including failure to notify changes in resident condition, unsafe and unclean environment conditions, failure to implement comprehensive care plans, failure to meet professional standards of care, inadequate bathing and toileting assistance, insufficient restorative programs, inadequate infection control, and insufficient nursing staff. Several residents were identified as at risk or affected by these deficiencies.
Complaint Details
The investigation was triggered by complaints #100965-C, #101285-C, #102250-C, #102451-C, #102585-C, #102615-C, #103978-C, #103996-C, #104342-C, #104892-C, #104895-C, #104982-C, and #105052-C and facility-reported incidents #102199-I, #102582-I, and #104962-I. Complaints #100965-C, #101285-C, #102250-C, #102451-C, #102585-C, #102615-C, #103996-C, #104342-C, #104892-C, #104895-C, and #105052-C were substantiated. Complaints #103978-C and facility-reported incidents #102199-I, #102582-I, and #104962-I were not substantiated.
Severity Breakdown
Level B: 1
Level D: 3
Level E: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to notify resident, physician, and representative of significant changes in resident condition. | — |
| Unsafe, unclean, and uncomfortable environment including peeling paint and buildup of dirt and debris in resident bathrooms. | Level B |
| Failure to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes. | Level D |
| Failure to meet professional standards of care including medication administration errors and failure to follow physician orders. | Level E |
| Failure to provide adequate bathing, toileting, and perineal care to residents as scheduled and per care plans. | Level E |
| Failure to provide adequate restorative nursing programs and therapies as planned. | Level E |
| Failure to maintain infection prevention and control program and proper use of personal protective equipment. | Level D |
| Failure to maintain sufficient nursing staff with appropriate competencies and skills. | Level E |
| Failure to maintain safe operating condition of essential equipment. | Level D |
Report Facts
Resident census: 50
Deficiencies cited: 9
Medication administration errors: 3
Residents reviewed for bathing/toileting: 4
Residents reviewed for restorative programs: 4
Residents with skin condition assessment failures: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant (CNA) | Named in observation of failure to use gait belt and ambulate resident safely |
| Staff B | Licensed Practical Nurse (LPN) | Observed setting up medications improperly |
| Staff C | Registered Nurse (RN) | Administered medications without observing setup |
| Staff D | Certified Nursing Assistant/Shower Aide | Described challenges completing showers due to staffing |
| Staff F | Certified Nursing Assistant (CNA) | Failed to provide scheduled baths/showers |
| Staff I | Certified Nursing Assistant/Certified Medication Aide | Failed to cleanse resident properly and removed saturated brief |
| Staff N | Certified Nursing Assistant (CNA) | Failed to retract resident's foreskin during cleansing |
| Staff E | Restorative Aide | Failed to perform restorative exercises as set up by therapy |
| Staff A | Certified Medication Aide (CMA) | Left medication cup unattended on resident's bedside table |
| Director of Nursing (DON) | Director of Nursing | Participated in observations and education sessions |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Nov 17, 2021
Visit Reason
The inspection was conducted as a Focused Infection Control Survey and investigation of complaint #100603-C.
Findings
The facility failed to follow professional standards and ensure medications were given as ordered for 1 of 4 residents reviewed, specifically Resident #1. The complaint was substantiated.
Complaint Details
Complaint #100603-C was substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to follow professional standards and ensure medications were given as ordered for Resident #1. |
Report Facts
Census: 48
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 30, 2021
Visit Reason
A revisit of the Recertification Survey and Complaints #96923-C, #96475-C, #95033-C and #98669-C ending July 28, 2021 and investigation of Complaint #98917 were conducted on September 28 - 30, 2021.
Findings
All deficiencies have been corrected and the facility is in compliance effective August 20, 2021. Complaint #98917-C was not substantiated.
Complaint Details
Complaint #98917-C was investigated and found not substantiated.
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 9
Jul 28, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaints #96923-C, #98669-C, #96475-C, and #95033-C completed between 7/19/21 and 7/28/21.
Findings
The facility was found to have multiple deficiencies including failure to provide reasonable accommodations for residents, incomplete Medicare Liability Notices, incomplete comprehensive assessments and care plans, insufficient nursing staff, improper medication storage, and inadequate food safety practices. Corrective actions and education were implemented with specified completion dates.
Complaint Details
Complaints #98669 and #96475 were substantiated; complaints #96923 and #95033 were not substantiated.
Deficiencies (9)
| Description |
|---|
| Facility failed to place the resident's call light within reach for 1 of 19 residents. |
| Facility failed to provide 1 of 3 residents discharged from skilled level of care with required Medicare Liability Notices. |
| Facility failed to complete accurate admission Minimum Data Set (MDS) including Preadmission Screening and Resident Review (PASRR) for 1 of 12 residents reviewed. |
| Facility failed to complete a comprehensive care plan based on residents' needs for 1 of 12 residents reviewed. |
| Facility failed to provide bathing assistance at least weekly for 2 of 19 residents reviewed. |
| Facility failed to ensure call lights were answered in a timely manner for 3 of 19 residents. |
| Medication room contained expired medications and unlabeled items. |
| Facility failed to provide each resident with a nourishing, palatable, well-balanced diet meeting nutritional and special dietary needs. |
| Facility failed to label and store food items properly to reduce risk of contamination and foodborne illness. |
Report Facts
Census: 55
Residents reviewed: 19
Residents reviewed: 12
Residents reviewed: 3
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 2
Residents reviewed: 3
Completion dates: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marsha James | Director of Nursing (DON) | Named in education and corrective action related to call light response, medication storage, and bathing schedule |
| Erin Melby | Regional Nurse Consultant | Named in education and corrective action related to PASRR and care plan reviews |
| Social Service Director | Named in relation to specialized services on care plan and PASRR oversight | |
| Business Office Manager | Named in education regarding Medicaid/Medicare Coverage and Liability Notices | |
| Administrator | Named in multiple interviews and responsible for auditing and monitoring corrective actions | |
| Dietary Manager | Named in relation to food safety, meal service, and dietary deficiencies | |
| Director of Nursing (DON) | Named in multiple interviews regarding call light expectations, bathing schedules, medication storage, and corrective actions | |
| Assistant Director of Nursing (ADON) | Named in documentation of fall incident and resident care |
Inspection Report
Abbreviated Survey
Census: 52
Deficiencies: 0
Dec 21, 2020
Visit Reason
A 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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total Census: 52
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 12, 2020
Visit Reason
A Focused Infection Control Survey and an investigation of Complaint #92588 was conducted by the Department of Inspections and Appeals from November 4 to 12, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. Complaint #92588 was not substantiated.
Complaint Details
Complaint #92588 was investigated and found to be not substantiated.
Inspection Report
Routine
Census: 57
Deficiencies: 0
Jun 17, 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.
Report
File
ScannedReport_1023_2025-11-05_074727.pdf
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