Inspection Reports for
Belle Plaine Specialty Care
1505 Sunset Drive, Belle Plaine, IA, 522081319
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
7.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
36 residents
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Census: 36
Deficiencies: 1
Date: Jan 21, 2026
Visit Reason
The inspection visit occurred due to a review of medication administration practices following an incident where medication intended for one resident was administered to another resident.
Findings
The facility failed to follow physician orders by administering medication intended for Resident #6 to Resident #1. The error was identified before further medications were given, and the doctor, family, and hospice were notified. The facility acknowledged the error and provided education to nursing staff on medication administration.
Deficiencies (1)
Failure to follow physician orders by administering medication intended for one resident to another resident.
Report Facts
Residents affected: 6
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Administered medication to wrong resident during second shift |
| Staff B | Licensed Practical Nurse (LPN) | Orienting Staff A and identified medication error |
| Director of Nursing | Director of Nursing (DON) | Explained expectations for training new nurses and facility policy on medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 30, 2025
Visit Reason
A complaint investigation for complaint #2654346-C was conducted from October 29, 2025 to October 30, 2025.
Complaint Details
Complaint #2654346-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
Complaint Investigation
Deficiencies: 0
Date: Oct 20, 2025
Visit Reason
A complaint investigation for #2612181-C was conducted on October 20, 2025.
Complaint Details
Complaint investigation #2612181-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to a survey ending August 28, 2025, with certification of compliance effective September 22, 2025.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification of compliance effective September 22, 2025.
Inspection Report
Plan of Correction
Census: 34
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was conducted to review the accuracy of the facility's Payroll Based Journal (PBJ) Staffing Data Report for the period January 1, 2025 to March 31, 2025, following concerns about inaccurate staff reporting and licensed nursing coverage.
Findings
The facility failed to submit accurate staff reports for the PBJ Staffing Data Report, with findings including excessively low weekend staffing and failure to provide 24-hour licensed nursing coverage on multiple days. The Director of Nursing's worked hours were not accurately reflected in the submitted data, and the facility lacked a policy for accurate PBJ data submission.
Deficiencies (1)
Failed to submit accurate staff reports for the PBJ Staffing Data Report, including failure to provide 24-hour licensed nursing coverage on multiple days.
Report Facts
Residents census: 34
Days with failure to provide 24-hour licensed nurse coverage: 10
PBJ Staffing Data Report period: January 1, 2025 - March 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Worked licensed nurse shifts 1-3 days per week; hours not accurately reflected in PBJ data | |
| Administrator | Reported corporate office responsibility for PBJ data submission and acknowledged inaccuracies |
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from August 25, 2025 to August 28, 2025.
Findings
The facility failed to submit accurate Payroll Based Journal (PBJ) staffing data for the period January 1, 2025 to March 31, 2025, including inaccurate reporting of licensed nursing coverage hours and lack of a policy for accurate PBJ data submission.
Deficiencies (1)
Failure to submit accurate direct care staffing information based on payroll data in a uniform format as required by CMS.
Report Facts
Resident census: 34
Days with failure to provide 24-hour licensed nurse coverage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mitchell Huff | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Director of Nursing (DON) | Named in interviews regarding staffing and PBJ data inaccuracies | |
| Administrator | Named in interviews regarding responsibility for PBJ data submission and acknowledgement of inaccuracies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 6, 2025
Visit Reason
The document is a Plan of Correction submitted following acceptance of a credible allegation of substantial compliance by the facility.
Findings
The facility was certified in compliance effective May 5, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 4
Date: Apr 14, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to respect resident dignity, improper handling of falls, unsafe transfers, and failure to provide timely care after a catheter was pulled out.
Complaint Details
The investigation was complaint-driven due to allegations of neglect, abuse, and failure to follow care plans, including verbal abuse by staff, unsafe transfers, and delayed medical care after a catheter incident.
Findings
The facility failed to respect resident dignity for 2 residents, improperly handled multiple falls without proper assessment, failed to provide timely intervention for a resident whose suprapubic catheter was pulled out, and failed to safely transfer a resident resulting in bruising injuries. Several staff were found to have acted inappropriately or negligently.
Deficiencies (4)
Failure to respect resident dignity and rights for 2 residents with cognitive impairments.
Failure to assess and properly document after Resident #3's falls, including verbal abuse by staff.
Failure to provide timely intervention for Resident #2 after suprapubic catheter was pulled out, resulting in delayed hospital transfer.
Unsafe transfer of Resident #6 without mechanical lift causing bruising and distress.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Bruise measurement: 7.03
Bruise measurement: 3.51
Bruise measurement: 2.65
CNA training days: 2
Resident census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Named in findings for verbal abuse and failure to assess Resident #3 after falls |
| Staff G | Certified Nursing Assistant (CNA) | Named in findings for unsafe transfer of Resident #6 and rough handling |
| Staff J | Certified Medication Assistant (CMA) | Witnessed and reported Staff B's verbal abuse and improper handling of Resident #3 |
| Staff D | Certified Nursing Assistant (CNA) | Witnessed and reported Staff B's verbal abuse and improper handling of Resident #3 |
| Staff K | Certified Medication Assistant (CMA) | Witnessed and reported Staff B's verbal abuse and improper handling of Resident #3 |
| Staff F | Certified Nursing Assistant (CNA) | Reported unsafe transfer and rough handling of Resident #6 by Staff G |
| Staff L | Registered Nurse (RN) | Notified about unsafe transfer and called DON; involved in investigation |
| Staff A | Registered Nurse (RN) | Assisted Resident #2 after fall and was unaware of catheter issue |
| Staff C | Certified Nursing Assistant (CNA) | Reported Resident #2's fall and missing catheter |
| Director of Nursing | Director of Nursing (DON) | Provided statements on expectations and staff training |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 5
Date: Apr 14, 2025
Visit Reason
The inspection was conducted as a result of complaints #127252-C, #125730-C, #127768-I, #127769-I, and #127866-I, as well as reported incidents at the facility between April 7 and April 14, 2025.
Complaint Details
Complaint investigation of multiple complaints (#127252-C substantiated, #125730-C substantiated, #127768-I not substantiated). The investigation found substantiated issues related to resident abuse, neglect, and failure to provide adequate care.
Findings
The facility was found to have failed to respect resident dignity and provide appropriate care, including inadequate supervision and handling of residents, resulting in bruises and injuries to residents #3 and #6. The facility also failed to provide proper catheter care for Resident #2 after a fall. Several staff members were reported to have acted inappropriately toward residents. The facility reported a census of 39 residents.
Deficiencies (5)
Failure to respect resident dignity and provide care, evidenced by incidents involving Resident #3 including falls, bruising, and inappropriate staff behavior.
Failure to provide appropriate assessment and care for Resident #6, resulting in bruising and agitation.
Failure to provide appropriate catheter care for Resident #2 after a fall, including failure to replace a suprapubic catheter timely.
Failure to ensure a safe environment free of accident hazards, including inadequate supervision and assistance devices.
Failure to maintain resident rights and dignity, including freedom from abuse, neglect, exploitation, and misappropriation.
Report Facts
Resident census: 39
Number of substantiated complaints: 2
Number of complaints investigated: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Certified Medication Assistant (CMA) | Named in findings related to failure to assess Resident #3 after a fall. |
| Staff B | Registered Nurse (RN) | Named in findings related to failure to assess Resident #3 after a fall and inappropriate behavior. |
| Staff D | Certified Nursing Assistant (CNA) | Named in findings related to failure to provide care and inappropriate handling of Resident #3. |
| Staff K | Certified Medication Assistant (CMA) | Named in findings related to inappropriate behavior and failure to document falls. |
| Staff G | Certified Nursing Assistant (CNA) | Named in findings related to rough handling and abuse of Resident #6. |
| Staff F | Certified Nursing Assistant (CNA) | Named in findings related to witnessing abuse and failure to provide care to Resident #6. |
| Staff L | Registered Nurse (RN) | Named in findings related to concerns about abuse and failure to provide care. |
| Staff M | Certified Nursing Assistant (CNA) | Named in findings related to witnessing abuse and failure to provide care to Resident #6. |
| Staff H | Emergency Medical Technician (EMT) | Named in findings related to transport and care of Resident #2. |
| Staff I | Emergency Medical Technician (EMT) | Named in findings related to transport and care of Resident #2. |
| Staff C | Certified Nursing Assistant (CNA) | Named in findings related to care and transfer of Resident #2. |
| Staff A | Registered Nurse (RN) | Named in findings related to assessments and care of Resident #2. |
| Staff B | Registered Nurse (RN) | Named in findings related to care and notification failures for Resident #2. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 18, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective November 8, 2024.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 7, 2024
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective November 1, 2024.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective November 1, 2024. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 3
Date: Oct 30, 2024
Visit Reason
The inspection was conducted as part of the facility's annual survey by the State of Iowa Department of Inspections, Appeals, & Licensing.
Findings
The facility failed to assess and document a resident's decline in condition over a 3-day period, resulting in minimal harm to a few residents. Specifically, Resident #2 experienced significant weight loss, malnutrition, and was not properly monitored for respiratory and diabetic conditions, leading to hospitalization in critical condition.
Deficiencies (3)
Failure to assess and document Resident #2's decline in condition over a 3-day period, including lack of physical assessments and monitoring of vital signs and breath sounds.
Failure to notify physician timely about significant changes in resident's condition and limited oral intake.
Inadequate monitoring and documentation of oxygen saturation and breath sounds for resident on oxygen and breathing treatments.
Report Facts
Census: 43
Resident weight records: 122
Blood sugar level: 667
Blood sugar level: 145
Medication dosages: 500
Medication dosages: 1200
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Documented resident assessments and nursing progress notes |
| Staff B | Registered Nurse (RN) | Provided nursing care and documented resident condition and medication administration |
| Staff C | Licensed Practical Nurse (LPN) | Provided nursing care and documented resident condition and oxygen saturation |
| Staff D | Licensed Practical Nurse (LPN) | Assigned nursing staff during inspection period |
| Staff E | Licensed Practical Nurse (LPN) | Assigned nursing staff during inspection period |
| Staff F | Director of Nursing (DON) at different facility | Interviewed regarding nursing assessment standards |
| Staff G | Director of Nursing (DON) | Facility DON who acknowledged deficiencies in resident assessment and care |
| Staff H | Certified Medication Aide (CMA) | Administered breathing treatments to resident |
| Staff I | Certified Nursing Assistant (CNA) | Reported resident's poor appetite and fluid intake |
| Staff J | Registered Nurse (RN), Assistant Director of Nursing (ADON) | Provided interview on nursing assessment requirements |
| RDLD | Registered and Licensed Dietician | Documented resident's malnutrition and dietary status |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
The inspection was conducted as a result of complaint #124403-C from October 28, 2024 to October 30, 2024, which was substantiated. The complaint involved failure to assess a resident's decline in condition and failure to complete required assessments.
Complaint Details
Complaint #124403-C was substantiated following investigation from October 28, 2024 to October 30, 2024.
Findings
The facility failed to assess Resident #2's decline in condition and did not complete required assessments over a 3-day period. The resident experienced significant health deterioration, including respiratory issues and weight loss, leading to hospitalization. The facility implemented corrective actions including staff education, monitoring, and audits to prevent recurrence.
Deficiencies (1)
Failure to assess a resident's decline in condition and complete required assessments over a 3-day period.
Report Facts
Resident census: 43
Deficiency count: 1
Resident weight records: 122
Resident blood sugar: 667
Medication dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in nursing progress notes and medication administration |
| Staff B | Registered Nurse (RN) | Contacted provider and documented resident condition changes |
| Staff C | Licensed Practical Nurse (LPN) | Documented late entries and resident monitoring |
| Staff F | Director of Nursing (DON) | Provided documentation and statements regarding resident condition and hospital transfer |
| Staff H | Certified Medication Aide (CMA) | Administered breathing treatments to resident |
| Staff J | Assistant Director of Nursing (ADON), RN | Provided statements on nursing assessments and protocols |
| Staff I | Certified Nursing Assistant (CNA) | Reported on resident appetite and support during COVID illness |
| Staff G | Director of Nursing (DON) | Reported on resident condition during annual survey and hospital transfer |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 6
Date: Oct 17, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of a facility reported incident #124032-I.
Complaint Details
Facility reported incident #124032-I was investigated and found to be unsubstantiated.
Findings
The facility was found deficient in multiple areas including failure to provide timely room trays with proper utensils, failure to respond to pharmacy recommendations for medication adjustments, failure to maintain proper food temperatures, serving incorrect diets to residents, failure to obtain physician orders for diet changes, and unsafe food handling practices.
Deficiencies (6)
Failed to provide a resident room tray until early afternoon and provided plastic utensils instead of metal for Resident #5.
Failed to have a provider respond to monthly pharmacy recommendations regarding Sertraline dose reduction for Resident #8.
Failed to maintain hot foods above 135°F and cold beverages below 41°F for 1 of 1 test trays.
Served 1 resident the wrong diet and initially set up inappropriate diets for 4 other residents with mechanical soft diets not properly prepared.
Failed to obtain a doctor's order for a diet change from pureed to mechanical soft for Resident #16.
Failed to safely handle food when preparing sandwiches; staff touched other items with gloved hands prior to touching bread with the same gloves.
Report Facts
Census: 37
Medication recommendations without provider response: 2
Food temperature readings: 149
Food temperature readings: 133.7
Food temperature readings: 121
Food temperature readings: 46.6
Food temperature readings: 43.2
Residents served wrong diet: 5
Residents reviewed for diet change: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Cook | Named in findings related to food temperature, diet preparation errors, and unsafe food handling |
| Staff C | Certified Nurse Aide (CNA) | Assisted Resident #27 with dining after incorrect diet served |
| Dietary Manager | Involved in diet preparation and acknowledged errors in diet service | |
| Registered Dietitian | Reviewed and approved menus, acknowledged diet errors, and implemented Nutrition Management program | |
| Director of Nursing (DON) | Discussed pharmacy recommendation responses and diet trial practices | |
| Mental Health Nurse Practitioner | Responded to pharmacy recommendation regarding Sertraline dose | |
| Administrator | Acknowledged diet and food handling deficiencies | |
| Staff A | Dietary Manager for another facility | Observed and corrected unsafe food handling practices |
| Staff D | Cook | Observed performing unsafe food handling practices |
Inspection Report
Routine
Census: 37
Deficiencies: 6
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication regimen reviews, food safety and diet management, and food handling practices at Belle Plaine Specialty Care.
Findings
The facility was found deficient in multiple areas including failure to provide timely and appropriate utensils for a resident's meal tray, failure to respond timely to pharmacy recommendations, serving food at unsafe temperatures, serving incorrect diets to residents, failure to obtain physician orders for diet changes, and unsafe food handling practices by staff.
Deficiencies (6)
Failed to provide a resident room tray until early afternoon and provided plastic eating utensils instead of metal.
Failed to have a provider respond to monthly pharmacy recommendations for medication adjustments.
Failed to maintain hot foods above 135°F and cold beverages below 41°F for a test tray.
Served one resident the wrong diet and initially set up incorrect diets for four other residents.
Failed to obtain a doctor's order for a diet change from pureed to mechanical soft for one resident.
Failed to safely handle food when preparing sandwiches; staff touched multiple items with the same gloves.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 1
Census: 37
Food temperatures: 149
Food temperatures: 133.7
Food temperatures: 121
Food temperatures: 46.6
Food temperatures: 43.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Cook | Named in findings related to serving wrong diets and unsafe food handling practices |
| Staff C | Certified Nurse Aide (CNA) | Assisted Resident #27 with dining after wrong diet served |
| Dietary Manager | Involved in diet setup and acknowledged errors in diet service | |
| Registered Dietitian | Provided diet orders and acknowledged errors in diet service | |
| Administrator | Acknowledged findings related to diet service and food handling | |
| Nurse Consultant | Acknowledged findings related to diet service and food handling | |
| Director of Nursing (DON) | Discussed medication regimen review responses and diet trial practices | |
| Staff A | Dietary Manager for another facility | Observed and corrected unsafe food handling practices |
| Staff D | Cook | Named in unsafe food handling practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 18, 2024
Visit Reason
The document reflects acceptance of the facility's credible allegation of substantial compliance and Plan of Correction.
Findings
The facility will be certified in compliance effective March 14, 2024, based on acceptance of the Plan of Correction.
Inspection Report
Routine
Census: 39
Deficiencies: 4
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with staffing requirements, dietary management, menu preparation, and administrative coverage at Belle Plaine Specialty Care.
Findings
The facility failed to employ a full-time Director of Nurses since 1/26/2024, a full-time Dietary Manager since 12/31/2023, and an Assistant Administrator to provide coverage for the Administrator responsible for two facilities. Dietary staff failed to serve correct food portions and lacked proper training.
Deficiencies (4)
Failed to employ a full-time Director of Nurses since 1/26/2024.
Failed to employ a full-time Dietary Manager since 12/31/2023.
Failed to prepare and serve the correct amount of food for 2 of 3 dining observations and failed to provide education for dietary staff prior to working independently.
Failed to employ an Assistant Administrator to provide Administrator coverage for two facilities managed by one Administrator.
Report Facts
Census: 39
Number of servings of spaghetti made: 40
Distance between facilities: 42.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrator | Named in multiple interviews regarding staffing and administrative coverage |
| Staff E | Director of Nurses (Interim) | Interim Director of Nurses from sister facility assisting temporarily |
| Staff C | LPN Assistant Director of Nurses | Transferred to the facility to help fill the Director of Nurses void |
| Staff A | Business Office Manager | Provided information on staffing and administrative coverage |
| Staff F | Certified Dietary Manager | From sister facility providing dietary coverage and re-education |
| Staff G | Registered Dietician | Provided dietary services once weekly and noted training issues |
| Staff H | Dietary staff observed serving incorrect food portions and lacking training | |
| Staff I | Dietary staff observed preparing pureed pears incorrectly |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 4
Date: Feb 23, 2024
Visit Reason
The inspection was conducted as an investigation of facility reported incident #116429-1 and complaints #117596-C and #118432-C between 2/19/24 and 2/23/24.
Complaint Details
Complaint #117596-C was substantiated without a deficiency. Complaints #116429-1 and #118432-C were not substantiated.
Findings
The investigation found that complaint #117596-C was substantiated without a deficiency, while complaints #116429-1 and #118432-C were not substantiated. Deficiencies were identified related to failure to employ a full-time Director of Nursing, failure to employ a full-time Dietary Manager, failure to prepare and serve correct amounts of food, and failure to employ an Assistant Administrator to provide Administrator coverage.
Deficiencies (4)
Failure to employ a full-time Director of Nursing as required by regulations.
Failure to employ a full-time Dietary Manager since 12/31/23, resulting in inadequate dietary management.
Failure to prepare and serve correct amounts of food for 2 of 3 dining observations and failure to provide education for dietary staff prior to working independently.
Failure to employ an Assistant Administrator to provide Administrator coverage for the facility.
Report Facts
Facility census: 39
Dates of survey: Survey conducted from 2/19/24 to 2/23/24.
Correction date: Plan of correction dated 03/14/2024.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrator | Provided multiple interviews regarding Director of Nursing and Dietary Manager staffing. |
| Staff C | LPN Assistant Director of Nurses | Transferred to facility to help fill Director of Nursing void. |
| Staff E | Director of Nursing (D.O.N.) | Full-time D.O.N. from sister facility, interim until replacement found. |
| Staff F | Certified Dietary Manager | Provided coverage from sister facility and involved in dietary observations. |
| Staff G | Registered Dietician | Reported coming to facility once a week after Dietary Manager left. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 2, 2023
Visit Reason
The document serves as a plan of correction following a credible allegation of compliance, indicating the facility's certification in compliance effective August 11, 2023.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Renewal
Census: 42
Deficiencies: 4
Date: Jul 20, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and an investigation of Facility Self-Reported Incidents from July 17, 2023 to July 20, 2023.
Findings
The facility was found deficient in several areas including failure to ensure clear direction of a resident's wishes regarding code status, failure to follow physician orders for tube feeding, failure to provide ordered nutrition supplements, and failure to meet food safety requirements including storage and sanitation.
Deficiencies (4)
Failed to ensure clear direction of a resident's wishes regarding code status for 1 of 16 residents reviewed for advanced directives (Resident #43).
Failed to follow physician orders during administration of tube feeding for 1 of 1 residents reviewed receiving tube feedings (Resident #9).
Failed to provide ordered nutrition supplements or contact Dietician/provider for alternate options for 1 of 2 residents reviewed for nutrition (Resident #7).
Failed to meet food safety requirements including procuring food from approved sources, storing and preparing foods under sanitary conditions, and maintaining clean kitchen and refrigerator areas.
Report Facts
Resident census: 42
Dates of survey: 4
MDS Brief Interview for Mental Status (BIMS) scores: 11
MDS BIMS score: 9
MDS BIMS score: 14
Medication Administration Record (MAR) order: 237
Medication Administration Record (MAR) order: 150
Dietary supplement frequency: 2
Resident #7 weights: 89
Resident #7 weight: 90
Resident #7 weight: 94
BMI: 16.7
Expired food items: 6
Dishwasher temperature dial reading: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Flushed resident's G-tube and did not mix feeding with water as ordered |
| Director of Nursing | Clarified and corrected Advance Directive order for Resident #43 and stated staff could check code status in EHR | |
| Administrator | Stated staff could check code status and expected staff to follow physician orders | |
| Staff C | Certified Medication Aide (CMA) | Confirmed supplement not available in Resident #7 progress notes |
| Staff D | Dietary Manager | Observed washing hands, noted dishwasher issues, and was aware of expired food items |
| Staff E | Dietary Aide | Observed washing hands and handling food delivery cart |
| Staff A | Administrator | Confirmed supervision of kitchen staff and expectation to follow hand washing policies |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 4
Date: Jul 20, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards in multiple areas including resident rights, medication administration, nutrition, and food safety.
Findings
The facility was found deficient in ensuring clear direction of residents' code status, following physician orders for tube feeding, providing ordered nutrition supplements or alternate options, and maintaining sanitary food storage and preparation conditions. Deficiencies were noted with minimal harm or potential for actual harm affecting few to some residents.
Deficiencies (4)
Failed to ensure clear direction of a resident's wishes regarding code status for 1 of 16 residents reviewed for advanced directives.
Failed to follow physician orders during the administration of a tube feeding for 1 of 1 residents reviewed receiving tube feedings.
Failed to provide ordered nutrition supplements or contact the Dietician or provider for alternate options for 1 of 2 residents reviewed for nutrition.
Failed to store and prepare foods under sanitary conditions for 2 of 2 kitchen observations.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 2
Resident census: 42
Resident weight: 89
Resident weight: 90
Resident weight: 94
BIMS score: 11
BIMS score: 9
BIMS score: 14
MNA score: 11
Nutrition supplement amount: 237
Nutrition supplement amount: 150
Nutrition supplement amount: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Named in tube feeding administration deficiency |
| Director of Nursing | Director of Nursing (DON) | Involved in clarifying code status and feeding order issues |
| Administrator | Administrator | Provided statements on staff expectations and facility policies |
| Staff D | Dietary Manager | Observed during kitchen sanitary deficiencies |
| Staff C | Certified Medication Aide (CMA) | Confirmed supplement availability issues |
| Staff E | Dietary Aide | Observed during kitchen sanitary deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 18, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and investigation of multiple complaints and a facility self-reported incident was conducted by the Department of Inspections and Appeals from April 12, 2023 to April 18, 2023.
Complaint Details
Investigation included Complaints #107767-C, #107850-C, #107852-C, #107866-C, #109261-C and Facility Self-Reported Incident #109269-I.
Findings
The facility was found to be in substantial compliance and in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 1, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective July 1, 2022.
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 5
Date: Jun 1, 2022
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of multiple complaints and facility self-reported incidents between May 22, 2022 and May 31, 2022.
Complaint Details
Complaints #100092-C and #101248-C were substantiated. The survey also investigated complaints #103959-C and facility self-reported incidents #100916-I and #104828-I.
Findings
The facility was found deficient in revising care plans after assessments, carrying out physician orders, meeting residents' nutritional needs, providing sufficient dietary support personnel, and following planned menus. Specific issues included failure to update Resident #5's care plan and transfer protocols, incomplete speech evaluations, inadequate meal portions, and insufficient trained dietary staff.
Deficiencies (5)
Failed to revise Resident #5's care plan after assessments, resulting in unsafe transfer practices.
Failed to carry out physician's orders for Resident #5, including lack of speech evaluation.
Failed to meet nutritional needs by serving less than specified portions and not following special diet orders for Resident #5.
Failed to provide sufficient dietary support personnel to safely and effectively prepare meals.
Failed to follow the planned menu for meals, resulting in inadequate portions and missing ingredients.
Report Facts
Census: 40
Deficiencies cited: 5
BIMS score: 2
Meals with insufficient portions: 3
Residents requiring mechanical soft diet: 3
Residents served less cauliflower: 3
Residents served less sweet potatoes: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Temporary Nurse Aide | Named in transfer observation with Resident #5 |
| Staff G | Certified Nursing Assistant | Named in transfer observation with Resident #5 |
| Staff H | Certified Nursing Assistant | Named in transfer observation with Resident #5 |
| Staff C | Licensed Practical Nurse / Charge Nurse | Interviewed regarding Resident #5's transfer and care plan |
| Director of Nursing | Interviewed regarding care plan discrepancies and expectations | |
| Staff D | Cook | Observed preparing meals with inadequate portions |
| Staff E | Covering Dietary Manager | Interviewed regarding dietary preparation and training |
| Business Officer Manager | Interviewed regarding dietary staffing and cooking duties | |
| Social Services Coordinator | Observed preparing lunch and interviewed regarding dietary staffing | |
| Registered Dietician | Interviewed regarding dietary assessments and recommendations | |
| Facility Supervising Physical Therapist | Interviewed regarding Resident #5's transfer needs |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Date: Mar 1, 2021
Visit Reason
The inspection was conducted as a recertification survey and investigation of complaint #94925 and facility self-reported incident #95013-I occurring March 1-4, 2021.
Complaint Details
Complaint #94925 and self-reported incident #95013-I were investigated; both were found not substantiated.
Findings
The facility failed to provide adequate assistance to prevent accidents by transferring a resident without using a gait belt, despite policies and staff interviews indicating gait belts should be used for transfers.
Deficiencies (1)
Failure to use a gait belt when assisting Resident #17 with transfers, contrary to facility policy and staff statements.
Report Facts
Residents reviewed: 3
Census: 21
Plan of correction audit period: 3
QA committee audit period: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Observed assisting resident without gait belt |
| Staff B | Certified Nursing Assistant (CNA) | Interviewed regarding gait belt use policy |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding gait belt availability and use |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding gait belt policy and auditing |
Inspection Report
Abbreviated Survey
Census: 33
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted on 12/09/20 and 12/10/20 by the Department of Inspections and Appeals.
Findings
The facility was found to be in compliance with the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 33
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/23/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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