Inspection Reports for
Dermott City Nursing Home

The complaint investigation was substantiated. Immediate Jeopardy (IJ) began on 12/02/2025 when CNA #1 improperly transferred Resident #1 without using the required mechanical stand-up lift or two-person assistance, resulting in a fall and acute right femur fracture requiring surgery. The IJ was removed on 12/23/2025 after the facility implemented a Plan of Removal including staff education and monitoring.

The facility failed to ensure proper implementation of a comprehensive care plan and adequate staff competency in resident transfers, leading to a resident sustaining an acute right femoral fracture after an improper transfer without the required mechanical stand-up lift and two-person assistance. The facility also lacked a licensed Administrator during the survey period.

The facility failed to post required daily nurse staffing data including total hours worked and resident census, failed to prepare and serve meals according to the planned menu affecting residents on mechanical soft diets, did not maintain proper food safety and hygiene practices including handwashing and food storage, and failed to provide appropriate bedding for a resident dependent on staff for positioning.

The complaint investigation was substantiated by findings that RN #3 attempted to transfer Resident #1 alone despite the care plan requiring two staff and a mechanical lift, resulting in a fall and fracture. The facility also lacked a licensed Administrator since 7/15/2024, with an Acting Administrator unlicensed and no formal assignment documentation.

The facility failed to transfer Resident #1 safely according to the care plan, resulting in a fracture to the resident's leg. Additionally, the facility was found to be operating without a licensed Administrator, which could potentially affect all residents.

The visit was complaint-related, investigating multiple allegations including inaccurate CPR documentation, failure to notify Ombudsman of hospital transfer, failure to complete PASARR screening, inadequate care planning, failure to follow physician orders, unsafe chemical storage, nutritional deficiencies, improper meal preparation, food safety violations, infection control lapses, and ineffective quality assurance.

The facility was found deficient in multiple areas including inaccurate CPR status documentation for Resident #39, failure to notify Ombudsman of Resident #42's hospital transfer, lack of PASARR screening for Resident #19, incomplete care plan for smoking for Resident #33, failure to provide rehabilitative services as ordered for Resident #19, unlocked janitor closet with chemicals accessible, failure to provide nutritional interventions and proper feeding for Resident #36, improper meal preparation and serving including incorrect portion sizes and food temperatures, poor food safety practices including expired and uncovered food items, inadequate hand hygiene and cross-contamination risks in dietary staff, and improper disinfection of glucometers leading to infection risk. The facility's Quality Assurance program failed to prevent repeated deficiencies related to PASARR screenings.

The facility was found deficient in maintaining resident dignity related to catheter privacy, failure to complete PASRR screening and update care plans for a resident with a new mental illness diagnosis, inadequate supervision leading to a resident fall during transportation, and failure to update the facility-wide assessment annually. All deficiencies were assessed as causing minimal harm or potential for actual harm.