Inspection Reports for
Elkader Care Center

The complaint investigation found substantiated failures in assessment and care for residents with pressure ulcers and respiratory issues, resulting in actual harm including resident death due to sepsis from a pressure ulcer and respiratory failure.

The facility failed to provide timely and appropriate assessments and interventions for two residents following changes in condition, including inadequate pressure ulcer care leading to worsening ulcers and sepsis resulting in death, and insufficient respiratory assessments. Staff failed to follow facility policies and communicate effectively with the primary physician.

The investigation was triggered by complaints #124129-C and #124187-C. The facility was found not in substantial compliance with quality of care requirements related to pressure ulcer prevention and treatment. Resident #3 and Resident #2 were discharged during the investigation period. Licensed nurses were re-educated regarding the Pressure Ulcer Prevention Program and wound assessments.

The facility was found not in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, specifically failing to provide proper assessments and interventions in a timely manner for residents with pressure ulcers and other conditions. Deficiencies were noted in quality of care, treatment and services to prevent and heal pressure ulcers, and administration.

The facility failed to ensure that one of five staff members completed the required Dependent Adult Abuse training within six months of hire and failed to complete required background checks prior to hire for two staff members. The facility has initiated a Quality Assurance Performance Improvement process to address these issues.

The facility reported incident #112338-I was investigated and found not substantiated.

The facility was found not to have substantiated the reported incident. Deficiencies were identified related to failure to ensure staff completed required Dependent Adult Abuse training within six months of hire and failure to complete Single Contact Repository (SING) background checks prior to hiring for some staff members.

The facility was found deficient in ensuring psychotropic drugs were administered only when necessary with proper documentation of non-pharmacological interventions prior to administration. Additionally, deficiencies were noted in menu preparation and nutritional adequacy, and in maintaining a quality assessment and assurance committee with required attendance.

Facility Reported Incident #98199-I was reviewed and found not substantiated.

The facility was found to be not in compliance due to failure to develop and implement a behavior-related care plan for one resident and failure to complete nursing assessments and monitoring after outpatient dialysis for one resident. The facility reported a census of 32 residents.