Deficiencies (last 7 years)
Deficiencies (over 7 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
94% occupied
Based on a January 2026 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 47
Deficiencies: 3
Date: Jan 14, 2026
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service standards, including food preparation, serving temperatures, therapeutic diet adherence, and kitchen sanitation.
Findings
The facility failed to maintain proper food temperatures during service, served meals not consistent with residents' therapeutic diet orders, and did not maintain a clean and sanitary kitchen environment. Multiple observations and interviews revealed issues with cold food, incorrect diet modifications, dirty kitchen equipment, missing cleaning logs, and structural deficiencies such as a missing ceiling tile and water leakage.
Deficiencies (3)
Food was often served cold or not at the proper temperature, with ground chicken measured at 110°F instead of the required minimum of 135°F.
Residents were served meals inconsistent with their prescribed mechanical soft diets, including the presence of pineapple chunks not approved for the diet.
The kitchen environment was unclean, with dirty equipment, undated and uncovered food items, missing internal thermometers, a missing ceiling tile, water dripping from the ceiling, and incomplete cleaning logs.
Report Facts
Census: 47
Temperature: 110
BIMS scores: 12
BIMS scores: 13
BIMS scores: 9
BIMS scores: 12
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Dietary Staff | Checked temperature of ground chicken during lunch service |
| Staff D | Dietary Aide | Reported on kitchen conditions and cleaning practices |
| Staff E | Cook | Interviewed regarding kitchen conditions |
| Registered Dietitian | Registered Dietitian (RD) | Provided education on therapeutic diets and covered kitchen responsibilities |
| Administrator | Facility Administrator | Oversaw kitchen operations and responded to deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 6, 2026
Visit Reason
The document is a plan of correction following a credible allegation of substantial compliance related to the facility's regulatory deficiencies.
Findings
Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction, the facility will be certified in compliance effective January 6, 2026.
Deficiencies (1)
Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Nov 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure safe transferring techniques for a resident who had multiple falls and required two staff assistance.
Complaint Details
The investigation was complaint-related, focusing on the fall of Resident #4 on 9/12/25 due to improper transfer by one staff instead of two as required. The resident had a history of falls and required two-person assistance. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure safe transferring techniques for Resident #4, who had multiple falls and required two staff assistance during transfers. On 9/12/25, the resident fell while being transferred with only one staff member, contrary to care plan and therapy recommendations.
Deficiencies (1)
Failure to ensure safe transferring techniques for Resident #4, resulting in a fall when transferred by only one staff instead of two as required.
Report Facts
Census: 46
Falls: 1
Staff assistance required: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nurse Aide (CNA) | Reported transferring Resident #4 alone on 9/14/25, resulting in a fall |
| Staff C | Certified Nurse Aide (CNA) | Reported Resident #4 required 1 to 2 staff assistance for transfers |
| Director of Nursing | Director of Nursing (DON) | Acknowledged therapy recommendations for two staff transfers; was not working at the time of the fall |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Nov 13, 2025
Visit Reason
The inspection was conducted as a result of complaint #2588287-C, investigating allegations related to resident safety and supervision.
Complaint Details
Complaint #2588287-C was substantiated, resulting in a deficiency related to accident hazards and supervision.
Findings
The facility failed to ensure safe transferring techniques for Resident #4, who experienced multiple falls and required two staff for assistance. The care plan was not consistently followed, leading to a deficiency in accident prevention and supervision.
Deficiencies (1)
Facility failed to ensure staff used safe transferring techniques for Resident #4, resulting in falls and inadequate supervision.
Report Facts
Resident census: 46
BIMS score: 12
Fall risk: 1
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pat Voelker | Administrator | Signed the report |
| Staff D | CNA | Provided statements about Resident #4's transfers and assistance |
| Staff C | CNA | Provided statements about Resident #4's transfer assistance |
| Director of Nursing | Director of Nursing | Acknowledged not working during Resident #4's fall and confirmed therapy recommendations |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
An onsite revisit of the health survey ending November 14, 2024 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective December 3, 2024.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 8
Date: Nov 14, 2024
Visit Reason
The inspection was conducted following complaints regarding resident care, including dignity and respect, assessment timeliness, care planning, mobility assistance, fall prevention, respiratory care, food sanitation, and infection control practices.
Complaint Details
The complaint investigation was triggered by allegations of resident mistreatment, incomplete assessments, inadequate care planning, unsafe mobility assistance, fall-related injuries, improper respiratory care, food sanitation concerns, and infection control failures. The investigation substantiated multiple deficiencies in these areas.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, incomplete Minimum Data Set assessments, inadequate care planning for MRSA, failure to provide appropriate mobility assistance, unsafe transfer techniques leading to resident falls and injuries, improper respiratory care including nebulizer maintenance, inadequate dishwashing sanitation, and failure to implement proper infection prevention and control measures including Enhanced Barrier Precautions.
Deficiencies (8)
Failure to ensure all residents were treated with dignity and respect; staff was demanding, forceful, and demeaning to a resident.
Failed to complete a comprehensive Minimum Data Set (MDS) assessment during the required timeline for one resident.
Failed to provide a comprehensive care plan including goals or interventions for MRSA diagnosis and enhanced barrier precautions.
Failed to provide services to increase mobility or prevent loss of mobility for a resident.
Failed to use safe transfer techniques for a resident resulting in falls, bruising, skin tears, and a C3 fracture; also failed to implement new interventions after repeat falls.
Failed to provide respiratory care and services in accordance with professional standards for a resident requiring nebulizer treatments.
Failed to follow proper sanitation to prevent spread of illness by serving residents on dishes not rinsed at appropriate temperatures.
Failed to use universal infection control measures and Enhanced Barrier Precautions during care for residents with indwelling devices or wounds.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: Some
Residents affected: Some
Facility census: 43
Skin tear size: 1.3
Skin tear size: 0.5
Skin tear size: 10.5
Skin tear size: 5
Skin tear size: 0.1
Skin tear size: 1
Skin tear size: 1.5
Dish machine wash temperature: 140
Dish machine rinse temperature: 170
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Staff Assistant (CSA) | Named in resident mistreatment and use of force incident with Resident #96 |
| Staff F | Registered Nurse (RN) | Witnessed and reported incident involving Staff D and Resident #96 |
| Staff H | Aide | Witnessed Staff D push Resident #96 and reported incident |
| Staff E | Licensed Practical Nurse (LPN) | Reported aggressive behavior of Staff D toward Resident #96 |
| Staff G | MDS Coordinator | Acknowledged failure to complete care plans and assessments |
| Staff Q | Nursing Consultant | Stated expectation for care plans for MRSA diagnosis |
| Staff B | Registered Nurse (RN) | Reported fall incident and unsafe transfer of Resident #37 |
| Staff C | Certified Nurse Aide (CNA) | Involved in fall incident with Resident #37, did not use gait belt |
| Staff J | Registered Nurse (RN) | Described nebulizer tubing change procedures |
| Staff K | Health Unit Coordinator (HUC) | Described documentation for nebulizer tubing changes |
| Staff M | Dietary Aide | Reported dish machine temperature issues and practices |
| Staff N | Certified Dietary Manager | Acknowledged dish machine temperature problems and repair plans |
| Staff I | Certified Nurse Assistant (CNA) | Failed to follow enhanced barrier precautions during catheter care |
| Staff L | Registered Nurse (RN) | Failed to wear gown during gastrostomy tube care |
| Staff A | Licensed Practical Nurse (LPN) | Failed to change gloves between nasal and eye medication administration |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: Nov 14, 2024
Visit Reason
The inspection was conducted following complaints regarding resident care, specifically concerning dignity and respect for Resident #96 and safe transfer techniques for Resident #37.
Complaint Details
The complaint investigation focused on allegations that staff treated Resident #96 in a demanding and demeaning manner, including an incident where a staff member pushed the resident's forehead after being bitten. For Resident #37, the complaint involved failure to use proper transfer techniques, leading to multiple falls and injuries, including a C3 fracture and skin tears.
Findings
The facility failed to ensure dignity and respect for Resident #96, who was treated in a demanding and forceful manner by staff, and failed to use safe transfer techniques for Resident #37, resulting in falls and injuries. The facility also failed to implement new interventions to reduce fall risks for Resident #37.
Deficiencies (2)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights for Resident #96.
Failure to use safe transfer techniques for Resident #37, resulting in falls, bruising, skin tears, and a C3 fracture.
Report Facts
Residents Affected: 1
Residents Affected: 1
Census: 43
Skin tear measurement: 10.5
Skin tear measurement: 5
Skin tear measurement: 0.1
Skin tear measurement: 1
Skin tear measurement: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Staff Assistant (CSA) | Involved in incident with Resident #96 where she was bitten and pushed the resident's forehead |
| Staff F | Registered Nurse (RN) | Witnessed and responded to incident involving Resident #96 and Staff D |
| Staff H | Certified Staff Assistant (CSA) | Witnessed Staff D push Resident #96 and reported the incident |
| Staff E | Licensed Practical Nurse (LPN) | Observed Staff D's aggressive interaction with Resident #96 |
| Staff B | Registered Nurse (RN) | Responded to Resident #37 fall and injury incident |
| Staff C | Certified Nurse Aide (CNA) | Assisted Resident #37 during fall incident without using gait belt |
| Administrator | Interviewed regarding incidents and staff training | |
| Director of Nursing (DON) | Interviewed regarding incidents and staff training | |
| Nurse Consultant (NC) | Interviewed regarding incidents and staff training |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 9
Date: Nov 14, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #124258-C and facility reported incident #123797-I.
Complaint Details
Complaint #124258-C was not substantiated. Facility reported incident #123797-I was substantiated.
Findings
The facility was found to have multiple deficiencies related to resident rights, comprehensive assessments, care planning, infection control, and safety measures. Specific issues included undignified treatment of a resident, incomplete comprehensive assessments, inadequate care plans for residents with infections and mobility issues, improper medication administration practices, and failure to follow proper sanitation and infection prevention protocols.
Deficiencies (9)
Facility failed to ensure all residents were treated with dignity and respect; staff were demanding, forceful, and demeaning to Resident #96.
Facility failed to complete a comprehensive Minimum Data Set (MDS) assessment timely for Resident #35.
Facility failed to develop and implement comprehensive person-centered care plans for residents, including Resident #22 with multidrug-resistant organism (MDRO).
Facility failed to provide services to increase mobility or prevent loss in mobility for Resident #12.
Facility failed to ensure adequate supervision and assistance devices to prevent accidents for Resident #37 who fell and sustained injuries.
Facility failed to provide respiratory care and services in accordance with professional standards for Resident #6 requiring a nebulizer.
Facility failed to follow proper hand hygiene and glove use during medication administration.
Facility failed to follow proper sanitation to prevent spread of illness; dishwasher temperatures were not consistently maintained at required levels.
Facility failed to establish and maintain an infection prevention and control program including proper use of Enhanced Barrier Precautions (EBP) for residents with MDROs.
Report Facts
Facility census: 43
Residents reviewed: 14
Residents reviewed: 5
Residents reviewed: 3
Residents reviewed: 1
Dishwasher temperature checks: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in medication administration deficiency for improper glove use. |
| Director of Nursing (DON) | Provided statements regarding staff training and infection control policies. | |
| Staff D | Involved in undignified treatment of Resident #96. | |
| Staff F | Registered Nurse (RN) | Witnessed and reported on incident involving Resident #96. |
| Staff H | Observed and reported on staff interactions with Resident #96. | |
| Staff E | Licensed Practical Nurse (LPN) | Reported on agitation of Resident #96 and staff interactions. |
| Staff G | MDS Coordinator | Provided information on MDS assessment completion. |
| Staff Q | Nursing Consultant | Provided expectations for care plans related to MRSA. |
| Staff C | Certified Nurse Aide (CNA) | Observed and reported on Resident #37 fall incident. |
| Staff B | Registered Nurse (RN) | Reported on Resident #37 fall and injury. |
| Staff J | Registered Nurse (RN) | Reported on nebulizer tubing maintenance. |
| Staff K | Health Unit Coordinator (HUC) | Reported on treatment administration record completion. |
| Staff L | Registered Nurse (RN) | Observed hand hygiene and care for Resident #9. |
| Staff M | Dietary Aide | Reported on dishwasher temperature and sanitation. |
| Staff N | Certified Dietary Manager | Reported on dishwasher maintenance and temperature issues. |
| Staff P | Dish Machine Maintenance Technician | Reported on dishwasher service and maintenance. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies identified during the inspection.
Findings
Elm Crest Retirement Home is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on the department's acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Routine
Census: 44
Deficiencies: 2
Date: Jul 21, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan development and implementation, and to assess the provision of appropriate treatment and care following resident falls.
Findings
The facility failed to review and revise care plans to reflect residents' current status for 4 residents and failed to provide needed services in accordance with professional standards by not completing assessments after falls with major injury for 2 residents. Additionally, the facility did not follow protocol for transferring a resident after a fall using a full body lift.
Deficiencies (2)
Failed to review and revise the care plan to reflect the resident's current status for 4 of 4 residents reviewed.
Failed to provide needed services by not completing assessments on individuals who sustained ground level falls with major injury for 2 of 4 residents reviewed.
Report Facts
Residents Affected: 4
Residents Affected: 2
Census: 44
Distance: 150
Distance: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nursing Assistant (CNA) | Assisted Resident #1 to the bathroom and described assistance needed for transfers, hygiene, and clothing management. |
| Staff F | Certified Nursing Assistant (CNA) | Provided statements regarding Resident #1's transfer abilities and self-transfer attempts. |
| Staff B | Certified Nursing Assistant (CNA) | Reported on Resident #1 and Resident #2's transfer and mobility status. |
| Staff H | Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) | Reported Resident #3's assistance needs for transfers. |
| Staff I | Registered Nurse (RN) | Reported Resident #3's transfer and restorative nursing participation. |
| Staff C | Registered Nurse, Director of Nursing | Discussed expectations for fall assessments and documentation. |
| Staff A | Licensed Practical Nurse | Described Resident #3's fall incident and post-fall assessment procedures. |
| Staff D | Administrator | Expressed expectations for timely completion of resident assessments and documentation. |
| J | Restorative Nurse | Described Resident #3's restorative nursing activities. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: Jul 21, 2024
Visit Reason
The inspection was conducted as a result of investigation of facility reported incidents #119835-I, #121288-I, and #121671-I, with one incident substantiated.
Complaint Details
Facility reported incidents #119835-I and #121288-I were not substantiated. Incident #121671 was substantiated.
Findings
The facility failed to meet requirements related to comprehensive care plans and quality of care, including failure to review and revise care plans for residents with falls and cognitive impairments, and failure to implement fall prevention protocols. The facility reported a census of 44 residents and identified deficiencies in care plan timing, revision, and fall risk management.
Deficiencies (2)
Failure to develop and revise comprehensive care plans within 7 days after assessment for residents with major injuries and cognitive impairments.
Failure to provide needed services in accordance with professional standards, resulting in falls with major injury for 2 of 4 residents and failure to implement fall prevention protocols.
Report Facts
Residents reviewed: 4
Census: 44
Fall incidents with major injury: 2
Care plan review timeframe: 7
Audit duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Provided observations on Resident #1's mobility and assistance needs |
| Staff B | Certified Nursing Assistant (CNA) | Assisted Resident #1 and provided statements on transfers |
| Staff H | Certified Medication Aide (CMA) | Stated Resident #3 required 1-2 staff assistance for transfers |
| Staff I | Registered Nurse (RN) | Stated Resident #3 completed transfers with assistance |
| Staff C | Registered Nurse, Director of Nursing | Provided statements on fall assessment and care plan documentation |
| Staff A | Licensed Practical Nurse | Reported Resident #3 fell while on break and became unresponsive |
| Director of Nursing | Director of Nursing (DON) | Provided documents for visual accountabilities and fall scene investigation |
| Staff D | Administrator | Expected care plans to reflect residents' current needs and provide guidance |
Inspection Report
Routine
Census: 40
Deficiencies: 4
Date: Oct 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, pharmaceutical services, food safety, and infection prevention at Elm Crest Retirement Community.
Findings
The facility was found deficient in safe transfer techniques for a resident requiring mechanical lift assistance, failure to dispose of discontinued narcotic medications for two residents, inadequate cleaning of the ice machine, and failure of staff to practice proper hand hygiene during meal service.
Deficiencies (4)
Failed to ensure staff used safe transfer techniques for a resident requiring a sit to stand mechanical lift, specifically not tightening the safety belt during transfer.
Failed to dispose of narcotic medications after discontinuation orders for two residents; narcotics were found still in storage.
Failed to keep the ice machine clean and sanitary; observed dirt spots inside the ice machine.
Failed to ensure staff practiced recommended hand hygiene during meal service; staff handled glasses with ungloved hands and did not wash or sanitize hands.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 40
Narcotic tablets: 60
Fall risk score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Assistant (CNA) | Observed using mechanical lift improperly during Resident #22 transfer |
| Staff B | Certified Nurse Assistant (CNA) | Observed using mechanical lift improperly during Resident #22 transfer |
| Staff C | Licensed Practical Nurse (LPN) | Provided information about narcotic medication counts and documentation |
| Dietary Manager | Reported on ice machine cleaning and hand hygiene expectations | |
| Staff D | Dietary Aide | Observed failing to practice hand hygiene during meal service |
| Director of Nursing (DON) | Director of Nursing | Provided expectations on narcotic medication destruction timing |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 4
Date: Oct 5, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey to assess compliance with federal regulations and identify any deficiencies.
Findings
The survey identified multiple deficiencies including failure to ensure safe transfer techniques for residents, improper disposal and storage of narcotic medications, unsanitary conditions in the kitchen ice machine, and inadequate infection prevention and control practices.
Deficiencies (4)
Failure to ensure safe transfer techniques for Resident #22 using a sit to stand mechanical lift.
Failure to properly dispose of narcotic medications and maintain accurate drug records for Residents #91 and #36.
Failure to keep the ice machine clean and sanitary, with dirt spots found inside the machine.
Failure to establish and maintain an infection prevention and control program, including inadequate hand hygiene practices by staff.
Report Facts
Census: 40
Narcotic tablets found: 60
Deficiency correction date: Correction date listed as 11/3/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy J Nauslar | Administrator | Signed the report and plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 19, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance for certification.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, effective September 30, 2022.
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 4
Date: Aug 25, 2022
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident care, medication administration, and facility safety.
Findings
The facility was found deficient in several areas including failure to implement fall prevention interventions for a resident requiring two-person assistance, inappropriate use of antibiotic therapy without proper infection evidence, medication administration errors related to insulin timing, and unsafe medication storage practices including unsecured controlled substances and inconsistent refrigerator temperature monitoring.
Deficiencies (4)
Failure to utilize interventions to prevent falls for Resident #36 requiring two-person assistance during transfers.
Inappropriate use of antibiotic therapy for Resident #34 without evidence of bacterial infection.
Failure to administer insulin with meals as ordered for Resident #30, increasing risk of hypoglycemia.
Failure to store medications securely, including unlocked medication refrigerator and storing discontinued controlled substances with current medications.
Report Facts
Resident census: 38
Falls: 3
Antibiotic doses: 10
Insulin units: 10
Insulin units: 6
Medication expiration dates: 4
Controlled substance tablets: 23
Fentanyl patches: 3
Liquid medication remaining: 17.5
Liquid medication remaining: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Confirmed staff expected to follow Resident #36's care plan and educated CNA staff on fall prevention |
| Director of Nursing | Director of Nursing (DON) | Confirmed expectations for staff to follow Resident #36's care plan and medication administration orders; acknowledged medication storage deficiencies |
| CNA 4 | Certified Nursing Assistant | Confirmed Resident #36 required two-person assistance and acknowledged facility education on care plan |
| RN 1 | Registered Nurse | Verified falls occurred due to staff not following care plan and confirmed potential for harm |
| LPN 2 | Licensed Practical Nurse | Observed administering insulin incorrectly and verified medication cart deficiencies |
| Clinical Manager | Registered Nurse | Verified missing vaccine refrigerator temperature logs and medication storage issues |
| Physician Assistant | Physician Assistant (PA) | Prescribed antibiotic for Resident #34 and explained rationale despite negative culture |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 5
Date: Aug 25, 2022
Visit Reason
The inspection was an annual recertification survey with complaint intakes #104550-C and 103778-C.
Complaint Details
Complaint #103778 was substantiated. Complaint #104550 was not substantiated.
Findings
The facility was found deficient in multiple areas including failure to prevent falls due to inadequate supervision and assistance, inappropriate use of antibiotics without adequate indication, medication administration errors related to insulin timing and technique, and improper storage and labeling of drugs and biologicals.
Deficiencies (5)
Failure to utilize interventions to prevent falls for Resident #36, including not providing two-person assistance during transfers as required by the care plan.
Failure to ensure appropriate use of antibiotic therapy for Resident #34, including treatment despite negative urine culture results.
Failure to follow physician's order for insulin administration timing for Resident #30, administering insulin before meal instead of with meal.
Failure to prime insulin pen before administration for Resident #30.
Failure to store medications and biologicals securely and properly, including unlocked medication refrigerator, lack of temperature monitoring, and storing discontinued controlled substances with current medications.
Report Facts
Resident census: 38
Sample size: 12
Falls: 3
Antibiotic doses: 10
Hydrocodone tablets: 23
Fentanyl patches: 3
Ativan remaining: 17.5
Morphine remaining: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy J Nauslar | Administrator | Signed plan of correction |
| LPN 1 | Confirmed staff education and care plan noncompliance related to Resident #36 falls | |
| LPN 2 | Observed medication administration errors for Resident #30 and medication cart issues | |
| RN 1 | Registered Nurse | Confirmed medication administration errors and care plan expectations |
| Director of Nursing (DON) | Confirmed expectations for care plan adherence, medication administration, and storage deficiencies | |
| Clinical Manager (CM) | Registered Nurse | Verified medication refrigerator issues and storage deficiencies |
| Physician Assistant (PA) | Prescribed antibiotic for Resident #34 and explained rationale | |
| Infection Preventionist (IP) | Discussed antibiotic stewardship and UTI diagnosis criteria | |
| Pharmacist | Provided information on insulin administration and medication storage |
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 3
Date: Feb 11, 2021
Visit Reason
The inspection visit was conducted as part of the facility's annual health survey and investigation of complaint 95207-C.
Complaint Details
Complaint 95207-C was substantiated as part of the investigation during the annual survey.
Findings
The facility was found deficient in developing and implementing accurate baseline care plans, ensuring professional standards in services provided, and maintaining proper food sanitation practices. Specific issues included incomplete baseline care plans for residents, failure to supervise medication self-administration, and inadequate sanitization of food service ware.
Deficiencies (3)
Failure to ensure an accurate completion of the baseline care plan by not listing the resident's high risk medications and their side effects.
Failure to ensure professional standards were maintained by leaving the resident's medications at the dining room table to self-administer without supervision.
Failure to assure proper sanitization of the food service ware; the sink used to sanitize pots and pans failed to have sanitizer in the water and documentation showed it had been that way for several days.
Report Facts
Resident census: 39
Admission date: Jan 27, 2021
Medication administration dates: Feb 9, 2021
Sanitizer concentration test results: 0
Sanitizer log entries: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy J Nauslar | Administrator | Signed the Plan of Correction and is referenced as Administrator. |
| Staff E | Registered Nurse (RN) | Observed passing medications and interviewed regarding medication administration. |
| Staff D | Licensed Practical Nurse (LPN) | Observed passing medications and educated on medication administration. |
| Director of Nursing | Interviewed regarding baseline care plans and medication policies. | |
| Clinical Nurse Manager/Assistant Director of Nursing | Interviewed regarding review of baseline care plans. | |
| Dietary Manager | Interviewed regarding food sanitation and sanitizer testing procedures. | |
| Staff A | Dietary Aide | Observed washing dishes and sanitizer testing. |
| Staff B | Dietary Aide | Observed washing pots and pans and sanitizer testing. |
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 0
Date: Nov 18, 2020
Visit Reason
A focused COVID-19 infection survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 45
Inspection Report
Routine
Census: 52
Deficiencies: 0
Date: Oct 6, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections 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 Facts
Resident Census: 52
Inspection Report
Routine
Census: 49
Deficiencies: 0
Date: Jun 4, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess 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: 49
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