Inspection Reports for English Valley Nursing Care Center

150 West Washington Street, IA, 523160430

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Deficiencies per Year

4 3 2 1 0
2020
2021
2022
2023
2024
Severe High Moderate Low Unclassified

Census Over Time

25 30 35 40 45 Jun '20 Sep '20 Mar '21 Oct '21 Jun '22 Oct '23
Inspection Report Annual Inspection Deficiencies: 0 Nov 21, 2024
Visit Reason
An annual recertification survey was conducted from November 18, 2024 to November 21, 2024.
Findings
The facility was found to be in substantial compliance during the annual recertification survey.
Inspection Report Re-Inspection Deficiencies: 0 Dec 27, 2023
Visit Reason
An on-site revisit was conducted on December 27, 2023, following the Recertification Survey completed on November 19, 2023, to verify correction of previously identified deficiencies.
Findings
The deficiency identified in the prior Recertification Survey was corrected, and the facility was found to be in substantial compliance effective November 8, 2023.
Inspection Report Annual Inspection Census: 35 Deficiencies: 1 Oct 19, 2023
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey and investigation of Facility Self-Reported Incidents #110059-I, #114801-I, and #115954-I from October 16, 2023 to October 19, 2023.
Findings
The facility failed to prevent falls causing major injuries for 3 out of 5 residents reviewed, with substantiated self-reported incidents. The facility did not ensure the resident environment remained free of accident hazards and did not provide adequate supervision and assistance devices to prevent accidents.
Severity Breakdown
SS=G: 1
Deficiencies (1)
DescriptionSeverity
The facility failed to prevent falls causing major injuries for 3 out of 5 residents reviewed and a history of major injury (Residents #16, #21, and #36).SS=G
Report Facts
Census: 35 Residents reviewed for falls: 5 Residents with major injuries: 3 BIMS score: 7 BIMS score: 15 BIMS score: 11
Employees Mentioned
NameTitleContext
Staff ACertified Nursing Assistant (CNA)Witnessed fall of Resident #36 and provided shower assistance
Staff BLicensed Practical Nurse (LPN)Reported history of behaviors and use of stand lift for Resident #36
Staff CRegistered Nurse (RN)Reported fall interventions and prevention measures for Resident #36
Staff DCertified Nursing Assistant (CNA)Reported use of shower chair to transport residents and fall prevention observations
Staff ECertified Nursing Assistant (CNA)Reported environmental hazard of bump between fire doors affecting shower chair transport
Staff FCertified Medication Aide (CMA)Reported Resident #36's fall history and fall precautions
Staff GCertified Nursing Assistant (CNA)Assisted Resident #36 with bath and transfer post-fall
Director of NursingDONReported Resident #36's upset about hair washing and directed fall prevention changes
Inspection Report Annual Inspection Census: 31 Deficiencies: 1 Jun 29, 2022
Visit Reason
An Annual Recertification Survey was conducted from June 27, 2022 to June 29, 2022 to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance overall; however, a deficiency was identified related to failure to document Veteran Status within 30 days of admission for 1 of 8 new admissions (Resident #83).
Deficiencies (1)
Description
Failure to check for Veteran Status within 30 days of admission to report potential Veterans to the Iowa Department of Veterans Affairs for Resident #83.
Report Facts
Census: 31 New admissions screened for Veteran Status: 8 Admissions with missing Veteran Status documentation: 1
Employees Mentioned
NameTitleContext
AdministratorInterviewed regarding the missing Veteran Status documentation for Resident #83
Inspection Report Routine Census: 32 Deficiencies: 0 Oct 7, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on October 6 - October 7, 2021.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report Renewal Census: 40 Deficiencies: 4 Mar 3, 2021
Visit Reason
The Iowa Department of Inspection and Appeals conducted a recertification survey in accordance with Medicare Conditions of Participation to assess compliance with regulatory requirements.
Findings
The facility was found to be not in compliance with multiple deficiencies including failure to complete criminal background checks for new hires, failure to report injuries of unknown origin, failure to meet professional standards in medication administration, and failure to maintain safe water temperatures.
Severity Breakdown
SS=D: 3 SS=E: 1
Deficiencies (4)
DescriptionSeverity
Failure to ensure completion of a criminal background check for 1 of 4 newly hired employees.SS=D
Failure to report an injury of unknown origin to the State Agency for 1 resident with an arm fracture.SS=D
Failure to meet professional standards in medication administration including improper priming of insulin pen and crushing non-crushable medication.SS=D
Failure to maintain minimum safe water temperatures in resident rooms and shower room.SS=E
Report Facts
Total residents: 40 Newly hired employees missing background check: 1 Residents with medication administration issues: 4 Water temperature readings: 6
Employees Mentioned
NameTitleContext
Staff BNew hire missing completed criminal background check
Staff CCertified Nursing AssistantObserved transferring resident and involved in injury reporting
Staff DRegistered NurseAssessed resident with injury and reported to staff
Staff ALicensed Practical NurseObserved insulin administration and medication pass
Director of NursingDONReported expectations for medication administration and injury reporting
Inspection Report Abbreviated Survey Census: 37 Deficiencies: 0 Sep 29, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted by the Department of Inspections and Appeals on 9/28-29/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 37
Inspection Report Routine Census: 39 Deficiencies: 0 Jun 23, 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.

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