Inspection Reports for English Valley Nursing Care Center
150 West Washington Street, IA, 523160430
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 21, 2024 found the facility to be in substantial compliance with no deficiencies noted. Earlier inspections showed a mix of results, including a fall prevention issue with major injuries cited in October 2023 and some documentation and procedural deficiencies in 2021 and 2022. The main themes of deficiencies involved resident safety related to fall prevention, medication administration, and documentation of veteran status. Complaint investigations were not noted in the available reports, and no fines, immediate jeopardy findings, or enforcement actions were listed. The facility appears to have addressed prior deficiencies over time, with the most recent inspections showing improvement and compliance.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
35 residents
Based on a October 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
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)
| Description | Severity |
|---|---|
| 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
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Witnessed fall of Resident #36 and provided shower assistance |
| Staff B | Licensed Practical Nurse (LPN) | Reported history of behaviors and use of stand lift for Resident #36 |
| Staff C | Registered Nurse (RN) | Reported fall interventions and prevention measures for Resident #36 |
| Staff D | Certified Nursing Assistant (CNA) | Reported use of shower chair to transport residents and fall prevention observations |
| Staff E | Certified Nursing Assistant (CNA) | Reported environmental hazard of bump between fire doors affecting shower chair transport |
| Staff F | Certified Medication Aide (CMA) | Reported Resident #36's fall history and fall precautions |
| Staff G | Certified Nursing Assistant (CNA) | Assisted Resident #36 with bath and transfer post-fall |
| Director of Nursing | DON | Reported 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
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed 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)
| Description | Severity |
|---|---|
| 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
| Name | Title | Context |
|---|---|---|
| Staff B | New hire missing completed criminal background check | |
| Staff C | Certified Nursing Assistant | Observed transferring resident and involved in injury reporting |
| Staff D | Registered Nurse | Assessed resident with injury and reported to staff |
| Staff A | Licensed Practical Nurse | Observed insulin administration and medication pass |
| Director of Nursing | DON | Reported 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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