Inspection Reports for
Good Samaritan Society – Holstein
505 West Second Street, Holstein, IA, 510255111
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
12.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
49 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 15, 2025
Visit Reason
A complaint investigation for complaint #2562203-C was conducted on October 15, 2025.
Complaint Details
Complaint #2562203-C was investigated and the facility was found to be in substandard compliance.
Findings
The facility was found to be in substandard compliance during the complaint investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 16, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility in compliance effective June 15, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification of compliance effective June 15, 2025. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Census: 49
Deficiencies: 3
Date: Jun 2, 2025
Visit Reason
The inspection was conducted to assess compliance with care plan development and updating requirements for residents at the facility.
Findings
The facility failed to update the care plans to accurately reflect the current conditions and interventions for 3 of 3 residents reviewed, including failure to document hospice care, fall interventions, and weight loss with diabetic management.
Deficiencies (3)
Failed to update Resident #1's care plan to reflect admission to hospice care.
Failed to place intervention on Resident #2's care plan related to stepping off the side of the lift platform after a fall.
Failed to update Resident #4's care plan to reflect weight loss, diabetic medications, and blood sugar monitoring.
Report Facts
Residents affected: 3
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan expectations | |
| Assisted Director of Nursing | Interviewed regarding care plan expectations |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Date: Jun 2, 2025
Visit Reason
The inspection was conducted as a result of investigation of complaint #127504-C from May 28, 2025 to June 2, 2025.
Complaint Details
Investigation of complaint #127504-C conducted from May 28, 2025 to June 2, 2025. The complaint was substantiated as the facility failed to update care plans for residents.
Findings
The facility failed to update the care plans for residents to accurately reflect their current conditions, including hospice care, fall interventions, and diabetes management. The deficiencies affected multiple residents and involved failure to revise care plans timely and comprehensively.
Deficiencies (1)
Facility failed to update the resident's care plan to accurately reflect the resident's current condition and needs, including hospice care, fall intervention, and diabetes management.
Report Facts
Resident census: 49
Resident #1 expiration date: Mar 25, 2025
Compliance date: Jun 15, 2025
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in compliance with health requirements effective April 12, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Routine
Census: 49
Deficiencies: 7
Date: Mar 20, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey of the Good Samaritan Society - Holstein nursing home to assess compliance with healthcare regulations and standards.
Findings
The facility was found to have multiple deficiencies including failure to implement residents' advanced directives, incomplete care plans for residents with complex needs, inadequate oral care documentation and provision, insufficient nursing supervision leading to a resident fall with fracture, failure to monitor and document wander guard functionality, lack of gradual dose reductions for psychotropic medications, and failure to follow infection prevention protocols during feeding assistance.
Deficiencies (7)
Failed to implement or document advanced directives for Resident #206.
Failed to develop and implement complete care plans addressing risk factors and interventions for Residents #10, #16, and #31.
Failed to provide adequate oral care and documentation for Residents #22 and #24.
Failed to provide adequate nursing supervision to prevent falls and failed to ensure gait belt use for Resident #46, resulting in a right femur fracture.
Failed to ensure daily checking and documentation of wander guard placement and functionality for Resident #49.
Failed to complete gradual dose reductions and include non-pharmacological interventions and target behaviors for Residents #21 and #31 on psychotropic medications.
Failed to serve food in a safe and hygienic manner; staff assisted multiple residents simultaneously without hand hygiene and made direct contact with eating utensils.
Report Facts
Residents reviewed: 21
Residents reviewed: 5
Census: 49
Fall risk score: 20
Medication dose: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant (CNA) | Involved in lowering Resident #46 to the floor during fall incident |
| Staff D | Registered Nurse (RN) | Responded to Resident #46 fall and assisted with emergency response |
| Staff J | Registered Nurse (RN) | Observed assisting residents with eating without proper hand hygiene |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including advanced directives, care plans, medication management, and infection control |
| Staff E | Registered Nurse (RN) | Verified lack of documentation for wander guard checks |
| Staff A | Registered Nurse (RN) | Interviewed about missing target behaviors in care plans |
| Staff B | Certified Nursing Aide (CNA) | Interviewed about documentation of resident behaviors |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 7
Date: Mar 20, 2025
Visit Reason
The inspection was conducted as an annual recertification survey of the Good Samaritan Society - Holstein facility from March 17, 2025 to March 20, 2025.
Findings
The facility was found to have multiple deficiencies including failure to implement advance directives, develop comprehensive care plans, provide adequate oral care, ensure adequate supervision to prevent accidents, and maintain infection prevention and control. Several residents' care plans and documentation were incomplete or missing key elements, and staff failed to consistently follow policies and procedures.
Deficiencies (7)
Failure to implement or follow through with advance directives per resident directive upon admission for 1 of 21 residents reviewed (Resident #206).
Failure to develop a comprehensive care plan addressing risk factors and interventions for 3 of 21 residents reviewed (#10, #16, #31).
Failure to provide adequate oral care for 2 of 2 residents reviewed (Resident #22, #24).
Failure to provide adequate nursing supervision to prevent accidents and injuries for 1 of 3 residents reviewed for falls (Resident #46).
Failure to ensure a wander guard device was working for 1 of 1 resident reviewed for elopement risk (Resident #49).
Failure to complete a gradual dose reduction for 1 of 5 residents reviewed for unnecessary psychotropic medications (Resident #21).
Failure to maintain infection prevention and control program including hand hygiene and safe food handling.
Report Facts
Residents reviewed for advance directives: 21
Residents reviewed for comprehensive care plans: 21
Residents reviewed for oral care: 2
Residents reviewed for falls: 3
Residents reviewed for elopement risk: 1
Residents reviewed for psychotropic medication dose reduction: 5
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident care plans, medication management, and supervision issues. |
| Staff C | Certified Nursing Aide (CNA) | Reported on resident falls and care activities. |
| Staff D | Registered Nurse (RN) | Involved in fall investigation and resident care. |
| Staff J | Registered Nurse (RN) | Observed assisting residents with eating and hand hygiene. |
| Staff A | Registered Nurse (RN) | Interviewed about resident behaviors and care plans. |
| Staff B | Certified Nursing Aide (CNA) | Reported on documentation of resident behaviors. |
| Staff E | Registered Nurse (RN) | Verified documentation of wander guard and medication orders. |
| Staff F | Certified Nurse Aide (CNA) | Interviewed about oral care documentation and feeding procedures. |
| Staff G | Registered Nurse (RN) | Confirmed responsibilities for oral care documentation. |
| Staff H | Registered Nurse (RN) | Confirmed oral care documentation requirements. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
A complaint investigation was conducted for facility reported incident #123806-I from November 12, 2024 to November 13, 2024.
Complaint Details
Investigation related to incident #123806-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 9, 2024
Visit Reason
An onsite revisit was conducted to verify correction of deficiencies from the survey ending August 17, 2024.
Findings
All previously cited deficiencies were corrected and the facility was found to be in substantial compliance effective August 27, 2024.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Aug 17, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse and neglect of Resident #1 by staff members, including use of punitive restrictions and restraints.
Complaint Details
The complaint investigation was substantiated with findings that staff members abused Resident #1 by using restraints and punitive measures, failed to report the abuse timely, and lacked proper training in dementia care. Immediate Jeopardy was identified starting July 29, 2024, and removed on August 17, 2024 after corrective actions.
Findings
The facility failed to ensure Resident #1 was free from abuse, as staff members used punitive restraints and restrictions to control her movements. The facility also failed to report suspected abuse immediately and did not separate the alleged abuser promptly. Staff lacked sufficient training and competency in dementia care and safe interventions.
Deficiencies (3)
Staff used punitive restrictions and restraints on Resident #1, including pushing her into a chair, holding her arms down, covering her mouth, and pinning her chair to a table.
Failure to report suspected abuse immediately and failure to separate alleged abuser from residents promptly.
Staff lacked sufficient competencies and skills to meet behavioral health needs of residents, including inadequate dementia care training and lack of hands-on competency testing.
Report Facts
Census: 51
Incident time: 1630
Immediate Jeopardy start date: Jul 29, 2024
Immediate Jeopardy removal date: Aug 17, 2024
Staff suspension count: 3
Audit duration: 10
Audit team members: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nurse Aide (CNA) | Named in abuse and restraint findings involving Resident #1 |
| Staff F | Certified Nurse Aide (CNA) | Named in abuse and restraint findings and failure to report |
| Staff B | Activities Director | Witnessed abuse and reported incident |
| Staff H | Assistant Director of Nursing (ADON) | Acknowledged restraint and staff training deficiencies |
| Staff D | Quality Assurance (QA) Nurse | Acknowledged restraint and staff training deficiencies |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Aug 17, 2024
Visit Reason
Investigation of a facility reported incident involving alleged abuse of Resident #1, triggered by a complaint and video evidence of staff actions on 7/29/2024.
Complaint Details
The complaint investigation was triggered by an incident on 7/29/2024 where Staff E was observed covering Resident #1's mouth and restraining her physically. Staff F failed to intervene or report. The abuse was not reported immediately, violating reporting requirements.
Findings
The facility failed to ensure Resident #1 was free from abuse, as Staff E and Staff F used punitive restrictions and restraints, including covering the resident's mouth and pinning her chair to the table, preventing her from moving. Staff failed to report the abuse immediately. The facility implemented corrective actions including staff education, leadership supervision, resident assessments, and audits.
Deficiencies (3)
Failure to ensure residents were free from abuse; Staff E and Staff F used punitive restrictions and restraints on Resident #1.
Failure to report suspected abuse immediately and failure to separate alleged abuser from residents.
Insufficient competent staff training and supervision for behavioral health needs; punitive restraints used on Resident #1.
Report Facts
Census: 51
BIMS score: 3
Incident date: Jul 29, 2024
Incident report time: 1630
Immediate Jeopardy start date: Jul 29, 2024
Immediate Jeopardy removal date: Aug 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nurse Aide (CNA) | Named in abuse finding for restraining Resident #1 and covering her mouth |
| Staff F | Certified Nurse Aide (CNA) | Named in abuse finding for failing to intervene and restraining Resident #1 by bracing the table |
| Staff B | Activities Director | Witnessed abuse and reported incident |
| Staff H | Assistant Director of Nursing (ADON) | Acknowledged restraint and lack of direct competency testing |
| Staff D | Quality Assurance (QA) nurse | Acknowledged restraint and lack of quarterly in-service training |
Inspection Report
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
null
Findings
null
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility in compliance effective June 27, 2024.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification of compliance effective June 27, 2024.
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 4
Date: Jun 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical services regulations, including accurate accounting and secure storage of medications.
Findings
The facility failed to ensure accurate accounting of Scheduled II medications for two residents and failed to secure medications in the cart and storage room. Observations included discrepancies in medication administration records, unsecured medication storage, and missing nurse initials on controlled drug count records.
Deficiencies (4)
Failed to ensure accurate accounting of Scheduled II medications for 2 residents (#3 and #4).
Medications were not securely locked in the medication cart and storage room.
Controlled Drug Count Record lacked two nurse initials on multiple dates.
Medication cart was left unattended with key attached to other keys and medication room door propped open.
Report Facts
Census: 57
Medication administrations discrepancy: 4
Missing nurse initials: 3
Leftover medication tabs destroyed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Nursing Supervisor | Investigated leftover pills for Resident #4 and destruction of extra medications |
| Director of Nurse | Witnessed destruction of leftover medications for Resident #4 | |
| Staff A | Licensed Practical Nurse | Pre-signed Controlled Drug Count Record for beginning and end of shift |
| Staff B | Certified Nurse Aide (CNA) | Observed medication cart unattended with key attached and medication room door propped open |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 6, 2024
Visit Reason
The document is a plan of correction submitted following a credible allegation of substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility is in substantial compliance with regulatory requirements based on the acceptance of the credible allegation and plan of correction. The facility will be certified in compliance effective January 18, 2024.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 21, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments and care planning, specifically focusing on the accuracy of the Minimum Data Set (MDS) documentation.
Findings
The facility failed to ensure that the MDS included resident-specific information regarding the use of restraints for one resident (Resident #31) who required a seat belt in her wheelchair to prevent sliding. The care plan and observations confirmed the use of restraints, but the MDS lacked this information.
Deficiencies (1)
Failure to ensure the Minimum Data Set (MDS) included resident-specific information regarding the use of restraints for Resident #31.
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 8
Date: Dec 21, 2023
Visit Reason
Recertification survey with an investigation of complaints #114466 and #115764, including review of medication administration, weight changes, restraint use, accident hazards, nursing staff competency, pharmacy services, and dietary staff qualifications.
Complaint Details
Complaints #114466 and #115764 were investigated and found not substantiated.
Findings
The facility was found non-compliant with federal regulations due to failure to notify physicians of medication and weight changes, improper use of restraints without consent or physician orders, inaccurate resident assessments, failure to provide scheduled medications, unsafe resident handling and supervision practices, inadequate orientation for agency staff, inaccurate narcotic medication records, and lack of qualified dietary staff.
Deficiencies (8)
Failed to notify physician when Resident #50 did not receive scheduled medication and failed to notify physician of significant weight loss for Resident #55.
Failed to ensure residents consented to restraints and obtain physician orders for Resident #31 using a wheelchair seatbelt restraint.
Minimum Data Set (MDS) for Resident #31 lacked information regarding use of restraints.
Resident #50 did not receive scheduled medication (Lexapro) due to staff failure to replenish supply.
Failed to keep residents safe from preventable accidents and hazards including falls from mechanical lifts, wheelchair falls, unsafe smoking with oxygen, transfers without gait belts, and injury from an unleashed dog.
Failed to provide orientation and training to temporary nursing staff (agency LPN and CNA).
Failed to accurately document, monitor, and reconcile narcotic medication (morphine) for Resident #1; discrepancies in narcotic counts and missing medication noted.
Dietary Manager lacked required certification and had not completed required coursework at time of survey.
Report Facts
Total census: 57
Weight loss: 11.2
Missed medication days: 18
Morphine missing: 5.25
Morphine discrepancy: 8
Oxygen liters: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Medication Aide | Described medication administration procedures and failure to notify nurse of missing medication |
| Staff G | Registered Nurse | Reported on Resident #31 wheelchair fall and transfer procedures |
| Staff J | Certified Nurse Aide | Described transfer of Resident #31 in wrong wheelchair without seatbelt |
| Staff I | Certified Nurse Aide | Described transfer of Resident #49 alone resulting in fall |
| Staff M | Licensed Practical Nurse | Reported lack of orientation when starting work at facility |
| Staff N | Certified Nurse Aide | Reported lack of formal training or orientation checklist |
| Staff O | Certified Medication Aide | Described narcotic count procedures |
| Staff A | Registered Nurse | Described narcotic count procedures and smoking safety concerns |
| Staff B | Certified Nurse Aide | Observed Resident #50 smoking with oxygen tank |
| Staff C | Director of Nursing | Discussed Resident #50 smoking and oxygen use, and agency staff orientation |
| Staff D | Registered Nurse | Described education provided to Resident #50 on oxygen and smoking safety |
| Dietary Manager | Dietary Manager | Reported lack of certification and enrollment in upcoming course |
| Director of Nursing | Director of Nursing | Discussed narcotic medication discrepancies and agency staff orientation |
Inspection Report
Routine
Census: 57
Deficiencies: 8
Date: Dec 21, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of the Good Samaritan Society - Holstein nursing home to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of missed medications and significant weight loss, improper use and documentation of physical restraints, unsafe resident handling leading to falls, unsafe smoking practices with oxygen use, lack of orientation for temporary nursing staff, inaccurate narcotic medication counts, and lack of qualified dietary service management.
Deficiencies (8)
Failed to notify physician when Resident #50 did not receive scheduled medication Lexapro and failed to notify physician of significant weight loss for Resident #55.
Failed to ensure residents consented to physical restraints and obtain physician's order for restraint use for Resident #31.
Minimum Data Set (MDS) lacked resident specific information regarding use of restraints for Resident #31.
Failed to ensure Resident #50 received scheduled medication Lexapro as ordered.
Failed to keep residents safe from preventable accidents and hazards including falls from mechanical lifts, wheelchair falls, unsafe smoking with oxygen, improper transfer without gait belt, and injury from an unleashed dog.
Failed to provide orientation or training to temporary nursing staff (Staff M and N).
Failed to accurately document, monitor, and reconcile narcotic medication counts for Resident #1; discrepancies found in morphine bottle volumes and incomplete narcotic count logs.
Dietary Service Manager lacked required Certified Dietary Manager certification at time of survey.
Report Facts
Residents present: 57
Missed medication days: 18
Weight loss percentage: 11.2
Morphine bottle volume discrepancy: 5.25
Morphine bottle volume discrepancy: 8
Scheduled smoking frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Medication Aide (CMA) | Discussed missed medication administration and notification procedures for Resident #50 |
| Staff G | Registered Nurse (RN) | Worked day Resident #31 slid from wheelchair and assessed Resident #49 fall; discussed restraint and transfer issues |
| Staff J | Certified Nurse Aide (CNA) | Involved in transfer of Resident #31 when she slid from wheelchair |
| Staff I | Certified Nurse Aide (CNA) | Transferred Resident #49 alone leading to fall |
| Staff B | Certified Nurse Aide (CNA) | Assisted Resident #50 with smoking outside |
| Staff A | Registered Nurse (RN) | Expressed concerns about Resident #50 smoking with oxygen and narcotic count procedures |
| Staff C | Director of Nursing (DON) | Discussed smoking policies, oxygen use, narcotic count issues, and dietary manager qualifications |
| Staff D | Registered Nurse (RN) | Provided education to Resident #50 on oxygen and smoking safety |
| Staff L | Licensed Practical Nurse (LPN) | Observed dog jumping on Resident #9 causing injury |
| Staff M | Licensed Practical Nurse (LPN) | Agency nurse reported lack of orientation |
| Staff N | Certified Nurse Aide (CNA) | Agency aide reported lack of orientation |
| Staff O | Certified Medication Aide (CMA) | Described narcotic count procedures and insistence on counting with nurse |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction effective January 13, 2023.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 15, 2022
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to timely report suspected abuse, neglect, or theft; failure to ensure accurate resident assessments; and failure to properly manage psychotropic medication use.
Complaint Details
The complaint investigation focused on three main issues: late reporting of a medication discrepancy incident involving Resident 25, inaccurate MDS assessment for Resident 35, and inappropriate use and monitoring of antipsychotic medication for Resident 35. The investigation included interviews with the Director of Nursing, Administrator, MDS Coordinator, Licensed Practical Nurses, Certified Nursing Assistants, Consultant Pharmacist, and review of clinical records and facility policies.
Findings
The facility failed to timely report a suspected medication discrepancy incident, failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, and failed to monitor and justify the use of an antipsychotic medication for another resident. These deficiencies were supported by clinical record reviews, staff interviews, and policy reviews.
Deficiencies (3)
Failure to timely report suspected abuse, neglect, or theft related to a medication discrepancy involving Resident 25.
Failure to ensure an accurate Minimum Data Set (MDS) assessment for Resident 35, including incorrect reporting of a fall with major injury.
Failure to implement gradual dose reductions and monitor the use of antipsychotic medication (Risperdal) for Resident 35, with inadequate clinical indications and monitoring.
Report Facts
Residents sampled: 18
Medication discrepancy: 0.5
MDS Assessment Reference Date: Nov 3, 2022
BIMS score: 3
Antipsychotic medication dose: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided information about late reporting and medication incident |
| Administrator | Administrator | Confirmed unawareness of late reporting |
| MDS Coordinator | MDS Coordinator | Confirmed MDS assessment error for Resident 35 |
| Licensed Practical Nurse 5 | Licensed Practical Nurse (LPN) | Interviewed regarding Resident 35's fall and behaviors |
| Certified Nursing Assistant 1 | Certified Nursing Assistant (CNA) | Interviewed regarding Resident 35's behaviors |
| Consultant Pharmacist | Consultant Pharmacist | Reviewed medications and confirmed inappropriate antipsychotic use for Resident 35 |
| Primary Care Physician | Primary Care Physician (PCP) | Provided information on Resident 35's symptoms and medication |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Dec 12, 2022
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions on behalf of the Iowa Department of Inspections and Appeals to investigate allegations of abuse, neglect, exploitation, or mistreatment and to assess compliance with federal regulations.
Complaint Details
The complaint investigation was substantiated based on staff interviews, clinical record reviews, and facility policy review. The facility failed to report a reasonable suspicion of a crime related to a facility reported incident involving a resident (Resident R25).
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were issued related to failure to report alleged violations timely, failure to ensure accurate assessments, and failure to ensure appropriate use and monitoring of psychotropic medications. Corrective actions and monitoring plans were outlined for each deficiency.
Deficiencies (3)
Failure to implement policies and procedures ensuring timely reporting of alleged abuse, neglect, exploitation, or mistreatment incidents.
Failure to ensure accurate Minimum Data Set (MDS) assessments reflecting resident status.
Failure to ensure residents were free from unnecessary psychotropic medications and failure to monitor and document appropriately.
Report Facts
Survey Census: 51
Sample Size: 18
Facility Reported Incident Date: Nov 4, 2021
Discrepancy in narcotic count: 1.5
Audit frequency: 8
Audit duration: 4
MDS assessment sample: 18
Residents with inaccurate MDS: 1
Psychotropic medication sample: 18
Residents with ongoing clinical indications for antipsychotic use: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided information about missing medication and expectations for MDS accuracy |
| Administrator | Administrator | Confirmed unawareness of late reporting and responsible for audit performance |
| Licensed Practical Nurse | Licensed Practical Nurse | Stated Resident R35 did not sustain falls with major injury and described resident behaviors |
| MDS Coordinator | MDS Coordinator | Confirmed MDS error and educated staff on accurate reporting |
| Consultant Pharmacist | Consultant Pharmacist | Reviewed residents' medications and confirmed diagnosis and medication appropriateness |
| Certified Nursing Assistant | Certified Nursing Assistant | Reported resident behaviors during interview |
| Primary Care Physician | Primary Care Physician | Provided information on resident symptoms and behaviors |
Inspection Report
Abbreviated Survey
Census: 36
Deficiencies: 0
Date: Dec 17, 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 in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 36
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess 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.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 6
Date: Feb 27, 2020
Visit Reason
The inspection was conducted as a health survey and investigation of complaint #87606-C completed February 24-27, 2020. The complaint was not substantiated.
Complaint Details
Complaint #87606-C was investigated and found not substantiated.
Findings
The facility was found deficient in multiple areas including failure to refer a resident for Level II PASARR evaluation, failure to review and revise care plans for residents with changing conditions, failure to provide services to prevent reduction in range of motion, failure to ensure adequate supervision to prevent accidents, failure to accurately assess and monitor nutritional and hydration needs, and failure to maintain infection prevention and control practices.
Deficiencies (6)
Failed to refer a resident for a Level II PASARR evaluation and determination for 1 of 1 residents reviewed (Resident #29).
Failed to review and revise the care plans for 3 out of 15 residents (Resident #27, #30 and #32) despite changes in condition.
Failed to provide services to prevent a reduction in range of motion for 1 of 1 residents reviewed (Resident #29).
Failed to assure each resident received adequate supervision and assistance to prevent accidents for 1 of 15 residents reviewed (Resident #48).
Failed to accurately assess and monitor the nutritional and hydration needs for 1 of 15 residents reviewed (Resident #27), resulting in significant weight loss and poor nutritional status without timely intervention.
Failed to provide a sanitary environment and proper infection prevention and control practices for 2 of 15 residents reviewed (Residents #30 and #39), including improper glove use and hand hygiene.
Report Facts
Census: 50
Weight loss percentage: 4.18
Weight loss percentage: 7.09
Mini Nutritional Assessment score: 11
Mini Nutritional Assessment score: 13
BIMS score: 5
BIMS score: 2
BIMS score: 4
BIMS score: 14
Number of meals with 0-25% eaten: 9
Number of meals with 26-50% eaten: 13
Number of meals with 51-75% eaten: 9
Number of meals with 76-100% eaten: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Prepared medication and assisted Resident #27 during meal observation |
| Staff C | Certified Nursing Assistant | Assisted Resident #27 during meal observation |
| Director of Nursing | Interviewed regarding care plan revisions, restorative programs, and safety concerns | |
| Social Services Director | Interviewed regarding PASARR evaluation expectations | |
| Staff A | Observed Resident #29's hand contracture and walking assistance | |
| Staff F | Licensed Practical Nurse | Observed pushing Resident #27 in wheelchair without foot pedals |
| Staff H | Certified Nursing Assistant | Provided peritoneal care to Resident #39 without changing gloves or hand hygiene |
| Staff E | Registered Nurse | Handled soiled brief without gloves and hand hygiene |
| Infection Control Nurse | Interviewed regarding infection control expectations | |
| Dietary Manager | Conducted Mini Nutritional Assessment and added high calorie pudding without documenting | |
| Dietician | Interviewed regarding nutritional assessment and recommendations |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 6
Date: Feb 27, 2020
Visit Reason
The inspection was conducted as a complaint investigation related to complaint #87606-C, which was completed February 24-27, 2020. The complaint was not substantiated.
Complaint Details
Complaint #87606-C was investigated February 24-27, 2020 and was not substantiated.
Findings
The facility failed to coordinate PASARR assessments for a resident, failed to review and revise care plans for multiple residents, failed to prevent reduction in range of motion for a resident, failed to ensure adequate supervision and accident prevention for a resident, failed to maintain proper nutrition and hydration status for residents, and failed to establish and maintain an infection prevention and control program.
Deficiencies (6)
Coordination of PASARR and Assessments - Facility failed to refer a resident for a Level II PASARR evaluation and determination.
Care Plan Timing and Revision - Facility failed to review and revise care plans for 3 out of 15 residents.
Increase/Prevent Decrease in Range of Motion/Mobility - Facility failed to provide services to prevent reduction in range of motion for 1 resident.
Free of Accident Hazards/Supervision/Devices - Facility failed to ensure adequate supervision and assistance to prevent accidents for 1 resident.
Nutrition/Hydration Status Maintenance - Facility failed to accurately assess and monitor nutritional and hydration needs for 1 of 15 residents.
Infection Prevention & Control - Facility failed to establish and maintain an infection prevention and control program including hand hygiene and staff education.
Report Facts
Residents reviewed for care plans: 15
Residents with care plan deficiencies: 3
Residents reviewed for accident hazards: 15
Residents with accident hazard deficiencies: 1
Residents reviewed for nutrition/hydration: 15
Residents with nutrition/hydration deficiencies: 1
Weight loss for Resident #27: 4.18
Weight loss for Resident #27: 7.09
Census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding psychotic disorder diagnosis and care plan revisions | |
| Social Services Director | Interviewed regarding PASARR completion and diagnosis expectations | |
| Dietician | Interviewed regarding nutritional assessments and interventions | |
| Dietary Manager | Educated on nutritional risk and audit processes | |
| Infection Control Nurse | Interviewed regarding hand hygiene and infection control expectations |
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