Inspection Reports for Harmony Marshalltown
910 East Olive Street, Marshalltown, IA, 501584195
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 23, 2025, found the facility in substantial compliance with all previously cited deficiencies corrected. Earlier inspections showed a pattern of deficiencies related primarily to resident care, including issues with dignity and respect, pressure ulcer prevention, safe discharges, and sufficient nursing staff, as well as concerns about infection control, food safety, and documentation. Several complaint investigations were substantiated over time, involving resident rights violations, inadequate supervision leading to elopements and falls, and lapses in infection control and immunization practices. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements recently, as indicated by the correction of deficiencies and compliance findings in the latest inspections following prior citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
12.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
177% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
51 residents
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 23, 2025
Visit Reason
A revisit of the survey ending August 25, 2025 was conducted September 22, 2025 to September 23, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective September 5, 2025.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 8
Date: Aug 5, 2025
Visit Reason
The inspection was conducted as a complaint survey investigation of intakes #1780338, #17880340, #2560420, and #2560484 from July 16, 2025 to August 5, 2025, including facility reported incidents.
Complaint Details
The investigation was based on complaints #1780338, #17880340, #2560420, and facility reported incidents #2560484. The complaint investigation found substantiated deficiencies related to resident rights violations, failure to notify physicians, inappropriate discharges, pressure ulcer care, accident hazards, staffing, resident records, and smoking policies.
Findings
The facility was found not in compliance with multiple federal requirements including resident rights, notification of changes, inappropriate transfers and discharges, treatment and services to prevent pressure ulcers, free of accident hazards, sufficient nursing staff, resident records confidentiality, and smoking policies. Deficiencies were identified related to failure to treat residents with dignity, failure to notify physicians of incidents, unsafe discharge practices, inadequate pressure ulcer prevention and treatment, unsafe environment, and insufficient staff response to call lights and supervision.
Deficiencies (8)
Resident Rights/Exercise of Rights - Facility failed to treat a resident with respect and dignity and failed to ensure resident rights without interference or coercion.
Notify of Changes - Facility failed to notify the resident's physician of an incident related to a resident left outside all night.
Inappropriate Discharge - Facility failed to ensure safe discharge and transfer planning and documentation.
Treatment/Services to Prevent/Heal Pressure Ulcers - Facility failed to provide necessary treatment and prevention for pressure ulcers.
Free of Accident Hazards/Supervision/Devices - Facility failed to ensure residents safely returned from smoking and failed to provide adequate supervision.
Sufficient Nursing Staff - Facility failed to provide sufficient nursing staff to assure resident safety and timely response to call lights.
Resident Records - Identifiable Information - Facility failed to maintain complete and accurate medical records and failed to safeguard resident information.
Smoking Policies - Facility failed to provide adequate smoking policies and supervision for residents who smoke.
Report Facts
Total census: 51
Deficiencies cited: 8
Resident #1 BIMS score: 14
Resident #2 BIMS score: 15
Resident #5 BIMS score: 14
Resident #18 BIMS score: 15
Resident #19 BIMS score: 15
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 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 will be certified in compliance with health requirements effective May 9, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 4
Date: Apr 10, 2025
Visit Reason
The inspection was conducted due to investigations of intakes #127722-C and #126847-I from April 7, 2025 to April 10, 2025. The visit was complaint-related with complaint #127722-C not substantiated and incident #126847-I substantiated.
Complaint Details
Complaint #127722-C was not substantiated. Incident #126847-I was substantiated.
Findings
The facility failed to conduct timely and thorough resident assessments, neurological checks, and supervision resulting in a resident elopement and injury. Deficiencies were found in quality of care, accident hazards/supervision, competent nursing staff, and resident records including medical documentation and nursing supervision.
Deficiencies (4)
Facility failed to initiate and complete resident assessments in a timely manner for 1 of 3 residents reviewed, including failure to conduct neurological assessments after injury and elopement.
Facility failed to provide adequate supervision resulting in elopement of Resident #1.
Facility failed to ensure sufficient nursing staff competency to provide care and supervision for residents.
Facility failed to maintain complete and accurate resident medical records, including documentation of neurological checks and skin/wound assessments.
Report Facts
Resident census: 52
Deficiency count: 4
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 23, 2025
Visit Reason
The document reflects acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, certifying the facility in compliance with health requirements effective January 9, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction; no specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 9
Date: Dec 12, 2024
Visit Reason
The Harmony Marshalltown Nursing Home was inspected due to its annual recertification survey combined with an investigation of multiple complaints (#123875-C, #123924-C, #124304-C, #124783-C, #125103-C, and #125333-C). Complaint #125333-C was substantiated.
Complaint Details
Complaint #125333-C was substantiated as part of the annual recertification survey and complaint investigation.
Findings
The facility was found not in compliance with several federal regulations including personal privacy/confidentiality of records, coordination of PASARR and assessments, care plan timing and revision, bowel/bladder incontinence and catheter care, respiratory/tracheostomy care, staffing requirements for a full-time registered nurse, food procurement and sanitation, influenza and pneumococcal immunizations, and COVID-19 immunization protocols. Multiple deficiencies were identified based on clinical record reviews, staff interviews, observations, and policy reviews.
Deficiencies (9)
Personal Privacy/Confidentiality of Records was not maintained for 1 of 1 resident reviewed.
Coordination of PASARR and Assessments was not met for 1 out of 2 residents reviewed with mental health changes.
Care Plan Timing and Revision requirements were not met for 3 of 20 residents reviewed.
Bowel/Bladder Incontinence, Catheter, UTI management was inadequate for 1 of 2 residents reviewed with urinary catheters.
Respiratory/Tracheostomy Care and Suctioning was deficient for 1 of 1 resident sampled for respiratory care.
RN coverage for 8 hours per day, 7 days per week was not provided as required.
Food Procurement, Store/Prepare/Serve-Sanitary practices failed to protect food from contamination during meal service.
Influenza and Pneumococcal Immunizations policies and procedures were not fully implemented for residents reviewed.
COVID-19 Immunization policies and procedures were not fully implemented for residents reviewed.
Report Facts
Complaints investigated: 6
Residents reviewed for care plan: 20
Residents reviewed for PASARR screening: 2
Residents reviewed for catheter care: 2
Residents reviewed for respiratory care: 1
Staff RN coverage hours missing: 6
Residents in facility census: 55
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
The document is a plan of correction related to prior surveys ending on 2024-09-12 and 2024-09-25, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective October 25, 2024.
Findings
The Harmony Marshalltown Nursing Home is in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on the acceptance of the credible allegation of substantial compliance and plan of correction for the prior surveys.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Date: Sep 25, 2024
Visit Reason
The inspection was conducted due to an investigation of multiple intake complaints and a facility reported incident between September 21, 2024 and September 25, 2024.
Complaint Details
The survey substantiated complaints #123516-C and #123601-C. The survey did not substantiate complaints #123372-C, #123436-C, #123529-C, and #123602-C, nor the facility reported incident #123535-I.
Findings
The facility failed to have adequate equipment to ensure resident safety during transfers, specifically missing safety hook spring tabs on Smart Stand Lifts used for resident transfers. The survey substantiated two complaints but did not substantiate others or the reported incident.
Deficiencies (1)
Facility failed to have adequate equipment to ensure resident safety during transfers; Smart Stand Lifts were missing safety hook spring tabs.
Report Facts
Census: 59
Number of lifts observed: 4
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 7
Date: Sep 12, 2024
Visit Reason
The inspection was conducted as an annual survey including investigation of multiple complaints and compliance with federal regulations.
Complaint Details
The survey substantiated multiple complaints (#122672-C, #122700-C, #123198-C, #123257-C, and #123265-C) investigated during the survey period.
Findings
The facility was found non-compliant in several areas including failure to provide adequate linens and supplies, failure to follow physician orders for residents, insufficient nursing staff response times, failure to follow dietitian approved menus, failure to maintain proper food temperatures, unsanitary food procurement and storage practices, and inadequate infection prevention and control practices.
Deficiencies (7)
Failure to provide clean, available linen soaker pads and adequate linens for resident care.
Failure to follow physicians' orders for 2 of 3 residents reviewed.
Failure to answer resident call lights in a timely manner for 2 of 3 residents reviewed.
Failure to follow dietitian approved menus as written.
Failure to maintain hot food items at 135 degrees or greater to prevent food borne illness and keep food palatable.
Failure to ensure food safety by serving expired food items, unlabeled and undated open food items, and maintaining unsanitary kitchen and equipment conditions.
Failure to maintain infection control practices including failure to complete hand hygiene for a resident care procedure.
Report Facts
Census: 62
Blood sugar level: 200
French fries temperature: 127
Expired chocolate milk quantity: 11
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding intakes #122115-C, #122153-I, and #122263-C from July 18, 2024 to July 24, 2024.
Complaint Details
Complaint investigation regarding intakes #122115-C, #122153-I, and #122263-C. The facility was found in substantial compliance.
Findings
The Grandview Heights Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities following the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation for intakes #118949-C, #120341-C, #119634-I, and #120167-I from May 13, 2024 to May 16, 2024.
Complaint Details
The investigation was related to multiple complaint intakes as listed, with findings indicating substantial compliance.
Findings
The Grandview Heights Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities following the complaint investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 22, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance by the facility.
Findings
The facility was certified in compliance effective February 22, 2024, based on the acceptance of the credible allegation and Plan of Correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
An investigation was conducted for a facility reported incident #118468-I on February 12-13, 2024.
Complaint Details
Investigation was related to facility reported incident #118468-I; no deficiencies cited indicating substantiation is unclear.
Findings
The facility was found to be in substantial compliance following the investigation.
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 9
Date: Feb 1, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of complaints and facility self-reported incidents from January 29, 2024 to February 1, 2024.
Complaint Details
The visit included investigation of complaints and facility self-reported incidents #116874-I and #118373-I, which were substantiated.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to obtain proper background checks for new hires, inadequate comprehensive care plans, failure to provide dialysis services consistent with professional standards, failure to maintain appropriate narcotic medication records, failure to employ a full-time Certified Dietary Manager, failure to properly puree food, failure to maintain proper food temperatures, and failure to maintain clean kitchen appliances and proper thermometer sanitization.
Deficiencies (9)
Facility staff failed to treat residents with respect and dignity.
Facility failed to obtain proper background check clearance prior to re-hiring 2 employees.
Facility staff failed to appropriately care plan catheter and provide appropriate intervention following a burn.
Facility failed to appropriately care for residents who receive dialysis treatment by not appropriately assessing them.
Facility failed to maintain an appropriate record of a narcotic medication prescribed to a resident.
Facility failed to employ a full-time Certified Dietary Manager (CDM).
Facility staff failed to puree food appropriately.
Facility staff failed to maintain cold food temperatures at or below 41°F while serving.
Facility staff failed to maintain clean kitchen appliances, labeled and dated items, and proper thermometer sanitization.
Report Facts
Census: 56
Deficiencies cited: 9
Narcotic audits: 52
Dietary Manager audits: 4
Dietary Manager audits: 4
Dietary Manager audits: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant (CNA) | Named in findings related to resident dignity and background check issues |
| Staff F | Licensed Practical Nurse (LPN) | Named in findings related to background check and narcotic medication record deficiencies |
| Staff G | Certified Medication Aide (CMA) | Named in findings related to background check deficiencies |
| Heather Keely | LPN/QA Nurse | Responsible for narcotic medication flow sheet review |
| Jo Schwickerath | LPN | Contact for dialysis assessment questions |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
A revisit of the facility-reported incident #114289-I and focus infection control survey ending September 18, 2023 was conducted on October 10, 2023 to October 11, 2023.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective September 21, 2023.
Report Facts
Incident number: 114289
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Sep 18, 2023
Visit Reason
A COVID-19 Focused Infection Control (FIC) Survey was conducted from September 13 to September 18, 2023, including investigation of facility reported incident #114289-I which was substantiated.
Complaint Details
Facility reported Incident #114289-I was substantiated following investigation.
Findings
The facility was found not in compliance with CMS and CDC recommended practices related to infection control and failed to provide appropriate nursing supervision to ensure safety of residents, resulting in a resident fall with a hip fracture. The facility also failed to offer and administer appropriate pneumococcal and influenza immunizations to residents.
Deficiencies (2)
Facility failed to provide appropriate nursing supervision to ensure safety of residents, resulting in Resident #1 falling and fracturing her hip.
Facility failed to offer and administer the appropriate dose of pneumococcal vaccine to residents.
Report Facts
Census: 51
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to nursing supervision and fall incident |
| Staff A | Physical Therapy Aide (PTA) | Interviewed regarding Resident #1's abilities and care |
| Staff B | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #1's care and fall incident |
| Staff C | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #1's care and fall incident |
| Staff D | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #1's care and fall incident |
| Staff E | Certified Medication Aide (CMA) | Interviewed regarding Resident #1's care and fall incident |
| Staff F | Certified Medication Aide (CMA) | Interviewed regarding Resident #1's fall and emergency response |
| Staff G | Nurse/Licensed Practical Nurse (LPN) | Responded to Resident #1's fall and emergency |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
An investigation of Complaint #111464-C and Facility Self-Reported Incidents #109194-I and #111825-I was conducted from July 5, 2023 to July 6, 2023.
Complaint Details
Investigation was related to Complaint #111464-C and Facility Self-Reported Incidents #109194-I and #111825-I. The facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 23, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction, indicating acceptance of the facility's credible allegation of compliance and plan of correction for certification.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, with certification effective December 23, 2022.
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 14
Date: Dec 6, 2022
Visit Reason
Annual Recertification Survey and investigation of substantiated complaints #106877-C, #107147-C, #108625-C and #108685-C.
Complaint Details
Complaints #106877-C, #107147-C, #108625-C and #108685-C were substantiated.
Findings
The facility had multiple deficiencies including failure to notify residents or families about antipsychotic medication risks, failure to provide quarterly financial statements, failure to provide proper Medicare notices, failure to report incidents timely, failure to maintain a safe environment, failure to maintain accurate care plans, medication errors, food safety violations, and infection preventionist training deficiencies.
Deficiencies (14)
Failed to notify family or residents of risks and benefits of starting antipsychotic medications on 2 residents (#27 and #44).
Failed to provide quarterly financial statements to residents for Quarter 3 of 2022.
Failed to comply with Medicare requirements governing Skilled Nursing Facility Advance Beneficiary Notice for 2 residents (#21 and #50).
Failed to provide a safe environment by failing to exercise reasonable care for the protection of residents' property from loss or theft.
Failed to report falls with fracture and elopement incidents to the Iowa Department of Inspections & Appeals within required timeframes for residents #39 and #56.
Failed to notify the Long Term Care Ombudsman of discharged residents (#54 and #57).
Failed to complete and transmit a resident's Minimum Data Set (MDS) Assessment within the required timeframe for Resident #16.
Failed to refer two residents (#33 and #18) with new mental health diagnoses to the state designated authority for Level II PASRR evaluation and determination.
Failed to develop a comprehensive care plan including ambulation and transfer status for Resident #56.
Failed to assure a resident (Resident #8) was given medication according to physician orders; administered wrong inhalant medication.
Failed to ensure medication administration accuracy; medication errors observed for Residents #8, #9, and #18 resulting in an error rate of 6.98%.
Failed to maintain sanitary food storage and preparation practices including improper storage of food containers, expired food, and inadequate sanitization solution concentration.
Failed to designate a qualified Infection Preventionist with completed specialized training in Infection Prevention and Control.
Failed to maintain a pest free environment with a bed bug infestation for Resident #57.
Report Facts
Census: 53
Medication error rate: 6.98
Sanitizer concentration: 500
Sanitizer concentration: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse | Unaware of consents required for antipsychotic medication; involved in medication administration and family notification |
| Staff D | Licensed Practical Nurse | Unaware of education requirements related to new medication orders |
| Staff C | RN/Co-Director of Nursing | Reported no consents or education provided for antipsychotic use; involved in care plan and incident reporting |
| Staff G | Certified Medication Aide | Administered wrong inhalant medication and medication errors |
| Staff B | RN/Co-Director of Nursing | Infection Preventionist designee; reported expectations for insulin pen use |
| Staff J | Cook | Tested sanitizing solution concentration |
| Staff L | RN | Infection Preventionist designee; reported on care plans and incident reporting |
| Staff E | Licensed Practical Nurse | Reported bed bug infestation and pest control protocol |
| Staff N | Certified Medication Aide | Reported resident elopement incident |
| Staff O | Certified Nursing Assistant | Reported resident elopement incident |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 9, 2022
Visit Reason
The onsite revisit was conducted to verify compliance following a prior inspection.
Findings
The facility was found to be in overall compliance effective May 12, 2022, based on the onsite revisit conducted June 8-9, 2022.
Inspection Report
Complaint Investigation
Census: 59
Capacity: 109
Deficiencies: 2
Date: May 10, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #102025-C, #103662-C and #104450-C, also a Facility Self-Reported Incident #104129-I were conducted by the Department of Inspections and Appeals from April 25, 2022 to May 10, 2022.
Complaint Details
Complaint #102025-C was substantiated. Facility Self-Reported Incident #104129-I was substantiated.
Findings
The facility was found in compliance with CMS and CDC guidelines at the time of the survey. Complaint #102025-C and Facility Self-Reported Incident #104129-I were substantiated. The facility failed to provide adequate nursing supervision to ensure a safe environment free of hazards, resulting in a resident elopement incident.
Deficiencies (2)
Facility failed to provide adequate nursing supervision to ensure the environment was free of hazards, resulting in a resident elopement.
Facility failed to have sufficient nursing staff with appropriate competencies and skills to assure resident safety and timely response to call lights.
Report Facts
Total Residents: 59
Licensed Bed Capacity: 109
Wandering Score: 27
Brief Interview for Mental Status (BIMS) Score: 12
Brief Interview for Mental Status (BIMS) Score: 14
Brief Interview for Mental Status (BIMS) Score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel M. Larmore | MS/Administrator | Signed the survey completion document |
| Staff A | Licensed Practical Nurse (LPN) | Documented resident elopement events and participated in search efforts |
| Staff B | Certified Medication Aide (CMA) | Assisted in counting narcotics and resetting alarm panel during elopement incident |
| Staff C | Certified Medication Aide (CMA) | Tested wander guard bracelet and interviewed resident |
| Staff D | Certified Nursing Assistant (CNA) | Reported on repositioning of Resident #5 |
| Staff E | Certified Nursing Assistant (CNA) | Reported on repositioning of Resident #5 |
| Staff G | Licensed Practical Nurse (LPN) | Reported on call light response times and resident concerns |
| Director of Nursing | Provided multiple statements regarding facility policies, resident safety, and elopement incident |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 3
Date: Oct 4, 2021
Visit Reason
The inspection was a COVID-19 Focused Infection Control Survey and complaint investigation conducted by the Department of Inspection and Appeals from September 27 to October 4, 2021, triggered by complaints #99831-C and #99965-C.
Complaint Details
Complaints #99831-C and #99965-C were substantiated as the facility failed to comply with visitation rights and infection prevention and control requirements.
Findings
The facility was found not in substantial compliance with CMS and CDC recommended practices for COVID-19 infection control, including failure to have a visitation policy consistent with CMS regulations and inadequate use of personal protective equipment such as eye protection during a high county transmission period. The facility also failed to timely notify residents and families of confirmed COVID-19 cases as required.
Deficiencies (3)
Failure to have a visitation policy that complied with CMS visitation regulations, limiting unvaccinated guests' access during high COVID-19 positivity rates.
Failure to establish and maintain an infection prevention and control program including proper use of eye protection during high community transmission.
Failure to timely inform residents, representatives, and families of confirmed COVID-19 infections within required timeframes.
Report Facts
Total Residents: 63
County COVID-19 Positivity Rate: 18.6
County Transmission Rate: 17.74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Daniel M. Larmore | Administrator | Named in facility response and signature on plan of correction |
| Staff B | Certified Medication Aide | Observed administering medication without eye protection |
| Staff C | Licensed Practical Nurse | Observed without eye protection during resident care |
| Staff D | Licensed Practical Nurse | Observed assisting resident without eye protection |
| Staff E | Certified Nursing Assistant | Observed without eye protection during resident transfer |
| Staff F | Certified Nursing Assistant | Observed without eye protection during resident transfer |
| Director of Nursing | Interviewed regarding facility's personal protective equipment requirements and COVID-19 testing |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 8
Date: Aug 19, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaints #94655, #94786-C, and incident #94620-I completed August 11-19, 2021.
Complaint Details
Complaint #94655 regarding infection control was substantiated. Issues included inconsistent use of cloth masks by staff, improper hand hygiene during medication administration, and inconsistent hand hygiene by dietary staff.
Findings
The facility was found to have deficiencies related to advance directives, abuse policy and criminal background checks, reporting of alleged violations, coordination of assessments, medication administration, nutrition and hydration, respiratory care, food safety, infection prevention and control, and other regulatory requirements. Complaint #94655 regarding infection control was substantiated.
Deficiencies (8)
Failure to ensure resident code status for Do Not Resuscitate (DNR) was consistently documented and communicated.
Failure to develop and implement abuse policies including criminal background checks for employees.
Failure to report resident to resident incidents within required regulatory time frames.
Failure to ensure medication administration followed professional standards and hand hygiene protocols.
Failure to maintain acceptable nutritional status and document supplement administration accurately.
Failure to provide respiratory care including proper documentation and monitoring of oxygen therapy.
Failure to ensure food safety including proper storage, labeling, and handling of food items.
Failure to establish and maintain an infection prevention and control program including hand hygiene and use of cloth masks.
Report Facts
Census: 66
Deficiencies cited: 8
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Date: Jul 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and investigation of Complaint #92207 was conducted due to concerns about infection control practices related to COVID-19.
Complaint Details
Complaint #92207 was substantiated. The investigation found the facility was not in compliance with CMS and CDC recommended practices to prepare for COVID-19, including failure to separate COVID-19 positive and negative residents and inadequate staff screening procedures.
Findings
The facility failed to separate COVID-19 positive and negative residents for 4 of 64 residents reviewed and failed to implement complete and consistent screening of employees, resulting in risk of transmission of COVID-19 among residents and staff.
Deficiencies (2)
Failure to separate COVID-19 positive and negative residents for 4 residents (Residents #6, #7, #8, and #9).
Failure to implement complete and consistent screening of employees, including incomplete documentation and failure to identify symptomatic staff.
Report Facts
Resident census: 64
COVID-19 positive residents: 47
Staff temperature entries: 238
Staff temperature entries total: 660
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Director of Nursing (DON) | Confirmed residents were not separated by COVID status and described staff screening process |
| Staff A | Certified Medication Aide (CMA) | Described staff screening process upon entering the facility |
| Staff B | Certified Nurse Aide (CNA) | Reported exposure to COVID-19 and described staff screening process |
| Staff C | Licensed Practical Nurse (LPN) | Described staff screening process and reported symptomatic staff allowed to work |
| Staff D | Registered Nurse (RN) | Described staff screening process and allowed symptomatic staff to work |
| Staff G | Certified Medication Aide (CMA) | Worked while symptomatic and later tested COVID-19 positive |
Inspection Report
Abbreviated Survey
Census: 67
Deficiencies: 4
Date: Jun 17, 2020
Visit Reason
The inspection was a COVID-19 Focused Infection Control Survey conducted by the Department of Inspections and Appeals on June 17-18, 2020, to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparedness.
Findings
The facility was found not in substantial compliance with infection prevention and control requirements, including failure to properly sanitize lift slings, inadequate hand hygiene, failure to maintain social distancing and mask use among residents, lack of PPE supplies and signage, and failure to notify residents and families of COVID-19 infections among staff. The facility reported a census of 67 residents.
Deficiencies (4)
Failure to properly sanitize lift slings between resident use and inadequate hand hygiene by staff.
Failure to maintain social distancing and mask use among residents in common areas.
Lack of PPE supplies and proper signage outside resident rooms requiring isolation.
Failure to notify residents, representatives, and families of confirmed COVID-19 infections among staff as required.
Report Facts
Census: 67
Dates of staff positive COVID-19 tests: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse Aide (CNA) | Observed applying lift sling and transferring residents |
| Staff C | Certified Nurse Aide (CNA) | Observed applying lift sling and transferring residents |
| Staff D | Certified Medication Aide (CMA) | Interviewed regarding hand hygiene and lift sanitization procedures |
| Staff A | Unit Manager | Interviewed regarding hand sanitization expectations and resident facemask policy |
| Administrator (ADM) | Interviewed regarding notification of COVID-19 infections to residents and families |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 5, 2020
Visit Reason
The inspection was conducted to investigate complaints #89229, #87916, and #89463.
Complaint Details
Complaints #89229, #87916, and #89463 were investigated and found to be not substantiated.
Findings
The complaints investigated were not substantiated according to the Code of Federal Regulations (42CFR) Part 483, Subpart B-C.
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