Inspection Reports for
Hawkeye Care Center Dubuque
5575 Pennslyvania Avenue, Asbury, IA, 520020420
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
71 residents
Based on a September 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: Dec 19, 2025
Visit Reason
A complaint investigation for complaint #2688378-C was conducted on December 18, 2025 to December 19, 2025.
Complaint Details
Complaint #2688378-C was investigated and 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 1, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to a prior survey ending September 18, 2025, indicating acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was certified in compliance effective October 10, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction. No specific deficiencies are detailed in this document.
Report Facts
Survey end date: Sep 18, 2025
Certification effective date: Oct 10, 2025
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 3
Date: Sep 18, 2025
Visit Reason
The inspection was conducted as part of the annual recertification and complaint survey to assess compliance with regulatory requirements, including residents' rights, quality assurance processes, and infection prevention and control.
Findings
The facility failed to timely update a resident's code status, resulting in conflicting documentation regarding resuscitation preferences. The Quality Assurance Performance Improvement (QAPI) process was ineffective, leading to repeated deficiencies in infection control. Staff failed to consistently use Personal Protective Equipment (PPE) as required for residents on contact and enhanced barrier precautions, increasing risk of infection transmission.
Deficiencies (3)
Failed to update a resident's code status in a timely manner, resulting in conflicting documentation and potential violation of the resident's right to refuse medical treatment.
Failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process, resulting in repeated deficiencies related to infection control.
Failed to use Personal Protective Equipment (PPE) as directed for two residents on contact and enhanced barrier precautions, increasing risk of infection transmission.
Report Facts
Residents census: 71
Deficiency citations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Named in relation to confusion about resident's code status documentation |
| Infection Preventionist | Registered Nurse (RN) | Provided information on infection control deficiencies and education |
| Director of Nursing (DON) | Registered Nurse (RN) | Discussed infection control education and quality assurance activities |
| Assistant Director of Nursing (ADON) | Involved in addressing code status documentation and infection control training | |
| Staff A | Registered Nurse (RN) | Observed failing to use PPE as required for resident care |
| Staff C | Certified Nurses Aide (CNA) | Interviewed regarding PPE use and infection control knowledge |
| Staff D | Certified Nurses Aide (CNA) | Observed not wearing PPE properly during resident care |
| Staff E | Certified Nurses Aide (CNA) | Observed not wearing PPE properly during resident care |
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 3
Date: Sep 18, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #2595225-C from September 15 to September 18, 2025.
Complaint Details
The visit included investigation of complaint #2595225-C. The complaint was substantiated as evidenced by findings related to failure to update residents' code status and inadequate infection control practices.
Findings
The facility was found not in compliance with requirements related to advance directives, quality assurance and performance improvement (QAPI) program, and infection prevention and control. Specific deficiencies included failure to update residents' code status timely, ineffective QAPI processes, and inadequate infection control practices including improper use of personal protective equipment (PPE).
Deficiencies (3)
Failure to update and document residents' code status and advance directives in a timely manner.
Failure to maintain an effective Quality Assurance Performance Improvement (QAPI) program addressing previously identified deficiencies.
Failure to establish and maintain an infection prevention and control program including proper use of PPE and enhanced barrier precautions.
Report Facts
Census: 71
Deficiency count: 3
Brief Interview for Mental Status (BIMS) score: 3
Brief Interview for Mental Status (BIMS) score: 15
Medication Administration frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in infection control deficiency related to failure to use gown and gloves properly |
| Staff B | Licensed Practical Nurse (LPN) | Involved in clarifying resident code status and showing documentation to surveyor |
| Staff C | Unspecified | Interviewed regarding C-diff infection control procedures |
| Staff D | Certified Nurse Aide (CNA) | Observed during infection control practices |
| Staff E | Certified Nurse Aide (CNA) | Observed during infection control practices |
| Director of Nursing | Director of Nursing (DON) | Named in infection control deficiency and QAPI program re-education |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in infection control deficiency and QAPI program re-education |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Date: Jul 22, 2025
Visit Reason
Investigation of complaint #1714303 and facility reported incident #1744300 conducted on 7/22/25.
Complaint Details
Investigation of complaint #1714303 and facility reported incident #1744300; facility found in compliance.
Findings
The Hawkeye Care Center Dubuque was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities following the investigation.
Report Facts
Total census: 80
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
A complaint investigation for complaints #126794-C and #127450-C was conducted from April 15, 2025 to April 21, 2025.
Complaint Details
Complaint investigation for complaints #126794-C and #127450-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance at the time of the survey.
Report Facts
Complaint numbers: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 11, 2025
Visit Reason
A complaint survey for Complaint #125785-C was conducted from 2025-02-10 through 2025-02-11.
Complaint Details
Complaint #125785-C was not substantiated.
Findings
Complaint #125785-C was not substantiated, and the facility was found in substantial compliance at the time of the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
A complaint investigation for complaint #123970-C was conducted on November 25, 2024.
Complaint Details
Complaint #123970-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance at the time of the investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 30, 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.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective September 25, 2024.
Inspection Report
Routine
Census: 73
Deficiencies: 3
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to assess compliance with care plan development, medication management, and infection prevention and control practices at the nursing home.
Findings
The facility failed to update the care plan timely for residents with pressure ulcers and psychotropic medication use, and failed to use appropriate personal protective equipment when laundering soiled items. The deficiencies were determined to cause minimal harm or potential for actual harm affecting a few or some residents.
Deficiencies (3)
Failure to update the care plan within 7 days of identifying pressure ulcers for Resident #33.
Failure to document medication side effects, emotional triggers, and behavior monitoring related to depression in the care plan for Resident #21.
Failure to use appropriate personal protective equipment (gown and gloves) when laundering soiled items.
Report Facts
Residents affected: 73
Residents affected: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN), MDS Coordinator | Stated care plan update procedures and timing |
| Director of Nursing | Registered Nurse (RN) | Stated expectations for care plan interventions |
| Assistant Director of Nursing | Registered Nurse (RN) | Explained care plan update responsibilities |
| Staff A | Laundry aide | Observed not wearing gown when handling soiled laundry |
| Housekeeping Supervisor | Explained PPE expectations for laundry staff |
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 2
Date: Sep 12, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from September 9, 2024 through September 12, 2024.
Findings
The facility was found deficient in updating comprehensive care plans timely for residents with pressure sores and psychotropic medications, and in maintaining an effective infection prevention and control program, including proper use of personal protective equipment during laundry processes.
Deficiencies (2)
Failure to update the Care Plan timely for residents with pressure sores and psychotropic medications.
Failure to establish and maintain an infection prevention and control program, including failure to use appropriate personal protective equipment when laundering soiled items.
Report Facts
Census: 73
Medication orders: 4
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON, Registered Nurse | Stated the Care Plan should be updated once a pressure ulcer is identified |
| Staff B | Licensed Practical Nurse, MDS Coordinator | Stated Care Plan should be updated immediately if a pressure ulcer develops |
| Director of Nursing | DON, Registered Nurse | Stated interventions should be put on the Care Plan as soon as changes are noted |
| Laundry aide | Staff A | Observed handling laundry without proper PPE |
| Housekeeping Supervisor | Explained expectations for staff to wear gowns and gloves when handling soiled linens |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 31, 2024
Visit Reason
A complaint investigation for complaint #122380-C was conducted on July 30, 2024 to July 31, 2024.
Complaint Details
Complaint #122380-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
An on-site revisit was conducted on June 12-13, 2024 for the Recertification Survey completed June 2, 2024.
Findings
No concerns were observed and all deficiencies were corrected; the facility will be certified in compliance effective June 18, 2024.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 2
Date: May 2, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to follow up with interventions for a skin problem and inadequate supervision during transfers leading to a resident fall.
Complaint Details
The complaint investigation found substantiated failures related to skin care follow-up and transfer supervision resulting in harm to residents.
Findings
The facility failed to provide appropriate treatment for a pressure sore on Resident #16 and failed to provide adequate supervision and assistance during transfers, resulting in a fall and injury to Resident #29. Both incidents involved insufficient follow-up and communication with physicians and staff.
Deficiencies (2)
Failure to follow up with interventions for a skin problem (pressure sore) for Resident #16.
Failure to provide adequate supervision and assistance with transfers leading to a fall causing harm to Resident #29.
Report Facts
Census: 70
Wound size: 4
Wound size: 5
Hematoma size: 9
Skin tear size: 1
Hematoma size: 10
Hematoma size: 14
Skin tear size: 2.5
Hematoma size: 12
Wound size: 1
Wound size: 4
Surgical wound size: 4
Remaining hematoma size: 3
Surgical site size: 0.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN), Admissions Nurse | Responsible for skin issues in the transitional care unit and monitoring wound orders for Resident #16 |
| Staff B | Registered Nurse (RN) | Assessed Resident #29 after fall and provided signed statement regarding transfer status error |
| Staff C | Certified Nursing Assistant (CNA) | Attempted transfer of Resident #29 alone, leading to fall |
| Director of Nursing (DON) | Director of Nursing | Provided interviews regarding wound care and transfer expectations |
Inspection Report
Routine
Census: 70
Deficiencies: 5
Date: May 2, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Hawkeye Care Center Dubuque.
Findings
The facility was found deficient in multiple areas including failure to notify family of a resident's skin breakdown, inadequate follow-up on pressure sore treatment, insufficient supervision leading to a resident fall causing harm, improper food handling practices, and failure to submit required Payroll Based Journaling data to CMS.
Deficiencies (5)
Failed to notify a family of an area of skin breakdown in 1 of 3 residents reviewed for pressure sores (Resident #16).
Failed to follow up with interventions for a skin problem for 1 out of 3 residents with pressure sores (Resident #16).
Failed to provide adequate supervision and assistance with transfers which led to a fall that caused a resident harm for 1 of 3 residents reviewed (Resident #29).
Failed to keep hands off of the drinking rim of cups for 2 of 3 dining rooms observed and failed to contain hair during meal preparation and serving for 2 of 5 staff observed.
Failed to submit Payroll Based Journaling (PBJ) data to CMS as required for the quarter of October 1 through December 31, 2023.
Report Facts
Residents affected: 70
Wound size: 4
Wound size: 5
Hematoma size: 9
Skin tear size: 1
Hematoma size: 10
Hematoma size: 14
Skin tear size: 2.5
Hematoma size: 12
Wound size: 1
Wound size: 4
Surgical wound size: 4
Remaining hematoma size: 3
Surgical site size: 0.6
Number of cups served touching drinking rim: 18
Number of glasses served touching drinking rim: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Assessed resident after fall and documented findings |
| Staff C | Certified Nursing Assistant (CNA) | Attempted transfer leading to resident fall |
| Staff E | Registered Nurse (RN) | Reported knowledge of skin area on Resident #16 |
| Staff F | Licensed Practical Nurse (LPN), Admissions Nurse | Responsible for skin issues in transitional care unit |
| Staff D | Dietary Aide | Observed touching drinking rim of cups and hair outside hairnet |
| Staff A | Dietary Aide | Observed touching drinking rim of glasses |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding skin breakdown notification and fall supervision |
| Administrator | Administrator | Confirmed failure to submit Payroll Based Journaling data |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 5
Date: May 2, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey combined with an investigation of complaint #120849-C from April 29, 2024 to May 2, 2024.
Complaint Details
Complaint #120849-C was substantiated based on findings related to skin breakdown notification and follow-up care.
Findings
The facility was found to have deficiencies related to failure to notify family of skin breakdown, inadequate follow-up care for pressure sores, insufficient supervision leading to resident falls, failure to maintain food safety standards, and failure to submit payroll-based journal data timely. The complaint was substantiated.
Deficiencies (5)
Failure to notify family of an area of skin breakdown in 1 of 3 residents reviewed (Resident #16).
Failure to follow up with interventions for a skin problem for 1 of 3 residents with pressure sores (Resident #16).
Failure to provide adequate supervision and assistance leading to a fall causing resident harm for 1 of 3 residents reviewed (Resident #29).
Failure to keep hands off drinking rim of cups in 2 of 3 dining rooms and failure to contain hair during meal preparation and serving for 2 of 5 staff observed.
Failure to submit Payroll Based Journaling (PBJ) data timely for the quarter of October 1 through December 31, 2023.
Report Facts
Resident census: 70
Open blister size: 4
Fall incident date: Fall incident involving Resident #29 occurred on 11/8/23
Hematoma size: 14
Number of dining rooms with issues: 2
Number of staff observed with hair covering issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Named in fall incident report involving Resident #29 |
| Staff C | Certified Nursing Assistant (CNA) | Named in fall incident report involving Resident #29 |
| Staff F | Licensed Practical Nurse (LPN), Admissions Nurse | Interviewed regarding skin issues and wound care for Resident #16 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding notification and fall incident; responsible for ongoing compliance |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and cup handling |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 31, 2023
Visit Reason
A complaint survey was conducted on October 31, 2023, to investigate multiple complaints numbered #116329-C, #114781-C, #114229-C, #113456-C, #113463-C, and #113465-C.
Complaint Details
Complaints #116329-C, #114781-C, #114229-C, #113456-C, #113465-C, and #113463-C were all not substantiated.
Findings
The investigation identified no concerns, and all complaints were found to be not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 25, 2023
Visit Reason
A complaint investigation was conducted for complaints #111839-C, #112388-C and a facility reported incident #111895-I from April 20, 2023 to April 25, 2023.
Complaint Details
Investigation involved complaints #111839-C, #112388-C and facility reported incident #111895-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 30, 2023
Visit Reason
The document is a plan of correction submitted by the facility following a prior inspection, indicating acceptance of a credible allegation of compliance.
Findings
The facility will be certified in compliance effective January 27, 2023, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 6
Date: Jan 27, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from December 19, 2022 to December 22, 2022.
Findings
The facility was found deficient in several areas including development and implementation of comprehensive care plans, meeting professional standards for services provided, tube feeding management, dialysis care, food procurement and sanitation, and infection prevention and control. Specific issues included failure to prevent incidents of coffee spills causing burns, inadequate use of tubi grips, failure to follow physician orders for enteral feeding and dialysis assessments, and inadequate dishwasher temperature monitoring.
Deficiencies (6)
Failure to develop and implement a comprehensive person-centered care plan including measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs.
Failure to ensure services provided meet professional standards of quality, including failure to provide tubi grips as ordered.
Failure to follow physician orders and facility policy for tube feeding management and placement verification.
Failure to ensure residents requiring dialysis receive appropriate pre and post dialysis assessments and documentation.
Failure to maintain sanitary dishwasher conditions and monitor food temperatures properly.
Failure to establish and maintain an infection prevention and control program including proper IV therapy and catheterization procedures.
Report Facts
Facility census: 76
Deficiencies cited: 6
Resident count: 3
Temperature readings: 140
Temperature readings: 160
Temperature readings: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Sims | Administrator | Signed the initial comments page dated 1-19-23 |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding tubi grips and tube feeding procedures |
| Staff D | Cook | Interviewed about dishwasher temperatures and maintenance |
| Staff F | Dining Services Aide | Interviewed about dishwasher temperature logs and meal service |
| Director of Nursing (DON) | Director of Nursing | Interviewed multiple times regarding care plans, tubi grips, dialysis assessments, and infection control |
| Staff E | Registered Nurse (RN) | Observed and interviewed regarding IV medication administration and catheter care |
| Food Services Director (FSD) | Food Services Director | Interviewed about dishwasher maintenance and temperature logs |
| Staff G | Certified Nursing Assistant and Dietary Aid | Interviewed about food temperature documentation |
| Staff H | Certified Nursing Assistant | Interviewed about meal preparation and food temperature taking |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 14, 2022
Visit Reason
The document is a plan of correction submitted by Hawkeye Care Center Dubuque following a prior inspection, indicating acceptance of a credible allegation of compliance.
Findings
The facility was certified in compliance effective October 14, 2022, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 3
Date: Sep 22, 2022
Visit Reason
The inspection was conducted as a result of investigations of multiple complaints (#101924-C, #107496-C, #107609-C, #107629-C, #107631-C) and a facility reported incident (#104495-I) from September 14, 2022 to September 22, 2022.
Complaint Details
Complaints #107496-C and #107631-C were substantiated. Facility reported incident #104495-I was substantiated.
Findings
The facility was found to have deficiencies related to resident rights, dignity, and care, including failure to provide a dignified dining experience, inappropriate staff communication with residents, inadequate catheter care, and insufficient dementia care. Several complaints and the facility reported incident were substantiated.
Deficiencies (3)
Failure to provide a dignified dining experience for Resident #3, including inappropriate and aggressive communication by staff.
Failure to provide adequate catheter care for Residents #5 and #6, resulting in inadequate catheter hygiene and care.
Failure to provide appropriate care and services for a dementia resident with physical aggressive behaviors (Resident #1).
Report Facts
Resident census: 67
Number of substantiated complaints: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Involved in inappropriate communication with Resident #3 and terminated for misconduct |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding investigation and catheter care standards |
| Staff E | Certified Nursing Assistant (CNA) | Involved in care of Resident #1 and dementia training |
| Staff F | Licensed Practical Nurse (LPN) | Involved in care of Resident #1 and dressing wounds |
| Staff G | Registered Nurse (RN) | Interviewed about Resident #1 incident and restraint practices |
| Administrator | Administrator | Interviewed regarding staff suspension and care plans |
Inspection Report
Renewal
Census: 56
Deficiencies: 3
Date: Jun 17, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification Survey and Investigation of a facility reported incident to assess compliance with Medicare Conditions of Participation.
Findings
The facility was found to be not in compliance due to deficiencies in medication administration practices, specifically failure to lock medication carts and properly prime insulin pens, as well as deficiencies in skin integrity care related to pressure ulcers and expired medications in the drug storage.
Deficiencies (3)
Failure to lock medication carts prior to administration and failure to prime insulin pens before administration.
Failure to identify resident with pressure ulcer upon admission and failure to follow care plan interventions for pressure ulcer prevention and treatment.
Failure to properly label and store drugs and biologics, including failure to dispose of expired medications.
Report Facts
Total residents: 56
Inspection dates: Onsite dates from 2021-06-14 to 2021-06-17
Expired medications found: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | LPN | Named in medication administration deficiencies for not locking medication cart and not priming insulin pen |
| Staff B | LPN | Named in medication administration deficiencies for not locking medication cart and improper insulin administration |
| Staff C | RN | Interviewed regarding medication cart locking and medication administration |
| Staff G | RN | Interviewed regarding medication administration procedures |
| Staff H | LPN | Conducted admission skin assessment and interviewed regarding pressure ulcer identification |
| Director of Nursing | DON | Interviewed regarding expectations for medication cart locking and pressure ulcer care |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Date: Jun 14, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification Survey and Investigation of a facility reported incident to determine compliance with Medicare Conditions of Participation.
Complaint Details
Facility Reported Incident #97873-I was not substantiated.
Findings
The facility was found to be NOT IN COMPLIANCE due to failures in medication administration practices, specifically failing to lock medication carts and properly prime insulin pens, and failures in skin integrity care related to pressure ulcers and documentation.
Deficiencies (3)
Failed to lock medication carts prior to administration and failed to prime the needle of the Humalog Kwikpen prior to insulin administration.
Failed to identify resident with pressure ulcer upon admission and failed to follow care plan interventions for pressure ulcer prevention and treatment.
Failed to properly label, store, and dispose of expired medications.
Report Facts
Total residents: 56
Inspection dates: Onsite dates 2021-06-14 to 2021-06-17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | LPN | Named in medication administration deficiencies for failing to lock medication cart and prime insulin pen |
| Staff B | LPN | Named in medication administration deficiencies for failing to lock medication cart and prime insulin pen |
| Staff C | RN | Interviewed regarding medication cart locking and expired medication disposal |
| Staff G | RN | Interviewed regarding medication administration procedures |
| Staff H | LPN | Conducted admission skin assessment and reported on pressure ulcer identification |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for medication cart locking and pressure ulcer care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 14, 2021
Visit Reason
The inspection was conducted to investigate Complaint #93518-C.
Complaint Details
Complaint #93518-C was investigated and not substantiated.
Findings
The complaint was investigated and found to be not substantiated.
Inspection Report
Abbreviated Survey
Census: 53
Deficiencies: 0
Date: Dec 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted 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
Total residents: 53
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 25, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals from 11/23 to 11/25/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Jul 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted along with an investigation of Complaint #91675-C during 7/20-7/27/20 to assess compliance with CMS and CDC recommended practices.
Complaint Details
The deficiency is related to the investigation of Complaint #91675-C conducted on 7/20-7/27/20.
Findings
The facility was found to be in compliance with COVID-19 infection control practices but failed to provide weekly measurements, assessments, and accurate documentation for a non-pressure skin integrity injury for one resident, indicating a deficiency in quality of care.
Deficiencies (1)
Failure to provide weekly measurements, assessments, and accurate documentation for a non-pressure skin integrity injury for one resident.
Report Facts
Total residents: 66
Complaint number: 91675
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding skin injuries and assessments |
| Staff A | Registered Nurse (RN), Wound Nurse and Quality Assurance Nurse | Interviewed regarding skin assessments and weekly documentation |
| Director of Nursing (DON) | Director of Nursing | Interviewed about responsibilities for skin concerns and care plan updates |
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