Inspection Reports for
Hillcrest Home, INC
915 West First Street, Sumner, IA, 506741271
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
43 residents
Based on a May 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 12, 2025
Visit Reason
A complaint investigation was conducted for complaints #2659823-C, #2617664-C, #2602000-C and a facility reported incident #2624047-I from November 12 to November 13, 2025.
Complaint Details
Investigation involved multiple complaints and a facility reported incident; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 9, 2025
Visit Reason
A complaint investigation was conducted for complaints #2633071-C, #2634511-C, and facility reported incident #2637176-I on October 8 and October 9, 2025.
Complaint Details
Investigation involved multiple complaints and a facility reported incident; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Report Facts
Complaint numbers: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
A complaint investigation for Facility Reported Incidents #1803713-I, #2562456-I and #2563765-I was conducted from August 18, 2025 to August 21, 2025.
Complaint Details
Investigation was related to three facility reported incidents. The facility was found in substantial compliance.
Findings
The facility was found in substantial compliance with no deficiencies cited.
Report Facts
Facility Reported Incidents: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 2, 2025
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective May 19, 2025. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Census: 43
Deficiencies: 1
Date: May 15, 2025
Visit Reason
The inspection was conducted to review the facility's compliance with submission requirements for Minimum Data Set (MDS) assessments as required by the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual and CMS regulations.
Findings
The facility failed to submit 2 completed Minimum Data Set (MDS) assessments for 1 of 5 residents reviewed. The facility is dually certified for all beds with CMS but did not submit required MDS data for Resident #197 as required by CMS.
Deficiencies (1)
Failed to submit 2 completed Minimum Data Set (MDS) assessments for 1 of 5 residents reviewed.
Report Facts
Residents present: 43
Number of residents reviewed: 5
Number of MDS assessments not submitted: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding facility certification and MDS submission | |
| Director of Nursing (DON) | Interviewed regarding MDS assessment completion and submission |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 1
Date: May 15, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included an investigation of complaint #128016-C.
Complaint Details
The complaint #128016-C was investigated and no deficiency was cited related to it.
Findings
No deficiencies were cited related to the complaint. The facility failed to submit 2 completed Minimum Data Set (MDS) assessments for 1 of 5 residents reviewed, specifically Resident #197. The facility reported a census of 43 residents at the time of the survey.
Deficiencies (1)
Failed to submit 2 completed Minimum Data Set (MDS) assessments for 1 of 5 residents reviewed.
Report Facts
Residents reviewed for MDS assessments: 5
Residents with incomplete MDS assessments: 1
Facility census: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Revealed the facility is dually certified for all beds with CMS. | |
| Director of Nursing (DON) | Revealed the facility follows the RAI manual for completing and submission of MDS assessments and acknowledged the entry and admission MDS had not been submitted to CMS as required. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
A revisit of the survey ending February 27, 2025 and investigation of complaint #127166-C was conducted from March 18, 2025 to March 25, 2025.
Complaint Details
Complaint #127166-C was substantiated without deficiency.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective March 11, 2025. Complaint #127166-C was substantiated without deficiency.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
The inspection was conducted based on complaints regarding the care of Resident #2, including delays in pain medication, nursing knowledge, staffing sufficiency, and hospice care integration. Additionally, falls and pain management issues for Resident #1 and Resident #2 were investigated.
Complaint Details
The complaint involved delays in pain medication administration, incompetent nursing knowledge, insufficient staffing, and lack of hospice and integrated nursing care for Resident #2 on 12/22/2024. The grievance was not formally responded to by the facility, and the grievance policy requires a written decision within 30 days.
Findings
The facility failed to promptly investigate and resolve a grievance related to Resident #2's care, delayed pain medication administration for Resident #2, failed to implement root cause analysis for falls resulting in injury for Resident #1, and failed to obtain proper physician orders for morphine dosage increases and suctioning for Resident #2. The facility reported a census of 44 residents.
Deficiencies (4)
Failed to make prompt efforts to resolve and investigate a complaint/grievance for Resident #2.
Failed to implement root cause analysis interventions for previous falls resulting in a fall with fracture and to thoroughly assess Resident #1 after a fall.
Failed to promptly implement a new order to increase morphine dosage for Resident #2.
Failed to obtain a doctor's order to increase morphine dosage and for suctioning during end of life care for Resident #2.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 3
Morphine dose increase: 0.25
Morphine dose increase: 0.5
Morphine dose increase: 1
Falls: 6
Timeframe for grievance decision: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse (LPN) | Named in complaint for delay in pain medication and suctioning Resident #2 |
| Staff B | Registered Nurse (RN) | Documented interactions with Resident #2 family |
| Staff I | Certified Medication Aide (CMA) | Found Resident #1 on floor after fall |
| Staff E | Registered Nurse (RN) | Assisted Resident #1 after fall and educated on fall protocol |
| Staff H | Advanced Registered Nurse Practitioner (ARNP) | Primary Care Provider for Resident #1 |
| Hospice Nurse #1 | Registered Nurse (RN) Clinical Manager | Provided statements on pain medication and suctioning for Resident #2 |
| Administrator | Interviewed regarding complaint and facility policies | |
| Director of Nursing (DON) | Interviewed regarding pain medication orders and fall protocols | |
| Resident #2 Primary Doctor | Interviewed regarding morphine orders and pain management |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
The inspection was conducted as a result of complaint #126537-C and facility reported incident #126776-I, both of which were substantiated. The investigation focused on grievances, accident supervision, pain management, and physician supervision.
Complaint Details
Complaint #126537-C was substantiated. Facility reported incident #126776-I was also substantiated. The investigation included review of grievance letters, resident interviews, staff interviews, and policy reviews.
Findings
The facility failed to make prompt efforts to resolve and investigate a grievance, resulting in a substantiated complaint. Deficiencies were found in grievance policy implementation, accident supervision including fall interventions, pain management including timely medication administration, and physician supervision regarding orders for pain medication. The facility reported a census of 44 residents during the investigation.
Deficiencies (4)
Failure to make prompt efforts to resolve and investigate a grievance regarding resident care and rights.
Failure to implement root cause analysis and interventions for falls resulting in injury for residents.
Failure to promptly implement pain management orders and increase pain medication dosage for residents in need.
Failure to ensure physician supervision and timely approval of pain medication orders for residents.
Report Facts
Census: 44
Complaint letters reviewed: 1
Residents reviewed for falls: 3
Residents reviewed for pain management: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marissa Dugan | RN, PDN | Signed the report on 3/11/25. |
| Beth Oden | Administrator | Signed the report on 3/11/25 and interviewed during investigation. |
| Staff C | Licensed Practical Nurse (LPN) | Named in findings related to delayed pain medication administration and suctioning. |
| Staff E | Registered Nurse (RN) | Nurse assisting Resident #1 during fall and interviewed about fall incident. |
| Staff I | Certified Medication Aide (CMA) | Documented finding Resident #1 on floor after fall. |
| Director of Nursing (DON) | Interviewed regarding fall incident and pain medication orders. | |
| Staff H | Advanced Registered Nurse Practitioner (ARNP) | Primary care provider for Resident #1 interviewed about memory and pain management. |
| Hospice Nurse #1 | Registered Nurse (RN) Clinical Manager | Interviewed regarding pain medication delays and hospice care. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
A complaint investigation was conducted for complaints #125065-C and facility reported incidents #125071-I from December 11, 2024 to December 12, 2024.
Complaint Details
Investigation related to complaints #125065-C and facility reported incidents #125071-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
A complaint investigation for complaint #121988-C and facility reported incident #122168-I was conducted from July 23, 2024 to July 25, 2024.
Complaint Details
Complaint investigation for complaint #121988-C and facility reported incident #122168-I; facility found 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: Jul 10, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the Plan of Correction, and certification in compliance is effective July 8, 2024.
Inspection Report
Routine
Census: 45
Deficiencies: 3
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, quality assurance meeting attendance, and staff training requirements.
Findings
The facility failed to follow physician orders for insulin administration for one resident, did not have required members present at all quarterly Quality Assurance meetings, and failed to ensure mandatory Dependent Adult Abuse training was completed timely for one staff member.
Deficiencies (3)
Failed to follow physician orders regarding insulin administration for Resident #16.
Failed to have the minimum required members present at quarterly Quality Assurance meetings.
Failed to ensure mandatory Dependent Adult Abuse training was completed within 6 months of employment for one staff member.
Report Facts
Residents census: 45
QA meetings conducted: 5
QA meetings with required members present: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Observed administering insulin contrary to physician orders |
| Staff A | Certified Nursing Aide | Failed to complete mandatory Dependent Adult Abuse training within required timeframe |
| Administrator | Interviewed regarding expectations for following physician orders and QA meeting attendance |
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 3
Date: Jun 20, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from June 17, 2024 to June 20, 2024.
Findings
The facility was found deficient in meeting professional standards for comprehensive care plans related to insulin administration for one resident, failure to have required members present at quarterly Quality Assurance (QA) meetings, and failure to ensure mandatory Dependent Adult Abuse training for staff. The facility reported a census of 45 residents during the survey.
Deficiencies (3)
Failure to provide services that meet professional standards regarding insulin administration for Resident #16.
Failure to have minimum required members present at quarterly Quality Assurance meetings as required by CMS.
Failure to ensure mandatory Dependent Adult Abuse training was completed within 6 months of employment for one staff member.
Report Facts
Deficiencies cited: 3
Resident census: 45
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 5, 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 found to be in substantial compliance and will be certified in compliance effective June 4, 2024. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 3
Date: May 30, 2024
Visit Reason
The inspection was conducted following a complaint regarding failure to treat a resident with dignity and respect, and failure to follow physician's medication orders for certain residents.
Complaint Details
The complaint investigation was substantiated with findings that Resident #1 was left unattended without a call light and missed a scheduled bath, and that Residents #3 and #4 did not receive medications as ordered by physicians.
Findings
The facility failed to treat Resident #1 with dignity and respect, as the resident was found unattended in the shower room without a call light and had not received her scheduled bath. Additionally, the facility failed to follow physician's medication orders for Residents #3 and #4, resulting in medication errors and missed doses.
Deficiencies (3)
Failure to treat Resident #1 with dignity and respect, leaving the resident unattended in the shower room without a call light and missing scheduled bath.
Failure to follow physician's orders for medication administration for Resident #3, resulting in administration of wrong medications.
Failure to follow physician's orders for medication administration for Resident #4, resulting in missed doses of potassium.
Report Facts
Residents affected: 1
Residents affected: 2
Census: 47
Medication doses missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Reported Resident #1 was not given bath and called nurse's office |
| Staff B | Certified Nursing Assistant (CNA) | Assigned to give Resident #1 a bath but left resident unattended |
| Staff C | Registered Nurse (RN) | Interviewed regarding Resident #1 incident |
| Staff D | Certified Nursing Assistant (CNA) | Reported searching for Resident #1 and communication over walkie talkie |
| Director of Nursing | Director of Nursing (DON) | Notified about medication error for Resident #3 |
| Facility Administrator | Administrator | Verified expectations for staff treatment of residents and medication administration policies |
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 2
Date: May 30, 2024
Visit Reason
This inspection was a revisit of the survey ending April 25, 2024, and an investigation of incident #120502-I conducted from May 29 to May 30, 2024. The revisit was triggered by a substantiated incident involving resident care.
Complaint Details
The revisit and investigation were related to incident #120502-I, which was substantiated by the facility.
Findings
The facility failed to treat a resident with respect and dignity, resulting in a resident being left unattended in a shower room without a call light. Additionally, the facility failed to follow physicians' orders for medication administration for two residents, resulting in medication errors and missed doses.
Deficiencies (2)
Failed to treat a resident with respect and dignity, leaving the resident unattended in a shower room without a call light.
Failed to follow physicians' orders for medication administration for two residents, resulting in medication errors and missed doses.
Report Facts
Resident census: 47
Medication errors: 2
Medication doses missed: 2
Date of incident: May 2, 2024
Date of incident: May 10, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (Staff A) | Reported that Staff B had not returned to give a resident a bath | |
| Certified Nursing Assistant (Staff B) | Failed to give a resident a bath and left the facility during the incident | |
| Registered Nurse (Staff C) | Interviewed regarding the incident of resident left unattended | |
| Certified Nursing Assistant (Staff D) | Reported on the search for the missing resident | |
| Facility Administrator | Verified expectations for staff to treat residents with dignity and respect and confirmed medication administration policies | |
| Director of Nursing | Director of Nursing (DON) | Notified immediately after medication error involving Resident #3 |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Apr 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication administration error involving Resident #2, which resulted in an emergency room visit.
Complaint Details
The complaint investigation revealed that Resident #2 was given Seroquel without a physician order by Staff B, Certified Medication Aide, who was subsequently terminated. The resident experienced acute hypoxemic respiratory failure requiring emergency care. The medication error was substantiated.
Findings
The facility failed to follow a physician's order and administered medication not prescribed to Resident #2, leading to acute hypoxemic respiratory failure and an emergency room visit. Staff errors included giving Seroquel without an order and improper medication administration practices.
Deficiencies (1)
Failed to follow a physician order resulting in emergency room visit for medication administration error involving Resident #2.
Report Facts
Census: 47
Medication dose: 12.5
Lorazepam dose: 1
Oxygen flow: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Medication Aide | Admitted to giving Resident #2 medication (Seroquel) without a physician order; terminated for this error. |
| Staff A | Registered Nurse | Reported Staff B's admission of medication error. |
| Staff C | Licensed Practical Nurse | Received verbal warning for changing medication order without physician approval. |
| Director of Nursing | Director of Nursing | Provided statements regarding medication errors and staff education. |
| Staff D | Hospice Nurse | Collaborated on medication orders and physician communications. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Apr 25, 2024
Visit Reason
The inspection was conducted as a result of complaint #120277-C and facility reported incidents #117758-I and #118683-I between April 23, 2024 and April 25, 2024.
Complaint Details
Complaint #120277-C was substantiated. Facility reported incidents #117758-I and #118683-I were not substantiated.
Findings
The facility failed to follow a physician order resulting in a medication administration error for one resident. The complaint was substantiated and incidents #117758-I and #118683-I were not substantiated. The facility reported a census of 47 residents during the inspection.
Deficiencies (1)
The facility failed to follow a physician order resulting in an emergency room visit for medication administration for Resident #2.
Report Facts
Census: 47
BIMS score: 10
Medication error report date: 1
Medication dose: 1
Medication dose: 12.5
Oxygen flow: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Medication Aide (CMA) | Terminated for giving medication without prescription; involved in medication error |
| Staff A | Registered Nurse (RN) | Reported on Staff B's medication error and statements |
| Staff C | Licensed Practical Nurse (LPN) | Received verbal warning for changing medication order without physician order |
| Director of Nursing | Involved in educating staff and monitoring compliance; convinced Resident #2 to take medications | |
| Assistant Director of Nursing | ADON | Reported Resident #2's anxious/agitated behavior and medication administration issues |
| Staff D | Hospice Nurse | Collaborated with facility nurse on medication and dosage issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 15, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
The facility was certified in compliance effective March 6, 2023, based on acceptance of a credible allegation of compliance and plan of correction.
Inspection Report
Routine
Census: 51
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to assess compliance with the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) manual requirements, specifically focusing on the transmission and accuracy of Minimum Data Set (MDS) assessments.
Findings
The facility failed to transmit a required MDS discharge assessment for one resident and inaccurately coded MDS assessments for two residents. Deficiencies included failure to submit a Discharge Return Not Anticipated Record timely and inaccurate documentation of insulin injections in MDS assessments.
Deficiencies (2)
Failed to transmit a Minimum Data Set (MDS) discharge assessment record for Resident #12.
Failed to accurately code the Minimum Data Set (MDS) assessments for Residents #36 and #159, including failure to document insulin injections correctly.
Report Facts
Residents Affected: 1
Residents Affected: 2
Census: 51
Insulin doses: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Named in relation to a medication administration error on 2/09/23 for Resident #36 |
| MDS Coordinator | Interviewed regarding MDS submission and coding errors | |
| Administrator | Interviewed regarding facility policies on MDS | |
| Director of Nursing | DON | Interviewed regarding expectations for MDS submission and accuracy |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 3
Date: Feb 23, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from February 20, 2023 to February 23, 2023.
Findings
The facility failed to transmit a Minimum Data Set (MDS) discharge assessment for one resident and failed to accurately code MDS assessments for two residents. Additionally, the facility failed to check veteran status within 30 days of admission for one resident. Deficiencies were related to MDS coding, accuracy of assessments, and admission documentation.
Deficiencies (3)
Facility failed to transmit a Minimum Data Set (MDS) discharge assessment record for one resident.
Facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents.
Facility failed to check Veteran status within 30 days of admission for one resident.
Report Facts
Census: 51
Residents with inaccurate MDS assessments: 2
Residents with missing veteran status check: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Reported forgetting to hit save in the EHR related to insulin administration for Resident #36 |
| Director of Nursing | Director of Nursing (DON) | Reported expectations for timely and accurate MDS submission |
| MDS Coordinator | Reported submitting MDS records weekly and acknowledged mistakes in discharge coding | |
| Social Worker | Completed social history and veteran status check for Resident #18 | |
| Administrator | Reported facility policies and expectations regarding MDS and veteran status submissions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 12, 2023
Visit Reason
A complaint investigation was conducted for complaint #108679-C and facility reported incidents #102532-I, #102698-I, and #110016-I from January 4th through January 12th, 2023.
Complaint Details
Complaint investigation for complaint #108679-C and facility reported incidents #102532-I, #102698-I, and #110016-I; facility found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 4
Date: Oct 5, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation from 9/27 to 10/5/21, including review of complaint #97223-C which was substantiated.
Complaint Details
Complaint #97223-C was substantiated based on investigation findings related to resident rights and care.
Findings
The facility was found deficient in ensuring residents' rights related to advance directives and code status, bed hold notification policies, pressure ulcer prevention and treatment, dialysis care, and documentation of treatments and notifications. Several residents' records showed failures in these areas, and the facility implemented corrective actions including staff education and policy updates.
Deficiencies (4)
Failure to ensure a resident's rights were respected regarding cardiopulmonary resuscitation (CPR) and advance directives, resulting in CPR being performed contrary to resident's wishes.
Failure to provide bed hold notification for facility-initiated transfers and therapeutic leave for 3 residents.
Failure to prevent and treat pressure ulcers appropriately for 1 of 2 residents reviewed.
Failure to assess and monitor dialysis access site and provide ongoing dialysis care for 1 resident requiring dialysis.
Report Facts
Residents reviewed for CPR rights: 17
Residents reviewed for bed hold notification: 3
Residents reviewed for pressure ulcer treatment: 2
Residents reviewed for dialysis care: 1
Facility census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deanna Kahler | Administrator | Provided education on bed hold policy and monitored compliance |
| Amber Brady | Director of Nursing | Developed policies, provided staff education, and monitored treatment compliance |
| Stacie Boess | Assistant Director of Nursing | Provided education and conducted audits related to nursing care and dialysis |
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on December 16 - 17, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 25, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on November 24 - 25, 2020.
Findings
The facility was found in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Jun 9, 2020
Visit Reason
The inspection was conducted as an onsite Infection Control survey related to allegations of non-compliance with infection prevention and control regulations.
Complaint Details
The visit was complaint-related, triggered by allegations of non-compliance with infection control practices. The Plan of Correction submitted by the facility constitutes their response to these allegations but does not admit to the existence of deficiencies.
Findings
The facility failed to ensure proper infection prevention and control practices, including inadequate hand hygiene, improper use of gloves, and failure to follow peri-care procedures. Specific issues were noted with staff handling of trash bags during peri-care and deficiencies in the facility's Incontinence Perineal Care Policy and Foley catheter care procedures.
Deficiencies (1)
Failure to establish and maintain an infection prevention and control program as required by 42 CFR Part 483, Subpart B-C.
Report Facts
Census: 44
Brief Interview for Mental Status score: 6
Brief Interview for Mental Status score: 13
Date: Jun 9, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Observed performing peri-care and hand hygiene during infection control survey |
| Staff B | Certified Nursing Assistant (CNA) | Observed performing peri-care and handling trash bags during infection control survey |
| Staff C | Licensed Practical Nurse | Interviewed regarding peri-care procedures and infection control practices |
| Staff D | Certified Nursing Assistant (CNA) | Interviewed regarding training on peri-care procedures |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding peri-care procedures, infection control policies, and COVID disinfectant practices |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding Foley catheter care and infection control risks |
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