Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 4
Dec 15, 2025
Visit Reason
The inspection was conducted as an investigation of complaints #2649531-C, #2661248-C, #2670562-C, and #2691485-C from December 8 to December 15, 2025. The visit was triggered by these complaints, some of which resulted in deficiencies.
Findings
The facility failed to provide a safe, clean, and homelike environment, failed to administer medications as prescribed for 2 of 3 residents reviewed, failed to provide a restorative program for 3 residents at risk of physical decline, and failed to have sufficient nursing staff to meet resident needs. Environmental concerns included unclean floors, rusted heating/air conditioning units, and a broken hopper. Medication administration delays and missed doses were documented. Residents reported delays in call light responses and lack of restorative programs.
Complaint Details
The visit was conducted as an investigation of complaints #2649531-C, #2661248-C, #2670562-C, and #2691485-C. Complaints #2649531-C, #2691485-C, and #2661248-C resulted in deficiencies.
Severity Breakdown
E: 1
D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide a safe, clean, and homelike environment including unclean floors, rusted heating/air conditioner units, and broken hopper. | E |
| Failure to administer medication as prescribed for 2 of 3 residents reviewed, including missed doses of Hydromorphone and delayed start of prescribed antibiotics and steroids. | D |
| Failure to provide a restorative program for 3 residents at risk of physical decline related to diagnosis and risk of falls. | D |
| Failure to have sufficient nursing staff to meet resident needs, including delayed response to call lights and insufficient aides on hallways. | D |
Report Facts
Census: 43
Medication missed doses: 5
Call light response time: 18
Call light response time: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Transportation/Maintenance | Reported hopper out of order and floors needing cleaning |
| Staff G | Assistant Director of Nursing | Reported medication errors and failure to order Hydromorphone on time |
| Staff H | Registered Nurse | Reported working on 12/7/2025 and described medication delay for Resident #2 |
| Staff F | Interim Director of Nursing | Reported staff failed to order medication timely and planned in-service on medication administration |
| Staff D | Occupational Therapist | Reported no restorative program and efforts to start one |
| Staff C | Certified Nursing Assistant | Reported staffing shortages and working late to complete resident baths |
| Staff B | Nurse Practitioner | Assisted Resident #6 with positioning and lunch |
| Administrator | Reported no restorative program and other pressing issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 4, 2025
Visit Reason
The document is a plan of correction following a survey ending on October 8, 2025, indicating acceptance of a credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the plan of correction submitted, leading to certification effective November 30, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Oct 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints (#2560439-C, #2563019-C, #2570444-C, #2586522-C, #2592954-C, and #2593408-C) from September 4, 2025 to October 8, 2025.
Findings
The facility failed to follow physician orders for 2 of 7 resident records reviewed, failed to complete appropriate wound condition assessments, and did not document that prescribed dressing/wound care treatments were completed as ordered for 1 of 3 residents reviewed with wounds. The facility reported a census of 44 residents. The deficiencies relate to quality of care and wound management.
Complaint Details
The investigation was triggered by complaints #2563019-C, #2570444-C, and #2586522-C which resulted in a deficiency.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to follow physician orders for 2 of 7 resident records reviewed and failed to complete appropriate wound condition assessments and documentation for 1 of 3 residents with wounds. | SS = D |
Report Facts
Complaints investigated: 6
Residents reviewed for physician order compliance: 7
Residents reviewed for wound care documentation: 3
Resident census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Director of Nursing | Stated nurse on duty should have implemented orders as directed by Nurse Practitioner |
| Staff C | RN | Completed wound care and dressing changes as ordered; documented wound healing |
| Staff F | Licensed Practical Nurse | Directed staff to implement new orders and documented wound care treatments |
| Staff J | LPN | Documented wound care on 8/5/25 |
| Staff D | LPN | Prepared wound care supplies and cleansed wound; observed wound care |
| Staff B | LPN | Administered medication and monitored resident |
| Staff K | LPN | Documented wound care on 8/6/25 and 8/7/25 |
| Staff L | Certified Nursing Assistant | Observed resident behavior and alerted nurse |
| Staff E | Corporate Consultant Nurse | Reviewed medical record documents and noted missing NP orders |
| Staff I | Occupational Therapist and Therapy Manager | Reported resident refusal of therapy and lack of notification to surgeon |
| Staff G | Nurse Practitioner | Provided orders and progress notes for resident care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 12, 2025
Visit Reason
A complaint investigation for complaint #129226-C was conducted from June 11, 2025 to June 12, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #129226-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 2, 2025
Visit Reason
The document serves as a Plan of Correction following a survey ending on May 8, 2025, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective May 30, 2025.
Report Facts
Survey end date: May 8, 2025
Certification effective date: May 30, 2025
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 7
May 8, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #127560-C, #127564-C, and #127924-C from May 5 to May 8, 2025.
Findings
The facility was found deficient in multiple areas including resident rights related to vaping inside the building, self-administration of medications, Medicaid/Medicare coverage notifications, quality of care regarding seizure management, free of accident hazards, bowel/bladder incontinence management, and medication error prevention. The facility failed to provide a homelike environment, adequate supervision, proper documentation, and timely notifications as required by regulations.
Complaint Details
The visit included investigation of complaints #127560-C, #127564-C, and #127924-C, all of which resulted in deficiencies.
Severity Breakdown
SS=D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to provide a homelike environment when staff used a nicotine vape pen in common areas. | SS=D |
| Facility failed to assess and care plan for a resident to self-administer medications. | SS=D |
| Facility failed to provide a notice of Medicare Non-Coverage upon discharge for a resident. | SS=D |
| Facility failed to assess the resident and notify the physician of changes in condition related to seizure activity. | SS=D |
| Facility failed to ensure a resident was positioned safely during meals to prevent choking. | SS=D |
| Facility failed to develop and implement interventions to restore or improve bladder function and prevent urinary tract infections. | SS=D |
| Facility failed to ensure residents were free from significant medication errors, including proper insulin pen priming and administration. | SS=D |
Report Facts
Census: 46
Deficiencies cited: 7
Seizures per day: 7
Seizures per day: 4
Insulin injections: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Activities Staff | Named in vaping inside facility deficiency and was counseled and reeducated on tobacco policy |
| Staff E | Certified Nursing Assistant (CNA) | Reported witnessing vaping and seizures, involved in observations and interviews |
| Staff F | Certified Medication Assistant (CMA) | Reported vaping and seizure observations, involved in medication administration |
| Staff G | Housekeeping | Witnessed Staff H smoking in office |
| Director of Nursing (DON) | Observed vaping, directed staff to stop, involved in seizure management and medication administration findings | |
| Administrator | Interviewed regarding vaping and policy, communicated plan of correction | |
| Staff A | Licensed Practical Nurse (LPN) | Involved in medication administration and seizure documentation |
| Staff B | Social Worker (SW) | Responsible for beneficiary notices of Medicare Non-Coverage |
| Staff J | Certified Nursing Assistant (CNA) | Reported on Resident #9 seizure activity |
| Staff P | Registered Nurse (RN) | Involved in seizure management and catheter care |
| Staff I | Certified Nursing Assistant (CNA) | Reported catheter tubing concerns |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 24, 2025
Visit Reason
The document is a Plan of Correction related to a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective March 18, 2025.
Findings
The facility submitted a Plan of Correction which was accepted, leading to certification in compliance effective March 18, 2025. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 2
Mar 3, 2025
Visit Reason
The inspection was conducted as an investigation of complaints #126468-C, #126956-C, and #126968-C from March 3 to March 4, 2025.
Findings
The facility failed to follow standard and transmission-based precautions to prevent the spread of infections for 4 of 4 residents reviewed. Additionally, the facility failed to employ an Infection Prevention Specialist. Observations and interviews revealed multiple failures in infection control practices including lack of signage, failure to don gowns during care, and inadequate staff education on Enhanced Barrier Precautions.
Complaint Details
Investigation of complaints #126468-C, #126956-C, and #126968-C conducted from March 3 to March 4, 2025. The complaints were substantiated as the facility failed to follow infection control protocols and lacked a qualified Infection Preventionist.
Deficiencies (2)
| Description |
|---|
| Failure to establish and maintain an infection prevention and control program including standard and transmission-based precautions. |
| Failure to employ an Infection Preventionist qualified by education, training, or certification. |
Report Facts
Resident census: 45
Residents reviewed for infection control: 4
Complaints investigated: 3
Dates of inspection: 2025-03-03 to 2025-03-04
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant (CNA) | Observed failing to don gowns during care and providing catheter care. |
| Staff D | Certified Nursing Assistant (CNA) | Observed failing to don gowns during care and providing catheter care. |
| Staff E | Certified Nursing Assistant (CNA) | Interviewed regarding gown use and infection control knowledge. |
| Staff F | Administrator | Interviewed about infection control staffing and education. |
| Staff B | Registered Nurse (RN) | Observed sanitizing hands and donning gloves but failing to don gown. |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 26, 2025
Visit Reason
The document is a Plan of Correction related to a prior survey ending on January 14, 2025, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective February 7, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction for the prior survey. No specific deficiencies or findings are detailed in this document.
Report Facts
Survey end date: Jan 14, 2025
Certification effective date: Feb 7, 2025
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Jan 14, 2025
Visit Reason
The inspection was conducted as a result of complaint investigations #123916-C and #124349-C, which were substantiated.
Findings
The facility failed to provide sufficient nursing staff to answer call lights within 15 minutes for all activated call lights reviewed. Observations and interviews revealed delayed responses to call lights and staffing shortages during the inspection period.
Complaint Details
Complaints #123916-C and #124349-C were substantiated.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide sufficient nursing staff to answer call lights within 15 minutes for all activated call lights reviewed. |
Report Facts
Census: 44
Call light activations: 4
Call light response times: 39
Call light response times: 32
Call light response times: 29
Call light response times: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding staffing and medication passing on East Hall |
| Staff B | Certified Nursing Assistant (CNA) | Interviewed about arrival time and car troubles |
| Staff C | Director of Nursing (DON) | Interviewed about call light audits and complaints |
| Staff D | Activities Director | Interviewed about resident complaints regarding call lights |
| Kelley Donohoay | Administrator | Signed the report and responsible for education and monitoring in plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 26, 2024
Visit Reason
A complaint investigation was conducted for complaints #122517-C, #122535-C, and #123537-C from September 20, 2024 to September 26, 2024.
Findings
The facility was found to be in substantial compliance with no deficiencies noted.
Complaint Details
Complaint investigation for complaints #122517-C, #122535-C, and #123537-C; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 8, 2024
Visit Reason
The document is a plan of correction submitted following a survey, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility will be certified in compliance effective August 6, 2024, based on acceptance of the plan of correction and credible allegation of compliance.
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 5
Jul 18, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #119785-C, #121600-C, and #121667-C.
Findings
The facility was found to have deficiencies related to resident rights, medication administration, accident prevention, infection control, and smoking policies. Some complaints were substantiated while others were not. The facility failed to uphold resident dignity and safety in several instances, including improper medication monitoring and failure to prevent accidents.
Complaint Details
Complaint #119785-C was not substantiated. Complaints #121600-C and #121667-C were substantiated.
Deficiencies (5)
| Description |
|---|
| Resident Rights - Facility failed to uphold resident rights and dignity for 1 of 1 residents reviewed on hospice care. |
| Services Provided Meet Professional Standards - Facility failed to provide services that met professional standards regarding medication administration and following physician orders for 2 of 9 residents reviewed. |
| Free of Accident Hazards/Supervision/Devices - Facility failed to protect a resident from hazards resulting in first degree burns from spilled coffee and failed to ensure proper smoking policy adherence. |
| Infection Prevention & Control - Facility failed to establish and maintain an infection prevention and control program to prevent cross contamination and infections for residents. |
| Food Safety - Facility failed to ensure proper personal hygiene practices to prevent contamination of food when staff failed to wear beard guards in the kitchen area. |
Report Facts
Census: 46
Residents reviewed for medication administration: 9
Residents with medication administration issues: 2
Residents with accident hazard issues: 1
Residents with infection control review: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Certified Nursing Assistant (CNA) | Named in observation of personal cell phone use while assisting a resident. |
| Staff I | Licensed Practical Nurse (LPN) | Named in medication administration documentation. |
| Staff J | Certified Medication Aide (CMA) | Reported medication cups left unattended on residents' bedside tables. |
| Staff G | Certified Medication Aide (CMA) | Reported observations related to resident medication and behaviors. |
| Staff H | Certified Nursing Assistant (CNA) | Involved in incident response for resident burn from hot coffee. |
| Staff C | Registered Nurse (RN) | Reported on medication administration and resident supervision. |
| Director of Nursing (DON) | Administrator/Designee | Responsible for education, audits, and follow-up related to deficiencies. |
| Assistant Director of Nursing (ADON) | Administrator/Designee | Reported on resident supervision and incident follow-up. |
| Staff F | Certified Nursing Assistant (CNA) | Reported on resident smoking behaviors and supervision. |
| Staff K | Housekeeper | Observed cleaning cigarette butts from facility grounds. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 2, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance, certifying the facility in compliance effective March 25, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification of compliance.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 3
Mar 5, 2024
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#119031-C, #118857-C, #118374-C, #117860-C, #115648-C, #115537-C, #115560-C, #115346-C, #114933-C) and a facility reported incident (#118061-I) between February 27, 2024 and March 5, 2024.
Findings
Several complaints and the facility reported incident were substantiated, including failure to document resident emergency contact picking up personal possessions after death, incomplete incontinence care, and inadequate supervision leading to an elopement. The facility implemented corrective actions including audits, education, and monitoring to address these deficiencies.
Complaint Details
Complaints #114993-C, #115648-C, #117860-C, #118374-C, and #119031-C were substantiated. Facility reported incident #118061-I was substantiated.
Deficiencies (3)
| Description |
|---|
| Facility failed to document if the resident's emergency contact picked up personal possessions after death for 1 of 5 residents reviewed (Resident #7). |
| Facility failed to perform complete incontinent cares following urinary incontinence for 1 of 3 residents reviewed (Resident #15). |
| Facility failed to ensure adequate supervision and assistance devices to prevent accidents, resulting in an elopement of 1 of 4 residents reviewed (Resident #5). |
Report Facts
Complaints investigated: 9
Facility reported incident: 1
Resident census: 39
Residents reviewed for personal possessions: 5
Residents reviewed for incontinent care: 3
Residents reviewed for supervision: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in findings related to personal possessions and elopement supervision |
| Administrator | Administrator | Named in findings related to resident belongings and elopement supervision |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed regarding resident #7 hospital transfer and belongings |
| Staff E | Certified Nursing Assistant (CNA) | Observed providing incontinent care to Resident #15 |
| Staff C | Registered Nurse (RN) | Observed Resident #5 last seen before elopement |
| Staff B | Certified Nurse Aide (CNA) | Responded to door alarm and observed Resident #16 outside |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding resident belongings and elopement |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 2, 2023
Visit Reason
The document serves as a plan of correction following a denial of payment for new admits (DPNA) from July 5, 2023 to August 16, 2023, indicating the facility's acceptance of compliance and plan of correction.
Findings
The facility was certified in compliance effective August 17, 2023, based on acceptance of a credible allegation of compliance and plan of correction. The DPNA was in effect from July 5, 2023 to August 16, 2023.
Report Facts
Denial of Payment for New Admits (DPNA) period: From July 5, 2023 to August 16, 2023
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 2
Aug 1, 2023
Visit Reason
The inspection was conducted as an On-Site Revisit of the Recertification Survey ending on May 25, 2023, and the investigation of Complaint #114098-C, conducted from July 26, 2023 to August 1, 2023.
Findings
The facility was found to be out of compliance with regulations related to smoking safety and pain management. Resident #1 smoked in non-designated areas, creating a fire hazard, and the facility failed to ensure proper supervision and safety measures. Additionally, the facility failed to order and administer narcotic pain medication in a timely manner for Resident #1, causing interruption of pain management.
Complaint Details
Complaint #114098-C was substantiated.
Deficiencies (2)
| Description |
|---|
| Facility staff failed to ensure 1 out of 15 residents who smoked used appropriate receptacles and failed to ensure safety when Resident #1 smoked in their room on repeated occasions. |
| Facility failed to order a resident's narcotic pain medication in a timely manner causing interruption of continuous pain management and control for 1 of 2 residents reviewed. |
Report Facts
Total Residents: 46
Residents who smoked: 15
Pain rating: 10
Fentanyl patches: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 6, 2023
Visit Reason
A complaint investigation was conducted for Complaints #113924-C, #113621-C and a Facility Self-Reported Incident #113876-I from July 3, 2023 to July 6, 2023.
Findings
No deficiencies were cited during the complaint investigation.
Complaint Details
Investigation involved Complaints #113924-C, #113621-C and a Facility Self-Reported Incident #113876-I; no deficiencies were found.
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 20
May 25, 2023
Visit Reason
The inspection was a Recertification Survey and an investigation of multiple complaints and facility self-reported incidents conducted by Healthcare Management Solutions, LLC on behalf of the Iowa Department of Inspections and Appeals from May 22 to May 25, 2023.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, care planning participation, notification of changes, medication management, safe environment, misappropriation of medication, comprehensive care planning, activities program, vision services, accident hazards, pain management, nurse staffing, nurse staffing posting, menu planning and adherence, food palatability, food safety and sanitation, binding arbitration agreements, payroll based journal submission, and pest control.
Complaint Details
Complaint #112321-C was substantiated. Facility Self-Reported Incident #112897-I was substantiated.
Severity Breakdown
SS=F: 7
SS=E: 4
SS=D: 7
Deficiencies (20)
| Description | Severity |
|---|---|
| Facility failed to treat one resident with dignity during observed staff conversation about the resident. | SS=D |
| Facility failed to ensure one resident was included in all aspects of person-centered care planning. | SS=D |
| Facility failed to provide resident rights orally and in writing annually to residents in resident council. | SS=F |
| Facility failed to notify physician or nurse practitioner when blood glucose levels were outside ordered parameters for one resident. | SS=D |
| Facility failed to maintain a safe, clean, comfortable, and homelike environment including proper cleaning and maintenance of smoking area and resident rooms. | SS=E |
| Facility failed to ensure one resident was free from misappropriation of medication; 10 doses of Gabapentin were missing and unaccounted for. | SS=D |
| Facility failed to develop and implement a comprehensive care plan for diabetes management for one resident. | SS=D |
| Facility failed to provide an ongoing activities program meeting resident interests and needs for four residents. | SS=E |
| Facility failed to ensure the activities program was directed by a qualified therapeutic recreation specialist or activities professional. | SS=F |
| Facility failed to assist one resident in gaining access to vision services to fix broken glasses. | SS=D |
| Facility failed to ensure one resident who smokes was smoking in a designated area and using appropriate receptacles for cigarette butts. | SS=D |
| Facility failed to reorder narcotic pain medication timely, notify provider timely of medication unavailability, and monitor effectiveness for one resident. | SS=D |
| Facility failed to ensure a Registered Nurse was on duty eight consecutive hours per day seven days a week. | SS=F |
| Facility failed to ensure nurse staffing information was complete, accurate, posted prominently, and in readable format. | SS=F |
| Facility failed to maintain an effective pest control program; residents reported insects and spiders in rooms and pest control receipts lacked treatment details. | SS=E |
| Facility failed to monitor side effects and adverse consequences of psychotropic medications for two residents. | SS=D |
| Facility failed to plan menus for a therapeutic diet for one resident and failed to follow menus for all residents reviewed. | SS=F |
| Facility failed to serve food that was palatable, attractive, and at an appetizing temperature to three residents. | SS=E |
| Facility failed to ensure kitchen floors and walls were clean and easily cleanable, foods stored in refrigerators and freezers were sealed, labeled, and discarded after expiration, and mop water was discarded properly. | SS=F |
| Facility failed to ensure residents understood the Binding Arbitration Agreement before signing for four residents. | SS=E |
Report Facts
Deficiencies cited: 19
Resident census: 51
Missing Gabapentin doses: 10
Days without RN coverage: 4
Days without 8 consecutive RN hours: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in medication misappropriation and blood glucose notification deficiencies. |
| Resident #21 | Resident | Named in medication misappropriation and binding arbitration agreement deficiencies. |
| Resident #3 | Resident | Named in psychotropic medication monitoring and therapeutic diet deficiencies. |
| Resident #26 | Resident | Named in psychotropic medication monitoring and food palatability deficiencies. |
| Resident #36 | Resident | Named in smoking area and activities program deficiencies. |
| Resident #48 | Resident | Named in pain management deficiency. |
| Administrator | Named in multiple deficiencies including medication, activities, pest control, and arbitration agreement. | |
| Corporate Administrator | Named in multiple deficiencies including medication, activities, pest control, and arbitration agreement. | |
| Vice President of Clinical Services | Named in multiple deficiencies including medication, activities, pest control, and arbitration agreement. | |
| Dietary Manager | Named in menu and food safety deficiencies. | |
| Business Office Manager | Named in binding arbitration agreement deficiency. | |
| Social Service Director | Named in binding arbitration agreement deficiency. | |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Named in blood glucose notification deficiency. |
| Registered Nurse 1 | Registered Nurse | Named in medication misappropriation deficiency. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 3, 2023
Visit Reason
A complaint investigation of Complaint #111897-C was conducted from March 30, 2023 to April 03, 2023.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #111897-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 9, 2023
Visit Reason
An on-site revisit of the complaint survey ending December 8, 2022, and an investigation of Complaints #109721-C, #109832-C, #109968-C, and Facility Self-Reported Incidents #109817-I and #111275-I was conducted from March 6, 2023 to March 9, 2023.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective January 13, 2023. Complaints and self-reported incidents investigated were not substantiated.
Complaint Details
Complaints #109721-C, #109832-C, #109968-C were not substantiated. Facility Self-Reported Incidents #109817-I and #111275-I were not substantiated.
Report Facts
Denial of Payment for New Admits (DPNA) duration: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 9, 2023
Visit Reason
This document is a plan of correction related to deficiencies identified during a survey conducted on 2023-03-09.
Findings
The document references deficiencies identified in the survey event ID #0CYD11 but does not provide specific details of the findings within this page.
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 8
Jan 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of resident neglect, abuse, and failure to provide adequate care and dignity to residents.
Findings
The facility failed to ensure residents were treated with dignity and respect, failed to provide adequate supervision and care, and did not properly investigate and report allegations of abuse and neglect. Multiple deficiencies were identified related to resident rights, care planning, medication administration, and staff training.
Complaint Details
The complaint investigation was substantiated with findings of neglect, abuse, and failure to provide adequate care and dignity to residents. The facility was found to have multiple deficiencies related to these allegations.
Deficiencies (8)
| Description |
|---|
| Staff failed to treat residents with dignity and respect, including failure to respond appropriately to resident needs and complaints. |
| Facility failed to ensure residents were free from abuse, neglect, and exploitation. |
| Failure to provide adequate supervision and care to prevent resident-to-resident altercations and injuries. |
| Inadequate investigation and reporting of abuse allegations. |
| Failure to provide adequate training and education to staff on abuse prevention and resident rights. |
| Failure to maintain accurate and complete clinical records and care plans. |
| Failure to ensure proper medication administration and monitoring. |
| Failure to maintain adequate infection control and safety measures. |
Report Facts
Resident census: 63
Deficiency count: 8
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 26, 2022
Visit Reason
The document reflects acceptance of the facility's credible allegation of compliance and plan of correction for regulatory deficiencies.
Findings
The facility was certified in compliance effective October 26, 2022, based on acceptance of the plan of correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Routine
Census: 59
Deficiencies: 9
Sep 26, 2022
Visit Reason
The inspection was a routine survey of Iowa City Rehab & Health Care to assess compliance with federal regulations including complaint investigations and follow-up on prior deficiencies.
Findings
The facility was found deficient in multiple areas including failure to document deposits of residents' personal funds, failure to follow physician orders for medications and treatments, inadequate bathing and hygiene care, failure to properly assess and treat pressure ulcers, medication administration errors, insufficient nursing staff response to call lights, incomplete documentation of resident assessments, and failure to provide medically-related social services.
Severity Breakdown
SS=E: 4
SS=D: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to document deposits of resident's monthly allowance for Medicaid funded resident. | — |
| Failed to follow physician orders for medications and treatments for multiple residents. | SS=E |
| Failed to provide twice weekly showers or bed baths to multiple residents. | SS=E |
| Failed to document assessments and interventions for resident with mental status changes and pain management. | SS=D |
| Failed to provide medically-related social services to address resident needs. | SS=D |
| Failed to complete daily shift narcotic counts and document controlled substance counts accurately. | SS=D |
| Medication error rate exceeded 5% with errors in medication administration and order entry. | SS=D |
| Failed to provide complete and accurate documentation of resident assessments, wound care, and medication administration records. | SS=E |
| Failed to ensure call lights were answered timely for residents. | — |
Report Facts
Census: 59
Medication error rate: 16
Pressure ulcer measurements: 25.3
Pressure ulcer measurements: 19.2
Pressure ulcer measurements: 1.2
Number of pressure ulcers: 12
Days without shower: 20
Days without shower: 18
Days without shower: 17
Medication administration missing documentation: 29
Medication administration missing documentation: 17
Medication administration missing documentation: 40
Medication administration missing documentation: 6
Medication administration missing documentation: 36
Medication administration missing documentation: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Medication Assistant | Named in medication error finding for administering wrong medications to Resident #18 and #19 |
| Staff A | Registered Nurse | Named in wound care and mental status change findings for Resident #1 |
| Staff C | Certified Nursing Assistant | Named in wound care and mental status change findings for Resident #1 |
| Staff E | Nurse Practitioner | Named in wound care and mental status change findings for Resident #1 |
| Staff O | Licensed Practical Nurse | Named in wound care and pressure ulcer assessment findings |
| Staff D | Registered Nurse | Named in wound care and pressure ulcer assessment findings |
| Staff J | Registered Nurse | Named in wound care and pressure ulcer assessment findings |
| Staff V | Registered Nurse | Named in narcotic count and medication administration findings |
| Staff Q | Licensed Practical Nurse | Named in narcotic count and medication administration findings |
| Staff R | Certified Nursing Assistant | Named in call light response deficiency |
| Staff M | Certified Nursing Assistant | Named in call light response deficiency |
| Staff N | Certified Nursing Assistant | Named in call light response deficiency |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 17, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective June 17, 2022.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 8
May 17, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from April 26, 2022 to May 17, 2022, along with the investigation of multiple complaints (#103517-C, #103942-C, #103997-C, #103999-C, #104614-C). The visit was complaint-driven to investigate allegations related to infection control and care deficiencies.
Findings
The facility was found not in compliance with CMS and CDC recommended practices to address COVID-19. Multiple deficiencies were identified including failure to provide adequate ADL care (bathing), insufficient nursing staff, inadequate quality of care related to wound management, failure to provide sufficient nursing staff, poor nutritional food temperature control, infection prevention and control program deficiencies, failure to properly sanitize laundry, and failure to properly administer influenza, pneumococcal, and COVID-19 immunizations.
Complaint Details
Complaints #103517-C, #103942-C, #103997-C, #103999-C, and #104614-C were substantiated. The investigation revealed multiple care and infection control deficiencies.
Deficiencies (8)
| Description |
|---|
| Failure to consistently provide necessary ADL care including bathing for dependent residents. |
| Failure to provide a comprehensive assessment for residents to ensure treatment and care in accordance with professional standards. |
| Failure to provide sufficient nursing staff with appropriate competencies and skills to assure resident safety and care. |
| Failure to ensure food was prepared and served at safe and appetizing temperatures. |
| Failure to establish and maintain an infection prevention and control program meeting regulatory requirements. |
| Failure to properly sanitize laundry resulting in unsanitized laundry for at least 3 months. |
| Failure to ensure residents received influenza and pneumococcal immunizations or properly documented refusals. |
| Failure to ensure residents received COVID-19 immunizations or properly documented refusals. |
Report Facts
Total Residents: 58
Number of residents not receiving at least two baths per week: 6
Number of residents reviewed for bathing deficiencies: 12
Number of residents reviewed for influenza and pneumococcal immunizations: 12
Number of residents reviewed for COVID-19 immunizations: 5
Laundry loads per day: 10
Laundry detergent bottles purchased: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gina Anderson | Administrator | Provided education on infection control practices and laundry detergent use; involved in root cause analysis and corrective action plans. |
| Staff G | Certified Nursing Assistant (CNA) | Interviewed regarding staffing and bathing issues. |
| Staff H | Registered Nurse (RN) | Confirmed staffing levels and bathing deficiencies. |
| Staff F | Dietary Staff | Interviewed about food temperature and meal service. |
| Staff E | Dietary Staff | Interviewed about food temperature and meal service. |
| Staff I | Registered Nurse (RN) | Interviewed about skin assessments and wound care. |
| Staff D | Housekeeping Supervisor | Interviewed about laundry detergent and cleaning supplies. |
| Staff K | Account and Service Representative | Reported unpaid invoices for chemical supplies. |
| Staff B | Licensed Practical Nurse (LPN) | Administered influenza vaccination. |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 21
Nov 8, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaints.
Findings
The facility was found to have multiple deficiencies including housekeeping and maintenance issues, inadequate abuse/neglect training for staff, failure to provide proper transfer and discharge documentation, insufficient care planning and assessments, medication administration errors, and infection control concerns. The facility reported a census of 61 residents during the inspection.
Deficiencies (21)
| Description |
|---|
| Housekeeping and maintenance services failed to maintain a sanitary, orderly, and comfortable interior, including holes in window screens, broken floor tiles, and pest control issues. |
| Facility failed to provide abuse/neglect training to all required staff within six months of hire. |
| Facility failed to provide proper transfer and discharge documentation for residents. |
| Facility failed to provide proper bed hold notices to residents upon transfer. |
| Facility failed to complete and transmit resident assessments and care plans timely and accurately. |
| Facility failed to ensure medication administration was done according to professional standards, including insulin pen priming and crushed medications without supervision. |
| Facility failed to ensure sufficient nursing staff to meet resident needs and failed to respond timely to call lights. |
| Facility failed to ensure residents were free from unnecessary psychotropic medications and properly monitored. |
| Facility failed to provide routine and emergency dental services timely. |
| Facility failed to ensure quality of care related to pressure ulcer prevention and treatment. |
| Facility failed to ensure infection prevention and control program was fully implemented. |
| Facility failed to ensure proper use and maintenance of bed rails. |
| Facility failed to ensure sufficient nursing staff with appropriate competencies and skills. |
| Facility failed to ensure residents received appropriate dialysis care and post dialysis assessments. |
| Facility failed to ensure residents received appropriate skin and wound care management. |
| Facility failed to ensure residents received appropriate discharge planning and recapitulation of stay. |
| Facility failed to ensure residents received appropriate dental care and timely referrals. |
| Facility failed to ensure residents received appropriate care planning and care conferences. |
| Facility failed to ensure residents were free from unnecessary psychotropic drugs and PRN use was properly documented and limited. |
| Facility failed to ensure proper hand hygiene and infection control practices during medication administration. |
| Facility failed to ensure residents with pressure ulcers received appropriate treatment and monitoring. |
Report Facts
Resident census: 61
Number of residents reviewed for bedrails: 1
Number of residents reviewed for dialysis: 1
Number of residents reviewed for psychotropic medication: 2
Number of residents reviewed for dental services: 3
Number of residents reviewed for pressure ulcers: 2
Number of residents reviewed for care planning: 5
Number of residents reviewed for discharge planning: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Housekeeping Supervisor | Named in findings related to housekeeping deficiencies and training |
| Staff G | Regional Nurse Consultant | Named in findings related to abuse training and medication recommendations |
| Staff C | Oral Medication Technician (OMT) | Named in findings related to medication administration |
| Staff B | Licensed Practical Nurse (LPN) | Named in findings related to insulin administration and wound care |
| Staff E | Registered Nurse (RN) | Named in findings related to wound care and medication administration |
| Staff H | Certified Nursing Assistant | Named in findings related to medication administration |
| Staff A | Licensed Practical Nurse (LPN) | Named in findings related to dialysis assessments |
| Staff D | Oral Medication Technician (OMT) | Named in findings related to medication administration |
| Staff I | Administrator | Named in findings related to housekeeping audits and facility plans |
| Staff G | Regional Nurse Consultant | Named in findings related to MDS and pharmacy recommendations |
| Staff C | Certified Medication Aid (CMA) | Named in findings related to medication administration |
| Staff E | Assistant Director of Nursing (ADON) | Named in findings related to wound care and assessments |
| Staff F | Licensed Practical Nurse (LPN) | Named in findings related to catheter care and medication administration |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Feb 8, 2021
Visit Reason
The inspection was conducted in response to multiple complaints (#895384, #89729, #93355, #94967, #94973, #95120, #95286, and #95397) reported between December 22, 2020 and February 8, 2021.
Findings
The facility failed to provide necessary care and services to maintain residents' optimal health and physical well-being, including inadequate wound assessments and pressure ulcer prevention and treatment. Specific deficiencies were noted in admission assessments, dialysis site assessments, and pressure ulcer care for residents #1 and #8.
Complaint Details
The investigation was related to complaints #94973 and #95286-C. The deficiencies cited relate to failure in quality of care and skin integrity standards as evidenced by Resident #1 and Resident #8's cases.
Deficiencies (2)
| Description |
|---|
| Failure to provide necessary care and services to maintain residents' optimal health and physical well-being, including inadequate wound assessments and dialysis site assessments for Resident #1. |
| Failure to ensure residents do not develop pressure ulcers unless unavoidable, and failure to provide necessary treatment and services consistent with professional standards for Resident #8. |
Report Facts
Complaints reported: 8
Census: 59
Dates of assessments and treatments: Dec 31, 2020
Pressure injury wound measurements: 1.5
Pressure injury wound measurements: 2
Pressure injury wound measurements: 3.2
Oxygen saturation: 77
Oxygen flow rate: 2.5
Temperature: 100.3
Pressure injury wound measurements: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer McClake | Administrator | Signed the plan of correction and provided statements regarding admission assessments. |
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding dialysis assessments for Resident #1. |
| Staff B | Registered Nurse | Interviewed regarding wound treatment documentation for Resident #8. |
| Director of Nursing | Provided statements about wound treatment changes and education for licensed nurses. |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #90428 was conducted by the Department of Inspections and Appeals.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. The complaint was not substantiated.
Complaint Details
Complaint #90428 was investigated and found not substantiated.
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