Inspection Reports for
Jackson Ridge Healthcare Center
1015 Wesley Drive, Maquoketa, IA, 520600000
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
120% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
59 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 23, 2025
Visit Reason
The document is a plan of correction submitted by Jackson Ridge Healthcare Center following a credible allegation of substantial compliance.
Findings
Based on acceptance of the credible allegation of substantial compliance and the submitted Plan of Correction, the facility will be certified in compliance with health requirements effective June 30, 2025.
Deficiencies (1)
Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction.
Report Facts
Date survey completed: Jul 23, 2025
Provider/Supplier/CLIA Identification Number: 165516
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 5
Date: Jun 26, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included an investigation of complaint #129007-C and a facility reported incident #129538-I.
Complaint Details
Complaint #129007-C and facility reported incident #129538-I were investigated but did not result in a deficiency.
Findings
The facility was found deficient in multiple areas including failure to follow a care plan intervention for a resident with weight loss, failure to serve the dietician approved pureed diet menu, failure to maintain sanitary food procurement and storage practices, failure to implement an effective Quality Assurance Performance Improvement (QAPI) program, and failure to properly sanitize a blood glucose meter used for multiple residents.
Deficiencies (5)
Failed to follow a Care Plan intervention for 1 out of 3 residents reviewed with weight loss (Resident #1).
Failed to serve the Dietician approved menu for 5 of 5 residents receiving a pureed diet.
Failed to minimize the risk of foodborne pathogens by storing dishes wet; failed to cover food during transport, and failed to maintain proper food temperatures.
Failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address a previously identified quality deficiency, resulting in a repeated deficiency.
Failed to properly sanitize a blood glucose meter used for multiple residents, risking transmission of blood-borne pathogens.
Report Facts
Residents on pureed diets: 5
Weight loss: 26.5
Food temperature: 133
Food temperature: 110.2
Census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nursing Assistant (CNA) | Provided information about Resident #1's meal redirection and care plan adherence |
| Staff D | Registered Nurse (RN) | Discussed supplements and snacks for Resident #1 and blood glucose meter use |
| Staff A | Cook | Prepared pureed diets and reported on food preparation issues |
| Staff B | Cook | Reported on pureed diet preparation and food serving practices |
| Staff C | Dietary Aide (DA) | Observed storing wet dishes and food transport practices |
| Staff E | Licensed Practical Nurse (LPN) | Explained blood glucose meter cleaning procedures |
| Administrator | Oversaw QAPI program and kitchen audits | |
| Consulting Dietician | Conducted kitchen audits and explained dietary expectations | |
| Infection Preventionist | Provided infection control expectations and blood glucose meter sanitization guidance |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 5
Date: Jun 26, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements related to resident care, dietary services, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to follow a resident's care plan for weight loss, failure to serve dietician-approved pureed menus, improper food storage and temperature maintenance, ineffective quality assurance processes related to dish drying, and inadequate infection control practices regarding sanitization of blood glucose meters.
Deficiencies (5)
Failed to follow a Care Plan intervention for 1 out of 3 residents reviewed with weight loss.
Failed to serve the Dietician approved menu for 5 of 5 residents receiving a pureed diet.
Failed to minimize the risk of foodborne pathogens by storing dishes wet; failed to cover food during transport, and failed to maintain proper food temperatures.
Failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address a previously identified quality deficiency related to dish drying.
Failed to properly sanitize a blood glucose meter used for multiple residents.
Report Facts
Residents on pureed diet: 5
Weight loss: 26.5
Food temperature: 133
Food temperature: 110.2
Census: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Nursing Assistant (CNA) | Named in care plan intervention and resident redirection finding |
| Staff D | Registered Nurse (RN) | Named in care plan intervention and blood glucose meter sanitization finding |
| Staff A | Dietary Staff | Named in pureed diet preparation and food temperature findings |
| Staff B | Dietary Staff | Named in pureed diet preparation and food temperature findings |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Named in pureed diet preparation, food temperature, and dish drying findings |
| Consulting Dietician | Consulting Dietician | Named in pureed diet preparation, food temperature, dish drying, and QAPI findings |
| Staff C | Dietary Aide (DA) | Named in dish drying and food transport findings |
| Staff E | Licensed Practical Nurse (LPN) | Named in blood glucose meter sanitization finding |
| Administrator | Administrator | Named in QAPI program oversight and dish drying findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
The inspection was conducted to investigate a facility reported incident #127323-I.
Complaint Details
Investigation of facility reported incident #127323-I; incident was not substantiated.
Findings
The facility reported incident #127323-I was investigated and found to be not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 28, 2024
Visit Reason
The document is a plan of correction submitted by the facility following a prior deficiency finding, indicating acceptance of credible allegation of compliance.
Findings
The facility will be certified in compliance effective August 8, 2024, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Routine
Census: 47
Deficiencies: 7
Date: Aug 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, care, medication management, food service, infection control, and facility maintenance at Jackson Ridge Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to repair bathroom lighting and door casings, inadequate documentation of resident showers, improper transfer and wheelchair safety techniques, unsecured narcotics and improper disposal of insulin pens, serving food at unsafe temperatures, improper infection control practices during incontinence care and food handling, and malfunctioning call light systems in resident bathrooms.
Deficiencies (7)
Failed to repair a bathroom light in one room and door casings to 6 other rooms in Unit 2.
Failed to document showers twice a week for 3 residents.
Failed to utilize proper transfer techniques for 1 resident and proper wheelchair foot pedal use for 2 residents.
Failed to ensure narcotics were properly secured and failed to properly dispose of an undated insulin pen.
Failed to serve foods that were warm and palatable during meal service.
Failed to implement proper infection prevention and control practices including improper hand washing and improper handling of washbasins during incontinence care.
Call light system failed to alert staff of call light initiated to a central staff work area or directly to a staff member in some resident bathrooms.
Report Facts
Residents affected: 47
Food temperatures: 110
Food temperatures: 134
Shower documentation gaps: 7
Shower documentation gaps: 10
Shower documentation gaps: 6
Falls: 2
Falls: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | CNA | Assisted Resident #23 with bathroom light issue and reported on maintenance reporting procedures |
| Staff G | CNA | Reported on maintenance reporting procedures and shower documentation |
| Maintenance Supervisor | Reported on maintenance work order procedures and repair status of door casings and lights | |
| DON | Director of Nursing | Reported on maintenance reporting, shower scheduling, transfer procedures, medication handling, and call light system awareness |
| Staff I | LPN | Observed improperly disposing of undated insulin pen and pushing wheelchair without foot pedals |
| Staff J | Certified Nursing Assistant | Observed transferring Resident #22 improperly and reported on transfer procedures |
| Staff A | Cook | Observed serving food at improper temperatures and improper hand washing technique |
| Staff B | Dietary Supervisor | Reported on food temperature monitoring and hand washing audits |
| Staff E | CNA | Observed improper infection control during incontinence care |
| Staff P | CMA | Observed improper infection control during incontinence care |
| Staff L | Housekeeping Supervisor | Reported on call light system malfunctions and bulb replacements |
| Staff M | CNA | Reported on call light system malfunctions |
| Staff D | Registered Nurse | Reported on call light system malfunctions |
Inspection Report
Routine
Census: 47
Deficiencies: 10
Date: Aug 7, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, facility maintenance, medication management, food service, infection control, and call light systems at Jackson Ridge Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to notify physician and family of changes in resident condition, inadequate maintenance of resident rooms, failure to update care plans, improper shower documentation, unsafe transfer and wheelchair techniques, unsecured narcotics and improper medication disposal, serving food at unsafe temperatures, improper food handling and sanitation, inadequate infection control practices, and malfunctioning call light systems.
Deficiencies (10)
Failure to document physician and family notification of changes in condition for Residents #23 and #49.
Failure to repair bathroom light in Resident #23's room and door casings in 6 other rooms.
Failure to update Care Plan to indicate correct transfer status for Resident #22.
Failure to document showers twice a week for Residents #6, #34, and #38.
Failure to utilize proper transfer techniques for Resident #22 and improper wheelchair pushing for Residents #23 and #27.
Failure to ensure narcotics were properly secured and failure to properly dispose of an undated insulin pen for Resident #27.
Failure to serve foods that were warm and palatable during meal service.
Failure to demonstrate proper food handling of utensils, allowing wet dishes and storage containers to be stacked, and storing wet wiping cloths improperly.
Failure to implement proper infection prevention and control practices including improper hand washing and failure to empty washbasins into toilet after incontinence care for Resident #46.
Failure to ensure call light system alerts staff appropriately in resident bathrooms and bathing areas.
Report Facts
Residents affected: 47
Falls: 2
Red drainage: 600
Food temperatures: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Licensed Practical Nurse (LPN) | Named in failure to notify physician/family and medication handling deficiencies |
| Staff G | Certified Nursing Assistant (CNA) | Named in observations of bathroom light and door casing issues |
| Staff J | Certified Nursing Assistant (CNA) | Named in transfer technique deficiency for Resident #22 |
| Staff A | Cook | Named in food temperature and food handling deficiencies |
| Staff B | Dietary Supervisor | Named in food temperature monitoring and food handling deficiencies |
| Staff E | Certified Nursing Assistant (CNA) | Named in infection control and bathroom light deficiencies |
| Staff L | Housekeeping Supervisor | Named in call light system deficiencies |
| DON | Director of Nursing | Provided multiple interviews regarding care plan updates, transfer techniques, medication handling, infection control, and call light system |
| Maintenance Supervisor | Named in call light system bulb replacement and maintenance issues |
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 7
Date: Aug 7, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of complaints #121047-C, #121823-C, and #121892-C, which were substantiated.
Complaint Details
Complaints #121047-C, #121823-C, and #121892-C were substantiated as part of the investigation during the annual survey.
Findings
The facility was found deficient in multiple areas including failure to notify physicians and families of significant resident changes, inadequate maintenance of safe environment and equipment, failure to provide adequate care plans and ADL assistance, improper medication and pharmacy services, food safety violations, and infection control deficiencies. The facility reported a census of 47 residents during the survey.
Deficiencies (7)
Failure to notify resident, physician, and family of significant changes including accidents and injuries.
Failure to maintain a safe, clean, comfortable, and homelike environment including repair of door casings and bathroom lights.
Failure to develop and revise comprehensive, person-centered care plans timely and to provide adequate ADL care.
Failure to provide proper pharmacy services including secure storage and disposal of medications.
Failure to provide safe and palatable food at appropriate temperatures.
Failure to maintain an effective infection prevention and control program including handwashing and sanitation.
Failure to maintain an adequate resident call system with functioning call lights.
Report Facts
Resident census: 47
Audit duration: 12
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance and will be certified effective August 28, 2023, based on the accepted Plan of Correction.
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 3
Date: Aug 24, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey combined with an investigation of complaint #113753-C.
Complaint Details
Complaint #113753 was investigated and found not substantiated.
Findings
The facility was found deficient in providing appropriate catheter care to prevent urinary tract infections and in employing a qualified dietary staff. The complaint was not substantiated. Multiple deficiencies related to catheter care and food safety were documented.
Deficiencies (3)
Failed to provide appropriate catheter treatment and services to prevent potential cross contamination leading to urinary tract infection for 1 resident.
Facility failed to employ a full-time qualified dietitian or clinically qualified nutrition professional.
Facility failed to maintain a sanitary kitchen, label food appropriately for storage, utilize good food handling/gloving to prevent cross contamination, and failed to ensure food maintained appropriate temperature to prevent food borne illness.
Report Facts
Census: 40
Complaint number: 113753
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Reported catheter tubing should not be in contact with the floor |
| Director of Nursing | Reported Foley catheter bags should have covers to keep clean | |
| Dietary Supervisor | Reported no training completed towards certified dietary manager training and no evidence of food safety training | |
| Staff B | Cook | Observed food handling and preparation deficiencies |
| Staff A | Cook | Observed food handling and preparation deficiencies |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Date: Aug 24, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate catheter care leading to potential urinary tract infections and concerns about dietary services including staffing, food safety, and sanitation.
Complaint Details
The complaint investigation was substantiated with findings of catheter care deficiencies and dietary service failures including staffing, food safety, and sanitation issues.
Findings
The facility failed to provide appropriate catheter care to prevent urinary tract infections for one resident, failed to employ a full-time qualified dietician, and failed to maintain sanitary kitchen conditions, proper food handling, and appropriate food temperatures. Multiple observations revealed improper catheter tubing placement, inadequate dietary staff training, and unsafe food preparation and serving practices.
Deficiencies (4)
Failure to provide appropriate catheter care to prevent urinary tract infections, including catheter tubing contacting the floor and lack of catheter bag covers.
Failure to employ a full-time qualified dietician or dietary manager with appropriate training.
Failure to maintain a sanitary kitchen, including dirty refrigerators, undated food items, grease buildup, and improper glove use leading to potential cross contamination.
Failure to serve the dietician-approved menu and failure to maintain appropriate food temperatures to prevent food borne illness.
Report Facts
Census: 40
Deficiencies cited: 4
Food temperature: 135.8
Food temperature: 122
Food temperature: 184
Food temperature: 162
Food temperature: 152
Date of hospital report: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Reported catheter tubing should not be in contact with the floor and attempted to adjust recliner foot rest |
| Infection Preventionist | Reported Foley catheter tubing should not be on the floor | |
| Director of Nursing (DON) | Director of Nursing | Reported Foley catheter bags should not be placed in basins without covers |
| Dietary Supervisor | Dietary Supervisor | Reported lack of formal training, responsible for training cooks, and dietary management |
| Staff A | Cook | Observed serving food with improper glove use |
| Staff B | Cook | Observed multiple food handling and temperature violations during meal preparation and service |
| Staff C | Cook | Observed not wearing hairnet in kitchen |
| Staff D | Dietary Aide | Assigned to clean refrigerators and signed off cleaning lists |
| Staff E | Cook | Signed off deep cleaning of steam table |
| Administrator | Administrator | Reported dietary supervisor's training status and dietician availability |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 9, 2023
Visit Reason
A complaint investigation of Complaints #109265-C and #109910-C was conducted from January 09, 2023 to January 11, 2023.
Complaint Details
Investigation involved Complaints #109265-C and #109910-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 10, 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 May 10, 2022.
Inspection Report
Recertification Survey
Census: 54
Deficiencies: 7
Date: Apr 26, 2022
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of Complaint #104009-C.
Complaint Details
Complaint #104009-C was substantiated and investigated during the survey period from 4/19/22 to 4/26/22.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining experiences, failure to provide required Medicare notices, inaccurate resident assessments, incomplete care plans, inadequate wound care documentation, unsanitary food storage and preparation conditions, and unsafe environmental conditions such as damaged curtains in resident rooms.
Deficiencies (7)
Failed to provide a dignified dining experience; staff did not sit while assisting residents to eat and drink; catheter bags were not covered for dignity.
Failed to provide CMS Skilled Nursing Facility Advanced Beneficiary Notice (ABN) of Non Coverage to 2 residents.
Failed to complete accurate Minimum Data Set (MDS) assessments for weight loss for one resident.
Failed to develop and implement a comprehensive care plan addressing significant weight loss for one resident.
Failed to complete weekly wound assessments for one resident with diabetic foot ulcers.
Failed to store and serve food under sanitary conditions, including unlabeled food items, dirty equipment, ice machines with residue, and inadequate cleaning schedules.
Failed to provide a clean and functional environment; curtains in four resident rooms were frayed, torn, or hanging off hooks.
Report Facts
Resident census: 54
Weight loss: 25.8
Weight loss percentage: 12.7
Weight loss: 29.2
Weight loss percentage: 14.7
Wound measurements: 3.5
Wound measurements: 4
Wound measurements: 9.2
Wound measurements: 2.9
Wound measurements: 4
Wound measurements: 7.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant (CNA) | Named in findings related to undignified dining assistance. |
| Staff E | Social Services Designee | Named in findings related to undignified dining assistance. |
| Staff F | Certified Nursing Assistant (CNA) | Named in findings related to undignified dining assistance. |
| Staff G | Certified Nursing Assistant (CNA) | Named in findings related to undignified dining assistance. |
| Staff I | Infection Preventionist | Interviewed regarding Medicare Non-Coverage forms. |
| Interim Director of Nursing | Interim Director of Nursing (DON) | Interviewed regarding dining assistance expectations, Medicare forms, MDS assessments, wound care, and food safety. |
| Administrator | Facility Administrator | Interviewed regarding catheter bag dignity, wound care expectations, and curtain maintenance. |
| Staff H | Registered Nurse (RN) | Interviewed regarding wound assessments. |
| Staff A | Cook | Interviewed regarding food storage and cleaning responsibilities. |
| Staff B | Registered Nurse (RN) | Interviewed regarding ice machine cleaning responsibilities. |
| Staff C | Dietary Aide | Interviewed regarding food storage, cleaning, and ice machine maintenance. |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage, cleaning schedules, and ice machine maintenance. |
| Licensed Dietician | Licensed Dietician | Interviewed regarding MDS nutrition section and weight loss documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 11, 2022
Visit Reason
Investigation of Complaints #98817 and #99805 completed between 2022-01-06 and 2022-01-11.
Complaint Details
Complaints #98817 and #99805 were investigated and both were not substantiated.
Findings
Both complaints were investigated and found to be not substantiated.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Date: Mar 3, 2021
Visit Reason
The inspection was conducted to investigate facility reported incident #96019-I and complaints #95161-C and #96018-C from 2/24 to 3/3/2021, which were substantiated with deficiencies.
Complaint Details
The visit was complaint-related, investigating incident #96019-I and complaints #95161-C and #96018-C. The complaints were substantiated as deficiencies were found in transfer/discharge documentation and resident safety.
Findings
The facility was found deficient in transfer and discharge requirements, failing to document appropriate transfer/discharge information in residents' medical records, and in ensuring a safe environment free of accident hazards, as evidenced by incidents involving residents with inadequate supervision and injury from a baseboard heater.
Deficiencies (2)
Failure to document appropriate transfer or discharge information in the resident's medical record and communicate it to the receiving health care institution or provider.
Failure to ensure the resident environment remains free of accident hazards, resulting in a resident sustaining burns from a baseboard heater.
Report Facts
Total residents: 49
Burn size: 5
Burn size: 0.75
Burn size: 20
Room temperature: 71.5
Room temperature: 75
Room temperature: 127
Bed hold days: 10
Drainage bottle cost: 1300
Fall mat placement frequency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing (DON) | Investigated catheter management and transfer orders; completed initial investigation of resident fall |
| Staff B | Licensed Practical Nurse (LPN) | Documented resident fall and injury; found resident on floor; notified physician |
| Staff D | Administrator | Reported resident transfer to hospital; reported thermostat settings and facility safety measures |
| Staff F | Certified Nursing Assistant (CNA) | Reported working shifts and observed resident fall and incontinence care |
| Staff G | Registered Nurse (RN) | Documented resident discharge planning and catheter management |
| Staff H | Registered Nurse (RN) | Reported experience with Pleurx catheter care and incident requiring time off work |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 6, 2021
Visit Reason
An investigation of Complaints #94333 and #94704 and a Facility Self-Reported Incident #95043 was conducted by the Department of Inspections and Appeals on 1/4-1/6/21.
Complaint Details
Investigation of Complaints #94333 and #94704 and Facility Self-Reported Incident #95043 found all intakes were not substantiated.
Findings
The investigation determined all Intakes were not substantiated.
Inspection Report
Routine
Census: 54
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
A Focused COVID-19 Infection Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 66
Deficiencies: 0
Date: Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/22/20 to assess 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.
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 7
Date: Feb 6, 2020
Visit Reason
The inspection was conducted as a complaint survey to investigate deficiencies related to the facility's annual health survey and specific complaints regarding care plans, specialized services, skin integrity, infection control, nutrition, and other resident care issues.
Complaint Details
This was a complaint survey conducted from 2/3/20 to 2/7/20 focusing on multiple areas of resident care including PASRR specialized services, care planning, pressure ulcer prevention and treatment, infection control, nutrition, and feeding tube management. The facility was found deficient in all these areas.
Findings
The facility was found deficient in multiple areas including failure to develop and implement appropriate care plans for residents requiring specialized psychiatric services, failure to prevent and treat pressure ulcers, inadequate infection prevention and control practices, failure to ensure proper nutritional care and feeding tube management, and failure to maintain comprehensive and updated care plans. The facility census was consistently reported as 64 residents during the investigation.
Deficiencies (7)
Failed to develop care plans addressing PASRR specialized services for multiple residents.
Failed to develop comprehensive person-centered care plans for residents.
Failed to follow physician orders for anticoagulation therapy and lab monitoring.
Failed to implement interventions to promote healing of pressure ulcers for residents.
Failed to ensure proper placement and care of feeding tubes and nutritional adequacy.
Failed to establish and maintain an infection prevention and control program.
Failed to provide safe, palatable, and appropriately prepared meals for residents.
Report Facts
Facility census: 64
Correction date: Mar 6, 2020
Number of residents reviewed: 20
Number of residents with pressure ulcers reviewed: 3
Braden Scale scores: 14
Braden Scale scores: 18
Number of residents on pureed diet: 3
Number of residents reviewed for care plan update: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Interviewed regarding anticoagulation therapy, wound care, and infection control. |
| Staff B | Certified Nursing Aide (CNA) | Interviewed regarding resident toileting and pressure ulcer care. |
| Staff C | Certified Nursing Aide (CNA) | Interviewed regarding resident isolation for MRSA. |
| Staff E | Licensed Practical Nurse (LPN) | Interviewed regarding pressure ulcer treatment. |
| Staff F | Certified Nurse Aide (CNA) | Observed assisting resident transfer and hand hygiene. |
| Staff H | Licensed Practical Nurse (LPN) | Observed providing dressing change for pressure ulcer. |
| MDS Coordinator | Registered Nurse (RN) | Interviewed regarding care plan updates and resident assessments. |
| Interim Director of Nursing (DON) | Director of Nursing | Interviewed regarding care plans, wound care, and infection control. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding audits and care plan oversight. |
| Dietary Manager | Interviewed regarding meal preparation and nutritional adequacy. | |
| Licensed Dietitian (LD) | Licensed Dietitian | Interviewed regarding nutritional care and pressure sore awareness. |
| Occupational Therapist (OT) | Occupational Therapist | Interviewed regarding pressure ulcer prevention and wheelchair cushions. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 7, 2020
Visit Reason
Complaint #87046-C was investigated on 2020-01-02 and 2020-01-07.
Complaint Details
Complaint #87046-C was investigated and found not substantiated.
Findings
The complaint investigation was completed and found to be not substantiated.
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