Inspection Reports for Kahl Home for Aged & Infirm
6701 Jersey Ridge Road, IA, 52807
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 30, 2025, identified deficiencies related to failure to implement a physician’s order for potassium chloride and failure to use isolation gowns when required. Earlier inspections showed a mixed pattern, with some periods of substantial compliance but also recurring issues in resident care, including pressure ulcer treatment, supervision to prevent accidents, and infection control practices. Complaint investigations substantiated concerns about medication errors, wound care, safe transfers, and documentation, while many other complaints were found unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates ongoing challenges in clinical care and safety, with some improvements noted after prior deficiencies were corrected but recent citations suggest these issues persist.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
104 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 2
Dec 30, 2025
Visit Reason
The inspection was conducted as an investigation of complaints #2685187-C, #2696692-C and facility reported incidents #2696925-I from December 22, 2025 to December 30, 2025. Complaint #2696692-C resulted in a deficiency.
Findings
The facility failed to implement a physician order for potassium chloride for Resident #1 after a low potassium lab result, and failed to utilize isolation gowns when providing care requiring Enhanced Barrier Precautions for Resident #3. These failures were confirmed by observations, clinical record reviews, and staff interviews.
Complaint Details
The visit was complaint-related, investigating complaints #2685187-C, #2696692-C and facility incidents #2696925-I. Complaint #2696692-C was substantiated resulting in deficiencies.
Severity Breakdown
SS = D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement a physician order for potassium chloride 10 mEq daily for Resident #1 after a low potassium lab result. | SS = D |
| Failure to utilize isolation gowns when providing care requiring Enhanced Barrier Precautions for Resident #3. | SS = D |
Report Facts
Resident census: 104
Lab potassium result: 3.2
Deficiency count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Interviewed regarding processing of new physician orders |
| Staff G | Licensed Practical Nurse (LPN) | Observed and interviewed regarding isolation gown use for Resident #3 |
| Staff F | Certified Nursing Assistant (CNA) | Observed and interviewed regarding isolation gown use for Resident #3 |
| Staff H | Registered Nurse (RN) | Observed wearing isolation gown and gloves while assisting Resident #3 |
| Nurse Practitioner (NP) | Wrote the potassium chloride order for Resident #1 and interviewed about order expectations | |
| Director of Nursing | Director of Nursing | Interviewed regarding order processing and isolation gown expectations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 20, 2025
Visit Reason
A complaint investigation was conducted for complaint #2653405-C and facility reported incident #2661896-I from November 18, 2025 to November 20, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Investigation related to complaint #2653405-C and facility reported incident #2661896-I; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 8, 2025
Visit Reason
A complaint investigation for complaint #2601737-C was conducted from October 6, 2025 to October 8, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #2601737-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 21, 2025
Visit Reason
An onsite revisit for the survey ending on July 3, 2025 and a complaint investigation for multiple complaints and facility reported incidents was conducted from August 18 to August 21, 2025.
Findings
All deficiencies identified in the prior survey were corrected and the facility was found to be in substantial compliance effective July 18, 2025.
Complaint Details
The visit included investigation of complaints #2572190-C, #2573885-C, #2573920-C, #2585174-C and facility reported incidents #2576283-I.
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 2
Jul 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaints #128707-C and #129583-C and a facility self-report #129649-I, covering the period from June 25, 2025 to July 3, 2025.
Findings
The facility was found deficient in treatment and services to prevent and heal pressure ulcers, resulting in a hospitalization for one resident. The facility failed to intervene and inform the provider about a worsening pressure ulcer. Additionally, the facility failed to ensure adequate supervision and assistance to prevent accidents, resulting in an injury to another resident.
Complaint Details
The investigation was based on complaints #128707-C and #129583-C. Deficiencies cited were related to allegations in these complaints. The facility self-report #129649-I was also reviewed. The findings substantiated the complaints regarding pressure ulcer care and accident hazards.
Severity Breakdown
S/S=G: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide care to prevent pressure ulcers and to treat existing pressure ulcers, leading to hospitalization of a resident. | S/S=G |
| Failure to ensure the resident environment is free of accident hazards and provide adequate supervision and assistance to prevent accidents, resulting in injury from improper use of a mechanical lift. | S/S=G |
Report Facts
Census: 106
Brief Interview for Mental Status (BIMS) score: 15
Staff signatures: 54
Staff signatures: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Registered Nurse (RN), Facility Wound Nurse | Interviewed regarding Resident #1's pressure ulcer history and care |
| Director of Nursing (DON) | Interviewed about wound clinic involvement and Resident #1's wound care | |
| Staff J | Certified Nurse Aide (CNA) | Interviewed about transfer and injury of Resident #2 |
| Staff N | Registered Nurse (RN) | Interviewed about Resident #2's injury and care |
| Staff O | Certified Nurse Aide (CNA) | Interviewed about Resident #2's injury and care |
| Staff P | Licensed Practical Nurse (LPN) | Interviewed about Resident #2's injury and care |
| Staff M | Registered Nurse (RN) Unit Manager | Reported incident of Resident #2's injury |
| Staff IP | Provided care and treatment for Resident #2's foot injury | |
| Hospice Case Manager (HCM) | Interviewed regarding Resident #2's foot injury and hospice care |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 7, 2025
Visit Reason
A complaint investigation for complaints #127526-C and #128199-C was conducted from May 5, 2025 to May 7, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint investigation for complaints #127526-C and #128199-C; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 18, 2025
Visit Reason
The document serves as a Plan of Correction following a survey ending on February 13, 2025, addressing the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective March 7, 2025.
Inspection Report
Annual Inspection
Census: 104
Deficiencies: 3
Feb 13, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and an investigation of complaint #125886-C.
Findings
The facility was found deficient in having sufficient nursing staff to meet resident needs timely, food procurement and storage practices including disposal of expired food items, and infection prevention and control measures including use of Enhanced Barrier Precautions. The complaint was not substantiated.
Complaint Details
Complaint #125886-C was investigated and found not substantiated.
Deficiencies (3)
| Description |
|---|
| Facility failed to have sufficient nursing staff to answer call lights within 15 minutes for one resident. |
| Facility failed to ensure proper disposal and labeling of expired food items in resident refrigerators. |
| Facility failed to utilize Enhanced Barrier Precautions properly for residents with infections or indwelling devices. |
Report Facts
Resident census: 104
Expired food items: 27
Residents observed with infection control issues: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 25, 2024
Visit Reason
A complaint investigation was conducted for multiple complaints and a facility reported incident from November 18, 2024 to November 25, 2024.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation covered complaints #122184-C, #123186-C, #123560-C, #123874-C, #124352-C, #124921-C and facility reported incident #124335-I.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 25, 2024
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 in compliance effective June 18, 2024. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 2
May 30, 2024
Visit Reason
Investigation of complaints #119840-C, #119908-C, and facility reported incident #119938-I conducted from May 28 to May 30, 2024.
Findings
The facility failed to properly document and review the bed hold policy prior to transferring residents to the hospital for three of four residents reviewed. Additionally, the facility failed to safely transfer one resident using a mechanical lift, resulting in a fall and injury.
Complaint Details
Complaint #119840-C was not substantiated. Complaint #119908-C was substantiated. Facility reported incident #119938-I was substantiated.
Deficiencies (2)
| Description |
|---|
| Failure to provide written notice of bed-hold policy and review it with residents/families prior to transfer for three residents. |
| Failure to safely transfer Resident #1 using a mechanical lift, resulting in a fall and head injury. |
Report Facts
Residents reviewed: 4
Census: 99
BIMS score: 13
BIMS score: 9
BIMS score: 15
Laceration length: 2.5
Plan of Correction completion date: Jun 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | CNA | Involved in transfer of Resident #1 and witness to fall incident. |
| Staff D | CNA | Involved in transfer of Resident #1 and witness to fall incident. |
| Director of Nursing | Director of Nursing | Reported on responsibility for reviewing Bed Hold Policy and mechanical lift transfer procedures. |
| Administrator | Administrator | Followed up with Resident #1's family regarding bed hold policy and bed hold charge waiver. |
| Staff C | Unit Clerk/CNA/CMA | Reported on informing Resident #1's family and involvement in incident reporting. |
| Staff G | LPN/Unit Manager | Looked for paperwork regarding Bed Hold Policy and reported on policy documentation. |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 16, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective April 12, 2024.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, leading to certification in compliance.
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 2
Mar 28, 2024
Visit Reason
The inspection was conducted as an annual recertification survey combined with investigation of multiple complaints and facility-reported incidents from March 25 to March 28, 2024.
Findings
The facility was found deficient in ensuring consistent documentation of code status for residents and in following physician orders for notification of elevated blood sugars. Deficiencies were based on interviews, record reviews, and policy reviews, with specific failures noted for residents #232 and #72.
Complaint Details
The visit included investigation of complaints #113310-C, #118919-C, #118984-C, #119802-C, and facility-reported incidents #112981-I and #116730-I.
Severity Breakdown
S: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure consistent documentation of code status for 1 of 8 residents reviewed for advanced directives. | S |
| Failed to follow physician orders to provide notification of elevated blood sugars for 1 of 5 residents reviewed for medications. | S |
Report Facts
Resident census: 83
Residents reviewed for advanced directives: 8
Residents reviewed for medications: 5
Brief Interview for Mental Status (BIMS) score: 15
Blood sugar result: 394
Blood sugar result: 384
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 22, 2023
Visit Reason
The document is a plan of correction related to a survey of the Kahl Home for the Aged & Infirmed Nursing Home to ensure compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements as of March 22, 2023, with no deficiencies cited in this document.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 3
Feb 23, 2023
Visit Reason
The inspection was a recertification and complaint survey conducted from February 20 to February 23, 2023, regarding multiple complaints and facility reported incidents.
Findings
The facility was found not to be in substantial compliance with federal regulations. Deficiencies included failure to revise care plans timely for residents with indwelling urinary catheters, improper catheter and incontinence care leading to potential urinary tract infections, and unsanitary food procurement, storage, preparation, and serving practices in the kitchen.
Complaint Details
The visit was triggered by complaints #109638-C, #109734-I, #109902-C, #110042-C, #110199-I. Complaints #109638, #109902, and #110042 were not substantiated. Facility reported incidents #110199 and #109734 were not substantiated.
Severity Breakdown
S/S=D: 2
S/S=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure the Care Plan was revised and updated to reflect care of indwelling urinary catheters for one resident. | S/S=D |
| Failure to provide proper positioning and drainage of the indwelling urinary catheter bag and appropriate incontinence and catheter care for one resident. | S/S=D |
| Failure to maintain the kitchen in a sanitary manner including unlabeled or expired food items, white residue on equipment, and improper glove use by dietary staff. | S/S=F |
Report Facts
Survey Census: 84
Sample Size: 33
Urinary catheter size: 16
Balloon size: 10
Refrigerator temperatures: 47
Refrigerator temperatures: 42
Refrigerator temperatures: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Confirmed responsibility for care plan development and revision; confirmed care plan deficiency for Resident 3 |
| Registered Nurse 1 | RN | Confirmed improper urinary drainage bag placement and improper catheter care by CNAs |
| Certified Nursing Assistant 2 | CNA | Observed providing improper incontinence care |
| Certified Nursing Assistant 5 | CNA | Observed providing improper incontinence care |
| Food Service Director | FSD | Provided information on kitchen sanitation deficiencies and food storage issues |
| Dietary Aide | DA | Observed removing clean dishes with same gloves used for soiled dishes |
| Director of Nursing | DON | Interviewed regarding care plan revision responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 29, 2022
Visit Reason
A complaint investigation was conducted for Complaints #108759-C, #109032-C, #109055-C and a Facility Self-Reported Incident #108765-I from November 16, 2022 to November 29, 2022.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for Complaints #108759-C, #109032-C, #109055-C and a Facility Self-Reported Incident #108765-I; facility found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 29, 2022
Visit Reason
A complaint investigation was conducted for Complaints #106937-C, #107299-C, #107624-C and a Facility Self-Reported Incident #104715-I from 9/26/22 to 9/29/22.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint Investigation for Complaints #106937-C, #107299-C, #107624-C and a Facility Self-Reported Incident #104715-I; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 12, 2022
Visit Reason
The inspection was conducted to investigate Complaint #101474 and a Facility Self-Reported Incident #101477.
Findings
Both the complaint and the incident were investigated and found to be not substantiated.
Complaint Details
Investigation of Complaint #101474 and Facility Self-Reported Incident #101477 completed 1/9/22 - 1/12/22; both were not substantiated.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 5
Oct 21, 2021
Visit Reason
Investigation of complaint #100193-C and facility-reported incident #100301-1.
Findings
The facility failed to update care plans for residents with changing mobility and pressure injuries, provide adequate incontinence care, prevent skin breakdown, and ensure proper supervision and safe transfer assistance. Multiple deficiencies were cited related to care plan timing, ADL care, quality of care, treatment to prevent pressure ulcers, and accident hazards.
Complaint Details
Investigation of complaint #100193-C and facility-reported incident #100301-1. Facility-reported incident #99802-1 did not result in deficiency.
Deficiencies (5)
| Description |
|---|
| Care Plan Timing and Revision - Facility failed to update care plans when resident's mobility status changed and pressure injury resolved. |
| ADL Care Provided for Dependent Residents - Facility failed to provide incontinence care and routine repositioning for dependent residents. |
| Quality of Care - Facility failed to provide skin treatment as ordered for residents with non-pressure skin breakdown. |
| Treatment/Services to Prevent/Heal Pressure Ulcer - Facility failed to provide wound treatment and repositioning for resident with pressure ulcers. |
| Free of Accident Hazards/Supervision/Devices - Facility failed to follow care plan interventions to prevent falls and provide safe transfer assistance. |
Report Facts
Census: 78
Deficiency count: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Named in observations related to resident transfers and care. |
| Staff B | Certified Nurse Aide (CNA) | Named in observations related to resident transfers and care. |
| Staff J | Licensed Practical Nurse / MDS Coordinator | Stated expectations for updating care plans. |
| Staff D | Licensed Practical Nurse (LPN) | Provided wound care and documented treatments. |
| Staff C | Registered Nurse (RN) | Reported on wound care and shift notes. |
| Staff G | Registered Nurse (RN) | Reported on wound care and shift notes. |
| Staff H | Certified Nurse Aide (CNA) | Reported on use of mechanical lifts and resident care. |
| Staff F | Certified Nurse Aide (CNA) | Involved in resident transfers and care. |
| Staff I | Occupational Therapist and Director of Therapy | Evaluated resident and recommended therapy. |
| Staff K | Licensed Practical Nurse / Unit Manager | Reported on care plan intervention and staff education. |
| Director of Nursing | Stated expectations for staff to update care plans and reposition residents. |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 6
Sep 7, 2021
Visit Reason
The inspection was a Recertification Survey and investigation of Complaints #99320 and #99844 conducted from 09/07/21 through 09/20/21. Complaint #99320 was substantiated.
Findings
The facility was found deficient in multiple areas including the right to participate in planning care, comprehensive care plans, treatment and services to prevent and heal pressure ulcers, nutrition and hydration status maintenance, dialysis services, and food procurement and safety. The facility failed to conduct/document care conferences quarterly for residents, ensure medication administration met professional standards, and provide adequate wound care and nutritional assessments.
Complaint Details
Complaint #99320 was substantiated as part of the Recertification Survey and complaint investigation conducted 09/07/21 through 09/20/21.
Deficiencies (6)
| Description |
|---|
| Right to Participate in Planning Care - facility failed to conduct/document Care Conferences quarterly for residents reviewed. |
| Services Provided Meet Professional Standards - medication error where resident received Xanax instead of Ativan. |
| Treatment/Services to Prevent/Heal Pressure Ulcer - failed to document complete assessments and prevent pressure ulcers for residents reviewed. |
| Nutrition/Hydration Status Maintenance - failed to maintain acceptable parameters and document nutritional assessments. |
| Dialysis - failed to provide documentation of pre and post dialysis assessments for resident receiving dialysis. |
| Food Procurement, Store/Prepare/Serve-Sanitary - failed to label and date food products properly. |
Report Facts
Census: 67
Resident count for care conferences: 2
Resident count for pressure ulcer review: 2
Resident count for dialysis review: 1
Resident count for nutrition assessment: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN)/Unit Manager | Reported care conferences should be held every 3 months. |
| Staff C | Registered Nurse (RN) | Involved in medication error where resident received Xanax instead of Ativan. |
| Staff D | Registered Nurse (RN) | Acknowledged medication error and explained related procedures. |
| Staff E | Human Resources Director | Acknowledged no disciplinary action for Staff D regarding medication error. |
| Staff B | Licensed Practical Nurse (LPN) | Reported pressure ulcers measured and documented weekly. |
| Staff H | Registered Nurse (RN) | Reported assessing resident's pressure ulcer and wound care. |
| Staff I | LPN/Unit Manager | Reported documentation of pressure ulcers and wound care. |
| Staff K | Registered Dietician (RD) | Provided nutritional assessments and dietary interventions. |
| Staff F | Licensed Practical Nurse (LPN) | Reported when resident receives dialysis, nurses should document vital signs. |
| Staff G | Registered Nurse (RN) | Reported nursing documentation for dialysis resident. |
| Staff Q | Speech Therapist | Provided emotional support and reported on resident's eating habits. |
| Administrator | Administrator | Queried about medication error forms and facility policies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 15, 2021
Visit Reason
The inspection was conducted to investigate Complaint #96465 and Facility Self-Reported Incidents #97027 and #97918.
Findings
The complaint and self-reported incidents were investigated on June 14-15, 2021 and were not substantiated.
Complaint Details
Complaint #96465 and Facility Self-Reported Incidents #97027 and #97918 were investigated and found not substantiated.
Report Facts
Complaint number: 96465
Facility Self-Reported Incident numbers: Incidents #97027 and #97918 investigated during the inspection
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Oct 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaint #93164 were conducted by the Department of Inspections and Appeals from 10/6/20 to 10/8/20.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #93164 was unsubstantiated.
Complaint Details
Complaint #93164 was investigated and found to be unsubstantiated.
Report Facts
Total residents: 88
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Jul 15, 2020
Visit Reason
The inspection was conducted as a result of an investigation of a Facility Self-Reported Incident #91844 from 7/9/20 to 7/15/20, which was substantiated.
Findings
The facility failed to provide adequate supervision for one of three residents reviewed, resulting in an elopement incident. The resident wandered off the premises and was found sitting on a bench at a car dealership approximately 0.6 miles from the facility. The facility implemented corrective actions including increased supervision and installation of a temporary alarm system.
Complaint Details
The complaint investigation was substantiated based on observation, staff interviews, and record review related to a resident elopement incident.
Severity Breakdown
J level: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the resident environment remains free of accident hazards and each resident receives adequate supervision and assistance devices to prevent accidents. | J level |
Report Facts
Resident census: 91
Residents on Dementia Unit: 21
Residents Dementia Unit capacity: 23
Speed limit: 45
Distance from facility to bench where resident was found: 0.6
Staffing ratio: 1
Staffing ratio CNA: 2
CNA to resident ratio: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported door alarm sounding and resident elopement |
| Staff B | Certified Nurse Assistant (CNA) | Heard door alarm, searched for resident, reported incident details |
| Staff C | Certified Medication Tech | Found resident sitting on bench during elopement |
| Staff D | Registered Nurse (RN) | Found resident sitting on bench, searched facility |
| Staff F | Scheduler | Reported usual staffing pattern and incident details |
| Staff G | Certified Nurse Assistant (CNA) | Reported resident moved up to front of Dementia Unit after first elopement |
| Staff H | Certified Nurse Assistant (CNA) | Reported staff hired to sit with resident, resident talked of plotting elopement |
| Staff I | Per Mar Security | Reported reviewing video footage and resident elopement details |
| Staff J | Registered Nurse (RN) | Reported previous incident of resident wandering and leaning on door |
| Director of Nursing (DON) | Director of Nursing | Reported resident history, staffing expectations, and incident details |
| Plant Operations Director | Plant Operations Director | Explained first floor exit door alarms and facility security |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 24, 2020
Visit Reason
Investigation conducted on 6/23-24/20 related to Complaint #91576 and a Facility Self-Reported Incident #91577.
Findings
The complaint and facility self-report were not substantiated according to the investigation findings.
Complaint Details
Complaint #91576 and Facility Self-Reported Incident #91577 were investigated and found not substantiated.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Jun 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and investigation of Complaints #90476 and #90573 was conducted by the Department of Inspections and Appeals on 6/8-9/20.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Both complaints were not substantiated.
Complaint Details
Complaints #90476 and #90573 were investigated and found not substantiated.
Report Facts
Total Residents: 87
Inspection Report
Annual Inspection
Census: 103
Deficiencies: 6
Jan 15, 2020
Visit Reason
The inspection was a recertification survey conducted from 1/12/20 through 1/15/20 to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including failure to revise care plans timely for residents with changing conditions, improper medication administration practices, inadequate incontinence care, lack of documentation of non-pharmacological interventions prior to PRN psychotropic medication use, unsanitary food service practices, and improper infection control techniques during wound care.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to revise and update resident care plans for changes in status or new concerns for 2 of 21 residents reviewed. | SS=D |
| Failed to follow professional standards and manufacturer instructions while administering insulin and failed to administer anti-acid medication as directed. | SS=D |
| Failed to provide proper incontinence care to 2 residents reviewed. | SS=D |
| Failed to document non-pharmacological interventions prior to administration of PRN anti-anxiety medications for one resident. | SS=E |
| Failed to maintain unit pantries and serving areas in a clean and sanitary manner and failed to serve food under sanitary conditions. | SS=D |
| Failed to utilize proper infection control techniques while providing wound care to one resident. | SS=D |
Report Facts
Residents reviewed: 21
Residents reviewed: 2
Residents reviewed: 3
Residents reviewed: 2
Residents census: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN), Nurse Manager | Named in insulin administration deficiency |
| Staff I | Certified Nursing Assistant (CNA) | Observed providing care to Resident #41 and toileting residents |
| Staff N | Registered Nurse (RN) | Observed adjusting Resident #41's feet in Broda Chair |
| Staff M | Certified Nursing Assistant (CNA) | Observed feeding Resident #41 and toileting residents |
| Staff L | Certified Nursing Assistant (CNA) | Observed toileting Resident #41 |
| Director of Nursing | Interviewed regarding care plan revisions, medication administration, toileting expectations, and wound care procedures | |
| Director of Therapy | Interviewed regarding Resident #41 positioning | |
| Staff F | Registered Nurse | Interviewed regarding care plan updates and PRN medication documentation |
| Staff H | Licensed Practical Nurse (LPN) | Interviewed regarding PRN medication interventions |
| Staff J | Certified Nursing Assistant (CNA) | Interviewed regarding toileting frequency |
| Staff K | Registered Nurse (RN) | Interviewed regarding toileting frequency |
| Staff D | Dietary Aide | Observed during meal service with improper glove and hand hygiene |
| Staff E | Dietary Aide | Observed during meal service with improper glove and hand hygiene |
| Dietary Director | Interviewed regarding cleaning and food handling practices | |
| Staff G | Licensed Practical Nurse (LPN) | Observed performing wound care with improper infection control technique |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 1
Jan 7, 2020
Visit Reason
The inspection was conducted following a substantiated self-reported incident involving a significant medication error that required hospital transfer of Resident #1.
Findings
The facility failed to prevent a significant medication error where Resident #1 was administered medications intended for another resident, including an allergen, resulting in hypotension and hospitalization. Staff interviews revealed multiple interruptions, lack of resident photo identification on medication records, and unfamiliarity with new residents contributed to the error.
Complaint Details
The facility's self-reported incident #87737-I was substantiated after investigation from 1/6/20 to 1/7/20 involving a medication error where Resident #1 received medications intended for Resident #2, including an allergy to Gabapentin. The error led to hypotension, ER transfer, and hospitalization.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to prevent a significant medication error that required transfer to the hospital Emergency Room for treatment and hospitalization for Resident #1. | SS=G |
Report Facts
Resident census: 107
Medications administered in error: 8
Blood pressure: 88
Blood pressure: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Administered the medications in error to Resident #1 |
| Staff B | Licensed Practical Nurse (LPN) | Provided interview regarding medication administration practices |
| Staff C | Certified Medication Aide (CMA) | Provided interview regarding identification of new residents |
| Staff D | Licensed Practical Nurse (LPN) | Provided interview regarding identification of new residents |
| Staff E | Registered Nurse (RN) | Provided interview regarding identification of new residents |
| Director of Nursing (DON) | Director of Nursing | Provided interview about medication administration expectations and follow-up actions |
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