Inspection Report
Plan of Correction
Deficiencies: 0
Nov 25, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status and certification.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective November 26, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Plan of Correction
Census: 31
Deficiencies: 1
Oct 21, 2025
Visit Reason
The visit was conducted as an investigation of a facility reported incident #2639123-I from October 20 to October 21, 2025, related to a resident transfer issue.
Findings
The facility failed to follow the Care Plan for proper and safe transfer for Resident #3, resulting in the resident being lowered to the floor during an attempted improper transfer. No injuries were reported. Deficiencies were cited related to free of accident hazards and supervision/devices.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to follow the Care Plan for proper and safe transfer for Resident #3, resulting in an accident where the resident was lowered to the floor during transfer. | SS = D |
Report Facts
Resident census: 31
Deficiency ID: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 19, 2025
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, leading to certification effective June 12, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 28
Deficiencies: 1
Jun 11, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey from June 9, 2025 to June 11, 2025.
Findings
The facility failed to follow the Care Plan for proper and safe transfer for one resident, resulting in a fall. The resident required assistance with transfers and ambulation using a gait belt and walker, but staff did not consistently use the gait belt as required.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the resident environment remains free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents, resulting in a fall for Resident #27. | SS=D |
Report Facts
Resident census: 28
Resident ID: 27
Morse Fall Scale score: 75
Date range: 2025-06-09 to 2025-06-11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Witnessed and involved in the fall incident with Resident #27 |
| Staff B | Licensed Practical Nurse (LPN) | Authored incident note documenting the fall of Resident #27 |
| Staff C | Certified Nurse Aide (CNA) | Observed walking Resident #27 without using a gait belt during ambulation/transfer |
| Director of Nursing | Director of Nursing | Stated staff should always use gait belts for transfers and ambulation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 19, 2025
Visit Reason
A complaint investigation was conducted for Complaints #126878-C, #126918-C and Facility Reported Incidents #125862-I, #126158-I from March 17, 2025 to March 19, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint investigation for Complaints #126878-C, #126918-C and Facility Reported Incidents #125862-I, #126158-I; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Sep 13, 2024
Visit Reason
The inspection was conducted in response to a facility complaint #122135-C.
Findings
Karen Acres Care Center was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities with no deficiencies cited.
Complaint Details
The complaint investigation was related to facility complaint #122135-C and was found to have no deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 10, 2024
Visit Reason
The document serves as a plan of correction following a survey, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility was found to be in compliance based on the accepted plan of correction, with no specific deficiencies detailed in the report.
Inspection Report
Annual Inspection
Census: 28
Deficiencies: 5
Jul 7, 2024
Visit Reason
The inspection was conducted as the facility's Annual recertification survey and included investigations of Complaints #120806-C, #121722-C, Facility Reported Incidents #120016-I, and Mandatory #119273-M.
Findings
The facility was found to have multiple deficiencies including failure to protect a resident from abuse related to unauthorized video recording and posting on social media, unsafe and cluttered hallways obstructing safe environment, failure to serve appropriate menus and follow food preparation standards, improper food storage and labeling, and inadequate infection prevention and control practices.
Complaint Details
Complaint #120806-C was substantiated. The complaint involved a certified nursing assistant recording a resident on a personal smartphone and posting the video on social media, violating resident rights and facility policies.
Deficiencies (5)
| Description |
|---|
| Failure to protect a resident from abuse when a certified nursing assistant used a personal smartphone to video record a resident and distribute the recording on social media. |
| Failure to maintain a safe, clean, comfortable, and homelike environment due to cluttered hallways obstructed by wheelchairs and equipment. |
| Failure to serve appropriate menus and follow standard pureed food preparation processes. |
| Failure to properly store, label, and date food items in the kitchen refrigerator and freezer. |
| Failure to maintain infection prevention and control practices including improper handling and disposal of lancets and failure to decrease infection risk for a resident with a urinary catheter. |
Report Facts
Resident census: 28
Resident census: 27
Number of meals observed with menu deficiencies: 2
Date survey completed: Jul 7, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant (CNA) | Named in abuse finding for recording and posting resident video on social media; terminated immediately. |
| Staff H | Certified Nursing Assistant (CNA) | Interviewed regarding the video incident and awareness of cell phone policy. |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed regarding the video incident and reporting. |
| Staff I | Director of Nursing (DON) | Interviewed regarding the video incident and facility response. |
| Staff E | Cook | Observed during meal preparation with noted deficiencies in food handling. |
| Staff F | Dietary Aide | Observed during meal service with noted deficiencies. |
| Staff K | Executive Chef | Interviewed about menu preparation and serving sizes. |
| Staff A | Registered Nurse (RN), Director of Nursing (DON) | Observed blood glucose testing and infection control deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 28, 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.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective March 26, 2024.
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Mar 12, 2024
Visit Reason
The inspection was conducted as a result of investigations into complaints #117110-C, #117889-C, #118203-C, #118408-C, and Facility Report Incident #119409-I from March 11 to March 12, 2024.
Findings
The facility failed to treat residents with dignity and respect, as evidenced by staff using rude language and tones toward residents, including telling a resident to 'shut up.' Several residents reported delays or issues with call light responses and care provision. The facility was found to have substantiated complaints related to resident rights violations.
Complaint Details
Complaint #117110-C was not substantiated. Complaint #117889-C was substantiated. Complaint #118203-C was substantiated. Complaint #118408-C was not substantiated. Facility Report Incident #119409-I was substantiated.
Deficiencies (1)
| Description |
|---|
| Facility failed to treat each resident with respect and dignity for 3 of 8 residents reviewed, including use of rude language and inappropriate tone by staff. |
Report Facts
Resident count: 28
Residents reviewed: 8
Complaints investigated: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nurse Aide (CNA) | Named in findings for rude behavior and loud voice toward Resident #2 |
| Staff E | Certified Nurse Aide (CNA) | Named in findings for rude behavior and disrespectful tone to residents |
| Staff F | Certified Nurse Aide (CNA) | Named in findings for rude behavior and disrespectful tone to residents |
| Staff A | Certified Nurse Aide (CNA) | Observed interacting with Resident #9 and mentioned in dignity findings |
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding resident dignity and care |
| Staff C | Anonymous employee | Reported witnessing rude behavior by staff to residents |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding expectations for resident dignity and staff interactions |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 25, 2023
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and certify the facility's compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective October 25, 2023.
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 2
Oct 12, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from October 9, 2023 to October 12, 2023.
Findings
The facility was found deficient in food safety practices, including failure to label open food items with dates and improper hand hygiene during food handling. Additionally, infection prevention and control deficiencies were identified related to improper handling of a urinary catheter bag and tubing for one resident, including lack of hand hygiene and failure to follow proper catheter care procedures.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to store food in accordance with professional standards by not labeling open foods with open dates and not practicing appropriate hand hygiene and glove changes during food handling. | SS=E |
| Failure to establish and maintain an infection prevention and control program, specifically failing to handle a urinary catheter bag and tubing with appropriate infection control standards for one resident. | SS=D |
Report Facts
Census: 29
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Named in infection control deficiency related to improper catheter care |
| Staff B | Certified Nurse Aide (CNA) | Named in infection control deficiency related to improper catheter care |
| Dietary Manager | Responsible for performing random audits of food service and food items for dating | |
| Director of Nursing | Director of Nursing | Provided immediate education to staff and will complete random audits of catheter care |
Inspection Report
Plan of Correction
Deficiencies: 0
May 13, 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 a credible allegation of compliance and plan of correction effective May 13, 2022.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 5
May 3, 2022
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in several areas including accuracy of assessments, development and implementation of comprehensive care plans, provision of ADL care, food safety practices, and infection prevention and control. Specific deficiencies included inaccurate medication documentation, incomplete care plans for oxygen, insulin, and anticoagulant use, failure to provide scheduled bathing, unlabeled and undated food items, and improper wound care infection control practices.
Severity Breakdown
SS=B: 1
SS=D: 3
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to accurately document use of anticoagulant medication on the quarterly Minimum Data Set (MDS) assessment for one resident. | SS=B |
| Failed to ensure oxygen use, insulin use, and anticoagulant medication were included in comprehensive care plans for three residents. | SS=D |
| Failed to provide bathing services for one resident who required assistance. | SS=D |
| Failed to ensure food items were labeled and dated when opened in the kitchen. | SS=E |
| Failed to practice proper infection control measures during wound care for one resident. | SS=D |
Report Facts
Census: 31
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in infection control deficiency related to improper wound care technique. |
| Pam Harned | Administrator | Signed the report and acknowledged deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 22, 2021
Visit Reason
An investigation was conducted related to facility reported incident 96479-M and complaints 96480-A, 96437-A, 96544-A, and 96449-A.
Findings
No deficiencies were identified related to these intakes. Additional findings for these incidents will be sent to the facility at a later date under separate cover.
Complaint Details
Investigation related to facility reported incident 96479-M and complaints 96480-A, 96437-A, 96544-A, and 96449-A found no deficiencies related to these intakes.
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 3
Mar 4, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Recertification survey and investigation of a facility reported incident and complaint to assess compliance with Medicare Conditions of Participation.
Findings
The facility was found to be NOT IN COMPLIANCE due to deficiencies in medication administration, pharmacy services, and frequency of meals/snacks at bedtime. Specific issues included improper handling of syringes, medication discrepancies, and failure to provide a substantial evening snack for all residents.
Complaint Details
The survey included investigation of a complaint which was found to be not substantiated (#89135 and #89136).
Severity Breakdown
Level D: 2
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure proper handling of a syringe and needle during insulin administration. | Level D |
| Facility failed to sign out controlled substances properly and maintain accurate drug records. | Level D |
| Facility failed to provide a substantial evening snack causing more than a 14 hour lapse of time between the evening meal and breakfast for 5 of 5 residents. | Level E |
Report Facts
Total residents: 29
Residents observed receiving insulin: 1
Residents affected by evening snack deficiency: 5
Medication cart controlled substances count: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pam Harned | Administrator | Signed the plan of correction |
| Staff D | Registered Nurse | Observed improperly handling syringe and medication discrepancies |
| Staff E | Registered Nurse | Reported on syringe safety and medication administration |
| Assistant Director of Nursing | ADON | Provided education and oversight on medication administration and narcotic counts |
| Staff A | Dietary Manager | Revealed information about evening snack preparation and distribution |
| Staff C | Dietary Aide | Interviewed about food storage and snack preparation |
| Staff B | Cook | Interviewed about snack preparation and distribution |
Inspection Report
Abbreviated Survey
Census: 23
Deficiencies: 0
Dec 14, 2020
Visit Reason
A focused COVID-19 infection survey was conducted from 12/10/20 through 12/14/20 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
Abbreviated Survey
Census: 28
Deficiencies: 1
Jul 29, 2020
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey by the Department of Inspection and Appeals on 07/28/2020.
Findings
The facility failed to properly implement infection prevention and control measures, including improper use of Personal Protective Equipment (PPE) by staff and inadequate sanitization of equipment such as the Hoyer lift. Observations and staff interviews revealed lapses in PPE usage and cleaning protocols in areas with COVID-19 positive and recovering residents.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to establish and maintain an infection prevention and control program including proper PPE use and equipment sanitization. | SS=E |
Report Facts
Total residents: 28
Date of survey: Jul 29, 2020
Inspection Report
Abbreviated Survey
Census: 32
Deficiencies: 0
Jun 30, 2020
Visit Reason
A COVID 19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/30/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total Residents: 32
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