Inspection Reports for
Lamoni Specialty Care

The visit was complaint-related, investigating complaints #126612-C, #126638-C, #126741-C, #127372-C, and #127398-C. Complaints #126741-C and #127372-C were substantiated resulting in deficiencies related to narcotic reporting and documentation.

The facility failed to report missing morphine from a resident's supply and failed to ensure accurate reconciliation and documentation of controlled medications and narcotic counts. Staff did not complete required narcotic counts at shift changes, and there was evidence of coercion of a nurse to falsely admit to spilling morphine. The Director of Nursing did not report the missing narcotics to the State Agency, believing the discrepancy was explained by spillage and manufacturer variance.

The complaint investigation was triggered by missing morphine from Resident #5's supply. The facility reported a census of 31 residents. Staff interviews revealed failure to report missing narcotics timely and incomplete narcotic counts. The Director of Nursing investigated and found no evidence of drug diversion but noted documentation and procedural failures.

The facility failed to timely report 4 milliliters of missing morphine from Resident #5's supply and did not ensure accurate reconciliation of controlled medications. Additionally, medical records were not accurately documented, with staff signing narcotic counts without completing them.

The complaint was substantiated. Resident #14 reported the ear flushing was not completed as ordered. Staff A, LPN acknowledged the transcription error and notified the Nurse Practitioner, who then issued a corrective order.

The facility failed to fully complete a physician's order for ear drops and flushing for Resident #14 due to incorrect transcription of the order. The resident's ears were not flushed as ordered until after the issue was identified and reported.

The facility failed to meet professional standards of quality related to accurate transcription of a physician order for Resident #14, resulting in incomplete administration of ear drops. The facility implemented corrective actions including separate orders for Debrox drops and flush, staff education, and audits to prevent recurrence.

The complaint investigation found that the transcription error was not intentional and was due to misreading the order. The facility implemented a double-check system for new orders and verbal verification with physicians to prevent recurrence.

The facility failed to correctly transcribe a physician's order for Fluconazole for Resident #4, resulting in the resident receiving a higher dose than prescribed. The error was identified after the resident was hospitalized with complications, and corrective measures were implemented to prevent future transcription errors.

Complaint #114409-C and Facility Reported Incident #117584-I were substantiated.

The facility failed to accurately transcribe and implement physician orders for one resident, resulting in a medication transcription error that contributed to hospitalization. Corrective actions included education of nursing staff, risk management, and implementation of double notation procedures for orders.

The complaint investigation found that the transcription error was not the cause of the resident's hospitalization, but the facility implemented corrective actions including double noting of orders by two nurses and verbal verification with physicians.

The facility failed to accurately transcribe and implement physician orders for Resident #4, resulting in the resident receiving Fluconazole daily instead of weekly as ordered. The transcription error was identified after the resident was hospitalized following a seizure and cardiac arrest related to hyponatremia.

Complaint #109210-C was substantiated. Complaint #109532-C was substantiated without facility deficiency. Complaint #110170-C was not substantiated. Facility-reported incident #108615-I was not substantiated.

The facility failed to ensure full implementation of nutritional assessments and interventions for one of three residents reviewed (Resident #5), resulting in significant weight loss and inadequate nutritional intake despite dietary recommendations and interventions.

Complaint #109210-C was substantiated. Complaint #109532-C was substantiated without facility deficiency. Complaint #108615-I and #110170-C were not substantiated.

Complaint #109210-C and #109532-C were substantiated, with #109532-C substantiated without facility deficiency. Complaint #108615-I and #110170-C were not substantiated. The facility failed to ensure full implementation of nutritional assessments and interventions for one resident, resulting in weight loss and malnutrition risk.

Investigation of complaints 100427-C, 100921-C, and 103585-C conducted August 22 - 29, 2022. All complaints were substantiated.

The facility failed to provide adequate nursing supervision and assistance devices to prevent accidents, resulting in a resident falling and sustaining a right lower leg fracture. The investigation detailed multiple incidents involving Resident #4 and Resident #9, including falls and inadequate fall risk interventions.

Complaints 99029-C and 99166-C were investigated and both were substantiated.

The facility failed to meet professional standards for safe medication administration for 2 of 5 residents reviewed, failed to properly label and store food items increasing risk of contamination, and did not ensure proper COVID-19 screening and PPE use by staff. Staff education and corrective actions were planned to address these deficiencies.