Inspection Reports for
Midlands Living Center LLC

The facility failed to maintain appropriate infection control practices for one of four residents reviewed (Resident #6), including improper hand hygiene and handling of catheter care supplies by staff during the procedure.

Complaint #127576-C was substantiated. Complaint #127950-C was not substantiated.

The facility failed to maintain appropriate infection control practices for one of four residents reviewed (Resident #6), specifically related to catheter care procedures. Observations revealed improper hand hygiene, reuse of dropped gauze, and improper handling of catheter supplies by staff during catheter care.

The facility failed to develop comprehensive care plans for Enhanced Barrier Precautions for 3 of 5 residents reviewed and failed to follow physician's medication orders for 3 of 17 residents, including improper administration of blood pressure medications and missed respiratory treatments.

The facility failed to develop comprehensive care plans addressing Enhanced Barrier Precautions for catheter use, failed to update care plans for residents with edema and antidepressant use, did not follow physician medication orders for blood pressure parameters and respiratory treatments, failed to use safe transfer techniques, and did not implement proper infection control practices including use of Enhanced Barrier Precautions during catheter care.

Complaint #125312-C was substantiated as stated in the report.

The facility was found deficient in developing and implementing comprehensive care plans, meeting professional standards for services provided, ensuring free of accident hazards, and infection prevention and control. Several residents' care plans lacked necessary interventions and monitoring, and the facility failed to follow physician orders and maintain proper policies.

The complaint was substantiated. Staff A was found to have spoken disrespectfully to Resident #2, who has dementia, and recorded the interaction on Snapchat. The facility suspended and then terminated Staff A. The Assistant Director of Nursing and Director of Nursing provided education and intervention during the investigation.

The facility failed to ensure Resident #2 was treated with dignity. Staff A was observed speaking to Resident #2 in a condescending and disrespectful manner, recorded the interaction, and shared it on Snapchat. The Assistant Director of Nursing intervened and provided education, but Staff A was ultimately terminated due to the incident.

Complaint #123426-C was not substantiated. Facility reported incidents #123580-I and #123650-I were substantiated.

The facility was found to have failed to ensure that Resident #2 was treated with dignity, as evidenced by staff interactions captured on video and staff statements. The complaint #123426-C was not substantiated, but the reported incidents #123580-I and #123650-I were substantiated.

The facility was found deficient in multiple areas including failure to refer a resident for Preadmission Screening and Resident Review (PASRR), incomplete care plans regarding anticoagulant medication side effects, inadequate infection prevention practices during blood glucose monitoring and medication administration, and failure to provide required dependent adult abuse training to staff.

The facility was found deficient in coordinating PASARR assessments, revising comprehensive care plans, infection prevention and control practices, and dependent adult abuse training. Specific issues included failure to update PASARR for a resident, incomplete care plan revisions for anticoagulant medication side effects, inadequate infection prevention practices during blood glucose monitoring, and insufficient dependent adult abuse training for staff.

The survey was complaint-driven, investigating multiple complaints identified by Iowa Department of Inspection and Appeals, including issues with resident self-administered medications, privacy violations, grievance process deficiencies, mobility and accident hazards, psychotropic medication use, therapeutic diet provision, environmental safety, and water availability.

The facility was found deficient in several areas including failure to ensure clinically appropriate self-administration of medications, lack of privacy during personal care, inadequate grievance procedures and resident awareness, failure to provide restorative nursing services, unsafe environmental conditions, improper monitoring of psychotropic medications, failure to serve therapeutic diets as ordered, and failure to maintain potable water supply. The census was 75 residents at the time of inspection.

The investigation was complaint-driven, focusing on grievances about call light response times, fall prevention and supervision failures, and infection control practices during a COVID-19 outbreak. The grievance related to Resident #18 was substantiated with findings of policy failure and lack of documentation. Fall supervision issues involved Residents #23 and #71. Infection control failures involved cohorting COVID-19 positive and negative residents.

The facility failed to establish and follow a grievance policy, did not provide adequate supervision to prevent accidents for certain residents, and failed to isolate COVID-19 positive residents from negative roommates. Several residents experienced delayed call light responses and unsafe conditions related to wheelchair use and fall risks. Infection control practices did not separate COVID-19 positive residents into private rooms, increasing exposure risk.

Complaint #104520-C was not substantiated. Complaint #105706-C was substantiated. Facility-reported incident #107392-I was substantiated.

The facility was found to have deficiencies related to grievance policies, failure to provide adequate supervision to prevent accidents, and infection control issues including COVID-19 management. Some complaints and incidents were substantiated, and the facility failed to ensure timely call light responses and proper fall prevention measures.

Complaint 97102-C was substantiated. The complaint involved failure to notify the physician of elevated blood sugar levels for Resident #45.

The facility failed to notify the physician of a blood sugar level over 400 for Resident #45 as directed by the physician's order. Additionally, the facility failed to maintain resident rooms in a clean, comfortable, and homelike manner, and failed to meet professional standards in medication administration for Resident #42.

The investigation involved complaints #84537-C, #84557-C, #85412-C, #85478-C, #95243-I, #95247-I, and #95322-C. All complaints and self-reports were found not substantiated. The specific allegation involved Staff B holding down Resident #7's arms while yelling at her during cares on 1/20/21. Staff A reported the incident to Staff C, RN, who instructed her to report to the Director of Nursing (DON), but the report to the DON was delayed by two days.

The facility failed to report an allegation of abuse in a timely manner involving Staff B holding Resident #7's hands down while yelling at her during cares. The complaints and self-reports investigated were all found to be not substantiated.

Complaint #94433-C was investigated from 11/10/2020 to 11/13/2020 and was substantiated.

The facility failed to notify the Powers of Attorney for three residents who tested positive for COVID-19 in a timely manner. Observations and interviews confirmed delays in notification and communication with residents' representatives regarding positive COVID-19 test results.