Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 15, 2025
Visit Reason
A complaint investigation for complaints #2572013-C was conducted from October 15, 2025 to October 16, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint #2572013-C was investigated and found to be unsubstantiated as the facility was in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 27, 2025
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and demonstrate substantial compliance for certification.
Findings
The facility was found to be in substantial compliance based on acceptance of the credible allegation and Plan of Correction, allowing certification effective January 14, 2025.
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 2
Jan 9, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found non-compliant due to deficiencies in developing and implementing comprehensive person-centered care plans for residents, and failure to maintain proper infection prevention and control practices during catheter care for two residents.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop and implement a comprehensive person-centered care plan for 2 of 11 residents reviewed, lacking measurable objectives and monitoring for mood, antidepressant medications, and high-risk medications. | SS=D |
| Failed to use appropriate infection control practices during catheter care for 2 of 2 residents reviewed, risking transmission of infections. | SS=D |
Report Facts
Residents reviewed for care plans: 11
Facility census: 36
Residents with catheter care reviewed: 2
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Jun 20, 2024
Visit Reason
The inspection was conducted due to complaint investigations of intakes #120313-C and #119980-I between June 19 and June 20, 2024. The visit aimed to investigate substantiated complaints and facility-reported incidents.
Findings
The facility failed to ensure the safety of a resident (Resident #1) during ambulation and transfer, resulting in a fall and a hip fracture. The deficiency involved staff releasing the gait belt during transfer, causing the resident to lose balance and fall. The facility provided staff education on proper transfer techniques as corrective action.
Complaint Details
Complaint #120313-C was substantiated. Facility reported incident #119980-I was substantiated.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure the safety of a resident during ambulation and transfer, resulting in a fall and hip fracture due to staff releasing the gait belt. | SS=G |
Report Facts
Total Census: 35
Fall date: Apr 3, 2024
BIMS score: 12
Number of residents reviewed: 3
Number of staff assisting at fall: 4
X-ray time: 1711
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Assisted Resident #1 during ambulation and transfer when fall occurred |
| Staff B | Certified Nursing Assistant (CNA) | Assisted Resident #1 during ambulation and transfer on day of fall |
| Staff C | Registered Nurse (RN) | Provided interview confirming staff expectations on gait belt use |
| Facility Administrator | Confirmed staff education on gait belt use | |
| Director of Nursing | Confirmed staff education on gait belt use |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 30, 2023
Visit Reason
The document is a plan of correction submitted by the facility following a prior inspection, indicating acceptance of compliance and certification effective November 7, 2023.
Findings
The facility submitted a credible allegation of compliance and plan of correction, leading to certification in compliance effective November 7, 2023. No specific deficiencies or severity levels are detailed in this document.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 3
Nov 2, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey from October 30, 2023 to November 2, 2023.
Findings
The facility was found deficient in several areas including dialysis care, medication cart security, and infection prevention and control practices. Specific issues included lack of physician orders for dialysis, failure to complete pre- and post-dialysis assessments, unlocked medication carts, and improper hand hygiene and catheter care.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to have a physician's order for a resident to receive dialysis and failed to consistently complete pre- and post-dialysis assessments. | D |
| Facility failed to properly secure and store medications; medication cart was found unlocked and unattended. | D |
| Facility failed to establish and maintain an infection prevention and control program, including failure to complete proper hand hygiene and catheter care. | D |
Report Facts
Census: 35
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Zellmer | Administrator | Signed the report and plan of correction |
| Director of Nursing | Named in findings related to dialysis orders, medication cart security, and infection control education |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 22, 2022
Visit Reason
A revisit of the survey ending October 20, 2022 was conducted on November 21 to November 22, 2022 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 14, 2022.
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 9
Oct 20, 2022
Visit Reason
The inspection resulted from the facility's annual recertification survey and investigation of complaint #104513-C and facility reported incident #104848-I conducted from October 10, 2022 to October 20, 2022.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, failure to provide reasonable accommodations, failure to notify changes in resident condition, failure to investigate and prevent abuse, failure to ensure accuracy of assessments, and insufficient nursing staff. Several residents were involved in incidents of abuse and neglect, and the facility failed to properly investigate and document these incidents.
Complaint Details
Complaint #104513-C was substantiated. Facility-reported incident #104848-I was substantiated. The complaint involved allegations of abuse and neglect of residents, including mistreatment by staff and failure to properly investigate and report incidents.
Severity Breakdown
B: 3
D: 4
G: 1
J: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to treat residents with dignity and respect, including failure to knock and request permission prior to entering rooms and mistreatment of residents by staff. | D |
| Failure to provide reasonable accommodations and preferences to residents, including access to bedside tables and water pitchers. | D |
| Failure to notify changes in resident condition in a timely and effective manner. | G |
| Failure to investigate, prevent, and correct alleged abuse and neglect, including failure to thoroughly investigate allegations and report to appropriate authorities. | D |
| Failure to ensure accuracy of resident assessments, including coding and documentation. | B |
| Failure to develop and implement comprehensive, person-centered care plans for residents. | D |
| Failure to provide adequate bowel and bladder incontinence care, catheter care, and UTI prevention. | J |
| Failure to maintain sufficient nursing staff to provide care and answer call lights timely. | B |
| Failure to comply with licensure requirements, including annual employee performance evaluations. | B |
Report Facts
Census: 37
Deficiencies cited: 9
Call light wait times: 15
Residents reviewed: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Zellmer | Administrator | Signed the plan of correction and involved in education and corrective actions. |
| Staff G | Certified Nursing Assistant | Named in abuse and mistreatment findings and involved in incident reports. |
| Staff H | Certified Nursing Assistant | Named in abuse and mistreatment findings and involved in incident reports. |
| Staff R | Charge Nurse | Involved in investigation and reporting of abuse allegations. |
| Staff Q | Registered Nurse | Reported on agency staff behavior and resident concerns. |
| Staff J | Registered Nurse | Involved in reporting and investigation of resident care concerns. |
| Staff D | Registered Nurse | Involved in resident assessments and reporting of symptoms. |
| Staff M | Licensed Practical Nurse | Involved in resident care and reporting of symptoms. |
| Staff K | Registered Nurse | Involved in resident care and reporting of symptoms. |
| Staff L | Registered Nurse | Involved in resident care and reporting of symptoms. |
| Staff F | Certified Nursing Assistant | Involved in resident care and hygiene. |
| Staff E | Certified Nursing Assistant | Involved in resident care and hygiene. |
| Staff O | Certified Nursing Assistant | Involved in resident care and reporting of symptoms. |
| Staff W | Certified Medication Aide | Named in licensure and employee evaluation findings. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Dec 13, 2021
Visit Reason
An onsite revisit was conducted on 12-13-21 following an investigation of Complaint #100123-C and Facility Reported Incident #98414-I, #100381-I, and #98387-M, #98394-A completed 10/18/21-11/2/21.
Findings
The facility failed to ensure one of three residents received adequate supervision and assistance devices to prevent accidents, specifically related to a fall incident where staff did not apply a gait belt as required.
Complaint Details
Complaint #100123-C was investigated with substantiated findings related to inadequate supervision and assistance devices leading to a resident fall.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure one of three residents received adequate supervision and assistance devices to prevent accidents, resulting in a fall incident where staff did not apply the gait belt as expected. | SS=D |
Report Facts
Census: 34
Brief Interview for Mental Status (BIMS) score: 14
Fall Risk Assessment score: 19
Number of residents reviewed for supervision: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Anderson | Director of Nursing | Named in plan of correction for staff education and audits on gait belt usage |
| Kayla Zellmer | Administrator | Named in plan of correction for staff education and audits on gait belt usage |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Nov 2, 2021
Visit Reason
An investigation was conducted from 10/18/21 to 11/2/21 related to Complaint #100123-C and Facility Reported Incidents #98414-I, #100381-I, #98387-M, and #98394-A. The investigation focused on substantiated complaints and incidents involving quality of care and accident hazards.
Findings
The facility failed to provide adequate assessment and timely intervention for a resident with a finger fracture and failed to ensure adequate supervision and use of assistive devices during resident transfers, resulting in a resident's fall, hip fracture, and subsequent death.
Complaint Details
Complaint #100123-C and Facility Reported Incidents #98414-I and #100381-I were substantiated. The investigation revealed failures in care assessment and supervision leading to injury and death.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide adequate assessment and timely intervention for Resident #3 with a right hand 5th digit fracture. | SS=D |
| Failed to ensure adequate supervision and use of assistive devices for Resident #1 during transfer, resulting in a fall and fatal hip fracture. | SS=G |
Report Facts
Resident census: 34
Fall risk assessment score: 13
BIMS score: 3
BIMS score: 15
Date of death: Jun 22, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Documented initial assessment of Resident #3's finger pain |
| Staff B | Licensed Practical Nurse (LPN) | Documented follow-up care for Resident #3's finger pain |
| Staff C | Registered Nurse (RN) | Assessed Resident #3's hand after family concern and communicated with provider |
| Staff D | Certified Nursing Assistant (CNA) | Assisted Resident #1 during transfer without gait belt, leading to fall |
| Staff E | Licensed Practical Nurse (LPN) | Responded to Resident #1's fall and documented incident |
| Director of Nursing (DON) | Director of Nursing | Reviewed investigation summary and confirmed neglect and staff termination |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Reviewed investigation summary and confirmed expectations for gait belt use |
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 2
Apr 19, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification survey and investigation of a facility reported incident and complaint to assess compliance with professional standards and care requirements.
Findings
The facility was found not in compliance due to failure to meet professional standards in medication administration for one resident and failure to provide appropriate treatment and services to maintain or improve range of motion for two residents. Specific deficiencies included improper insulin injection technique and incomplete restorative nursing care.
Complaint Details
Facility reported incidents and complaints #96665-C and #96719-I were reviewed and found not substantiated.
Deficiencies (2)
| Description |
|---|
| Failure to follow manufacturer instructions for insulin administration using Basaglar Kwikpen for Resident #27. |
| Failure to provide appropriate treatment and services to increase or prevent decrease in range of motion for Residents #14 and #19. |
Report Facts
Total residents: 33
Brief Interview of Mental Status (BIMS) score: 15
Insulin dose: 5
Restorative exercise frequency: 3
Restorative exercise duration: 15
Restorative plan frequency: 6
Restorative plan distance: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse (LPN) | Administered insulin to Resident #27 with improper technique |
| Director of Nursing | Stated expectations for insulin administration and acknowledged incomplete range of motion documentation | |
| Staff A | Restorative aide/certified nursing assistant | Reported inability to complete restorative/range of motion programs due to staffing issues |
| Staff B | Occupational Therapist | Provided information on range of motion exercises and expectations |
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 0
Nov 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on November 23-24, 2020 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
Abbreviated Survey
Census: 36
Deficiencies: 0
Jun 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/24/20 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.
Report Facts
Total residents: 36
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