Inspection Reports for
Oskaloosa Care Center
605 Highway 432, Oskaloosa, IA, 52577
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
99% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
A second revisit was conducted for the original visit ending September 17, 2025, and a first revisit for the survey ending November 13, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 20, 2025.
Inspection Report
Re-Inspection
Census: 82
Deficiencies: 1
Date: Nov 13, 2025
Visit Reason
The inspection visit was conducted as a revisit following a prior survey ending September 17, 2025, and an investigation of Facility Reported Incident #2644723-1.
Findings
The facility failed to meet the quality of care requirement related to the bowel regulatory program for four residents, including inadequate assessment, intervention, and monitoring of bowel movements. Documentation and nursing interventions were incomplete or missing for multiple residents.
Deficiencies (1)
Failure to assess, intervene, and monitor interventions per the facility's Bowel Regulatory Program for four residents, resulting in inadequate bowel care and documentation.
Report Facts
Census: 82
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Director of Nursing (DON) | Interviewed regarding Resident #2 hospital admission and bowel obstruction |
| Staff D | Registered Nurse | Interviewed regarding Resident #2 hospital admission and bowel obstruction |
| Staff A | Licensed Practical Nurse (LPN) | Documented nursing progress notes related to Resident #2's condition and interventions |
Inspection Report
Census: 76
Deficiencies: 3
Date: Sep 17, 2025
Visit Reason
The inspection was conducted to investigate multiple deficiencies related to resident care, including failure to follow cardiopulmonary resuscitation (CPR) orders, failure to provide timely assessment and intervention for a resident with chest pain, and deficiencies in staff training programs.
Findings
The facility failed to carry out CPR according to a resident's wishes, resulting in immediate jeopardy to resident health and safety. The facility also failed to provide timely assessments and interventions for a resident with chest pain, leading to actual harm. Additionally, the facility failed to provide required training in Quality Assurance and Performance Improvement (QAPI), infection control, and compliance and ethics for multiple staff members.
Deficiencies (3)
Failure to carry out CPR in accordance with resident's wishes, resulting in immediate jeopardy to resident health or safety.
Failure to carry out timely assessments and interventions after a resident complained of chest pain, resulting in actual harm.
Failure to implement training for multiple topics including Quality Assurance and Performance Improvement (QAPI), compliance and ethics, and infection control for staff.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 6
Census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Named in findings related to failure to initiate CPR and failure to assess resident with chest pain |
| Staff F | Advanced Registered Nurse Practitioner (ARNP) | Provided orders related to CPR and resident care |
| Staff C | Registered Nurse (RN) | Involved in resident care during CPR incident |
| Staff E | Certified Nursing Assistant (CNA) | Witnessed events related to CPR incident |
| Staff D | Certified Nursing Assistant (CNA) | Witnessed events related to CPR incident |
| Staff H | Licensed Practical Nurse (LPN) | Involved in care and reporting for resident with chest pain |
| Staff I | Certified Nursing Assistant (CNA) | Reported resident complaints of chest pain |
| Staff J | Certified Nursing Assistant (CNA) | Reported resident condition and staff interactions |
| Staff L | Director of Nursing (DON) | Provided statements regarding resident care and staff training |
| Staff M | Certified Nursing Assistant (CNA) | Reviewed for training deficiencies |
| Staff N | Certified Nursing Assistant (CNA) | Reviewed for training deficiencies |
| Staff O | Certified Nursing Assistant (CNA) | Reviewed for training deficiencies |
| Staff P | Certified Nursing Assistant (CNA) | Reviewed for training deficiencies |
| Staff Q | Certified Nursing Assistant (CNA) | Reviewed for training deficiencies |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 3
Date: Sep 10, 2025
Visit Reason
The inspection was conducted as a result of complaint #2611557-C and facility reported incident #2613253-I between September 10, 2025 and September 17, 2025 to investigate alleged deficiencies related to cardiopulmonary resuscitation (CPR) and quality of care.
Complaint Details
Complaint #2611557-C was investigated and did not result in a deficiency. Facility reported incident #2613253-I resulted in a deficiency related to failure in CPR procedures and resident care.
Findings
The facility failed to correctly identify and follow the resident's CPR code status, resulting in immediate jeopardy to the resident's health and safety. Additionally, the facility failed to carry out timely assessments and interventions for a resident with chest pain and failed to provide adequate staff training in multiple areas including infection control and quality assurance.
Deficiencies (3)
Failure to carry out cardiopulmonary resuscitation (CPR) in accordance with the resident's wishes and physician's orders, including failure to correctly identify resident's CPR code status and locate crash cart.
Failure to carry out timely assessments and interventions after a resident complained of chest pain.
Failure to implement training for multiple topics including infection control, quality assurance, compliance and ethics for all staff.
Report Facts
Census: 76
Complaint Number: 2611557
Incident Number: 2613253
Staff Training Topics: 6
Staff Reviewed for Training: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant involved in CPR incident and post-mortem care | |
| Staff B | Licensed Practical Nurse (LPN) | Involved in CPR incident, failed to locate crash cart, and was terminated after resident 9 incident |
| Staff C | Registered Nurse (RN) | Involved in CPR incident and assessment of resident |
| Staff L | Director of Nursing | Provided statements regarding resident care and staff training |
| Staff H | Licensed Practical Nurse (LPN) | Assessed resident 9 and involved in emergency response |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 26, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance 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 June 26, 2025.
Inspection Report
Routine
Census: 81
Deficiencies: 5
Date: Jun 19, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards including medication use, care planning, medication administration, food safety, and infection control at the nursing facility.
Findings
The facility was found deficient in limiting PRN psychotropic medication use without appropriate diagnosis, incomplete care plans for residents on anti-anxiety medication, unsupervised medication administration, improper food storage and sanitation practices, and failure to perform hygienic perineal care for incontinent residents.
Deficiencies (5)
Failed to limit PRN psychotropic drug use to 14 days and ensure appropriate diagnosis for psychotropic medication for 1 of 6 residents reviewed (Resident #28).
Failed to develop and implement a comprehensive person-centered Care Plan for 1 of 19 residents reviewed (Resident #28) related to anti-anxiety medication use.
Failed to follow professional standards during medication administration observation; left medications with a resident unsupervised for 1 of 7 observed (Resident #45).
Failed to ensure open food items were dated, covered, labeled, and stored properly; failed to test dishwasher temperature and chemical sanitizer twice daily.
Failed to perform perineal care for incontinent residents in a hygienic manner for 3 of 3 residents observed (Residents #1, #38, and #63).
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Days missing documentation: 18
Days missing documentation: 8
Days missing documentation: 18
Medication doses administered: 7
Medication doses administered: 11
Medication doses administered: 17
Medication doses administered: 30
Medication doses administered: 15
Medication doses administered: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Observed leaving medications unsupervised for Resident #45 |
| Staff B | Registered Nurse (RN) | Relayed care plan details for Resident #45 |
| Staff C | Certified Nurse's Aide (CNA) | Observed performing perineal care with improper glove use for Residents #1 and #63 |
| Staff D | Certified Nurse's Aide (CNA) | Observed performing perineal care with improper glove use for Resident #1 |
| Staff E | Certified Nurse's Aide (CNA) | Observed performing perineal care with improper glove use for Resident #38 |
| Staff F | Certified Nurse's Aide (CNA) | Interviewed about proper glove use during perineal care |
| Staff G | Licensed Practical Nurse (LPN) | Interviewed about glove use during perineal care |
| Director of Nursing (DON) | Director of Nursing | Acknowledged failure to respond to pharmacy recommendations and improper glove use during perineal care |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Acknowledged care plan deficiencies for Resident #28 |
| Administrator | Facility Administrator | Stated expectations regarding psychotropic medication use, care plans, medication administration, and food safety |
| Dietary Manager (DM) | Dietary Manager | Acknowledged food safety and sanitation deficiencies |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 5
Date: Jun 19, 2025
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey and investigation of Facility Reported Incidents #127850-I, #129145-I, 129264-I and 128868-M from June 16, 2025 to June 19, 2025.
Findings
The facility was found deficient in several areas including failure to limit psychotropic drug use without appropriate diagnosis or documentation, failure to develop and implement comprehensive person-centered care plans, failure to meet professional standards during medication administration, and failure to maintain food safety standards including proper dishwasher sanitation. The facility also failed to implement adequate infection control practices.
Deficiencies (5)
Failure to ensure residents are free from chemical restraints and psychotropic drugs are properly prescribed and monitored.
Failure to develop and implement comprehensive person-centered care plans for residents.
Failure to meet professional standards during medication administration, including unsupervised administration and lack of documentation.
Failure to maintain food safety requirements, including improper storage, labeling, and dishwasher sanitation.
Failure to implement infection prevention and control program to prevent spread of communicable diseases.
Report Facts
Census: 81
Medication doses: 9
Deficiency counts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cema Duffy | Administrator | Signed initial comments and plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 22, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification effective February 22, 2025.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 4
Date: Jan 23, 2025
Visit Reason
The inspection was conducted following complaints regarding the facility's treatment of residents, including concerns about excessive force used during a urine sample collection, falsification and removal of clinical records, failure to provide appropriate assessments and care, and inadequate supervision of residents with aggressive behaviors.
Complaint Details
The investigation was complaint-driven, triggered by allegations of excessive force used on Resident #1 during urine sample collection, falsification and removal of clinical records for Residents #1 and #2, failure to provide appropriate care and assessments, and inadequate supervision of residents with aggressive behaviors leading to multiple resident-to-resident incidents.
Findings
The facility failed to treat a resident in a dignified manner during a urine sample collection involving excessive force, failed to maintain accurate and complete clinical records for two residents, failed to provide appropriate assessments and interventions for residents, and failed to adequately supervise residents with physical aggression tendencies, resulting in multiple incidents of resident-to-resident aggression.
Deficiencies (4)
Facility failed to treat Resident #1 in a dignified manner using excessive force to restrain her for urine sample collection.
Documentation was intentionally falsified and clinical records were removed for Residents #1 and #2.
Failed to ensure Resident #1 was appropriately assessed and provided interventions to maintain optimal health and well-being.
Failed to ensure adequate supervision and prevention of accidents related to physical aggression among Residents #2, #3, #4, and #7.
Report Facts
Residents Affected: 1
Residents Affected: 2
Residents Affected: 1
Residents Affected: 4
Bruise size: 4
Bruise size: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse | Named in documentation falsification and removal, and reporting bruising on Resident #1 |
| Staff D | Licensed Practical Nurse | Nurse on duty during urine sample collection incident with Resident #1 |
| Staff F | Certified Nurse Aide | Reported concerns about Resident #1's condition and treatment |
| Staff G | Licensed Practical Nurse | Charge nurse during Resident #1's concerning behavior, did not assess Resident #1 |
| Staff H | Certified Nurse Aide | Involved in restraining Resident #1 during urine sample collection |
| Staff I | Certified Nurse Aide | Witnessed urine sample collection with excessive force on Resident #1 |
| Staff L | Certified Nurse Aide | Involved in restraining Resident #1 during urine sample collection |
| Staff B | Certified Nurse Aide | Reported bruising on Resident #1 and wrote a statement |
| Staff O | Licensed Practical Nurse | Documented incident involving Resident #2 and altered documentation |
| Staff P | Certified Nurse Aide | Witnessed Resident #3's aggressive behavior towards Resident #2 |
| Staff Q | Certified Medication Aide | Witnessed and reported incident involving Residents #2 and #3 |
| Staff T | Certified Medication Aide | Reported on Resident #3's aggressive behavior and medication changes |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding resident-to-resident aggression and interventions |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 4
Date: Jan 8, 2025
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#122360-C, #125582-C) and facility reported incidents (#125465-I, #125951-I, #126072-I, #126117-I) between January 8 and January 23, 2025. The complaints and incidents were substantiated and involved concerns about resident rights and care.
Complaint Details
The visit was complaint-related, investigating substantiated complaints #125582-C and facility reported incidents #125465-I, #125951-I, #126117-I. The complaints involved allegations of excessive force, improper care, falsification of records, and inadequate supervision.
Findings
The facility failed to treat residents with dignity, using excessive force to obtain a urine sample from Resident #1, and failed to meet professional standards in documentation, including falsification and removal of clinical records for residents #1 and #2. Additional findings included inadequate assessment accuracy, failure to ensure resident safety from physical aggression, and failure to provide appropriate supervision and care interventions.
Deficiencies (4)
Failure to treat Resident #1 in a dignified manner, including use of excessive force to obtain a urine sample.
Intentional falsification and removal of clinical records for Residents #1 and #2.
Failure to accurately assess residents' status and meet professional standards.
Failure to ensure resident safety and adequate supervision to prevent physical aggression and reoccurrences.
Report Facts
Complaint numbers investigated: 5
Facility census: 81
Residents reviewed: 8
Pages of nurse's notes describing incident: 7
Dates of incidents: Aug 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nurse Aide (CNA) | Reported concerns about Resident #1's behavior and care |
| Staff G | Licensed Practical Nurse (LPN) | Involved in care and monitoring of Resident #1 during incident |
| Staff D | Licensed Practical Nurse (LPN) | Collected urine sample without order, involved in incident with Resident #1 |
| Staff C | Nurse | Reported bruising on Resident #1, completed incident report and nurse's notes |
| Staff J | Shower Aide | Witnessed Resident #1's condition during incident |
| Staff L | Certified Nurse Aide | Assisted during urine sample collection incident |
| Staff B | Certified Nurse Aide | Reported bruising and trauma on Resident #1 |
| Staff P | Certified Nurse Aide | Witnessed and reported incident involving Residents #2 and #3 |
| Staff O | Licensed Practical Nurse (LPN) | Involved in incident reporting and documentation related to Resident #2 |
| Staff Q | Certified Med Aide (CMA) | Witnessed incident involving Residents #2 and #3 |
| ADON | Assistant Director of Nursing | Queried regarding resident events and protocols |
| Staff T | Certified Medication Aide | Responsible for medication administration and reported on Resident #3's behavior |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 22, 2024
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 the credible allegation of compliance and plan of correction effective August 22, 2024.
Inspection Report
Routine
Census: 83
Deficiencies: 2
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments and staffing adequacy at Oskaloosa Care Center.
Findings
The facility failed to accurately complete Minimum Data Set (MDS) assessments for 77 of 83 residents by incorrectly coding physical restraints. Additionally, the facility failed to provide sufficient nursing staff, particularly in the Chronic Confusion or Dementing Illness Unit (CCDI), resulting in unsafe supervision and delayed response times.
Deficiencies (2)
Failed to accurately complete Minimum Data Set (MDS) assessments for 77 out of 83 residents, incorrectly coding physical restraints.
Failed to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift, especially in the CCDI unit.
Report Facts
Residents affected: 77
Census: 83
Residents in CCDI: 10
Call light response delays: 31
Call light response delays: 24
Call light response delays: 24
Residents requiring one-on-one supervision: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | MDS Coordinator | Confirmed incorrect coding of physical restraints for 77 residents |
| Staff G | Certified Nurses Aide (CNA) | Observed supervising CCDI unit alone during meal times and reported staffing shortages |
| Staff H | Certified Nurses Aide (CNA) | Frequently pulled from CCDI unit to assist other units, leaving CCDI understaffed |
| Staff J | Certified Nurses Aide (CNA) | Reported daily staffing shortages in CCDI unit and safety concerns |
| Director of Nursing | Director of Nursing (DON) | Stated expectation to always have two staff in CCDI and staffing goals |
Inspection Report
Routine
Census: 83
Deficiencies: 4
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, pre-admission screening, therapy services, and staffing adequacy at the nursing facility.
Findings
The facility was found to have multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments for physical restraints, failure to submit required Level 2 PASARR evaluations for residents with new mental health diagnoses, inadequate implementation of therapy and restorative programs for residents, and insufficient nursing staff to meet resident needs, particularly in the Chronic Confusion or Dementing Illness Unit (CCDI).
Deficiencies (4)
Failed to accurately complete Minimum Data Set (MDS) assessments for 77 out of 83 residents, incorrectly coding physical restraints.
Failed to submit a Level 2 Preadmission Screening and Resident Review (PASARR) evaluation for 1 of 2 residents with new mental health diagnoses and medication revisions.
Failed to carry out therapy recommendations and provide restorative exercises for 1 of 4 residents reviewed for rehabilitation services and/or limited range of motion.
Failed to provide sufficient nursing staff every day to meet the needs of every resident; specifically, only one staff member was present in the CCDI unit during multiple observations, impacting resident safety.
Report Facts
Residents affected: 77
Census: 83
Call light response delays: 31
Call light response delays: 24
Call light response delays: 24
Residents in CCDI unit: 10
Residents requiring one-on-one supervision: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | MDS Coordinator | Confirmed incorrect coding of physical restraints on MDS for 77 residents |
| Staff A | Social Services | Verified PASARR evaluation details and explained Level 2 PASARR not indicated |
| Staff B | Restorative Aide | Reported on restorative program implementation and resident participation |
| Staff F | Licensed Practical Nurse (LPN) | Reported on resident #64 condition and decline |
| Staff G | Certified Nurses Aide (CNA) | Observed supervising CCDI unit alone and reported staffing concerns |
| Staff H | Certified Nurses Aide (CNA) | Reported staffing concerns and frequent pull from CCDI unit |
| Staff J | Certified Nurses Aide (CNA) | Reported staffing concerns in CCDI unit |
| Director of Nursing | Director of Nursing (DON) | Reported therapy and staffing expectations and goals |
| Staff E | Physical Therapist | Reported on therapy discharge and restorative program recommendations |
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 3
Date: Jul 29, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and included investigation of multiple complaints and facility reported incidents.
Complaint Details
Complaints #121815-C and #121985-C were substantiated. Facility Reported Incident #121663-I was substantiated.
Findings
The facility was found to have multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments for physical restraints, failure to submit required PASARR evaluations, insufficient nursing staff on the Chronic Confusion or Dementing Illness Unit (CCDI), and inadequate restorative nursing program documentation and implementation.
Deficiencies (3)
Facility failed to accurately complete Minimum Data Set (MDS) assessments for 77 out of 83 residents, incorrectly coding physical restraints.
Facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASARR) evaluation for 1 of 2 residents with new mental health diagnoses and medication revisions.
Facility failed to provide sufficient nursing staff to ensure safety and supervision of residents on the CCDI unit, with only one Certified Nursing Assistant (CNA) observed supervising 10 residents.
Report Facts
Residents with inaccurate MDS assessments: 77
Facility census: 83
Residents in CCDI unit: 10
Call light response times: 31
Call light response times: 24
Call light response times: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | MDS Coordinator | Interviewed regarding MDS coding and physical restraints. |
| Staff A | Social Services | Interviewed regarding PASARR completion for Resident #53. |
| Staff B | Restorative Aide | Reported on restorative program activities and documentation. |
| Staff E | Physical Therapist | Reported on therapy discharge summary and restorative program. |
| Staff F | Licensed Practical Nurse (LPN) | Reported on Resident #64 care and decline. |
| Staff G | Certified Nursing Assistant (CNA) | Observed supervising residents on CCDI unit and interviewed about staffing. |
| Staff H | Certified Nursing Assistant (CNA) | Interviewed about staffing and resident care on CCDI unit. |
| Staff J | Certified Nursing Assistant (CNA) | Interviewed about staffing and resident care on CCDI unit. |
| Director of Nursing (DON) | Director of Nursing | Reported on therapy recommendations and staffing concerns. |
| Administrator | Administrator | Signed initial comments and involved in staff re-education and monitoring PASARR. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and certify the facility in compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective February 8, 2024.
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 1
Date: Jan 10, 2024
Visit Reason
The inspection was conducted to assess compliance with care plan requirements, specifically to verify if care plans were updated appropriately for residents.
Findings
The facility failed to update the care plan for one resident who was observed ambulating without a walker despite the care plan indicating walker use. The Director of Nursing acknowledged the discrepancy and the facility lacked a policy for care plan revision.
Deficiencies (1)
Failure to update a Care Plan for Resident #73 to reflect current mobility status.
Report Facts
Residents Affected: 1
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged care plan discrepancy for Resident #73 |
Inspection Report
Routine
Census: 78
Deficiencies: 5
Date: Jan 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, medication administration, psychotropic medication use, respiratory care, and food safety at Oskaloosa Care Center.
Findings
The facility was found to have multiple deficiencies including inaccurate coding on Minimum Data Set (MDS) assessments, failure to update care plans, incorrect transcription of oxygen orders on the Medication Administration Record (MAR), failure to limit PRN psychotropic medication orders to 14 days without physician rationale, and inadequate food safety practices related to utensil and countertop cleanliness.
Deficiencies (5)
Inaccurate coding on residents' Minimum Data Set (MDS) assessments, including incorrect restraint coding on 18 of 20 residents and an incorrect pneumonia diagnosis for one resident.
Failure to update a Care Plan for one resident who was ambulating without a walker contrary to the care plan instructions.
Failure to ensure accurate transcription of oxygen orders on the Medication Administration Record (MAR) for one resident, resulting in missing oxygen flow rate information.
Failure to limit PRN psychotropic medication orders to a 14-day limit without physician rationale for extension for three residents.
Failure to clean countertop surfaces or place a clean barrier under a rubber spatula during food pureeing, risking cross-contamination.
Report Facts
Residents affected: 18
Census: 78
PRN psychotropic medication orders: 3
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (MDS Nurse) | Interviewed regarding inaccurate MDS coding and pneumonia diagnosis |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding oxygen order transcription on MAR |
| Director of Nursing | Director of Nursing (DON) | Acknowledged care plan discrepancy and issues with psychotropic medication review |
| Food Service Supervisor | Acknowledged failure to place clean barrier during food pureeing | |
| Administrator | Administrator | Acknowledged issues with MAR transcription and psychotropic medication policy absence |
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 6
Date: Jan 7, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of complaints #114236-C, #114492-C, and #115395-C from January 7, 2024 to January 10, 2024.
Complaint Details
The inspection included investigation of complaints #114236-C, #114492-C, and #115395-C.
Findings
The facility was found to have multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments, failure to update care plans, inadequate respiratory care documentation, insufficient RN coverage, improper psychotropic medication management, and food safety violations. The facility reported a census of 78 residents during the survey.
Deficiencies (6)
Inaccurate coding of restraints on residents' Minimum Data Set (MDS) assessments.
Failure to update Care Plans for residents, including Resident #73.
Failure to ensure accurate transcription of Physician orders to the Medication Administration Record (MAR) for oxygen for Resident #233.
Failure to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week.
Failure to limit psychotropic medication PRN orders to 14 days without physician rationale.
Failure to maintain sanitary food preparation surfaces and barriers during food service.
Report Facts
Residents reviewed for MDS accuracy: 20
Residents coded incorrectly for restraints: 18
Census: 78
Residents sampled for respiratory care: 3
Days RN coverage missing: 3
Psychotropic medication PRN orders reviewed: 5
Psychotropic medication PRN orders exceeding 14 days without rationale: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | MDS Nurse | Interviewed regarding MDS coding and restraint use. |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding oxygen orders and MAR transcription. |
| Staff A | Registered Nurse (RN) | Interviewed regarding hospice admitting orders and oxygen administration. |
| Director of Nursing (DON) | Director of Nursing | Acknowledged care plan discrepancies, RN coverage issues, and medication order transcription problems. |
| Staff B Cook | Food Service Staff | Observed during food preparation and sanitation process. |
| Food Service Supervisor | Food Service Supervisor | Acknowledged need for clean barrier during food preparation. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 18, 2023
Visit Reason
A revisit of the survey ending May 18, 2023 and investigation of Complaint #113826-C was conducted on July 17-18, 2023.
Complaint Details
Complaint #113826-C was not substantiated.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective May 25, 2023. Complaint #113826-C was not substantiated.
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Date: May 18, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding abuse, neglect, and failure to provide timely and appropriate care to residents, including catheter care and respect for residents' preferences.
Complaint Details
The complaint investigation revealed substantiated findings of verbal abuse by staff to residents #2, #3, and #6, and failure to provide timely catheter care and physician notification for resident #1, resulting in immediate jeopardy that was removed after corrective actions.
Findings
The facility failed to provide respectful care to residents, with documented incidents of verbal abuse and neglect by staff. Additionally, the facility failed to assess and intervene timely for residents with urinary catheter issues, resulting in an immediate jeopardy situation that was later abated by corrective actions.
Deficiencies (2)
Failure to talk to residents with respect and provide care in a respectful manner, including verbal abuse and neglect of resident preferences.
Failure to assess and provide timely intervention for residents with catheter care needs, including failure to notify physician of critical blood glucose levels, resulting in immediate jeopardy.
Report Facts
Resident census: 76
Blood sugar levels: 557
Urinary output volumes: 0
Number of residents affected: 3
Number of residents reviewed for catheter care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Certified Nursing Assistant (CNA) | Named in verbal abuse and neglect findings for residents #2 and #6 |
| Staff J | Certified Nursing Assistant (CNA) | Named in verbal abuse and neglect findings for resident #3 |
| Staff M | Certified Nursing Assistant (CNA) | Reported abuse incident involving Staff J and resident #3 |
| Staff C | Licensed Practical Nurse (LPN) | Intervened in catheter care emergency for resident #1 |
| Staff E | Registered Nurse (RN) | Resident #1's nurse involved in catheter care failure |
| Staff D | Advanced Registered Nurse Practitioner (ARNP) | Provided orders and oversight for resident #1 catheter care |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding staff expectations and abuse complaints |
| Staff G | Certified Medication Aide (CMA) | Reported no urinary output for resident #1 |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Date: May 18, 2023
Visit Reason
The inspection was conducted as a result of investigation of Complaint #112523-A and Facility Reported Incidents #112230-I, #112233-I, and #112672-I between April 26, 2023 and May 18, 2023.
Complaint Details
Complaint #112523-A was substantiated. Facility Reported Incidents #112230-I, #112233-I, and #112672-I were substantiated.
Findings
The facility was found to have failed to provide care in a respectful manner to residents, resulting in substantiated abuse complaints for three residents. Additionally, the facility failed to assess and provide timely intervention for catheter care and failed to notify the physician of critical blood glucose levels for one resident, resulting in an immediate jeopardy situation that was later abated.
Deficiencies (2)
Failure to talk to residents with respect and provide care in a respectful manner, including failure to incorporate residents' goals, preferences, and choices for 3 of 5 residents reviewed.
Failure to assess and provide timely intervention for catheter care for 3 of 3 residents reviewed, including failure to notify the attending physician of blood glucose levels greater than 400 for 1 resident, resulting in immediate jeopardy.
Report Facts
Resident census: 76
Blood sugar levels: 557
Urinary output: 0
Deficiency counts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Certified Nursing Assistant (CNA) | Named in abuse findings related to disrespectful care and failure to assist residents timely. |
| Staff J | Certified Nursing Assistant (CNA) | Named in abuse findings related to verbal abuse and neglect of Resident #3. |
| Staff C | Licensed Practical Nurse (LPN) | Responded to Resident #1's urinary catheter issue and attempted intervention. |
| Staff E | Registered Nurse (RN) | Resident #1's nurse, involved in failure to timely intervene on urinary catheter obstruction. |
| Staff D | Advanced Registered Nurse Practitioner (ARNP) | Provided orders for Resident #1's catheter care and transfer to hospital. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding expectations for respectful care and nurse reporting. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 27, 2023
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility will be certified in compliance effective February 23, 2023, based on acceptance of the plan of correction and credible allegation of compliance.
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 2
Date: Jan 10, 2023
Visit Reason
The inspection was conducted as a result of investigations into complaints #106366-C, #106474-C, and facility reported incidents #10911-I, #108911-I, and #109961-I. Complaints #106366-C and #106474-C, as well as incident #109961-I, were substantiated.
Complaint Details
The visit was complaint-related, investigating complaints #106366-C and #106474-C, both substantiated, and facility reported incidents #10911-I, #108911-I, and #109961-I, with incident #109961-I substantiated.
Findings
The facility failed to treat residents with respect and dignity during care and interactions for 2 of 4 residents reviewed, including inappropriate physical restraint and handling. Additionally, the facility failed to ensure staff were not under the influence of alcohol or intoxicating drugs while providing care, with evidence of a licensed practical nurse exhibiting impaired behavior during a night shift and suspected diversion of narcotic medications.
Deficiencies (2)
Failure to treat residents with consideration and respect throughout all cares and interactions for 2 of 4 residents reviewed (Residents #1 and #3), including inappropriate physical restraint and handling.
Failure to ensure staff under the influence of alcohol or intoxicating drugs are not permitted to provide services in the nursing facility.
Report Facts
Facility census: 77
Complaint numbers substantiated: 2
Facility reported incidents substantiated: 1
Medication administration times: 12.53
Medication administration times: 9.17
Medication administration times: 4.24
Medication administration times: 7.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Witnessed and reported incidents involving Resident #1 and Resident #3 |
| Staff B | Certified Nurse Aide | Involved in physical restraint and handling of Resident #1 and Resident #3 |
| Staff C | Registered Nurse | Provided statements regarding appropriate care and restraint policies for residents |
| Director of Nursing | Director of Nursing | Provided information on dementia training and restraint policies |
| Staff E | Registered Nurse | Observed impaired behavior of Staff F and reported concerns about medication administration |
| Staff F | Licensed Practical Nurse | Observed under influence during shift, suspected of diverting narcotic medications |
| Staff G | Certified Nurse Aide | Reported observations of Staff F's impaired behavior and questioned medication administration |
| Staff H | Certified Nurse Aide | Reported observations of Staff F's behavior and medication administration irregularities |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance of the facility.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and the submitted plan of correction effective July 28, 2022.
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 1
Date: Jul 27, 2022
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaints #100225-C, #101895-C, 101954-C, and a facility reported incident #100167-I from July 17, 2022 to July 27, 2022.
Findings
The facility failed to include all mental illness diagnoses on a Level 1 PASRR (Preadmission Screening and Resident Review) for one resident, which did not meet regulatory requirements. Interviews with staff and review of clinical records confirmed this deficiency.
Deficiencies (1)
Failure to include all mental illness diagnoses on a Level 1 PASRR for one resident.
Report Facts
Resident census: 66
Complaints investigated: 3
Facility reported incident: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Steffens | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Renewal
Census: 55
Deficiencies: 5
Date: Jul 13, 2021
Visit Reason
The inspection was a Recertification Survey conducted from July 6 to July 13, 2021, to assess compliance with federal regulations for continued certification and licensure of the facility.
Findings
The facility was found deficient in multiple areas including failure to ensure staff completed mandatory Dependent Adult Abuse training, failure to coordinate PASRR assessments and referrals, failure to follow physician orders, failure to properly store and secure controlled substances, and failure to maintain an effective infection prevention and control program.
Deficiencies (5)
Facility failed to ensure 4 of 5 staff members completed the two hour Dependent Adult Abuse training within 6 months of hire date.
Facility failed to refer a resident with a negative Level I PASRR result but possible serious mental disorder to the appropriate state-designated authority for Level II PASRR evaluation.
Facility failed to follow physician's orders for 1 of 15 sampled residents related to blood sugar testing and documentation.
Facility failed to properly store, secure, and record a controlled substance (liquid Lorazepam) in the medication room; unaccounted 9 milliliters observed.
Facility failed to maintain an infection prevention and control program that included proper hand hygiene, use of gloves, and isolation procedures.
Report Facts
Census: 55
Unaccounted medication volume: 9
Medication doses administered: 6
Medication doses recorded: 8
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 2
Date: Jun 1, 2021
Visit Reason
The inspection was conducted as an investigation of multiple complaints (#84865, #84872, #92916, #92956, #93729, #94005, #98123, and #98124) and facility reported incidents (#97613 and #97614) from May 10, 2021 to June 1, 2021.
Complaint Details
Complaints #92916 and #92956 were substantiated. Complaints #84865, #84872, #93729, #94005, #98123, and #98124 were not substantiated. Facility reported incidents #97613 and #97614 were not substantiated.
Findings
The facility failed to provide bathing and oral hygiene services in accordance with professional standards for 4 of 4 sampled residents unable to carry out activities independently. Additionally, the facility failed to ensure residents received restorative therapies to increase range of motion and prevent further decline for 3 of 3 residents sampled.
Deficiencies (2)
Failure to provide bathing and oral hygiene services for dependent residents as per professional standards.
Failure to ensure residents receive restorative therapies to increase range of motion and prevent further decline.
Report Facts
Census: 48
Complaints investigated: 8
Facility Reported Incidents investigated: 2
Residents sampled for bathing and oral hygiene deficiency: 4
Residents sampled for restorative therapy deficiency: 3
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 3
Date: Nov 3, 2020
Visit Reason
The inspection was conducted as a Focused Infection Control Survey and complaint investigations related to complaints #94012, #94052, #94054, #94104, and #94315, all of which were substantiated.
Complaint Details
Complaints #94012-C, #94052-C, #94054-C, #94104-C, and #94315-C were all substantiated.
Findings
The facility failed to administer medications as ordered by the physician for multiple residents, failed to provide adequate bathing services for dependent residents, and failed to properly utilize Personal Protective Equipment (PPE) to mitigate the spread of COVID-19. The facility had 36 out of 62 residents positive for COVID-19 and failed to meet infection prevention and control requirements.
Deficiencies (3)
Facility failed to administer medications as ordered by the physician for 3 out of 3 sampled residents.
Facility failed to provide bathing services for 3 out of 3 sampled dependent residents.
Facility failed to utilize proper Personal Protective Equipment (PPE) for COVID-19 positive and negative residents, contributing to infection control deficiencies.
Report Facts
Residents positive for COVID-19: 36
Census: 62
Residents sampled for medication administration deficiency: 3
Residents sampled for bathing deficiency: 3
Inspection Report
Abbreviated Survey
Census: 74
Deficiencies: 1
Date: Jun 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on June 18, 2020, to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility failed to implement CMS recommended infection control practices to prevent the spread of disease for 2 of 3 sampled residents, including improper use of face masks by staff and failure to maintain social distancing of 6 feet among residents. The facility policy did not adequately address face mask usage.
Deficiencies (1)
Failure to implement infection control practices to prevent disease spread, including improper face mask use by staff and inadequate social distancing among residents.
Report Facts
Total residents: 74
Observation time: 3
Viewing
Loading inspection reports...
