Inspection Reports for
Ossian Care Center
114 Fisher Avenue, Ossian, IA, 521610098
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
37 residents
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Census: 37
Deficiencies: 6
Date: Jan 22, 2026
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, notification procedures, resident assessments, and facility sanitation.
Findings
The facility was found deficient in obtaining informed consent for psychotropic medications, notifying providers of vital sign changes when holding cardiac medications, providing Medicaid/Medicare coverage notices, accurately coding resident assessments, following proper insulin pen administration procedures, and maintaining sanitary kitchen practices.
Deficiencies (6)
Failed to obtain informed consent prior to starting psychotropic medications with black box warnings for 5 residents.
Failed to notify physician/provider when holding cardiac medication according to ordered vital sign parameters for 1 resident.
Failed to provide adequate notification of financial responsibility when Medicare Part A services were discontinued for 1 resident.
Failed to accurately code the use of restraints on Minimum Data Set (MDS) assessments for 2 residents.
Failed to follow manufacturer's patient information for proper administration of an insulin pen for 1 resident.
Failed to maintain sanitary practices by improperly storing clean dishes and maintaining a clean kitchen.
Report Facts
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Medication Aide (CMA) | Named in cardiac medication holding and vital sign monitoring deficiency |
| Staff A | Certified Nursing Assistant (CNA) | Interviewed regarding resident use of side rails |
| Staff B | Certified Nursing Assistant (CNA) | Interviewed regarding resident use of side rails |
| Staff C | Licensed Practical Nurse (LPN) | Named in insulin pen administration deficiency |
| Assistant Director of Nursing (ADON) | Interviewed regarding psychotropic medication consent, cardiac medication notification, insulin pen administration, and MDS coding | |
| Director of Nursing (DON) | Interviewed regarding cardiac medication notification and insulin pen administration | |
| Dietary Manager | Interviewed regarding kitchen sanitation and cleaning practices | |
| Administrator | Interviewed regarding Medicare Part A notification deficiency | |
| Provider/Medical Director | Interviewed regarding cardiac medication notification expectations |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 3, 2025
Visit Reason
The document is a plan of correction acceptance following a survey ending October 20, 2025, certifying the facility in compliance effective December 2, 2025.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted for the prior survey.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Oct 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely interventions and notification to a resident's physician after the resident presented with low blood pressure and altered mental status.
Complaint Details
The complaint investigation found that the facility did not notify the physician when Resident #1 had blood pressures lower than 90/50 mmHg and altered mental status. Staff interviews revealed expectations for notification were not met, and reassessment of blood pressure using a manual cuff was not performed timely.
Findings
The facility failed to provide appropriate treatment and timely notification to the physician for a resident with critically low blood pressure and altered mental status. Interviews with staff, pharmacist, and physician confirmed expectations for notification were not met, and reassessment of blood pressure was inadequate.
Deficiencies (1)
Failure to provide timely interventions and notification to the resident's physician after low blood pressure and altered mental status were observed.
Report Facts
Resident census: 40
Blood pressure readings: 63
Blood pressure readings: 36
Medication dosage: 12
Medication dosage: 1
Medication dosage: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Interviewed regarding blood pressure monitoring and notification procedures |
| Staff E | Certified Nursing Assistant (CNA) | Observed Resident #1 during the night and reported changes in condition |
| Assistant Director of Nursing (ADON) | Interviewed about assessment and notification expectations for low blood pressure | |
| Director of Nursing (DON) | Interviewed about expectations for reassessment and notification of low blood pressure |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Oct 20, 2025
Visit Reason
The inspection was conducted as a result of a facility reported incident #2620217-I that occurred between October 15, 2025 and October 20, 2025, involving concerns about quality of care related to a resident's low blood pressure and medication management.
Complaint Details
The visit was complaint-related due to a facility reported incident #2620217-I. The complaint involved concerns about quality of care, specifically failure to monitor and respond appropriately to a resident's low blood pressure and altered mental status. The complaint was substantiated as evidenced by the deficiency cited.
Findings
The facility failed to provide timely interventions and notification to the resident's physician after a resident presented with low blood pressure and altered mental status. Multiple staff interviews and record reviews revealed issues with monitoring vital signs, medication administration, and communication. The facility implemented a plan of correction including staff education, revised care plans, and periodic audits to ensure compliance.
Deficiencies (1)
Failure to provide timely interventions and notification to the resident's physician after a resident presented with low blood pressure and altered mental status.
Report Facts
Resident census: 40
MDS assessment date: Sep 11, 2025
Medication administration dates: Sep 17, 2025
Plan of correction completion date: Dec 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Marshall | Administrator | Signed the plan of correction document |
| Staff D | Educated on blood pressure parameters and involved in resident care and reassessment | |
| Assistant Director of Nursing | ADON | Involved in assessment and communication regarding resident's blood pressure |
| Director of Nursing | DON | Involved in reassessment and education related to resident's blood pressure |
| Staff E | Certified Nursing Assistant | Observed resident and reported on condition |
| Licensed Practical Nurse | LPN | Explained medication changes and blood pressure concerns |
| Pharmacist | Interviewed regarding concerns about low blood pressure |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 4, 2025
Visit Reason
A complaint investigation for facility reported incident #1788009-I was conducted from September 2, 2025 to September 4, 2025.
Complaint Details
Complaint investigation related to incident #1788009-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 30, 2024
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 will be certified in compliance effective December 21, 2024, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Nov 21, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to a fall incident involving Resident #36, focusing on whether fall interventions, specifically the use of a clip alarm, were properly implemented.
Complaint Details
The visit was complaint-related due to a fall incident involving Resident #36 on 9/28/24, resulting in a major injury. The complaint investigation found that the clip alarm was not in use during the fall, and staff were unsure about alarm usage and care plan details.
Findings
The facility failed to ensure that the clip alarm was attached to Resident #36's clothing at the time of a fall, which resulted in a major injury. Staff interviews and record reviews revealed gaps in staff knowledge and adherence to the care plan interventions.
Deficiencies (1)
Failure to ensure 1 of 1 residents reviewed for falls with major injury fall interventions had the clip alarm attached at the time of the fall.
Report Facts
Residents present: 37
Date of fall incident: Sep 28, 2024
Date of major injury determination: Oct 2, 2024
Date of care plan revision: Oct 1, 2024
Date of care plan instruction: May 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse Aide | Named in relation to the fall incident and staff knowledge regarding alarm usage |
| Director of Nursing | Signed the State for Resident #36 Fall Resulting in Fracture document | |
| MDS Coordinator | Interviewed regarding care plan revision after the fall | |
| Administrator | Interviewed regarding staff expectations for care plan adherence |
Inspection Report
Routine
Census: 37
Deficiencies: 7
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility safety at Ossian Care Center.
Findings
The facility was found deficient in multiple areas including failure to ensure timely physician signatures on advance directives, incomplete comprehensive assessments and care plans for residents, inadequate fall prevention interventions, improper use and consent for psychotropic medications, failure to maintain proper dishwasher sanitation, and failure to follow CDC COVID-19 infection control guidance including improper use of PPE by staff.
Deficiencies (7)
Failed to ensure 1 of 16 residents' Advance Directive forms was signed by the resident and their Doctor in a reasonable amount of time upon admission.
Failed to complete comprehensive Minimum Data Set (MDS) assessments resulting in failure to implement a comprehensive Care Plan for 2 of 4 residents reviewed.
Failed to ensure 1 of 1 residents' Preadmission Screening and Resident Review (PASRR) reflected all current diagnoses related to mental health.
Failed to ensure 1 of 1 residents reviewed for falls with major injury fall interventions were in place at the time of a fall when a clip alarm failed to be attached to a resident's clothing.
Failed to ensure antipsychotic medication had appropriate diagnoses for use, create resident specific interventions and medication side effects, and obtain informed consent for use of psychotropic medications for 1 of 1 residents reviewed.
Failed to have a proper system in place to ensure proper sanitation of all dishware; dishwasher was not sanitizing dishes properly due to equipment malfunction and lack of documentation.
Failed to follow CDC COVID-19 guidance and utilize personal protective equipment (PPE) to prevent the potential spread of COVID-19 affecting 7 of 10 residents in the CCDI unit.
Report Facts
Residents affected: 37
Residents positive for COVID-19: 9
Dishwasher wash temperature: 150
Dishwasher rinse temperature: 151
Antipsychotic medication dose: 12.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse Aide (CNA) | Named in fall incident report for Resident #36 |
| Staff F | Licensed Practical Nurse (LPN) | Named in multiple infection control PPE noncompliance observations |
| Staff I | Registered Nurse (RN) | Performed COVID-19 nasal swab testing and PPE noncompliance |
| Staff J | Certified Nursing Assistant (CNA) | Observed PPE noncompliance during resident care |
| Staff K | Dietary Staff | Tested dishwasher sanitation strips |
| Staff L | Dietary Staff | Reported dishwasher sanitation testing |
| Maintenance Director | Maintenance Director | Reported dishwasher repair and issues |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for care plans and infection control |
| Administrator | Facility Administrator | Interviewed regarding expectations for care plans and infection control |
| Social Worker | Social Worker | Interviewed regarding care plan and PASRR expectations |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan and medication consent processes |
| Infection Preventionist | Infection Preventionist | Interviewed regarding PPE and infection control policies |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Interviewed regarding dishwasher sanitation procedures |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 7
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of a facility reported incident.
Findings
The facility was found deficient in multiple areas including failure to ensure timely physician and resident signatures on advance directives, incomplete comprehensive assessments and care plans for residents with mental health diagnoses, failure to ensure fall interventions were in place, improper use and documentation of psychotropic medications, inadequate dishwasher sanitation, and failure to follow COVID-19 infection prevention and control protocols including improper PPE use.
Deficiencies (7)
Failure to ensure 1 of 16 residents' Advance Directive forms was signed by the resident and their doctor in a reasonable amount of time upon admission (Resident #9).
Failure to complete comprehensive Minimum Data Set assessments resulting in failure to implement a comprehensive Care Plan for 2 of 4 residents reviewed (Resident #3 and #36).
Failure to ensure PASRR reflected all current mental health diagnoses for Resident #3.
Failure to ensure fall interventions were in place at the time of a fall when a clip alarm was not attached to Resident #36's clothing.
Failure to ensure antipsychotic medication had appropriate diagnoses, resident specific interventions, side effect monitoring, and informed consent for Resident #36.
Failure to ensure proper sanitation of all dishware due to dishwasher malfunction and inadequate monitoring/documentation.
Failure to follow CDC COVID-19 guidance and utilize appropriate PPE to prevent spread of COVID-19 affecting 7 of 10 residents on the dementia unit.
Report Facts
Residents on COVID isolation: 9
Residents reviewed for advance directives: 16
Residents reviewed for comprehensive assessments: 4
Residents reviewed for fall interventions: 1
Residents reviewed for psychotropic medication use: 1
Dishwasher temperature: 150
Dishwasher temperature: 151
Dishwasher sanitizer level: 10
Dishwasher sanitizer level: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse | Named in findings related to improper PPE use and COVID-19 infection control breaches |
| Staff I | Registered Nurse | Named in findings related to COVID-19 testing and improper PPE use |
| Staff G | Certified Nursing Assistant | Named in findings related to COVID-19 infection control breaches |
| Staff J | Certified Nursing Assistant | Named in findings related to COVID-19 infection control breaches |
| Staff H | Certified Nursing Assistant | Named in findings related to COVID-19 infection control breaches |
| Staff K | Dietary Staff | Named in findings related to dishwasher sanitation testing |
| Staff L | Dietary Staff | Named in findings related to dishwasher sanitation testing |
| Staff M | Dietary Staff | Named in findings related to dishwasher sanitation testing |
| Director of Nursing | Director of Nursing | Named in findings related to multiple deficiencies including COVID-19 infection control and care planning |
| MDS Coordinator | MDS Coordinator | Named in findings related to care plan deficiencies and infection control assistance |
| Social Worker | Social Worker | Named in findings related to PASRR and care plan deficiencies |
| Certified Dietary Manager | Certified Dietary Manager | Named in findings related to dishwasher sanitation |
| Maintenance Director | Maintenance Director | Named in findings related to dishwasher repair and sanitation |
| Administrator | Administrator | Named in findings related to multiple deficiencies including advance directives and infection control |
| Infection Preventionist | Infection Preventionist | Named in findings related to COVID-19 infection control |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective November 12, 2023, based on the Plan of Correction submitted.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Oct 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of abuse and to properly investigate the allegation.
Complaint Details
The complaint investigation found the facility did not report suspected abuse within the required 2-hour timeframe and failed to conduct a thorough investigation, including physical assessments of the resident and others potentially affected. The Administrator acknowledged the reporting delay and investigation deficiencies.
Findings
The facility failed to report an allegation of abuse within the required 2-hour timeframe and did not complete a thorough investigation, lacking documentation of physical assessments for the affected resident and others potentially involved.
Deficiencies (2)
Failure to timely report suspected abuse to the Iowa Department of Inspections, Appeals, and Licensing within 2 hours.
Failure to complete a thorough investigation after an allegation of abuse, including lack of physical assessments and documentation.
Report Facts
Census: 38
Date of incident note: Apr 20, 2023
Date of admission: Nov 16, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Documented red marks on resident's neck and informed supervisor |
| Staff E | Certified Medication Aid (CMA) | Reported red marks on resident's neck |
| Staff F | Licensed Practical Nurse (LPN) | Typed summary of situation and informed Administrator; acknowledged lack of assessment |
| Administrator | Acknowledged failure to report allegations within required timeframe |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Oct 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of abuse within the required 2-hour timeframe to the Iowa Department of Inspections, Appeals, and Licensing (DIAL).
Complaint Details
The complaint investigation found that the facility failed to report an allegation of abuse within the required 2-hour timeframe to DIAL. The Administrator acknowledged the delay in reporting.
Findings
The facility failed to report suspected abuse in a timely manner and also failed to properly label and date opened food items prior to storage, which was observed during kitchen inspections. The facility acknowledged these deficiencies and identified a census of 38 residents.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to properly label and date opened food prior to storage in the kitchen.
Report Facts
Census: 38
Date of survey completion: Oct 12, 2023
Number of unlabeled/undated food items: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Documented red marks on resident's neck |
| Staff E | Certified Medication Aid (CMA) | Reported red marks on resident's neck |
| Staff F | Typed summary of the situation and informed Administrator | |
| Staff B | Dietary Aide | Reported food labeling and dating requirements |
| Staff C | Cook | Reported all opened food must be labeled and dated |
| Staff A | Dietary Manager | Reported expectations for labeling and dating food |
| Administrator | Acknowledged failure to timely report abuse allegations |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 3
Date: Oct 12, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of facility reported incidents #112481-1 and #115334-1.
Complaint Details
Facility reported incidents #112481-1 and #115334-1 were investigated and found not substantiated. The complaint investigation revealed failure to report abuse allegations timely and incomplete investigations.
Findings
The facility failed to report an allegation of abuse within the required 2-hour timeframe to the Iowa Department of Inspections, Appeals, and Licensing. The investigation was incomplete and lacked thorough documentation, including missing physical assessments and failure to properly label and date opened food items in the dietary department.
Deficiencies (3)
Failure to report an allegation of abuse within the required 2-hour timeframe to the Iowa Department of Inspections, Appeals, and Licensing.
Failure to complete a thorough investigation after an allegation of abuse.
Failure to properly label and date opened food items in the dietary department.
Report Facts
Resident census: 38
Deficiency count: 3
Correction date: Nov 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Documented red marks on resident's neck and informed staff of findings. |
| Staff E | Certified Medication Aid (CMA) | Reported red marks on resident's neck. |
| Staff F | Licensed Practical Nurse (LPN) | Documented communication of red marks and informed the Administrator. |
| Staff B | Dietary Aide | Reported that all opened food should be labeled and dated. |
| Staff C | Cook | Reported all opened food is to be labeled and dated prior to storage. |
| Staff A | Dietary Manager | Reported expectations for labeling and dating food items. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 26, 2023
Visit Reason
Investigation of facility reported incidents #106689-I and #110589-I.
Complaint Details
Investigation of facility reported incidents #106689-I and #110589-I resulted in no deficiencies. The facility was found in substantial compliance.
Findings
No deficiencies were found and the facility was determined to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 29, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Ossian Senior Hospice, indicating acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was certified in compliance effective July 29, 2022, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 5
Date: Jun 29, 2022
Visit Reason
The inspection was the facility's annual recertification survey conducted from June 26, 2022 to June 29, 2022.
Findings
The facility failed to serve beneficiary notices correctly for 3 residents, failed to implement the use of a roho cushion for 1 resident, failed to follow physician ordered parameters for daily weights and use of a roho cushion for 2 residents, and failed to provide proper nutritional servings and food safety measures. Multiple deficiencies were cited related to Medicaid/Medicare coverage notices, comprehensive care plans, professional standards, menus and nutritional adequacy, and food procurement and sanitation.
Deficiencies (5)
Failed to serve beneficiary notices correctly for 3 of 3 residents sampled.
Failed to implement the use of a roho cushion per the care plan for 1 of 13 residents reviewed.
Failed to follow physician ordered parameters on daily weights and utilize a roho cushion as ordered for 2 of 13 residents sampled.
Failed to provide the servings size called for with residents on pureed diets with regular serving sizes.
Failed to ensure the automatic dishwasher sanitized dishes/utensils as required.
Report Facts
Deficiencies cited: 5
Resident census: 31
Residents sampled: 13
Residents sampled: 3
Residents sampled: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nursing Assistant (CNA) | Observed moving resident and noted cushion placement. |
| Staff D | Certified Nursing Assistant (CNA) | Reported on resident cushion preference and care plan. |
| Staff D | Registered Nurse (RN) | Reported on care plan and cushion orders. |
| Director of Nursing | Interviewed regarding cushion use and care plan compliance. | |
| Staff B | Cook | Observed meal preparation and serving sizes. |
| Staff A | Cook | Interviewed about dishwasher temperatures and maintenance. |
| Dietary Manager | Interviewed about dishwasher issues and food service. |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 6
Date: Jul 29, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification Survey in accordance with Medicare Requirements for Long Term Care Facilities to assess compliance.
Findings
The facility was found to be NOT IN COMPLIANCE with multiple deficiencies identified including failure to ensure residents' wishes regarding advance directives were documented, quality of care issues leading to hospitalization, incomplete nurse staffing data posting, medication preparation errors, food safety violations, and infection control deficiencies.
Deficiencies (6)
Failure to ensure the resident's wishes per the Iowa Physician Orders for Scope of Treatment (IPOST) were documented and consistent with physician orders.
Quality of care deficiency including failure to prevent hospitalization for a resident and inadequate assessment and response to resident's condition.
Failure to post accurate nurse staffing data for 20 out of 27 days in July 2021.
Failure to properly prepare a prefilled medication device before administration.
Failure to serve food at safe and appetizing temperatures, including mashed potatoes served below safe temperature.
Failure to maintain an effective infection prevention and control program including inadequate hand hygiene and glove use during resident care.
Report Facts
Total residents: 38
Survey dates: 2021-07-26 to 2021-07-29
Days nurse staffing data missing: 20
Residents receiving mashed potatoes: 27
Residents observed for hand hygiene: 2
Residents with blood sugar check observed: 1
Residents with wound dressing observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in medication preparation and blood sugar check findings |
| Staff B | Licensed Practical Nurse (LPN) | Named in resident unresponsiveness and Narcan administration findings |
| Staff C | Licensed Practical Nurse (LPN) | Named in resident unresponsiveness and Narcan administration findings |
| Staff D | Director of Nursing (DON) | Named in multiple interviews regarding resident care and infection control |
| Staff E | Named in food temperature observation | |
| Staff F | Named in infection control observation | |
| Administrator | Named in interviews regarding staffing and infection control |
Inspection Report
Routine
Census: 36
Deficiencies: 0
Date: Dec 9, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on December 9 - 10, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Report Facts
Total Census: 36
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 3
Date: Oct 22, 2020
Visit Reason
The inspection was conducted as a Focused Infection Control Survey and Complaint investigations #88204 and #93010 between October 13 and 22, 2020.
Complaint Details
Complaint #88204-C was substantiated. Complaint #93010-C was not substantiated.
Findings
The facility was found to have deficiencies related to infection control, including failure to follow CMS COVID-19 screening recommendations for sampled residents, failure to notify residents and families timely about COVID-19 exposures, and issues with staffing and documentation regarding the Director of Nursing position and COVID-19 policies.
Deficiencies (3)
Failure to meet the requirement for a full-time Director of Nursing with specific duties and responsibilities.
Failure to follow CMS COVID-19 screening recommendations for 5 of 5 sampled residents.
Failure to notify residents, representatives, and families timely about COVID-19 exposures and positive test results.
Report Facts
Census: 38
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse, Acting Director of Nursing | Named as Acting Director of Nursing and involved in COVID-19 screening and notification deficiencies. |
| Staff G | Registered Nurse, Acting Director of Nursing | Named as Acting Director of Nursing and involved in Director of Nursing duties coverage. |
| Ana Scott | RN | Mentioned as acting Director of Nursing until permanent hire. |
| Brittany Bodensteiner | LPN | Mentioned as acting Director of Nursing until permanent hire. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/15/20 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.
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