Inspection Reports for Scottish Rite Park Health Care Center
2909 Woodland Avenue, IA, 503123822
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Inspection Report
Plan of Correction
Deficiencies: 0
Jul 2, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification effective July 2, 2025.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 2
Jun 26, 2025
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey from June 23, 2025 to June 26, 2025 to assess compliance with federal regulations.
Findings
The facility was found deficient for failing to complete and transmit a resident's Minimum Data Set (MDS) discharge assessment within the required timeframe for one resident (Resident #14). Additionally, the facility failed to follow the care plan related to the use of a left wrist splint for another resident (Resident #28), including lack of documentation and inconsistent application of the splint.
Deficiencies (2)
| Description |
|---|
| Failed to complete and transmit a resident Minimum Data Set discharge assessment within the required timeframe for Resident #14. |
| Failed to follow the resident's care plan regarding the application and documentation of a left wrist splint for Resident #28. |
Report Facts
Residents reviewed: 15
Residents reviewed: 13
Census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Physical Therapist | Documented that Resident #28 and staff forgot to put on the left wrist brace at night |
| Staff D | Occupational Therapist | Recommended splint wear for Resident #28 and documented goals related to splint use |
| Director of Nursing | Director of Nursing | Reported no official written policy for MDS and lack of documentation regarding splint application for Resident #28 |
| MDS Coordinator | Reported missing completion of Resident #14's discharge MDS and later completed and submitted it |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 6, 2025
Visit Reason
A revisit of the survey ending January 8, 2025 was conducted on February 6, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective January 24, 2025.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 2
Jan 8, 2025
Visit Reason
The inspection was conducted following a facility reported incident involving Resident #1 who sustained a fall and fractured her left ankle. The incident was substantiated and the investigation focused on the facility's failure to implement and follow safety interventions, including gait belt use, as outlined in the resident's care plan.
Findings
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents, resulting in Resident #1's fall and fracture. Staff interviews and record reviews revealed inconsistent use of gait belts despite care plan requirements, inadequate staff orientation and competency checks, and lack of a formal care plan policy. Staff A did not use a gait belt during the incident, leading to injury. The facility implemented corrective actions including staff education and new onboarding orientation checklists.
Complaint Details
The visit was complaint-related due to a facility reported incident #123546-I involving Resident #1's fall and injury. The incident was substantiated based on investigation findings.
Severity Breakdown
SS=G: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement and follow safety interventions including gait belt use for Resident #1, resulting in a fall and fractured ankle. | SS=G |
| Failure to ensure nurse aides possessed competencies and skills necessary to safely transfer residents as identified in the plan of care. | SS=D |
Report Facts
Resident census: 30
Incident date: Sep 8, 2024
Incident investigation date: Jan 6, 2025
Staff A hire date: May 30, 2024
Staff A CNA certification date: Feb 17, 2024
Staff education dates: 2024-08-01 to 2024-08-11
Plan of correction date: Jan 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Named in medication error finding and fall incident for Resident #1; failed to use gait belt as required |
| Staff B | Licensed Practical Nurse | Interviewed regarding Resident #1's fall and staff supervision |
| Staff C | Registered Nurse | Interviewed regarding Resident #1's care and gait belt use |
| Staff D | Shower Aide | Interviewed regarding gait belt use and fall incident |
| Staff E | Certified Nursing Assistant | Reported to have trained new staff and orientation practices |
| Staff F | Registered Nurse | Reported on QA Committee and Performance Improvement Plan for falls |
| Chief Nursing Officer | CNO | Conducted incident investigation, provided education, and reported on facility policies and corrective actions |
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 1
Aug 29, 2024
Visit Reason
A revisit of the survey ending July 18, 2024 was conducted to verify correction of a previously cited deficiency related to safe resident transfer using a mechanical lift.
Findings
The facility was found to be in substantial compliance as of August 12, 2024. The report details a past incident where a resident was not safely transferred using a mechanical standing lift, resulting in a fall and neck discomfort. The facility has since implemented training and policies to ensure safe transfers.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to safely transfer a resident using a mechanical lift for 1 of 3 residents reviewed, resulting in a fall and neck discomfort. | SS=D |
Report Facts
Resident census: 34
Resident weight: 311
Resident height: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Involved in the transfer incident and provided video education training |
| Staff B | Certified Nurse Aide (CNA) | Assisted in transfer and witnessed the sling failure |
| Staff C | Certified Nurse Aide (CNA) | Assisted in transfer of Resident #2 on 8/29/24 |
| Staff D | Certified Nurse Aide (CNA) | Assisted in transfer of Resident #2 on 8/29/24 |
| Staff E | Certified Medication Aide (CMA) | Assisted in transfer of Resident #2 on 8/29/24 |
| Director of Nursing | Director of Nursing (DON) | Provided statements on staff training and expectations regarding transfers |
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 3
Jul 18, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaint #120103-C from July 15 to July 18, 2024.
Findings
The facility was found deficient in completing timely and accurate quarterly Minimum Data Set (MDS) assessments for multiple residents, developing and implementing comprehensive care plans reflecting residents' needs such as oxygen use, and ensuring safe use of assistive devices like the EZ stand lift. Resident #2 experienced multiple falls related to improper use and supervision during transfers with the EZ stand lift, resulting in a fracture. The facility lacked policies and staff competency checks for EZ stand use.
Complaint Details
Complaint #120103-C was substantiated related to deficiencies in MDS assessments and resident care.
Severity Breakdown
Level D: 2
Level G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to complete and transmit quarterly MDS assessments timely and accurately for 4 of 12 residents sampled. | Level D |
| Failure to develop and implement a comprehensive person-centered care plan for Resident #7 that included oxygen use and related interventions. | Level D |
| Failure to ensure Resident #2 received adequate supervision and safe use of an EZ stand mechanical lift, resulting in multiple falls and a fracture. | Level G |
Report Facts
Residents sampled for MDS assessment review: 12
Facility census: 32
Falls with injury: 1
Errors in MDS assessments: 25
Errors in MDS assessments: 23
Errors in MDS assessments: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | MDS Coordinator | Reported incomplete MDS assessments prior to her start date and reviewed all MDS sections for accuracy |
| Director of Nursing | DON | Self-identified concerns about MDS timeliness, confirmed staffing changes, and acknowledged failure to report fall with fracture to State |
| Staff B | Registered Nurse | Reported Resident #2 found lying on floor after fall from EZ stand |
| Staff J | Registered Nurse | Performed wound care on Resident #2 while standing in EZ stand; involved in fall incident |
| Staff C | Certified Nursing Assistant | Assisted with transfers and lowering Resident #2 during fall incidents |
| Staff F | Certified Nursing Assistant | Assisted with transfers and lowering Resident #2 during fall incidents |
| Staff G | Certified Nursing Assistant | Witnessed fall of Resident #2 from EZ stand and assisted with lowering |
| Staff E | Registered Nurse | Reported use of Hoyer lift and EZ stand for Resident #2 transfers |
| Staff K | Physical Therapist | Provided therapy recommendations for Resident #2 and advised on use of Hoyer sling |
| Staff H | Certified Medication Aide | Described proper use of EZ stand lift and safety precautions |
| Staff I | Certified Nursing Assistant | Described EZ stand lift use and safety measures |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 12, 2023
Visit Reason
A complaint investigation was conducted for facility reported incidents #117395-I and #116117-I from December 11, 2023 to December 12, 2023.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Complaint Details
Complaint investigation for incidents #117395-I and #116117-I; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
May 11, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's certification compliance.
Findings
The facility was certified in compliance effective May 11, 2023, based on acceptance of a credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 25
Deficiencies: 1
May 10, 2023
Visit Reason
The inspection was conducted as part of the Annual Recertification Survey from May 8 to May 10, 2023.
Findings
The facility was found to have expired food items in the kitchen, indicating failure to ensure food safety requirements related to procurement, storage, preparation, and serving of food. The dietary staff failed to prevent serving expired food items, posing a risk of contamination and food-borne illness.
Deficiencies (1)
| Description |
|---|
| Expired food items found in the kitchen including oyster sauce, malt vinegar, crackers, coconut milk, and oats. |
Report Facts
Expired food items: 7
Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding expired food items and food safety procedures |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 21, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
The facility was certified in compliance effective February 16, 2022, based on acceptance of a credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 28
Deficiencies: 1
Feb 17, 2022
Visit Reason
The inspection was a recertification survey conducted from February 14 to 17, 2022, to assess compliance with federal regulations.
Findings
The facility failed to ensure accurate assessments for 2 of 3 residents reviewed regarding unnecessary medications, specifically discrepancies in documenting depression diagnoses in Minimum Data Set (MDS) assessments despite residents receiving antidepressants.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure accurate assessments for residents regarding unnecessary medications, with discrepancies in documenting depression diagnoses in MDS assessments for Residents #11 and #19. | SS=B |
Report Facts
Census: 28
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Verified discrepancies in resident assessments and acknowledged need for correction |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 2
Apr 12, 2021
Visit Reason
The inspection was conducted as part of an investigation related to complaint numbers 96387-A and 96393-A, focusing on allegations of abuse, neglect, and improper use of restraints at Scottish Rite Park.
Findings
The facility failed to ensure residents were treated with respect and dignity, specifically regarding the improper use of physical restraints on Resident #1. The facility also failed to properly report incidents of abuse and ensure staff followed abuse reporting protocols. Staff showed poor nursing judgment in the use of restraints, and the facility did not take adequate corrective actions during the investigation period.
Complaint Details
The visit was complaint-related, investigating allegations of abuse and improper restraint use involving Resident #1. The complaint was substantiated as the facility failed to prevent improper restraint use and failed to report incidents properly. The Chief Nursing Officer (CNO) acknowledged poor nursing judgment and failure to report the incident to the Department of Inspections and Appeals.
Deficiencies (2)
| Description |
|---|
| Failure to ensure residents were free from physical or chemical restraints imposed for convenience or discipline, and failure to treat residents with respect and dignity. |
| Failure to ensure incidents of abuse were properly reported and investigated in a timely manner. |
Report Facts
Resident census: 21
Resident #1 MDS score: 12
Dates of incident: Incident involving gait belt restraint occurred on 3/1/21
Dates of staff work: Staff B worked on 3/2/21, 3/9/21, and 3/11/21 after the alleged incident
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Named in the restraint incident involving Resident #1 and poor nursing judgment |
| Staff A | Licensed Practical Nurse (LPN) | Reported concern about gait belt restraint to Chief Nursing Officer |
| Staff C | Certified Nursing Assistant (CNA) | Observed and reported gait belt restraint incident |
| Staff D | Certified Nursing Assistant (CNA) | Observed gait belt restraint incident and did not report it |
| Staff E | Certified Nursing Assistant (CNA) | Observed gait belt restraint incident and did not report it |
| Chief Nursing Officer | CNO | Interviewed regarding the incident and acknowledged poor nursing judgment and failure to report |
Inspection Report
Routine
Census: 23
Deficiencies: 0
Dec 14, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted by the Department of Inspections and Appeals 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: 25
Deficiencies: 0
Jun 23, 2020
Visit Reason
A COVID 19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals 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: 25
Inspection Report
Renewal
Census: 26
Deficiencies: 3
Feb 20, 2020
Visit Reason
The inspection was conducted as a recertification survey of the facility to assess compliance with federal regulations, including CPR certification, menu and nutritional adequacy, and food safety requirements.
Findings
The facility failed to ensure availability of staff certified in CPR for each shift, failed to serve proper puree diet portions for a resident, and failed to provide safe and proper sanitization while serving food. Deficiencies were identified related to CPR certification, menu preparation and portion sizes, and food safety practices.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure availability of a staff member certified with cardiopulmonary resuscitation (CPR) for each shift. |
| Facility failed to serve the proper portion for one resident on a pureed diet. |
| Facility failed to provide safe and proper sanitization while serving food, including hairnets not fully covering hair. |
Report Facts
Census: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse | CPR certification expired in December 2019 |
| Staff A | Dietary Aide | Served improper puree diet portions and had hairnet issues |
| Staff B | Cook | Prepared puree diet portions incorrectly |
| Director of Nursing | DON | Verified CPR certification status of Staff C |
| Dietary Manager | DM | Reported on puree scoop size and hairnet expectations |
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