Inspection Reports for Silver Oak Nursing and Rehabilitation LLC
455 31st Street, IA, 523023723
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 23, 2025 found the facility in substantial compliance with no deficiencies cited. Earlier inspections showed a pattern of deficiencies primarily related to resident dignity and privacy, timely reporting of incidents, medication administration, staffing sufficiency, and quality of care including infection control and fall prevention. Several complaint investigations were substantiated over time, involving issues such as failure to report abuse promptly, inadequate assessments, and lapses in care protocols, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility took corrective actions including staff disciplinary measures and plans of correction, and more recent inspections indicate improvement with fewer and less severe deficiencies. Complaint investigations in the latest period were unsubstantiated, suggesting progress in addressing prior concerns.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
16.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
268% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
70 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 23, 2025
Visit Reason
A complaint investigation was conducted for complaints #2687025-C, #2689517-C, #2698592-C, and a facility reported incident #2664973-I from December 17, 2025 to December 23, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Investigation involved multiple complaints and a facility reported incident; the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 8, 2025
Visit Reason
The document is a plan of correction following a survey ending October 23, 2025, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective December 5, 2025.
Findings
No specific deficiencies are detailed in this document; it confirms acceptance of the plan of correction and certification of compliance.
Report Facts
Survey end date: Oct 23, 2025
Certification effective date: Dec 5, 2025
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 15, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the certification compliance of Silver Oak Nursing and Rehabilitation Center LLC.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective October 15, 2025. No specific deficiencies are detailed in this document.
Report Facts
Certification effective date: Certification effective October 15, 2025
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Oct 23, 2025
Visit Reason
The inspection was conducted as an investigation of complaints #2633185-C, #2627723-C, and facility reported incidents #2648170-I, #2642008-I, and #2642081-I from October 20 to October 23, 2025.
Findings
The facility failed to ensure that 2 of 5 residents received respectful and dignified care protecting their right to privacy. An Activity Assistant entered residents' rooms without knocking while they were receiving personal care or dressing, causing distress and discomfort to the residents. The facility acknowledged prior similar incidents involving the same staff member.
Complaint Details
The complaint investigation involved substantiated allegations that Staff D, an Activity Assistant, entered Resident #2's and Resident #8's rooms without knocking, violating their privacy rights. The facility confirmed multiple incidents and took disciplinary action against Staff D.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents' right to privacy and dignified care when an Activity Assistant entered rooms without knocking during personal care or dressing. | SS = D |
Report Facts
Complaint numbers investigated: 2
Facility reported incidents investigated: 3
Resident census: 70
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Activity Assistant | Named in privacy violation findings for entering residents' rooms without knocking |
| Staff A | Certified Nurses Aide (CNA) | Provided personal care to Resident #2 during incident and reported the event |
| Administrator | Administrator | Provided disciplinary action reports and oversaw staff re-education |
| Corporate Nurse | Corporate Nurse | Confirmed repeated incidents of Staff D entering rooms without knocking |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Sep 15, 2025
Visit Reason
The inspection was conducted due to allegations of abuse, neglect, exploitation, or mistreatment involving residents #3 and #4, reported through multiple facility incidents and complaints between September 8 and September 15, 2025.
Findings
The facility failed to report an allegation of resident-to-resident abuse within the required timeframe. Resident #4 slapped Resident #3, causing injury and requiring antibiotic treatment. Staff failed to notify appropriate personnel at the time of the incident. The facility also failed to implement effective Quality Assurance and Performance Improvement (QAPI) activities to prevent recurrence.
Complaint Details
The complaint investigation was substantiated. The facility reported an incident between Resident #3 and Resident #4 involving physical abuse that was not reported timely to the state survey agency as required. The facility failed to notify staff and state officials within mandated timeframes. The facility reported a census of 76 residents during the investigation period.
Severity Breakdown
Level D: 1
Level E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an allegation of resident abuse within required timeframes as per state law and federal regulations. | Level D |
| Failure to carry out effective Quality Assurance and Performance Improvement (QAPI) activities to ensure corrective measures and prevent ongoing prevalence of deficiencies. | Level E |
Report Facts
Facility census: 76
Incident dates: 2025-09-08 to 2025-09-15
Date of compliance for abuse reporting deficiency: Sep 30, 2025
Date of compliance for QAPI deficiency: Oct 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Nurse Practitioner | Saw resident on 6/27/2025 concerning a blister and ordered antibiotics |
| Staff D | Administrator | Indicated incident involving Residents #3 and #4 should have been reported to the state |
| Staff C | Director of Nursing | Indicated incident involving Residents #3 and #4 should have been reported to the state |
| Staff A | Licensed Practical Nurse (LPN) | Reported Resident #4 slapped Resident #3 on 6/21/2025 |
| Director of Clinical Services | Educated Administrator on requirements for reporting abuse and on QAPI policy and procedures |
Inspection Report
Plan of Correction
Deficiencies: 0
May 15, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was certified in compliance effective May 9, 2025, based on acceptance of the credible allegation of substantial compliance and the Plan of Correction.
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 13
Apr 9, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey including investigation of multiple complaints and a reported incident.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, advance directives, abuse prevention and reporting, medication administration, nursing staff sufficiency, infection control, and quality of care related to skin and wound management. Several residents were affected by these deficiencies.
Complaint Details
Complaints #126563-C, #127121-C, #127196-C, #127475-C, and #127628-C were substantiated. Facility reported incident #127679-I/M information will be sent separately.
Deficiencies (13)
| Description |
|---|
| Facility failed to treat residents with dignity and respect while providing care and services. |
| Facility failed to ensure resident records included advance directives (IPOST) and related documentation. |
| Facility failed to protect residents from abuse, neglect, exploitation, and failed to report alleged violations timely. |
| Facility failed to ensure timely medication administration and proper documentation. |
| Facility failed to provide sufficient nursing staff to meet residents' needs. |
| Facility failed to ensure staff were properly certified as nurse aides prior to employment. |
| Facility failed to maintain accurate medication administration records and timely medication availability. |
| Facility failed to provide nutritional needs for residents on puree diets and maintain food at safe, palatable temperatures. |
| Facility failed to maintain sanitary conditions in dietary kitchen areas. |
| Facility failed to establish and maintain an effective infection prevention and control program. |
| Facility failed to provide required influenza and pneumococcal immunizations and related education. |
| Facility failed to provide required COVID-19 immunizations and related education. |
| Facility failed to provide required in-service training for nurse aides including dementia and abuse prevention training. |
Report Facts
Deficiency counts: 13
Residents affected: 7
Residents census: 74
Plan of correction completion date: May 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Certified Nursing Assistant | Named in deficiency related to lack of CNA certification and training. |
| Staff M | Nurse | Named in findings related to abuse, medication administration, and inappropriate relationship. |
| Staff F | Certified Nursing Aide | Named in findings related to resident dignity and abuse reporting. |
| Staff G | Licensed Practical Nurse | Named in findings related to resident care and abuse reporting. |
| Staff H | Certified Medication Aide | Named in findings related to abuse reporting and resident care. |
| Staff L | Scheduling | Named in findings related to CNA training and certification. |
| Staff D | Cook | Named in findings related to food temperature and meal preparation. |
| Staff E | Certified Nursing Assistant | Named in findings related to resident dignity and privacy. |
| Staff I | Licensed Practical Nurse | Named in findings related to medication administration and abuse reporting. |
| Staff K | Unknown | Named in findings related to CNA certification and training. |
| Staff N | Licensed Practical Nurse | Named in findings related to medication administration and abuse reporting. |
| Staff A | Certified Nursing Assistant | Named in findings related to resident care and abuse reporting. |
| Staff C | Certified Nursing Assistant | Named in findings related to resident care and abuse reporting. |
| Staff J | Certified Nursing Assistant | Named in findings related to CNA training and certification. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 12, 2025
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey, indicating acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction, resulting in certification of compliance effective March 7, 2025.
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 3
Feb 5, 2025
Visit Reason
Investigation of complaint #126237-C conducted from February 3, 2025 through February 5, 2025.
Findings
The facility failed to promptly notify residents' representatives and providers of test results related to changes in clinical conditions for 2 of 3 residents reviewed. The facility also failed to maintain sufficient resident assessments and interventions to ensure resident safety and well-being.
Complaint Details
Complaint #126237-C was substantiated.
Deficiencies (3)
| Description |
|---|
| Failure to notify resident representatives and providers timely of test results related to changes in clinical conditions for 2 of 3 residents. |
| Failure to maintain sufficient resident assessments and interventions to maintain residents' highest practical physical and psychosocial well-being for 2 of 3 residents reviewed. |
| Failure to maintain accurate and complete clinical records for 2 of 3 residents reviewed. |
Report Facts
Census: 77
Residents reviewed: 3
Residents with notification failure: 2
Residents with assessment failure: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse (LPN) | Reported nurse practitioner was not notified on 1/18/25 and new order was given by telephone. |
| Staff B | Licensed Practical Nurse (LPN) | Reported passing messages about x-ray results and assessments. |
| Staff F | Certified Nursing Assistant (CNA) | Observed resident's condition and reported to nurses. |
| Staff D | Licensed Practical Nurse (LPN) | Reported monitoring and assessments were sometimes missed due to being busy. |
| Staff G | Registered Nurse (RN) | Received messages about x-ray results. |
| Director of Nursing | Director of Nursing (DON) | Reported taking x-ray results from fax machine and acknowledged delays in notification and assessments. |
| Advanced Registered Nurse Practitioner | ARNP | Assessed resident on 1/17/25 and reported delayed receipt of chest x-ray results. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 21, 2025
Visit Reason
An investigation of complaint #125943-C and facility reported incident #126015-I was conducted from 1/16/25 to 1/21/25.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation of complaint #125943-C and facility reported incident #126015-I; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 31, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of a credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective December 21, 2024.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 3
Nov 25, 2024
Visit Reason
The inspection was conducted as a result of investigations of complaints #124910-C and #125055-C, and a facility reported incident #124696-I, conducted from November 19, 2024 to November 25, 2024.
Findings
The facility was found deficient in quality of care related to failure to complete pre- and post-dialysis assessments for a resident on dialysis, failure to routinely assess a resident's skin condition, and failure to serve hot food at appropriate temperatures and provide palatable meals. Complaints #124910-C and #125055-C were substantiated, while the facility reported incident #124696-I was not substantiated.
Complaint Details
Complaints #124910-C and #125055-C were substantiated. Facility reported incident #124696-I was not substantiated.
Severity Breakdown
Level D: 1
Level E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to complete pre-dialysis and post-dialysis assessments and monitor dialysis access site for Resident #2. | Level D |
| Failure to routinely assess and document skin condition for Resident #4 with a red, itchy rash. | Level E |
| Failure to serve hot food at least 135 degrees Fahrenheit and provide palatable meals for residents. | Level E |
Report Facts
Residents present: 78
Correction date: Dec 21, 2024
Food temperature: 135
Food temperature: 140
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 24, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective September 21, 2024.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Aug 21, 2024
Visit Reason
The inspection was conducted related to the investigation of complaints #120982-C, #122218-C, #122656-C, and facility reported incidents #122804-I and #122827-I from August 19 to August 21, 2024.
Findings
The facility failed to provide adequate assessment and timely interventions for one of four residents reviewed (Resident #2), who experienced critically low blood sugar and did not receive timely glucagon injection as ordered. Staff re-education and corrective actions were planned to prevent recurrence.
Complaint Details
Complaints #120982-C and #122656-C were substantiated. Complaint #122218-C and incidents #122804-I and #122827-I were not substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate assessment and timely interventions for Resident #2 with critically low blood sugar, including failure to administer glucagon injection as ordered. | SS=D |
Report Facts
Resident census: 73
Blood sugar level: 40
Blood sugar level: 46
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A LPN | Licensed Practical Nurse | Noted resident was unresponsive with low blood sugar and delayed glucagon administration |
| Staff B RN | Director of Nurses | Stated expectation for immediate glucagon administration and completed re-education of Staff A LPN |
Inspection Report
Plan of Correction
Deficiencies: 0
May 21, 2024
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective May 17, 2024.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, with no specific deficiencies detailed in this document.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 2
Apr 24, 2024
Visit Reason
The inspection was conducted as a result of complaints #120314-C and #120414-C, which were substantiated, to investigate deficiencies related to care and medication administration at Silver Oak Nursing and Rehabilitation Center LLC.
Findings
The facility failed to follow physician orders for medication administration for Resident #2 and failed to provide appropriate assessment and interventions for Resident #1. Issues included missed medication orders, incorrect medication dosages, failure to arrange treatment, and inadequate care related to PICC line management and quality of care.
Complaint Details
Complaints #120314-C and #120414-C were substantiated based on investigation findings.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to follow physician orders for Resident #2, including missed Suboxone administration and incorrect Fluoxetine dosage. | SS=D |
| Facility failed to provide appropriate assessment and interventions for Resident #1, including management of PICC line and infection prevention. | SS=D |
Report Facts
Resident census: 70
Date survey completed: Apr 30, 2024
Correction date: May 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse Practitioner | Reported resident condition and medication issues |
| Staff B | Director of Nursing | Reported medication order errors and submitted education outline |
| Staff D | Registered Nurse | Reported resident behaviors and medication administration issues |
| Staff C | Licensed Practical Nurse | Reported resident condition changes and physician notifications |
| Staff F | Nurse Practitioner | Examined resident and reported PICC line concerns |
| Lawrence Munsell | Administrator | Signed the statement of deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 15, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on April 15, 2024, related to the facility's compliance status.
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 April 15, 2024.
Inspection Report
Re-Inspection
Census: 68
Deficiencies: 1
Apr 4, 2024
Visit Reason
The visit was a revisit of the survey ending February 22, 2024, and an investigation of complaint #119984-C conducted from April 9 to April 11, 2024.
Findings
The facility failed to complete a resident assessment for self-administration of medications for one of three residents reviewed, with the complaint found unsubstantiated. The facility reported a census of 68 residents and lacked a self-administration medication assessment in the electronic health record.
Complaint Details
Complaint #119984-C was unsubstantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete a resident assessment for self-administration of medications for Resident #11. | SS=D |
Report Facts
Resident census: 68
Medications prescribed: 14
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Assistant (CMA) | Reported observations regarding Resident #11's medication self-administration |
| Medical Director | Provided assessment of Resident #11's ability to take medications independently | |
| Administrator | Reported on facility sweep of resident rooms and medication pill case removal |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 7, 2024
Visit Reason
A complaint investigation for complaint #119254-C and a facility reported incident #119242-I was conducted from March 5, 2024 to March 7, 2024.
Findings
No deficiencies were identified during this survey.
Complaint Details
Complaint #119254-C was investigated and found to have no deficiencies.
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 11
Feb 22, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey, investigation of complaints #118859-C and facility self-reported incident #118928-I.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, incomplete resident assessments for self-administration of medications, failure to follow manufacturer recommendations for insulin administration, inadequate wound care and documentation, lack of accurate transfer agreements, and insufficient staff competency documentation. Several residents were found at risk due to these deficiencies.
Complaint Details
Complaint #118859 was substantiated. Incident #118928 was substantiated.
Severity Breakdown
SS=E: 1
SS=D: 6
SS=J: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to treat 4 out of 4 residents with dignity and respect during care and meals. | SS=E |
| Failure to complete resident assessment for self-administration of medications for 1 resident. | SS=D |
| Failure to follow manufacturer recommendations for insulin administration for 1 resident. | SS=D |
| Failure to assess and document an open ulcerated wound and perform hand hygiene during wound care for 1 resident. | SS=D |
| Failure to prevent elopement of a cognitively impaired resident resulting in immediate jeopardy. | SS=J |
| Failure to ensure nursing staff competency for 2 employees. | SS=D |
| Failure to ensure residents are free of significant medication errors for 1 resident. | SS=D |
| Failure to procure, store, prepare, serve, and maintain food in a sanitary manner. | — |
| Failure to maintain transfer agreements with local hospitals. | — |
| Failure to provide mandatory dependent adult abuse training for 1 staff member. | SS=D |
| Failure to document VA eligibility checks for multiple residents. | — |
Report Facts
Census: 67
Residents reviewed: 4
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 2
Residents reviewed: 1
Staff reviewed: 5
Residents reviewed: 5
Residents reviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Named in insulin administration and competency findings |
| Staff C | Licensed Practical Nurse (LPN) | Named in wound care and competency findings |
| Staff F | Named in dependent adult abuse training deficiency | |
| Staff G | Cook | Named in elopement incident |
| Staff H | Certified Nursing Assistant (CNA) | Named in elopement incident |
| Staff I | Certified Nursing Assistant (CNA) | Named in elopement incident |
| Staff K | Registered Nurse (RN) | Named in elopement incident |
| Director of Nursing | Administrator | Named in multiple findings and plan of correction |
| Human Resource Director | Named in dependent adult abuse training deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 21, 2023
Visit Reason
The inspection was conducted following a complaint investigation of intakes #116572-C and #116530-I from November 20 to November 21, 2023.
Findings
The Silver Oak Nursing and Rehabilitation Center was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. Complaint #116572 and Facility Reported Incident #116530 were both not substantiated.
Complaint Details
Complaint #116572 was not substantiated. Facility Reported Incident #116530 was not substantiated.
Report Facts
Discretionary Denial of Payment duration: 2
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 7
Oct 5, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaints and facility reported incidents between September 26, 2023 and October 5, 2023.
Findings
The facility was found not in compliance with several requirements including maintaining a safe, clean, and homelike environment, following physician's orders for care, providing adequate assistance with activities of daily living, ensuring resident safety to prevent accidents, securing medication carts, and providing pain management. Specific deficiencies included mold in shower rooms, failure to follow physician orders for a resident's feeding tube care, inadequate bathing assistance for multiple residents, a resident falling from bed resulting in a hip fracture, unlocked medication carts, and missed doses of pain medication.
Complaint Details
The investigation involved complaints #114902, #114904, #114935, #115229, #115618, #115757 and facility reported incidents #114951 and #115734. Most complaints were substantiated except complaint #115618 which was not substantiated.
Severity Breakdown
SS=E: 2
SS=D: 1
SS=G: 2
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide housekeeping services to maintain a safe, clean, comfortable, and homelike environment including mold in shower rooms and grime on floors. | SS=E |
| Failed to follow physician's orders for feeding tube care for Resident #9. | SS=D |
| Failed to provide adequate bathing assistance to 4 residents reviewed. | SS=E |
| Failed to provide adequate supervision and assistance to prevent a resident from falling out of bed resulting in a hip fracture; also failed to secure medication carts. | SS=G |
| Failed to provide pain medications for Resident #3, missing 14 doses of fentanyl patch resulting in increased pain. | SS=G |
| Failed to have 8 continuous hours of RN coverage for two days in September 2023. | SS=F |
| Failed to complete shift to shift narcotic counts on medication carts, with multiple missed counts documented. | SS=E |
Report Facts
Deficiency counts: 97
Deficiency counts: 18
Missed medication doses: 14
RN coverage hours: 6.25
RN coverage hours: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrator | Reported on 10/5/23 about epidemiologist visit, staffing issues, and RN coverage problems. |
| Staff E | Certified Nurse Aide (CNA) | Observed Resident #9 without proper feeding tube covering and reported staffing shortages affecting resident care. |
| Staff P | Director of Nursing (DON) | Reported on feeding tube care expectations and narcotic count issues. |
| Staff H | Certified Nurse Aide (CNA) | Involved in incident where Resident #6 fell from bed. |
| Staff I | Registered Nurse (RN) / Assistant Director of Nursing (ADON) | Received call about Resident #6 fall and coordinated hospital transfer. |
| Staff N | Licensed Practical Nurse (LPN) | Observed leaving medication cart unlocked and admitted not signing narcotic counts. |
| Staff B | Certified Nurse Aide (CNA) | Reported on Resident #3 pain and gave report to Staff H about Resident #6 care needs. |
| Staff F | Agency Certified Nurse Aide (CNA) | Worked on 8/4/23 and reported lack of shift report and knowledge of Resident #6 care needs. |
| Staff K | Advanced Registered Nurse Practitioner (ARNP) | Reported on Resident #6 condition and care needs. |
| Staff J | Certified Occupational Therapy Assistant (COTA) | Reported on Resident #6 therapy evaluation and assistance needs. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 8, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance certification.
Findings
The facility was certified in compliance effective July 8, 2023, based on acceptance of a credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 8
Jun 8, 2023
Visit Reason
Investigation of multiple complaints and facility self-reported incidents from May 30, 2023 to June 8, 2023, including allegations of failure to provide translator services, incomplete care plans, failure to update care plans after falls, inadequate tracheostomy care, and failure to document physical assessments after abuse allegations.
Findings
The facility failed to provide translator services for a non-English speaking resident, did not update care plans timely or comprehensively for residents with new medical devices or after falls, failed to obtain and transcribe physician orders for wound care, did not follow proper infection control during incontinence care, failed to document physical assessments after abuse allegations, and did not prevent or properly respond to falls including incomplete neurological assessments. Additionally, tracheostomy care was not performed according to professional standards.
Complaint Details
The investigation was triggered by complaints #112691-C, #112805-C, #112986-C, #113177-C and facility self-reported incidents #112163-I and #113362-I. Complaints #112691-C, #112805-C, #112986-C and #113177-C were substantiated. Facility Self-Reported Incident #112163-I was substantiated.
Severity Breakdown
SS=D: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to address resident's need for translator services for a non-English speaking resident (Resident #6). | SS=D |
| Failed to ensure Baseline Care Plan addressed presence of Jackson-Pratt tube and need for translation service for Resident #6. | SS=D |
| Failed to update Care Plan with new interventions after a fall for Resident #2. | SS=D |
| Failed to obtain physician orders, transcribe orders, and change dressings as ordered for Jackson-Pratt tube for Resident #6. | SS=D |
| Failed to provide proper incontinence care by not changing gloves or washing hands after handling soiled brief for Resident #6. | SS=D |
| Failed to document physical assessments after allegations of abuse for Residents #4, #9, and #10. | SS=D |
| Failed to prevent falls in the dining room, failed to document complete neurological assessments after falls for Residents #1 and #2. | SS=D |
| Failed to utilize proper technique for tracheostomy care including improper glove use and suctioning technique for Resident #6. | SS=D |
Report Facts
Deficiencies cited: 8
Resident census: 56
BIMS scores: 99
BIMS scores: 0
BIMS scores: 15
BIMS scores: 12
BIMS scores: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Reported resident did not speak English and spoke Haitian; observed incontinence care |
| Staff E | Licensed Practical Nurse | Reported resident spoke Creole French; admitted entering orders without full info; involved in tracheostomy care |
| Director of Nursing | Director of Nursing | Reported expectations for care plans, orders, and fall assessments; educated staff; responsible for audits |
| Staff M | Licensed Practical Nurse | Reported care plan update process; infection control education; post-abuse assessments |
| Staff H | Licensed Practical Nurse | Reported fall assessment procedures and care plan updates |
| Staff L | Registered Nurse | Completed head to toe assessments after abuse allegations but did not document in charts |
| Staff C | Certified Nurse Assistant | Observed treating residents with dignity; denied physical abuse; present during fall observations |
| Staff J | Certified Nurse Assistant | Reported dining room staffing and fall incident; assisted moving resident after fall |
| Staff I | Certified Nurse Assistant | Reported dining room staffing and fall incident |
| Staff D | Licensed Practical Nurse | Reported fall assessment procedures; observed tracheostomy care |
| Staff O | Licensed Practical Nurse | Observed incontinence care |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 31, 2023
Visit Reason
The document serves as a plan of correction following a denial of payment for new admits (DPNA) period from March 10, 2023 to March 30, 2023, indicating acceptance of a credible allegation of compliance.
Findings
The facility will be certified in compliance effective March 31, 2023, following acceptance of the credible allegation of compliance and plan of correction. The DPNA was in effect from March 10 to March 30, 2023.
Report Facts
Denial of Payment for New Admits (DPNA) period: 21
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 29, 2023
Visit Reason
This document is a plan of correction related to deficiencies identified in a prior survey event ID #TN8BII.
Findings
No specific deficiencies or findings are detailed in this document; it references another event ID for survey results.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Mar 29, 2023
Visit Reason
The inspection was conducted as an On-Site Revisit of a Complaint Survey ending January 31, 2023, and investigation of Complaints #110839-C, #111894-C and a Facility Self-Reported Incident #111820-I conducted from March 20, 2023 to March 29, 2023.
Findings
The facility failed to complete appropriate vital signs and neurological assessments post unwitnessed resident falls for 3 of 5 residents reviewed, despite documented care plans and protocols. Staff did not consistently follow the Neuro Checks protocol, especially when residents were asleep, and neurological assessments were incomplete or missing. The complaint #110839-C was substantiated.
Complaint Details
Complaint #110839-C was substantiated.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to complete appropriate vital signs and neurological assessments post unwitnessed resident falls for 3 of 5 residents reviewed. | Level D |
Report Facts
Residents reviewed with fall histories: 5
Census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Transcribed nursing progress notes related to resident falls and Neuro Checks documentation. |
| Staff B | Licensed Practical Nurse (LPN) | Provided interview about Neuro Checks protocol and documented resident fall assessments. |
| Staff C | Registered Nurse (RN) | Documented vital sign and neurological assessments post resident falls. |
| Staff D | Registered Nurse (RN) | Interviewed regarding Neuro Checks protocol and expectations for neurological assessments. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for Neuro Checks protocol adherence and staff compliance. |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 4
Jan 31, 2023
Visit Reason
The inspection was conducted following multiple complaint intakes and allegations of abuse, neglect, and mistreatment, including a resident elopement and fall resulting in injury, inadequate nursing assessments, and pain management concerns.
Findings
The facility failed to report a resident elopement and fall injury to the Department of Inspections and Appeals, failed to provide adequate nursing assessments for two residents, and failed to provide adequate pain management for a resident with burn injuries. The facility also failed to adequately supervise a resident to prevent elopement and subsequent injury.
Complaint Details
Complaints #110417, #110440, #110549, and #110633 were substantiated. Complaint #110438 was not substantiated. Facility reported incidents #110504, #110641, and #110639 were not substantiated.
Severity Breakdown
SS=G: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to report to DIA when a resident exited the facility unattended and suffered a fall with injury. | — |
| Failure to provide adequate nursing assessments for two residents, including admission, discharge, and pain assessments. | SS=G |
| Failure to provide adequate pain management and assessment for a resident with second to third degree burns from spilled hot chocolate. | SS=G |
| Failure to adequately supervise a resident to prevent elopement and subsequent fall with injury. | SS=G |
Report Facts
Resident census: 52
MDS BIMS score: 12
MDS BIMS score: 0
Pain score: 10
Temperature: 135.4
Temperature: 143
Morse Fall Scale score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nurse Aide (CNA) | Allowed Resident #3 to exit facility unattended, unaware she was a resident |
| Staff D | Licensed Practical Nurse (LPN) | Assessed Resident #3 after fall and transferred to emergency room |
| Staff E | Administrator | Reported video footage of elopement, re-educated staff, and provided education to Staff F |
| Staff C | Licensed Practical Nurse (LPN) | Documented Resident #3 did not sign out and assessed post-fall condition |
| Staff H | Registered Nurse (RN)/Assistant Director of Nursing (ADON) | Assessed Resident #2 and Resident #6, observed burn wounds, and reported pain management concerns |
| Staff L | Licensed Practical Nurse (LPN) | Assessed Resident #6 burns and administered Silvadene cream |
| Staff M | Dietary Aide | Served hot chocolate to Resident #6 and responded to spill incident |
| Staff N | Certified Nurse Aide (CNA) | Assisted Resident #6 after hot chocolate spill and reported incident |
| Staff O | Certified Nurse Aide (CNA) | Assisted Resident #6 after hot chocolate spill and reported pain |
| Staff R | Medication Aide | Reported Resident #6 pain and lack of daily pain assessments |
| Staff Q | Medication Aide | Reported assisting Resident #6 in bed and observed pain response |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 19, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was certified in compliance based on acceptance of the credible allegation of compliance and plan of correction effective January 19, 2023.
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 11
Dec 15, 2022
Visit Reason
The inspection was conducted as an Annual Recertification Survey combined with a substantiated complaint investigation (#109340-C) from December 5 to December 15, 2022.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, call light accessibility, advanced directives, medication administration, quality of care, accident prevention, tube feeding management, dialysis care, pharmacy services, and medication storage. Specific issues included delayed staff response to call lights, missing resident property, inconsistent advanced directive documentation, failure to follow physician orders, inadequate supervision during transfers, improper tube feeding management, incomplete dialysis assessments, delayed medication delivery, and unsecured medications.
Complaint Details
Complaint #109340-C was substantiated based on findings related to resident dignity, call light response, and missing property.
Severity Breakdown
SS=D: 9
SS=E: 1
SS=B: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure residents' dignity and respect, including timely response to call lights and protection of resident property. | SS=D |
| Failure to ensure call lights were within reach for residents with limited mobility. | SS=D |
| Failure to have advanced directives in place or consistent documentation for multiple residents. | SS=E |
| Failure to provide required Medicaid/Medicare coverage and liability notices at the end of skilled facility stay. | SS=B |
| Failure to follow physician orders and provide professional standard care including oxygen therapy, medication administration, and admission assessments. | SS=D |
| Failure to provide quality of care including documentation of assessments/interventions for skin breakdown, transportation arrangements, and admission assessments. | SS=D |
| Failure to provide adequate supervision to prevent injury during resident transfer. | SS=D |
| Failure to properly manage tube feeding including secure tubing and prevention of complications. | SS=D |
| Failure to complete proper dialysis assessments before and after treatments. | SS=D |
| Failure to provide timely delivery of medications from pharmacy for new admissions. | SS=D |
| Failure to keep medications stored in locked compartments and failure to date insulin vials when opened. | SS=D |
Report Facts
Residents with dignity issues: 3
Residents with missing property: 1
Residents with call light issues: 2
Residents without advanced directives: 4
Residents with medication delivery issues: 1
Residents with insulin vials not dated: 1
Residents with dialysis assessment issues: 1
Residents with tube feeding management issues: 1
Residents with injury due to inadequate supervision: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Peter Mammy | Registered Nurse | Reported oxygen order not transcribed correctly for Resident #34. |
| Staff A | Registered Nurse | Left inhalers unsecured in Resident #41's room; reported insulin vials should be dated when opened. |
| Staff B | Certified Nursing Assistant | Reported Resident #14's leg was injured during transfer due to lack of Tubigrips. |
| Staff C | Certified Nursing Assistant | Assisted with transfer of Resident #14 when injury occurred. |
| Staff I | Licensed Practical Nurse | Reported Resident #151 ran out of tizanidine due to pharmacy delivery issues. |
| Interim Director of Nursing | Director of Nursing | Provided multiple clarifications on facility policies and deficiencies. |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 21, 2022
Visit Reason
An on-site revisit of the survey ending September 7, 2022 and investigation of Complaints #108170-C, #108198-C, #108563-C, #108628-C and a Facility Self-Reported Incident #108567-I was conducted from November 10, 2022 to November 21, 2022.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective October 15, 2022. Complaints and the facility self-reported incident investigated were not substantiated.
Complaint Details
Complaints #108170-C, #108198-C, #108563-C, #108628-C were not substantiated. Facility Self-Reported Incident #108567-I was not substantiated.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 8
Sep 7, 2022
Visit Reason
The inspection was conducted as a result of investigations of multiple substantiated complaints and facility self-reported incidents from August 24, 2022 to September 7, 2022.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect due to staffing shortages, failure to maintain a clean and safe environment, failure to protect residents from abuse including resident-to-resident altercations, failure to report alleged abuse in a timely manner, failure to thoroughly investigate abuse allegations, failure to follow physician orders for a resident with bleeding, insufficient nursing staff to meet resident needs, and failure to provide adequate staff to prevent behaviors in a cognitively impaired resident.
Complaint Details
Complaints #106613-C, #107188-C, and #107286-C were substantiated. Facility Self-Reported Incidents #106615-I, #106616-I, and #107290-I were substantiated.
Severity Breakdown
SS=E: 3
SS=D: 4
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to treat residents with dignity and respect due to delayed call light response and inadequate staffing causing residents to remain in bed and become incontinent. | SS=E |
| Failure to maintain a safe, clean, comfortable, and homelike environment as evidenced by soiled shower room and trash in resident rooms. | SS=E |
| Failure to protect residents from abuse including resident-to-resident altercations causing injury. | SS=D |
| Failure to report alleged abuse and resident-to-resident incidents within required timeframes. | SS=E |
| Failure to thoroughly investigate abuse allegations and implement interventions to prevent further abuse. | SS=D |
| Failure to follow physician orders for a resident with bleeding, including failure to apply pressure or dressing to bleeding wound. | SS=D |
| Failure to provide sufficient nursing staff to meet resident needs, resulting in inadequate care and unsafe conditions, especially on weekends. | SS=F |
| Failure to provide sufficient and competent staff to address behavioral health needs of a resident with dementia and aggressive behaviors. | SS=D |
Report Facts
Census: 48
Residents requiring mechanical lift: 14
Residents requiring two-person assist for transfers: 20
Deficiency count: 8
Call light response time: 50
Staffing ratio: 1
Staffing ratio: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse | Documented resident bleeding and failed to apply pressure dressing |
| Staff B | Licensed Practical Nurse / Unit Manager | Responded to resident bleeding, called 911, and assisted with care |
| Interim Director of Nursing | Director of Nursing | Provided statements regarding abuse incidents and staffing |
| Staff N | Certified Nursing Assistant | Witnessed resident altercation and described staffing shortages |
| Staff O | Certified Nursing Assistant | Reported lack of behavioral interventions and staffing concerns |
| Staff H | Registered Nurse | Reported short staffing on 8/28/22 and impact on resident care |
| Staff A | Certified Nursing Assistant | Reported resident bleeding and staff response |
| Staff D | Registered Nurse | Provided report on resident bleeding and provider communication |
| Staff J | Certified Nursing Assistant | Reported staffing shortages and resident care delays on 8/28/22 |
| Staff K | Certified Nursing Assistant | Reported staffing shortages and resident care delays on 8/28/22 |
| Staff F | Certified Nursing Assistant | Reported knowledge of video of resident injury and reporting |
| Staff C | Licensed Practical Nurse / Unit Manager | Received report of video and reported to DON |
| Staff M | Certified Nursing Assistant | Denied taking video of resident injury |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 14, 2022
Visit Reason
The document is a plan of correction submitted by the facility following a previous inspection, indicating acceptance of compliance and certification effective August 14, 2022.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 5
Jul 11, 2022
Visit Reason
The inspection was conducted as an onsite revisit from a Complaint Survey conducted May 4, 2022 to May 17, 2022, and the investigation of Complaints #105228-C and #105226-C, and a Facility Self-Reported Incident #105472-I conducted July 7, 2022 to July 14, 2022.
Findings
The facility was found to have multiple deficiencies including failure to respect residents' dignity, failure to maintain a clean and homelike environment, failure to thoroughly investigate alleged abuse, neglect, exploitation, or mistreatment, and failure to provide adequate ADL care and restorative services. Several residents required extensive assistance and the facility failed to provide scheduled baths/showers and restorative programs as required.
Complaint Details
Complaints #105228-C and Facility Self-Reported Incident #105472-I were substantiated. The deficiencies from the Complaint Survey conducted May 4, 2022 to May 17, 2022 were corrected.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to respect a resident's dignity by not providing care in a timely manner for one of three residents reviewed. | SS=D |
| Failure to maintain a clean and homelike environment for three of three shower rooms observed. | SS=E |
| Failure to complete and document a thorough investigation of a resident reported incident of alleged abuse. | SS=D |
| Failure to provide at least two baths or whirlpool baths per week for three of five residents reviewed. | SS=D |
| Failure to provide a restorative program to four of four residents sampled who needed restorative services. | SS=D |
Report Facts
Resident census: 53
Number of residents reviewed for dignity deficiency: 3
Number of shower rooms with cleanliness issues: 3
Number of residents reviewed for bathing deficiency: 5
Number of residents needing restorative services: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Nursing (DON) | Reported expectations for staff to provide assistance before incontinence accidents |
| Staff C | Nurse Manager | Reported expectations for staff to provide assistance before incontinence accidents and concerns about missed baths/showers |
| Staff B | Certified Nurses Aide (CNA) | Reported black fuzzy residue in shower rooms and primary shower aide on day shift |
| Staff F | Maintenance Director | Reported ordering PVC trim for mold resistant cleaning of shower rooms |
| Staff J | Certified Nurses Aide (CNA) | Involved in resident incident of alleged abuse |
| Staff I | Interim Administrator | Reported lack of investigation file and efforts to contact previous administrator |
| Staff E | Therapy Director (TD) | Reported facility did not have a restorative program in place |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
May 4, 2022
Visit Reason
The inspection was conducted as a result of Complaint #104424-C and a Facility Self-Reported Incident #104003-I from May 4, 2022 to May 17, 2022 to investigate allegations related to staff background checks and medication management.
Findings
The facility was found to have failed to conduct a criminal background check for one of six employees prior to hire, and deficiencies were found in the management and reconciliation of controlled medications, including missing morphine and inadequate narcotic count documentation.
Complaint Details
The Facility Self-Reported Incident #104003-I was substantiated. The complaint investigation revealed failure to conduct required background checks and medication management deficiencies.
Deficiencies (3)
| Description |
|---|
| Failure to conduct a Criminal Background Check prior to hire for one employee. |
| Failure to carry out and/or document regular reconciliation of controlled medications, including missing morphine and incomplete narcotic counts. |
| Failure to store Schedule II Narcotic Medications in a separately locked, permanently affixed compartment limited to authorized personnel only. |
Report Facts
Employees reviewed for Criminal Background Checks: 6
Census: 51
Medication Count Missing: 30
Medication Count Missing: 14.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Flemming | Director of Business Services | Provided education and training related to hire process and background checks. |
| Staff F | Employee hired without prior criminal background check; involved in medication cart and narcotic box access. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding background check policies and narcotic count procedures. |
| Staff C | Certified Medication Aide (CMA) | Observed during narcotic counts and medication cart activities. |
| Staff J | Registered Nurse (RN) | Observed during narcotic counts and medication cart activities. |
| Staff B | Licensed Practical Nurse (LPN) | Involved in narcotic counts and medication cart observations. |
| Staff D | Counted narcotics and reported missing morphine. | |
| Staff E | Registered Nurse (RN) | Discovered missing morphine during narcotic count. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed about narcotic count procedures. |
| Staff H | Certified Nursing Assistant (CNA) | Observed Staff F in medication cart. |
| Staff G | Certified Nursing Assistant (CNA) | Observed Staff F in medication cart. |
| Interim DON | Interim Director of Nursing | Interviewed about narcotic count procedures and staff access to medication cart. |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 27, 2022
Visit Reason
Revisits of the Recertification Survey ending December 28, 2021 and the Federal Comparative Survey ending February 4, 2022, along with investigation of Complaints #102003-C, #102286-C, #103390-C and a Facility Self-Reported Incident #102704-I, were conducted from April 18, 2022 to April 27, 2022.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective March 23, 2022. Complaints #102003-C, #102286-C, and #103390-C were not substantiated. Facility reported incident #102704-I was also not substantiated.
Complaint Details
Complaints #102003-C, #102286-C, and #103390-C were investigated and found not substantiated. Facility reported incident #102704-I was also not substantiated.
Report Facts
Complaint numbers: 3
Inspection Report
Complaint Investigation
Census: 55
Capacity: 180
Deficiencies: 13
Jan 25, 2022
Visit Reason
A Federal Comparative Survey was conducted by the Centers for Medicare and Medicaid Services (CMS) on Feb. 4, 2022 following an Iowa Department of Inspections and Appeals Recertification Survey on 12/28/2021. The survey investigated multiple complaints related to advance directives, Medicaid/Medicare coverage and liability notices, transfer/discharge notices, comprehensive assessments, accuracy of assessments, baseline care plans, treatment to prevent/heal pressure ulcers, free of accident hazards, label/store drugs and biologicals, facility assessment, infection prevention and control, antibiotic stewardship, and other regulatory compliance issues.
Findings
The facility was found deficient in multiple areas including failure to determine and inform residents about advance directives, failure to provide proper Medicaid/Medicare notices, failure to provide transfer/discharge notices, incomplete comprehensive assessments and baseline care plans, inadequate treatment and documentation for pressure ulcers, failure to maintain a safe environment free of accident hazards, improper labeling and storage of drugs and biologicals, incomplete facility assessments, and deficiencies in infection prevention and control programs. The facility also failed to provide proper documentation and notifications related to transfers, bed hold policies, and infection control. Systemic measures and plans of correction were outlined for each deficiency.
Complaint Details
The survey was complaint-driven, investigating multiple complaints identified by Iowa Department of Inspections and Appeals. The complaints included issues with advance directives, Medicaid/Medicare notices, transfer/discharge notices, comprehensive assessments, pressure ulcer treatment, accident hazards, drug storage, infection control, and antibiotic stewardship. The report includes substantiation of these complaints through record reviews, interviews, and policy reviews.
Deficiencies (13)
| Description |
|---|
| Facility failed to determine whether residents had an advance directive and inform residents for three of eight residents reviewed. |
| Facility failed to ensure Medicare residents received proper notice upon termination of therapy services. |
| Facility failed to provide proper Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to residents upon discontinuation of services. |
| Facility failed to provide proper notice before transfer or discharge for residents. |
| Facility failed to provide written notification of bed-hold policy and duration to residents or representatives upon transfer. |
| Facility failed to complete comprehensive Minimum Data Set (MDS) assessments timely for residents. |
| Facility failed to accurately complete Minimum Data Set (MDS) for one resident following a fall with major injury. |
| Facility failed to provide adequate treatment and documentation for pressure ulcers for one resident. |
| Facility failed to provide showers as scheduled for residents and document refusals. |
| Facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls. |
| Facility failed to maintain a safe environment free of accident hazards and failed to provide adequate supervision and assistance devices to prevent falls. |
| Facility failed to provide proper infection prevention and control program including surveillance, tracking, and staff training. |
| Facility failed to implement an antibiotic stewardship program and monitor antibiotic use. |
Report Facts
Census: 55
Total Capacity: 180
Deficiencies cited: 12
Completion Dates: Mar 23, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy | Assistant Director of Nursing (ADON) | Mentioned in relation to transfer form completion and bed hold policy documentation. |
| R44 | Resident | Mentioned in relation to refusal of showers and care plan documentation. |
| R50 | Resident | Mentioned in relation to multiple falls, injury documentation, and care plan. |
| R11 | Resident | Mentioned in relation to Minimum Data Set assessments and fall risk. |
| RN3 | Registered Nurse | Observed medication storage and infection control practices. |
| RN1 | Registered Nurse | Provided information on resident care and refusals. |
| Licensed Practical Nurse (LPN1) | Licensed Practical Nurse | Provided information on resident care and refusals. |
| Director of Nursing (DON) | Director of Nursing | Mentioned in relation to infection preventionist training and fall prevention. |
| Interim Director of Nursing | Interim Director of Nursing | Hired as Infection Preventionist and mentioned in infection control program. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 23, 2021
Visit Reason
The visit was conducted to investigate multiple complaints (#94715, #96258, #96881, #96977, #97300) and facility self-reported incidents (#96906 and #97564) between 5/10/21 and 6/23/21.
Findings
The complaints and self-reported incidents investigated during the survey period were not substantiated.
Complaint Details
Complaints #94715, #96258, #96881, #96977, and #97300 and Facility Self-Reported Incidents #96906 and #97564 were investigated from 5/10/21 to 6/23/21 and found not substantiated.
Inspection Report
Routine
Census: 54
Deficiencies: 0
Nov 17, 2020
Visit Reason
A Focused COVID-19 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: 54
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Oct 29, 2020
Visit Reason
A focused COVID-19 Infection Control Survey and an investigation of Complaint #94106 were conducted from 10/26/20 through 10/29/20.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #94106 was not substantiated.
Complaint Details
Complaint #94106 was investigated and found not substantiated.
Report Facts
Total residents: 60
Inspection Report
Abbreviated Survey
Census: 62
Deficiencies: 0
Jul 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 7/15-16/20 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.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #91467 and #91499 were conducted by the Department of Inspections and Appeals on 6/15-16/20.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Both complaints were not substantiated.
Complaint Details
Complaints #91467 and #91499 were investigated and found not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 10, 2020
Visit Reason
The document is a plan of correction related to a facility self-reported incident #89168 which was investigated and found not substantiated.
Findings
The facility self-reported an incident which was investigated and determined to be not substantiated according to 42 CFR Part 483, Subpart B-C.
Report Facts
Incident number: 89168
Report
Mar 31, 2022
File
ScannedReport_916_2022-03-31_103241.pdf
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