Inspection Reports for Stacyville Community Nursing Home
413 South Broad Street, IA, 504765003
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 28, 2025
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on June 28, 2025, related to certification compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction, resulting in certification in compliance with health requirements effective June 28, 2025.
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 4
Jun 5, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #127981, #128038, #128503-C, and #128658-I from June 2, 2025 to June 5, 2025.
Findings
The facility was found not in compliance with 42 CFR Part 483 requirements due to deficiencies related to failure to report alleged violations of abuse, neglect, exploitation, and mistreatment timely, failure to complete significant change assessments for hospice residents, failure to accurately complete Minimum Data Set (MDS) assessments, and failure to meet professional standards for services provided including following physician orders.
Complaint Details
The investigation of complaints #127981, #128038, and #128503 did not result in deficiencies. The investigation of complaint #128658-I did not result in a deficiency. However, the facility was found deficient for failure to report abuse allegations timely related to Resident #9.
Deficiencies (4)
| Description |
|---|
| Failure to report an allegation of abuse within the required timeframe to the Iowa Department of Inspection, Appeals, and Licensing (DIAL) for Resident #9. |
| Failure to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) for Resident #17 after hospice election. |
| Failure to accurately complete MDS assessments for Resident #6, including certification and coordination requirements. |
| Failure to meet professional standards for services provided, including following physician orders for Residents #6 and #11. |
Report Facts
Resident census: 22
Missing money reported: 250
Additional missing money: 57
Stolen money reported: 400
MDS accuracy audit period: 6
Audit weekly review period: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Reported knowledge of Resident #9's missing money and reported it to the nurse |
| Staff C | Social Services | Verified Resident #9's report of missing money and reported it to the Administrator |
| Administrator | Conducted a 90-day retrospective review of incident logs and grievance reports; acknowledged failure to report Resident #9's missing money incidents to DIAL; spoke with Resident #9 about lockbox; confirmed facility did not complete Resident #17's SCSA assessment; reported no prior or current incidents of missing money to DIAL | |
| Staff A | MDS Coordinator | Reported starting work on 5/5/25; acknowledged failure to complete Resident #17's SCSA assessment; reported previous MDS coordinator coded medication error; reported facility lacked policy for MDS accuracy and completion |
| Director of Nursing (DON) | Director of Nursing | Will conduct monthly audits and random weekly audits of physician orders and documentation; responsible for oversight of corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 0
May 5, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance with health requirements, and certification will be effective April 25, 2025.
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 5
Apr 1, 2025
Visit Reason
The inspection was conducted due to facility complaints #127345-C and #127385-C from 3/26/25 through 4/1/25 to investigate alleged deficiencies.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483 requirements, with deficiencies related to resident rights, care plan timing and revision, restorative services, pharmacy services, and quality assurance performance improvement (QAPI) program. Specific issues included failure to allow a resident to make decisions, incomplete care plans, inadequate restorative nursing services, improper medication compounding, and ineffective QAPI program.
Complaint Details
The visit was complaint-related based on complaints #127345-C and #127385-C. The investigation found multiple deficiencies as detailed in the report. The complaint was substantiated with findings of deficient practices.
Severity Breakdown
Level D: 4
Level F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to allow Resident #4 to exercise rights and make decisions, including following physician orders and use of electric wheelchair. | Level D |
| Care plans for residents #2, #3, #4, and #5 were incomplete or not updated to address restorative nursing programs and risk for falls. | Level D |
| Failure to provide adequate restorative services to residents #2, #3, and #5, including documentation and care plan updates. | Level D |
| Pharmacy services deficiency related to improper compounding/mixing of medications by nursing staff outside scope of practice. | Level D |
| Quality Assurance and Performance Improvement (QAPI) program was ineffective and lacked proper documentation and monitoring. | Level F |
Report Facts
Census: 27
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in medication compounding deficiency |
| Staff B | Licensed Practical Nurse (LPN) | Redirected Staff A related to medication compounding |
| Staff C | Certified Nursing Assistant (CNA) | Confirmed restorative program issues during interview |
| Assistant Director of Nursing | ADON | Provided information on restorative program and staffing issues |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 11
Feb 7, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding multiple complaints (#124908-C, #123853-C, #124877-I, #125325-I, #126148-I, and #126149-I) related to resident intakes and treatment at Stacyville Community Nursing Home.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, specifically failing to treat residents with dignity and respect, report missing narcotics timely, maintain adequate nursing staff, and ensure safe medication administration and equipment operation. Multiple deficiencies were identified related to resident rights, abuse reporting, quality of care, nursing staff sufficiency and competency, pharmacy services, administration, and quality assurance programs.
Complaint Details
The complaint investigation was triggered by multiple complaints (#124908-C, #123853-C, #124877-I, #125325-I, #126148-I, and #126149-I) conducted January 17, 2025 through February 7, 2025. Complaints #124908-C and #123853-C were not substantiated. Facility reported incidents #123717-I, #124877-I, #125325-I, #126148-I, and #126149-I were not substantiated. The investigation included review of clinical records, staff interviews, and resident interviews.
Severity Breakdown
F 550: 1
F 609: 1
F 684: 1
F 689: 1
F 725: 1
F 726: 1
F 727: 1
F 755: 1
F 835: 1
F 865: 1
F 908: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility staff failed to treat one resident with dignity and respect while speaking with them (Resident #9). | F 550 |
| Facility failed to report missing narcotics to the Department of Inspections within 24 hours. | F 609 |
| Facility failed to provide adequate assessments and interventions in a timely manner for Resident #3 following a change of condition. | F 684 |
| Facility failed to maintain a safe environment for Resident #15 by allowing possession of a marijuana pipe and medication without proper removal. | F 689 |
| Facility failed to have sufficient nursing staff with appropriate competencies and skills; observed Licensed Practical Nurse (LPN) sleeping on duty. | F 725 |
| Facility failed to have competent nursing staff to perform intravenous medications and failed to properly intervene with residents exhibiting erratic behavior. | F 726 |
| Facility failed to provide sufficient nursing staff to meet resident needs and maintain highest practicable well-being. | F 727 |
| Facility failed to provide pharmacy services that assure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals. | F 755 |
| Facility failed to properly administer opioid medication to Resident #1 without witness and proper knowledge of syringe contents. | F 835 |
| Facility failed to administer nursing services in a manner that enables highest practicable physical, mental, and psychosocial well-being of each resident. | F 865 |
| Facility failed to maintain patient care equipment in safe operating condition; suction machine malfunctioned during resident emergency. | F 908 |
Report Facts
Resident census: 28
Deficiency count: 11
Medication administration observation: 1
Staff training hours: 2
Resident pain rating: 5
Resident BIMS scores: 15
Resident BIMS score: 9
Medication administration dates: 23
Staff training shifts: 2.5
Facility census: 30
Facility staff: 51
Facility census: 31
Facility staff: 55
Medication administration syringe volume: 1
Medication administration dose: 5
Medication administration dates: 4
Medication administration days: 23
Medication administration hours: 8
Dates with inadequate RN coverage: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse (LPN) | Named in findings for sleeping on duty and failure to treat Resident #9 with dignity |
| Staff D | Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) | Involved in escorting Staff C, medication administration, and nursing interventions |
| Staff E | Certified Nursing Assistant (CNA) | Witnessed Staff C sleeping on duty |
| Staff B | Licensed Practical Nurse (LPN)/Interim Director of Nursing (DON) | Named in findings for medication administration errors, failure to follow nursing standards, and staff management |
| Staff A | Registered Nurse (RN) | Named in findings for medication administration and reporting changes in resident condition |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 4, 2024
Visit Reason
This inspection was conducted as an onsite revisit following a previous survey ending July 17, 2024, to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Stacyville Community Nursing Home was found to be in substantial compliance effective August 16, 2024. The discretionary denial of payment for new admissions did not take effect.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 9
Jul 17, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of specific intake complaints #120435-C and #120126-C.
Findings
The facility was found not in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with deficiencies related to accuracy of assessments, coordination of PASARR and assessments, comprehensive care plans, discharge planning, staffing, infection control, and immunizations. Several residents were affected by these deficiencies.
Complaint Details
Complaints #120435-C and #120126-C were substantiated. Facility reported incident #120180-I was substantiated.
Severity Breakdown
Level 2: 2
Level 3: 7
Deficiencies (9)
| Description | Severity |
|---|---|
| Accuracy of Assessments - Facility failed to accurately document and submit accurate resident Minimum Data Set (MDS) assessments for 4 of 7 residents reviewed. | Level 2 |
| Coordination of PASARR and Assessments - Facility failed to submit a new Pre-admission Screening and Resident Review (PASARR) for 1 resident with new diagnoses. | Level 3 |
| Develop/Implement Comprehensive Care Plan - Facility failed to accurately complete comprehensive care plans for 3 of 14 residents reviewed. | Level 3 |
| Discharge Planning Process - Facility failed to implement discharge planning upon admission for 1 resident. | Level 3 |
| RN Staffing - Facility failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 10 days out of 90. | Level 3 |
| Free from Unnecessary Psychotropic Medications/PRN Use - Facility failed to ensure 1 resident received appropriate psychotropic medication orders and monitoring. | Level 3 |
| Payroll Based Journal Submission - Facility failed to accurately report staffing information based on payroll data for the second quarter of fiscal year 2024. | Level 2 |
| Infection Prevention and Control - Facility failed to establish and maintain an infection prevention and control program including training and oversight. | Level 3 |
| Influenza and Pneumococcal Immunizations - Facility failed to ensure residents received or were offered influenza and pneumococcal immunizations. | Level 3 |
Report Facts
Resident census: 31
Days RN coverage missing: 10
Residents reviewed for care plans: 14
Residents affected by care plan deficiencies: 3
Weeks of audit for bed rail usage: 4
Weeks of audit for care plans: 3
Weeks of audit for psychotropic medication: 4
Residents reviewed for infection control: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Micaela Engelhart | Administrator | Signed the plan of correction and provided statements during interviews regarding coding of bed rails and care plan policies |
| Staff B | Certified Medication Aide (CMA) | Provided statement regarding medication administration to Resident #1 |
| Staff E | Certified Nurse Aide (CNA) | Provided statement regarding medication administration and nurse call for Resident #1 |
| Staff F | Licensed Practical Nurse (LPN) | Provided statement regarding medication errors and resident monitoring |
| Staff G | Registered Nurse (RN) | Provided statements regarding medication administration and resident monitoring |
| Interim Director of Nursing (DON) | Provided multiple interviews regarding coding of bed rails, care plans, and staffing | |
| Administrator | Provided interviews and statements regarding care plans, staffing, and infection control | |
| Resident #1 Pharmacist | Pharmacist | Explained medication effects for Resident #1 |
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 18, 2024
Visit Reason
A revisit of the survey ending February 15, 2024 and investigation of facility reported incident #119592-I was conducted on March 18, 2024.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective March 15, 2024. Facility reported incident #119592-I was not substantiated.
Complaint Details
Facility reported incident #119592-I was not substantiated.
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 2
Feb 15, 2024
Visit Reason
The inspection was conducted as an investigation of complaints #114365-C, #114369-C, and #118843-C, as well as facility reported incidents #116263-I, #117988-I, #118031-I, and #118557-I. The complaints and incidents were substantiated.
Findings
The facility failed to ensure residents' rights were respected, including dignity and freedom from interference, coercion, discrimination, or reprisal. The facility also failed to prevent accidents, as evidenced by a resident's fall resulting in a fatal subdural hematoma. Multiple interviews, record reviews, and policy assessments confirmed these deficiencies.
Complaint Details
Complaints #114365-C, #114369-C, and #118843-C were substantiated. Facility reported incidents #116263-I, #117988-I, and #118557-I were also substantiated.
Severity Breakdown
Level G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents can exercise their rights without interference, coercion, discrimination, or reprisal. | — |
| Failure to ensure the resident environment remains free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents. | Level G |
Report Facts
Census: 22
Resident reviewed: 3
Resident reviewed: 1
Resident reviewed: 3
Resident reviewed: 1
Date of fall: Oct 12, 2023
Date of death: Oct 14, 2023
Blood pressure: 171
Blood pressure: 78
Glasgow Coma Score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Engelhart | Administrator | Signed the report on 02-22-2024 |
| Staff D | Registered Nurse (RN) | Named in resident #4 interview and fall investigation |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 10, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, effective June 30, 2023.
Inspection Report
Annual Inspection
Census: 17
Deficiencies: 3
May 18, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from 2023-05-15 to 2023-05-18.
Findings
The facility was found deficient in coordinating PASARR assessments for residents with new mental health diagnoses, failed to properly assess and treat pressure ulcers in a resident, and did not limit PRN antipsychotic medication use to 14 days without re-evaluation for one resident. The facility acknowledged these deficiencies and proposed corrective actions.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to submit a Level 2 PASRR evaluation for a resident with a new mental health diagnosis. | SS=D |
| Failed to routinely assess and report changes for a resident with pressure ulcers to promote healing and prevent infection. | SS=D |
| Failed to limit PRN antipsychotic medication to 14 days without a new order and evaluation for a resident. | SS=D |
Report Facts
Census: 17
PRN antipsychotic medication doses beyond 14-day order: 5
Pressure ulcer wound measurements: 3.1
Pressure ulcer wound measurements: 2.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Acknowledged failure to submit Level 2 PASRR evaluation and failure to limit PRN antipsychotic medication | |
| Administrator | Confirmed expectation for Level 2 PASRR evaluation for new psychosis diagnosis | |
| Staff A Licensed Practical Nurse (LPN) | Observed dressing changes and resident pain related to pressure ulcers | |
| Staff B Licensed Practical Nurse (LPN) | Assisted with dressing changes and reported physician's assessment |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 21, 2023
Visit Reason
An investigation of a facility complaint #103055-C conducted April 18 - 21, 2023.
Findings
The investigation resulted in no deficiencies.
Complaint Details
Complaint #103055-C was investigated and found to have no deficiencies.
Inspection Report
Annual Inspection
Census: 20
Deficiencies: 4
Nov 18, 2021
Visit Reason
The inspection was conducted as the facility's annual recertification survey from 11/15/21 to 11/18/21. The survey also investigated incident #100686 and complaint #96614, both of which were not substantiated.
Findings
The facility was found deficient in several areas including failure to provide proper bed-hold notices upon resident transfer, incomplete comprehensive care plans for residents with specific medical conditions, inadequate discharge summaries, and deficiencies in infection prevention and control practices related to oxygen tubing management. The facility reported a census of 20 residents during the survey.
Complaint Details
Complaint #96614 was investigated and found to be not substantiated.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide bed-hold notice upon transfer for 2 residents. | SS=D |
| Failure to develop and implement comprehensive care plans including monitoring of medications for 1 of 5 residents reviewed. | SS=D |
| Failure to develop and provide a discharge summary for 1 resident discharged to the community. | SS=D |
| Failure to establish and maintain an infection prevention and control program, including proper handling and documentation of oxygen tubing for residents. | SS=D |
Report Facts
Census: 20
Residents reviewed for bed-hold notice deficiency: 2
Residents reviewed for comprehensive care plan deficiency: 5
Residents reviewed for infection control deficiency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ray Frantz | Administrator | Signed the plan of correction on 12/8/21. |
| Director of Nursing (DON) | Interviewed regarding bed-hold policy, care plan expectations, and infection control practices; no full name provided. | |
| MDS Coordinator | Mentioned in relation to audits and education; no full name provided. |
Inspection Report
Routine
Census: 20
Deficiencies: 0
Jun 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection 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.
Report Facts
Total residents: 20
Loading inspection reports...
