Inspection Reports for
Stacyville Community Nursing Home
413 South Broad Street, Stacyville, IA, 504765003
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
16.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
277% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
40
30
20
10
0
Census
Latest occupancy rate
22 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
Deficiencies (4)
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
Complaint Investigation
Census: 22
Deficiencies: 4
Date: Jun 5, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse and neglect, failure to complete required assessments after hospice election, inaccurate Minimum Data Set (MDS) assessments, and failure to follow physician's orders for certain residents.
Complaint Details
The complaint investigation focused on allegations of abuse related to missing money for Resident #9, failure to complete required assessments after hospice election for Resident #17, inaccurate MDS documentation for Resident #6, and failure to follow physician's orders for Residents #6 and #11. The facility was found to have failed in timely reporting abuse and in completing required assessments and orders.
Findings
The facility failed to timely report an allegation of abuse involving missing resident funds, failed to complete a Significant Change Status Assessment (SCSA) after a resident elected hospice, inaccurately documented and submitted an MDS assessment for a resident, and failed to follow physician's orders for two residents. The census was reported as 22 residents.
Deficiencies (4)
Failed to timely report suspected abuse involving missing money for Resident #9 to the Iowa Department of Inspection, Appeals, and Licensing (DIAL).
Failed to complete a Significant Change Status Assessment (SCSA) MDS after Resident #17 elected hospice services.
Failed to accurately document and submit an accurate MDS assessment for Resident #6, including incorrect medication coding.
Failed to follow physician's orders for Resident #6 and Resident #11, including missed medication administration and missed therapy orders.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Missing money amounts: 250
Missing money amounts: 57
Reported stolen money: 400
Facility census: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Reported knowledge of Resident #9's missing money and reporting to nurse |
| Staff C | Social Services | Verified Resident #9's report of missing money and reported to Administrator |
| Administrator | Acknowledged failure to report Resident #9's missing money incidents to DIAL and discussed lockbox with Resident #9 | |
| Staff A | MDS Coordinator | Reported failure to complete SCSA for Resident #17 and acknowledged coding errors for Resident #6 |
| Director of Nursing | Reported staff missed physician therapy orders for Resident #6 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
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.
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.
Deficiencies (5)
Failure to allow Resident #4 to exercise rights and make decisions, including following physician orders and use of electric wheelchair.
Care plans for residents #2, #3, #4, and #5 were incomplete or not updated to address restorative nursing programs and risk for falls.
Failure to provide adequate restorative services to residents #2, #3, and #5, including documentation and care plan updates.
Pharmacy services deficiency related to improper compounding/mixing of medications by nursing staff outside scope of practice.
Quality Assurance and Performance Improvement (QAPI) program was ineffective and lacked proper documentation and monitoring.
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: 27
Deficiencies: 5
Date: Apr 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with resident rights, care planning, restorative services, pharmaceutical services, and quality assurance at Stacyville Community Nursing Home.
Complaint Details
The complaint investigation identified deficiencies related to Resident Rights, Pharmacy Services, and Quality Assurance and Performance Improvement (QAPI). The investigation concluded on 2025-04-01 with findings of deficient practices.
Findings
The facility was found deficient in honoring resident rights, maintaining complete and accurate care plans, providing restorative services, following pharmaceutical standards, and having an effective quality assurance program. Deficiencies affected multiple residents with minimal harm or potential for harm.
Deficiencies (5)
Failed to honor a resident's right to make decisions and follow physician orders related to electric wheelchair use for Resident #4.
Failed to maintain complete and accurate care plans for 4 residents, including failure to address restorative programs and fall risk.
Failed to provide restorative services to maintain or improve range of motion and mobility for 3 residents due to staffing issues.
Failed to follow professional pharmaceutical standards by compounding treatment ointments/creams without physician orders for Resident #1.
Failed to have an effective quality assurance and performance improvement (QAPI) program in place.
Report Facts
Census: 27
Deficiencies cited: 5
Morse Fall Scale score: 35
Restorative program frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in pharmaceutical services deficiency for compounding medications |
| Staff B | Licensed Practical Nurse (LPN) | Redirected Staff A regarding compounding medications |
| Staff C | Certified Nursing Assistant (CNA) | Confirmed restorative program was affected by staffing issues |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Involved in communication with Resident #4's POA and confirmed restorative program issues |
| Business Office Manager | Responsible for monitoring the QAPI program and acknowledged its ineffectiveness |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 11
Date: 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.
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.
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.
Deficiencies (11)
Facility staff failed to treat one resident with dignity and respect while speaking with them (Resident #9).
Facility failed to report missing narcotics to the Department of Inspections within 24 hours.
Facility failed to provide adequate assessments and interventions in a timely manner for Resident #3 following a change of condition.
Facility failed to maintain a safe environment for Resident #15 by allowing possession of a marijuana pipe and medication without proper removal.
Facility failed to have sufficient nursing staff with appropriate competencies and skills; observed Licensed Practical Nurse (LPN) sleeping on duty.
Facility failed to have competent nursing staff to perform intravenous medications and failed to properly intervene with residents exhibiting erratic behavior.
Facility failed to provide sufficient nursing staff to meet resident needs and maintain highest practicable well-being.
Facility failed to provide pharmacy services that assure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals.
Facility failed to properly administer opioid medication to Resident #1 without witness and proper knowledge of syringe contents.
Facility failed to administer nursing services in a manner that enables highest practicable physical, mental, and psychosocial well-being of each resident.
Facility failed to maintain patient care equipment in safe operating condition; suction machine malfunctioned during resident emergency.
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
Routine
Census: 28
Deficiencies: 11
Date: Feb 7, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal regulations and state rules for nursing homes, including review of resident care, staffing, medication management, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, timely reporting of missing narcotics, inadequate assessments following change of condition, unsafe environment due to resident possession of unauthorized items, staff sleeping on duty, lack of competent nursing staff including unqualified IV medication administration, failure to provide adequate RN coverage and designate a qualified Director of Nursing, improper medication handling, ineffective leadership, inadequate quality assurance program, and failure to maintain essential equipment such as suction machines.
Deficiencies (11)
Failed to treat one resident with dignity and respect while speaking with them.
Failed to timely report missing narcotics from emergency narcotic box within required 24 hours.
Failed to provide adequate assessments and interventions in a timely manner for a resident following a change of condition.
Failed to maintain a safe environment by allowing a resident to keep marijuana pipe and medication bottle without physician notification or removal.
Failed to have a licensed nurse awake and capable of rendering nursing service for one day; staff observed sleeping on duty.
Failed to have competent staff to perform IV medication administration; unqualified LPN administered IV antibiotics without Iowa approved certification.
Failed to have a registered nurse on duty 8 consecutive hours per day and failed to designate a RN as Director of Nursing.
Failed to follow professional standards of practice for medication administration; nurse drew up liquid morphine without witness and another nurse administered it without knowledge of contents.
Failed to provide effective leadership and follow federal regulations regarding nursing leadership and chain of command.
Failed to have an effective quality assurance program to ensure quality care and adequate RN coverage.
Failed to maintain patient care equipment in safe operating condition; suction machine did not work during resident choking incident.
Report Facts
Residents affected: 28
Dates without 8 hours RN coverage: 26
Hours worked by Staff C on 1/22/25: 4.6
IV antibiotic administration days: 23
DON training hours billed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse (LPN) | Named in findings for sleeping on duty and failing to treat resident with dignity |
| Staff D | Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) | Named in findings for escorting Staff C out, administering IV antibiotics without proper certification, and involvement in suction machine incident |
| Staff E | Certified Nursing Assistant (CNA) | Witnessed Staff C's inappropriate behavior and involved in marijuana pipe incident |
| Staff B | Licensed Practical Nurse (LPN)/Interim Director of Nursing (DON) | Named in findings for improper medication administration, diagnosing residents outside scope, using unsecured social media, and leadership deficiencies |
| Staff A | Registered Nurse (RN) | Named in findings related to medication administration and reporting concerns about Staff B |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaints #120435-C and #120126-C were substantiated. Facility reported incident #120180-I was substantiated.
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.
Deficiencies (9)
Accuracy of Assessments - Facility failed to accurately document and submit accurate resident Minimum Data Set (MDS) assessments for 4 of 7 residents reviewed.
Coordination of PASARR and Assessments - Facility failed to submit a new Pre-admission Screening and Resident Review (PASARR) for 1 resident with new diagnoses.
Develop/Implement Comprehensive Care Plan - Facility failed to accurately complete comprehensive care plans for 3 of 14 residents reviewed.
Discharge Planning Process - Facility failed to implement discharge planning upon admission for 1 resident.
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.
Free from Unnecessary Psychotropic Medications/PRN Use - Facility failed to ensure 1 resident received appropriate psychotropic medication orders and monitoring.
Payroll Based Journal Submission - Facility failed to accurately report staffing information based on payroll data for the second quarter of fiscal year 2024.
Infection Prevention and Control - Facility failed to establish and maintain an infection prevention and control program including training and oversight.
Influenza and Pneumococcal Immunizations - Facility failed to ensure residents received or were offered influenza and pneumococcal immunizations.
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
Routine
Census: 31
Deficiencies: 8
Date: Jul 17, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident assessments, care planning, staffing, medication administration, infection prevention, and other regulatory requirements at Stacyville Community Nursing Home.
Findings
The facility failed to accurately document resident assessments, complete comprehensive care plans, provide required RN coverage, ensure proper medication administration resulting in a medication error causing actual harm, and designate a qualified infection preventionist. Several residents' Minimum Data Set (MDS) assessments and care plans were incomplete or inaccurate, and the facility lacked proper policies and oversight in multiple areas.
Deficiencies (8)
Failed to accurately document and submit accurate resident Minimum Data Set (MDS) assessments for 4 of 7 residents reviewed.
Failed to submit a new Pre admission Screening and Resident Review (PASRR) for 1 resident when new diagnoses were documented.
Failed to develop and implement a complete care plan that meets all the resident's needs for 3 of 14 residents reviewed.
Failed to revise care plan within 7 days of comprehensive assessment for 1 resident with new diagnoses.
Failed to implement discharge planning upon admission for 1 resident who voiced desire to discharge.
Failed to provide a Registered Nurse (RN) in the facility for eight consecutive hours per day as required.
Failed to ensure residents are free from significant medication errors; one resident received another resident's medications causing sedation and hospital admission.
Failed to designate a qualified infection preventionist to be responsible for the infection prevention and control program.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 31
Dates without RN coverage: 10
Medication error incident date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Registered Nurse (RN) | Named in medication error finding for administering wrong medications to Resident #1 |
| Staff E | Certified Nurse Aide (CNA) | Reported concerns about medication error involving Resident #1 |
| Staff B | Certified Medication Aide (CMA) | Reported observations related to medication error involving Resident #1 |
| Staff F | Licensed Practical Nurse (LPN) | Monitored Resident #1 after medication error and provided statements |
| Staff A | Registered Nurse (RN) | Infection Preventionist who took class but did not complete certification test |
| Interim Director of Nursing | Provided multiple interviews regarding MDS coding and care plan expectations | |
| Administrator | Provided multiple interviews regarding MDS coding, care plans, staffing, and medication error expectations | |
| Resident #1's Pharmacist | Pharmacist | Provided expert opinion on medication error impact |
Inspection Report
Routine
Census: 31
Deficiencies: 12
Date: Jul 17, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident assessments, care planning, medication administration, staffing, infection control, and vaccination policies at Stacyville Community Nursing Home.
Findings
The facility failed to accurately document resident assessments, develop comprehensive care plans, provide required RN staffing, ensure proper medication administration, maintain infection control practices, accurately report staffing data, designate a qualified infection preventionist, and implement vaccination policies.
Deficiencies (12)
Failed to accurately document and submit accurate resident Minimum Data Set (MDS) assessments for 4 of 7 residents reviewed.
Failed to submit a new Pre admission Screening and Resident Review (PASRR) for 1 resident when new diagnoses were documented.
Failed to develop and implement a complete care plan that meets all the resident's needs for 3 of 14 residents reviewed.
Failed to develop the complete care plan within 7 days of the comprehensive assessment for 1 resident.
Failed to plan the resident's discharge to meet the resident's goals and needs for 1 resident.
Failed to have a registered nurse on duty for eight consecutive hours per day as required.
Failed to ensure psychotropic medication was used appropriately for 1 resident.
Failed to ensure residents are free from significant medication errors; 1 resident received another resident's medications causing hospitalization.
Failed to electronically submit accurate Payroll Based Journal (PBJ) data for licensed nursing staff.
Failed to adequately sanitize blood sugar meters and use barriers during blood sugar checks and insulin administration for 3 residents.
Failed to designate a qualified infection preventionist responsible for the infection prevention and control program.
Failed to develop and implement policies and procedures for flu and pneumonia vaccinations, including documentation of resident education and declination.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 31
Dates without RN coverage: 10
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Infection Preventionist who took class but did not complete certification test |
| Staff B | Certified Medication Aide | Observed improper blood sugar meter sanitation and medication administration |
| Staff C | Registered Nurse | Observed improper blood sugar meter sanitation and insulin administration |
| Staff E | Certified Nurse Aide | Reported medication error involving Resident #1 |
| Staff F | Licensed Practical Nurse | Monitored Resident #1 after medication error |
| Staff G | Registered Nurse | Administered wrong medications to Resident #1 |
| Administrator | Provided multiple interviews confirming findings and expectations | |
| Interim Director of Nursing | Interim DON | Provided multiple interviews confirming findings and expectations |
| Pharmacist | Provided expert opinion on medication error impact |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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.
Complaint Details
Facility reported incident #119592-I was not substantiated.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective March 15, 2024. Facility reported incident #119592-I was not substantiated.
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
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.
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
Complaint Investigation
Census: 22
Deficiencies: 2
Date: Feb 15, 2024
Visit Reason
The inspection was conducted based on complaints regarding staff behavior towards residents and failure to prevent falls resulting in harm.
Complaint Details
The complaint investigation found substantiated issues including disrespectful communication by Staff D towards Resident #4 and inadequate fall prevention and supervision leading to Resident #8's fall and death.
Findings
The facility failed to ensure respectful communication by staff towards Resident #4 and failed to implement adequate fall prevention measures for Resident #8, which resulted in a fall causing a subdural hematoma and subsequent death.
Deficiencies (2)
Failure to ensure Resident #4 was spoken to respectfully and in a dignified manner by facility staff.
Failure to implement root cause analysis and provide interventions to prevent future falls for Resident #8, resulting in a fall with actual harm.
Report Facts
Residents affected: 3
Census: 22
Subdural hematoma size: 6.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse (RN) | Named in disrespectful communication finding and fall investigation |
| Staff A | Administrator's Assistant | Witnessed disrespectful encounter involving Staff D and Resident #4 |
| Staff B | Certified Nurses Aide (CNA) | Witness statement regarding Resident #8 fall |
| Staff C | Certified Nurses Aide (CNA) | Witness statement regarding Resident #8 fall |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (3)
Failed to submit a Level 2 PASRR evaluation for a resident with a new mental health diagnosis.
Failed to routinely assess and report changes for a resident with pressure ulcers to promote healing and prevent infection.
Failed to limit PRN antipsychotic medication to 14 days without a new order and evaluation for a resident.
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
Routine
Census: 17
Deficiencies: 3
Date: May 18, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including pre-admission screening, pressure ulcer care, and psychotropic medication use.
Findings
The facility failed to submit a required Level 2 PASRR evaluation for a resident with a new psychosis diagnosis, failed to routinely assess and report changes in a resident's pressure ulcers leading to inadequate treatment, and failed to limit PRN antipsychotic medication use to 14 days without a new order or evaluation for one resident.
Deficiencies (3)
Failed to submit a Level 2 PASRR evaluation for a resident with a new mental health diagnosis.
Failed to routinely assess a resident with pressure ulcers and report changes to the provider for necessary treatment and infection prevention.
Failed to limit PRN antipsychotic medication to 14 days without a new order and evaluation for a resident.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Census: 17
PRN antipsychotic medication administrations past order date: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set (MDS) nurse | Acknowledged missing Level 2 PASRR evaluation for Resident #4 | |
| Administrator | Confirmed expectation for Level 2 PASRR evaluation for new psychosis diagnosis | |
| Director of Nursing (DON) | Discussed wound care deficiencies and acknowledged PRN antipsychotic medication order issue | |
| Staff A Licensed Practical Nurse (LPN) | Prepared and completed dressing changes for resident with pressure ulcers | |
| Staff B Licensed Practical Nurse (LPN) | Assisted with dressing changes and communicated with resident about pain | |
| Staff C Certified Nursing Assistant (CNA) | Assisted with resident transfer | |
| Staff D Certified Nursing Assistant (CNA) | Assisted with resident transfer |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 21, 2023
Visit Reason
An investigation of a facility complaint #103055-C conducted April 18 - 21, 2023.
Complaint Details
Complaint #103055-C was investigated and found to have no deficiencies.
Findings
The investigation resulted in no deficiencies.
Inspection Report
Annual Inspection
Census: 20
Deficiencies: 4
Date: 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.
Complaint Details
Complaint #96614 was investigated and found to be 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.
Deficiencies (4)
Failure to provide bed-hold notice upon transfer for 2 residents.
Failure to develop and implement comprehensive care plans including monitoring of medications for 1 of 5 residents reviewed.
Failure to develop and provide a discharge summary for 1 resident discharged to the community.
Failure to establish and maintain an infection prevention and control program, including proper handling and documentation of oxygen tubing for residents.
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
Date: 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
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