Inspection Reports for The New Homestead Care Center
2306 State Street, Guthrie Center, IA, 501158896
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 7, 2026, identified one deficiency related to acceptance of a credible allegation of substantial compliance and plan of correction. Earlier inspections showed a pattern of deficiencies involving insufficient nursing staff to respond timely to call lights, issues with resident care such as pressure ulcer prevention and bathing, infection control lapses, and failures in notification and documentation practices. Several substantiated complaint investigations found concerns including resident abuse by staff, medication misappropriation, and failure to protect resident rights and dignity. Enforcement actions included staff terminations and criminal charges related to medication diversion, but fines or license suspensions were not listed in the available reports. The facility has shown some improvement with recent acceptance of plans of correction and certification of compliance following prior deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
7.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
47 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
Plan of Correction
Deficiencies: 1
Date: Jan 7, 2026
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status following a prior inspection or complaint.
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 January 7, 2026.
Deficiencies (1)
Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Oct 22, 2025
Visit Reason
The inspection was conducted as a result of investigation of complaints #2634622-C and #2634271-C from October 20 to October 22, 2025, focusing on nursing staff sufficiency and response to call lights.
Complaint Details
The complaint investigation was substantiated as the facility failed to provide timely nursing response to call lights for residents, confirmed by interviews with residents, family members, nursing staff, and review of call light logs and policies.
Findings
The facility failed to provide sufficient nursing staff to assure resident safety by not responding to call lights in a timely manner for 3 of 3 residents reviewed. Interviews and document reviews confirmed delays in call light responses exceeding 15 minutes.
Deficiencies (1)
The facility must designate a licensed nurse to serve as a charge nurse on each tour of duty and provide sufficient nursing staff to respond to call lights timely.
Report Facts
Census: 47
Call light response times: 47
Complaint numbers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hilaree Stingham | Administrator | Signed the report and provided information regarding call light logs and facility actions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 3, 2025
Visit Reason
An investigation for Facility Reported Incident #129202-I was conducted on July 2 - July 3, 2025.
Complaint Details
Investigation was related to Facility Reported Incident #129202-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 24, 2025
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility will be certified in compliance effective May 24, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 10
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of a substantiated complaint #127212-C.
Complaint Details
Complaint #127212-C was substantiated related to failure to notify residents timely about Medicare Part A and B service terminations.
Findings
The facility was found deficient in multiple areas including failure to notify residents timely about Medicare Part A and B service terminations, failure to notify the Long-Term Care Ombudsman of resident hospital transfers, inadequate provision of bathing and ADL care, failure to prevent pressure ulcers, insufficient range of motion exercises, inadequate nursing staff response to call lights, improper monitoring of warfarin therapy during antibiotic use, serving food at improper temperatures, improper food storage and labeling, and inadequate infection prevention and control practices including hand hygiene.
Deficiencies (10)
Failed to notify residents 48 hours in advance of Medicare Part A or Part B therapy termination for 2 of 3 residents reviewed.
Failed to notify the Long-Term Care Ombudsman of a hospital transfer for 1 of 3 residents reviewed.
Failed to offer bathing/showering on a regular basis for 1 of 3 residents reviewed.
Failed to implement timely interventions to prevent pressure ulcers for 1 of 2 residents reviewed.
Failed to provide range of motion exercises as required for 1 of 2 residents reviewed.
Failed to provide sufficient nursing staff to respond to call lights in a timely manner for 5 of 5 residents reviewed.
Failed to ensure adequate monitoring of warfarin therapy during concurrent antibiotic use for 1 of 1 resident reviewed.
Failed to provide food at safe and appetizing temperatures for 2 of 5 residents reviewed.
Failed to properly label stored food and prevent cross-contamination during meal service.
Failed to ensure staff used adequate hand hygiene techniques to prevent spread of pathogens for 2 of 3 residents reviewed.
Report Facts
Census: 50
Deficiencies cited: 10
Call light response times: 76
Baths/showers offered: 2
Pressure injury size: 0.4
Pressure injury size: 0.3
Warfarin dose: 6
Warfarin dose: 4
INR lab result: 1.5
Food temperature: 99.4
Milk temperature: 53.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Named in bathing and infection control deficiencies for Resident #16 |
| Staff B | Certified Nurse Aide | Named in bathing and infection control deficiencies for Resident #16 |
| Staff M | Licensed Practical Nurse | Performed skin assessment for Resident #16 |
| Staff H | Registered Nurse | Provided information on INR monitoring for Resident #41 |
| Staff J | Chef | Named in food handling and sanitation deficiencies |
| Staff I | Registered Nurse | Named in infection control deficiency related to catheter care for Resident #30 |
| Staff C | Certified Nurse Aide | Reported call light issues |
| Staff D | Maintenance | Reported call light maintenance and battery replacement |
| Administrator | Administrator | Provided multiple interviews regarding notification and call light system |
| Director of Nursing | Director of Nursing | Provided multiple interviews and acknowledged deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interview regarding restorative program and infection control |
| Certified Dietary Manager | Certified Dietary Manager | Observed and interviewed regarding food temperature and storage |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
The inspection was conducted as an investigation of complaints #124455-C, #125029-A and facility reported incidents #123260-I, #124515-M and #126705-I from February 17 to February 20, 2025.
Complaint Details
Complaint #125029-A was substantiated. Facility reported incident #124515-I was substantiated. Additional findings for complaint #125029-A and facility reported incident #124515-M will be sent separately.
Findings
The facility failed to protect one resident (Resident #1) from abuse by a Certified Nurse Assistant (Staff A). Video evidence showed Staff A was rough, rushed, and uncommunicative during care, causing physical and emotional harm to the resident. Staff A was terminated following the incident. The resident and Power of Attorney reported distress and fear due to the abuse. The facility policy prohibits abuse and mandates resident dignity and respect.
Deficiencies (1)
Failure to protect Resident #1 from abuse by Staff A, including rough handling, verbal mistreatment, and neglect of resident's requests.
Report Facts
Census: 46
Complaints investigated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Assistant (CNA) | Named in abuse finding involving rough care and neglect of Resident #1 |
| Staff B | Certified Nurse Assistant (CNA) | Witnessed part of the incident between Resident #1 and Staff A |
| Staff C | Licensed Practical Nurse (LPN) | Received report of incident from Staff A and assessed Resident #1 |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
The inspection was conducted as an investigation of complaints #124455-C, #125029-A and facility reported incidents #123260-I, #124515-M, and #126705-I from February 17 to February 20, 2025.
Complaint Details
Complaint #125029-A was substantiated. Facility reported incident #124515-I was substantiated. Additional findings for complaint #125029-A and facility reported incident #124515-M will be sent under separate cover.
Findings
The facility failed to protect one resident from abuse by a Certified Nurse Assistant (Staff A), who was observed on video being rough, uncommunicative, and neglectful during care. The resident was physically and verbally mistreated, resulting in the termination of Staff A. The complaint #125029-A and facility incident #124515-I were substantiated.
Deficiencies (1)
Failure to protect resident from abuse including rough handling, verbal abuse, and neglect by staff.
Report Facts
Census: 46
Complaints investigated: 3
Date range of investigation: 2025-02-17 to 2025-02-20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Assistant (CNA) | Named in abuse and neglect findings; terminated after investigation |
| Staff B | Certified Nurse Assistant (CNA) | Witnessed part of the incident involving Resident #1 and Staff A |
| Staff C | Licensed Practical Nurse (LPN) | Received report of incident, documented it, and reported to Director of Nursing |
| Administrator | Facility Administrator | Interviewed regarding expectations for resident treatment |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 13, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction, indicating acceptance of a credible allegation of substantial compliance and certification of the facility in compliance effective July 13, 2024.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction, resulting in certification of compliance effective July 13, 2024.
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 6
Date: Jun 13, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #116816-C and #118049-C, which were substantiated.
Complaint Details
The visit was triggered by complaints #116816-C and #118049-C, both of which were substantiated.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, activities of daily living maintenance, incontinence care infection prevention, tube feeding administration, sufficient nursing staff to respond to call lights timely, and infection prevention and control practices during medication administration.
Deficiencies (6)
Accuracy of Assessments - The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected residents' status for 2 of 15 residents reviewed.
Activities of Daily Living - The facility failed to complete restorative programs as planned for 1 of 2 residents reviewed.
Incontinence Care - The facility failed to follow infection prevention standards during incontinence care for 1 of 4 residents reviewed.
Tube Feeding Management - The facility failed to administer tube feeding per physician orders for 1 of 1 resident reviewed.
Sufficient Nursing Staff - The facility failed to answer residents' call lights in less than 15 minutes for 3 call lights observed and residents reported extended response times.
Infection Prevention & Control - The facility failed to implement appropriate infection prevention practices during medication administration by staff not completing hand hygiene between residents and touching pills with bare hands.
Report Facts
Residents reviewed for accuracy of assessments: 15
Residents reviewed for restorative program: 2
Residents reviewed for incontinence care: 4
Residents reviewed for tube feeding: 1
Facility census: 48
Call light response times observed: 3
Call light response time in minutes: 51
Call light response time in minutes: 31
Call light response time in minutes: 22
Tube feeding ordered volume: 552
Tube feeding administered volume: 522
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Named in infection prevention failure during incontinence care |
| Staff B | Certified Nurse Aide | Assisted Staff A during incontinence care |
| Staff C | Licensed Practical Nurse | Named in infection prevention failure during medication administration |
| Staff D | Certified Nurse Aide | Observed tablet turned off and unaware of call light duration |
| Staff E | Certified Nurse Aide | Cleared call light after 51 minutes |
| Staff F | Licensed Practical Nurse | Administered tube feeding with incorrect volume |
| Staff G | Registered Nurse, Nurse Consultant | Observed tube feeding administration |
| Director of Nursing | Provided multiple statements regarding deficiencies and expectations | |
| Administrator | Signed plan of correction and provided statement on call light policy |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 11, 2023
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 October 6, 2023, based on the acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 18, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 9/18/23 to 9/20/23, including investigation of Complaint #114865-C and Facility Report Incident #114980-I.
Complaint Details
Complaint #114865-C was investigated and found not substantiated. Facility Report Incident #114980-I was substantiated.
Findings
The facility was found to be in substantial compliance with CMS and CDC recommended COVID-19 practices. Complaint #114865-C was not substantiated, while Facility Report Incident #114980-I was substantiated. A deficiency was identified related to resident rights and dignity for one of four residents reviewed.
Deficiencies (1)
The facility failed to treat each resident with dignity and honor the choices of care for 1 of 4 residents reviewed, as evidenced by a staff member giving a shower instead of a whirlpool bath as requested, causing resident distress.
Report Facts
Mental Status (BIMS) score: 14
Residents reviewed: 4
Date range of survey: 9/18/23 through 9/20/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hilane Stringham | Administrator | Signed report and plan of correction |
| Staff A | Certified Nurse Aide | Involved in the incident with Resident #1 regarding bathing care |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 31, 2023
Visit Reason
The document is a plan of correction related to a nursing home inspection to address compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on an allegation of compliance as of 7/6/23.
Findings
The New Homestead Care Center Nursing Home is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on the allegation of compliance as of 7/6/23.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 5
Date: Jun 8, 2023
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Iowa Department of Inspections and Appeals to assess compliance with federal regulations.
Complaint Details
The visit was complaint-related, triggered by allegations regarding failure to provide required written notices for transfers, discharges, and bed holds, inadequate care planning for mental health, inconsistent mental health services, and food safety concerns.
Findings
The facility was found not in substantial compliance with 42 CFR 483 subpart B, with deficiencies including failure to provide written transfer/discharge notices and bed hold notices to residents and their representatives, failure to develop comprehensive care plans for mental health diagnoses, failure to ensure consistent mental health services, and food safety violations including improper food storage and unclean kitchen equipment.
Deficiencies (5)
Failed to provide four of five residents and their representatives with written transfer/discharge notices including reasons for transfer, place of transfer, and appeal rights.
Failed to provide four of five residents and/or their representatives with written bed hold notices specifying duration and policies.
Failed to develop comprehensive care plans for two residents regarding mental health diagnoses and management.
Failed to ensure one resident consistently received mental health services as delineated in the Mental Health Assessment and Care Plan.
Failed to label, date, and cover stored foods, discard expired yogurt, and keep kitchen equipment clean.
Report Facts
Survey Census: 50
Sample Size: 20
Supplemental Residents: 1
Expired Yogurts: 8
Raisin Bread Packages: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hilary Stringham | Administrator | Named in relation to findings on transfer/discharge notices, bed hold notices, and food safety |
| LPN 1 | Licensed Practical Nurse | Described transfer process and paperwork provided to residents |
| Regional Nurse Consultant | Provided information on facility policies and mental health notes | |
| Director of Nursing | DON | Involved in mental health telehealth sessions and care planning |
| Business Office Manager | BOM | Involved in notification processes for bed holds and transfers |
| Dietary Manager | DM | Provided information on food storage and kitchen cleanliness |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating acceptance of the facility's credible allegation of compliance and plan of correction.
Findings
The facility will be certified in compliance effective December 21, 2022, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Dec 20, 2022
Visit Reason
Investigation of a facility reported incident involving misappropriation of medications, specifically a fentanyl patch, by a staff member.
Complaint Details
The complaint investigation was substantiated. Staff A admitted to taking a fentanyl patch from Resident #1 and was arrested. Law enforcement confirmed Staff A's blood tested positive for fentanyl. The facility reported the incident to the Iowa Board of Nursing and local law enforcement.
Findings
The investigation found that Staff A, a registered nurse, tampered with and misappropriated a fentanyl patch from Resident #1 by removing, flipping, and reapplying the patch to the resident, thereby diverting medication for personal use. Staff A was terminated and criminal charges were pursued. The facility implemented new procedures for visual inspection of fentanyl patches at shift changes.
Deficiencies (1)
Failure to ensure Resident #1 was free from misappropriation of medications as Staff A diverted a fentanyl patch for personal use.
Report Facts
Census: 48
Dates of incident investigation: December 1, 2022, December 2, 2022, and December 20, 2022
Fentanyl patch dosage: 75
Staff A employment dates: Employed from 9/19/22 to 10/21/22
Staff A arrest date: November 18, 2022
Staff A court date: March 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Employee who diverted fentanyl patch from Resident #1 and was terminated and arrested |
| Staff B | Licensed Practical Nurse | Nurse who applied the fentanyl patch on 10/18/22 and oriented Staff A |
| Staff C | Licensed Practical Nurse | Nurse who applied the fentanyl patch on 10/21/22 and oriented Staff A |
| Hilaree Stringham | Administrator | Facility Administrator who reported and investigated the incident |
| Director of Nursing | Director of Nursing | Facility DON involved in investigation and notification of physician |
| Assistant Director of Nursing | Assistant Director of Nursing | Facility ADON involved in investigation and notification of physician |
Inspection Report
Renewal
Census: 54
Deficiencies: 4
Date: Jan 6, 2022
Visit Reason
A recertification health survey was conducted from January 3 to January 6, 2022, to assess compliance with federal regulations and facility standards.
Findings
The facility was found deficient in updating comprehensive care plans, ensuring residents are free of significant medication errors, maintaining infection prevention and control practices, and complying with admission, transfer, and discharge policies related to veterans' benefits.
Deficiencies (4)
Failure to update one of 16 care plans when the physician ordered discontinuation of a right arm sling and initiation of therapy.
Failure to ensure staff administered the proper amount of insulin by not priming an insulin flexpen prior to administration for one of three residents observed.
Failure to follow infection control practices, including wearing gloves when administering injections and eye medications, and failure to conduct an annual review of the infection prevention and control program.
Failure to submit 3 of 10 resident admissions reviewed to the Iowa Department of Veteran Affairs within 30 days of admission.
Report Facts
Census: 54
Care Plans: 16
Residents with medication errors observed: 1
Resident admissions reviewed: 10
Resident admissions not submitted timely: 3
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 5
Date: Feb 24, 2021
Visit Reason
An investigation of Complaint #95791-C was conducted from February 15 to 24, 2021, regarding medication self-administration, access to medical records, and other care concerns.
Complaint Details
Complaint #95791-C was substantiated based on findings related to medication self-administration, access to medical records, and care deficiencies.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents were properly assessed for self-administration of medications, failure to provide requested medical records timely, failure to follow physician orders for wound care and anticoagulant monitoring, insufficient nursing staff to respond timely to call lights, and failure to maintain safe food temperatures during meal service.
Deficiencies (5)
Facility failed to assure residents were assessed and supervised properly for self-administration of medications.
Facility failed to provide requested medical records in a timely manner for one resident.
Facility failed to provide professional standards of care including following physician orders for wound care and anticoagulant therapy monitoring.
Facility failed to assure timely response to resident call lights.
Facility failed to maintain safe food temperatures during breakfast meal service and failed to document temperatures.
Report Facts
Total residents: 44
Call light response time: 82
Call light response time: 51
Medication self-administration residents assessed: 1
BIMS score: 15
BIMS score: 0
Prothrombin time: 40.5
INR: 3.9
Prothrombin time: 36.2
INR: 3.5
Prothrombin time: 13.8
INR: 1.3
Food temperature: 127
Food temperature: 142
Food temperature: 141
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hilwee Stringham | Administrator | Signed the inspection report and plan of correction |
| Hilwee Stringham | Administrator | Responsible for monitoring timely delivery of record requests |
| Director of Nursing | Interviewed regarding medication self-administration, call light issues, and lab monitoring | |
| Assistant Director of Nursing | Interviewed regarding PEG feeding training and double check system for new orders | |
| Staff D | Licensed Practicing Nurse | Observed preparing and administering PEG feeding |
| Staff G | Dietary Aide | Observed serving breakfast meal |
| Staff H | Dietary Aide | Interviewed about food temperature monitoring |
| Dietary Manager | Interviewed about food preparation and temperature monitoring |
Inspection Report
Routine
Census: 39
Deficiencies: 0
Date: Dec 31, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 39
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 3
Date: Aug 17, 2020
Visit Reason
The inspection was a COVID-19 survey and investigation of Complaint #91475-C and Complaint #92220-C, both substantiated, focusing on resident rights, notification of changes, and infection control practices.
Complaint Details
Complaint #91475-C and Complaint #92220-C were substantiated. The investigation focused on visitation restrictions during end of life and failure to notify family and physician of resident condition changes.
Findings
The facility failed to ensure resident rights by not allowing family visitation during end of life for one resident, failed to notify the physician and family of significant changes in a resident's condition, and failed to implement proper infection control practices including inadequate hand hygiene and incomplete COVID-19 visitor screening logs.
Deficiencies (3)
Failed to ensure resident rights by not allowing family visitation during end of life for Resident #1.
Failed to notify physician and family of significant changes in Resident #1's condition including weight loss and functional decline.
Failed to utilize appropriate infection control practices during care of Resident #2 and failed to complete adequate COVID-19 visitor screening logs.
Report Facts
Resident census: 46
Weight loss: 16.8
COVID-19 screening accuracy rate: 55
Total COVID-19 screenings: 1078
Fully completed screenings: 383
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding visitation policy, notification of changes, and infection control expectations | |
| Administrator | Interviewed regarding visitation policy and COVID-19 screening log compliance | |
| Staff C | Nurse involved in communication with resident's family during end of life | |
| Staff D | Primary hospice nurse interviewed about visitation and hospice care | |
| Staff E | On-call nurse during resident's end of life, interviewed about visitation communication | |
| Staff F | Nurse who found resident deceased, interviewed about resident's condition and family visitation | |
| Physician | Interviewed regarding notification of resident condition changes |
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/24/20 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.
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 11
Date: Jan 9, 2020
Visit Reason
The inspection was conducted as a recertification survey of the facility to assess compliance with federal regulations.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of resident condition changes, failure to notify the Ombudsman of hospital transfers, failure to document bed hold decisions, failure to update care plans and restorative programs, failure to assess residents after condition changes, inadequate incontinence care, lack of communication with dialysis providers, failure to monitor high-risk medication labs, failure to annually review infection control policies, and failure to offer influenza vaccination to a resident.
Deficiencies (11)
Failed to notify the physician regarding a resident following a change in condition.
Failed to notify the Office of the Long-Term Care Ombudsman of a hospital transfer for a resident.
Failed to document the resident's or representative's decision to hold the resident's bed during hospitalization.
Failed to update the resident's care plan to give direction regarding a restorative program.
Failed to assess a resident following a change in condition.
Failed to provide range of motion exercises for a resident with limited mobility.
Failed to provide adequate incontinence care, including improper cleansing technique and hand hygiene.
Failed to provide ongoing communication and collaboration with the dialysis facility for a resident receiving dialysis.
Failed to adequately monitor laboratory results for high-risk medications for residents.
Failed to establish an annual review of the Infection Control Policies and Procedures Manual.
Failed to offer and administer the influenza vaccination for a resident during the current influenza season.
Report Facts
Census: 47
BIMS score: 15
BIMS score: 15
BIMS score: 12
BIMS score: 2
Furosemide dose: 20
Warfarin dose: 3.5
INR: 1.8
INR: 2.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Restorative Certified Nurses' Aide | Provided information about restorative care schedule and resident participation |
| Staff B | Licensed Practical Nurse | Previously maintained restorative program |
| Staff C | Certified Nurse's Aide | Observed providing incontinence care with improper technique |
| Director of Nursing | Director of Nursing | Provided multiple clarifications and confirmations regarding deficiencies and policies |
| Nurse Consultant | Nurse Consultant | Provided information about restorative program documentation |
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