Inspection Reports for
United Presbyterian Home
1203 East Washington, Washington, IA, 523532198
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
111% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
49 residents
Based on a July 2025 inspection.
Occupancy over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 19, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to a prior survey ending July 17, 2025, indicating acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction, with certification effective August 7, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Routine
Census: 49
Deficiencies: 3
Date: Jul 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including pressure ulcer management, nutrition monitoring, and fall prevention.
Findings
The facility failed to notify the provider timely when a resident with a pressure ulcer did not wear ordered orthotic shoes and failed to notify the provider of significant weight loss for another resident. Additionally, the facility failed to assess the appropriateness and effectiveness of bolsters used for fall prevention for a resident who experienced multiple falls.
Deficiencies (3)
Failed to notify provider when resident with pressure ulcer did not wear ordered orthotic shoes.
Failed to notify provider timely of significant weight loss for a resident.
Failed to assess appropriateness and effectiveness of cushioned bolsters used for fall prevention.
Report Facts
Resident census: 49
Weight loss percentage: 5
Wound measurement: 1.6
Wound measurement: 1.3
Wound measurement: 0.2
BIMS score: 8
BIMS score: 6
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Wound Doctor of Nursing Practice (DNP) | Directed staff to consult occupational therapy for off-loading footwear and involved in wound treatment plans |
| Staff C | Licensed Practical Nurse (LPN) | Measured wound on Resident #10 and involved in fall incident documentation |
| Staff B | Licensed Practical Nurse (LPN) | Confirmed boots were not orthotic shoes and discussed weight monitoring |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding orthotic orders and fall prevention interventions |
| Staff L | Physical Therapy Assistant (PTA) | Reported on custom shoe order and resident footwear |
| Staff A | Licensed Practical Nurse (LPN) | Interviewed about weight loss monitoring and fall prevention |
| Dietician | Reviewed resident weights and weight loss notifications | |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Discussed weight loss notifications and provider communication |
| Advanced Registered Nurse | Advanced Registered Nurse Practitioner (ARNP) | Reviewed significant weight changes and confirmed notification expectations |
| Staff F | Certified Nursing Aide (CNA) | Reported observations related to bolsters and fall prevention |
| Staff G | Certified Nursing Aide (CNA) | Reported observations related to bolsters and fall prevention |
| Staff C | Licensed Practical Nurse (LPN) | Reported on bolsters and fall incidents |
| Staff J | Activities Aide | Found resident after fall and reported on bolster positioning |
| Staff H | Certified Nursing Aide (CNA) | Reported on resident fall and bolster status |
| Staff I | Certified Nursing Aide (CNA) | Reported on resident climbing over bolsters and fall prevention |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 2
Date: Jul 14, 2025
Visit Reason
The inspection was conducted as an annual recertification survey from July 14, 2025 to July 17, 2025 to assess compliance with federal regulations.
Findings
The facility was found deficient in notifying the provider when a resident with a pressure ulcer did not wear ordered orthotic shoes and failed to notify the provider of significant weight loss for a resident. Additionally, the facility failed to ensure a safe environment free of accident hazards related to bed bolsters and fall prevention for residents.
Deficiencies (2)
Failure to notify the provider when a resident with a pressure ulcer did not wear ordered orthotic shoes and failure to notify the provider of significant weight loss for a resident.
Failure to ensure the resident environment remains free of accident hazards, including inadequate supervision and assistance devices to prevent accidents related to bed bolsters and fall prevention.
Report Facts
Resident census: 49
Residents reviewed for nutrition: 3
Residents reviewed for pressure ulcers: 2
Residents reviewed for fall risk: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Wound Doctor of Nursing Practice (DNP) | Directed staff to consult occupational therapy for off-loading footwear recommendations and confirmed orthotic use |
| Staff B | Licensed Practical Nurse (LPN) | Measured wounds and confirmed orthotic use |
| Staff C | Licensed Practical Nurse (LPN) | Observed resident and reported on orthotic use and fall incidents |
| Staff A | Licensed Practical Nurse (LPN) | Queried about monitoring significant weight loss |
| Staff F | Certified Nursing Assistant (CNA) | Reported on resident falls and bed bolster incidents |
| Staff J | Activities Aide | Reported resident fall and observations related to bed bolsters |
| Director of Nursing | DON | Provided information on orthotic orders and fall prevention interventions |
| Assistant Director of Nursing | ADON | Queried about resident weight loss and dietician notifications |
| Director of Healthcare | Director of Healthcare | Reviewed and updated policies and communicated with residents' POAs regarding bed bolsters |
| Dietician | Dietician | Reviewed resident weights and care plans, alerted staff to weight loss |
| Advanced Registered Nurse Practitioner | ARNP | Reviewed resident weights and confirmed notification requirements |
| Staff L | Physical Therapy Assistant (PTA) | Reported on custom shoe orders and resident footwear |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 17, 2024
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 certified in compliance effective September 12, 2024, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey, including investigation of complaint #119751-C and facility reported incidents #122363-I and #122364-I.
Complaint Details
Complaint #119751-C was investigated and found to be not substantiated. Facility reported incidents #122363-I and #122364-I were also not substantiated.
Findings
The facility failed to maintain adequate kitchen sanitation in two kitchen areas and failed to carry out sanitary food handling for two of two meals observed. Several concerns were noted including dust particles on a dishwasher fan, staff not wearing proper hair restraints, and improper glove use during food service.
Deficiencies (1)
Failure to maintain adequate kitchen sanitation and sanitary food handling practices.
Report Facts
Census: 42
Correction date: Correction date set for 2024-09-12.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | CDM | Mentioned in relation to food handling and cleaning procedures; had a mustache and did not wear a mustache cover while preparing food. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of a credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective December 15, 2023.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Date: Nov 28, 2023
Visit Reason
The inspection was conducted following a complaint related to inadequate supervision and safety hazards when a confused resident with dementia eloped from the facility by entering an elevator and exiting into the basement unobserved.
Complaint Details
The visit was complaint-related due to an incident where Resident #27, a confused and independently mobile resident with dementia, eloped by entering an elevator and exiting into the basement. The complaint was substantiated with findings of inadequate supervision and failure to maintain effective safety measures.
Findings
The facility failed to provide adequate supervision to prevent hazards when a safety intervention (Elpas Wanderguard) was disarmed by staff, allowing Resident #27, who was at high risk for elopement, to leave the health center unsupervised and enter an unalarmed exit door in the basement. The investigation revealed gaps in staff communication and monitoring, and the facility conducted staff training and meetings to address these issues.
Deficiencies (1)
Failure to provide adequate supervision to prevent accidents when a safety intervention was disarmed, resulting in a resident elopement.
Report Facts
Residents affected: 51
Residents listed as high risk for elopement: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Maintenance Director | Interviewed regarding video review of elopement incident |
| Staff I | Wellness Staff | Interviewed regarding response to Wanderguard alert and resident location |
| Staff J | Independent Center Maintenance | Observed in video during resident elopement timeline |
| Staff K | Certified Nursing Assistant (CNA) | Interviewed about search efforts and staff training following elopement |
| Staff L | Certified Nursing Assistant (CNA) | Found resident in basement daycare and notified health center |
| Staff M | Certified Nursing Assistant (CNA) | Interviewed about clearing Wanderguard alert and search efforts |
| Director of Healthcare | Director of Healthcare | Interviewed regarding facility safety systems and video surveillance |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 3
Date: Nov 28, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and included investigation of Complaints #116941-C and #117058-C and Facility Reported Incidents #112573-I, #114879-I, and #116815-I.
Complaint Details
The investigation included Complaints #116941-C and #117058-C and Facility Reported Incidents #112573-I, #114879-I, and #116815-I. Facility reported incidents #112573-I, #114879-I, and #116815-I were substantiated.
Findings
The facility was found deficient in providing adequate supervision to prevent resident elopement, maintaining food at appetizing temperatures, and ensuring sanitary food preparation surfaces. Multiple residents reported cold food, and an elopement incident occurred due to inadequate supervision and disarming of a wanderguard alarm.
Deficiencies (3)
Failed to provide adequate supervision to prevent hazards when a safety intervention was disarmed, resulting in a resident eloping to the basement.
Failed to provide foods at an appetizing temperature for 1 of 1 meals observed, with multiple residents reporting cold food.
Failed to maintain sanitary surfaces on the counter used for cutting meat, risking cross-contamination for 14 of 36 residents served the meat option.
Report Facts
Census: 51
Residents with Wanderguards: 10
Residents served meat option: 36
Residents affected by sanitary deficiency: 14
Temperature of ground meat: 117.4
Temperature of mashed potatoes: 130.5
Temperature of squash: 130.8
Expected hot holding temperature: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Certified Nursing Assistant (CNA) | Worked day shift on 8/16/23, cleared Elpas alert without visualizing resident. |
| Staff L | Certified Nursing Assistant (CNA) | Found Resident #27 unattended in daycare and notified health center. |
| Staff K | Certified Nursing Assistant (CNA) | Participated in search for Resident #27 and reported on training after incident. |
| Staff H | Maintenance Director | Reviewed video footage of elopement incident. |
| Staff F | Cook | Observed using same counter for menus and cutting meat, contributing to sanitary deficiency. |
| Staff G | Dietary Manager | Reported complaints of cold food and witnessed sanitary issues during meal service. |
| Staff C | Registered Nurse (RN) | Reported resident complaints about cold food. |
| Staff E | Certified Nursing Assistant (CNA) | Reported resident complaints about cold food. |
| Staff D | Certified Nursing Assistant (CNA) | Reported resident complaints about cold food. |
| Director of Healthcare | Provided information about wanderguard system and staff alerts. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Nov 28, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision and safety hazards, specifically involving a confused resident who eloped by entering an elevator unsupervised.
Complaint Details
The complaint investigation focused on Resident #27 who eloped on 8/16/23 by disarming the Elpas wanderguard and entering an elevator unsupervised. The resident was missing for approximately 15 minutes before being found in the basement daycare area. The facility conducted a search and staff interviews revealed gaps in supervision and communication. The facility identified 10 residents as high risk for elopement and reviewed elopement policies.
Findings
The facility failed to provide adequate supervision to prevent accidents when a resident with dementia eloped by disarming a safety wanderguard and entering an elevator, leading to a delayed discovery. Additional findings included failure to maintain food at safe temperatures during meals and failure to maintain sanitary conditions on food preparation surfaces.
Deficiencies (3)
Failed to provide adequate supervision to prevent hazards when a confused resident eloped by disarming a wanderguard and entering an elevator unsupervised.
Failed to provide foods at an appetizing temperature for 1 of 1 meals observed, with food temperatures below facility policy standards.
Failed to maintain sanitary surfaces on the counter used for cutting meat, risking possible cross-contamination of food.
Report Facts
Census: 51
Food temperature: 117.4
Food temperature: 130.5
Food temperature: 130.8
Resident BIMS score: 3
Resident BIMS score: 13
Resident BIMS score: 15
Resident BIMS score: 15
Resident BIMS score: 15
Number of residents with wanderguards: 10
Number of residents served meat option: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Maintenance Director | Interviewed regarding video review of elopement incident |
| Staff I | Wellness Staff | Interviewed regarding elopement incident and search |
| Staff J | Independent Center Maintenance | Observed during elopement incident |
| Staff K | Certified Nursing Assistant (CNA) | Involved in elopement incident and search |
| Staff L | Certified Nursing Assistant (CNA) | Found resident during elopement search |
| Staff M | Certified Nursing Assistant (CNA) | Interviewed about elopement incident and search |
| Director of Healthcare | Director | Provided information on elopement incident and facility alarm system |
| Staff A | Involved in food temperature observation and meal preparation | |
| Staff B | Obtained food temperatures during meal observation | |
| Staff C | Registered Nurse (RN) | Reported resident complaints about cold food |
| Staff D | Certified Nursing Assistant (CNA) | Reported resident complaints about cold food |
| Staff E | Certified Nursing Assistant (CNA) | Reported resident complaints about cold food |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Reported complaints about cold food and staffing issues |
| Staff F | Cook | Observed using same counter for menus and cutting meat |
| Staff G | Dietary Manager | Interviewed about sanitary food handling practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 23, 2022
Visit Reason
The document is a plan of correction accepted following a survey revisit ending 10/3/22 to address previous deficiencies and certify the facility in compliance.
Findings
Based on acceptance of the facility's credible allegation of compliance and plan of correction following the survey revisit, the facility was certified in compliance effective November 23, 2022.
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
The visit was a re-inspection conducted from September 29, 2022 to October 3, 2022, following a previous survey ending July 14, 2022, to verify correction of cited deficiencies.
Findings
The inspection found deficiencies related to food safety and hand hygiene practices among staff during meal service in the dining rooms. Observations included failure to perform hand hygiene, improper handling of food items, and uncovered hands touching masks and clothing. The facility acknowledged these issues and implemented corrective actions including staff training and policy reviews.
Deficiencies (1)
Failure to handle food and beverages in a sanitary manner showing a lack of consistent hand hygiene in dining rooms.
Report Facts
Census: 51
Inspection Report
Routine
Census: 49
Deficiencies: 16
Date: Jul 14, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, infection control, staffing, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to notify physicians timely after incidents, failure to protect residents from abuse, failure to provide timely notifications of transfers and bed hold notices, failure to incorporate PASRR recommendations, failure to administer medications as ordered, insufficient staffing leading to delayed care, medication errors, improper food handling, infection control lapses, failure to notify residents/families of COVID-19 cases, and failure to test staff per vaccination status and community transmission levels.
Deficiencies (16)
Failure to treat resident with dignity by not keeping urinary catheter bag covered for 1 of 3 residents.
Failure to notify physician timely following seizure and fall incidents for 2 of 4 residents.
Failure to protect residents from resident-to-resident abuse including sexual gestures and physical aggression by one resident towards four others.
Failure to provide timely bed hold notice and notification to Ombudsman for resident transfers.
Failure to incorporate PASRR recommendations into care plan for resident with mental illness.
Failure to administer seizure medication (Ativan) as ordered following two seizure episodes.
Failure to assess and intervene timely for resident with abdominal pain and vomiting prior to hospital transfer.
Failure to lock unattended medication cart containing medications.
Insufficient nursing and CNA staffing resulting in delayed call light response times and missed resident care such as baths.
Failure to provide routine medications timely due to pharmacy delays and medication shortages.
Medication error where nurse administered wrong resident's medications resulting in hospital transfer.
Failure to ensure no more than 14 hours elapsed between evening meal and breakfast; lack of documentation of evening snacks.
Improper glove use and hand hygiene by dietary and housekeeping staff leading to potential cross contamination.
Failure to perform catheter dressing change and wound care with appropriate infection control practices including hand hygiene and glove changes.
Failure to notify residents and/or representatives timely of new positive COVID-19 cases among staff and residents.
Failure to test staff not up-to-date on COVID-19 vaccinations per community transmission levels.
Report Facts
Residents affected: 49
Call light response time: 27
Call light response time: 21
Call light response time: 18
Call light response time: 24
Call light response time: 20
Call light response time: 19
Call light response time: 24
Medication doses missed: 6
Staff COVID tests: 2
Community transmission level: 4
Residents reviewed for staffing: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Registered Nurse | Documented seizure event and medication administration |
| Staff H | Licensed Practical Nurse | Involved in medication error and resident abuse incident |
| Staff I | Certified Medication Aide | Administered medications and interviewed about staffing and COVID testing |
| Staff J | Certified Medication Aide | Interviewed about resident behaviors and staffing |
| Staff K | Licensed Practical Nurse | Performed catheter dressing change |
| Staff L | Licensed Practical Nurse | Performed wound care |
| Staff O | Certified Nursing Assistant | Witnessed resident abuse and staffing issues |
| Director of Nursing | Director of Nursing | Interviewed about multiple deficiencies including staffing, infection control, medication |
| Infection Preventionist | Infection Preventionist | Interviewed about infection control and COVID testing |
| Administrator | Administrator | Interviewed about staffing and COVID testing |
| Dietary Manager | Dietary Manager | Interviewed about food service and glove use |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 16
Date: Jul 14, 2022
Visit Reason
The inspection was conducted as an annual recertification survey and investigation of complaints #98567-C and #100666-C.
Complaint Details
Complaint #98567-C was not substantiated. Complaint #100666-C was substantiated.
Findings
The facility was found deficient in multiple areas including resident rights, notification of changes, abuse prevention, transfer/discharge notice, PASARR screening, professional standards, quality of care, accident hazards, sufficient nursing staff, pharmacy services, medication errors, meal frequency, food safety, infection control, and COVID-19 reporting and testing.
Deficiencies (16)
Failed to treat a resident with dignity and respect by not keeping his urinary catheter bag covered.
Failed to notify the physician in a timely manner following a resident's seizure and after a resident fell and sustained injuries.
Failed to protect residents from resident to resident altercations including sexual gestures, physical touching, grabbing, and attempted hitting by Resident #51.
Failed to provide a bed hold notice at the time of transfer for a hospitalized resident.
Failed to incorporate PASRR recommendations into the resident's plan of care for self-directed violent thoughts.
Failed to ensure a resident received medications per physician order following two episodes of seizures.
Failed to assess and intervene after a change of condition for a resident with abdominal pain and vomiting.
Failed to ensure medication carts were locked when unattended.
Failed to assure sufficient staff available at all times to provide nursing and related services to meet residents' needs.
Failed to ensure provision of routine medications for a resident due to medication unavailability.
Failed to ensure residents were free of significant medication errors; a resident received wrong medications resulting in hospital transfer.
Failed to ensure no more than 14 hours elapsed between a substantial evening meal and breakfast the next morning and failed to provide documentation of evening snacks.
Failed to handle food and beverages in a sanitary manner, including extended use of gloves without changing or hand hygiene.
Failed to ensure appropriate hand hygiene and glove use when staff moved between resident rooms, collected trays, passed water, and during catheter dressing change.
Failed to notify residents and/or resident representatives of new positive COVID-19 cases among staff and residents in a timely manner.
Failed to ensure staff members who were not up-to-date on COVID-19 vaccinations were tested per community transmission level of COVID-19.
Report Facts
Census: 49
Deficiencies cited: 15
Call light response time: 27
Call light response time: 21
Call light response time: 18
Call light response time: 24
Call light response time: 20
Call light response time: 19
Call light response time: 24
Call light response time: 27
Call light response time: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Certified Medication Aide | Named in dignity bag and catheter care finding |
| Staff F | Registered Nurse | Named in medication administration and seizure finding |
| Staff H | Licensed Practical Nurse | Named in medication error and resident to resident abuse finding |
| Staff P | Certified Nursing Assistant | Named in resident to resident abuse finding |
| Staff I | Certified Medication Aide | Named in COVID testing and staffing findings |
| Staff Q | Registered Nurse | Named in medication error finding |
| Staff O | Certified Nursing Assistant | Named in resident to resident abuse and staffing findings |
| Staff N | Certified Nursing Assistant | Named in resident to resident abuse and staffing findings |
| Staff B | Resident Assistant | Named in food handling glove use finding |
| Staff A | Cook | Named in food handling glove use finding |
| Staff C | Housekeeper | Named in food handling glove use finding |
| Staff K | Licensed Practical Nurse | Named in catheter dressing change and infection control finding |
| Staff L | Licensed Practical Nurse | Named in catheter dressing change and infection control finding |
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 6
Date: Jun 10, 2021
Visit Reason
The inspection was a re-certification survey and investigation of a facility reported incident #95788 conducted from June 7, 2021 to June 8, 2021. The visit was to assess compliance with care plan development, medication administration, infection control, staffing, and other regulatory requirements.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for residents, securing chemicals to prevent accidents, ensuring sufficient nursing staff, maintaining proper call light response times, and following infection control policies. Deficiencies included failure to update care plans after falls, incomplete medication administration documentation, and inadequate staff response to call lights. The facility provided plans of correction and education to staff.
Deficiencies (6)
Failure to develop and implement comprehensive care plans for residents #15 and #19.
Failure to secure chemicals in an environment free from accident hazards for 15 cognitively impaired residents.
Failure to provide sufficient nursing staff to assure resident safety and care.
Failure to ensure call lights are answered timely and staff are educated on call light expectations.
Failure to maintain infection prevention and control program and proper linen handling.
Failure to properly administer insulin and document medication administration.
Report Facts
Census: 51
Residents reviewed: 18
Residents with insulin administration observed: 3
Residents with care plan deficiencies: 2
Residents with chemical storage deficiency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to care plan development, fall interventions, and medication administration findings. |
| Administrator | Administrator | Named in relation to chemical storage audit, call light system, linen handling, and infection control findings. |
| Staff D | Registered Nurse | Observed and reported on insulin administration and call light system. |
| Staff T | Licensed Practical Nurse | Reported on insulin care plan interventions. |
| Staff G | Licensed Practical Nurse | Reported on insulin care plan interventions and call light system. |
Inspection Report
Abbreviated Survey
Census: 49
Deficiencies: 0
Date: Jan 4, 2021
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from December 31, 2020 to January 4, 2021 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 17, 2020
Visit Reason
A focused Infection Control survey and complaint #92762 were conducted from September 15 to 17, 2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaint #92762-C was investigated and found to be not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #92762-C was not substantiated.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Jun 25, 2020
Visit Reason
The inspection was conducted as a COVID-19 focused infection control survey to assess compliance with CMS and CDC recommended practices for infection prevention and control.
Complaint Details
This was a complaint-related visit focused on infection control practices related to COVID-19. The facility was found not in substantial compliance with infection control requirements.
Findings
The facility was found not in substantial compliance with infection control requirements, failing to implement proper screening practices for staff and infection control measures during care for sampled residents. Specific failures included lack of screening questions, failure to wear masks, and inadequate hand hygiene.
Deficiencies (1)
Failure to implement CMS and CDC recommended infection control screening practices to prevent the spread of COVID-19.
Report Facts
Census: 44
Date of survey completion: Jun 25, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Nurse Aide | Observed entering facility without screening questions asked and walking without a mask. |
| Staff B | Medication Aide | Observed entering facility without screening questions asked and walking without a mask. |
| Staff C | Nurse Aide | Observed entering facility without screening questions asked and walking without a mask. |
| Staff D | Licensed Practical Nurse | Observed entering facility without screening questions asked and walking without a mask; stated staff did not answer screening questions upon arrival. |
| Staff E | Nurse Aide | Assisted resident and failed to perform hand hygiene; stated staff did not answer screening questions upon arrival. |
| Staff F | Nurse Aide | Stated staff did not answer screening questions upon arrival. |
| Director of Nursing | DON | Provided screening checklist and stated staff were supposed to answer screening questions prior to entry. |
| Administrator | Administrator | Stated plan to ensure staff had masks on when entering the facility. |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 3
Date: Jan 14, 2020
Visit Reason
The inspection was conducted as an investigation of complaints #85975, #85990, and #86217 related to failure to notify physician and resident representative of a newly developed wound, failure to report and investigate injuries of unknown origin, and quality of care issues following a fall.
Complaint Details
The visit was complaint-related based on complaints #85975, #85990, and #86217. The investigation found substantiated failures in notification of wound changes, reporting injuries of unknown origin, and quality of care following a fall.
Findings
The facility failed to notify the physician and resident representative of a newly developed wound for Resident #2, failed to operationalize policies for reporting and investigating injuries of unknown origin related to a bruise on Resident #2, and failed to provide comprehensive assessments and timely intervention following a fall for Resident #1, resulting in delayed treatment of fractures.
Deficiencies (3)
Failure to notify physician and resident representative of a newly developed wound for Resident #2.
Failure to operationalize policies and procedures for identifying, reporting, and investigating injuries of unknown origin for Resident #2.
Failure to provide comprehensive assessments and timely intervention following a fall for Resident #1, delaying treatment of fractures.
Report Facts
Census: 53
Deficiencies cited: 3
Dates: Aug 16, 2019
Dates: Aug 17, 2019
Dates: Sep 13, 2019
Dates: Sep 14, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Registered Nurse | Named in failure to notify physician and family of Resident #2's wound |
| Staff J | Nurse Aide | Named in failure to timely report bruise on Resident #2 |
| Director of Nursing | DON | Interviewed regarding wound notification failure and audits |
| Director of Health Services | DHS | Interviewed regarding bruise investigation on Resident #2 |
| Staff A | Licensed Practical Nurse | Involved in assessment and care of Resident #1 after fall |
| Staff B | Nurse Aide | Reported Resident #1 moaning in pain after fall |
| Staff C | Licensed Practical Nurse | Assessed Resident #1 post-fall and documented findings |
| Staff D | Nurse Aide | Reported Resident #1's pain and refusal to get up |
| Staff E | Nurse Aide | Reported Resident #1's pain and vomiting |
| Staff F | Nurse Aide | Noticed Resident #1's arm swelling and bruising |
| Staff G | Licensed Practical Nurse | Assessed Resident #1's injuries and arranged hospital transfer |
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