Deficiencies (last 3 years)
Deficiencies (over 3 years)
23 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
423% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
84 residents
Based on a May 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 22, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to complete follow-up assessments after a resident fall, inadequate nursing staff coverage leading to missed medication administration, and failure to maintain complete medical records.
Complaint Details
The complaint investigation revealed failure to follow up after a resident fall, inadequate nursing coverage for approximately four hours resulting in missed medications for three residents, including one who called 911 due to severe pain, and failure to maintain proper medical records. The immediate jeopardy was removed after corrective actions were implemented.
Findings
The facility failed to complete follow-up assessments after a fall for one resident, failed to provide adequate nursing coverage resulting in missed medications and an immediate jeopardy situation affecting multiple residents, and failed to maintain complete medical records for three residents. Corrective actions and education were implemented following these findings.
Deficiencies (3)
Failed to complete follow-up assessments after a fall for one resident (Resident #18).
Failed to provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift, resulting in immediate jeopardy to resident health or safety.
Failed to maintain complete medical records in accordance with professional standards for three residents.
Report Facts
Residents affected: 4
Residents affected: 53
Residents affected: 3
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Registered Nurse | Authored progress note regarding fall follow-up for Resident #18 and provided statements about the incident |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding missing incident reports and facility policies; involved in internal investigation |
| Staff P | Licensed Practical Nurse (LPN) | Nurse on duty during Resident #18 fall who resigned immediately after incident |
| Staff D | Registered Nurse (RN) | Nurse who left facility during night shift causing inadequate staffing and was suspended and later terminated |
| Staff F | Registered Nurse (RN) | Nurse who left facility during night shift causing inadequate staffing and was placed on Do Not Return list |
| Staff E | Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON) | On-call manager during staffing incident; provided statements about communication and response |
| Staff H | Registered Nurse (RN) | Arrived for day shift and administered medications to Resident #3 after staffing incident |
| Staff A | Certified Medication Aide (CMA) | Worked night shift during staffing incident and provided statements about medication administration failures |
| Staff B | Certified Nurse Aide (CNA) | Worked night shift during staffing incident and provided statements about nurse leaving and medication issues |
| Staff C | Certified Nurse Aide (CNA) | Worked night shift during staffing incident and provided statements about resident needs and nurse absence |
| Staff I | Licensed Practical Nurse (LPN) | Arrived for day shift and reported on staffing incident and resident neglect concerns |
Inspection Report
Routine
Census: 84
Deficiencies: 13
Date: May 20, 2025
Visit Reason
Routine inspection of Royal Oaks Nursing and Rehabilitation Center to assess compliance with regulatory standards including resident care, medication management, safety, infection control, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to provide timely incontinence care, incomplete baseline care plans, failure to follow physician orders, unsafe transfer practices resulting in resident injury, inadequate respiratory care, medication errors including failure to verify resident identity leading to medication omission, improper medication storage and counting, food safety and temperature issues, and failure to safeguard resident information. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (13)
Failed to provide incontinence care at resident's request for 1 of 23 residents.
Failed to develop a baseline care plan within 48 hours after admission for 1 of 23 residents.
Failed to follow physician's orders for 1 of 23 residents.
Failed to ensure safety during transfers for 1 of 3 residents resulting in fall with fractures and failed to properly use mechanical lifts for others.
Failed to provide respiratory care in accordance with professional standards for 2 of 4 residents requiring oxygen.
Failed to include psychotropic medication target behaviors and non-pharmacologic interventions in care plan for 1 of 23 residents.
Failed to verify resident identity to ensure accurate antipsychotic medication orders upon admission for 1 of 3 residents, resulting in medication omission and psychosocial harm.
Failed to have a process for consistent accurate count of controlled medications resulting in unaccounted narcotics for 1 resident.
Failed to provide food at an appetizing temperature and failed to prevent food contamination by staff touching food with bare hands for 2 residents.
Failed to store, prepare, distribute and serve food in accordance with professional standards and maintain kitchen in safe and hygienic manner.
Failed to properly protect resident information from unauthorized access.
Failed to utilize Enhanced Barrier Precautions during wound and catheter care and failed to disinfect mechanical lift between residents.
Failed to complete appropriate hand hygiene and medication handling during medication pass.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Y | Licensed Practical Nurse | Named in incontinence care deficiency |
| Staff Z | Certified Nursing Assistant | Named in incontinence care deficiency |
| Director of Nursing | Director of Nursing | Provided statements on multiple deficiencies |
| Staff BB | MDS Registered Nurse | Commented on baseline care plan deficiency |
| Staff CC | Certified Medication Aide | Commented on physician order noncompliance |
| Staff E | Licensed Practical Nurse | Commented on physician order noncompliance and respiratory care |
| Staff DD | Certified Nurse Aide | Commented on physician order noncompliance |
| Staff EE | Certified Nurse Aide | Commented on physician order noncompliance |
| Staff O | Certified Nurse Aide | Commented on physician order noncompliance and mechanical lift use |
| Staff Q | Certified Nurse Aide | Commented on mechanical lift use |
| Staff F | Licensed Practical Nurse | Commented on mechanical lift use and respiratory care |
| Staff I | Certified Nurse Aide | Commented on mechanical lift use |
| Staff B | Registered Nurse | Involved in medication count and medication order error |
| Staff J | Licensed Practical Nurse | Involved in medication count |
| Staff S | Licensed Practical Nurse | Involved in medication count |
| Staff H | Licensed Practical Nurse | Involved in medication count and wound care |
| Staff U | Registered Nurse | Involved in medication count discrepancy |
| Staff V | Licensed Practical Nurse | Involved in medication count |
| Staff X | Registered Nurse | Involved in medication count |
| Staff W | Certified Nurse Aide | Witnessed medication count disagreement |
| Staff AA | Assistant Director of Nursing | Involved in medication order error and medication cart audit |
| Staff D | Licensed Practical Nurse Assistant Director of Nursing | Involved in medication order error and medication discontinuation |
| Staff C | Dietary Supervisor | Commented on food temperature and food handling |
| Staff N | Cook | Commented on kitchen flooding and conditions |
| Staff L | Cook | Commented on kitchen flooding and conditions |
| Staff FF | Registered Nurse | Left laptop open with resident information visible |
| Staff G | Certified Nursing Assistant | Failed to wear gown during catheter care |
| Staff EE | Certified Nurse Aide | Touched food with ungloved hands |
| Staff R | Cook | Touched food with ungloved hands |
Inspection Report
Routine
Census: 84
Deficiencies: 6
Date: May 12, 2025
Visit Reason
Routine inspection of Royal Oaks Nursing and Rehabilitation Center to assess compliance with healthcare regulations, including resident care, safety, medication management, and food service standards.
Findings
The facility was found deficient in multiple areas including failure to provide timely incontinence care, unsafe resident transfers causing injury, incomplete behavioral health care plans, medication errors including failure to verify resident identity leading to medication omission, inaccurate controlled medication counts, and unsafe food service practices including kitchen flooding and improper food handling.
Deficiencies (6)
Failure to provide incontinence care at the resident's request resulting in minimal harm.
Failure to ensure safety during transfers causing a fall with fractures and actual harm to the resident.
Failure to include psychotropic medication target behaviors and non-pharmacologic interventions in the Care Plan.
Failure to verify resident identity resulting in medication errors and psychosocial harm.
Failure to maintain accurate controlled medication counts resulting in missing narcotic medications.
Failure to maintain kitchen and food service safety including flooding, broken equipment, improper food handling, and unsafe food temperatures.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: Many
Medication administrations missing: 12
Medication cards: 2
Medication doses: 30
Medication doses: 50
Medication doses: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Y | Licensed Practical Nurse (LPN) | Named in incontinence care deficiency |
| Staff Z | Certified Nursing Assistant (CNA) | Named in incontinence care deficiency |
| Director of Nursing (DON) | Provided statements on multiple deficiencies including incontinence care, transfer safety, medication errors, and controlled substance counts | |
| Staff A | Certified Nurse Aide (CNA) | Named in unsafe transfer causing resident fall |
| Staff B | Registered Nurse (RN) | Named in unsafe transfer and controlled medication count discrepancies |
| Staff Q | Certified Nursing Assistant (CNA) | Observed performing unsafe mechanical lift transfer |
| Staff O | Certified Nursing Assistant (CNA) | Observed performing unsafe mechanical lift transfer |
| Staff F | Licensed Practical Nurse (LPN) | Observed performing unsafe mechanical lift transfer |
| Staff I | Certified Nursing Assistant (CNA) | Observed performing unsafe mechanical lift transfer |
| Staff EE | Certified Nursing Assistant (CNA) | Observed touching food with bare hands |
| Staff R | Cook | Observed touching resident food with bare hands |
| Staff P | Marketing Director | Reported resident complaint about food contamination |
| Staff U | Registered Nurse (RN) | Involved in controlled medication count discrepancies and suspected in missing narcotics |
| Staff J | Licensed Practical Nurse (LPN) | Involved in controlled medication count and reported missing narcotics |
| Staff S | Licensed Practical Nurse (LPN) | Involved in controlled medication count and reported missing narcotics |
| Staff H | Licensed Practical Nurse (LPN) | Involved in controlled medication count and reported missing narcotics |
| Staff V | Licensed Practical Nurse (LPN) | Worked with Staff U during medication pass |
| Staff X | Registered Nurse (RN) | Worked with Staff U during medication pass |
| Staff W | Certified Nursing Assistant (CNA) | Witnessed disagreement about medication cart assignments |
| Staff AA | Assistant Director of Nursing (ADON) | Responsible for admission orders entry and medication cart audits |
| Staff D | Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON) | Responsible for medication discontinuation process |
| Staff M | Licensed Practical Nurse (LPN) | Documented medication order error for Resident #56 |
| Staff GG | Licensed Practical Nurse (LPN) | Documented resident medication refusal |
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 12
Date: Dec 13, 2024
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident rights, care, safety, medication management, infection control, and environmental conditions.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to dignity and self-determination, improper maintenance of call lights, unsanitary conditions, incomplete care plans, medication administration errors, improper resident transfers, inadequate infection control practices, unsecured medication carts, unlabeled controlled substances, and pest infestation.
Deficiencies (12)
Failed to allow residents to make their own choices and treat residents with dignity and respect, including failure to knock and wait for invitation before entering rooms.
Failed to maintain call lights within reach of residents.
Failed to provide a clean, sanitary, and homelike environment and maintain cleanliness of resident transfer devices.
Failed to implement complete care plan for resident's personal hygiene needs including shaving.
Failed to meet professional standards of quality in medication administration, including documenting treatments not performed.
Failed to provide appropriate care and assistance with activities of daily living, including improper transfers, oral care, and grooming.
Failed to properly assess residents following falls and injuries and failed to follow physician orders for medication administration.
Failed to maintain locked and secured treatment and medication carts and provide adequate supervision to prevent falls.
Failed to follow infection prevention and control practices including failure to don gowns and maintain proper catheter tubing placement.
Failed to provide pharmaceutical services meeting professional standards, including allowing unlicensed staff to pre-draw and administer controlled medications and failure to reconcile controlled drug records.
Failed to label liquid Morphine and Lorazepam syringes and store drugs and biologicals in locked compartments with proper labeling.
Failed to maintain a pest control program resulting in cockroach infestation throughout the facility.
Report Facts
Residents affected: 3
Residents affected: 83
Medication syringes: 9
Skin tear size: 1
Cockroach infestation: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN)/Nurse Manager/Supervisor | Named in medication pre-drawing and labeling deficiencies |
| Staff E | Certified Medication Aide (CMA) and Certified Nursing Assistant (CNA) | Witnessed staff failing to knock before entering rooms and improper resident transfers |
| Staff J | Licensed Practical Nurse (LPN) | Named in medication administration and treatment documentation deficiencies |
| Staff G | Licensed Practical Nurse (LPN) | Failed to don gown during catheter care and touched resident's bedding with gloved hands |
| Staff C | Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) | Witnessed improper resident transfers and failure to don PPE |
| Staff I | Licensed Practical Nurse (LPN) | Identified unlabeled Morphine syringes and medication cart key handling issues |
| Staff K | Licensed Practical Nurse (LPN)/Nurse Manager/Supervisor | Confirmed failure to don gown and improper catheter care |
| Staff O | Registered Nurse (RN) | Failed to don gown during PICC line care |
| Staff D | Certified Nursing Assistant (CNA) | Confirmed witnessing staff failing to don PPE |
| Staff F | Licensed Practical Nurse (LPN) | Confirmed administering unlabeled pre-drawn Morphine syringes |
| Staff N | Physical Therapy Director | Confirmed expectation for two staff to assist with resident transfers using lift devices |
| Director of Nursing (DON) | Director of Nursing | Confirmed failures in medication reconciliation, resident supervision, and medication administration practices |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 3
Date: Oct 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate assessment and intervention following a resident fall and failure to provide proper pressure ulcer care and safe transfer practices.
Complaint Details
The complaint investigation focused on Resident #1 who fell during a sliding board transfer with only one staff member assisting, contrary to the care plan requiring two staff. The resident sustained no injuries but the facility failed to complete required assessments and documentation post-fall. Additionally, the facility failed to provide timely and complete pressure ulcer care for the resident's left heel blister and failed to follow care plan directives for safe transfers.
Findings
The facility failed to assess and intervene appropriately after a resident fall, did not complete ordered skin assessments and treatments timely for a pressure ulcer, and failed to follow care plan directives for safe transfers, resulting in a resident fall. The facility reported a census of 77 residents and identified deficiencies related to treatment, pressure ulcer care, and accident prevention.
Deficiencies (3)
Failed to provide assessment and intervention following a resident fall, including lack of assessments post-fall and prior to transfer to higher level of care.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, including delayed treatment initiation and incomplete assessments.
Failed to provide a safe transfer for a resident by not utilizing 2 staff as required, resulting in a fall.
Report Facts
Residents affected: 1
Census: 77
Pressure ulcer size: 3.5
Pressure ulcer size: 3
Braden Scale score: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported fall incident and assisted resident after fall |
| Staff B | Certified Nursing Assistant (CNA) | Assisted resident during fall and provided statements about transfer |
| Interim Director of Nursing | Director of Nursing (DON) | Provided expectations for fall assessments and transfer procedures |
Inspection Report
Routine
Census: 83
Deficiencies: 1
Date: Sep 7, 2024
Visit Reason
The inspection was conducted to assess compliance with physician orders and appropriate catheter care for residents with indwelling catheters, based on clinical record review, observation, staff interviews, and facility policy review.
Findings
The facility failed to follow physician orders for catheter care for 2 of 3 residents reviewed, including failure to document catheter changes and use of incorrect catheter sizes. The facility policies on medication administration, catheter care, and physician services were reviewed and found to be in place but not consistently followed.
Deficiencies (1)
Failure to follow physician orders for catheter care for Residents #2 and #5, including undocumented catheter changes and incorrect catheter sizes.
Report Facts
Census: 83
Catheter size: 22
Catheter size: 18
Catheter change date: Aug 31, 2024
Catheter last changed date: Jul 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Director of Nursing | Spoke about undocumented catheter changes and lack of knowledge about catheter sizes | |
| Staff A | Observed and reported catheter sizes and care procedures for Residents #2 and #5 |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 4
Date: Jul 1, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify physicians of significant changes in residents' nutritional status and failure to follow physician orders related to catheter flushing, medication administration, and self-administration of creams.
Complaint Details
The complaint investigation revealed substantiated issues including failure to notify physicians of significant weight loss and failure to follow physician orders related to catheter care, insulin administration, and medication self-administration.
Findings
The facility failed to notify the physician of significant weight loss for one resident and failed to follow physician orders for catheter flushing, proper insulin pen administration, and allowing a resident to self-administer a cream without a physician order for four residents. These failures were confirmed through record reviews, observations, interviews, and policy reviews.
Deficiencies (4)
Failure to notify physician of significant weight loss for Resident #6.
Failure to provide catheter flushing as ordered for Resident #61 and others.
Improper insulin pen administration by staff for Resident #50.
Allowing a resident to self-administer a cream without a physician order.
Report Facts
Resident census: 80
Weight loss: 21.55
Weight loss percentage: 13.43
Catheter flush omissions: 20
Insulin units: 45
Insulin units: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Dietician | Acknowledged failure to notify physician of Resident #6's weight loss |
| Staff A | Registered Nurse (RN) | Observed improperly administering insulin to Resident #50 |
| Director of Nursing (DON) | Reported expectations for catheter irrigation and insulin pen administration | |
| Administrator | Confirmed expectation that physician orders be followed |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 9
Date: Jul 1, 2024
Visit Reason
The inspection was conducted following a complaint alleging rough handling and potential abuse of Resident #48 by a male staff member during transfers and bed mobility.
Complaint Details
The complaint alleged that a male staff member roughly handled Resident #48 during transfers and bed mobility, causing bruising and anxiety. The family and a family friend reported the incident to the facility. The facility did not report the allegation to the state agency and did not interview the alleged staff member. The staff member continued to provide care to Resident #48.
Findings
The facility failed to report the alleged abuse to the state agency and did not conduct a thorough investigation. The alleged staff member continued to work with residents. Resident #48 reported anxiety due to the rough handling. The facility also failed to ensure congruency in code status documentation for Resident #64, failed to notify the physician of significant weight loss for Resident #6, failed to provide a comprehensive care plan for Resident #17 with a urostomy, failed to follow physician orders for catheter flushing for Resident #61, failed to properly administer insulin pens for Resident #40, and failed to ensure a safe environment for Resident #48 who smokes but lacks a smoking safety policy.
Deficiencies (9)
Failed to report alleged abuse of Resident #48 to the State survey and certification agency and failed to conduct a thorough investigation.
Failed to ensure code status between the Iowa Physician's for Scope of Treatment (IPOST) and Care Plan were congruent for Resident #64.
Failed to notify the physician of a significant change in nutritional status and weight loss for Resident #6.
Failed to develop and implement a comprehensive person-centered care plan for Resident #17 with a urostomy and urostomy bag.
Failed to ensure catheter flushing was completed as ordered for Resident #61.
Failed to properly administer insulin pens for Resident #40, including priming the pen and leaving the needle under the skin for 10 seconds.
Failed to ensure Resident #48's environment was free from accident hazards related to smoking, including lack of smoking safety assessment and policy.
Failed to have all required members present at quarterly Quality Assurance meetings.
Failed to establish policies regarding smoking, smoking areas, and smoking safety for Resident #48.
Report Facts
Resident census: 80
Weight loss: 21.55
Urostomy bag capacity: 2000
Missed catheter flushes: 20
Insulin units: 45
Insulin units: 66
Quality Assurance meetings missing members: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant | Alleged staff member responsible for rough handling of Resident #48; worked weekend of 6/14/24 to 6/16/24; denied allegations; no disciplinary action taken |
| Social Services Director | Received complaint call from family member; conducted partial investigation; documented findings | |
| Director of Nursing | DON | Interviewed resident and staff; provided education to Staff D; acknowledged care plan deficiencies |
| Administrator | Oversaw complaint investigation; did not report to state agency; provided statements on facility policies and investigation | |
| Staff A | Registered Nurse | Observed improperly administering insulin pens to Resident #40 |
| Staff B | Dietician | Monitored Resident #6's weight loss; acknowledged failure to notify physician |
| Staff C | Certified Nursing Assistant | Observed cigarettes and lighter in Resident #48's room |
Inspection Report
Routine
Census: 80
Deficiencies: 5
Date: Jan 30, 2024
Visit Reason
The inspection was a routine regulatory visit to assess compliance with healthcare standards including resident dignity, infection prevention, environmental safety, and sanitation.
Findings
The facility failed to provide catheter drainage bag covers for some residents, did not consistently perform proper hand hygiene during wound care, failed to maintain sanitary conditions in resident bathrooms and assistive devices, improperly handled COVID-19 contaminated laundry, and did not adequately clean air unit vents in resident rooms.
Deficiencies (5)
Failed to provide catheter drainage bag covers for 3 of 4 residents reviewed for dignity.
Failed to perform proper hand hygiene during wound dressing and treatments for 2 of 3 residents reviewed.
Failed to maintain sanitary conditions of resident assistive devices, toilets, and drainage canisters.
Failed to properly wash clothes of residents with COVID-19 separately from residents without COVID-19.
Failed to maintain a safe and sanitary environment by not adequately cleaning wall air unit vents in resident rooms.
Report Facts
Residents affected: 3
Census: 80
COVID-19 cases: 31
Residents with COVID-19 during last outbreak: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in infection control deficiency related to improper hand hygiene during wound care |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding hand hygiene and catheter dignity bag use |
| Staff D | Licensed Practical Nurse (LPN) | Interviewed regarding hand hygiene and catheter dignity bag use |
| Director of Nursing | Provided statements on catheter dignity bag policy and hand hygiene expectations | |
| Staff F | Housekeeping Aide | Reported improper laundry handling of COVID-19 contaminated linens |
| Staff H | Assistant Director of Nursing (ADON) | Discussed laundry procedures and changes during COVID-19 outbreak |
| Staff E | Housekeeping Aide | Reported mixing of COVID-19 positive and non-positive resident clothes in laundry |
| Staff G | Previous Laundry Aide | Acknowledged washing COVID-19 positive and non-positive clothes together per supervisor instruction |
| Staff B | Maintenance Staff | Acknowledged cleaning schedule and condition of wall air unit vents |
| Environmental Supervisor | Provided information on cleaning schedules and housekeeping checklists | |
| Administrator | Provided documented washing procedures for COVID/Isolation linen |
Inspection Report
Routine
Census: 81
Deficiencies: 5
Date: Dec 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, treatment and dressing changes, oxygen use, pressure ulcer care, respiratory care, and pharmaceutical services at Royal Oaks Nursing and Rehabilitation Center.
Findings
The facility failed to develop comprehensive care plans for residents, failed to follow physician orders for treatments and oxygen use, failed to provide appropriate pressure ulcer care, failed to ensure safe respiratory care for residents needing oxygen during appointments, and failed to ensure accurate controlled substance medication counts and proper destruction procedures.
Deficiencies (5)
Failed to develop comprehensive care plans for three of four residents reviewed.
Failed to follow physician's orders for treatment and dressing changes and oxygen use for residents.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident.
Failed to provide safe and appropriate respiratory care for a resident needing oxygen during doctor's appointments.
Failed to ensure accurate controlled substance medication counts and proper destruction of controlled substances, including forged witness signatures.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Deficiency count: 86
Medication doses: 172
Resident census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Named in medication destruction and diversion finding |
| Staff B | Registered Nurse | Named as nurse whose signature was forged on medication destruction form |
| Staff C | Registered Nurse | Witnessed medication destruction and reported concerns |
| Staff E | Assistant Director of Nursing | Reported and investigated medication destruction incident |
| Staff F | Assistant Director of Nursing | Reported on pressure ulcer care and medication destruction investigation |
| Staff K | Registered Nurse | Performed wound treatment on Resident #9 |
| Staff L | Certified Nursing Assistant | Reported lack of care plan access and knowledge of oxygen use |
| Staff M | Certified Nursing Assistant | Reported lack of care plan access and knowledge of oxygen use |
| Staff O | Certified Nursing Assistant | Reported use of set sheets for resident care but pressure ulcer info missing |
| Staff D | Registered Nurse | Reported narcotic count and destruction procedures |
| Staff G | Certified Nursing Assistant | Reported no observation of medication diversion or impairment |
| Staff I | Certified Nursing Assistant | Reported no observation of medication diversion or impairment |
| Staff J | Nurse Practitioner | Reported on wound treatment orders for Resident #5 |
| Director of Nursing | Director of Nursing | Reported on medication destruction investigation and oxygen use incidents |
| MDS Coordinator | MDS Coordinator | Reported on care plan development and oxygen use expectations |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
Date: Sep 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to follow physician orders for medication administration and improper destruction of narcotic medication.
Complaint Details
The complaint investigation revealed that Resident #2 did not receive prescribed Parkinson's medication on 8/1/23 and 8/2/23, causing uncontrolled tremors and hospitalization. The facility Director of Nursing confirmed the failure to follow physician orders. For Resident #6, narcotic medication destruction procedures were not followed, with missing narcotic bottles and discrepancies in narcotic logs. Interviews with staff and facility leadership confirmed these failures.
Findings
The facility failed to administer Parkinson's Disease medication to Resident #2 for two days, resulting in hospitalization due to severe tremors. Additionally, the facility failed to properly destroy Resident #6's narcotic medication per policy, with discrepancies found in narcotic logs and medication disposal procedures.
Deficiencies (2)
Failure to follow physician orders for Resident #2, resulting in missed Parkinson's Disease medication for two days and subsequent hospitalization.
Failure to properly destroy Resident #6's narcotic medication according to facility policy and procedures.
Report Facts
Residents Affected: 1
Residents Affected: 1
Census: 83
Medication doses missed: 2
Morphine remaining volume discrepancy: 2.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Identified narcotic medication discrepancy and initiated investigation |
| Staff B | Certified Medication Aide | Reported morphine bottle was empty and discarded |
| Staff C | Registered Nurse | Confirmed facility policy for destroying narcotic medications |
| Staff D | Registered Nurse | Confirmed facility policy for destroying narcotic medications |
| Director of Nursing | Director of Nursing | Confirmed failure to follow physician orders for Resident #2 and narcotic destruction policy |
| Facility Administrator | Facility Administrator | Confirmed failure to follow narcotic destruction policy |
Inspection Report
Routine
Census: 81
Deficiencies: 6
Date: Apr 4, 2023
Visit Reason
The inspection was conducted to assess compliance with Medicare/Medicaid regulations including resident notices, transfer notifications, care planning, nutrition, menu compliance, and food safety.
Findings
The facility was found deficient in providing required Medicare/Medicaid notices to residents, notifying the LTC Ombudsman of hospital transfers, developing comprehensive care plans addressing high-risk medications and nutritional needs, serving appropriate pureed food portions according to the menu, and properly sanitizing dishes due to dishwasher malfunction.
Deficiencies (6)
Failed to provide residents or their representatives with appropriate written notices when they no longer qualified for Skilled Care Services covered by Medicare for 3 residents.
Failed to notify the State Long Term Care Ombudsman for 2 of 4 residents reviewed for transfers out of the facility.
Failed to develop a comprehensive care plan that included measurable objectives and time frames related to medications prescribed for 4 of 19 residents reviewed.
Failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 2 residents reviewed for nutrition.
Failed to serve the appropriate portion of meat for 5 residents who received pureed meat and failed to serve the posted menu for 4 residents who received full pureed meals.
Failed to properly sanitize resident dishes and utensils due to dishwasher not reaching proper temperature during wash and rinse cycles.
Report Facts
Residents affected: 3
Residents affected: 2
Residents reviewed: 19
Residents affected: 1
Residents affected: 5
Residents affected: 4
Census: 81
Weight loss percentage: 11.2
Weight loss percentage: 16.1
Weight loss percentage: 17.8
Weight loss percentage: 16.8
Weight loss percentage: 13.2
Weight loss percentage: 11
Weight loss percentage: 11.1
Weight loss percentage: 14.95
Pureed meat serving size: 5.33
Pureed butternut squash serving size: 4
Dishwasher temperature: 160
Dishwasher temperature: 180
Dishwasher temperature: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed Medicare coverage dates and care plan expectations |
| Administrator | Administrator | Provided information on LTC Ombudsman notification and dishwasher issues |
| Dietary Manager | Dietary Manager | Reported dishwasher malfunction and pureed food preparation expectations |
| Registered Dietitian | Registered Dietitian | Provided dietary assessments and expectations for pureed food portions |
| MDS Coordinator | MDS Coordinator | Reported care plan review process and errors |
| Staff A | Cook | Prepared pureed food and used dishwasher during meal preparation |
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