The most recent inspection on December 12, 2024 found the facility to be in substantial compliance with no deficiencies cited. Earlier inspections showed a mixed record, with prior annual surveys noting deficiencies related to care plan timing and revision, resident assessments, and infection control. Complaint investigations were mostly unsubstantiated, except for a substantiated case in September 2022 involving inadequate wound care that resulted in a resident’s death. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history suggests improvement over time, with recent surveys showing compliance following earlier issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
43210
2020
2021
2022
2023
2024
2025
Census
Latest occupancy rate45 residents
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
A complaint investigation for complaint #115348-C was conducted from April 29, 2024 to April 30, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #115348-C was investigated and the facility was found to be in substantial compliance.
Inspection Report Plan of CorrectionDeficiencies: 0Nov 28, 2023
Visit Reason
The document serves as a Plan of Correction following a survey to address deficiencies and certify the facility's compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective November 28, 2023.
The inspection visit was conducted as part of the facility's Annual Recertification Survey and an investigation of Complaint #114091-C and Facility Self-Reported Incident #116828-I from November 13, 2023 to November 16, 2023.
Findings
The facility failed to ensure comprehensive care plans were reviewed and revised for residents as required, including hearing aid placement, pain management, and medication monitoring. Deficiencies were noted in care plan timing, revision, and documentation for multiple residents.
Complaint Details
The visit included an investigation of Complaint #114091-C and Facility Self-Reported Incident #116828-I.
Deficiencies (1)
Description
Care plans were not developed within 7 days after completion of the comprehensive assessment and were not reviewed and revised by the interdisciplinary team after each assessment.
Report Facts
Resident census: 50
Employees Mentioned
Name
Title
Context
Richard Curley
Administrator
Signed the initial comments on the statement of deficiencies
Director of Nursing (DON)
Stated plans for resident hearing aids and care plan expectations
RAI Coordinator
Confirmed hearing aid placement and care plan documentation issues
The inspection was conducted to evaluate the facility's compliance with care plan requirements, specifically reviewing comprehensive care plans for residents related to hearing, hypnotic medication use, and pain management.
Findings
The facility failed to ensure comprehensive review and revision of Care Plans for 3 residents: Resident #19's hearing needs were not adequately addressed, Resident #24's hypnotic medication use was not monitored, and Resident #39's pain diagnosis lacked goals and interventions. Observations and interviews confirmed these deficiencies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
Description
Severity
Care Plan for Resident #24 failed to address use of hypnotic medication and failed to direct staff to monitor for adverse effects.
Level of Harm - Minimal harm or potential for actual harm
Care Plan for Resident #19 failed to include focus area, goal, or interventions related to hearing and hearing aid placement.
Level of Harm - Minimal harm or potential for actual harm
Care Plan for Resident #39 failed to include goals and interventions related to pain diagnosis.
Level of Harm - Minimal harm or potential for actual harm
Report Facts
Residents Affected: 3Census: 50
Employees Mentioned
Name
Title
Context
Director of Nursing
Director of Nursing (DON)
Reported expectations for Care Plan content and confirmed deficiencies
RAI Coordinator
Resident Assessment Instrument Coordinator
Confirmed hearing aid placement not documented and stated expectations for pain-related Care Plan documentation
Administrator
Administrator
Stated expectations for documentation of pain and related Care Plans
Inspection Report Plan of CorrectionDeficiencies: 0Dec 14, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance of the facility.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective December 14, 2022.
The inspection was conducted as the facility's Annual Recertification Survey from November 14, 2022 to November 17, 2022.
Findings
The facility was found deficient in multiple areas including accuracy of resident assessments, care plan timing and revision, professional standards of services provided, and infection prevention and control. Specific issues included inaccurate pain medication coding, failure to follow care plans for residents, inadequate infection control practices, and failure to document incidents properly.
Severity Breakdown
SS=D: 4
Deficiencies (4)
Description
Severity
Accuracy of Assessments - facility failed to accurately code the use of as needed pain medication on the Minimum Data Set (MDS) Assessment for residents.
SS=D
Care Plan Timing and Revision - facility failed to follow care plans as written for residents and did not include all required interdisciplinary team members in care plan development.
SS=D
Services Provided Meet Professional Standards - facility failed to provide professional standards of quality for medication review and care planning.
SS=D
Infection Prevention & Control - facility failed to establish and maintain an infection prevention and control program including proper hand hygiene and blood glucose monitoring procedures.
SS=D
Report Facts
Census: 45Deficiencies cited: 4Pain medication doses: 10Brief Interview for Mental Status (BIMS) score: 11Brief Interview for Mental Status (BIMS) score: 3Brief Interview for Mental Status (BIMS) score: 15Brief Interview for Mental Status (BIMS) score: 4Fluid intake: 501
Employees Mentioned
Name
Title
Context
Staff A
Registered Nurse (RN)
Observed administering medication and performing hand hygiene incorrectly
Staff B
Registered Nurse (RN)
Observed performing blood glucose monitoring with improper glove use
Staff C
Registered Nurse (RN)
Reported use of isolation bin and failure to wear gown during PICC line care
Staff D
Certified Nurse Aide (CNA)
Interviewed regarding incident recall
Staff E
Certified Nurse Aide (CNA)
Interviewed regarding resident pills incident
Director of Nursing (DON)
Director of Nursing
Interviewed regarding policies and expectations for MDS accuracy and care plans
Staff F
Registered Nurse (RN)
Re-educated on assessment and reporting requirements and provided late medication error report
Staff nurse
Requires additional training on glucometer use and hand hygiene/gloving per corrective action plan
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and to evaluate the quality of care and services provided to residents at West Ridge Care Center.
Findings
The facility was found deficient in multiple areas including inaccurate coding of pain medication use on the MDS assessment, failure to follow care plans especially related to enhanced barrier precautions and gastric residual volume monitoring, failure to provide professional standards of quality in medication management, and inadequate infection prevention practices related to blood glucose monitoring.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
Description
Severity
Failed to accurately code the use of as needed pain medication on the Minimum Data Set (MDS) Assessment for 1 of 2 residents sampled for pain.
Level of Harm - Minimal harm or potential for actual harm
Failed to develop and follow the complete care plan within 7 days of the comprehensive assessment for 2 of 12 residents, including failure to follow Enhanced Barrier Precautions and failure to measure gastric residual volume prior to tube feeding.
Level of Harm - Minimal harm or potential for actual harm
Failed to provide professional standards of quality for medication review for 1 of 5 residents, including lack of documentation and notification following a medication incident.
Level of Harm - Minimal harm or potential for actual harm
Failed to implement infection prevention and control program properly, including failure to change gloves between blood glucose check and sanitizing the blood glucose machine for 1 of 2 residents reviewed.
Level of Harm - Minimal harm or potential for actual harm
The inspection was conducted as an investigation of complaints #105176-C, #105230-C, #107464-C, and a facility self-reported incident #105168-M during the period 9/13/22 to 9/21/22.
Findings
The facility failed to assess, document, notify the provider and family, and provide ongoing assessment and treatment for a reported wound on Resident #2, which led to infection, surgery, and the resident's death. Complaints #105176-C and #105230-C were substantiated, while complaint #107464 was not substantiated.
Complaint Details
Complaints #105176-C and #105230-C were substantiated. Complaint #107464 was not substantiated.
Severity Breakdown
SS=G: 1
Deficiencies (1)
Description
Severity
Failure to assess, document, notify provider and family, and provide ongoing assessment and treatment for a reported wound on Resident #2.
SS=G
Report Facts
Complaint numbers: 3Facility self-reported incident: 1Census: 50Dates of incident and survey: Incident dates 9/13/22 to 9/21/22; wound dressing dated 5/31/22; resident passed away 6/27/22
Employees Mentioned
Name
Title
Context
Staff A
Registered Nurse (RN)
Named in wound assessment and documentation deficiencies
Staff B
Registered Nurse (RN)
Completed Re-Admission Skin Assessment and notified provider and family
Director of Nursing
Director of Nursing (DON)
Interviewed regarding wound assessment and documentation
Medical Director
Medical Director (MD)
Interviewed regarding wound care expectations and resident condition
Physical Therapist
Physical Therapist (PT)
Confirmed open area on resident's left elbow
Orthopedic Surgeon
Orthopedic Surgeon
Provided medical opinion on wound and surgery
MDS Coordinator
MDS Coordinator
Confirmed wound assessment and documentation deficiencies
The inspection was conducted as a Recertification Survey and investigation of a Facility Self-Reported Incident #91050 from 7/26/21 to 7/29/21.
Findings
The facility was found to have deficiencies related to enteral nutrition and food safety requirements, including failure to ensure proper checking of gastric tube placement prior to feeding and failure to date opened food items in the refrigerator and properly label and store dried food items.
Deficiencies (2)
Description
Failure to ensure a resident fed by enteral means receives appropriate treatment and services to prevent complications of enteral feeding.
Failure to date opened items when placed in the refrigerator and to properly label and store dried food items.
A Focused COVID-19 Infection Control Survey was conducted from 12/2 - 12/3/2020 by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 7/13-14/20 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.
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 to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 41
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