Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 24, 2025
Visit Reason
The document reports acceptance of a credible allegation of substantial compliance and approval of a Plan of Correction for the facility.
Findings
The facility will be certified in compliance effective March 21, 2025, based on acceptance of the Plan of Correction and substantial compliance.
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 6
Mar 6, 2025
Visit Reason
The inspection was conducted as the facility's annual recertification survey from March 3, 2025 to March 6, 2025.
Findings
The survey identified multiple deficiencies related to grievance policy implementation, notification of transfers to the Long-Term Care Ombudsman, accuracy of assessments including immunization status, registered nurse staffing requirements, and payroll-based journal staffing data submission. Plans of correction were provided for vaccination status deficiencies.
Severity Breakdown
Level B: 3
Level D: 2
Level F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to utilize a grievance form to address missing resident items for 1 of 2 residents sampled (Resident #40). | Level B |
| Facility failed to inform the Long-Term Care Ombudsman office of a resident hospitalized for 2 of 2 residents reviewed (Resident #4 and Resident #46). | Level B |
| Facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the health status of 1 of 5 residents reviewed for pneumococcal immunizations (Resident #31). | Level B |
| Facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day as required by Federal Regulations. | Level F |
| Facility failed to submit accurate staffing reports for the Payroll Based Journal (PBJ) Staffing Data Report for the quarter of July 1, 2024 to September 30, 2024. | Level D |
| Facility failed to develop policies and procedures to ensure influenza immunizations were offered and documented for residents and their representatives. | Level D |
Report Facts
Resident census: 44
Deficiencies cited: 6
RN coverage gaps: 5
Dates of RN coverage gaps: 7/6/24, 7/7/24, 8/4/24, 8/17/24, 8/18/24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Assistant Director of Nursing (ADON)/Admission Nurse | Acknowledged failure to submit required notification to LTC Ombudsman and responsible for sending notifications |
| Staff B | Licensed Practical Nurse (LPN) | Recalled Resident #40 missing a black hooded sweatshirt |
| Administrator | Reported on grievance policy implementation, RN coverage gaps, and staffing data submission | |
| MDS Coordinator | Explained immunization record review and coding of MDS assessment | |
| DON | Director of Nursing | Will perform audits on vaccination status and MDS accuracy |
| Assistant Director of Nursing (ADON) | Acknowledged responsibility for LTC Ombudsman notifications |
Inspection Report
Plan of Correction
Deficiencies: 0
May 1, 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 found to be in substantial compliance based on the accepted Plan of Correction, leading to certification effective May 1, 2024.
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 3
Apr 18, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from April 15, 2024 to April 18, 2024.
Findings
The facility was found deficient in several areas including failure to provide proper bed hold policy notification for a resident transferred to hospital, failure to follow a physician's order for tube feeding flush frequency, and failure to provide 8 consecutive hours of RN coverage daily. Corrective actions and audits were planned to address these deficiencies.
Deficiencies (3)
| Description |
|---|
| Failed to provide the bed hold policy for 1 of 2 residents reviewed (Resident #39) transferred to hospital without proper notification to resident's representative. |
| Failed to follow physician's order for tube feeding flush every 2 hours; machine was running flush every hour instead. |
| Failed to provide 8 consecutive hours of Registered Nurse coverage daily for 8 days in a 24-hour period. |
Report Facts
Census: 51
Residents reviewed: 2
Resident ID: 39
Deficiency count: 3
RN coverage days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Stated no bed hold for Resident #39 and acknowledged pump calibration issues |
| Director of Nursing | DON | Stated pump recalibration and audit plans for feeding pump and RN coverage |
| Staff A | Registered Nurse | Acknowledged pump flush rate error and provided punch detail for shifts |
Inspection Report
Follow-Up
Deficiencies: 0
Nov 9, 2023
Visit Reason
An on-site revisit of the complaint survey ending September 28, 2023 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective October 20, 2023. The Denial of Payment for New Admits (DPNA) was not effectuated.
Complaint Details
This visit was a follow-up to a complaint survey ending September 28, 2023. All deficiencies were corrected and substantial compliance was achieved.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Sep 21, 2023
Visit Reason
The inspection was conducted as an investigation of Complaints #114596-C, #112729-A and Facility Self-Reported Incidents #114116-I and #112697-M between 9/21/23 and 9/28/23.
Findings
The facility failed to implement safety measures and interventions to protect residents on the Chronic Confusion and Dementing Illness (CCDI) Unit from resident physical abuse, specifically involving Resident #3 assaulting other residents and staff. Additionally, the facility failed to ensure Resident #1 remained free from misappropriation of medication. The Facility Self-Reported Incident #114116-I was substantiated.
Complaint Details
The Facility Self-Reported Incident #114116-I was substantiated. Findings for facility reported incident #112697-M and Complaint #112729-A will be sent separately. The investigation revealed Resident #3 physically assaulted other residents and staff, causing injuries and requiring emergency room visits. The facility failed to implement adequate safety measures and supervision. Resident #1 experienced misappropriation of Tramadol medication by staff.
Severity Breakdown
SS=G: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to protect residents from abuse and neglect, including physical abuse by Resident #3 on other residents and staff. | SS=G |
| Failure to ensure Resident #1 remained free from misappropriation/exploitation of medication. | SS=D |
Report Facts
Resident census on CCDI unit: 19
Total facility census: 51
MDS BIMS score: 4
MDS BIMS score: 3
Bruise size: 8
Medication unaccounted: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) | Documented progress notes witnessing Resident #3 striking Resident #2 and responding to resident altercations. |
| Staff F | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #3's aggressive behavior and physical assault on staff. |
| Staff G | Licensed Practical Nurse (LPN) | Documented progress notes and interviewed about Resident #7's injuries and behavior. |
| Staff H | Certified Nursing Assistant (CNA) | Reported witnessing Resident #3 in Resident #7's room and described events leading to injuries. |
| Staff A | Licensed Practical Nurse (LPN) | Involved in medication administration and investigation of missing Tramadol medication for Resident #1. |
| Staff B | Licensed Practical Nurse (LPN) | Admitted verbally ordering medication refill and stealing Tramadol medication for Resident #1. |
| Director of Nursing (DON) | Director of Nursing | Investigated peer complaint of Resident #7 being struck and involved in medication reconciliation and policy review. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Reviewed progress notes and discussed supervision decisions for Resident #3. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 10, 2023
Visit Reason
The document reflects acceptance of the facility's credible allegation of compliance and plan of correction to certify the facility in compliance.
Findings
The facility was found to be in compliance based on the accepted plan of correction and credible allegation of compliance effective March 10, 2023.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 3
Feb 13, 2023
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of Complaint #100477-C from February 13, 2023 to February 16, 2023.
Findings
The facility failed to complete timely Quarterly Minimum Data Set (MDS) Assessments for 11 of 20 residents reviewed and failed to update an individual Care Plan for 1 of 8 residents reviewed. Additionally, the facility did not ensure staff were trained and on duty for Cardiopulmonary Resuscitation (CPR) as required.
Complaint Details
The visit was triggered by Complaint #100477-C. The complaint investigation found overdue MDS assessments and care plan deficiencies. The complaint was substantiated as evidenced by the findings.
Deficiencies (3)
| Description |
|---|
| Facility failed to complete Quarterly Minimum Data Set (MDS) Assessments in a timely manner for 11 residents. |
| Facility failed to update an individual Care Plan for 1 of 8 residents reviewed. |
| Facility failed to ensure staff trained in Cardiopulmonary Resuscitation (CPR) were on duty at all times. |
Report Facts
Residents with overdue MDS assessments: 11
Residents reviewed for Care Plan update: 8
Facility census: 47
Dates of overdue MDS assessments: Specific due dates listed for 11 residents
Dates of CPR training deficiency: 5
Residents requesting CPR initiation: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Relayed resident no longer received Hospice Services |
| Administrator | Stated facility did not have MDS or Care Plan policies and discussed CPR certification expectations | |
| Assistant Director of Nursing (ADON)/MDS Coordinator | Reported assessment and submission of MDS fell behind and care plan update issues | |
| Licensed staff member AH | Licensed staff member | Took BLS class and received certification on 2-17-2023 |
Inspection Report
Renewal
Census: 48
Deficiencies: 3
Sep 1, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification Survey and Investigation of a facility reported incident to assess compliance with Medicare Requirements for Long Term Care Facilities.
Findings
The facility was found to be not in compliance with deficiencies related to resident rights, advance directives, and accident hazards/supervision. Education and corrective actions were implemented by the Administrator and Assistant Director of Nursing, with compliance dates noted.
Complaint Details
Facility Reported Incident #94418-I was reviewed and substantiated.
Deficiencies (3)
| Description |
|---|
| Failure to ensure a dignified dining experience with proper assistance and seating arrangements for residents during meals. |
| Failure to consistently document Do Not Resuscitate (DNR) status in clinical records and face sheets for residents. |
| Failure to provide adequate supervision and assistance devices to prevent accidents, specifically related to elopement risks in the memory care unit. |
Report Facts
Total residents: 48
Survey dates: 8/29/2021 to 9/1/2021
Resident scored on mental status exam: 14
Elopement drills completed: 8
Residents in memory care unit lacking supervision: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Roth | Administrator | Provided education to staff and conducted audits related to feeding and resident rights |
| Assistant Director of Nursing | Assisted in education, audits, and removal of code status from face sheets | |
| Staff E | Certified Nursing Assistant (CNA) | Observed assisting residents during meals and noted for not sitting next to residents |
| Staff A | Registered Nurse (RN) | Explained charting of DNR orders and code status |
| Staff F | Certified Medication Aide (CMA) | Reported on repairman visits and alarm disarming in memory care unit |
| Staff G | Certified Nursing Assistant (CNA) | Reported on resident supervision and alarm monitoring in memory care unit |
| Staff H | Physical Therapy Assistant | Reported on resident walking and returning to facility |
| Business Office Manager | Reported repairman visits and alarm system status |
Inspection Report
Abbreviated Survey
Census: 30
Deficiencies: 0
Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections 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: 30
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