Inspection Reports for Winslow House Care Center
3456 Indian Creek Road, IA, 523021119
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 2, 2025, found the facility in substantial compliance with no deficiencies cited. Prior inspections showed a pattern of deficiencies related mainly to resident care, including issues with activities of daily living (ADL) assistance, infection prevention and control, medication administration, and documentation accuracy. Several complaint investigations were conducted, with some substantiated cases involving resident safety and care concerns, including a notable immediate jeopardy situation in April 2023 that was resolved through corrective actions. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, particularly evident in the most recent clean inspection following earlier citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
48 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 2, 2025
Visit Reason
The document is a plan of correction submitted following a survey ending September 25, 2025, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective November 25, 2025.
Findings
No specific deficiencies are detailed in this document; it confirms acceptance of the plan of correction and certification of compliance.
Report Facts
Survey end date: Sep 25, 2025
Certification effective date: Nov 25, 2025
Inspection Report
Renewal
Census: 48
Deficiencies: 5
Sep 25, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #1767812-C and #2587463-C from September 22, 2025 through September 25, 2025.
Findings
The facility was found to have multiple deficiencies related to resident rights, accuracy of assessments, coordination of PASARR and assessments, ADL care, nurse staffing information posting, and infection prevention and control. The facility failed to maintain accurate documentation, provide adequate care in several areas, and comply with infection control protocols. Corrective actions and systemic changes were planned or implemented to address these deficiencies.
Severity Breakdown
D: 3
C: 1
E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to maintain code status records for residents and provide advance directive information as required. | D |
| Failure to accurately code and coordinate PASARR Level II assessments and resident diagnoses. | D |
| Failure to provide adequate ADL care, including bathing and grooming, for dependent residents. | D |
| Failure to post accurate nurse staffing information daily and maintain required staffing data. | C |
| Failure to establish and maintain an effective infection prevention and control program, including proper use of Enhanced Barrier Precautions (EBP) and PPE. | E |
Report Facts
Resident census: 48
Deficiencies cited: 5
Brief Interview for Mental Status (BIMS) score: 14
Brief Interview for Mental Status (BIMS) score: 11
Brief Interview for Mental Status (BIMS) score: 2
Brief Interview for Mental Status (BIMS) score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Practical Nurse | Named in findings related to failure to locate code status documentation for Resident #21 |
| Staff F | Certified Nurses Aide | Interviewed regarding bathing refusals and hygiene care for Resident #28 |
| Staff G | Certified Nurses Aide | Interviewed regarding bathing refusals and hygiene care for Resident #28 |
| Staff D | Registered Nurse | Interviewed regarding nurse staffing posting records |
| Staff E | Registered Nurse | Interviewed regarding nurse staffing posting records |
| Staff K | Certified Nurse Aide | Reported on Enhanced Barrier Precautions (EBP) sign on Resident #3's door |
| Staff A | Certified Nurse Aide | Observed providing care to Resident #3 and failure to use EBP |
| Staff B | Certified Nurse Aide | Observed providing care to Resident #3 and failure to use EBP |
| Staff C | Certified Nurse Aide | Observed providing care to Resident #32 and failure to wear gown or gloves |
| Staff F | Certified Nurse Aide | Interviewed about bathing refusals and hygiene care |
| Staff L | Laundry Staff | Reported failure to wear apron and gown when handling laundry |
| Staff J | Environmental Supervisor | Reported failure to use PPE when handling laundry and contamination concerns |
| Staff J | Registered Nurse | Reported staff needed to use EBP for residents with wounds |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings related to code status, PASARR, bathing schedules, nurse staffing, and infection control |
| Administrator | Administrator | Provided statements and documents related to code status and bathing policies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 23, 2025
Visit Reason
Investigation of complaint #128275-C conducted on 6/23/2025.
Findings
Complaint #128275-C was not substantiated, and the facility was in substantial compliance at the time of the survey.
Complaint Details
Complaint #128275-C was investigated and found not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 23, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance by the facility.
Findings
The facility was found to be in substantial compliance and will be certified effective April 17, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 5
Apr 1, 2025
Visit Reason
The inspection was conducted as part of an investigation of a facility-reported incident and complaint #126961-C related to medication administration and controlled substances management.
Findings
The facility failed to ensure accurate inventory and documentation of controlled medications for four residents, with multiple instances of incomplete medication administration records and discrepancies in narcotic counts. The complaint was not substantiated, but the facility was found deficient in maintaining proper controlled substance records and administration procedures.
Complaint Details
Facility reported incident #126193-I was substantiated. Complaint #126961-C was not substantiated.
Deficiencies (5)
| Description |
|---|
| Failure to ensure an accurate inventory of medications by accounting for controlled medications received, dispensed, and administered for four residents. |
| Failure to provide complete Controlled Substance Shift Count and Usage Records for multiple medications. |
| Incomplete documentation of medication administration on residents' MARs. |
| Failure to sign out narcotics at the time of administration by nursing staff. |
| Failure to maintain possession and control of medication cart keys according to policy. |
Report Facts
Residents reviewed: 4
Facility census: 44
Medication delivery counts: 473
Medication delivery counts: 90
Medication delivery counts: 100
Medication delivery counts: 73
Medication delivery counts: 473
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Director of Nursing | Reported working at the facility for one year and involved in investigation and education regarding medication administration and narcotic counts. |
| Staff E | Medication Aide | Identified medication cassette issue and reported concerns to Staff H and DON. |
| Staff A | Registered Nurse | Reported working at the facility for two years, involved in narcotic counts and medication administration. |
| Staff D | Registered Nurse | Verified initials on Controlled Substance Shift Count and Usage Records and involved in disciplinary actions related to documentation errors. |
| Staff C | Administrator | Interviewed regarding expectations for nurses to sign out narcotics at time of administration. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 16, 2024
Visit Reason
A complaint survey was conducted to investigate complaint #123619-C on 12/16/2024.
Findings
The complaint #123619-C was not substantiated following the investigation.
Complaint Details
Complaint #123619-C was investigated and found not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 24, 2024
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility will be certified in compliance effective September 19, 2024, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 2
Aug 29, 2024
Visit Reason
The inspection was conducted as an annual recertification survey of Winslow House Care Center from August 26, 2024 to August 29, 2024.
Findings
The facility failed to ensure comprehensive care plans were reviewed and revised timely for 2 of 12 residents, and failed to meet professional standards of medication administration for 1 resident requiring gastric tube medications. Deficiencies were related to care plan content and medication administration practices.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Care plans were not reviewed and revised in a timely manner for 2 of 12 residents, lacking goals, triggers, and interventions related to diagnoses such as schizophrenia and hearing impairment. | SS=D |
| The facility failed to meet professional standards of medication administration for 1 resident with gastric tube medications, including late medication administration, crushing extended release tablets, and failure to follow Enhanced Barrier Precautions. | SS=D |
Report Facts
Census: 46
Residents reviewed: 12
Residents with care plan deficiencies: 2
Resident with medication deficiency: 1
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Aug 9, 2024
Visit Reason
Investigation of a facility self-reported incident #122492-I and a facility complaint #122416-C conducted from August 8, 2024 through August 9, 2024.
Findings
No deficiencies resulted from the investigation of the self-reported incident and complaint.
Complaint Details
Investigation of a facility self-reported incident #122492-I and a facility complaint #122416-C; no deficiencies found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 16, 2024
Visit Reason
A complaint investigation for complaint #121219-C and facility reported incident #120937-I was conducted from July 16, 2024 to July 17, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for complaint #121219-C and facility reported incident #120937-I.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 3, 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, resulting in certification effective April 3, 2024.
Inspection Report
Re-Inspection
Census: 46
Deficiencies: 2
Mar 28, 2024
Visit Reason
This visit was a revisit related to the annual survey conducted March 4-7, 2024, with the revisit conducted March 26-28, 2024, to verify correction of previously cited deficiencies.
Findings
The facility failed to treat residents with dignity during meal assistance and failed to administer medications within the scheduled timeframe for 3 residents. The facility re-educated staff on resident rights, feeding assistance, and medication administration policies and implemented monitoring and auditing procedures.
Deficiencies (2)
| Description |
|---|
| Failure to treat residents with dignity while providing meal assistance to Residents #21 and #27. |
| Failure to administer medications within the scheduled timeframe for Residents #10, #39, and #41. |
Report Facts
Census: 46
Medication administration audit: 27
Medication administration audit: 12
Medication administration audit: 53
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 3
Mar 7, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of a facility-reported incident #116083-I.
Findings
The facility was found to have deficiencies related to resident rights and dignity during meals, medication administration outside scheduled times, and failure to ensure wheelchair safety devices were used, resulting in resident injury. Several residents were observed not being treated with dignity and respect, and medication administration times were not consistently met.
Complaint Details
The facility reported incident #116083-I was substantiated.
Deficiencies (3)
| Description |
|---|
| Facility failed to treat residents with dignity during meals, specifically Residents #21 and #42. |
| Facility failed to administer medications within scheduled time frames for Resident #10. |
| Facility failed to ensure wheelchair foot pedals were in place, resulting in injury to Resident #200. |
Report Facts
Residents reviewed for dignity during meals: 3
Medication administration late occurrences: 15
Resident census: 45
Residents involved in wheelchair incident: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant (CNA) | Observed feeding Resident #42 and noted scraping food from resident's face and clothing without using a napkin. |
| Staff B | Registered Nurse (RN) | Interviewed regarding Resident #10's medication schedule and sleep patterns. |
| Staff A | Registered Nurse (RN) | Interviewed regarding Resident #10's late medication administration. |
| Staff E | Certified Nursing Assistant (CNA) | Involved in incident pushing Resident #200 in wheelchair without foot pedals, resulting in injury and subsequent disciplinary action. |
| Director of Nursing | Director of Nursing (DON) | Interviewed about feeding assistance training and medication administration policies. |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 8, 2023
Visit Reason
An on-site revisit of the complaint survey ending April 24, 2023 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective April 25, 2023. The Denial of Payment for New Admits (DPNA) was not effectuated.
Complaint Details
This visit was a follow-up to a complaint survey. The deficiencies identified in the complaint survey were corrected, and the facility achieved substantial compliance.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 3
Apr 24, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaint #112257-C and Facility Self-Reported Incident #112308-I were conducted due to allegations of resident-to-resident abuse and safety concerns.
Findings
The facility failed to ensure adequate supervision and protection of residents, resulting in Resident #2 attempting to suffocate Resident #1 with a pillow and blanket. The facility had a history of resident-to-resident altercations involving Resident #2 and failed to evaluate the effectiveness of interventions. Immediate Jeopardy was identified but removed after corrective actions including 1:1 supervision and care plan updates.
Complaint Details
Complaint #112257-C was substantiated. Facility Self-Reported Incident #112308-I was substantiated. Immediate Jeopardy began on April 10, 2023 and was removed on April 19, 2023 after corrective actions were implemented.
Severity Breakdown
Immediate Jeopardy: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to prevent resident-to-resident abuse when Resident #2 attempted to suffocate Resident #1 with a pillow and blanket. | Immediate Jeopardy |
| Failed to evaluate effectiveness of interventions implemented to prevent harm from resident-to-resident altercations. | Immediate Jeopardy |
| Failed to provide adequate supervision to prevent accidents and abuse. | Immediate Jeopardy |
Report Facts
Resident census: 45
BIMS score: 3
BIMS score: 2
Medication dosage: 50
Date of incident: Apr 10, 2023
Date Immediate Jeopardy began: Apr 10, 2023
Date Immediate Jeopardy removed: Apr 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Witnessed and intervened in resident-to-resident abuse incident on 4/10/23 |
| Staff B | Certified Nursing Assistant | Witnessed Resident #2 pushing pillow onto Resident #1's face and called nurse |
| Staff C | Registered Nurse | Provided information on Resident #2's behaviors and interventions |
| Staff D | Certified Nursing Assistant | Reported awareness of Resident #2's aggressive behaviors and supervision attempts |
| Administrator | Administrator | Acknowledged incidents and interventions; signed initial comments |
| Director of Nursing | Director of Nursing | Discussed medication management and supervision related to Resident #2 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 28, 2023
Visit Reason
A complaint investigation for complaints #110902-C and #110371-C was conducted on February 27 and 28, 2023. Additionally, a COVID-19 Focused Infection Control Survey was conducted during the same period.
Findings
The facility was found to be in substantial compliance with no deficiencies cited. The COVID-19 survey found the facility in compliance with CMS and CDC recommended practices.
Complaint Details
Complaint investigation for complaints #110902-C and #110371-C was conducted and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 4, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and the submitted plan of correction effective January 4, 2023.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 4
Dec 12, 2022
Visit Reason
Investigation of Complaints #107505-C, #108675-C, #109363-C and Facility Self-Reported Incidents #108026-I, #109192-I, #109471-I, #108077-M conducted from November 28, 2022 to December 12, 2022.
Findings
The facility failed to provide adequate ADL care including bathing for dependent residents, failed to provide accurate and timely wound care assessment and interventions, failed to ensure residents were safe by preventing falls and responding timely to call lights, and failed to follow infection control guidelines during wound care and resident assistance.
Complaint Details
Complaints #108675-C and #109363-C were substantiated. Complaint #107505-C was not substantiated. Facility Self-Reported Incident #109192-I was substantiated. Facility Self-Reported Incidents #108026-I and #109471-I were not substantiated.
Severity Breakdown
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide showers twice a week for 3 out of 3 residents reviewed with no refusals documented. | — |
| Failed to provide accurate and timely assessment and interventions for wounds for Resident #7, including improper wound measurement and lack of wound record documentation. | SS=D |
| Failed to ensure residents were safe by failing to prevent falls and respond timely to call lights for Residents #7 and #8. | SS=D |
| Failed to follow infection control guidelines for Resident #7 during wound care and assistance, including lack of hand hygiene and glove use. | SS=D |
Report Facts
Residents reviewed for bathing deficiency: 3
Census: 44
BIMS score: 13
Wound measurement: 10
Wound measurement: 3
Call light response time: 21
Call light wait time: 420
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Observed assisting Resident #7 off toilet without gloves and delayed call light response. |
| Staff D | Registered Nurse | Observed providing wound care for Resident #7 without changing gloves or performing hand hygiene. |
| Staff C | Certified Nurse Aide | Observed assisting Resident #8 and noted lack of dycem on wheelchair. |
| Administrator | Facility Administrator | Acknowledged issues with call light response and infection control; provided education plans. |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 2, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and ensure compliance.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective September 2, 2022.
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 4
Aug 11, 2022
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey and included investigation of multiple complaints.
Findings
The facility was found deficient in documenting review of Skilled Nursing Facility of Beneficiary Notice of Non-Coverage for two residents, failure to meet professional standards in applying tubigrips and insulin pen priming for two residents, failure to maintain a safe environment preventing a fall due to cluttered hallways, and failure to label insulin pens with opening dates.
Complaint Details
Complaints #99028-C and #100864-C were substantiated as part of this inspection.
Severity Breakdown
SS=B: 1
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to document review of Skilled Nursing Facility of Beneficiary Notice of Non-Coverage for two residents. | SS=B |
| Failed to apply tubigrips as ordered and failed to prime insulin pen prior to administration. | SS=D |
| Failed to provide a safe environment and prevent a fall due to cluttered hallways with wheelchairs and equipment. | SS=D |
| Failed to document dates on insulin pens when opened for three residents. | SS=D |
Report Facts
Resident census: 43
Deficiencies cited: 4
BIMS scores: 9
BIMS scores: 15
BIMS scores: 14
BIMS scores: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sadie Maurer | Administrator | Signed the inspection report and plan of correction |
| Staff J | Administrative Assistant | Reported procedures for Notice of Non-Coverage and documentation issues |
| Staff A | Registered Nurse | Observed failing to prime insulin pen prior to administration |
| Staff E | Licensed Practical Nurse | Witnessed resident fall and reported insulin pen priming procedures |
| Staff F | Licensed Practical Nurse | Reported details about resident fall and insulin pen priming |
| Staff N | Certified Nursing Assistant | Reported tubigrips application procedures |
| Staff G | Certified Nursing Assistant | Observed not applying tubigrips to resident |
| Staff C | Nurse Consultant/Interim Infection Preventionist | Reported on resident fall and equipment storage |
| Staff B | Certified Nursing Assistant | Reported on hallway equipment clutter |
| Staff H | Certified Nursing Assistant | Reported no storage rooms for equipment |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 3
May 27, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and Investigation of Complaint #96978 completed 5/24-27/2021. The complaint was substantiated.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, failed to hold quarterly Quality Assessment and Assurance (QAA) Committee meetings with required attendance, and failed to establish and maintain an effective infection prevention and control program including proper hand hygiene and laundry handling. Multiple observations and interviews revealed deficiencies in care and infection control practices.
Complaint Details
Complaint #96978 was investigated from 5/24-27/2021 and was substantiated as per the report.
Deficiencies (3)
| Description |
|---|
| Failure to develop and implement a comprehensive person-centered care plan for a resident, including fall prevention interventions. |
| Failure to hold quarterly Quality Assessment and Assurance (QAA) Committee meetings with minimum required members in attendance. |
| Failure to establish and maintain an infection prevention and control program, including failure to perform appropriate hand hygiene for residents during perineal care and failure to disinfect equipment and use PPE according to CDC guidelines. |
Report Facts
Census: 44
Date Survey Completed: May 27, 2021
Date of Compliance for F656: Jun 23, 2021
Date of Compliance for F868: Jun 22, 2021
Date of Compliance for F880: Jun 19, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bridget Martin | Signed the plan of correction documents on 6/18/2021 and 6/23/2021. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan and infection control deficiencies; responsible for monitoring compliance. |
| Medical Director | Medical Director | Attending QAPI meetings and responsible for timely attendance. |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Apr 27, 2021
Visit Reason
Investigation of facility self-reported incidents #94055 and #96713 and complaint #96384 from 4/1/2021 to 4/27/2021.
Findings
The incidents and complaint investigated were not substantiated according to the Code of Federal Regulations (42CFR) Part 483, Subpart B-C.
Complaint Details
Facility Self-Reported Incidents #94055 and #96713 and Complaint #96384 were investigated from 4/1/2021 - 4/27/2021 and not substantiated.
Report Facts
Total residents: 45
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 0
Oct 12, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey and the investigation of a Facility Self-Reported Incident and multiple Complaints was conducted from 10/5/20 through 10/12/20.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. The Self-Report and Complaints were not substantiated.
Complaint Details
The investigation included Complaints ##87565, #90795, #90896, #92894, #92896, #93421, and #93728 and the Self-Reported Incident #89759. None were substantiated.
Report Facts
Total residents: 39
Inspection Report
Abbreviated Survey
Census: 35
Deficiencies: 6
Sep 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 9/14-17/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation and infection control.
Findings
The facility failed to follow CDC recommendations and their own policies to provide a safe and sanitary environment to prevent transmission of COVID-19. Observations and interviews revealed multiple failures in PPE use, hand hygiene, and cleaning protocols, with 12 COVID-19 positive residents and 4 suspected residents identified.
Deficiencies (6)
| Description |
|---|
| Failure to establish and maintain an infection prevention and control program including surveillance, reporting, isolation procedures, and hand hygiene. |
| Failure to follow CDC recommendations and facility policies for PPE use, including donning and doffing procedures, and failure to cleanse PPE and face shields properly. |
| Failure to maintain isolation carts with bleach wipes and proper sanitizing supplies. |
| Staff failed to change PPE or cleanse face shields between resident contacts in COVID-19 positive and suspected areas. |
| Failure to properly clean medication bottles and equipment before use. |
| Failure to properly don and doff PPE gowns and masks as per facility policy. |
Report Facts
COVID-19 positive residents: 12
Suspected COVID-19 residents: 4
Total residents: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Practical Nurse (LPN) | Observed donning fresh PPE and handling blood sugar testing supplies |
| Staff F | Certified Nursing Aide (CNA) | Observed transferring resident and failing to change PPE or clean face shield |
| Staff I | Certified Nursing Aide (CNA) | Observed failing to change PPE or clean face shield between rooms |
| Staff A | Registered Nurse (RN) | Observed donning PPE improperly and failing to cleanse face shield |
| Staff D | Certified Nursing Aide (CNA) | Observed passing medications and following mask protocols |
| Staff C | Certified Nursing Aide (CNA) | Observed cleansing hands, putting on gloves and gown improperly |
| Staff B | Registered Nurse (RN) | Reported PPE gown and shield cleaning procedures and observed staff compliance |
| Staff G | Therapy Staff Person | Observed wearing mask and shield but no gown while working with COVID resident |
| Director of Nursing | Administrator | Reported COVID-19 positive and suspected residents and infection control practices |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Aug 13, 2020
Visit Reason
The inspection was conducted as an investigation of multiple complaints (#92549, #92561, #92581) and a facility self-reported incident (#92580) completed on 8/5-13/20.
Findings
The facility failed to provide adequate supervision to prevent the elopement of one resident, as evidenced by multiple staff interviews and review of care plans and incident reports. The investigation revealed that door alarms could not be heard in certain resident rooms, contributing to the incident.
Complaint Details
Complaints #92549, #92561, #92581 and Facility Self-Reported Incident #92580 were substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide adequate supervision and assistance devices to prevent accidents, resulting in elopement of a resident. | SS=D |
Report Facts
Census: 42
Complaints investigated: 4
Inspection Report
Routine
Census: 45
Deficiencies: 0
Jul 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals from 7/27/20 to 7/30/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 49
Deficiencies: 0
Jun 16, 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: 49
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