Walnut Ridge

Based on observations, staff interview, and policy review, the facility failed to ensure appropriate kitchen sanitation practices were followed (hand hygiene, cleanliness, and equipment sanitizing). The facility reported a census of 32. Findings include: 1. During the initial Care Center kitchen observation on 7/7/25 at 10:15 AM, the floor drain located near the beverage table was noted with a black, sludge-like build up all around. The floor underneath the beverage table, especially where the floor meets the wall, a moderate amount of debris and small trash items were noted. This included whole food items and chemical spray bottle. 2. During the initial Care Center kitchen observation on 7/7/25, the dish machine was not currently in use but had been used earlier. July ' s dish machine temperature log reviewed and several missing entries noted, including a temperature for the current day. During the initial Main kitchen observation on 7/7/25 at 10:30 AM, July ' s dish machine temperature log reviewed. The log had only 2 temperatures recorded for the month thus far.Review of the Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Resident #25Bladder and Bowel Incontinence Based on clinical record review, observations, staff interview and facility policy review, the facility failed to reposition/toilet a resident per her Care Plan for one of twelve residents reviewed. The facility reported a census of 32 residents. Findings include:The Quarterly Minimum Data Set (MDS) of Resident #25 dated 5/8/25 recorded a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS documented the resident was dependent on staff for toilet transfer and toilet hygiene. The MDS coded the resident to require substantial/maximal assistance for bed mobility. The MDS coded the resident to be frequently incontinent of both bowel and bladder. The Care Plan of Resident #25 identified a Focus Area of Risk of Impaired Skin Integrity, initiated 2/5/25. The Care Plan directed staff to provide assistance for repositioning and toileting upon rise, before and after meals, before bedtime and to use a bedpan on the overnight shift. The Care Plan identified an additional Focus Area of Resident #25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observation, staff interview and review of the facility Medication Administration Procedure, the facility failed to prime an insulin flexpen prior to administering the insulin dose to ensure the proper amount of insulin administered for one of one residents observed who received insulin during medication pass (Resident #88). The facility reported a census of 32 residents. Findings include: The Electronic Health Record (EHR) Medical Diagnosis list revealed Resident #88 had a diagnoses of Type 2 Diabetes Mellitus. The Order Summary for Resident #88 dated 7/8/25 included a physician's order for Glargine (insulin) 4 units subcutaneously (SQ) every morning for diabetes started on 7/8/25. The Medication Administration Record (MAR) dated 7/1/25 - 7/31/25 revealed an order for Glargine insulin 4 units SQ. The MAR revealed Staff D, Registered Nurse (RN), documented Glargine insulin 4 units SQ administered on 7/8/25 AM. During observation on 7/8/25 at 8:34 AM, Staff D, RN, reported Resident #88's blood sugar was 168. Staff D checked the medication order on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interview, and policy review, the facility failed to ensure appropriate serving sizes for residents on an altered textured diet for 3 for 4 residents observed during lunch service. The facility reported a census of 32. Findings include: The lunch menu on 7/8/25 for the Soft and Bite Sized diet (SB6) consisted of Minced and Moist (MM5) beef (#6 scoop), orzo pasta (1/2c), fork-mash able California vegetables (1/2c), and ripe bananas cut into <1/2 pieces. The alternative hot entree was scrambled eggs (#8 scoop) along with a serving of puree bread. Puree Clam Chowder (#6 scoop) was the soup of the day. Puree cookies were offered for dessert. A total of 2 residents prescribed a SB6 diet. The lunch menu on 7/8/25 for the Easy-to-Chew diet (EC7) consisted of MM5 beef (#6 scoop), buttered pasta (1/2c), fork-mash able California vegetables, and a soft/ripe banana. Assorted cookies (2) were offered for dessert. A total of 2 residents prescribed a EC7 diet. During an observation on 7/8/25 at 11:30 AM, Staff E, Cook, obtained clean equipment and placed several…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, the 2022 Food and Drug Administration (FDA) Food Code, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food and failed to follow guidelines for checking the sanitizer parts per million (ppm) for 2 of 2 meals observed. The facility reported a census of 35 residents. Findings include: 1. On 8/5/24 at 10:36 AM, Dietary Manager (DM), during initial walk through, the following was observed: In the Refrigerator #4, the following items did not have open date label: Prune juice, gallon of skim milk, gallon of 2% milk. A clear container with red lid had light red creamy liquid contents did not have a label for identification or date. The following items were not fully covered, cottage cheese and coleslaw. In the Refrigerator #3, the following item were not fully covered or dated, American cheese. In the Freezer, the following items were not covered, has brown and loaf of gluten bread. 2. On 8/07/24 12:25 PM DM revealed they have not been checking the sanitizer concentration for ppm. The staff member…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and facility policy review, the facility failed to clarify the Doctor's order resulting in the medication error for 1 of 7 residents reviewed for medication administration (Resident #22). The facility reported a census of 35 residents. Findings include: On 8/7/24 at 8:30 AM Staff E, LPN reviewed the Electronic Medication Administration Record (EMAR) as she prepared the scheduled AM medication, including Senna S 50mg-8.6mg two tablets. The staff member placed the tablets in the medication cup looked over the tablets, reviewed the EMAR, then administered the tablets to the resident, including Senna S 50mg-8.6mg two tablets. The staff reviewed the EMAR and signed the administered medication, Senna S 50mg-8.6mg two tablets was administered. The EMAR dated 8/7/24 revealed Senna 8.6mg give two tablet by mouth two times a day for constipation, order date 1/25/23. On 8/7/24 at 2:40 PM Staff C, RN removed medication card from medication cart, verified the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, record reviews, and policy review, the facility failed to implement the Infection Prevention and Control Program (IPCP) by staff not discarding Personal Protective Equipment (PPE) immediately after use. The facility reported a census of 35 residents. Findings include: On 8/07/24 at 9:30 AM, two (2) Person Protective Equipment (PPE) gowns were observed hanging on a hook rack in a resident's room with Enhanced Barrier Precautions in place. At 9:31 AM, Staff A, Certified Nurse Aide (CNA) stated the PPE gowns were required due to the resident's sacral wound. She stated the gowns were hung on the hook rack so they would be closer to the door. She stated when staff were finished using the PPE gowns, they hung them back up or got new one. She stated there was no way to know who used which gown but identified the gown on the right hook was the one she used. At 9:41 AM, Staff B, Health Information Manager (Medical Records) provided the PPE gown product number which indicated the manufacturer identified the PPE gowns as single-use gowns. At 1:22 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, document review, and staff interviews, the facility failed to provide appropriate infection prevention practices for disinfecting the reusable medical equipment. The facility reported a census of 32 residents. Findings include: During an interview with Staff C, Certified Nursing Assistant (CNA) on 1/17/24 at 9:00 AM, it was reported the facility sanitized transfer lifts that are used between residents with Clorox wipes at the end of each day, including if a resident was on Transmission-Based Precautions (TBP). During an interview with Staff A, Registered Nurse (RN) on 1/17/24 at 10:00 AM, showed where the disinfecting wipes are stored in the facility and pointed at the shelf with boxes of Clorox wipes. During an interview with the facility's Infection Preventionist on 1/17/24 at 10:00 AM, she acknowledged the facility did not use EPA-registered disinfectant for healthcare settings on reusable medical equipment. Facility provided policy titled Infection Control undated, documented equipment or items in the resident environment likely to have been contaminated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility investigation file review, resident, family, and staff interviews, and policy review, the facility failed to report an allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing (DIAL) timely for 1 of 1 residents reviewed for abuse (Resident #26). The facility reported a census of 32 residents. Findings include: A facility self-report to DIAL on 10/9/23 at 9:38 AM revealed an allegation of abuse occurred 10/7/23 at approximately 2:30 PM. Resident #26 expressed anxiety and concerns about an interaction with a specific staff member. Staff member placed on administrative leave on 10/9/23 during the investigation. The Minimum Data Set (MDS) assessment form dated 9/5/23 revealed Resident #26 had diagnoses of vertebral fracture and osteoporosis. The resident admitted to the facility 8/30/23. The assessment revealed the resident required extensive assistance of one person for ambulation, transfers, dressing, and toileting. The MDS documented the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review, the facility failed to refer one of two residents who had a change in mental health diagnoses and psychotropic medications to the appropriate state-designated authority for a Preadmission Screening and Resident Review (PASRR) re-evaluation and determination (Resident #5). The facility reported a census of 32 residents. Findings include: The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. The MDS revealed resident had no serious mental illness and had not met criteria for a Level II Preadmission Screening and Resident Review (PASRR). The resident had no physical or verbal behaviors. The MDS assessment recorded the resident took antipsychotic (AP), antianxiety (AA), and antidepressant (AD) medications, and had no psychological therapy during the look-back period. The Care Plan revised 6/13/23 revealed the resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, and staff interviews the facility failed to follow the menu and provide the residents with the correct diet of a soft and bite sized diet as ordered by the physician for 2 of 32 residents reviewed (Resident # 13, and Resident #14) . The facility reported a census of 32 residents. Findings include: 1.The Minimum Data Set (MDS) assessment for Resident #13 dated 11/15/23, included diagnoses of Non-Alzheimer's Dementia and heart failure. The MDS documented the resident on a mechanically altered diet (require change in texture of food or liquids). The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. On 1/17/24 during lunch service starting at 11:45 AM, Staff C, [NAME] placed 2 deep-fried chicken tenders and ranch dressing in the food processor and processed to a ground meat texture, which was then served to Resident #13, along with pureed oranges, and soft small cut green beans. Resident #13's clinical Physician Order Summary report documented an order for a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review, and staff interview, staff failed to serve food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness. The facility reported a census of 32 residents. Findings include: On 1/17/24, during a continuous observation in the dining room starting at 11:45 AM, the Dietary Manager (DM) served a resident's plate, applied a clothing protector to the resident touching the resident's clothing and hair, and cut up food for the resident. The DM did not complete hand hygiene and proceeded to pass another resident's plate, touch the resident's drinking glasses, applied the resident's clothing protector, touching the resident's clothing and hair, and cut up the resident's food using the resident's silverware. Without completing any hand hygiene between residents, the DM continued to serve 3 more residents, touching their plates, cups and glasses, applying each resident's clothing protector, touching each resident's clothing and hair and 1 resident's arm, and then cutting food for each resident using their silverware. The DM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interviews, the facility failed to provide adequate supervision for 1 of 4 residents reviewed who were at risk for falls. (Resident #2) The facility reported census was 28. Findings include: According to a Minimum Data Set (MDS) with an assessment reference date of 3/13/23, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 8 indicating a moderately impaired cognitive status. Resident #2 required extensive assistance with transfers, mobility, dressing, toilet use, and personal hygiene needs. Resident #2's diagnoses included congestive heart failure. In an interview on 9/12/23 at 9:16 a.m. Staff A, certified nurse aide, stated on the morning of 5/20/23, she was getting Resident #2 up for a shower. Staff A stated she placed a gait belt on Resident #2 and ambulated to the bathroom using her wheel walker. Staff A stated Resident #2 was upright with her walker when she turned and grabbed the shower chair and placed it over the toilet. Staff A stated she then turned and grabbed the gait belt as she was positioned in front and to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.