Ivy at Davenport

Based on observations, clinical record review, resident and staff interviews, the facility failed to assist 1 of 1 residents (Resident #59) to wash her hair in a preferred manner in an attempt to lessen the physical discomfort the task caused the resident. The facility reported a census of 59 residents.Findings include:The Minimum Data Set (MDS) for Resident #59 dated 02/02/2026 included diagnoses of other forms of scoliosis lumbar region, hypercalcemia (calcium too high), and need for assistance with personal care. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 14/15 which indicated intact cognition. The MDS indicated Resident #59 required partial/moderate assistance with shower/bathe self, and set up or clean up assistance with personal hygiene.Review of the electronic health record (EHR) Diagnosis List revealed a Need for Assistance with Personal Care added as an Additional Diagnosis on 12/23/25. The Care Plan for Resident #59 included a Focus area, dated 11/20/25, to address The Resident has an ADL (activities of daily living) self-care performance…

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, policy review, and staff interview, the facility failed to monitor resident weights per physician orders for 1 of 2 residents (Resident #65) reviewed for nutrition. The facility reported a census of 59 residents.Findings include: The Minimum Data Set(MDS) assessment tool for Resident #65, dated 3/10/26, list of diagnoses included malnutrition, weakness, and heart failure. The MDS listed the resident's Brief Interview for Mental Status Score (BIMS) score as 10 out of 15, indicating moderately impaired cognition. A 3/7/26 Daily Skilled note stated the resident admitted to the facility on [DATE], received tube feedings, and was nothing by mouth(NPO) status.On Order Summary Report listed a 3/6/26 order for daily weights x 3 days, weekly weights x 4 weeks followed by monthly weights. The March 2026 Treatment Administration Record (TAR) listed a 3/6/26 order for daily weights x 3 days, weekly weights x 4 weeks followed by monthly weights. The 3/6/26 and 3/9/26 entries for daily weights…

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 personnel file review, facility policy review, and staff interviews, the facility failed to ensure 2 of 3 Certified Nursing Assistants (CNAs) received performance evaluations every 12 months. The facility reported a census of 59 residents. Findings include: 1. An untitled employee profile report, dated 3/25/26, listed Staff S CNA's hire date as 7/11/23.The facility lacked documentation of a completed performance evaluation for Staff S in the last 12 months. 2. An untitled employee profile report, dated 3/25/26, listed Staff T CNA's hire date as 9/30/20.The facility lacked documentation of a completed performance evaluation for Staff T in the last 12 months. On 3/25/26 at 8:04 a.m., via phone, the Director of Clinical Services stated the facility should carry out yearly performance evaluations for CNA's.The facility policy Evaluation Process, revised 8/27/25, stated the facility would review the work performance of employees with a formal written evaluation. The policy did not specify how often the facility completed the evaluations.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure the medication error rate did not exceed 5% for 2 of 4 residents observed during medication administration (Residents #6 and #65). The facility's medication error rate calculated as 7.69%. The facility reported a census of 59 residents. Findings included: 1. The Minimum Data Set (MDS) assessment tool, dated 3/3/26, list of diagnoses for Resident #6 included diabetes (a disease which caused fluctuations in blood sugar), heart failure, and anxiety disorder. The MDS stated the resident received insulin (an injectable medication used to lower blood sugar) and listed the resident's Brief Interview for Mental Status (BIMS) score as 13 out of 15, indicating intact cognition. The March 2026 Medication Administration Record (MAR) listed an order for insulin glargine (a long-acting insulin with a brand name of Lantus) 30 units every 12 hours.On 3/18/26 at 8:15 a.m., Staff F, Licensed Practical Nurse (LPN) retrieved Resident #6's Lantus pen from the medication cart and stated she…

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, facility policy review, and staff interviews, the facility failed to ensure 2 of 8 residents (Residents #6 and #39) reviewed for medications were free of a significant medication error The State Agency intervened prior to a nurse giving Resident #6 the incorrect dose of insulin; and Resident #39 missed a dose of an intravenous antibiotic. The facility reported a census of 59 residents.Findings include:1. The Minimum Data Set (MDS) assessment tool, dated 3/3/26, list diagnoses for Resident #6 included diabetes (a disease which caused fluctuations in blood sugar), heart failure, and anxiety disorder. The MDS stated the resident received insulin (an injectable medication used to lower blood sugar) and listed the resident's Brief Interview for Mental Status (BIMS) score as 13 out of 15, which indicated intact cognition. The March 2026 Medication Administration Record (MAR) listed an order for insulin glargine (a long-acting insulin with a brand name of Lantus) 30 units…

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 interview and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies on the current survey which had been previously identified in 2025. The facility reported a census of 59 residents.Findings include:Review of the CMS 2567 form dated 3/6/25 revealed, in part, deficiencies had been identified with notification of changes, care planning, assistance with activities of daily living, accidents and hazards, and kitchen sanitation.Concerns with the above areas were identified during the facility's current recertification and complaint survey completed 3/25/26.Review of the CMS 2567 form dated 7/16/25 revealed, in part, deficiencies identified with accidents and hazards. Concerns with the above area was identified during the facility's current recertification and complaint survey, completed 3/25/26. Review of the CMS 2567 form dated 12/16/25 revealed, in part, deficiencies identified with accidents and hazards.…

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 facility policy review, the facility failed to ensure residents had a safe, homelike environment. Observations of the facility revealed the floor heating vent covers bent, broken, or falling off showing the internal metal heating elements in resident rooms for 1 of 3 hallways and in 1 of 1 resident common area. The facility reported a census of 66 residents. Findings include: During an observation on 12/15/25 at 11:30 AM, room B4 had a baseboard heater that ran along the bottom length of one wall. The metal cover on the heater appeared bent away from the wall and exposed a large area of the internal heating element. The internal heating element contained metal plates that felt warm when touched. The resident's bed, in room B4, placed approximately 2 feet away and parallel to the baseboard heater. On 12/15/25 at 2:48 PM, the metal cover in room B4 appeared straightened and replaced. The baseboard heater no longer exposed the heating elements. During an observation on 12/16/25 at 9:26 AM, room B1 had a baseboard heater that ran along 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, employee personnel record review, and facility policy review, the facility failed to ensure a background check was completed on staff, prior to working with dependent adults, for 1 of 5 staff personnel files reviewed. The facility reported a census of 66 residents. Findings include: Review of the facility provided document, titled New Hire Orientation Schedule, revealed Staff A, Certified Nursing Assistant (CNA), completed new hire orientation on 11/20/25 Review of the facility provided document, titled Background Screening Report, ordered 11/19/25, listed the results as pending for a national criminal and sex offender search. Review of the facility requested Single Contact License and Background Check for Staff A, dated 11/19/25, revealed that Staff A's criminal history required further research. Review of the facility provided document, titled Iowa Criminal History Record Check Request SING form S, dated 11/20/25, revealed Staff A had simple and serious misdemeanor convictions. Review…

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, payroll record review, facility policy review, resident and staff interviews the facility failed to prevent neglect which resulted in a fall, and verbal abuse which caused a resident to feel bad about them self for 1 of 7 (Resident #1) residents reviewed for abuse. The facility reported a census of 66 residents.Findings include:Review of the Minimum Data Set (MDS) assessment tool dated 4/2/25 revealed a list of diagnoses for Resident #1 which included hypertension (high blood pressure), depression, generalized weakness and difficulty walking. The Brief Interview for Mental Status (BIMS) score of 14 out of 15 points, indicated intact cognition. The assessment indicated Resident #1 always able to make herself understood, understood others and had no symptoms of delirium. The assessment revealed the resident required maximal staff assistance to reposition in bed, transfer to and from bed or chair, toileting, toileting hygiene, dressing the lower body and the resident unable 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.

Based on record review and staff interviews, the facility failed to ensure resident freedom from potential abuse by permitting an alleged preparator to return to work prior to the initiation and completion of an investigation by the State Agency for 1 of 2 allegation of resident abuse reviewed. The facility reported a census of 66 residents. Findings include:Review of the Minimum Data Set (MDS) assessment tool dated 5/9/25 revealed a list of diagnoses for Resident #2 which included schizophrenia, non-Alzheimer's dementia, and anxiety. The Brief Interview for Mental Status (BIMS) score of 8 out of 15 points indicated a severe cognitive impairment. The MDS revealed Resident #2 presented with history of delirium, which included disorganized thoughts and unable to focus attention. The MDS assessed Resident #2 required substantial staff assistance to transfer on and off the toilet and toilet hygiene. Review of a facility self-reported incident revealed, in part,.On 6/13/25, HR Manager [name redacted] reported to the administrator that Resident [name redacted, Resident #2] told her that…

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, clinical record review, facility policy review, resident and staff interviews, the the facility failed to ensure staff followed transfer precautions identified on the resident's care plan that resulted in a fall (Resident #1) for 1 of 3 residents reviewed for transfer techniques, and failed to ensure that nursing staff utilized gait belts during resident transfers as required. The facility reported a census of 66 residents. Findings include:Review of the Minimum Data Set (MDS) assessment tool dated 4/2/25 revealed a list of diagnoses for Resident #1 which included hypertension (high blood pressure), depression, generalized weakness and difficulty walking. The Brief Interview for Mental Status (BIMS) score of 14 out of 15 points, indicated intact cognition. The assessment indicated Resident #1 always able to make herself understood, understood others and had no symptoms of delirium. The assessment revealed the resident required maximal staff assistance to reposition in bed, transfer to and from bed or chair, toileting, toileting hygiene, dressing the lower body…

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, Food and Drug Administration Drug Labeling resource, resident responsible party and staff interviews, the facility failed to ensure prescribed psychotropic's where adequately clinically indicated and necessary to treat a specific condition for 4 of 4 residents (Resident #1, Resident #4, Resident #5, and Resident #6). The facility failed to coordinate services between the psychiatric provider and primary care provider to prevent the potential of administering unnecessary medications for 1 of 4 residents (Resident #1) in the sample. The facility reported a census of 64 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment tool dated 4/20/25 revealed a list of diagnoses for Resident #1 which included cerebrovascular accident (a stroke), anxiety, and depression. A Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicated moderately impaired cognition. The Behavior section indicated no hallucinations, delusions, or physical or verbal behavioral symptoms…

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 staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies on the current survey previously identified in 2023 and 2024. The facility reported a census of 65 residents. Findings include: Review of the Department of Inspections, Appeals and Licensing (DIAL) website under the facility's visit history revealed deficient practices identified during the Recertification and Complaint Survey ending on 3/6/25 also cited during the following survey's: a. F689 cited during Recertification Surveys ending on 6/5/23 and 6/24/24, and a Complaint Survey on 10/21/23. b. F812 cited during Recertification Surveys ending on 6/5/23, and 6/24/24. c. F865 cited during Recertification Survey ending on 6/24/24. During an interview on 3/5/25 at 12:20 PM the Administrator reported awareness of repeated deficiencies cited during the past survey and the current survey. The Administrator…

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, record review and staff interview, the facility failed to provide a homelike environment free of odors in 2 of 4 hallways, and failed to ensure the handrails of one of four hallways to be free of exposed sharp edges. The facility reported a census of 65 residents. Findings include: #1. During an interview on 2/24/25 at 10:59 AM, a resident representative for Resident #45 stated when she visited the facility the smell of urine was overpowering. She stated she could smell it as soon as she walked into the building. Observations of the A and B halls revealed the following: On 2/24/25 at 12:33 PM, the end piece to the handrails outside room B2 and B8 missing, exposed sharp edges noted. On 2/24/25 at 1:40 PM, hallway outside room B5 noted to have a strong odor of urine. On 2/25/25 at 8:00 AM, strong odor of urine noted in back dining room by A and B halls. During an interview on 3/4/25 at 11:00 AM, the Administrator reported the facility currently did not have a Maintenance Supervisor as the last one quit on 3/1/25. During an interview on 3/4/25 at 11:40 AM, Staff…

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, record review, resident and staff interviews, the facility failed to maintain a safe, palatable temperature of foods served at the noon meal on 2/25/25. The facility reported a census of 65 residents. Findings include: On 2/25/25 at 12:11 PM, the State Agency requested a test tray for the noon meal. At 12:17 PM, the Dietary Manager took food temperatures of the refried beans with a result of 134.2 degrees F (Fahrenheit); and of jello cake with whipped topping with a result of 69.2 degrees F. During an interview on 2/25/25 at 12:20 PM, the Dietary Manager reported he expected temperatures for hot food items be at least 135 degrees F, and cold food items be under 41 degrees F. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated the resident required supervision or touching assistance with eating. During an interview on 2/24/25 at 11:44 AM,…

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, staff interviews, and the facility policy, the facility failed to ensure 1 of 5 dietary staff covered their hair while in the kitchen. The facility reported a census for 65 residents. Findings include: During a kitchen observation on 2/25/25 at 11:00 AM, Staff G, Dietary Aide hairnet covered part of her hair. Staff G had multiple long braids of hair not covered by the hairnet and braids hung down her back. During an interview on 2/26/25 at 11:52 AM, Staff G only had part of her hair covered with 2 hairnets. Staff G had part of her braids hang down her back not in the hairnet. Staff G asked about wearing hairnets in the kitchen and Staff G stated they needed to wear them and she had 2 of them on. Staff G queried if all her hair needed to be in the hairnet and she stated yes, all of her needed covered. Staff G informed part of her hair not covered by the hairnet and she tried to put her hair in the hairnet and was unsuccessful and commented she had a lot of hair and had a hard time getting all of it in her hairnet. During an interview on 2/27/25 at 9:41 AM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, family and staff interviews, the facility failed to notify the resident representative of a change in the medication regime for 1 of 2 residents (Resident #10) reviewed. The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #10 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 12 out of 15. Diagnoses listed on the MDS included: depression, cognitive communication deficit, and dysphagia (difficulty swallowing). Review Resident #23 Care Plan, Date Initiated: 1/13/22 included a Focus area to address The resident has impaired cognitive function or impaired through processes r/t (related to) HX (history) of ETOH (alcohol) abuse. Interventions included, in part: a. Communicate with the resident/family/caregivers regarding his capabilities and needs. Date Initiated: 1/13/2022. b. The resident needs supervision/assistance with all decision making. Date Initiated: 1/22/22. During an interview on 3/3/25 at…

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, interview, and clinical record review the facility failed to complete a significant change Minimum Data Set (MDS) assessment when the resident discontinued hospice services for one of one resident reviewed for hospice (Resident #53). The facility reported a census of 65 residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #53 dated 1/24/25 revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident was cognitively intact. The General Note dated 12/24/24 at 12:23 PM revealed, Resident expressed wanting to come off hospice, hospice RN (Registered Nurse) and social worked came and resident signed off services effective today. MD (Medical Doctor) notified. The Physician Progress Note dated 12/27/24 at 12:13 PM revealed, Reason for visit: staff reports resident is off hospice and wishes to pursue treatment for her cancer .States that she did not want hospice any longer when she was informed that they do not do chemo (chemotherapy) treatments…

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, record review and staff interview, the facility failed to address smoking as a focus area for 2 of 3 residents reviewed for smoking (Residents #51 and #264). The facility reported a census of 65. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #264 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 and had the following diagnoses: malnutrition, anxiety disorder and respiratory failure. The MDS identified Resident #264 dependent on staff for toileting, lower body dressing, putting on and taking off footwear. During an observation on 2/24/25 at 1:33 PM, Staff A, Certified Nursing Assistant (CNA) pushed Resident #264 in her wheelchair outside to the smoking area. Resident #264 proceeded to smoke a cigarette. Review of the Care Plan revealed a lack of a Focus area, Goal and Interventions to address Smoking. During an interview on 3/3/25 at 3:04 PM Staff B, Registered Nurse (RN) reported Resident #264 smoked and that should have been…

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, interview, clinical record review, and facility policy review the facility failed to hold care conferences quarterly, failed to revise the care plan when the resident discontinued hospice services for four of twenty-two residents reviewed for care plans (Resident #18, Resident #52, Resident #53, Resident #54). The facility reported a census of 65 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident was cognitively intact. On 2/26/25, review of Resident #53's Care Plan revealed, I am receiving Specialty Services such as Hospice with [Hospice Company Redacted]. The General Note dated 12/24/24 at 12:23 PM revealed, Resident expressed wanting to come off hospice, hospice RN (Registered Nurse) and social worked came and resident signed off services effective today. MD (Medical Doctor) notified. The Physician Progress Note dated…

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 2. The MDS dated [DATE] listed diagnoses for Resident #265 included: neurogenic bladder (lack of bladder control due to nerve damage) , urinary tract infection and epilepsy. The MDS indicated Resident #265 dependent on staff for assistance with toileting, showers, dressing, putting on and removing footwear and personal hygiene. The MDS identified Resident #265 with an indwelling catheter. Review of Resident #265's Care Plan, dated 12/18/24, revealed a Focus area to address The resident has a seizure disorder r/t (related to) epilepsy. Interventions included, in part: a. Give medications as ordered. Monitor/document for effectiveness and side effects. Date Initiated: 12/18/24. b. Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. Date Initiated: 12/18/24. Review of the Order Summary Report, document dated 3/4/25, revealed a Physician's Order for Epidiolex Oral Solution 100 Mg (milligrams/Ml (milliliters)(Cannabidiol). Give 2.5 ml by mouth two times a day for partial…

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 observations, clinical record review, resident and staff interview, the facility failed to provide set up assistance for resident identified with an impaired ability to eat independently for 1 of 1 residents (Resident #23) in the sample. The facility reported a census of 65 residents. Findings include: 1. Review of Resident #23's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 12, which indicated a moderate cognitive impairment. The MDS included diagnoses of metabolic encephalopathy (brain function impairment), Crohn's disease, end stage renal disease and diabetes. Per the MDS, Resident #23 required set up or clean up assistance for eating. Review of the Care Plan, Date Initiated: 2/11/25 identified a Focus area to address Resident is at risk for or has actual IMPAIRED ABILITY TO EAT INDEPENDENTLY. The Intervention directed staff to EATING AND DRINKING: The resident usually requires a helper to provide SETUP ASSISTANCE prior to or following…

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, staff interview, and clinical record review the facility failed to ensure wheelchair foot pedals utilized when residents assisted via wheelchair, and failed to ensure staff utilized a gait belt during transfer for 2 of 9 residents reviewed for accidents (Resident #12, #21). The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. Per this assessment the resident used a walker and wheelchair. Review of Resident #12's Care Plan dated 10/18/23 revealed, Resident is at risk for or has actual IMPAIRED ABILITY TO INDEPENDENTLY MOVE/NAVIGATE WHEELCHAIR R/T (related to) Limited Mobility, Musculoskeletal impairment. The Intervention dated 10/25/23 revealed, Foot pedals when push assist is given for navigating in wheelchair. On 2/24/25 at 11:23 AM, Staff F, Certified Nursing Assistant (CNA) pushed…

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, record review and staff interviews, the facility failed secure the tubing for a urinary catheter in a position that prevented it from sitting on the floor for 1 of 2 residents reviewed for catheter care (Resident #45). The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #45 as cognitively impaired with a BIMS of 6 and had the following diagnoses: renal insufficiency (kidney failure), encephalopathy (a medical condition characterized by a general dysfunction of the brain) and malnutrition. The MDS also identified used an indwelling urinary catheter. On 12/23/22, the Care Plan identified Resident #45 with the problem of an Indwelling Catheter related to urinary retention, obstructive and reflux uropathy (a condition where urine flows backward from the bladder into the ureters). During an observation on 2/26/25, Resident #45 sat up in her wheelchair in the back dining room. The catheter tubing noted to be 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to coordinate communication with the dialysis center for 1 of 2 residents reviewed for dialysis (Resident #18). The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated the resident received dialysis. The MDS revealed the medical diagnosis for renal insufficiency, renal failure, or end-stage renal disease (ESRD). The Care Plan revealed a Focus area dated 10/22/24 for hemodialysis related to ESRD. The Intervention dated 10/22/24 indicated encourage the resident to go for the scheduled dialysis appointments on Tuesday, Thursday, and Saturday every day shift at 9:30 . Review of the Physician Orders revealed the an order for Outpatient hemodialysis treatments: Day/s of the Week & Approximate Time: Tues…

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, staff interview, and facility policy review the facility failed to ensure timely follow up for medication regimen review recommendations identified by the Pharmacist for 1 of 5 residents reviewed for unnecessary medications (Resident #47). The facility reported a census of 65 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #47 dated 12/3/24 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, the resident took antianxiety medication. The Pharmacist Review/Visit Progress Note dated 12/31/24 at 1:10 PM revealed, in part, Alprazolam PRN (as needed) and hydroxyzine PRN orders require stop dates - letter generated. The Pharmacist Review/Visit Progress Notes dated 1/28/25 and 2/24/25 stated the same recommendation and documented letters were generated/regenerated. On 3/4/25 at 2:40 PM, Resident #47's pharmacy recommendations and response communication requested for the following dates 12/31/24, 1/28/25, and 2/24/25. One…

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, interview, clinical record record review, and facility policy review the facility failed to ensure enhanced barrier precautions (EBP) utilized for incontinence care, wound care, and gastrostomy tube site care for one of two residents reviewed for EBP, and failed to ensure appropriate infection control practices during medication administration for one of ten residents observed during medication administration (Resident #16) when a barrier was not utilized for the glucometer. The facility also failed to ensure the infection control policies were reviewed annually by the facility's Medical Director. The facility reported a census of 65 residents. Findings include: 1. On 2/27/25 at approximately 8:16 AM during an observation conducted for medication administration, Staff L, Registered Nurse (RN) had the glucometer directly on Resident #16's over the bed table. Staff L checked the resident's blood sugar and set the glucometer back on the table. At 8:19 AM, Staff L set the glucometer by the sink…

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 record review, staff interview and policy review, the facility failed to provide immunizations to 3 of 5 residents reviewed. (Residents #23, #50 and #58). The facility reported a census of 65 residents. Findings include: A review of the immunization records revealed the following: Residents #23 and #48 did not have documentation of the pneumococcal vaccine given. Residents #23 and #50 did not have documentation of the influenza vaccine given in 2024. During on interview on 3/4/25 at 9:59 AM, the Director of Nursing/Infection Preventionist stated she had not had a chance to look at immunization status related to flu and pneumvax since she started at the facility a month ago. She stated currently, there is no one assigned to enter the immunization data when residents are admitted . A review of the facility policy titled: Influenza Vaccination dated as last revised 7/1/24 had documentation of the following: 1. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has…

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 and physician interviews, the facility failed to follow physician orders directing treatment for pressure ulcers for 2 of 3 resident's reviewed for pressure ulcers (Resident's #1 and #2), and failed to follow standard infection control practices during wound care for 1 of 1 residents reviewed. (Resident #1.) The facility reported a census of 57 residents. Findings include 1. The Minimum Data Set (MDS) Assessment, dated 7/6/24, revealed Resident #1 diagnoses included multiple sclerosis, diabetes and cerebrovascular accident (a stroke). The resident's Brief Interview for Mental Status (BIMS) score of score 15 out of 15 indicated intact cognition. The MDS indicated Resident #1 required extensive staff support to reposition in bed, transfer to and from bed and chair, and for dressing, toileting and bathing. The assessment revealed the presence of a Stage 3 (a full-thickness ulcer that extends through the skin and into deeper tissue and fat, but does not reach muscle, tendon, or bone) pressure ulcer present on admission to 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, interviews, facility document review and facility policy review, the facility failed to maintain sanitary conditions for the storage, preparation and handling of beverage cups during 1 of 1 meal services observed; and failed to maintain appropriate temperatures for frozen food stored in 1 of 3 freezers. The facility reported a census of 60 residents. Findings include: On 06/17/24 at 10:10 AM, during an initial tour of the main kitchen, the stand alone freezer thermometer indicated a temperature of 30 degrees Fahrenheit. The kitchen stove top appeared to be coated with a black substance and grease. During an observation of the noon meal on 6/17/24 from 12:15 PM to 12:38 PM Staff A, Dietary Aide served 10 glasses to 9 residents with bare fingers touching the drinking rim surface of the glass. On 06/18/24 at 11:00 AM, throughout lunch preparation the floor in kitchen noted to be heavily flooded around the dishwasher, continuing towards the front of the kitchen near the preparation sink, in front of the steam table, and in front of the food preparation counter.…

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 observations, clinical record review, staff interviews and facility policy review the facility failed to implement Enhanced Barrier Precautions (EBP) for 2 of 2 resident reviewed for EBP (Resident #9, #25). The facility failed to handle laundry with Personal Protective Equipment (PPE) for 2 out of 2 observations. The facility reported a census of 60 residents. Findings include: 1. The MDS for Resident #9 dated 5/1/24, listed diagnoses of venous insufficiency and diabetes mellitus. The MDS reflected she scored 11 out of 15 on the Brief Interview for Mental Statues (BIMS), indicating moderately impaired cognition. The MDS reflected 2 venous ulcers. The Diagnoses Sheet for Resident #9 dated 6/20/24, listed diagnoses resistant to multiple antimicrobiales drugs (MDRO), venous insufficiency and diabetes mellitus. The Care Plan for Resident #9 revised on 5/20/24, lack her MDRO diagnosis and lack intervention related to EBP. The facility Matrix dated 6/12/24, listed Resident #9 with a stage 4 pressure ulcer (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and resident and staff interviews the facility failed to keep the facility free from vermin. The facility reported a census of 60 residents. Findings include: 1. During an observation on 6/17/24 at 2:40 PM a hole in the outside soffit (underside of roof overhang) measuring roughly 2 feet by 2 feet on the right side of the entrance was found. In an interview on 6/18/24 at 11:59 AM Staff D, Registered Nurse (RN) remarked she had heard things in the ceiling and assumed they were raccoons. In an interview on 6/18/24 at 12:31 PM Staff I, Occupational Therapist noted she had heard residents complain about raccoons in the ceiling. She reported there is a crawl space attic above the front of the building. In an interview on 6/18/24 at 1:30 PM the Director of Maintenance stated he started working at the facility about three months ago. At that time, he put all the soffit back up that had fallen down. He reported there were raccoons in the facility before he started. He was just made…

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 staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey previously identified during surveys completed in the last twelve months. The facility reported a census of 60 residents. Findings include: 1. Review of the facility's CMS-2567 form from a recertification survey which occurred 04/11/23 to 06/05/23 revealed the facility received immediate jeopardy level and harm level citations related to the following areas: a. Free of accidents, hazards, supervision, and devices b. Food procurement, storage/preparation/service and kitchen sanitation. c. Treatment and services to prevent or heal pressure ulcers The facility's plan of correction for this survey revealed documentation present at the end of the CMS-2567 form included the following: a.) Free of accidents and hazards: Residents were reviewed…

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 personnel file review, staff interview, and policy review the facility failed to ensure staff members were provided mandatory education on the rights of residents and the responsibilities of the facility for 5 of 6 employees reviewed. The facility reported a census of 60 residents. Findings include: A review of the employee education files on 6/20/24 at 9:42 AM revealed the following staff did not have record of resident rights and facility responsibilities education: a. Staff H, Licensed Practical Nurse (LPN) b. Staff C, Certified Nursing Assistant (CNA) c. Staff K, CNA d. Staff A, Dietary Aide e. Staff J, LPN On 6/20/24 at 11:30 AM a request made to facility clinical administrative staff to provide documentation of the required education. A second request made at 1:36 PM. In an interview on 6/20/24 03:08 PM the Director of Clinical Service explained she expected all staff to complete their core competency requirements for education, including the 12 hours of yearly education and the yearly competency evaluations. The facility policy titled Orientation, revised 10/01/22…

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 staff interview, clinical record review, and facility policy review, the facility failed to clarify and ensure a current copy of a resident's advance directive was in the medical record for 2 of 3 residents (Resident #253 and Resident #15) reviewed for advanced directives. The facility reported a census of 60 residents. Findings include: 1. The Order Summary for Resident #253, dated [DATE], revealed both an active Physician order for full code/cardiopulmonary resuscitation (CPR) with the start date of [DATE] and an active Physician order for Do Not Resuscitate (DNR) with the start date of [DATE]. The Electronic Health Records (EHR) lacked documentation of Iowa Physician Orders for Scope Of Treatment (IPOST). The EHR and Nursing Progress Notes additionally lacked documentation the facility offered or assisted with completion of advanced directives. The Care Plan, initiated [DATE] and revised [DATE], revealed Resident #253 had advanced directives on record with the goal that if the resident's heart stops…

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 record review, policy review, and staff interview the facility failed to have staff complete the Dependent Adult Abuse training within 6 months of hire for 1 of 6 employees reviewed, and to complete the Single Contact License & Background prior to the start date of a nursing staff for 1 of 6 employees reviewed. The facility reported a census of 60 residents. Findings include: 1. During employee file record reviews on 6/20/24 at 9:34 AM Staff C, Certified Nursing Assistant (CNA) was found to be hired on 3/30/23. The Dependent Adult Abuse (DAA) training certificate was absent from her employee file. On 6/20/24 at 11:30 AM, request made to facility administrative staff for documentation of DAA training completion for Staff C, A second request made at 1:36 PM. During an interview on 6/20/24 at 1:44 PM, the Director of Clinical services stated the facility did not have a DAA training certificate for Staff C. 2. During employee personnel file reviews on 6/20/24 at 9:34 AM Staff J, Licensed Practical Nurse (LPN) found to be hired on 5/23/24. A Single Contact License & Background…

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, record review, policy review, and staff interview the facility failed to identify, assess and treat a skin tear in a timely manner (Res# 304). The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], documented Resident #304 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. The MDS included diagnoses: stroke, non-Alzheimer's dementia, and hemiparesis (inability to move one half of the body). The Care Plan updated 5/14/24 included goals to maintain or develop clean or intact skin. Interventions instructed staff to follow facility protocols for treatment of injury, monitor/document location, size and treatment of skin injury, and conduct weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The Physician Order dated 6/05/24 instructed staff to complete 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview the facility failed to have a physician conduct the first resident assessment within 30 days of admission for three of five residents reviewed (Res #47, Res #5, Res #304). The facility reported a census of 60 residents. Findings include: 1. The Minimum Data Set (MDS) report dated 5/07/24 for Resident #47 documented a Brief Interview for Mental Status (BIMS) score of 9 out of 5 indicating moderately impaired cognition. The MDS diagnoses included: stroke, seizure disorder, and metabolic encephalopathy (chemical imbalance that damages the brain). The Electronic Health Record (EHR) indicated Resident #47 admitted to the facility on [DATE]. A review of the Physician Progress Note dated 2/19/24 at 10:36 AM revealed a new resident initial visit was conducted by a Nurse Practitioner (ARNP). 2. The MDS dated [DATE] for Resident #50 documented a BIMS score of 9 out of 15 indicating moderately impaired cognition. The MDS diagnoses included: fractures and…

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, staff interview, and policy review the facility failed to ensure Certified Nursing Assistants (CNA) were provided routine competency evaluations for two of three employees reviewed. The facility reported a census of 60 residents. Findings include: 1. A review of the employee personnel files on 6/20/24 at 10:05 AM revealed Staff C, CNA did not receive routine competency evaluations. The employee was hired on 3/30/23. 2. A review of the employee education files on 6/20/24 at 10:45 AM revealed Staff K, CNA did not receive routine competency evaluations. Staff K was hired on 4/01/20. On 6/20/24 at 11:30 AM documentation of CNA competency evaluations requested. A second request made at 1:36 PM . On 6/24/24 the Director of Clinical Services reported she could not find a performance evaluation for Staff K. During an interview on 6/20/24 03:08 PM, the Director of Clinical Services explained she expected all staff to complete their core competency requirements for education, including the 12 hours of yearly education and the yearly competency evaluations. 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 record review, staff interview, and policy review the facility failed to ensure Certified Nursing Assistants were provided the required minimum of 12 hours of in-service education yearly for one of three employees reviewed. The facility reported a census of 60 residents. Findings Include: A review of the employee education files including online training transcripts and in-service sign in sheets on 6/20/24 at 10:05 AM revealed Staff C, CNA did not have 12 hours of in-service education yearly. The employee was hired on 3/30/23. On 6/20/24 at 11:30 AM, a request made to the facility clinical administrative staff to provide documentation of the required education. A second request made at 1:36 PM. In an interview on 6/20/24 03:08 PM the Director of Clinical Service explained she expected all staff to complete their core competency requirements for education, including the 12 hours of yearly education and the yearly competency evaluations. The facility policy titled Required Training, Certification, and Continuing Education of Nurse Aides, revised 10/01/22 instructed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and the facility policy, the facility failed to ensure the resident's urinary catheter bag and tubing didn't touch the floor for 1 of 3 residents reviewed for incontinent cares (Resident #14). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #14 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated cognition moderately intact. The MDS revealed the resident used an indwelling catheter. The MDS revealed medical diagnoses of neurogenic bladder and obstructive uropathy. The Care Plan revealed a focus area dated 12/23/22 for indwelling catheter related to urinary retention, obstructive and reflux uropathy. The intervention dated 12/23/22 revealed position catheter bag and tubing below the level of the bladder. The EMR (Electronic Medical Record) revealed the following medical diagnoses: a. flaccid neuropathic bladder, not elsewhere classified b. retention of…

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, Pharmacist and staff interviews, and facility policy review, the facility failed to receive and administer medications for a newly admitted resident as prescribed and ordered by the physician for 1 of 3 Residents reviewed (Resident #1). The facility reported a census of 59 residents. Findings include: A Daily Skilled Progress Note dated 12/7/23 at 7:18 PM, documented Resident #1 admitted to the facility for skilled services. The note recorded the resident with the following conditions: GU (genitourinary, referring to the reproductive or urinary system), neurological (brain or nerve related), and mood condition. Hospital records for the prior hospitalization from 11/23/23 to 12/7/23 revealed the diagnosis for the visit as seizure and stroke risk. A review of hospital records for the 11/23/23 admission revealed prior to discharge the resident last received the anti-epileptic medications as following: a. Lamotrigine 100 milligrams (mgs) 1 tab at 12/7/23 at 9:24 AM. b. Levetiracetam,…

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, personnel record review, the Iowa Board of Nursing and staff interviews, the facility failed to ensure that nursing staff had appropriate competence to administer intravenous (IV) medications, fluids and assessment skills related to care for 2 residents with central IV lines (Resident's #3 and #4), and compliance with mandated regulations that included those set forth by the Iowa Board of Nursing for 2 nursing staff, Staff F, Licensed Practical Nurse (LPN) from a staffing agency, and Staff G, facility LPN. The facility reported a census of 56 residents. Findings include: 1. The 7/6/23 Minimum Data Set (MDS) Assessment tool revealed Resident #3 had diagnoses that included renal failure, intestinal malabsorption, anxiety and long term use of antibiotics. The MDS documented the resident required assistance of 1 staff to reposition in bed, transfer to and from bed and chair, dressing, toileting, personal hygiene, and unable to ambulate. The Nursing Care Plan included the following problem: Resident is receiving TPN (total parenteral nutrition) Initiated…

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.