Hillcrest Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Electronic Health Records (EHR) review, staff interview, family interview and policy review the facility failed to notify the resident's representative / family / Power of Attorney (POA) when a resident had a change in condition that lead to a transfer to the Emergency Department (ED) for 1 of 3 residents (Residents #10) reviewed. The facility reported a census of 57 residents.Findings included:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #10 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. Review of Resident #10's EHR titled, Census documented Resident #10 was transferred to the hospital 1/7/26 and returned 1/22/26.Review of Resident #10's EHR titled, Progress Note documented an entry at 5:40 AM on 1/7/26 by Staff E, Licensed Practical Nurse (LPN) on-call provider gave orders to send Resident #10 to the ED via ambulance for evaluation and supply oxygen, updated resident on orders as resident is own POA.Review of Resident #10's EHR titled,…

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.

The facility failed to properly complete the Centers of Medicare & Medicaid form #10123 for 1 of 3 sampled residents. (Residents #4). The facility reported a census of 58 residents.Findings Include: The ABN form #10123 dated 12/23/25 for Resident #4 revealed the Social Worker documented a 48 hour notice waived. During an interview on 3/18/26 at 1:14 PM, the Social Worker reported that she had completed form #10123 and documented that Resident #4 waived a 48-hour notice. She further stated she could not recall the rationale for the waiver and indicated she would investigate the matter. During an interview on 3/18/26 at 2:51 PM, the Social Worker reported that she had been unable to locate documentation or rationale regarding the resident's waiver of the 48-hour notice on form #10123. When asked if a 48-hour notice should be documented as waived by the resident because the facility failed to provide the proper 48 hour advance notice, the Social Worker stated no. The undated Advance Beneficiary Notice of Non Coverage Part A failed to address form #10123 or the required 48 hour notice…

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 and staff interview the facility failed to discontinue antipsychotic medication when ordered to be stopped therefore the medication was continued to be administered for 1 out of 5 residents (Resident #20 ) for unnecessary medication. The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnoses of anxiety disorder and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of order signed by the physician on 10/16/25 revealed discontinue quetiapine. Review of October Medication Administration Record (MAR) revealed quetiapine was administered daily from October 17- 31, 2025. Review of November MAR revealed quetiapine was administered daily from November 1- 30, 2025. Review of December MAR revealed quetiapine was administered daily from December 1-11, 16, 18, 27-30 with a discontinue date 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, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 2 of 4 residents reviewed for abuse (Resident #3 and #50). The facility reported a census of 57 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of coronary artery disease, diabetes mellitus and muscle weakness. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12 indicating no cognitive impairment. Review of facility provided Incident Report dated 3/8/26 at 3:21 p.m., revealed Staff I, Registered Nurse (RN) was at the nursing station paging at about 3:21 p.m., to get update on another resident when caregiver came up to nurse and stated, just letting you know Resident #2 was in this resident room attempting to get in bed with her. This writer hung up 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to complete a recapitulation of stay after discharge for 2 of 3 residents reviewed for discharges (Resident #61 and #63). The facility reported a census of 57 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #61 documented diagnoses of hypertension, Bell's Palsy and prediabetes. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the Census tab revealed stop billing on 1/12/26. Review of the January 2026 notice to the Long Term Care Ombudsman revealed the resident was discharged to home on 1/12/26. Review of the medical record lacked a recapitulation of stay. 2. The MDS assessment dated [DATE] for Resident #63 documented diagnoses of hypertension, muscle weakness and cardiac murmur. The MDS showed the BIMS score of 14 indicating no cognitive impairment. Review of the Census tab revealed stop billing 1/15/26. Review of the Progress…

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 Medication Administration Records - Treatment Administration Records (MAR-TAR) Electronic Health Records (EHR) review, document review, policy review and staff interviews the facility failed to incorporate the required recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination and failed to refer a resident with a later identified with newly evident or possible serious MD or ID related condition to the appropriate state-designated authority for a level II evaluation for 3 out of 4 residents (Resident #4, #5, and #15) reviewed for PASRR requirements. The facility reported a census of 57 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. MDS also documented diagnoses of major depressive disorder and schizophrenia. Review of Resident #4's document dated 11/19/25 titled, Notice of PASRR Level II outcome documented ongoing psychiatric…

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 Electronic Health Record (EHR) review, document review, staff interviews and policy review the facility failed to revise a comprehensive care plan to include updated recommendations when a Preadmission Screening and Resident Review (PASRR) Level II Outcome was completed for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 57 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. MDS also documented diagnoses of major depressive disorder and schizophrenia.Review on of Resident #4's EHR titled Care Plan on 3/18/26 documented you will receive this service for one year through 3/13/2027. Continued need will be assessed by the case manager once a year through 12/21/2030. Behavioral Health would provide case management services and the social worker at the NF will be responsible for arranging for these services prior to discharge on [DATE]. You will have…

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, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance twice weekly for 2 of 3 residents reviewed for bathing (Resident #20 and #50). The facility reported a census of 57 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnoses of anxiety disorder and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of facility provided documentation titled Follow Up Question Report dated 1/19/26-3/19/26 revealed the following information:2/7/26- bathing was documented as refused. Resident received a bath on 2/4/26 and again on 2/11/26. Resident went 6 days without a bath. 3/11/26- bathing was documented as not applicable. Resident received a bath on 3/7/26 and again on 3/14/26. Resident went 6 days without a bath. Review of Care Plan with a revision date of 2/7/25 revealed resident is totally…

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 Electronic Health Record (EHR) review, Medication Administration Record - Treatment Administration Record (MAR-TAR) review, policy review and staff interviews the facility failed to provide appropriate interventions for the urinary catheter to provide appropriate services to prevent urinary tract infections to 1 of 3 residents reviewed (Resident #10). The facility reported a census of 57 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #10 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS documented Resident #10 had a diagnosis of neuropathic bladder.Review of document dated 2/25/26 titled, Hospital Discharge Summary documented Resident #10 had a chronic indwelling foley catheter placed on 2/11/26-present and a urinary tract infection associated with indwelling urethral catheter noted on 2/20/26-present. Hospital Discharge Summary documented Resident #10 had the catheter last changed on 2/21/26 prior 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 Electronic Health Records (EHR), staff interview, observation and policy review the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by pushing enteral formula with a piston syringe into feeding tube for 1 of 1 residents (Resident #2). The facility reported a census of 57 residents.Findings include:Observation on 3/19/26 at 9:04 AM of Resident #2's enteral medication administration by Staff C, Licensed Practical Nurse (LPN) revealed Staff C checked residual, completed an auscultation of air bolus for placement, flushed 30cc H20, pushed water through syringe with palm of hand, drew up medication separately, pushed forcefully with palm of hand, Staff C explained she had to use force because the syringe itself is difficult to push, flushed with 10cc h20 between medications, obtained new syringe, obtained fresh water about 4 oz, left room, obtained 81mg low dose from other cart, returned to medication cart, crushed medication, completed hand hygiene, applied gloves, flushed with 30cc, administered medication and flushed with…

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 and staff interview the facility failed to address dementia care for 2 out of 3 residents reviewed (Resident #7 and #28). The facility reported a census of 57 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of Non-Alzheimer's Dementia, Multiple Sclerosis and cognitive communication deficit. The MDS showed the Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Review of the MDS dated [DATE] revealed active diagnosis of Non-Alzheimer's Dementia. Review of Resident #7's active diagnosis list revealed dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance with a date of 10/18/23. Review of Resident #7's Care Plan with a revision date of 1/15/26 lacked information regarding dementia care. Review of facility provided policy titled Dementia Care with a revised date of 7/2025 revealed the facility is to develop 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 record review, manufacturer's guidelines and staff interview, the facility failed to assure residents insulin pen was primed by performing a safety check prior to insulin administration preventing a significant medication error for 1 of 1 resident reviewed (Resident #16). The facility reported a census of 58 residents.Findings include:Observation on 3/19/26 at 8:25 AM, showed that Staff J, Licensed Practical Nurse (LPN) accessed Resident #16's medication record via computer, retrieved Resident #16's insulin pen, attached the pen needle, and dialed the dosage to the prescribed 10 units of insulin. Staff J failed to perform a safety test dose of 2 units of insulin as required by the manufacturer's instruction. Staff J donned gloves, lifted Resident #16's shirt, applied an alcohol wipe to the skin, and administered the insulin to the right flank area. Review of the Injections, Insulin policy last reviewed July 2022 failed to provide information or instruction regarding use of an insulin pen. Review of the manufacturer's guidelines dated 2022 showed to perform a safety…

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 record review and staff interviews the facility failed to provide and maintain accurate resident records to accurately record residents weights in the facility for 1 of 3 residents (Residents #35). The facility reported a census of 57 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #35 documented diagnoses of heart failure, atrial fibrillations and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Review of residents weights revealed the following information:On 1/9/26- 200 pounds (lbs) hospital weight.On 1/18/26- 177.2 lbs - wheelchair.On 1/24/26- 176.0 lbs - mechanical lift.On 1/31/26- 259.5 lbs - wheelchair.On 2/1/26- 257.3 lbs - wheelchair.On 3/1/26- 168.4 lbs - standing. Review of the clinical records lacked documentation of the weight fluctuations. Interview on 3/24/2026 at 2:19 p.m., with the Director of Nursing (DON) revealed when looking at the weights she stated the 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.

Based on previous CMS-2567 review, staff interview and facility policy review the facility failed to ensure a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 57 residents. Findings include: Review of the Department of Inspections, Appeals and Licensing (DIAL) website under the facility's visit history revealed repeated deficient practices identified during the facility's annual survey and the previous annual survey conducted 3/11/25. The repeat deficiencies cited included: F582- Medicaid/Medicare Coverage/Liability notice cited on 3/11/25 and cited during the current survey. F584- Safe/Clean/Comfortable/Homelike Environment cited on 3/11/25 and cited during the current survey. F677- ADL Care provided for Dependent Residents cited on 3/11/25 and cited during the current survey. F684- Quality of Care cited on 3/11/25 and cited during the current survey. F880- Infection Prevention & Control cited on 3/11/25 and cited during the current survey. Review of the facility provided policy titled QAPI with a revised date…

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, interview, and facility policy the facility failed to have a Infection Preventionist present for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 57.Findings include: Review of facility documentation titled QAPI attendance dated 12/18/2025 lacked a trained infection preventionist (IP) present at the meeting. Review of facility provided policy titled Quality Assessment Performance Improvement (QAPI) with a revised date of 10/2022 revealed the committee will maintain a record of the dates of all meetings and the names/titles of those attending each meeting. Interview on 3/26/2026 at 9:45 a.m., with the Administrator revealed there was no IP with training present from October 2025 until the current IP got her training at the QAPI meetings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to update care plan interventions for resident after falls for 1 of 3 residents reviewed, (Resident #2).Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of Alzheimer's Disease, dementia and malnutrition. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment.The Incident Reports for Resident #6 showed the following falls:3/31/25 at 9:00 PM- resident found on floor,4/2/25 at 10:30 PM- resident found sitting on the floor, 4/7/25 at 8:55 PM- resident found sliding on her buttock across the floor,4/19/25 at 10:30 AM- resident stood up from recliner and fell,6/12/25 at 4:30 AM- resident found sitting on the floor,6/15/25 at 2:45 PM- resident found sitting on the floor.The Care Plan for Resident #1 showed the facility failed to place interventions on the care plan related to the falls. In an interview on 10/7/25 at 11:07 AM, Staff 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, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility and failed to provide written notice of bed hold for 4 of 4 residents reviewed (Residents #4, #11, #40 and #45). The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of diabetes mellitus, depression and seizure disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Review of Resident #4's census tab revealed the following information: 3/9/24- hospital no charge, 3/21/24- active. Review of Progress Notes revealed the following: On 3/9/24 at 7:46 p.m., resident being assessed at local hospital. On 3/10/24 at 3:17 a.m., resident being transferred via helicopter to a larger hospital. On 3/21/24 at 11:44 p.m., resident readmitted…

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, resident interview, staff interview, observation, and policy review the facility failed to provide an opportunity for bath or shower to 4 of 6 residents reviewed (Residents #2, #37, #46, and #202). The facility reported a census of 50 residents. Findings include: 1. Review of Resident #46's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS revealed an admission date of 11/5/24 from a short-term general hospital stay. The MDS revealed Resident #46 required substantial assistance with bathing. Interview on 2/26/25 at 11:48 AM with Resident #46 revealed that he is only getting a shower maybe once a week, and would like to have showers more frequently. Interview on 2/26/25 at 11:51 AM Staff E Certified Nursing Assistant (CNA) revealed residents are supposed to get bathed twice a week. Staff E then revealed that staff will document in the Electronic Healthcare Record (EHR). Staff E…

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 document review and staff interview the facility failed to employ a clinically qualified nutrition professional by not having a Certified Dietary Manager (CDM). The facility reported a census of 50 residents. Findings include: Interview on 2/24/25 at 11:03 AM with the Administrator revealed that the facility does not have a CDM, and that the facility does have an interim manager working on his CDM. Interview on 2/27/25 at 9:50 AM with the Administrator revealed that the facility does have a person with a CDM certification that is training starting this week, and acknowledged that the facility did not have a CDM prior to this. The Administrator then revealed her expectation would be for a Certified Dietary Manager to be in charge of the kitchen. Interview on 3/6/25 at 12:30 PM with Staff C Facility consultant revealed her expectation would be to have a certified dietary manager in charge of the kitchen. Staff C further revealed that the facility does not have a policy for certified dietary managers.

Based on clinical record review and staff interview, the facility failed to obtain physical signatures or record attempts to obtain physical signatures on notification of the Notice of Medicare Non-Coverage (NOMNC) Centers of Medicare & Medicaid (CMS)-10123 and CMS form CMS-10055 for 1 of 3 sampled residents (Residents #204). The facility reported a census of 50 residents. Findings Include: Record review for Resident #204 revealed form CMS 10123-NOMNC with a services end date of 9/4/24. Resident #204's representative gave verbal consent for signature on 9/4/24 however lacked a signature of resident or resident representative. Review of Resident #204's Progress Notes lacked any documentation on any attempts to obtain physical signatures on CMS 10123-NOMNC and CMS-10055. Review of the Centers (CMS) Medicare Claims Processing Manual Chapter 30 with a revision date of 1/21/22 revealed the following information under ABN options for Delivery other than in-person revealed ABNs should be delivered in-person and prior to the delivery of medical care which is presumed to be non-covered. In…

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 resident interview, family interview, staff interview, and policy review the facility failed to ensure 1 of 1 resident's personal property was protected from loss or theft, (Resident #48). The facility reported a census of 50 residents. Findings include: Review of Resident #48's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Interview on 2/25/25 at 1:17 PM with Resident # 48 revealed that she had a quilt that went missing from the laundry. Resident #48 revealed she had let the facility know, but it had not been replaced. Review of an untitled and undated document for inventory with Resident #48's name revealed nothing marked for personal inventory. Interview on 3/6/25 at 10:32 AM Staff D Social Services revealed that he was not the Social Worker at the time when Resident #48 was admitted to the facility. Staff D then revealed that he did not complete the form but the previous social service personnel should…

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 and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for 1 out of 22 sampled residents reviewed for comprehensive care plans (Resident #13). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 documented diagnoses of coronary artery disease, fibromyalgia and respiratory failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Review of Order Summary Report dated 3/6/25 revealed an order for oxycodone-actaminophen (opioid medication) tablet with an order date of 1/30/25. Review of the undated current Care Plan lacked usage of opioid medication and side effects to watch for with opioid medication usage. Review of the facility provided policy titled Comprehensive Person Centered Care Planning with a revision date of 03/2022 revealed this facility…

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 record review, resident and staff interviews and facility policy review the facility failed to provide physician ordered daily weights 1 of 1 residents reviewed (Resident #11) and failed to provide pressure ulcer dressing changes as ordered by the physician for 1 of 1 residents reviewed (Resident #44). The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 documented heart failure, hypertension and coronary artery disease. The MDS showed the Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Review of signed Physician Order dated 9/5/24 revealed an order for daily weights, call clinic for a weight gain of 2-3 pounds overnight or 5 pounds in 1 week. Review of signed Order Summary Report dated 2/5/25 revealed an order for daily weights with an order date of 10/18/24 with a start date of 10/19/24. Review of the Progress Notes revealed the following: 11/4/24 at 2:10 p.m., daily weight,…

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 document review, staff interview, and policy review the facility failed to provide adequate nursing supervision for 2 of 3 residents reviewed (Residents #22, and #48). The facility reported a census of 50. Findings include: 1. Review of Resident #22's Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had problems with short and long term memory problems. The MDS further revealed diagnosis of non-traumatic brain dysfunction, and Alzheimer's disease. Review of the Electronic Healthcare Records (EHR) page titled, Progress Notes revealed an entry dated 10/18/24 at 4:01 PM. This entry revealed Resident #22 was noted outside of the facility in the parking lot by a staff member and brought back inside. Further review of the Progress Notes revealed Resident #22 had eloped from the facility on 9/26/24 per an entry made on 9/27/24 at 4:35 PM. This entry revealed Resident #22 had exited through a hallway into the assisted living portion of the building. Review of a document titled…

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 and staff interview the facility failed to identify side effects, non-pharmalogical interventions to try prior to medication, specific targeted behaviors related to high risk medications in 2 out of 5 sampled residents reviewed (Resident #4 and #13). The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 documented diagnoses of chronic obstructive pulmonary disease (COPD), respiratory failure and dependence on supplemental oxygen. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Review of Resident #4's signed Order Summary report dated 2/7/25 revealed the following order: a. Zyprexa (antipsychotic medication) oral tablet with a start date of 1/29/25. Review of Resident #4's Care Plan with a revision date of 10/30/24 revealed a focus of resident uses anti-anxiety medications with a created date of 9/5/21. It lacked specific targeted behaviors…

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 infection control policy the facility failed to use universal infection control measures and Enhanced Barrier Precautions (EBP) during incontinence cares for 1 of 3 residents reviewed for infection control (Resident #45). The facility reported a census of 50 residents. Findings include: Review of Resident #45's Minimum Data Set (MDS) dated [DATE] revealed Resident #45 utilized an indwelling catheter. The MDS further revealed diagnosis of neurogenic bladder, and hemiplegia following a cerebral infarction. Review of a document titled Order Summary Report dated 2/3/25 revealed an order to change Resident #45's indwelling catheter monthly and as necessary. Observation on 2/27/25 at 11:17 AM Staff A Certified Nursing Assistant (CNA), and Staff B CNA completed hand hygiene and donned gloves. Staff A and Staff B then proceed to reposition Resident #45 and complete peri cares. No gown was donned by either staff while repositioning or completing peri cares for Resident #45.…

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 review of the planned menu, observation and staff interviews facility staff failed to follow the planned menu for residents. The facility identified a census of 46 residents. Findings include: The facility's Week 1 menu identified the following items as part of the planned menu for the lunch meal on 7/25/24: Fried Chicken Potato Salad Green Beans with bacon Strawberry Sponge Shortcake Milk Observation on 7/25/24 starting at 12:23 p.m. the lunch meal being served consisted of: Chicken wrap Potato salad Potato chips Lemon Pudding Interview on 7/26/24 at 8:44 a.m., with Staff C, Dietary Manager revealed on 7/25/24 she did not have enough fried chicken for the noon meal as she did not order enough and she called the dietician for substitutions so she made a decision to make chicken wraps. Staff C revealed she has only been in her position for approximately a week and half but has worked in the kitchen since April and has not had any training as a dietary manager. Staff C further revealed she was not able to serve the strawberry sponge shortcake as they only got 1 spongecake on…

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, facility record review and resident and staff interviews the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 46 residents. Finding Include: Ongoing observation on 7/26/24 starting at 12:03 p.m., revealed the following: a. Observation of 3 dietary trays sitting on the table with covers on upon entering the kitchen. b. Observation during meal service Staff C, Dietary Manager called call room trays were ready. Verified with Staff C the room tray was ready to leave the kitchen and go to the resident. Asked Staff C to take meal temperatures. Temperatures are as follows: Fish Sticks- 94.3 degrees Fahrenheit (F), Carrots 93.5 degrees F and cheesy rice 102 degrees F. Staff C left the cover off of the meal tray. Approximately 10 minutes later Staff C revealed the room tray needed to be remade. c. Puree food on a tray with covers went to service window. Asked Staff C what the food was. Staff C revealed it was pureed cheesy rice and she had just taken it out of the microwave. Asked Staff C to check 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, resident and staff interviews, and facility policy reviews the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. The facility identified a census of 46 residents. Findings include: 1. Observation on 7/25/24 at 12:23 p.m., the first meal was served in the dining room and the last meal was served at 1:25 p.m. 2. Interview on 7/26/24 at 11:36 a.m., with Resident #9 revealed meals are always late. They usually are about 30 minutes late. 3. Interview on 7/26/24 at 12:35 p.m., with Resident #16 revealed on 7/25/24 supper was approximately 30 minutes late. 4. Interview on 7/26/24 at 2:26 p.m., with Staff E, Certified Nursing Assistant (CNA) revealed meals lately have been about 15 minutes late. 5. Interview on 7/26/24 at 2:54 p.m., with Staff F, CNA revealed meals are usually 15 minutes late depending on the day. 6. Interview on 7/26/24 at 3:03 p.m., with Staff G, CNA revealed meals are usually late around 20 minutes but…

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, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene with perineal care for 1 of 3 residents reviewed (Resident #12). The facility also failed use proper hand hygiene during dining service for 2 out of 3 residents reviewed (Resident #17 & #18) and when preparing food in the kitchen. The facility reported a census of 46 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 documented diagnoses of non-traumatic brain dysfunction, dementia and dysphagia. The MDS documented Resident #12 totally dependent for toileting hygiene, showering and personal hygiene. The MDS showed the Brief Interview for Mental Status (BIMS) score of 01 which indicated severe cognitive impairment. On 7/27/24 at 1:20 PM observed Staff A, Certified Nursing Assistant (CNA) and Staff J, CNA removed Resident #12's pants, unfastened the brief, pulled down the brief then rolled the resident onto her left side. Staff J then held 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 facility policy review the facility failed to provide for resident's dignity during dining. The facility reported a census of 46 residents. Findings include: During an ongoing observation on 7/25/24 starting at 12:23 p.m., revealed Staff H, Certified Nursing Assistant was feeding Resident #17 and Resident #18. Resident #17 was noted to be sitting herself forward in her wheelchair Staff H took her left arm and placed it across Resident #17's chest and continued to assist Resident #18 with eating. Staff H did not say anything to Resident #17 until after she had assisted Resident #18 with 3 more bites of food. Staff H got up from the table at 12:25 p.m., and asked another staff member to watch Resident #17. Staff H returned to the table at 12:34 p.m Staff H sat down and without talking to Resident #17 and Resident #18 assisted with eating their meal. Review of facility provided policy titled Resident Rights reviewed 6/2023 revealed the resident has the right to be treated with consideration, respect, and full recognition of his or her dignity…

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 facility record review and resident and staff interviews, the facility staff failed to provide reasonable accommodation of needs by not placing the call light within reach of residents for 2 out of 6 residents reviewed (Resident #1 and #6). The facility reported a census of 46 residents. 1. The Grievance Resolution form dated 5/28/24 at 1:00 PM identified Resident #1 stated the call light was left out of reach after cares. The resident called the front desk to ask for assistance. The grievance conclusion identified staff confirmed the call light was out of reach upon entering the resident's room. Corrective action identified as education to staff on call lights. The Grievance Resolution form dated 6/10/24 identified Resident #1 reported during a mechanical lift transfer the nurse left the resident unattended and without a call light. The form identified the resident felt fearful as if she may fall out of the chair before they got back. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #6…

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 interviews the facility failed to use the mechanical lift in an appropriate manner to avoid hazards and prevent accidents for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 46 residents. The findings include: The Grievance Resolution Form dated 6/10/24 showed the facility received a report from Resident #1 that identified staff banged her foot on the mechanical lift during a transfer. A staff member instructed the other to be more careful with transfers. The resident reported the incorrect placement of her body in the wheelchair caused her to feel that she may slip out. The nurse then left the resident unattended, and without the call light, while she went to get help. Resident #1 reported feeling fearful as if she may fall out of her chair before staff returned to the room. Resident #1 also reported when staff later returned her to bed they used the emergency button to lower her into bed which released quickly and scared her. The nurse stated to the Certified Nursing Assistant (CNA), we only use this in an emergency. 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, staff interview and facility policy, the facility failed to provide complete and appropriate incontinence care in a manner to prevent urinary tract infections for 1 of 3 residents observed (Resident #12). The facility reported a census of 46 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 documented diagnoses of non-traumatic brain dysfunction, dementia and dysphagia. The MDS documented Resident #12 totally dependent for toileting hygiene, showering and personal hygiene. The MDS showed the Brief Interview for Mental Status (BIMS) score of 01 which indicated severe cognitive impairment. On 7/27/24 at 1:20 PM observed Staff A, Certified Nursing Assistant (CNA) and Staff J, CNA removed Resident #12's pants, unfastened the brief, pulled down the brief then rolled the resident onto her left side. Staff J then held the resident's right leg while Staff A stood behind the resident, reached between the resident's legs to the front perineal area then…

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 facility record review and resident and staff interviews, the facility staff failed to consistently answer call lights within a reasonable amount of time. Residents reported call light response time over 15 minutes for 3 out 6 residents reviewed (Residents #1, #8, and #15). The facility reported a census of 46 residents. 1. The Grievance Resolution form dated 5/28/24 at 1:00 PM identified Resident #1 turned on the call light at 6:30 AM. The call light wasn't answered until 7:30 AM. The resident reported incontinence due to the delay. The investigation listed on the grievance included staff educated on answering call lights in a timely manner. The Grievance identified corrective action included education to staff regarding call light response time. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #8 had a Brief Interview for Mental Status (BIMS) of 15 which indicated no cognitive impairment. The MDS documented Resident #8 dependent or required substantial assistance for personal hygiene.…

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, resident and staff interviews and facility policy review the facility failed to provide alternatives or substitutions during meals to residents. The facility reported a census of 46 residents. Finding Include: 1. Review of the grievances provided by the facility revealed the following: a. Summary of the grievance- 4/1/24 There have been numerous residents with weight loss concerns since the change of dietary rules for residents' choice with meals. Options have been taken away from them. It's been told to the residents if its not on the menu, they can't have it This includes toast, yogurt, applesauce, pudding, eggs, ect. Steps taken to investigate- Executive Director educated staff there is a daily menu with alternative menu option as well. Summary of findings- Residents will choose between a daily menu or an alternative menu. Many choices-yogurt is also available per request. Corrective action- Education to staff about residents rights. b. Summary of the grievance- 6/14/24 Resident #1 revealed she had asked for an egg sandwich for breakfast and was told it was…

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, facility policy, Centers for Disease Control and Prevention (CDC), and staff interviews, the facility failed to don and doff Personal Protection Equipment (PPE) correctly, dispose of PPE correctly, disinfect reusable PPE correctly, disinfect used laundry containers correctly, and perform hand hygiene in between assistance residents eat their meals. The facility reported a census of 42 residents. Findings include: 1. In a concurrent observation and interview on 1/22/24 at 11:22 AM of an uncovered red trash bin with a N95 mask in it along with other discarded PPE. A reusable PPE gown hung on Resident #17's outside room door. Staff R, Certified Nurse Assistant (CNA) reported that someone must have left it there. Staff R then bagged it in a clear trash bag and threw it away in a regular trash bin kept in the hallway. Observation on 1/24/24 at 2:00 PM of Staff I, Certified Nurse Assistant (CNA) did not tie the waist of her gown before entering a resident's isolation room. When Staff I exited the room, took off her face shield and placed it on top…

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, facility policy, and staff interview the facility failed to provide for resident's dignity during dining when staff engaged in conversation that was not resident focused. The facility reported a census of 42 residents. Findings include: Continual observation on 1/24/24 from 1:05 PM to 2:30 PM of the table in the dining room in which residents sat at who needed assistance with eating revealed: 1. Staff D, Certified Nurse Assistant (CNA) and Staff I, CNA talking about personal issues while assisting Resident #4 with eating. 2. Staff D and Staff J, CNA talking to one another and not with Resident #22. The Policy/Procedure dated July 2023 directed that staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings. In an interview on 1/31/24 at 10:09 AM, when asked about resident's dignity when staff talk between themselves instead of keeping table conversation resident focused, Staff L, Market Leader, initially responded that she would like to know…

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, facility policy, and staff interview, the facility failed to place grievance forms in a location accessible to residents. The facility reported a census of 42 residents. Findings include: Observation of the facility on 1/25/24 at 12:15 PM did not reveal grievance forms in the facility. Closed boxes were fixed outside of office doors to submit anonymous grievances. In a concurrent facility tour and interview on 1/25/24 at 12:55 PM, Staff H, Social Services Supervisor found grievance forms located in the foyer to the facility, a location that was locked off for resident access. The Policy/Procedure dated November 2007 revealed in pertinent part that grievance forms are available from Social Services, Administration, Activities Department and Nursing Stations. In an interview on 1/25/24 at12:30 PM, Staff L, Market Leader reported that she was unsure exactly what this facility's process is for grievances; that the corporation's grievance process is for a resident or a resident representative to report a concern to facility staff, ask for a grievance form, 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 personnel file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal Background check and dependent adult/child abuse registry check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff A). The facility reported a census of 42 residents. Findings include: Review of facility provided document titled Hires from 11/01/2022-1/22/2024 revealed Staff A, Licensed Practical Nurse (LPN) documented a hire date of 11/18/22. The personnel file for Staff A revealed documention of an criminal background check and dependent adult and child abuse registry check was compelted on 12/22/22 at 10:54 a.m The file lacked documentation of the Iowa Criminal Background Check and dependent adult/child abuse registry check prior to hire. Review of facility provided policy titled Abuse Prevention and Reporting with a revision date of 5/2007 revealed pre-employment screening is done on employees, including obtaining information from previous or current employers, and criminal background checks to assure…

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 facility records, facility policy, and family, resident, and staff interviews, the facility failed to answer call lights within 15 minutes. The facility reported a census of 42 residents. Findings include: In an interview on 1/22/24 at 10:30 AM, Resident #11 reported that when she calls for aide and the aide needs a second aide it takes forever to get the second person. In an interview on1/23/24 at 9:14 AM Resident #28 reported there has been a lot of temporary staff working here and they don't know what they are doing and have a hard time with that. It depends on who is working and how many staff are working, but when 2 people are needed to assist him, it takes a while during those times. In an interview1/23/24 at 1:33 PM, Resident #193 reported that to have assistance in going back to room after lunch takes up to 3 hours, quite often, the wait time was 2 hours. Resident #193 reported it can take so long to get her call light answered, she has wondered if it was broken. Resident #193 reported that 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.

Based on document review and staff interview the facility failed to verify professional nursing licensure prior to hire for 1 of 3 staff members reviewed (Staff A). The facility reported a census of 28 residents. Findings include: Review of facility provided document titled Hires from 11/01/2022-1/22/2024 revealed Staff A, Licensed Practical Nurse (LPN) documented a hire date of 11/18/22. The personnel file for Staff A revealed documentation of the nursing license verification report dated 11/22/22 at 9:20 a.m The file lacked documentation of verification of Staff A ' s professional nursing licensure prior to hire. Review of facility provided policy titled Abuse Prevention and Reporting with a revision date of 5/2007 revealed pre-employment screening is done on employees, including obtaining information from previous or current employers, and criminal background checks to assure that the facility does not employ individuals who have been convicted of a disqualifying event and to assure the employee has a current licensure or certification of is in the process of obtaining hte…

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, resident and staff interviews, and facility policy review the facility failed to ensure the kitchen had the appropriate staff to carry out the tasks of the kitchen in a safe and effective manner. The facility identified a census of 42 residents. Findings include: Observation on 1/22/24 at 10:07 a.m., residents seated at the assisted table were being served and assisted with their breakfast meal. Interview on 1/22/24 at 10:07 a.m., with Resident # 2 revealed she does not like most of the food so will order an alternative but it takes forever to get the food. Interview on 1/22/24 at 10:11 a.m., with Staff I, Certified Nursing Assistant (CNA) revealed breakfast time depends everyday as the facility has a new Dietary Manager (DM) and she is trying to learn and catch up with the serving. Residents usually eat their breakfast but then do not usually eat much for lunch as they have just finished their breakfast. Observation on 1/22/24 at 1:28 p.m., of residents in the dining room still eating meals and resident room trays being served. Observation on 1/23/24 at 10:04…

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 review of the planned menu, observation and staff interviews facility staff failed to follow the planned menu for residents. The facility identified a census of 42 residents. Findings include: The facility's Week 2 menu identified the following items as part of the planned menu for the evening meal on 1/24/24: corn chip chicken shredded lettuce and tomato refried beans mandarin oranges Milk Observation on 1/24/24 at 5:22 p.m. the evening meal being served consisted of: scalloped potatoes and ham lettuce salad with dressing mandarin oranges Observation made during meal service revealed Resident #4 and #5 receive a pureed diet. On 1/24/24 for evening meal the menu consisted of: Pureed corn chip chicken Purred shredded lettuce and tomato Pureed refried beans Pureed mandarin oranges Milk. Observation of Resident #4 and #5 meals being prepared in the kitchen. The DM revealed she did not like how the meals pureed so she was going to get the resident something else to eat. Resident #4 and #5 received the following items for 1/24/24 evening meal: Puree green beans Mashed potatoes…

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, facility record review and resident and staff interviews the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 42 residents. Finding Include: Interview on 1/22/24 at 10:29 a.m., with Resident # 11 revealed the eggs were cold when she received them this morning. Resident #11 revealed staff did warm them up but it happens all the time. Interview on 1/22/24 at 10:07 a.m., with Resident # 2 revealed the food is always cold when she gets it. Resident #2 further revealed she does not like most of the food so will order an alternative but it takes forever to get the food. Lunch tray requested on 1/22/24 at 12:54 p.m., Dietary Manager (DM) revealed everyone had been served. DM served on a plate chicken breast, peas in a cup, breadstick, and brownie and covered. Temperature of food was checked as follows: Chicken breast- 104.6 degrees Cup of peas- 120.4 degrees Breadstick- luke warm and hard Brownie- sticky in appearance and stuck to the spoon used to cut it in half Observation on 1/22/24 at 1:28 p.m., 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.

Based on observations, resident and staff interviews, and facility policy reviews the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. The facility identified a census of 42 residents. Findings include: Observation on 1/22/24 at 10:07 a.m., residents seated at the assisted table were being served and assisted with their breakfast meal. Interview on 1/22/24 at 10:07 a.m., with Resident # 2 revealed she does not like most of the food so will order an alternative but it takes forever to get the food. Interview on 1/22/24 at 10:11 a.m., with Staff I, Certified Nursing Assistant (CNA) revealed breakfast time depends everyday as the facility has a DM and she is trying to learn and catch up with the serving. Residents usually eat their breakfast but then do not usually eat much for lunch as they have just finished their breakfast. Observation on 1/22/24 at 1:28 p.m., of residents in the dining room still eating meals and resident room trays…

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, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 42 residents. Findings include: 1. Observation on 1/24/24 at 11:24 a.m., revealed the following: A sugar container with lid on dated 1/16 revealed a styrofoam cup laying in the sugar ready for use. Window on the north side of the kitchen was open with air blowing on pan with uncovered bread and margarine being prepared for lunch. Bread and margarine was served to residents for lunch on 1/24/24. 2. Observation on 1/25/24 at 8:49 a.m., revealed sugar container with lid on dated 1/16 revealed a styrofoam cup laying in the sugar ready for use. Review of the facility provided policy titled Food Storage Guidelines updated January 2019 revealed: Store food in a clean, dry location not exposed to splashes, dust or other contamination. Interview on 1/25/24 at 8:51 a.m., with Staff G, Licensed Nursing Home Administrator (LNHA), Certified Dietary Manager (CDM) revealed the cup should not be in the sugar…

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 facility policy and staff interview, the facility failed to make good faith attempts to correct quality deficiencies and have governance or leadership oversight with their Quality Assurance and Performance Improvement program (QAPI). The facility reported a census of 42 residents. Findings include: An untitled, undated list of Licensed Nursing Home Administrators (LNHA) since the last recertification survey that occurred 11/10/22 revealed there were 2 previous LNHA prior to the current LNHA. In an interview on 1/31/24 at 8:22 AM, Staff E, Maintenance Supervisor, reported that he has issues related to coordinating work with the housekeeping department and has not brought this to the attention of the facility staff that he reports to. When asked if he had brought his issue with the housekeeping department for a potential QAPI issue to work on, he reported that he had not and was not familiar with his ability to bring issues to QAPI meetings for review. In an interview on 1/31/24 1:05 PM, when asked if there had been QAPI efforts related to the facility's pattern of repeated…

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 facility documents, facility policy, and staff interview, the facility failed to have the required Quality Assurance and Performance Improvement (QAPI) members present for meetings. The facility reported a census of 42 residents. Findings include: Review of the QAPI sign in sheets revealed the Medical Director was not present for meetings held in July 2023 or October 2023. In an interview on1/23/24 at 4:25 PM, the Director of Nursing (DON) reported that the Medical Director was not present for the QAPI meetings that took place in July 2023 or October 2023. They had an ad hoc QAPI meeting in November of 2023, but she was unable to locate the sign in sheet for that meeting. The QAPI - Role of the Medical Staff (Medical Director and Attending Physicians) Policy revised April 2014 lacked direction that the Medical Director attended QAPI meetings at a minimum of quarterly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and policy review the facility failed to provide a clean homelike environment for all the residents living in the facility by not changing soiled linens or cleaning ceiling vent for 2 of 4 residents reviewed (Residents #2 and #193). The facility reported a census of 42. Findings include: 1. Observation on 1/22/24 at 9:30 a.m. of Resident #2 ' s bed linens revealed brown and red soiled areas covered up with a blanket. Resident #2 revealed their sheets have been soiled like this for approximately a week. Resident #2 revealed they have asked the staff to change the soiled sheets and they have not been changed. On 1/23/24 at 12:17 PM observation of linens on bed and they are soiled with a red and brown matter. 2. Observation on 1/24/24 at 11:16 a.m. of Resident #2 ' s bed linens revealed brown and red soiled areas covered up with a blanket with a personal blanket covering the area. 3. Observation on 1/29/24 at 11:13 a.m., revealed Resident #2 laying in their bed. When 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 and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 3 of 4 residents reviewed who transferred to the hospital (Resident #1, #13 and #20). The facility reported a census of 42 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of chronic obstructive pulmonary disease (COPD), hypertension and asthma. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicated no cognitive impairment. Review of Resident #1 ' s Census tab revealed the following: On 5/6/23- Hospital No Charge. On 5/9/23- Active. Review of Resident #1 ' s Progress Notes revealed the following information: On 5/6/23 at 1:46 p.m., Resident #1 admitted to the local hospital. On 5/9/23 at 2:23 p.m., Resident #1 readmitted to the facility at this time. The facility lacked documentation of May 2023 notification to the LTC Ombudsman of discharges. 2. The MDS assessment dated [DATE] for Resident #13…

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, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by resident and or the resident's responsible person when residents transferred out of the facility for 3 of 4 residents reviewed (Residents #1, #13 and #34). The facility reported a census of 42 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of chronic obstructive pulmonary disease (COPD), hypertension and asthma. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicates no cognitive impairment. Review of Resident #1 ' s Census tab revealed the following: On 5/6/23- Hospital No Charge. On 5/9/23- Active. On 12/4/23- STOP BILLING. On 12/8/23- Active. Review of Resident #1 ' s Progress Notes revealed the following information: On 5/6/23 at 1:46 p.m., Resident #1 admitted to the local hospital. On 5/9/23 at 2:23 p.m., Resident #1 readmitted to the facility at this time. On 12/4/23 at 11:26 a.m.,…

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, facility policy, and staff interview, the facility failed to accurately code a Minimum Data Set (MDS) for 1 of 14 residents reviewed (Resident #20). The facility reported a census of 42 residents. Findings include: The MDS dated [DATE] for Resident #20 revealed the Resident had short and long term memory problems. The Resident had diagnoses of dementia, malnutrition, and edema. The Resident had 1 unhealed pressure ulcer that was unstageable and the Resident did not have a pressure reducing device for her bed. The Order Summary Report signed by a physician on 1/4/24 revealed an order to check inflation of air overlay (on bed) every shift with a start date of 6/12/23. In an interview on 1/25/24 at 10:15 AM, the Director of Nursing (DON) reported that an Advance Practice Registered Nurse (ARNP) verbally advised her that the wound was a pressure ulcer. Addendum Wound Care Progress Note signed by an ARNP dated 1/25/24 revealed the Resident had an ulcer to the right second toe that was not…

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, facility policy, and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) for a change in condition for 1 of 2 residents reviewed (Resident #10). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #10 revealed a Brief Interview of Mental Status score of 15 which indicated intact cognition. Diagnoses included schizoaffective disorder, depressive type, dementia, anxiety, depression, and psychotic disorder. The Level 1 Form for PASRR Review dated 6/12/20 revealed: 1. Diagnoses of schizoaffective disorder, anxiety, sleep disorder, and adjustment disorder. 2. Medications: a. Clonazepam 0.5 milligrams (mg) daily for major depressive disorder. b. Pristiq 50 mg daily for schizoaffective disorder. c. Nortriptyline 25 mg daily for sleep disorder. 3. The resident did not have a diagnosis of dementia. 4. Should there be an exacerbation related to mental illness or a discrepancy in 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 and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for in 1 out of 13 sampled residents reviewed for comprehensive care plans (Resident #11). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 documented diagnoses of chronic obstructive pulmonary disease (COPD), heart failure and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment. The MDS revealed the resident was taking diuretic medication in the review period. Review of the January 2024 Medication Administration Record (MAR) revealed an order for furosemide (diuretic medication) with an order date of 7/13/23. Review of the Order Summary Report signed by the physician dated 1/8/24 revealed an order for furosemide daily with an order date of 7/13/23 and start date of 7/14/23. Review of 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, facility policy, and staff interviews, the facility failed to follow physician orders for 1 of 15 residents reviewed (Resident #32). The facility reported a census of 42 residents. Findings include: TheMinimum Data Set (MDS) assessment dated [DATE] for Resident #32 documented diagnoses of Non-Alzheimer ' s Dementia, anxiety disorder, and pain. Resident was currently under hospice care. The MDS showed the BIMS score was not assessed. Resident cognitive skills for daily decision making revealed moderately impaired. Review of the Hospice Plan of Care dated 1/11/24 at 1:10 p.m., revealed current medication orders signed by the physician dated 1/10/24: Acetaminophen oral solution every 4 hours as needed with a start date of 11/1/22 Acetaminophen tablet every 12 hours with a start date of 11/1/22 Acetaminophen rectal suppository every 6 hours as needed with a start date of 11/1/22 Bisacodyl rectal suppository as needed for constipation with a start date of 11/1/22 Haloperidol oral concentrate…

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, facility policy, and staff interview, the facility failed to implement non pharmacological care plan interventions prior to obtaining an order for a psychotropic medication for 1 of 6 residents reviewed (Resident #41). The facility reported a census of 42 residents. Findings include: The MDS dated [DATE] for Resident #41 revealed he had severely impaired decision making skills for daily life and needed partial to moderate assistance with toileting and transferring from chair to bed. Resident #41 had diagnoses of Alzheimer's disease, dementia, anxiety, and depression. The Nursing Note on 12/5/2023 at 9:30 PM written by Staff K, Licensed Practical Nurse (LPN) revealed the Resident appeared to be agitated, yelling, he was being physical towards staff, and he was trying to leave the building multiple times. Residents Doctor was notified for one time order for Lorazepam. Dr ordered 2mg Lorazepam PO. Resident was given Lorazepam at 2130 (9:30 PM), resident was given a cup of coffee, while…

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, facility policy, and staff interview, the facility failed to obtain a correct verbal order for a psychotropic medication with a dose administered that was not what was ordered for 1 of 6 residents reviewed (Resident #41). The facility reported a census of 42 residents. Findings include: The MDS dated [DATE] for Resident #41 revealed he had severely impaired decision making skills for daily life and he needed partial to moderate assistance with toileting and transferring from chair to bed. Resident #41 had diagnoses of Alzheimer's disease, dementia, anxiety, and depression. The Nursing Note on 12/5/2023 at 9:30 PM written by Staff K, Licensed Practical Nurse (LPN) revealed the Resident appeared to be agitated, yelling, he was being physical towards staff, and he was trying to leave the building multiple times. Residents Doctor was notified for one time order for Lorazepam. Dr ordered 2mg Lorazepam PO. Resident was given Lorazepam at 2130 (9:30 PM), resident was given a cup of coffee,…

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, facility policy, and staff interviews, the facility failed to administer influenza vaccination to 2 of 5 residents reviewed (Residents #9 and #39). The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #9 revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The resident did not receive an influenza vaccination because the facility did not offer one. 2. The MDS dated [DATE] for Resident #39 revealed a BIMS score of 14 which indicated intact cognition. The resident did not receive an influenza vaccination because the facility did not offer one. The clinical record included the Vaccine Consent Form signed by the resident on 10/3/23 to receive the influenza vaccine. The Order signed by a physician on 10/9/23 directed that the resident receive an influenza vaccination. The Immunizations- Residents Policy dated July 2023 directed in pertinent part that this facility to administer…

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, family and staff interviews and facility policy review, the facility failed to ensure residents were unable to ingest cream for external use only for 1 of 1 residents reviewed (Resident # 8). The facility reported a total census of 41 residents. Findings include: The The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 8 documented diagnoses non-Alzheimer ' s dementia, depression and arthritis. The MDS included a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. Review of the Progress Notes revealed the following: a. On 6/13/23 at 2:30 a.m., nurse was called to the resident's room by CNA ' s, the previous nurse left a small medicine cup of calmospetine ointment on the bedside table. The resident had taken the cup and with her fingers licked it out. Resident was alert and oriented and no coughing or shortness of breath noted. Nurse contacted Iowa Poison Control and received instructions if the resident was awake to give them…

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.