Harvest Acres Nursing and Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and the facility policy, the facility failed to notify the provider for blood glucose levels over 400 mg/dl (milligrams per deciliter) for 1 of 3 residents reviewed for assessment/intervention (Resident #1). The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated that cognition severely impaired. The MDS revealed diagnosis for Type II diabetes mellitus and the resident received insulin 4 out of 7 days. The Care plan revealed a focus area dated 11/17/25 for potential for hypo/hyperglycemia related to diabetes mellitus and resident had a Dexcom. The interventions dated 11/17/25 revealed accuchecks as ordered, and call MD (Medical Director) for accuchecks greater than 400 and less than 70.The Electronic Medical Record (EMR) revealed the following Physician Orders: a. dated 11/10/25- Blood Glucose…

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, interviews, and policy review the facility failed to maintain a medication administration error rate under 5% related to unprofessional standards and principles during the survey process. Of 31 medications observed 3 were not administered according to provider orders or medication inserts, and a missing medicated patch that was to be removed from a resident was not located. (Residents #1, 7,12, and 13) The facility reported a census of 27 residents.Findings include:1. The Minimum Data Set (MDS) for Resident #1 dated 11/10/25 documented diagnoses of pneumonia, thyroid disorder, and schizophrenia. The Brief Interview for Mental Status (BIMS) documented a score of 5/15 which indicated severely impaired cognition.At 7:47 AM on 12/9/24 Resident #1 was observed seated in a recliner in the common area after eating breakfast.During a medication administration observation on 12/9/25 at 8:02 AM Staff B, Licensed Practical Nurse (LPN) administered Levothyroxine Sodium Oral…

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, interviews, and policy review the facility failed to administer medications in a sanitary manner during medication administration. A nurse was observed putting pills in her hand before putting them in medication cups, applying a medicated patch without washing her hands afterward, and touching personal items between medication passes without washing her hands. The facility reported a census of 27 residents.Findings include:During a medication administration observation on 12/9/25 at 7:35 AM Staff B, Licensed Practical Nurse (LPN) unlocked the medication cart to administer medication. The Electronic Health Record (EHR) showed the resident was scheduled for a controlled medication located in a second locked area of the cart. Staff B took out the resident's medication card for Trazodone, matched the card to the EHR, and popped the pill into her left hand, and placed it in the pill cup. After administering the medication she washed her hands and moved on to another resident. During a medication administration observation on 12/9/25 at 7:49…

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, policy review, and staff interviews, the facility failed to ensure sufficient nursing staff to provide care to residents in accordance with the care plan by failing to supervise 1 of 1 resident with a history of physical resident to resident altercations from other residents(Resident #22) and by failing to provide timely assistance for 1 of 1 resident reviewed with a history of falls and seizures(Resident #2). The facility reported a census of 26 residents. Findings include: 1. The Minimum Data Set(MDS) assessment tool, dated 6/21/24, listed diagnoses for Resident #22 which included diabetes, arthritis, and hip fracture. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 1 out of 15, indicating severely impaired cognition. The MDS stated the resident had the following: a. physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) which occurred 1-3 days out of the 7 day review period. b. verbal behavioral symptoms directed towards others (e.g.,…

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, policy review, and staff interview, the facility failed to provide care and services according to accepted standards of clinical practice by preparing medications in advance for 4 of 9 residents(Residents #2, #9, #11, #12) observed during observations of the medication administration pass and the medication cart. The facility reported a census of 26 residents. Findings include: On 11/6/24 at 5:59 a.m., Staff B Licensed Practical Nurse(LPN) walked up to the medication cart and unlocked it. In the top drawer of the cart, there was an unlabeled medication cup which contained 3 pills. Staff B stated she just set them up and stated they were Resident # 3's Amlodipine(a blood pressure medication), Carbidopa(a medication used to treat Parkinson's, a disease which causes symptoms such as tremors), and Citalopram(an antidepressant). Staff B stated she just set them up. On 11/13/24 at 8:24 a.m., the top drawer of the medication cart located in the medication room contained 3 unlabeled medication cups each containing multiple medications. Staff B…

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 2567 review, staff 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 identified on the facility's current recertification and complaint survey that were previously identified during surveys completed in the last twelve months. The facility reported a census of 26 residents. Findings include: Review of the facility's CMS-2567 form from a recertification and complaint survey dated 1/16/24 to 1/23/24 revealed, in part, deficient practices identified with advanced directives, care plan revision, activities of daily living related to incontinence care, lack of a qualified Infection Preventionist to attend Quality Assurance meetings, and lack of a qualified Infection Preventionist. During the facility's current recertification and complaint survey initiated 11/4/24 to 11/19/24, deficient practices were again identified with all of the above areas from the facility's previous…

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 employ a required Quality Assurance(QA) committee member, a qualified Infection Preventionist, to perform infection control surveillance and report to the governing body. The facility reported a census of 26 residents. Findings include: The QAPI Plan, dated 9/01/2021, revealed that staff members with the most knowledge and commitment to QAPI efforts will participate. Review of QAPI sign in sheets between 3/21/24 and 9/25/24 revealed no Infection Preventionist had been identified as present at meetings. The Facility Assessment, reviewed by Quality Assurance Committee on 8/15/24, revealed services and care offered based on resident needs included infection prevention and control, identification and containment of infection, and prevention of infections. On 11/19/24 at 2:06 PM, Facility Administrator reported that Director of Nursing (DON) had acted as Infection Preventionist for the facility, but was unsure if DON had been certified. Administrator informed that facility was unable to produce an Infection Preventionist…

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 policy review and staff interviews the facility failed to provide an Infection Preventionist with specialized training or certification to monitor and provide oversight for the facility's Infection Prevention and Control Program. The facility reported a census of 26 residents. Findings include: The facility policy titled, Infection Prevention and Control Program, revised 10/2018, revealed that the facility's infection prevention and control program is coordinated and overseen by the facility Infection Preventionist. On 11/19/24 at 2:06 PM, Facility Administrator reported that Director of Nursing (DON) had acted as Infection Preventionist for the facility, but was unsure if DON had been certified. Administrator informed that facility was unable to produce an Infection Preventionist certification. Director of Nursing (DON) unavailable during periods of state survey to provide additional information on Infection Preventionist certification. On 11/19/24, the facility was unable to produce any data that indicated a certified Infection Preventionist was employed at the facility.

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 ensure residents were treated in a manner to preserve dignity and respect for 1 of 2 residents reviewed for dignity (Resident #20) when staff failed to ensure residents had been kept clean and free from odors following episodes of incontinence in a timely manner (Resident #20), made unkind comments in the presence of residents in the dining room, and staff interview revealed concerns with a staff member being unkind. The facility reported a census of 26 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. Resident #20 required substantial to maximal amount of staff assistance for toilet hygiene and frequently incontinent of urine. Diagnoses included non-traumatic brain dysfunction, non-Alzheimer's dementia, heart failure, depression, 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 observation, interview, and record review, the facility failed to ensure consistent documentation of code status to indicate whether to perform Cardiopulmonary Resuscitation (CPR) or Do Not Resuscitate (DNR) status for one of three residents reviewed for advanced directives (Resident #22). The facility reported a census of 26 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #22 dated [DATE] revealed the resident scored 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Review of the Resident's Care Plan did not address the resident's code status. On [DATE], review of Resident #22's chart revealed an Iowa Physician Orders for Scope of Treatment (IPOST) form dated [DATE] which directed CPR/Attempt Resuscitation. The resident was noted to have a DNR order in the resident's electronic orders. Review of the Physician Order dated [DATE] revealed, DNR (DO NOT RESUSCITATE). On [DATE] at 10:14 AM, Staff B,…

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 clinical record review, the facility failed to safeguard the resident ' s personal and medical information. The facility reported a census of 26 residents. Findings Include: On 11/06/24 between 08:23a.m. -8:26 a.m., State Agency (SA) observed the computer left on and no one at the nurses desk with the point click care system (electronic charting software) open to document on residents and several names displayed. On 11/06/24 between 09:22 a.m. -11/06/24 09:31 a.m. when the computer timed out, the point click care (PCC) was open with several residents ' names displayed and no one sitting at desk. On 11/06/24 at 12:54 p.m., PCC system was open on a resident ' s chart and no one was sitting at the desk. On 11/06/24 at 02:25 p.m., Staff D, LPN walked away and left the resident chart open. Staff D, LPN Went to grab something in a different room and came back to the computer. Resident Rights Policy Statement with revised date of January 2019, directed staff as follows; The unauthorized release, access, or disclosure of resident information is…

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, policy review, and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman of a hospital transfer for 1 of 4 residents reviewed for hospitalizations(Resident #3). The facility reported a census of 26 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool, dated 9/18/24, listed diagnoses for Resident #3 which included diabetes, non-Alzheimer's dementia, and psychotic disorder. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 0 out of 15, indicating severely impaired cognition. The facility policy Transfer or Discharge, Facility-Initiated, dated October 2022, stated the facility would provide notice of therapeutic discharges to the long-term care ombudsman. A 10/19/24 Physician's Order Note stated the facility received an order to send the resident to the ER for evaluation and treatment. A 10/21/24 Health Status Note stated the resident returned to the facility. The facility lacked documentation of notification of the transfer to the Office of the State…

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, and record review the facility failed to complete a significant change assessment following a resident starting hospice services for one of three residents reviewed for hospice (Resident #22). The facility reported a census of 26 residents. Findings include: Review of the quarterly Minimum Data Set (MDS) assessment for Resident #22 dated 9/18/24 revealed the resident scored 00 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident did not receive hospice services while a resident. The next MDS for the resident was a quarterly assessment dated [DATE], which remained in progress. Review of Resident #22's Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 10/1/24 revealed start of care date for hospice services on 9/19/24. On 11/19/24 at 12:34 PM during an interview with a Director of Nursing (DON) from a sister facility, the DON queried about…

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 3. The MDS assessment tool, dated 10/23/24, listed diagnoses for Resident #3 which included non-Alzheimer's dementia, depression, and psychotic disorder. The MDS stated the resident was dependent on staff for toilet and chair transfers and listed his BIMS score as 0 out of 15, indicating severely impaired cognition. A 9/10/24 Care Plan entry stated the resident transferred independently. On 11/6/24 at 12:15 p.m., Staff C Certified Nursing Assistant(CNA) and Staff M CNA assisted the resident with a gait belt to stand up in order to pull down his pants and remove his brief. On 11/19/24 at 1:59 via phone, the Director of Nursing of a sister facility stated Care Plans should be up to date with regard to transfer status. Based on interview, record review, and facility policy review the facility failed to ensure Care Plan revision following discontinuation of antidepressant medication, failed to revise to include receipt of hospice services, failed to revise to include new skin concerns, and failed to revise 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure timely assistance with incontinence cares and positioning for 3 of 3 residents reviewed for incontinence cares (Residents #3, #20, and #22) and failed to provide eating assistance for 1 of 3 residents reviewed for nutrition(Resident #20). The facility reported a census of 26 residents. Findings include: 1. The Significant Change Minimum Data Set(MDS) assessment tool, dated 10/23/24, listed diagnoses for Resident #3 which included diabetes, non-Alzheimer's dementia, and psychotic disorder. The MDS stated the resident was dependent on staff for toilet transfers and toileting hygiene and was always incontinent of bowel and bladder. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 0 out of 15, indicating severely impaired cognition. Care Plan entries, dated 3/20/24, directed staff to ensure the resident toileted frequently before meals, after meals, at bedtime, and as needed.…

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, policy review, and staff interview, the facility failed to provide ongoing, resident centered activities for 2 of 2 residents reviewed for activities(Residents #3, and #11). The facility reported a census of 26 residents. Findings: 1. The annual Minimum Data Set(MDS) assessment tool, dated 12/10/23, listed diagnoses for Resident #3 which included non-Alzheimer's dementia, diabetes, and arthritis. The MDS stated the resident felt the following activities were somewhat important: group activities, news, fresh air. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 7 out of 15, indicating severely impaired cognition. Care Plan entries, dated 1/1/24, stated the resident had the potential for alteration in recreational activities and socialization related to cognition, diabetes, depression, psychotic disorder and arthritis. The entries stated the resident enjoyed playing cards, attending group activities, bantering with other residents, singing, dog visits, music, outdoor events, exercises, table games, good…

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 record review the facility failed to treat a urinary tract infection in a timely manner for one of two residents reviewed for urinary tract infection (Resident #12). The facility reported a census of 26 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 9/13/24 revealed the resident scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident was frequently incontinent of urine. The Care Plan dated 2/18/24 revealed, [Resident #12] has episodes of bladder incontinence and is at risk for impaired skin, UTI's, irritation in the peri-area. The Intervention dated 2/18/24 revealed, Monitor/document for s/sx (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The Health Status Note dated 10/25/24 at 4:50 PM…

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

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to ensure the dimensions from the mattress to the bed rail or the bed rail gaps were less than 4 3/4 inches to ensure the bed rails did not pose a risk of entrapment or injury for 1 of 26 residents reviewed for bed rail safety(Resident #2). The facility reported a census of 26 residents. Findings include: The Minimum Data Set(MDS) assessment tool, dated 9/13/24, listed diagnoses for Resident #2 which included seizure disorder, anxiety disorder, and depression. The MDS stated the resident was independent with rolling right to left and moving from lying to sitting. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 0 out of 15, indicating severely impaired cognition. A 9/10/24 Bed Rails Informed Consent for Use stated the resident utilized bed rails for mobility and security(fear of falling out of bed). Care Plan entries, dated 9/10/24 , stated the resident was at risk for injury related to the use of bed rails/grab bars and stated the resident had a right…

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, policy review, and staff interview, the facility failed to provide necessary behavioral health care such as psychiatric services and the development and implementation of person-centered care plans that included and supported the behavioral health care needs for 1 of 2 residents reviewed for behaviors(Resident #17). The facility reported a census of 26 residents. Findings include: The Minimum Data Set(MDS) assessment tool, dated 9/4/24, listed diagnoses for Resident #17 which included traumatic brain injury, depression, and alcohol abuse with alcohol-induced mood disorder. The MDS stated the resident had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) which occurred 1-3 days out of the 7 day review period, verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) which occurred 4-6 days out of the 7 day review period, other behavioral symptoms not directed toward others (e.g., physical symptoms such as…

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, policy review, and staff interviews, the facility failed to ensure its medication error rates were not 5 percent or greater. The facility's medication error rate calculated as 12% after staff administered an incorrect dose of Vitamin D3, failed to prime an insulin pen, and failed to administer insulin in a timely manner with regard to the meal time. The facility reported a census of 26 residents. Findings include: a. On 11/6/24 at 6:20 a.m., Staff B Licensed Practical Nurse(LPN) administered Vitamin D3 125 micrograms(mcg) to Resident #4. The November 2024 MAR(Medication Administration Record) listed an order for Vitamin D3 50 mcg 1 tablet orally one time a day. b. On 11/6/24 at 6:26 a.m., Staff B LPN checked Resident #2's blood sugar and it was 136 milligrams/deciliter(mg/dl). Staff B set the dosage of Resident #4's Humalog(a type of insulin) pen to 5 units and set the dosage of her Humulin(a type of insulin) pen to 5 units. Staff B did not prime the needle prior to setting the dose to 5 units. After the State Agency(SA) queried her as…

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, policy review, and staff interview, the facility failed to ensure residents were free of significant medication errors by failing to ensure a resident consumed food in a timely manner after the administration of rapid acting insulin(Resident #4) and by failing to prime insulin pens prior to administration The facility reported a census of 26 residents. Findings include: The Minimum Data Set(MDS) assessment tool, dated 10/16/24 listed diagnoses for Resident #4 which included diabetes, non-Alzheimer's dementia, and unspecified dementia. The MDS listed the resident's Brief Interview for Mental Status score as 6 out of 15, indicating severely impaired cognition. On 11/6/24 at 6:26 a.m., Staff B Licensed Practical Nurse(LPN) checked Resident #2's blood sugar and it was 136 mg/dl. Staff B set the dosage of Resident #4's Humalog pen to 5 units and set the dosage of her Humulin pen to 5 units. Staff B did not prime the needle prior to setting the dose to 5 units. After the State Agency(SA) queried her as to if there was anything additional 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 observation, interview, clinical record review, and facility documents review, the facility failed to ensure all menu items were served to residents with an alternate diet for 2 of 2 residents (R#1 and R#226) on a pureed diet. The facility reported a census of 26 residents. Findings include: 1. The Care Plan, revised 2/20/24, revealed that Resident #1 is at risk for nutritional problems related to diagnosis of Cerebral Palsy and required pureed diet with honey thickened liquids. Resident #1 diet order, dated 10/27/2017, revealed order for regular, puree texture diet and honey consistency drinks. Review of Nutritional Assessment, dated 11/04/24, informed that Resident #1 remains at increased risk for altered nutrition. 2. The Care Plan, dated 10/31/24, revealed that Resident #226 has nutritional problem or potential for nutritional problem and required regular diet with pureed texture. Resident #226 diet order, dated 10/31/24, revealed order for regular, puree texture diet and thin liquids. Review of Nutritional Assessment, dated 11/04/24, informed that Resident #226 is 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, the facility failed to ensure the accuracy of records for 1 of 2 residents receiving Hospice services(Resident #9) and for 1 of 5 residents reviewed for a change in condition(Resident #20). The facility reported a census of 26 residents. Findings include: 1. The Minimum Data Set(MDS) assessment tool, dated 8/14/24, listed diagnoses for Resident #9 which included Parkinson's disease(a disease which causes symptoms such as tremors), anxiety, and depression and listed his Brief Interview for Mental Status(BIMS) score as 9 out of 15, indicating moderately impaired cognition. An 8/27/24 Hospice Discharge Summary stated the resident was no longer terminally ill and discharged from Hospice on 8/23/24. A 10/1/24 Nursing Note stated the provider visited on 9/25/24 with no new orders and to continue on Hospice. A provider Encounter Note, dated 10/23/24, stated the resident received Hospice services. An 11/4/24 Dietary Note stated the resident remained 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 observation, policy review, and staff interview, the facility failed to carry out infection control practices for 1 of 6 residents observed during medication pass observations(Resident #6). The facility reported a census of 26 residents. Findings include: On 11/6/24 at 6:08 a.m., Staff B Licensed Practical Nurse(LPN) administered the following medications(pills) to Resident #6: Lisinopril(a medication for blood pressure), Olanzapine(an antipsychotic), calcium and vitamin D, iron, and Omeprazole(a medication for heartburn). The resident dropped one of the pills in his lap and Staff B picked up the medication with her bare hand and placed it back in the resident's mouth. On 11/19/24 at 1:59 via phone, the Director of Nursing(DON) of a sister facility stated staff should pick up medications with gloved hands. The facility policy Administering Medications, revised December 2012, directed staff to follow infection control procedures during the administration of medications.

Based on record review and staff interviews, the facility failed to implement an infection control surveillance plan to identify, track, monitor and report infections. The facility failed to provide documented evidence from February 2023 through January 2024 for an infection control surveillance program. The facility reported a census of 27 residents. The findings include: The facility provided a document titled Monthly Surveillance Report dated January 2023 which revealed: A Urinary Tract Infection (UTI) treated with an antibiotic. An eye infection The facility provided 3 documents titled Anti-infectives for Keota Healthcare Center revealed: Dated 2/1/23 to 2/28/23 listed a resident name and medication. Dated 3/1/23 to 3/31/23 listed 2 residents and 4 medications. Dated 4/1/23 to 4/30/23 listed 4 residents and 5 medications. Lacked evidence of surveillance for February, March and April 2023. The Facility Assessment amended on date 1/3/23 listed Services and Care Offered Based on Resident Needs revealed infection prevention and control, identification and containment of infection…

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 facility policy, facility document review or lack of, and staff interviews the facility failed to maintain an Infection Prevention and Control Program (ICPC) that included a functional Antibiotic Stewardship Program. The failure to have a system in place that monitors antibiotic use in accordance with established protocols has the potential to affect all 27 residents of the facility. Findings Include: Review of a policy provided by the facility titled Antibiotic Stewardship revised October 2018, documented antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. 1. Review of Resident # 2 Electronic Medical…

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 policy review and staff interviews the facility failed to provide an Infection Preventionist with specialized training or certification to monitor and provide oversight for the facility's Infection Prevention and Control Program. The facility reported a census of 27 residents. Findings include: The policy, titled Infection Control Policy and Procedure Manual, OBRA regulations and Interpretive Guidelines page 35, revised 08/2017, documented the facility Infection Preventionist is responsible for the facility's infection prevention and control program. On 01/22/24 8:47 AM Staff A, RN and Infection Control Preventionist, reported she had taken the Centers for Disease Control (CDC), Infection Control Preventionist course but was unable to take the certification test. Completed documentation for a specialized staff Infection Preventionist was not available. Staff Staff A demonstrated a lack of understanding of information necessary to complete her duties as the facility Infection Preventionist. She indicated she took over the infection prevention role several months ago. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy the facility failed to implement advanced directives per resident and family directives upon admission for 1 of 3 residents reviewed and failed to clarify conflicting orders for 1 of 3 residents reviewed (Resident#5). The facility reported a census of 27 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #5 had the diagnoses including Diabetes Mellitus, stroke, and dementia. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The Care Plan dated [DATE] directed staff in regards to the care of Resident #5 as follows; a. Advanced Directives, the resident wishes to be Full Code. b. Initiate transfer to the hospital of choice. c. Maintain a copy of code status in the chart. A Clinical Resident Profile documented the resident code status as full code, with initial admission date of [DATE]. The Iowa Physician Orders for…

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 interviews the facility failed to ensure resubmission of the Preadmission Screening and Resident Review (PASRR) following new mental health diagnoses for 1 of 2 residents reviewed for PASRR (Resident #25). The facility reported a census of 27 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 documented diagnoses including, neurological conditions, diabetes, encephalopathy, hypokalemia, delirium due to known physiological condition. Did not include any diagnosis in the psychiatric, mood category. A Brief Interview for Mental Status (BIMS) assessment coded 5 out of 15 which indicated severe cognitive impairment. The Quarterly, Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 documented diagnoses including, orthopedic conditions, diabetes, delirium due to known physiological condition. Major depressive disorder, recurrent, unspecified was added and encephalopathy diagnosis had been removed. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review, the facility failed to complete a care plan within 48 hours of admission for one of one newly-admitted residents reviewed (Resident #25). The facility reported a census of 27 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] documented resident admitted to the nursing facility from the hospital on [DATE]. The initial Care plan dated 5/24/23 documented Resident #25 potential risk for altered nutritional status as evidenced by history of encephalopathy, confusion, diabetes, constipation, and obesity. The Care plan clinical electronic health record lacked any documentation of a baseline care plan being completed within 48 hours of the resident's admission to the facility to direct staff on resident care needs. An Interview on 01/22/24 at 01:02 PM with the Business Office Manager (BOM) revealed a base line care plan could not be located in the clinical electronic record and was not in the resident's hard chart. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, and staff interviews, the facility failed to update a Care Plan to include antipsychotic medication for 1 of 5 resident's care plan reviewed for unnecessary medications (Resident #25). The facility reported a census of 27 residents. Findings Include: The Quarterly, Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 documented diagnoses including, orthopedic conditions, diabetes, delirium due to known physiological condition. Major depressive disorder, recurrent, unspecified was added and encephalopathy diagnosis had been removed. The MDS coded that antipsychotic medications were given during the last seven days and resident received on a routine basis. BIMS Score coded 7 out of 15 which indicated severe cognitive impairment. The Care Plan last revised on 1/10/24 documented that Resident #25 received antidepressant, diuretic, antihypertensive and antidiabetic medication. The Care Plan did not address that the resident received an antipsychotic…

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 interview, clinical record review and policy review, the facility failed to ensure resident is dry and free from odors for 1 of 3 reviewed for incontinent residents (Resident #3). The facility reported a census of 27. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool, dated 12/21/23 listed diagnoses for Resident #3 which included medically complex conditions, cancer, heart disease, renal disease, dementia, malnutrition, anxiety, pulmonary disease. The MDS coded the resident for always incontinent of urine, revealed substantial and maximal assistance needed for toileting and hygiene. The Brief Interview for Mental Status (BIMS) assessment was not scored, which indicated the resident with cognitive impairment. The MDS document that the resident was rarely/never understood. The Care Plan with revision date of 3/22/23 documented the following for Resident #3; incontinent of bladder with risks of skin integrity, falls and infection. The Care Plan interventions directed staff to clean peri-area with each incontinence, monitor and document…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to limit a As Needed (PRN) psychotropic medication to fourteen (14) day limit and failed ensure Gradual Dose Reduction (GDR) for 2 of 5 residents reviewed for unnecessary medications (Resident #15 & #25). The facility reported a census of 27 residents. Findings include: 1. The Quarterly, Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 included diagnoses, orthopedic conditions, diabetes, delirium due to known physiological condition and major depressive disorder, recurrent, unspecified. A Brief Interview for Mental Status (BIMS) assessment coded 7 out of 15 which indicated severe cognitive impairment The Care Plan with last revision date of 1/10/24 documented that Resident #25 received antidepressant, diuretic, antihypertensive and antidiabetic medication. The Care Plan fail to address that the resident received a psychotropic medication. The Medication Administration Record (MAR) dated January 2024 for…

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 employ a required Quality Assurance(QA) committee member, a qualified Infection Preventionist, to perform infection control surveillance and report to the governing body, and the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis. The facility reported a census of 27 residents. Findings Include: The QAPI Plan dated 9/1/22 revealed: a. QAPI meetings will be held no less than quarterly. b. Staff members with the most knowledge and commitment to QAPI efforts will participate. The Facility Assessment amended on date 1/3/23 listed Services and Care Offered Based on Resident Needs revealed infection prevention and control, identification and containment of infection and prevention of infections. This also included a Staffing Plan that revealed the facility worked to recruit and maintain appropriate staffing levels to meet the residents' needs. In the event of staff openings in the nursing department, nursing administration will be available to assure that all…

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.