Westview Acres Care Center

Based on electronic health record review, document review, and staff interviews the facility failed to complete and submit a comprehensive assessment related to a significant change for 1 of 5 residents reviewed (Resident #5). The facility reported a census of 35 residents. Finding include: A review of the Electronic Health Record (EHR) for Resident #5 section Minimum Data Set (MDS) revealed the latest quarterly assessment completed on 3/13/2025. A review of the Care Plan for Resident #5 reflected a focus area Hospice initiated on 3/19/2025 due to a decline in health status. Interventions/Tasks documented the hospice services company name and a contact number for emergency services. It further describes steps to take in care of any decline and/or improvement in health. In an interview with the Director of Nursing (DON) on 6/05/25 at 11:10 am, she stated a significant change in Resident #5's health status occurred when the Care Plan was updated with the Hospice services initiated on 3/19/2025. The DON reviewed the EHR and noted there was no MDS entry made on or within 14 days 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.

Based on observations, staff interviews, document reviews, and policy review, the facility failed to implement a comprehensive water management program and identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. The facility also failed to implement appropriate hand hygiene practices during resident care. The facility reported a census of 40 residents. Findings include: 1. On 7/25/24 at 11:00 AM, the Maintenance Director stated the facility did not have a current water flow diagram, a water management plan, or a process in place to identify areas in the building to reduce the risk or growth of Legionella or other waterborne pathogens. On 7/25/24 at 11:20 AM, the Environmental Services Director stated she flushed every resident toilet and turned on the water in every resident room sink for 30 seconds every day. She also stated she wasn't able to provide documentation of the completed task. During an interview on 7/25/24 at 11:20 AM, the Director of Nursing (DON) stated there hadn't been a resident room vacant…

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, facility policy, and staff interview, the facility failed to have the Doctor signature on the Iowa Physician Orders for Scope of Treatment (IPOST) for 1 of 16 residents reviewed for Advance Directives (Resident # 17). The facility reported a census of 40 residents. Findings include: The Iowa Physician Orders for Scope of Treatment (IPOST) dated 12/11/23 revealed no Doctor signature for a code status of Do Not Resuscitate. On 7/23/24 at 10:05 AM the Social Worker (SW) revealed the IPOST did not get signed by the Doctor. The facility policy titled Advance Directives revised 7/18/24 instructed staff the residents attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the residents condition changes in an effort to clarify and adhere to the residents wishes. The Interdisciplinary Team will conduct ongoing review of the residents decision-making capacity and communicate significant changes to the residents legal representative. Such changes will be documented in the care plan 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 observations, resident interview, and policy review, the facility failed to respond to resident call lights in a timely manner for 5 of 5 residents reviewed (#1, #7, #13, #30, & #32). The facility reported a census of 40. Findings include: 1. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of hypertension, Non-Alzheimer's dementia, anxiety, depression, and bipolar disorder. It indicated the resident was independent in all activities of daily living (ADLs) but required moderate assistance with bathing. The Care Plan revised 12/28/23 documented Resident #13 is at moderate risk for falls and directed staff to encourage her to wear her shoes with all transfers and gripper socks when not wearing shoes. The Care Plan also directed staff to encourage her to get out of her bed and out of her room every day due to anxiety and tends to isolate herself. 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 employee file review, staff interview, and facility policy, the facility failed to ensure 1 of 5 staff members reviewed (Staff A, Certified Nurse Aide) completed the two hour Dependent Adult Abuse training within 6 months of their hire date. The facility reported a census of 40 residents. Findings include: Review of the employee file of Staff A, conducted on 7/24/24, revealed a hire date of 10/6/23. The employee file documented the Iowa Department of Public Health (IDPH) approved Dependent Adult Abuse Mandatory Reporter training was completed on 7/23/24. On 7/24/24 at 10:50 am, the Director of Nursing (DON) stated Staff A had done the training in February but failed to finalize it until 7/23/24. She stated the facility is conducting an audit of all employee files for current training. The facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, dated July 2019, documented the following: - Within six months of hire each employee shall be required to complete an initial 2-hour training course provided by the Iowa Department…

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 facility policy review, the facility failed to revise the care plan for 1 of 16 residents reviewed for revision of care plan (Resident #23). The facility reported a census of 40 residents. Findings include: The Minimum Data Sheet (MDS) assessment dated [DATE] identified a BIMS score of 14 which indicated cognition intact. The MDS revealed the resident independent with bed mobility, personal care, transfers, toileting, eating, and dressing. The MDS revealed the resident frequently incontinent of urine and occasional incontinent of bowel. The MDS documented diagnoses that included: other and unspecified nontraumatic intracranial hemorrhage, hypertension, diabetes mellitus, cerebrovascular accident, asthma, chronic obstructive pulmonary disease (COPD), morbid (Severe) obesity, unspecified mental disorder due to known physiological condition, restless legs syndrome, and atrial fibrillation. The MDS revealed antidepressant, insulin, and diuretic. The Care Plan…

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 ensure a psychotropic medication (a medication that affects a person's mental state) gradual dose reduction (GDR) was appropriately attempted for 1 of 1 resident (#13) reviewed. The facility reported a census of 40. Findings include: On 7/22/24 at 4:19 PM, Resident #13 stated she slept about 5 hours during the daytime after sleeping at night. She did not know what medications she was prescribed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of hypertension, Non-Alzheimer's dementia, anxiety, depression, and bipolar disorder. It indicated the resident received an antidepressant and antianxiety medication but had not exhibited a crying episode during the previous 7-day look-back period. The Electronic Health Record (EHR) included an order dated 12/07/23 for Buspirone…

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

Based on staff interviews, facility record review, facility policy review, and Centers for Disease Control information the facility failed to follow proper infection control practices to mitigate the risk for the spread of infectious disease. The facility reported a resident census of 33. Findings include: On 2/27/24 at 8:00 a.m. Staff C, Dietary Aide (DA), stated she has gotten COVID twice since working at the facility. Staff C stated she doesn't recall specific dates, but recalled in September 2023, not feeling well and discussed her symptoms with the cook. Staff C stated she then texted the Dietary Supervisor (DS) and reported her symptoms. The DS instructed her to take a COVID test per protocol. Staff C stated she did and it was positive for COVID. Staff C stated she texted the DS with the results and was instructed to go home per protocol. Staff C stated she was not allowed to work for several days. On 2/27/24 at 8:25 a.m. the Dietary Supervisor (DS) stated she recalled receiving a text from Staff C reporting that she was not feeling well. The DS stated she still had the text…

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

Based on clinical record review, staff interview and facility policy review the facility failed to provide bed hold notice for 1 of 1 residents reviewed (Resident #25). The facility reported a census of 34. Findings include: The Minimum Data Set (MDS) assessment tool dated 5/2/23 for Resident #25 documented a Brief Interview for Mental Status (BIMS) of 6 out of 15 possible points indicating severe cognitive impairment. Review of the Clinical Census revealed Resident #25 discharged from the facility to the hospital on 3/31/23. The clinical record lacked documentation of any explanation of the bed hold notification to the resident or the resident's representative when the resident discharged to the hospital on 3/31/23. In an interview on 5/23/23 at 12:49 PM, Staff A, Social Services reported there was not a bed hold notice completed for Resident #25 for his transfer to the hospital and the nurse had forgot to complete one. In an interview on 5/23/23 at 1:12 PM, the Director of Nursing (DON) stated it was the expectation a bed hold be completed every time a resident was transferred 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 observations, staff interviews and facility policy review, the facility failed to ensure food and medications were not stored together in the same refrigerator for 2 of 2 unit medication storage refrigerators. The facility reported a census of 34 residents. Findings included: On 05/22/23 at 02:40 PM, an observation of the [NAME] and East nursing station medication refrigerators revealed multiple insulin vials along with chocolate pudding containers, applesauce pouches, and liquid thickener used during medication pass. On 05/23/23 at 07:32 AM, Staff C, Licensed Practical Nurse (LPN) stated the applesauce is kept in the door of the refrigerator at the East nursing station because the residents like it cold with the medication. She stated that is where it has always been kept. On 05/23/23 at 01:00 PM, the Director of Nursing confirmed the medication storage policy specified that food was not to be stored with medications in the same refrigerator. On 05/23/23 at 01:02 PM, the facility policy titled Medication Storage in the Facility revised January 2018 instructed staff that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and facility policy review, the facility failed to ensure the sanitizing solution used to clean kitchen equipment maintained proper dilution levels to adequately disinfect kitchen equipment. The facility reported a census of 34 residents. Findings include: On 5/22/23 at 11:45 AM, Staff D, Dietary Cook, wiped a food serving counter with a rag immersed in a sanitizing solution bucket. On 5/22/23 at 12:00 PM, Staff D, Dietary Cook, performed a sanitizing solution concentration check. She removed approximately two (2) inches of ribbon from a Hydrion QT-40 test strip case and submerged it into the sanitizing solution for six (6) seconds. She removed the strip from the solution and compared it to the reference chart on the back of the strip case. She verbalized the result was 0 parts-per-million (ppm). On 5/22/23 at 12:02 PM, Staff E, Dietary Cook, performed a sanitizing solution concentration check on a separate bucket. She removed approximately two (2) inches of ribbon from 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 personnel record review, staff interviews, and facility policy review the facility failed to ensure all employees received education and training on what constitutes abuse and the facilities procedures for reporting incidents of abuse when 1 of 5 staff files (Staff B) reviewed did not complete; The State of Iowa Department of Health and Human Services (HHS), Dependent Adult Abuse Mandatory Reporter Training, within the past three (3) years. The facility reported a census of 34 residents. Findings include: Record review of Staff B, Certified Nursing Assistant, staff file on [DATE] at 1:25 PM revealed her Dependent Adult Abuse Mandatory Training was completed on [DATE] and expired on [DATE]. During an interview on [DATE] at 1:58 PM with the Administrator, she stated it was her expectation for all employees to be up to date on all training including Dependent Adult Abuse Mandatory Reporter Training. During an interview on [DATE] at 2:03 PM with the Director of Nursing, she stated it was her expectation 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.