Harmony Marshalltown

Based on electronic health record review, staff interview, and state regulation review, the facility failed to initiate and complete resident assessments in a timely manner for 1 of 3 residents reviewed nursing for supervision (Resident #1). On 2/17/25, the facility staff observed a bruise to Resident #1's face. The facility failed to conduct neurological assessments following the injury to Resident #1's face, even after Resident #1 reported someone knocked her into the wall. Then on 4/7/25, after Resident #1 returned to the facility from exiting independently without staff knowledge, the facility failed to conduct a thorough assessment of her. The facility reported a census of 52. Findings include: Resident #1's Minimum Data Set (MDS) assessment, dated 3/6/25, identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required substantial to maximum assistance with transfers and moving from sitting to standing. The MDS included diagnoses of Alzheimer's disease, generalized muscle weakness, history of an ischium (the bones…

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 record review, facility document review, staff interviews, and policy review, the facility failed to provide adequate supervision resulting in a resident elopement for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 52. Findings include: Resident #1's Minimum Data Set (MDS) assessment, dated 3/6/25, identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required substantial to maximum assistance with transfers and moving from sitting to standing. The MDS included diagnoses of anxiety, Alzheimer's disease, generalized muscle weakness, history of an ischium (the bones humans sit on that connect 3 strong bones together) fracture, and respiratory failure. The MDS reflected Resident #1 used a wander/elopement alarm. The Care Plan last reviewed 3/7/25 included the following Focus areas: a. 9/16/24: Resident #1 required assistance with activities of daily living (ADLs). i. Transfer with substantial to maximal assistance of 2 staff with a front wheeled walker (FWW). ii.…

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 record review, staff interview and policy review, the facility failed to ensure the nursing staff had the knowledge to initiate appropriate responses during resident care for 1 of 3 residents reviewed for nursing supervision (Resident #1). The facility reported a census of 52. Findings include: Resident #1's Minimum Data Set (MDS) assessment, dated 3/6/25, identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required substantial to maximum assistance with transfers and moving from sitting to standing. The MDS included diagnoses of anxiety, Alzheimer's disease, generalized muscle weakness, history of an ischium (the bones humans sit on that connect 3 strong bones together) fracture, and respiratory failure. The MDS reflected Resident #1 used a wander/elopement alarm. The Care Plan last reviewed 3/7/25 included the following Focus areas: a. 9/16/24: Resident #1 required assistance with activities of daily living (ADLs). i. Transfer with substantial to maximal assistance of 2 staff with a front…

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 record review, staff interviews, and policy review, the facility failed to ensure the resident's medical record contained sufficient and adequate medical information for 2 of 3 residents reviewed for nursing supervision (Residents #1 and #3). The facility reported a census of 52. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment, dated 3/6/25, identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Resident #1 required substantial to maximum assistance with transfers and moving from sitting to standing. The MDS included diagnoses of anxiety, Alzheimer's disease, generalized muscle weakness, history of an ischium (the bones humans sit on that connect 3 strong bones together) fracture, and respiratory failure. The MDS reflected Resident #1 used a wander/elopement alarm. The Care Plan last reviewed 3/7/25 included the following Focus areas: a. 9/16/24: Resident #1 required assistance with activities of daily living (ADLs). i. Transfer with substantial to maximal assistance of 2 staff with a…

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

Based on observation, staff interview, and facility policy, the facility failed to protect food from contamination during meal service. The facility reported a census of 55 residents. Findings include: On 12/11/24 at 11:20 AM, observed Staff F, Dietary Aide, prepare multiple peanut butter and jelly sandwiches. Under constant observation Staff F repeatedly touched the bread with gloved hands while making the sandwiches. In addition, Staff F touched a variety of surfaces with their gloved hands including, but not limited to: the outside of the bread bag, the surface of the counter, pen pulled and replaced in Staff F's pocket, the peanut butter container, jelly squeeze bottle, and storage bags. On 12/11/24 at 12:20 PM, watched Staff G, Cook, prepare toast. Under constant observation Staff G touched the bread when placing slices in the toaster after touching a variety of surfaces with gloved hands including, the counter top, drawer handle, and toaster. On 12/11/24 at 12:25 PM, Staff E, Dietary Aide, prepared a grilled turkey and cheese sandwich. Under constant observation 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 resident, family and staff interviews and policy review, the facility failed to maintain the confidentiality of a resident's private personal and medical records for 1 of 1 resident reviewed (Resident #27). The facility reported a census of 55 residents. Findings included: In an interview on 12/10/24 at 10:39 AM, Resident #27 reported their family member found another resident of the facility's death certificate who passed away on 11/23/34 on a bedside table in his room. He stated the family member turned it into the head nurse. He reported he didn't know it was there and didn't look at it prior to their family member finding the document. In an interview on 12/10/24 at 1:00 PM, Resident #27's family member reported a couple of weeks before they saw a paper on Resident #27's night stand below his television (TV). They thought it was a list of his upcoming appointments. When they opened it, they found it was actually another resident from the facility's death certificate. They explained they took the paper to the Director of Nursing (DON) and reported finding it in 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 staff interview, clinical record review and Preadmission Screening and Resident Review (PASRR) evaluation, the facility failed to complete a PASRR screening for 1 out of 2 residents reviewed in the current sample who had mental health changes (Resident #40). The facility reported a census of 55 residents. Findings include: Resident #40's Minimum Data Set (MDS) assessment dated [DATE] identified an incomplete Brief Interview for Mental Status (BIMS), due to being unable to complete the interview. The MDS included diagnoses of psychiatric/mood disorders including anxiety, depression, psychotic disorders. Resident #40 used antipsychotic and antidepressant medications within the lookback period. The Care Plan Focus dated 10/7/24 identified Resident #40 used psychotropic medications related to depression. The Care Plan lacked the updated mental health diagnosis. The Notice of PASRR Level I Screen Outcome dated 11/1/22 reflected the facility completed the assessment due to Resident #40's admission to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review, the facility failed to fully review and revise the comprehensive Care Plan for 3 of 20 residents (Residents #1, #2 and #40) sampled for Care Plan review. The facility reported a census of 55 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of medically complex conditions, heart failure, non Alzheimer's dementia, anxiety disorder, bipolar disorder and post-traumatic stress disorder (PTSD). Resident #1's electronic health record included an order dated 11/19/24 for sertraline HCI oral tablet 150 milligrams (mg) one time a day related to generalized anxiety disorder and unspecified dementia. Resident #1's Medical Diagnosis reviewed 12/11/24 reflected a diagnosis dated 7/18/24 of unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance 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, observation, family interview, staff interview and facility policy the facility failed to adequately manage a resident's urinary catheter to minimize risk for infections for 1 of 2 residents reviewed for catheters (Resident #56). The facility reported a census of 55 residents. Findings include: Resident #56's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The MDS listed Resident #40 had an indwelling catheter. The MDS included diagnoses of diabetes mellitus, obstructive uropathy (blockage affecting urination), and retention of urine. The Care Plan Focus dated 9/13/24 documented Resident #56 required the use of an indwelling catheter related to obstructive uropathy. The Goal indicated he would remain free of complications related to the catheter. On 12/9/24 at 11:29 AM observed Resident #56 sitting in a wheel chair, with his catheter bag on the floor and under the wheel chair…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, resident interview and facility policy, the facility failed to follow physician orders and manage oxygen use for 1 of 1 resident sampled for respiratory care (Resident #5). The facility reported a census of 55 residents. Findings include: Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of acute and chronic respiratory failure with hypoxia (low blood oxygen levels), unspecified cardiac arrest, and ventricular fibrillation (abnormal heart rate). The MDS reflected Resident #5 used special treatments of oxygen therapy while a resident. Resident #5's Physician Order dated 10/11/24 instructed to use oxygen (O2) at 3 liters per nasal cannula (L/NC). Resident #5's December 2024 Medication Administration Record (MAR) included an order dated 10/11/24 to use 3 L/NC of O2 as needed for shortness of breath (SOB). The MAR lacked…

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 daily staffing review and staff interview the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day as required by Federal Regulations. The facility reported a census of 55 residents. Findings include: Review of the facility's Daily Staffing Sheets from 11/9/24 to 12/9/24 lacked an RN on Saturday 11/23/24. On Sunday 11/24/24 an agency RN worked from 10:00 PM to 6:00 AM, only providing two hours of RN staffing for the full day on 11/24/24. An Email communication on 12/12/24 at 10:34 AM, the Administrator reported they identified the lack of RN coverage the week prior to survey. The Administrator acknowledged the facility didn't have RN coverage on Saturday 11/23/24 and they only had 2 of the 8 required consecutive hours provided on Sunday 11/24/24. On 12/12/24 at 10:45 AM, the Administrator stated the facility didn't have a specific policy for RN staffing, as they followed the Federal Regulations.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, resident interview and provided Center of Disease Control (CDC) protocol, the facility failed to maintain infection control interventions for 1 of 1 resident on transmission based precautions (Resident #56). The facility reported a census of 55 residents. Findings include: Resident #56's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The MDS listed Resident #40 had an indwelling catheter. The MDS included diagnoses of diabetes mellitus, pain, anemia (low blood iron), obstructive uropathy (blockage affecting urination), and retention of urine. The Care Plan Focus dated 11/25/24 identified Resident #56 received antibiotic therapy related to C diff (refers to Clostridium difficile, a bacterial, highly contagious intestinal infection, common symptoms include diarrhea). The Goal added 12/9/24 Resident #56 would remain free of complications related to the use…

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, Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to screen for eligibility, offer, provide education, and document vaccine consent or refusal for the pneumococcal immunizations for 2 of 5 resident reviewed (Residents #33 and #24) for immunizations. The facility reported a census of 55 residents. Findings include: 1. Resident #33's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 7, indicating moderately impaired cognition. The Clinical Census reflected Resident #33 admitted to the facility on [DATE]. Resident #33's Clinical - Immunizations reviewed on 12/12/24 identified he received the PCV13 (pneumonia vaccine) on 6/11/15. The clinical record lacked documentation someone educated, offered a consent or a refusal about pneumonia vaccinations (PPSV23, PCV20 or PVC21). 2. Resident #24's MDS assessment dated [DATE] identified a BIMS score of 15,…

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, Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to screen for eligibility, offer, provide education and document vaccine consent or refusal for the COVID-19 (coronavirus disease) immunization for 2 of 5 resident reviewed (Residents #56 and #24). The facility reported a census of 55 residents. Findings include: 1. Resident #56's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The Clinical Census listed Resident #56's admission date as 8/29/24. Resident #56's Clinical - Immunizations reviewed on 12/12/24 identified he received a COVID vaccination on 7/6/22. The clinical record lacked documentation that someone offered, educated, or Resident #56 refused an additional COVID-19 vaccination since admission to the facility on 8/29/24. 2. Resident #24's MDS assessment dated [DATE] identified a BIMS score 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 observation of equipment, staff interview, and Smart Stand Lift (a sit to stand machine used to help move a resident) Manual, the facility failed to have adequate equipment to ensure residents safety during transfers for 2 of 4 lifts observed. The facility reported a census of 59 residents. Findings include: The Smart Stand Lift Service Manual dated 6/7/24 directed to check the safety tabs to make sure they are installed correctly, not missing or torn. Any detected deficiency must be rectified before the stand is put back into service. On 9/21/24 at 11:00 AM observed one Smart Stand Lift missing the safety hook spring tab on one side and the other both tabs missing the safety hook spring tabs. In an interview on 9/21/24 Staff A, Certified Nurse Aide (CNA), and Staff B, CNA, reported the Smart Stand Lift didn't have any safety tabs since they have worked at the facility. In an interview on 9/23/24 at 11:20 AM, the Maintenance Man reported the Smart Stand Lifts should have the safety tabs on the machine for safety where the loops connect to the harness.

Based on observations, environmental tour, resident, staff and laundry personnel interviews, the facility failed to provide clean, available linen soaker pads (pads used to protect furniture from incontinence) for resident care. The facility reported a census of 62 residents. Findings include: On 9/9/24 at 2:00 PM Staff C, Certified Nursing Assistant (CNA), stated that the facility didn't have enough wash cloths and gloves. Staff C added the learned new management is taking over and once the current supplies run out then the new management will order what they want. Staff C said it is hard to get work done and do good cares without the needed supplies, such as soaker pads, red, or white washcloths for peri cares, and no washcloths to clean face and hands. On 9/9/24 at 4:00 PM Resident #4 stated the facility didn't have enough washcloths, soaker pads, and linens for the staff to take care of her. On 9/10/24 at 9:26 AM, Staff G, CNA, reported the floor staff need to go to laundry at times to get washcloths/towels etc. to provide cares to the residents as they can't do their job until…

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 procedure, and staff and resident interviews, the facility failed to follow physicians' orders for 2 of 3 residents reviewed. (Residents #3 and #4). The facility reported a census of 62 residents. Finding include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. Resident #3 required partial to moderate assistance with all activities of daily living. In addition, they used a walker or wheelchair for mobility. The MDS included diagnoses of coronary artery disease (heart disease), hypertension (high blood pressure), renal (kidney) failure, non Alzheimer's dementia, and heart failure. Resident #3 used a diuretic (pill used to remove excess fluid from the body) during the lookback period. The Care Plan Focus dated 10/31/21 indicated Resident #3 had altered cardiovascular (heart) status related to atrial fibrillation…

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 and staff interviews, along with the facility policy, the facility staff failed to answer resident call lights in a timely manner (not longer than 15 minutes) for 2 of 3 residents reviewed (Residents #2 and #4). The facility identified a census of 62 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #2 required partial assistance with bed mobility, toilet use, and personal hygiene. In addition, they required total assistance of one-person physical assist with bathing. The MDS included diagnoses of hypertension (high blood pressure), diabetes mellitus, depression and chronic back pain. On 9/9/24 at 1:25 PM Resident #2 stated the staff take over a half an hour to answer the call light. On 9/9/24 at 2:00 AM Resident #2 put on her call light, she reported the staff didn't answer it until 2:45 AM. She explained this bothered her due to being diabetic 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 observation, facility menu review, staff interview and policy review the facility failed to follow the dietician approved menu as written. The facility reported a census of 62 residents. Findings include: 1. Review of the 9/9/24 dietician approved menu for lunch, the menu directed to give the residents: a. Fire braised pork on a bun b. Baked yams c. Pea Salad d. Bread/margarine e. Fruit crisp The residents received instead at lunch on 9/9/24: a. Fire braised pork ribs b. Baked yams c. Buttered peas d. Pudding 2. Review of the 9/10/24 Dietitian approved menu for lunch, the menu directed to give the residents: a. Cheeseburger on a bun b. French fries c. Creamy coleslaw d. scotcheroo The residents received instead at lunch on 9/10/24: a. Cheeseburger on a bun b. French fries c. Creamy coleslaw d. Ice cream cone or ice cream sandwich 3. Review of the 9/11/24 Dietitian approved menu for lunch, the menu directed to give the residents. a. Italian pasta bake b. Seasonal vegetables c. Garlic toast d. Pears The residents received instead at lunch on 9/11/24: a. Italian pasta bake 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, staff interview, and policy review, the facility failed to maintain hot food items at 135 degrees or greater to prevent potential for food borne illness and to keep the food palatable for resident's satisfaction. The facility reported a census of 62 residents. Findings include: During an observation of the noon meal on 9/10/24, the post temperatures completed at 12:25 PM reflected the temperature of French fries of 127 degrees Fahrenheit (F), below the required 135 degrees F. On 9/10/24 at 12:30 PM the facility provided a test tray in an insulated plate cover to sample. The tray contained a cheeseburger on a bun, coleslaw and French fries. The tray contained palatable food of a warm cheeseburger on a bun and chilled coleslaw. In addition, the tray contained food not considered palatable of cool, chewy French fries. On 9/10/24 at 4:00 PM, the Corporate Dietitian acknowledged the French fries didn't have a compliant temperature. They voiced they understood the test tray contained cool French fries for consumption. She reported the kitchen would get a new steam…

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 and policy review, the facility failed to ensure they didn't serve expired food items. In addition, the facility failed to label open food items, date open food items, ensure a clean, sanitary kitchen and equipment to reduce the risk of contamination and food borne illness. The facility reported a census of 62 residents. Findings include: On 9/9/24 at 9:48 AM during the initial tour of the facility kitchen, observed the following: a. Refrigerated items: i. An open tub, not labeled or dated, of covered potato salad. ii. An open tub, not labeled or dated, of covered ham salad. iii. 11 gallons of chocolate milk with a best by date of 9/8/24. b. Freezer items: i. An open not labeled or dated, bag of meat patties. ii. An open not labeled or dated, bag of taco shells. iii. An open not labeled of date, bag of buns. On 9/9/24 at 9:48 AM during the initial tour of the facility kitchen, observed the following sanitary concerns: a. The handwashing station sink had chunks of food debris on it. b. The Prep counter across from the stove very dirty with food…

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, and staff interview the facility failed to maintain infection control practices, including failing to complete hand hygiene for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 62 residents. Finding include: Resident #4's MDS assessment dated [DATE], reflected they could make themselves understood and could understand others. The MDS identified a BIMS score of 13, indicating no cognitive impairment. The MDS included diagnoses of cancer, heart failure, hypertension, diabetes mellitus, depression and respiratory failure. Resident #4 required total dependence with toileting hygiene and transfers. They didn't walk and used a wheelchair for mobility. The Care Plan Focus initiated 3/2/23 indicated Resident #4 had a risk for potential decline in functional range of motion (ROM) and activity daily living (ADL) related to weakness related to their medical diagnosis. The Interventions directed Resident #4 used a full-body mechanical lift with 2 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 observations, staff interview, and facility policy review, the facility failed to serve food within an appropriate temperature range and palatable manner. The facility reported a census of 56 residents. Findings include: On 1/29/24 at 10:40 AM, observed Staff E, Cook, obtain temperatures of the food items located in the serving table: a. A container with lettuce displayed a holding temperature of 52 degrees Fahrenheit (F). b. A container with shredded cheese displayed a holding temperature of 42 F degrees. Staff E, documented the temperatures in the Temperature Log and verbalized the temperatures for cold foods must be below 40 F degrees. A review of the facility's undated policy titled Food Temperatures, documented cold foods stay below 41 F degrees until received by the customer.

Based on observations, staff interviews, and policy review, the facility failed to store and prepare food in accordance with professional standards for 56 residents. The facility reported a census of 56 residents. Findings Include: 1. On 1/29/24 from 10:00 AM -11:00 AM, a continuous observation during the initial Primary Kitchen Tour revealed the following: a. The upright stainless steel refrigerators and freezer units exterior door handles were covered with a sticky dark substance. b. A buildup of debris noted on the bottom of all units. c. Multiple shelves inside the units were covered with yellow colored sticky substance. d. All units had several items not labeled/dated: lettuce, carrots, diced tomatoes. e. The 2-compartment industrial oil deep fryer had a buildup of solid brown substance on the top and all sides. f. A gas range with 16 grates had a buildup of dark brown substance and debris. g. The tile floor underneath the food prep equipment was covered with layers of debris. h. Stainless steel tables and shelves storing clean dishes, pots and pans, noted to have debris…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The MDS for Resident #14, dated 11/8/23, reflected a BIMS score of 13 out of 15, indicating intact cognition. The MDS further documented diagnoses to include medically complex conditions, heart failure and diabetes. The Care Plan for Resident #14, with a revision date of 5/22/23, reflected the resident dependent on staff for activities, cognitive stimulation and social interaction due to immobility and physical limitations. The Care Plan directed staff to please be kind and considerate with all interactions. On 1/29/24 at 1:05 PM, Resident #14 stated during an interview there is a staff person, Staff D, CNA, who made her feel degraded when the resident had an accident. The staff person will make comments such as that is not what I wanted to do today, pick up your bowel movement or clean up your urine. Resident #14 stated she felt degraded by this staff as unable control her urine or bowel movement at times. Staff D commented she doesn't want to clean up after her, and makes comments in front of other 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 review of employee files and staff interviews the facility failed to complete a criminal background check for 3 of 3 hired employees prior to the employee being allowed to work alone with residents in the facility (Staff D, Staff F and Staff G). The facility reported a census of 56 residents. Findings Include: 1. Review of the employee file for Staff D, Certified Nursing Assistant (CNA), revealed Staff D hired and employed by the facility on 4/16/2018 to 7/2/2018. A document dated 3/26/2018 revealed the results of a criminal background check showed Criminal History found. On 4/8/2018 a document titled Record Check Evaluation (RCE) received from the Iowa Department of Human Services (DHS) indicating DHS had completed RCE on the criminal history of the applicant and the results indicated applicant may work for the agency. Noted on this document from DHS, Staff D has disposition on her pending court case, if she receives a conviction and or deferred judgment then a new RCE must be done. No further documentation for this background check found for Staff D. Staff D was rehired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The MDS assessment dated [DATE], indicated Resident #19 with diagnoses of malnutrition, Alzheimer's Disease, impaired cognition, and non-traumatic Brain Dysfunction. Resident able to eat independently without assistance, uses a wheelchair and are Substantial/maximal assistance for transfers and cares. The Care Plan dated 11/16/23, indicated having impaired physical mobility, Resident #19 is non-ambulatory, requiring transfers with EZ Stand (a mechanical lift) and assistance of two. Resident able to feed independently with setup, prompting and cueing. Resident eats at an over the bed table in the dining room, as Resident's wheelchair is too high for dining room tables. Also indicated in Care Plan, a revision dated 12/24/23, burn to right thigh with interventions to refer to Wound Clinic. An Incident Report dated 12/24/23, revealed Resident #19 spilled coffee on her lap at breakfast causing a burn. Progress Notes dated 12/24/23 revealed Resident had a fluid filled blister on her right thigh from the 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 review, Electronic Health Records (EHR) review, staff interviews and facility policy review, the facility failed to provide Dialysis services consistent with professional standards by not completing a Dialysis Assessment to 1 of 1 residents reviewed (Resident #63). The facility reported a census of 56 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #63 documented an admission date of 1/19/24 and a diagnosis of end stage renal disease (ESRD). Review of the EHR for Resident #63 revealed Nursing Assessments Pre/Post Dialysis treatments were not completed. A weight gain since admission of +5 lbs was not addressed by the nurses nor reported to the Primary Care Physician (PCP). Review of Resident #63's Care Plan lacked documentation of Dialysis services, Nursing Assessments, monitoring, interventions or goals. On 1/31/24 at 1:26 PM, Staff A, Registered Nurse (RN) stated she knew Resident #63 had Dialysis services three times a week from the Post-It notes…

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 the resident narcotics were counted between shifts for 1 of 1 residents reviewed (Resident #48). The facility reported a census of 56 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #48 with diagnoses of hip fracture, cancer and had a mild (1) intensity of pain in the previous five (5) days. The Pharmacy delivered 30 tablets of Hydrocodone-Acetaminophen 5-325 milligram (MG) on 8/1/23. The Electronic Health Record (EHR) review revealed Resident #48 received Hydrocodone-Acetaminophen 5-325 milligram (MG) 1 tablet by mouth every 4 hours on as needed basis 18 times between 8/1/23 and 10/27/23. Facility completed a routine audit of controlled substances on 11/13/23 and discovered Resident #48 did not have remaining medications of 12 tablets of Hydrocodone-Acetaminophen 5-325 milligram (MG). The Controlled Substance Count Sheet for every shift change was also missing.…

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

Based on observation, staff interviews and facility policy review, the facility's Dietary Staff failed to perform the proper functions of food and nutrition services for the pureed food process for 2 of 2 residents requiring a pureed diet. The facility reported a census of 54 residents. Findings Include: During an observation 1/31/24 at 9:00 AM, Staff E, Cook, began the process to puree the lunch meal for residents at the facility on a pureed diet. Staff E was unsure of the entire puree process, inquiring if water could be used for the liquid added while pureeing and if the food should be measured after it is pureed. Initially Staff E did not measure the amount of food pureed, but then did get a measuring bowl to measure the amount of food pureed. Staff E was then unsure how to read the chart for pureed food and initially did not read the chart correctly for the size of scoop to use for the proper amount to give each resident during the meal service. During an interview 1/31/23 at 9:10 AM, Staff E acknowledged not using the chart previously to determine what size scoop to use 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 interviews and clinical record review, the facility failed to offer and administer a 2nd dose of pneumococcol vaccine for 1 of 5 residents reviewed (Resident #3). Resident #3 received 1 of the 2 recommended doses. The facility reported a census of 51 residents. Findings include: A Minimum Data Set, dated [DATE], documented that Resident #3 was admitted to the facility on [DATE]. A Clinical Immunizations record, documented that Resident #3's birth date was 7/28/1929. This record documented that this resident had her first pneumococcal vaccine dose on 8/13/14. It lacked documentation of a 2nd pneumococcal vaccine dose. On 9/14/23 at 5:10 p.m., the Administrator and the DON questioned what the guidelines were for a 2nd pneumococcal vaccination. They stated understanding that the guidelines differ regarding age and comorbidities. The Administrator and the DON stated they would look into the guidelines to see if the facility was following them. In an email sent on 9/18/23 at 10:14 a.m., the Administrator…

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