Northern Mahaska Specialty Care

Based on observation, diet spreadsheet/menu review, resident diet type report, staff interviews, policy review, and the Simplified Diet Manual the facility failed to serve the appropriate portions for 3 of 3 residents who received pureed diets (Resident #19, #33 and #49) and 1 of 1 resident served only pureed meat (Resident #29). The facility staff also failed to serve the appropriate portion size of meat for 10 of 11 residents on a mechanical soft diet (Resident #7, #8, #27, #30, #37, #38, #42, #55, #58, #67 and #68). The facility reported a census of 78 residents. Findings include:1. The facility's Cycle Day 4 Diet Spreadsheet identified one (1) serving of a deviled pork chop, 1 serving of squash, and 1 serving of a wheat roll to be served as part of the planned pureed textured diet for the lunch meal served on 9/24/25.The facility's Cycle Day 4 Diet Spreadsheet identified a 3 ounce (oz.) of deviled pork chop to be served as part of the planned mechanical soft textured diet for the lunch meal served on 9/24/25.The facility's Diet Type Report revealed three (3) residents on 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 record review, observation, staff interview, policy review, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to implement infection control practices consistent with CDC guidelines pertaining to COVID precautions and Enhanced Barrier Precautions to prevent cross contamination by staff failing to wear proper Personal Protective Equipment (PPE) during routine cares for 2 out of 4 halls (Residents #16, #23, #29 and #44). The facility also failed to perform hand hygiene after catheter care for 1 of 2 residents with catheters (Resident #44). The facility reported a census of 78 residents.Findings include:1. The Care Plan initiated 09/8/25 for Resident #16 indicated she was in isolation for COVID-19 infection. The Care Plan lacked information on the type of isolation. The Care Plan also indicated to follow CDC guidelines and recommendations. The Care Plan initiated 07/30/25 for Resident #29 indicated he was in isolation for COVID-19 infection that resolved 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, observation, staff interview, and policy review, the facility failed to develop a comprehensive person-centered care plan to include pain for one of three residents reviewed (Resident #44). The facility reported a census of 78 residents. Findings include: The admission Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #44 admitted to the facility on [DATE]. The MDS revealed the resident had diagnoses of spinal stenosis, neuropathy and diabetes. The MDS recorded the resident took pain medication but had no pain in the past 5 days during the look-back period. The Care Area Assessment (CAA's) revealed pain not triggered. The MDS assessment was completed on 8/28/25. The Care Plan initiated 8/20/25 lacked information regarding the resident's pain and staff directives for pain management interventions. The admission Evaluation dated 8/20/25 revealed under Section F /Conclusion was marked no to the statement about the resident had new acute and/or chronic pain, used…

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, policy review, American Heart Association (AHA) and Automated External Defibrillator (AED) Manufacture's Guide, the facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to provide nursing interventions, including the use of an AED and administering a shock on a conscious, breathing resident, for 1 of 3 residents (Resident #64) reviewed for a change of condition and hospitalizations. The facility reported a census of 78 residents. Findings include:Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #64's Brief Interview for Status (BIMS) of 6, indicating severe cognitive impairment with diagnoses of Coronary Artery Disease, Heart Failure, Non-Alzheimer's Dementia, Chronic Obstructive Pulmonary Disease (COPD), Anxiety, Depression, Schizophrenia, and health conditions of shortness of breath or trouble breathing when lying flat. Resident #64's The MDS also documented Resident #64 receives 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review, and review of facility provided documents, the facility failed to report an allegation of abuse timely, within the required two hours, of staff becoming aware that allegation existed for 1 of 3 residents (Resident #1) reviewed for resident's rights and dignity. Findings include: The admission Minimum Data Set (MDS) assessment, dated 1/14/25, revealed Resident #1 admitted to facility on 1/08/25, and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Resident #1 diagnoses included Bipolar Disorder, End Stage Renal Disease (ESRD), and atrial fibrillation. The Care Plan [NAME], a document Direct Care Staff use to direct resident care needs, dated 2/25/25, revealed Resident #1 required the presence of 2 staff for when performing care related to accusations of abuse and resident behaviors during cares. On 2/26/25 at 12:18 PM, Staff A, Certified Nursing Assistant (CNA), confirmed working the day shift with 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 observation, resident, family and staff interview the facility failed to maintain comfortable building temperatures between 71 degrees F (Fahrenheit) and 81 degrees F in the resident's rooms for 4 residents reviewed (Residents #5, #6, #7, and #8). The facility identified a census of 71 residents. Findings include: 1. During an observation and interview on a facility tour 12/19/2023 at 1:45 p.m., the Director of Facilities Maintenance checked temperatures in random resident rooms and revealed the following temperatures as identified: a. The room of Resident #6 (401) measured 69.4 degrees F (Fahrenheit) in the room. The resident stated that the room had been cold for the last couple of weeks and was covered in a wool blanket and wearing long sleeve shirt. b. The room of Resident #7 (room [ROOM NUMBER]) measured 68.0 degrees F in the room. The resident stated that it was cold in their room and sat with arms folded across their chest, and wearing a long sleeve hoodie and sweat pants. A family member was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, record review and policy review the facility failed to ensure adequate staffing for 4 of 30 residents reviewed (Residents #55, #26, #29, and #59). The facility census is 68. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #55 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognitive response. The MDS further documented the resident had diagnoses including medically complex conditions, heart disease, diabetes, severe obesity, difficulty in walking, unsteadiness on feet, muscle weakness. The MDS indicated under functional limitation needed extensive assist of two-person physical assist with bed mobility, transfer, locomotion off and on the unit. In addition, was coded Resident #55 needed extensive assistance of two-person physical assistance with toilet use and personal hygiene. The Care Plan for Resident #55 revised 1/7/23 revealed focus area Activities of Daily Living (ADL) documented the resident required…

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 interviews the facility failed to treat residents with dignity and respect for 2 of 23 residents reviewed, (Resident #29 and #59). The facility reported a census of 68. Findings include: 1. The Minimum Data Set (MDS) for Resident #29 dated 6/8/23 revealed the resident scored 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Diagnoses included depression, non-Alzheimers dementia, and orthostatic hypotension (sudden drop in blood pressure with position change). The resident required extensive assist of two for bed mobility and toileting and extensive assist of one for dressing and personal hygiene. A Care Plan focus area initiated on 5/26/23 documented the need for hospice services. A focus area revised 7/17/23 documented chronic pain. A goal revised 6/16/23 indicated the resident did not want to experience an increase in depression. On 8/27/23 at 2:01 PM Resident #29 stated some aides have a nonchalant attitude. She stated she spilled lemonade at a meal and no one moved to help her clean 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 clinical record review, policy review, and staff interview, the facility failed to ensure the safety of a resident by not accommodating a resident's need for a mechanical lift sling to ensure safe transfers while at dialysis for 1 of 3 residents reviewed receiving dialysis services (Resident #32). The facility reported a census of 68 residents. Findings: The 6/22/23 Minimum Data Set( MDS) assessment tool listed diagnoses for Resident #32 which included heart failure, kidney failure, and diabetes. The MDS stated the resident required extensive assistance of 2 staff for transfers and listed the resident's Brief Interview for Mental Status(BIMS) score as 13 out of 15, indicating intact cognition. The 7/25/23 MDS stated the resident required extensive assistance for transfers. The facility policy Accommodation of Needs, revised March of 2021, stated the facility would evaluate the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment. Dialysis Treatment Details Reports revealed the following: A 5/26/23…

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.