Inspection Report Summary
The most recent inspection on July 15, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a mixed pattern, with some reports noting deficiencies related to resident safety, medication administration, food safety, and documentation, while others found the facility in compliance. Main themes of deficiencies included accident hazards and supervision, coordination of mental health assessments, medication management, and food handling practices. Several complaint investigations were unsubstantiated, though some substantiated incidents involved resident falls and medication errors, but no fines or enforcement actions were listed in the available reports. The facility’s recent inspections suggest some improvement following prior citations, with the latest survey showing compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
184% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
67 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Date: Jul 15, 2025
Visit Reason
Investigation of complaint #129724-C conducted from July 10, 2025 to July 15, 2025.
Complaint Details
Complaint #129724-C was investigated and found not to be substantiated as no deficiencies were identified.
Findings
The investigation of complaint #129724-C did not result in any deficiencies; the facility was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 28, 2025
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility in compliance with health requirements effective April 17, 2025.
Findings
The facility was found to be in substantial compliance with health requirements based on the accepted Plan of Correction; no specific deficiencies or severity levels are detailed in this document.
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 5
Date: Mar 26, 2025
Visit Reason
The inspection was conducted based on complaints and concerns related to failure to submit Level II PASRR evaluations, unsafe smoking/vaping practices by residents, inadequate catheter care leading to urinary tract infections, improper food storage practices, and inaccurate staffing data submissions.
Complaint Details
The complaint investigation included failure to submit PASRR evaluations, unsafe vaping in resident rooms, inadequate catheter care leading to UTIs, improper food storage, and inaccurate staffing data submissions. The facility acknowledged deficiencies and lack of specific policies in some areas.
Findings
The facility failed to submit a required Level II PASRR evaluation for a resident with new mental health diagnoses, allowed a resident to vape in his room contrary to policy, failed to provide appropriate catheter care for multiple residents leading to potential urinary tract infections, did not properly label and store food items in the kitchen, and submitted inaccurate staffing data to CMS Payroll Based Journal system.
Deficiencies (5)
Failed to submit a Level II PASRR evaluation for 1 of 1 residents with new mental health diagnoses.
Failed to ensure residents environment was free from accident hazards by not assessing a resident who vaped in his room.
Failed to provide appropriate interventions to minimize or prevent urinary tract infections for 3 of 4 residents with urinary catheters.
Failed to label, date and store food/utensils properly to reduce risk of contamination and food borne illness.
Failed to submit accurate staffing data to CMS Payroll Based Journal system, resulting in coding errors and inaccurate reporting.
Report Facts
Residents affected: 69
Medication orders: 3
UTI residents: 3
Staffing coding errors: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Interviewed regarding resident vaping practices |
| Staff B | Registered Nurse (RN) | Interviewed regarding resident vaping and catheter care |
| Administrator | Interviewed regarding PASRR policy, smoking policy, catheter care, and staffing data submission | |
| Assistant Director of Nurses (ADON) / Infection Preventionist (IP) | Assistant Director of Nurses / Infection Preventionist | Interviewed regarding UTI trends and catheter care |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding food storage and labeling practices |
| Director of Nurses (DON) | Director of Nurses | Observed catheter care and tubing placement |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 6
Date: Mar 26, 2025
Visit Reason
The inspection was conducted as a recertification survey and investigation of complaint #126482-C from March 23, 2025 to March 26, 2025 at Accura Healthcare of Ames Nursing Home.
Complaint Details
Complaint #126482-C was investigated from March 23 to March 26, 2025 and was not substantiated.
Findings
The facility was found not in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with deficiencies related to coordination of PASARR assessments, free of accident hazards, bowel/bladder incontinence care, food safety and storage, and payroll-based journal staffing data submission. The complaint was not substantiated.
Deficiencies (6)
Failed to submit a Level II Preadmission Screening and Resident Review (PASARR) evaluation for a resident with new mental health diagnoses.
Failed to ensure the resident environment was free from accident hazards by not assessing a resident's use of a vape pen in their room.
Failed to provide adequate supervision and assistance devices to prevent accidents related to smoking/vaping.
Failed to ensure residents with urinary catheters and incontinence received appropriate care to prevent urinary tract infections.
Failed to label, date, and store food/utensils in accordance with professional food safety standards.
Failed to submit accurate and timely payroll-based journal staffing data to CMS.
Report Facts
Total census: 69
Dates of inspection: 4
Staffing coding errors: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Reported facility policies and expectations related to PASARR, smoking, catheter care, and staffing data. |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) / Infection Preventionist (IP) | Acknowledged knowledge of UTI trends and need for additional education and interventions. |
| Dietary Manager | Dietary Manager (DM) | Reported knowledge of food safety requirements and staff training. |
| Staff A | Certified Nursing Assistant (CNA) | Interviewed regarding resident vaping and smoking supervision. |
| Staff B | Registered Nurse (RN) | Interviewed regarding resident vaping observations. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
Investigation of complaints #124671 and #125006 conducted from December 16, 2024 to December 17, 2024.
Complaint Details
Complaints #124671 and #125006 were investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. Complaints #124671 and #125006 were not substantiated.
Inspection Report
Re-Inspection
Census: 62
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
The onsite revisit of the survey ending September 18, 2024, was conducted to verify compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Accura Healthcare of Ames was found to be in compliance effective October 11, 2024, following the onsite revisit conducted on October 31, 2024.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Date: Sep 18, 2024
Visit Reason
The inspection was conducted following complaints and incidents involving resident safety, specifically falls resulting in injury due to inadequate supervision and failure to accompany residents to appointments.
Complaint Details
The investigation was complaint-related, substantiated by findings that Resident #1 was left unattended during personal care leading to a fall and fracture, and Resident #2 was transported to an appointment without staff assistance, resulting in a fall and dental injury.
Findings
The facility failed to ensure adequate supervision of residents requiring assistance, resulting in Resident #1 falling in the bathroom and sustaining a left hip fracture, and Resident #2 falling unattended at a dental appointment causing dental fractures. Staff education was provided after the incidents.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents.
Report Facts
Residents affected: 2
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Assisted Resident #1 and left resident unattended leading to fall |
| Staff B | Registered Nurse (RN) | Performed head-to-toe assessment on Resident #1 after fall |
| Staff C | Certified Nursing Assistant (CNA) | Observed Resident #1 transfer with gait belt and walker |
| Staff D | Certified Nursing Assistant (CNA) | Observed Resident #1 transfer with gait belt and walker |
| Director of Nursing | Provided education to staff on supervision expectations | |
| Facility Administrator | Accompanied Resident #2 to ER and confirmed policy on staff accompaniment to appointments |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Date: Sep 18, 2024
Visit Reason
The survey was conducted due to substantiated complaints #123077-C and #123140-C, as well as a substantiated facility-reported incident #121910-I, investigating compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Complaint Details
The survey substantiated complaints #123077-C and #123140-C and a facility-reported incident #121910-I. The investigation confirmed that Resident #1 was left alone in the bathroom, resulting in a fall and fractured femoral neck. Staff failed to provide required assistance and supervision.
Findings
The facility failed to ensure a resident environment free from accident hazards, resulting in Resident #1 sustaining a left hip fracture after a fall when left alone in the bathroom. The investigation revealed inadequate supervision and assistance for residents requiring help with activities of daily living.
Deficiencies (1)
Failure to ensure the resident environment remains free of accident hazards, leading to Resident #1's fall and injury.
Report Facts
Resident census: 65
MDS assessment score: 8
MDS assessment score: 6
Fall incident date: Jul 4, 2024
Education date: Jul 5, 2024
Education date: Sep 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Left Resident #1 alone in bathroom leading to fall; received education on supervision |
| Staff B | Registered Nurse (RN) | Confirmed Resident #1 needed assistance and verified fall circumstances |
| Staff C | Certified Nursing Assistant (CNA) | Assisted Resident #1 during transfer on 9/17/24 |
| Staff D | Certified Nursing Assistant (CNA) | Assisted Resident #1 during transfer on 9/17/24 |
| Director of Nursing | Director of Nursing | Verified staff expectations and education on supervision requirements |
| Facility Administrator | Administrator | Provided education and confirmed policies on resident supervision and appointment accompaniment |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
The document is a Plan of Correction related to the facility's substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, based on acceptance of a credible allegation of substantial compliance.
Findings
The Accura Healthcare of Ames Nursing Home was found to be in substantial compliance effective June 21, 2024, with no specific deficiencies detailed in this document.
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Date: May 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain confidentiality of residents' personal and medical records during medication administration.
Complaint Details
The complaint investigation found that confidentiality was breached for Residents #19 and #46. The facility did not have a policy to ensure securing computer screens with resident information. The Director of Nursing expected staff to follow professional standards and the 5 rights of medication administration.
Findings
The facility failed to maintain confidentiality for 2 of 5 residents reviewed during medication administration, including leaving medication unsupervised and exposing resident information on a computer screen.
Deficiencies (1)
Failed to maintain confidentiality of residents' personal and medical records during medication administration.
Report Facts
Residents reviewed: 5
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Medication Aide (CMA) | Left medication unsupervised for Resident #19 |
| Staff G | Registered Nurse (RN) | Failed to secure computer screen after administering insulin to Resident #46 |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding facility policies and staff expectations |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 8
Date: May 22, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of a reported incident #120527-I from May 19, 2024 to May 22, 2024.
Findings
The facility was found to have multiple deficiencies including failure to maintain confidentiality of resident records, inadequate supervision during medication administration, failure to coordinate PASARR assessments, unsafe medication storage and handling, inadequate nutritional services, improper food storage and sanitation, and lapses in infection control practices.
Deficiencies (8)
Failure to maintain confidentiality of personal and medical records for residents #19 and #46.
Failure to coordinate PASARR assessments for resident #57 with a diagnosed serious mental disorder.
Failure to provide adequate supervision to 3 of 5 residents during medication administration (Residents #19, #31, and #46).
Medication carts left unlocked and unattended; failure to lock medication carts when not in use.
Failure to serve correct protein portions for pureed diets for 3 of 5 residents.
Failure to maintain safe and appetizing food temperatures; food items served above safe temperature limits.
Failure to maintain sanitary food storage and handling practices; presence of unlabeled and undated food items in refrigerators and freezers.
Failure to maintain infection control practices; staff failed to perform hand hygiene and properly handle linens, increasing risk of infection transmission.
Report Facts
Census: 64
Residents reviewed: 5
Residents with pureed diet deficiencies: 3
Medication passes audit frequency: 3
Medication passes audit frequency: 2
Medication passes audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Medication Aide (CMA) | Named in findings related to leaving medication unattended and failure to supervise medication administration. |
| Staff G | Registered Nurse (RN) | Named in findings related to failure to secure resident information on medication cart computer. |
| Staff E | Certified Medical Assistant (CMA) | Named in findings related to medication administration errors and leaving medication unattended. |
| Staff A | Cook | Named in findings related to incorrect portion sizes and food temperature issues. |
| Staff B | Cook | Named in findings related to food delivery and temperature monitoring. |
| Staff C | Dietary Aide (DA) | Named in findings related to failure to wear hairnet and beard net in food preparation area. |
| Staff D | Maintenance Assistant | Named in findings related to failure to wear hairnet and beard net in food service area. |
| Staff H | Certified Medication Aide (CMA) | Named in findings related to failure to perform hand hygiene during medication preparation. |
| Staff B | Cook | Named in infection control education and food service supervision. |
Inspection Report
Routine
Census: 64
Deficiencies: 8
Date: May 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident confidentiality, PASARR assessments, medication administration supervision, medication cart security, dietary services, infection control, and other facility operations.
Findings
The facility was found deficient in maintaining resident confidentiality during medication administration, failing to refer a resident for a Level II PASARR evaluation, inadequate supervision during medication administration for multiple residents, leaving medication carts unlocked, serving incorrect food portions and unsafe food temperatures, improper food storage and sanitation practices, and lapses in infection prevention and control practices.
Deficiencies (8)
Failed to maintain confidentiality of residents during medication administration.
Failed to refer a resident with a serious mental disorder for Level II PASARR evaluation.
Failed to provide adequate supervision during medication administration for 3 residents.
Left medication cart unlocked and unattended.
Failed to serve correct serving size of protein for residents on pureed diets.
Failed to serve food at safe and appetizing temperatures.
Failed to maintain sanitary food storage and preparation practices; staff failed to wear hairnets.
Failed to maintain proper infection control practices including hand hygiene and proper handling of resident blankets.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 64
Medication orders: 2
Temperature: 99
Temperature: 127.9
Temperature: 44.7
Temperature: 117.2
Temperature: 130.1
BIMS score: 10
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Medication Aide (CMA) | Left medication unattended and failed to supervise medication administration |
| Staff G | Registered Nurse (RN) | Failed to close computer screen with resident information and left medication supplies unattended |
| Director of Nursing (DON) | Director of Nursing | Provided interviews regarding policies and expectations on medication administration and confidentiality |
| Staff E | Certified Medical Assistant (CMA) | Left medication unattended in resident room |
| Administrator | Administrator | Provided interview regarding PASARR policies and dietary service expectations |
| Staff A | Cook | Prepared pureed diets and checked food temperatures |
| Staff B | Cook | Delivered resident trays and placed blankets in sink |
| Staff C | Dietary Aide (DA) | Observed not wearing hairnet in food preparation area |
| Staff D | Maintenance Assistant | Observed not wearing hairnet or beard covering in food service area |
| Staff H | Certified Medication Aide (CMA) | Failed to perform hand hygiene after coughing and blowing nose during medication preparation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 2, 2024
Visit Reason
The document is a plan of correction following a survey to address deficiencies and confirm substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The Accura Healthcare of Ames Nursing Home is in substantial compliance based on acceptance of a credible allegation of substantial compliance effective March 15, 2024. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 21, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow professional standards for medication administration, specifically the failure to administer prescribed pain medication (Dilaudid) to Resident #6 as ordered for post-surgical pain.
Complaint Details
The complaint investigation found that Resident #6 was not administered the correct amount of PRN Dilaudid for post-surgical pain as ordered. The resident reported being denied pain medication at one point and only received one pain pill instead of the prescribed one or two based on pain rating. The Director of Nursing confirmed staff failed to follow the ordered pain medication parameters.
Findings
The facility failed to administer Dilaudid as ordered for Resident #6, who had severe post-surgical pain following cervical spinal fusion. Documentation and interviews confirmed that the resident did not receive the correct dosage of pain medication as prescribed, and the facility lacked a specific policy for PRN medication administration.
Deficiencies (1)
Failure to follow professional standards for medication administration by not administering Dilaudid as ordered for Resident #6.
Report Facts
Pain medication doses documented: 5
Medication dosage: 2
Date of survey completion: Feb 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided interview confirming failure to administer medication as ordered |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Feb 21, 2024
Visit Reason
The inspection was conducted due to complaints #116248-C, #117750-A, #117826-M, #118975-A, and #118991-M regarding compliance with federal regulations for long term care facilities.
Complaint Details
Complaint #116248-C was not substantiated.
Findings
The facility was found not in compliance with 42 CFR Part 483 related to medication administration standards, specifically failing to administer pain medication as ordered for one resident. The complaint #116248-C was not substantiated. Corrective actions included staff education and auditing physician orders to ensure compliance.
Deficiencies (1)
Failure to follow professional standards for medication administration by not administering Dilaudid as ordered for one resident.
Report Facts
Complaint numbers: 5
Resident census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to administer pain medication as ordered |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 5, 2023
Visit Reason
A complaint investigation was conducted for complaints #112447-C, #112564-C, #113706-C, #114264-C, #115755-C, and #115904-C from October 2, 2023 to October 5, 2023.
Complaint Details
Complaint investigation for multiple complaints was conducted and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 16, 2023
Visit Reason
Revisit with investigation of incident #110886-C conducted March 13, 2023 - March 16, 2023 related to the recertification survey ending January 26, 2023.
Complaint Details
Complaint #110886 was investigated and found not substantiated.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. Complaint #110886 was not substantiated. A discretionary denial of payment for new admissions was effectuated from February 22, 2023 to February 26, 2023.
Report Facts
Denial of Payment Duration (days): 5
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 12
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as an annual survey of Accura Healthcare of Ames, LLC to assess compliance with regulatory requirements for nursing homes.
Findings
The facility was found deficient in multiple areas including failure to honor residents' advance directives, protect residents' property, timely complete assessments, provide appropriate treatment and care, prevent pressure ulcers, ensure safety related to smoking, maintain nurse aide certification, prevent medication errors, serve proper food portions, and maintain sanitary food preparation practices.
Deficiencies (12)
Failed to have a consistent plan, policy, or procedure for advance directives for 1 of 25 residents reviewed.
Failed to exercise reasonable care for the protection of resident's property from loss or theft for 1 of 3 residents reviewed.
Failed to complete 1 of 1 Minimum Data Set (MDS) assessment within 14 days of admission.
Failed to document a Preadmission Screening and Resident Review (PASRR) and accurately code an anticoagulant drug classification medication for 1 of 1 residents reviewed.
Failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 1 residents reviewed.
Failed to ensure residents did not develop avoidable pressure ulcers for 1 of 1 residents reviewed.
Failed to store residents smoking materials in a secure location and failed to complete an assessment for safety related to smoking for 1 of 1 resident reviewed.
Failed to ensure certification of a Nurse Aide after 4 months of employment for 1 of 5 employee records reviewed.
Failed to follow-up on the provided order for an adequate rationale to continue the use of an as needed psychotropic medication for 1 of 1 resident sampled.
Failed to provide 3 of 5 residents with medications as ordered, including medication errors resulting in hospitalization and improper medication administration.
Failed to serve portions as directed by the facility menu for 3 of 4 residents reviewed for pureed diets.
Failed to maintain sanitary practices by improperly storing, preparing, and serving food.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 3
Food items: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Practical Nurse | Administered wrong medications to Resident #19 on 4/13/22 |
| Staff F | Advanced Registered Nurse Practitioner | Ordered hospital transfer for Resident #19 after medication error |
| Staff C | Certified Medication Aide | Prepared incorrect medication dose for Resident #34 and crushed extended release medication for Resident #50 |
| Staff A | Licensed Practical Nurse | Applied steri-strips to Resident #4's skin tear but failed to document injury |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including advance directives, smoking policy, wound care, and nurse aide certification |
| Administrator | Administrator | Interviewed regarding missing wheelchair and smoking policy noncompliance |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 11
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey with an investigation of intakes #103627-C and #104071-I from January 23, 2022 to January 26, 2023.
Complaint Details
Complaint #103627-C was not substantiated. Facility reported incident #104071-I was substantiated.
Findings
The facility was found not in compliance with several regulatory requirements including advance directives, safe environment, comprehensive assessments, accuracy of assessments, quality of care, treatment to prevent pressure ulcers, free from accident hazards, and medication administration. The facility reported a census of 64 residents during the survey.
Deficiencies (11)
Facility failed to have a consistent plan, policy, or procedure for advance directives for 1 of 25 residents reviewed (Resident #35).
Facility failed to exercise reasonable care for the protection of resident's property from loss or theft for 1 of 3 residents reviewed (Resident #3).
Facility failed to complete initial and periodic comprehensive assessments for residents within required timeframes (Resident #14).
Facility failed to accurately reflect resident's status in assessments and failed to complete required assessments (Resident #14 and #8).
Facility failed to ensure residents received treatment and care in accordance with professional standards, including skin tear management (Resident #4).
Facility failed to implement interventions to prevent pressure ulcers and failed to provide appropriate care for pressure ulcers (Resident #8).
Facility failed to ensure the resident environment was free of accident hazards related to smoking for 1 resident (Resident #25).
Facility failed to ensure proper hiring and use of nurse aides, including certification and competency evaluation (Staff M).
Facility failed to ensure residents were free of significant medication errors, including proper medication administration and documentation (Residents #19, #34, #50, #60).
Facility failed to ensure psychotropic drugs were used appropriately and with proper documentation (Resident #60).
Facility failed to maintain sanitary food storage and preparation areas, including temperature control and proper handling (Food service observations).
Report Facts
Resident census: 64
Residents reviewed: 25
Residents reviewed: 3
Residents reviewed: 1
Residents reviewed: 5
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Registered Nurse (RN) | Interviewed regarding resident code status and door signage. |
| Staff J | Certified Medication Aide (CMA)/Certified Nurse Aide (CNA) | Interviewed regarding emergent situation procedures. |
| Director of Nursing (DON) | Director of Nursing | Verbalized facility policy deficiencies and involved in corrective actions. |
| Administrator | Administrator | Interviewed regarding missing wheelchair and grievance process. |
| Staff A | Licensed Practical Nurse (LPN) | Involved in skin tear incident and medication administration. |
| Staff B | Registered Nurse (RN) | Involved in skin tear incident and medication administration. |
| MDS Coordinator | MDS Coordinator | Explained assessment timing and coding issues. |
| Social Services Director | Social Services Director | Verified MDS assessment data. |
| Staff C | Certified Medication Aide (CMA) | Observed medication administration errors. |
| Staff F | Advanced Registered Nurse Practitioner (ARNP) | Involved in medication error and resident transfer. |
| Staff G | Pharmacist Consultant | Reviewed medication regimen and errors. |
| Staff O | Cook | Observed food preparation and serving. |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding food service and menu preparation. |
| Staff P | Kitchen Staff | Observed wearing hairnet and food handling. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 10, 2022
Visit Reason
The document is a plan of correction following an investigation of facility reported incidents and a complaint completed between 2/8/22 and 2/24/22.
Complaint Details
Investigation involved Facility Reported Incidents #101624-I, #102222-I and Complaint #101967-C completed 2/8/22-2/24/22.
Findings
Based on the facility's plan of correction and credible allegation of compliance, the facility will be certified in compliance effective 3-10-22.
Report Facts
Facility Reported Incident: 2
Complaint: 1
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 3
Date: Feb 24, 2022
Visit Reason
The inspection was conducted as a result of investigations into Facility Reported Incidents #101624-I and #102222-I and Complaint #101967-C to assess compliance with federal and state regulations.
Complaint Details
Facility Reported Incidents #101624-I and #102222-I were substantiated. Complaint #101967-C was not substantiated.
Findings
The facility failed to ensure the resident environment was free of accident hazards, resulting in an elopement incident involving a cognitively impaired resident. Additionally, deficiencies were found related to labeling, storage, and counting of controlled drugs and biologicals, including failure to reconcile narcotic counts and medication discrepancies.
Deficiencies (3)
Failure to ensure the resident environment remained free of accident hazards, leading to elopement of a cognitively impaired resident.
Failure to label drugs and biologicals in accordance with accepted professional principles and to store drugs and biologicals properly.
Failure to immediately report and reconcile Schedule II narcotic count discrepancies and failure to validate actual medication amounts.
Report Facts
Census: 58
Brief Interview for Mental Status (BIMS) score: 5
Brief Interview for Mental Status (BIMS) score: 9
Temperature: 5
Temperature: -8
Distance: 1000
Speed limit: 45
Medication dose: 0.5
Medication remaining: 28.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse (LPN) | Documented last sighting of Resident #1 and conducted assessments after elopement. |
| Staff F | Certified Nursing Assistant (CNA) | Informed Staff E about Resident #1 outside and confirmed proper function of WanderGuard bracelet. |
| Staff G | Certified Nursing Assistant (CNA) | Answered phone call from technician and confirmed WanderGuard alarm sounded when Resident #1 returned. |
| Director of Nursing | Director of Nursing (DON) | Confirmed staff training on magnetic lock indicator light and narcotic count procedures. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed staff training and participated in medication count observations. |
| Staff A | Licensed Practical Nurse (LPN) | Administered morphine sulfate to Resident #4 and involved in medication count discrepancies. |
| Staff B | Licensed Practical Nurse (LPN) | Counted controlled drugs with Staff C and involved in medication count discrepancies. |
| Staff C | Licensed Practical Nurse (LPN) | Counted controlled drugs with Staff B and involved in medication count discrepancies. |
| Staff D | Registered Nurse (RN) | Completed shift controlled medication count and verbalized knowledge of reporting expectations. |
Inspection Report
Routine
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
A COVID-19 Focused Infection Control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 7
Date: Sep 13, 2021
Visit Reason
A recertification health survey and investigation of complaints #97723-C, #97765-C, and #98112-C, along with facility reported incidents #99439-I and #99538-I, were conducted from 8/29/21 to 9/13/21.
Complaint Details
Complaints #97723-C, #97765-C, and #98112-C were not substantiated. Facility reported incidents #99439-I and #99538-I were substantiated.
Findings
The investigation found that complaints #97723-C, #97765-C, and #98112-C were not substantiated, while facility reported incidents #99439-I and #99538-I were substantiated. Deficiencies were identified related to baseline care plans, free of accident hazards, dialysis care, pharmacy services, food safety, quality assurance, and infection control.
Deficiencies (7)
Facility failed to complete baseline care plan for 1 of 17 residents within 48 hours of admission.
Resident #41 received thermal burns from e-stim diathermy machine due to inadequate supervision and failure to follow manufacturer recommendations.
Facility failed to ensure residents who require dialysis received consistent assessments and monitoring.
Facility failed to maintain accurate and timely narcotic controlled drug count records.
Facility failed to maintain clean and sanitary kitchen conditions to prevent food-borne illness.
Facility failed to sustain a Quality Assurance and Performance Improvement (QAPI) program with documented evidence of prior quarterly meetings.
Facility failed to establish and maintain an infection prevention and control program to prevent spread of infections.
Report Facts
Resident census: 63
Residents reviewed: 17
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 2
Burn measurements: 5.8
Burn measurements: 6.2
Medication doses: 500
Dish racks identified: 3
Sheet pans identified: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meagan Dailey | COTA | Provided education on e-stim machine usage to prevent recurrence of burns. |
| Christen Bliss | Director of Clinical Services | Provided education on e-stim machine usage and maintenance. |
| Staff F | Certified Nursing Aide (CNA) | Reported Resident #41 received burns from diathermy machine. |
| Staff C | Therapy Director | Identified e-stim machine location and was involved in investigation. |
| Staff A | Licensed Practical Nurse (LPN) | Revealed controlled drug count record deficiencies. |
| Staff B | Registered Nurse (RN) | Revealed controlled drug count record deficiencies. |
| Administrator | Acknowledged lack of service/calibration records for e-stim machine and involvement in QAPI meetings. | |
| Director of Nursing (DON) | Acknowledged baseline care plan issues and infection control education. |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 6
Date: Apr 15, 2021
Visit Reason
A revisit of a complaint survey and investigation of complaint #96755-C was conducted from 4/7-15/21, substantiating the complaint.
Complaint Details
Complaint #96755-C was substantiated. The investigation found multiple deficiencies related to resident dignity, fall notification and assessment, pressure ulcer care, fall prevention, and catheter care.
Findings
The facility was found deficient in multiple areas including failure to assure resident dignity related to catheter care, failure to notify physician and family of a resident fall, failure to immediately assess a resident after a fall, failure to prevent and properly treat pressure ulcers, failure to provide adequate supervision to prevent a fall, and failure to provide appropriate catheter care and infection control.
Deficiencies (6)
Failure to assure a resident's dignity related to uncovered catheter bags.
Failure to notify physician or family of a reported fall.
Failure to immediately assess a resident after a fall.
Failure to provide care consistent with professional standards to prevent and treat pressure ulcers, resulting in multiple unhealed pressure ulcers.
Failure to assure adequate staff assistance to prevent a fall.
Failure to provide appropriate catheter care including keeping catheter bags off the floor and using catheter straps.
Report Facts
Resident census: 58
Urine culture colony count: 100000
Urine culture colony count: 100000
Medication duration: 7
Medication duration: 3
Pressure ulcer measurements: 4.5
Pressure ulcer measurements: 3.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse | Reported repeated catheter issues and educated staff on catheter care |
| Staff G | Licensed Practical Nurse | Provided wound care treatment and described pressure ulcer injuries |
| Director of Nursing | Provided statements regarding expectations for catheter bag dignity, fall notification, and pressure ulcer policy | |
| Staff E | Certified Nursing Assistant | Assisted resident during fall incident and described circumstances |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 3
Date: Mar 9, 2021
Visit Reason
Investigation of complaint #95017-C and facility reported incident #96017-I was completed between 2/24/21 and 3/9/21. The complaint was not substantiated but the incident was substantiated.
Complaint Details
Complaint #95017-C was not substantiated. Incident #96017 was substantiated. The incident involved Resident #1 choking on inappropriate food and subsequent death.
Findings
The facility failed to ensure 6 sampled residents received the appropriate diet and adequate nursing supervision while consuming altered textured diets. Resident #1 choked on whole brussel sprouts despite being on a mechanical soft diet requiring supervision, resulting in death. Multiple residents were served food inconsistent with their prescribed mechanical soft diets, including whole brussel sprouts, unshredded lettuce, garlic bread with crust, and baked potatoes with skin. The facility lacked approved menus signed by a dietitian and staff were inadequately trained on diet orders and feeding supervision.
Deficiencies (3)
Resident #1 was served whole brussel sprouts instead of a mechanical soft diet and was not adequately supervised while eating, resulting in choking and death.
Multiple residents on mechanical soft diets were served foods not prepared according to diet texture requirements, including uncut brussel sprouts, unshredded lettuce, garlic bread with crust, and baked potatoes with skin.
Facility failed to have menus approved and signed by a dietitian and failed to ensure staff were trained to follow diet orders and assist residents properly during meals.
Report Facts
Resident census: 62
Residents on mechanical soft diet: 8
Duration of choking incident: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Documented progress notes and assisted Resident #1 during choking incident |
| Staff B | Certified Nurses Assistant (CNA) | Assisted Resident #1 to dine, failed to identify mechanical soft diet, terminated after incident |
| Staff C | Licensed Practical Nurse (LPN) | Assisted during choking incident, suctioned resident, provided oxygen |
| Nursing Home Administrator (NHA) | Administrator | Interviewed regarding incident and menus, confirmed lack of dietitian-approved menus |
| Staff D | Certified Nurses Assistant (CNA) | Witnessed incident aftermath, assisted Resident #1 post-choking |
| Staff E | Cook | Prepared food, stated brussel sprouts not served on evening menus |
| Contracted Dietitian | Dietitian | Interviewed regarding diet orders, menus, and incident |
| ARNP | Advanced Registered Nurse Practitioner | Provided medical orders, notified dietitian, involved in resident care |
| Staff F | Agency CNA | Interviewed about diet order knowledge |
| Staff G | Agency CNA | Witnessed incident, assisted during choking event |
| Staff H | Certified Nurses Assistant (CNA) | Assisted Resident #1 during choking event |
| Staff I | Agency CNA | Witnessed feeding of Resident #1 with whole brussel sprouts, assisted during choking event |
| Staff J | Dietary Aide and Cook | Observed serving unthickened juice to Resident #4 |
| Reimbursement Nurse Consultant | Registered Nurse (RN), Acting Director of Nursing | Acting DON after incident, not involved in investigation |
| Assistant Dietary Manager (ADM) | Dietary Manager | Interviewed about menus, diet preparation, and training |
| Food Service Director (FSD) | Certified Dietary Manager | Started after incident, working on diet orders and menu approvals |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Oct 7, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted in conjunction with an investigation of complaints #93515-C, #92926-C and facility reported incident #93427-I from 9/29/20 through 10/7/20.
Complaint Details
Complaint #93515-C was not substantiated. Complaint #92926-C was not substantiated. Incident #93427-I was not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. The investigations of complaints #93515-C, #92926-C, and incident #93427-I resulted in no deficiencies and were not substantiated.
Report Facts
Total residents: 55
Inspection Report
Routine
Census: 53
Deficiencies: 1
Date: Aug 12, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from 08/10/20 to 08/12/20 to assess compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found not in compliance with infection prevention and control requirements, specifically failing to properly screen employees prior to entering and exiting the facility. Multiple deficiencies were noted in employee screening logs and temperature checks.
Deficiencies (1)
Failure to properly screen employees prior to entering and exiting the facility as evidenced by incomplete employee screening logs and missing temperature checks.
Report Facts
Resident census: 53
Dates of survey: 3
Employee screening forms reviewed: 10
Inspection Report
Abbreviated Survey
Census: 58
Deficiencies: 0
Date: Jul 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from 7/21/20 to 7/23/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Investigation of complaint #90380-C and complaint #91044-C did not result in deficiency.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Investigations of complaint #90380-C and complaint #91044-C did not result in any deficiencies.
Report Facts
Total residents: 58
Inspection Report
Routine
Census: 71
Deficiencies: 0
Date: Jun 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaint #90000-C was investigated and found to be not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #90000-C was not substantiated.
Report Facts
Total residents: 71
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 5, 2020
Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaints (#87573, #87575, #89575, #89730) and incidents (#89024, #89634, #89727).
Complaint Details
Complaint #87573, #87575, #89575 & #89730 and incident #89024, #89634 & #89727 were not substantiated.
Findings
The complaints and incidents investigated were not substantiated according to the Code of Federal Regulations (42CFR) Part 483, Subpart B-C.
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