Inspection Report Summary
The most recent inspection on October 16, 2025, was a complaint investigation that found no deficiencies. Earlier inspections showed a mixed record with several citations related to resident care, including failures in post-fall assessments, pain management, dependent adult abuse training, medication errors, and infection control. Substantiated complaints primarily involved issues with care planning, supervision, and timely interventions after falls. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with recent inspections demonstrating substantial compliance following earlier deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
53 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
Investigation of facility reported incident #2632953-M conducted on October 15-16, 2025.
Complaint Details
Investigation of facility reported incident #2632953-M; no deficiencies found.
Findings
The investigation resulted in no deficiencies. Findings for the incident will be sent to the facility at a later date under separate cover.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 23, 2025
Visit Reason
A facility investigation for a reported incident #2588909-I was conducted on September 23, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Report Facts
Incident number: 2588909
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, and will be certified in compliance effective June 25, 2025.
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 1
Date: May 29, 2025
Visit Reason
The inspection was conducted to ensure the facility provided residents with prescribed therapeutic diets and to assess compliance with dietary requirements.
Findings
The facility failed to provide the correct mechanically altered diet to Resident #30, serving a regular diet soup with large meat chunks instead of the prescribed mechanically soft diet. Interviews with staff confirmed confusion regarding diet orders and responsibilities for plating and serving food.
Deficiencies (1)
Failed to provide residents with prescribed therapeutic diets for 1 of 3 residents reviewed (Resident #30).
Report Facts
Census: 53
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Certified Nurse Aide (CNA) | Observed feeding Resident #30 and noted the soup was not appropriate for the mechanically altered diet |
| Staff C | Dietary Assistant | Observed bringing Resident #30 his lunch |
| Dietary Manager | Confirmed the soup served was not approved for Resident #30's diet and provided the correct alternative | |
| Director of Nursing | Director of Nursing (DON) | Provided expectations regarding therapeutic diet provision |
| Registered Dietician | Registered Dietician | Provided information on Resident #30's diet history and hospice orders |
| Staff H | Certified Medication Aide (CMA) | Explained responsibilities of kitchen and CNAs regarding plating and serving food |
Inspection Report
Routine
Census: 53
Deficiencies: 6
Date: May 29, 2025
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including resident care, medication administration, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to complete dependent adult abuse training for staff, inadequate documentation and follow-up of skin assessments, improper wheelchair safety practices, medication administration errors involving crushing extended release medications, serving incorrect therapeutic diets, and failure to implement Enhanced Barrier Precautions for a resident with a pressure ulcer.
Deficiencies (6)
Failure to ensure completion of dependent adult abuse training within six months of hire for 1 of 5 employee files reviewed.
Failure to document follow-up skin assessments for 1 of 3 residents reviewed for skin concerns.
Failure to protect residents from potential accidents and hazards related to improper wheelchair foot positioning for 1 of 16 residents reviewed.
Medication error rate exceeded 5% due to crushing extended release medications for 2 residents.
Failure to provide prescribed mechanically altered diet for 1 of 3 residents reviewed.
Failure to follow Enhanced Barrier Precautions for a resident with an open pressure injury.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 2
Residents Affected: 1
Residents Affected: 1
Medication error rate: 6.67
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Certified Medication Aide | Named in dependent adult abuse training deficiency |
| Director of Nursing | DON | Confirmed dependent adult abuse training deficiency and commented on skin assessment and wheelchair safety deficiencies |
| Staff K | Licensed Practical Nurse | Involved in skin assessment documentation deficiency |
| Staff E | Certified Nurse Aide | Observed improperly pushing resident in wheelchair |
| Staff O | Certified Medication Aide | Observed crushing extended release medication |
| Staff F | Certified Medication Aide | Observed crushing extended release medication |
| Staff I | Certified Nurse Aide | Observed feeding resident incorrect diet |
| Dietary Manager | Confirmed serving incorrect diet to resident | |
| Staff A | Licensed Practical Nurse | Performed wound care without gown |
| Staff J | Registered Nurse | Commented on Enhanced Barrier Precautions usage |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 6
Date: May 29, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and an investigation of complaint #128028-C from May 27 to May 29, 2025.
Complaint Details
Complaint #128028-C was investigated during the survey and resulted in a deficiency related to dependent adult abuse training.
Findings
The facility was found deficient in multiple areas including failure to ensure dependent adult abuse training for staff, inadequate documentation and assessment of skin conditions for residents, failure to protect residents from accidents related to wheelchair use, medication errors exceeding the allowed rate, failure to provide prescribed therapeutic diets, and insufficient infection prevention and control practices.
Deficiencies (6)
Failure to ensure completion of dependent adult abuse training within six months of hire for staff.
Failure to document follow-up skin assessments and skin concerns for residents with wounds or bruises.
Failure to protect residents from potential accidents and hazards related to wheelchair use.
Medication error rate exceeded 5%, with 2 errors out of 30 opportunities (6.67%).
Failure to provide residents with prescribed therapeutic diets and proper food textures.
Failure to establish and maintain an effective infection prevention and control program.
Report Facts
Census: 53
Medication error rate: 6.67
Medication error opportunities: 30
Medication errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Certified Medication Aide | Named in deficiency for lack of dependent adult abuse training. |
| Director of Nursing | Confirmed lack of dependent adult abuse training documentation for Staff P and involved in skin assessment interviews. | |
| Staff F | Certified Nurse Aide (CNA) | Observed improperly pushing Resident #46 in wheelchair. |
| Staff K | Licensed Practical Nurse (LPN) | Reported resident condition changes and incomplete skin assessments. |
| Staff M | Licensed Practical Nurse (LPN) | Reported skin assessments and monitoring of Resident #2. |
| Staff N | Certified Nursing Assistant (CNA) | Reported on bruises and care of Resident #2. |
| Staff H | Certified Medication Aide (CMA) | Reported on wheelchair safety and medication administration. |
| Staff J | Registered Nurse (RN) | Reported wound care assessments and use of Enhanced Barrier Precautions. |
| Staff O | Certified Medication Aide (CMA) | Observed medication preparation and administration errors. |
| Staff A | Licensed Practical Nurse (LPN) | Reported on alternate medication forms and wound care. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
A revisit of the survey ending March 12, 2025 was conducted on April 9, 2025 to April 10, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective March 25, 2025.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Date: Mar 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide a thorough assessment and timely intervention for Resident #1 after she was lowered to the floor and subsequently suffered a displaced hip fracture.
Complaint Details
The investigation was complaint-driven, focusing on Resident #1's fall and subsequent injury. The complaint was substantiated as the facility failed to assess and treat the resident appropriately, leading to actual harm.
Findings
The facility failed to properly assess and intervene for Resident #1 after she was found on the floor on 2/23/25. Staff delayed assessments and pain management, resulting in a hip fracture diagnosis on 2/25/25. Multiple staff interviews and record reviews revealed communication failures and inadequate pain management. Resident #1 underwent surgery but later died on 3/11/25.
Deficiencies (2)
Failure to provide a thorough assessment and timely intervention for Resident #1 after being lowered to the floor, resulting in a displaced hip fracture.
Failure to administer ordered pain medication (Oxycodone) to Resident #1.
Report Facts
Residents present: 53
Pain medication doses administered: 9
PRN pain medication administration: 2
Oxycodone doses ordered but not administered: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Failed to complete thorough assessment after Resident #1 was lowered to the floor and did not administer pain medication. |
| Staff B | Medical Doctor (MD) | Examined Resident #1, ordered discontinuation of Oxycodone due to side effects, later ordered Oxycodone for pain after assessment. |
| Staff F | Certified Nurse Assistant (CNA) | Notified nurse about Resident #1 on the floor, provided care, reported resident's pain and refusal to get up. |
| Staff G | Certified Nurse Assistant (CNA) | Assisted Resident #1 off the floor, notified nurse who failed to act. |
| Staff J | Speech Therapist (ST) | Noted Resident #1's distress and pain on 2/24/25, consulted ADON about concerns. |
| Staff I | Director of Rehabilitation | Notified ADON of Resident #1's pain and change of condition on 2/24/25. |
| Staff M | Certified Nurse Assistant (CNA) | Worked with Resident #1 on 2/24/25, reported resident's pain and refusal to get up. |
| Staff K | Licensed Practical Nurse (LPN) | Worked overnight shift, was not informed about Resident #1 being on the floor or in pain. |
| ADON | Assistant Director of Nursing | Notified of Resident #1's pain on 2/24/25, delayed assessment until hours later, asked DON about x-ray. |
| DON | Director of Nursing | Conducted assessment on 2/24/25, ordered pain medication but failed to ensure administration, coordinated x-ray and family communication. |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #126928-C, which was substantiated. The investigation focused on quality of care concerns for Resident #1, including failure to provide timely assessment and pain management after a fall and injury.
Complaint Details
Complaint #126928-C was substantiated. The complaint involved failure to assess and treat pain and injuries after Resident #1 was found on the floor on 2/23/25, resulting in a delayed diagnosis of a hip fracture and inadequate pain management.
Findings
The facility failed to provide a thorough assessment and timely intervention for Resident #1 after she was found on the floor and in pain on 2/23/25. Pain medications were ordered but not administered as prescribed, and an x-ray revealing a hip fracture was delayed until 2/25/25. The resident was transferred for surgery but later died on 3/11/25. Multiple staff interviews revealed communication failures and inadequate response to the resident's pain and fall.
Deficiencies (1)
Failure to provide a thorough assessment and timely intervention for Resident #1 after being found on the floor and in pain.
Report Facts
Census: 53
Dates of complaint investigation: Complaint investigation completed on 3/10/25 to 3/12/25
Pain medication administration times: Acetaminophen administered on 2/23/25, 2/24/25, 2/25/25 at 8AM, 2PM, 10PM; PRN meds given early morning 2/25/25
Date of fracture x-ray: X-ray revealing hip fracture performed on 2/25/25
Date of resident death: Resident died on 3/11/25 at 10:10 AM
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in failure to assess and administer pain medication after resident was found on floor |
| Staff B | Medical Doctor | Ordered pain medication and evaluated resident; stated expectation that Oxycodone be administered |
| Staff C | Registered Nurse (RN) | Documented skilled assessment on 2/23/25 |
| Staff D | Licensed Practical Nurse (LPN) | Notified physician and obtained order for x-ray on 2/25/25 |
| Staff F | Certified Nurse Assistant (CNA) | Reported resident on floor and pain complaints; notified nurse who failed to assess |
| Staff G | Certified Nurse Assistant (CNA) | Assisted resident off floor and reported pain complaints |
| Staff H | Physical Therapy Assistant (PTA) | Provided therapy and described resident's condition on 2/21/25 |
| Staff I | Director of Rehabilitation | Observed resident's condition and notified ADON of pain and distress |
| Staff J | Speech Therapist (ST) | Assisted resident and reported pain and distress on 2/24/25 |
| Staff K | Licensed Practical Nurse (LPN) | Night shift nurse not informed of resident on floor or pain |
| ADON | Assistant Director of Nursing | Conducted assessments, notified physician, and managed care after resident found on floor |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified effective December 3, 2024, based on the Plan of Correction submitted.
Report Facts
Certification effective date: Facility certification effective December 3, 2024
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Nov 26, 2024
Visit Reason
The inspection was conducted as an investigation of complaint #123823-C regarding failure to provide post-fall assessments and interventions.
Complaint Details
Complaint #123823-C was substantiated based on investigation findings.
Findings
The facility failed to provide required post-fall assessments and neurological follow-up for three residents who had unwitnessed falls. The complaint was substantiated based on record reviews, staff interviews, and policy review.
Deficiencies (1)
Failure to provide post-fall assessments and interventions for residents with unwitnessed falls.
Report Facts
Residents reviewed for post-fall assessments: 3
Census: 55
Required follow-up neurological assessments: 14
Completed neurological assessments: 12
Completed neurological assessments: 3
Completed neurological assessments: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Verified the residents' falls and neurological assessment documentation. |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding fall assessment protocols and documentation practices. |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 1
Date: Nov 25, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of quality, specifically focusing on post-fall assessments and interventions for residents.
Findings
The facility failed to provide complete post-fall neurological assessments and interventions for 3 of 3 residents reviewed who had unwitnessed falls. Documentation was incomplete for required follow-up neurological assessments despite the facility's fall protocol.
Deficiencies (1)
Failure to provide post-fall assessments and interventions for 3 residents with unwitnessed falls.
Report Facts
Residents affected: 3
Census: 55
Required follow-up neurological assessments: 14
Completed follow-up neurological assessments for Resident #1: 12
Completed follow-up neurological assessments for Resident #2: 3
Completed follow-up neurological assessments for Resident #3: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Verified the falls were unwitnessed and explained neurological assessment protocol |
| Director of Nursing (DON) | Explained the post-fall neurological assessment protocol and confirmed lack of completed assessments |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 29, 2024
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a facility inspection, confirming certification in compliance based on acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance, and the plan of correction was accepted, resulting in certification effective June 29, 2024.
Inspection Report
Routine
Census: 51
Deficiencies: 4
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including notification procedures, skin assessments, incontinence care, and staffing requirements at Arbor Springs of West Des Moines L L C.
Findings
The facility failed to notify the long term care ombudsman for a resident transfer, did not consistently document skin assessments including wound measurements, failed to provide proper incontinence care minimizing infection risk, and did not maintain required RN coverage for at least 8 consecutive hours a day.
Deficiencies (4)
Failed to notify the long term care ombudsman for a resident transfer to an acute care hospital for 1 of 2 residents reviewed.
Failed to document skin assessments for one of two residents reviewed for skin conditions, including incomplete wound measurements.
Failed to ensure staff provided incontinence care to minimize risk of cross-contamination and urinary tract infections, including failure to change gloves when contaminated.
Failed to maintain a Registered Nurse on duty for at least 8 consecutive hours a day.
Report Facts
Census: 51
Deficiency count: 4
RN coverage gap hours: 48
Wound measurements: 1.8
Wound measurements: 0.9
Wound measurements: 5.5
Wound measurements: 2
Wound measurements: 9.9
Wound measurements: 2.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Observed wound and skin condition of Resident #9 |
| Staff E | Certified Medication Aide (CMA) | Reported nurse completed residents' skin assessments |
| Staff F | Registered Nurse (RN) | Reported nurse completed residents' skin assessments at least weekly |
| Staff G | Registered Nurse (RN) | Reported skin assessments documented weekly and during showers |
| Director of Nursing (DON) | Director of Nursing | Reported on skin assessment procedures, audits, and RN coverage expectations |
| Staff A | Certified Nursing Assistant (CNA) | Observed providing incontinence care to Resident #26 |
| Staff B | Certified Nursing Assistant (CNA) | Observed providing incontinence care to Resident #26 |
| Staff C | Certified Nursing Aide (CNA) | Interviewed about RN coverage knowledge |
| Administrator | Administrator | Provided staffing schedules and emails regarding RN coverage |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 4
Date: Jun 3, 2024
Visit Reason
The inspection was conducted as the facility's Annual Recertification survey from June 3, 2024 to June 6, 2024.
Findings
The facility was found deficient in multiple areas including failure to notify the long-term care ombudsman of resident transfers, incomplete documentation of skin assessments for residents with wounds, improper pericare practices, and failure to maintain required RN staffing levels for at least 8 consecutive hours a day, 7 days a week.
Deficiencies (4)
Failed to notify the long term care ombudsman for a resident transfer to an acute care hospital.
Failed to document skin assessments for one of two residents reviewed for skin conditions.
Failed to provide incontinent care minimizing risk of cross-contamination and urinary tract infections for one of four residents observed.
Failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week.
Report Facts
Census: 51
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Medication Aide (CMA) | Reported nurse completed residents' skin assessments. |
| Staff F | Registered Nurse (RN) | Reported nurse completed residents' skin assessments at least weekly. |
| Staff G | Registered Nurse (RN) | Reported skin assessments documented weekly and marked on MAR. |
| Director of Nursing | Director of Nursing (DON) | Reported nurses completed skin assessments and documented in EHR; confirmed deficiencies and corrective actions. |
| Staff A | Certified Nursing Assistant (CNA) | Observed providing incontinent care during inspection. |
| Staff B | Certified Nursing Assistant (CNA) | Observed providing incontinent care during inspection. |
| Administrator | Provided information on IT report issues and facility policies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 23, 2024
Visit Reason
A complaint investigation was conducted for Complaints #116320-C and #118106-C from May 20, 2024 to May 23, 2024.
Complaint Details
Investigation of Complaints #116320-C and #118106-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
The inspection was conducted as a complaint survey regarding an investigation of complaint #116201-C.
Complaint Details
Complaint #116201-C was investigated and found not substantiated.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, and the complaint #116201-C was not substantiated.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 4, 2023
Visit Reason
An onsite revisit regarding the facility's annual recertification survey was conducted on May 2-4, 2023.
Findings
The facility was found in substantial compliance effective March 31, 2023.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 3
Date: Mar 9, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to provide required Medicare Liability Notices and Beneficiary Appeals forms timely, inadequate pressure ulcer care, and failure to maintain acceptable nutritional status for residents.
Complaint Details
The complaint investigation focused on failure to timely provide Medicare Non-Coverage notices and appeals information, inadequate pressure ulcer prevention and care, and failure to maintain adequate nutrition leading to weight loss in residents.
Findings
The facility failed to provide Medicare Non-Coverage notices within the required 48 hours for 2 of 3 residents reviewed, failed to prevent pressure ulcers for 1 resident, and failed to maintain adequate nutrition for 2 residents resulting in significant weight loss. Documentation and implementation of care plans and interventions were inconsistent.
Deficiencies (3)
Failed to provide required Medicare Liability Notices and Beneficiary Appeals forms within 48 hours of skilled services ending for 2 residents and failed to inform residents of their right to appeal.
Failed to implement intervention to prevent a resident from developing a pressure ulcer and failed to document wound care properly.
Failed to provide adequate nutrition and maintain acceptable nutritional status for 2 residents, resulting in significant weight loss.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Census: 53
Weight loss percentage: 17.2
Weight loss percentage: 10.5
Pressure ulcer measurement: 1.7
Pressure ulcer measurement: 1.6
Pressure ulcer measurement: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Reported contacting Resident #100's representative and providing notice | |
| Administrator | Reported facility had no policy for ABNs but followed CMS guidelines | |
| Staff B | Licensed Practical Nurse (LPN) | Documented stage four pressure area and wound care notes for Resident #6 |
| Staff C | Registered Nurse (RN) | Documented wound care and physician orders for Resident #6 |
| Staff D | Licensed Practical Nurse (LPN) | Documented wound care observations for Resident #6 |
| Staff E | Registered Nurse (RN) | Reported on Resident #6's wound presence at admission |
| Staff F | Registered Nurse (RN) | Performed wound care and repositioning for Resident #6 |
| Director of Nursing | Director of Nursing (DON) | Reported on wound care documentation and nutritional interventions |
| Registered Dietitian | Registered Dietitian (RD) | Authored multiple nutritional notes and weight change notes for Residents #26 and #37 |
| Staff L | Certified Nurse Aide (CNA) | Prepared food and assisted Resident #26 |
| Staff A | Certified Nurse Aide (CNA) | Provided meal supervision and cues for Resident #26 and Resident #37 |
| Staff M | Certified Nurse Aide (CNA) | Reported on Resident #37's eating habits |
| Staff N | Certified Nurse Aide (CNA) | Reported on dietary card meanings |
| Staff O | Certified Nurse Aide (CNA) | Reported on dietary card meanings |
| Staff P | Certified Nurse Aide (CNA) | Reported on dietary card meanings |
| Staff Q | Certified Nurse Aide (CNA) | Reported on dietary card meanings |
| Staff B | Licensed Practical Nurse (LPN) | Reported on dietary card meanings |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 4
Date: Mar 6, 2023
Visit Reason
The inspection was the facility's annual recertification survey conducted from March 6, 2023 to March 9, 2023 to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found not in compliance with several requirements including timely issuance of Medicare Non-Coverage Notices, prevention and treatment of pressure ulcers, and maintenance of nutritional status for residents. Deficiencies were identified related to notification processes, skin integrity, and nutrition/hydration status.
Deficiencies (4)
Failure to provide required Medicare Liability Notices and Beneficiary Appeals within 48 hours for skilled services ending for residents #17 and #100.
Failure to implement interventions to prevent development of pressure ulcers for resident #6.
Failure to maintain acceptable nutritional status parameters for residents #26 and #37, resulting in significant weight loss.
Failure to complete a significant change assessment within 14 days for resident #3.
Report Facts
Census: 53
Residents reviewed for Medicare Non-Coverage Notices: 3
Residents reviewed for pressure ulcer deficiency: 1
Residents reviewed for nutrition deficiency: 2
Residents reviewed for significant change assessment deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Documented stage four pressure area and wound care for Resident #6 |
| Staff C | Registered Nurse (RN) | Documented pressure wound and notified physician for Resident #6 |
| Staff D | Licensed Practical Nurse (LPN) | Documented wound care and observations for Resident #6 |
| Staff F | Nurse | Provided wound care and repositioning for Resident #6 |
| Director of Nursing | Director of Nursing (DON) | Reported wound care and weight loss issues for Resident #6 and Resident #26 |
| Registered Dietitian | Registered Dietitian (RD) | Authored dietary notes and weight change documentation for Residents #26 and #37 |
| Social Worker | Social Worker (SW) | Reported notification processes for skilled services ending |
| Administrator | Administrator | Provided information on facility policies and education regarding ABN and MDS processes |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 31, 2022
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating the facility's acceptance of compliance and certification effective September 13, 2022.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction as per 42 CFR Part 483, Subpart B-C.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 3
Date: Aug 18, 2022
Visit Reason
The inspection visit was conducted as an investigation of complaints #103578-C, #105093-C, and #106985-C from August 18 to August 25, 2022. Complaints #103578-C and #106985-C were substantiated.
Complaint Details
Complaints #103578-C and #106985-C were substantiated based on observations, clinical record reviews, staff interviews, and facility policy review. The investigation found failures related to care planning, supervision, and notification after a resident eloped.
Findings
The facility failed to update a Care Plan for a resident at risk for elopement and failed to notify appropriate staff members after the resident eloped. The resident was found outside unattended, and staff did not properly supervise or report the incident. The facility lacked documentation related to the resident's risk of elopement and failed to ensure proper supervision to prevent residents from going outside unattended.
Deficiencies (3)
Failed to update a Care Plan for a resident at risk for elopement.
Failed to notify appropriate staff members after resident eloped so an assessment could be completed.
Residents did not have appropriate supervision to prevent them from going outside unattended.
Report Facts
Complaint investigation dates: August 18, 2022 to August 25, 2022
Census: 55
Resident wandering days: 4
Alarm response time: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Dietary Aide | Noticed Resident #1 outside and alerted Staff B |
| Staff B | Certified Nursing Assistant (CNA) | Responded to Resident #1 outside and brought him back inside |
| Staff A | Licensed Practical Nurse (LPN) | Reported not being informed about Resident #1 leaving the building |
| Staff D | Certified Medication Aide (CMA) | Administered medications and did not report Resident #1 leaving the building |
| Director of Nursing | DON | Responded to questions about elopement assessments and policies |
| Education Director | Provided investigation summary and education on emergency door alarms | |
| MDS Coordinator | Coordinated investigation and communication regarding Resident #1 elopement |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: Sep 9, 2021
Visit Reason
A recertification health survey and investigation of Complaint #96746-C and Facility Reported Incidents #97076-I and #98544-I was completed from 8/31/21 to 9/9/21.
Complaint Details
Complaint #96746-C was not substantiated. Facility Reported Incident #97076-I was not substantiated. Facility Reported Incident #98544-I was not substantiated.
Findings
The facility failed to follow physician orders for one resident regarding ACE wraps and failed to provide rationale for continuing psychotropic medications for two residents as recommended by the pharmacist.
Deficiencies (2)
Facility failed to follow physician orders for ACE wraps for Resident #29.
Facility failed to provide rationale for continuing psychotropic medications for two residents (#48 and #51) as recommended by the pharmacist for a Gradual Dose Reduction (GDR).
Report Facts
Census: 55
Residents reviewed for GDR: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed resident did not wear ACE wraps and acknowledged physician orders; reported plans to follow up with staff |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Date: Jul 23, 2020
Visit Reason
The inspection was a COVID-19 Focused Infection Control Survey and investigation of Facility Reported Incident #91444-I and Complaint #91893-C, conducted due to a complaint and reported incident involving resident care and abuse allegations.
Complaint Details
Complaint #91893-A was substantiated. Facility Reported Incident #91444-I was not substantiated.
Findings
The facility failed to report an incident of neglect and immediately segregate the alleged perpetrator after Resident #2 fell due to improper ambulation assistance by Staff A. The resident suffered injuries including bruises and an open wound on the left knee. Staff did not follow care plans requiring use of a gait belt and wheelchair follow during ambulation. The facility also failed to ensure adequate supervision and assistance devices to prevent accidents.
Deficiencies (2)
Failure to report an incident of neglect and immediately segregate the alleged perpetrator as required by Abuse Prevention policy.
Failure to ensure resident received transfer assistance as directed by care plan, resulting in a fall and injuries.
Report Facts
Resident census: 42
Date of fall incident: Jun 16, 2020
Date survey completed: Jul 23, 2020
Number of bruises documented: 4
Size of largest bruise: 6
Number of eschar/dry scab open areas: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | CNA/CMA | Named in findings for improper ambulation and failure to follow care plan resulting in resident fall |
| Staff C | CNA | Witnessed fall and improper ambulation by Staff A |
| Staff D | CNA | Witnessed fall and improper ambulation by Staff A |
| Staff E | LPN | Provided education to Staff A on following care plan after fall |
| Staff F | Occupational Therapist | Observed resident ambulation with gait belt and walker |
| Assistant Director of Nursing | ADON | Conducted fall investigation and obtained witness statements |
Inspection Report
Routine
Census: 41
Deficiencies: 0
Date: Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess 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.
Report Facts
Total census: 41
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