Inspection Report Summary
The most recent inspection on December 4, 2025 cited multiple deficiencies related to medication management, PASARR assessments, dietary interventions, dialysis assessments, food handling, vaccination documentation, and the facility’s QAPI program. Earlier inspections showed a pattern of similar issues including inadequate staffing, incomplete care plans, delayed abuse reporting, and food safety concerns. Several complaint investigations were substantiated over time, particularly involving abuse reporting, medication administration, and resident dignity, while most recent complaints were unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility has shown some correction of deficiencies between inspections, but recurring themes suggest ongoing challenges in care coordination, staff response, and food service practices.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
29.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
566% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
51 residents
Based on a December 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 3
Date: Dec 4, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to PASARR screening, nutritional needs and food service safety in the facility.
Findings
The facility failed to fully submit a Level 1 PASARR evaluation timely for one resident, failed to serve correct portion sizes for residents on pureed diets, and failed to maintain proper food handling and sanitation practices in the kitchen, including improper glove use, uncovered food, and lack of beard nets for staff.
Deficiencies (3)
Failed to fully submit a Level 1 PASARR evaluation to the appropriate state-designated authority prior to admission or within 30 days for 1 of 4 residents reviewed.
Failed to ensure residents on a therapeutic pureed diet were served the correct amount and serving size.
Failed to ensure proper food handling procedures, including hair covering, clean kitchen area, covered food on room trays, and proper hand placement on glassware to prevent contamination.
Report Facts
Residents on pureed diet: 4
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Social Services Director | Interviewed regarding PASARR screening deficiencies |
| Staff E | Cook | Observed preparing and serving pureed food with incorrect portion sizes and improper glove use |
| Staff D | Dietary Aide | Observed improper food handling including hand placement on cups, uncovered food trays, and lack of beard net |
| Certified Dietary Manager | CDM | Interviewed regarding food service expectations and acknowledged deficiencies |
| Administrator | Interviewed regarding PASARR screening expectations and acknowledged gap in compliance |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 11
Date: Dec 4, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey to assess compliance with regulatory requirements and quality of care standards.
Findings
The facility was found deficient in multiple areas including psychotropic medication management, PASRR screening and referrals, dietary interventions for weight loss, dialysis care assessments, medication regimen reviews, food service and handling practices, vaccination offerings, and quality assurance performance improvement. Several deficiencies were repeated from prior surveys.
Deficiencies (11)
Failed to limit PRN psychotropic medication to 14 days without clinical rationale or end date for Resident #21.
Failed to refer Resident #3 for Level II PASRR evaluation following newly diagnosed mental disorder.
Failed to fully submit Level I PASRR evaluation to state authority within 30 days for Resident #50.
Failed to implement timely dietary interventions for Resident #44 experiencing significant weight loss.
Failed to perform pre and post dialysis assessments for Resident #6.
Failed to complete Abnormal Involuntary Movement Scale (AIMS) assessment timely for Resident #21 on antipsychotic medication.
Failed to serve correct portion sizes for residents on pureed diets (Residents #24, #38, #40, #42).
Failed to ensure proper food handling procedures, hair covering, kitchen cleanliness, food coverage on trays, and proper hand placement on glassware to prevent contamination.
Failed to correct repeated deficiencies related to food procurement, storage, preparation, and sanitation despite prior citations.
Failed to offer recommended pneumococcal and influenza vaccines to eligible residents (Residents #14, #33, #41, #50).
Failed to offer recommended COVID-19 vaccines to eligible residents (Residents #14, #41, #50) and properly document vaccination status.
Report Facts
Residents on pureed diet: 4
Number of residents reviewed for vaccines: 5
Number of residents with vaccination deficiencies: 4
Number of residents reviewed for PASRR: 4
Number of residents reviewed for psychotropic medication: 5
Number of residents reviewed for dialysis care: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Social Services Director | Interviewed regarding PASRR screening and submission for Residents #3 and #50 |
| Director of Nursing | Director of Nursing (DON) | Acknowledged deficiencies related to psychotropic medication orders and dialysis assessments |
| Staff G | Registered Nurse (RN) | Described dialysis pre and post assessments |
| Staff E | Cook | Observed preparing pureed food and plating meals with improper glove use |
| Staff D | Dietary Aide | Observed with improper food handling and hair covering |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Acknowledged food service deficiencies and expectations |
| Staff A | Infection Preventionist (IP) | Interviewed regarding vaccination offering and documentation |
| Administrator | Administrator | Acknowledged repeated deficiencies and vaccination gaps |
| Chief Operating Officer | Chief Operating Officer (COO) | Discussed follow-up on dietary recommendations and provider communication |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 11
Date: Dec 4, 2025
Visit Reason
Annual recertification survey and investigation of complaints #2625141-C, #2671743-C, and #2678226-C conducted December 1, 2025 through December 4, 2025.
Complaint Details
The inspection included investigation of complaints #2625141-C, #2671743-C, and #2678226-C. Deficiencies were cited for complaints #2671743-C and #2678226-C. No deficiency was cited for complaint #2625141-C.
Findings
Multiple deficiencies were cited including failure to limit PRN psychotropic drugs to 14 days, failure to coordinate PASARR assessments, failure to implement dietary interventions timely for weight loss, failure to perform pre/post dialysis assessments, failure to act on pharmacist drug regimen review recommendations, failure to serve pureed diets in correct portions, failure to maintain sanitary food handling practices, failure to offer and document influenza, pneumococcal, and COVID-19 vaccinations, and failure to maintain an effective QAPI program.
Deficiencies (11)
Failed to limit PRN psychotropic drug to 14 days for 1 of 5 residents (Resident #21).
Failed to refer a resident (Resident #3) for Level II PASARR evaluation following newly diagnosed mental disorder.
Failed to fully submit Level I PASRR evaluation within 30 days for 1 of 4 residents (Resident #50).
Failed to implement dietary interventions timely for significant weight loss (Resident #44).
Failed to perform pre and post dialysis assessments for 1 of 1 resident reviewed for dialysis (Resident #6).
Failed to follow through on pharmacist recommendations to complete Abnormal Involuntary Movement Scale (AIMS) assessment for 1 of 5 residents (Resident #21).
Failed to serve pureed diet residents correct portion sizes and serving sizes (Residents #24, #38, #40, #42).
Failed to ensure proper food handling, hair covering, kitchen cleanliness, food coverage on trays, and proper hand placement on glassware, risking food contamination.
Failed to correct repeated deficiencies related to food procurement, storage, preparation, and serving sanitary practices.
Failed to offer and properly document influenza and pneumococcal vaccinations for 4 of 5 residents reviewed (Residents #14, #33, #41, #50).
Failed to offer and properly document COVID-19 vaccinations for 3 of 5 residents reviewed (Residents #14, #41, #50).
Report Facts
Residents reviewed for PRN psychotropic drug use: 5
Facility census: 51
Weight loss percentage: 11.91
Number of pre/post dialysis assessments logged: 10
Residents reviewed for vaccinations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Social Services Director | Acknowledged delayed PASRR submission for Resident #50. |
| Staff A | Infection Preventionist | Responsible for vaccination tracking and acknowledged missed vaccinations. |
| Staff E | Cook | Observed serving incorrect pureed food portions and improper food handling. |
| Staff D | Dietary Aide | Observed improper hand placement on cups and lack of beard net. |
| Staff G | Registered Nurse | Described dialysis pre/post assessments process. |
| Director of Nursing | Director of Nursing | Acknowledged deficiencies in AIMS assessments and dialysis assessments. |
| Certified Dietary Manager | Certified Dietary Manager | Acknowledged pureed diet portion size and food handling deficiencies. |
| Chief Operating Officer | Chief Operating Officer | Acknowledged responsibility for following RD recommendations and QAPI deficiencies. |
| Administrator | Administrator | Acknowledged PASRR screening deficiencies. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 12, 2025
Visit Reason
A revisit of the survey ending September 11, 2025 was conducted from November 6, 2025 to November 12, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in compliance effective October 3, 2025. DPNA will not be effectuated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 23, 2025
Visit Reason
A complaint investigation for Complaint #2636145-C was conducted on October 23, 2025.
Complaint Details
Complaint #2636145-C was investigated and no deficiencies were cited; the complaint was not substantiated.
Findings
No deficiencies were cited with investigation of the complaint. However, due to a previous visit ending on September 11, 2025, the facility is not in compliance and an onsite visit will be scheduled at a later date.
Report Facts
Complaint number: 2636145
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 6
Date: Sep 11, 2025
Visit Reason
The inspection was conducted based on complaints and observations regarding the facility's failure to provide a safe, clean, and homelike environment, adequate supplies, proper staffing, food safety, and infection control.
Complaint Details
The visit was complaint-related due to multiple reports of inadequate supplies, poor environmental conditions, pest infestations, insufficient staffing, delayed response to call lights, and infection control failures. The facility was placed under Immediate Jeopardy for kitchen sanitation and pest control issues starting at least 04/29/2025, which was removed on 09/04/2025 after corrective actions.
Findings
The facility failed to maintain a clean and safe environment, including inadequate supplies of briefs and linens, poor kitchen sanitation with pest infestation, insufficient staffing to meet resident needs, improper use of mechanical lifts, and failure to follow infection control protocols. Multiple residents and staff reported issues with cleanliness, odors, pest presence, and delayed care.
Deficiencies (6)
Failure to provide a safe, clean, comfortable and homelike environment, including inadequate supplies of briefs and linens.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Failure to procure food from approved sources and maintain kitchen sanitation, resulting in immediate jeopardy due to pest infestation and unsanitary conditions.
Failure to administer the facility in a manner that enables it to use its resources effectively and efficiently, including inadequate management of supplies and environment.
Failure to provide and implement an infection prevention and control program, including improper glove use and failure to sanitize equipment and slings between residents.
Report Facts
Residents affected: 59
Packages of briefs: 4
Boxes of gloves: 10
Call light response times: 23
Number of mice caught: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Nursing Assistant (CNA) | Observed failing to lock bed brakes and improper infection control during resident care |
| Staff F | Certified Nursing Assistant (CNA) | Observed failing to lock bed brakes and improper infection control during resident care |
| Staff J | Central Supply Staff | Reported ordering and managing supplies, including briefs and gloves |
| Regional Director of Operations | Reported on facility conditions, staffing, and management issues | |
| Director of Nursing | DON | Reported expectations for staff and infection control practices |
| Staff B | Licensed Practical Nurse (LPN) | Reported supply shortages and resident illness |
| Staff A | Certified Nursing Assistant (CNA) | Reported supply shortages and use of improvised briefs |
| Staff M | Dietary Aide | Reported daily presence of mice in kitchen and poor kitchen conditions |
| Staff L | Cook | Reported daily presence of mice in kitchen and poor kitchen conditions |
| Staff R | Registered Nurse (RN) | Reported infection control expectations for enhanced barrier precautions |
| Infection Preventionist | IP | Reported infection control expectations and observed care |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 31, 2024
Visit Reason
A revisit of the survey ending November 26, 2024 and investigation of Complaint #125479-C was conducted on December 30, 2024 to December 31, 2024.
Complaint Details
Complaint #125479-C was investigated and found not substantiated.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 27, 2024. Complaints #125479-C was not substantiated.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 13
Date: Nov 26, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and investigation of reported incidents #122246-I-I, 124480-I, and 125064-I.
Findings
The facility was found to have multiple deficiencies including failure to provide required Medicaid Liability Notices timely, failure to report allegations of abuse promptly, inadequate investigation and reporting of abuse, incomplete and inaccurate resident assessments, insufficient nursing staff response to call lights, and unsafe food storage and handling practices.
Deficiencies (13)
Failure to provide properly filled Medicaid Liability Notices and Beneficiary Appeals within 48 hours for sampled residents.
Failure to report allegations of abuse timely to the Department of Inspections, Appeals and Licensing (DIAL).
Failure to ensure all allegations of abuse including verbal threats and rough treatment were reported to facility administration timely.
Failure to accurately complete Minimum Data Set (MDS) assessments for residents.
Failure to submit a new readmission screening and resident review (PASRR) level 1 screening for resident.
Failure to ensure the resident environment remains free of accident hazards including cluttered hallways and improperly stored equipment.
Failure to maintain sufficient nursing staff with appropriate competencies and skills to assure resident safety and care.
Failure to respond to call lights in a timely manner and failure to document call light response times accurately.
Failure to ensure residents are free of significant medication errors including insulin administration errors.
Failure to ensure safe and effective use of the Lispro Kwikpen injector system for insulin administration.
Failure to procure, store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Failure to maintain food storage areas clean, free of debris, and properly labeled with use-by dates.
Failure to ensure staff wore gloves and practiced hand sanitation when handling resident food.
Report Facts
Facility census: 49
Number of residents reviewed for Medicaid Liability Notices: 3
Number of residents reviewed for abuse allegations: 4
Number of residents with incomplete MDS assessments: 1
Number of residents screened for PASRR: 20
Number of call lights documented on Staff A's disciplinary action: 7
Number of call lights response times documented: 20
Number of residents receiving psychotropic medication: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in abuse and neglect findings related to Resident #10 and Resident #38 |
| Staff B | Certified Nursing Assistant (CNA) | Named in abuse and neglect findings related to Resident #38 |
| Staff G | Licensed Practical Nurse (LPN) | Reported abuse concerns and participated in investigation |
| Staff J | Licensed Practical Nurse (LPN) | Reported observations related to Resident #10 and abuse investigation |
| Staff K | Registered Nurse (RN) | Reported observations of staff behavior and resident agitation |
| Staff P | Licensed Practical Nurse (LPN) | Observed insulin administration and medication handling |
| Staff Q | Regional Corporate Nurse Consultant | Interviewed regarding medication administration and staff hygiene |
| Staff C | Dietary Cook | Observed during dinner service with food handling deficiencies |
| Staff D | Dietary Aide | Observed during dinner service with food handling deficiencies |
| Staff E | Dietary Cook | Observed food storage and sanitation deficiencies |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding abuse investigation and staff education |
| Regional Director of Operations | Regional Director of Operations | Reported on call light response times and staff disciplinary actions |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Date: Nov 26, 2024
Visit Reason
The inspection was conducted due to allegations of abuse involving staff to resident verbal threats, rough treatment, and inappropriate touching reported for multiple residents, as well as concerns about call light response times and staffing adequacy.
Complaint Details
The complaint investigation involved allegations of staff verbal threats, rough treatment, and inappropriate touching of residents #10, #38, and #28. The facility failed to report incidents timely to the Department of Inspections, Appeals and Licensing (DIAL). Resident #10 reported rough pericare and racial slurs by Staff A. Resident #38 reported rough handling and threatening statements by Staff A. Resident #28 reported unkind treatment by staff, which was not initially reported or investigated. Multiple staff interviews revealed delays and failures in reporting abuse. The facility initiated staff re-education and suspended involved staff pending investigation.
Findings
The facility failed to timely report allegations of abuse for three residents and did not investigate or report an allegation for a fourth resident until the survey. Multiple staff interviews and resident assessments revealed inconsistent reporting and delayed notifications to authorities. Additionally, the facility failed to respond to call lights in a timely manner, with documented extended response times and resident complaints. Staffing levels were reviewed and found to be insufficient to meet resident needs consistently.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to answer call lights in a timely manner, with multiple documented instances of response times exceeding 15 minutes, some lasting over an hour.
Report Facts
Census: 49
Call light response times: 16
Call light response times: 35
Call light response times: 5
Call light response times: 6
Call light response times: 42
Call light response times: 17
Call light response times: 6
Call light response times: 27
Call light response times: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in allegations of rough treatment and verbal abuse toward Residents #10 and #38; suspended pending investigation |
| Staff B | Certified Nursing Assistant (CNA) | Reported abuse by Staff A toward Resident #38; suspended and re-educated on abuse reporting |
| Staff G | Licensed Practical Nurse (LPN) | Conducted assessments and interviews related to abuse allegations |
| Staff J | Licensed Practical Nurse (LPN) | Conducted skin assessments and interviews related to abuse allegations |
| Staff K | Registered Nurse (RN) | Agency nurse who oversaw staff and reported on abuse training and response |
| Director of Nursing (DON) | Director of Nursing | Oversaw investigation, education, and reporting of abuse allegations |
| Unit Manager | Unit Manager | Conducted interviews and observations related to abuse allegations |
| Interim Administrator | Interim Administrator | Reported abuse to authorities and initiated investigation |
| Regional Director of Operations | Regional Director of Operations | Reported on call light response times and staffing issues |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 9
Date: Nov 26, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide proper Medicare Liability Notices, failure to timely report suspected abuse and neglect, and other regulatory concerns.
Complaint Details
The complaint investigation included issues related to failure to provide Medicare Liability Notices, failure to timely report and investigate abuse allegations, inaccurate MDS assessments, failure to submit PASRR screenings, unsafe environment due to clutter, inadequate staffing and call light response, failure to track behaviors for residents on psychotropic medications, medication administration errors, and unsanitary food handling practices.
Findings
The facility failed to provide required Medicare Liability Notices timely for three residents, failed to timely report and investigate allegations of abuse for multiple residents, failed to accurately complete a resident's MDS assessment, failed to submit required PASRR screening for a resident, failed to maintain a safe and clutter-free environment, failed to ensure timely call light response, failed to track and document behaviors for residents on psychotropic medications, failed to properly administer insulin, and failed to store and serve food in a sanitary manner.
Deficiencies (9)
Failed to provide Medicare Liability Notices and Beneficiary Appeals within 48 hours for three residents.
Failed to timely report suspected abuse and neglect for multiple residents and failed to investigate allegations properly.
Failed to accurately complete MDS assessment for Resident #47.
Failed to submit new PASRR level 1 screening for Resident #32 after significant change in condition.
Failed to maintain a homelike environment and reduce clutter in hallways, creating hazards and impeding resident mobility.
Failed to provide enough nursing staff to meet resident needs and failed to ensure timely call light response.
Failed to track and document behaviors for residents on psychotropic medications for three residents.
Failed to properly administer insulin using the Lispro pen injector, including failure to prime and hold pen for recommended time.
Failed to store and serve food in a sanitary manner, including unlabeled and undated food items, improper food handling, and inadequate hygiene during food service.
Report Facts
Census: 49
Call light response times: 12
Call light response times: 10
Insulin dose: 8
Behavior observation dates: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in abuse allegations and investigation related to rough care and inappropriate statements to residents |
| Staff B | Certified Nursing Assistant (CNA) | Named in abuse allegations and investigation related to rough care and failure to report abuse timely |
| Staff P | Licensed Practical Nurse (LPN) | Observed administering insulin without proper priming and holding technique |
| Staff Q | Regional Corporate Nurse Consultant | Interviewed regarding insulin administration and PASRR screening |
| Staff R | Licensed Pharmacist | Interviewed regarding proper insulin pen administration |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse investigations, call light response expectations, and medication administration |
| Regional Director of Operations | Regional Director of Operations | Interviewed regarding abuse reporting, call light response, and equipment storage policy |
| Staff C | Dietary Cook | Observed with poor hygiene during food service and interviewed regarding food safety |
| Staff E | Dietary Cook | Observed with improper hair covering and handling of food |
| Staff D | Dietary Aide | Observed with improper hair covering |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
A complaint investigation for Facility Reported Incident #119950-I was conducted from April 22, 2024 to April 25, 2024, including a revisit of a prior survey ending March 14, 2024.
Complaint Details
Complaint investigation for Facility Reported Incident #119950-I was conducted and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance. All deficiencies from the prior survey were corrected as of April 8, 2024.
Inspection Report
Routine
Census: 48
Deficiencies: 10
Date: Mar 14, 2024
Visit Reason
Routine inspection of Azria Health Park Place nursing home to assess compliance with resident rights, safety, care quality, and regulatory standards.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate environmental cleanliness and maintenance, medication administration errors, failure to follow physician orders, inadequate incontinence care, pressure ulcer prevention and treatment deficiencies, insufficient supervision of residents, unlocked medication carts, incomplete medical records, and failure to answer call lights timely.
Deficiencies (10)
Failed to treat residents with respect and dignity, leaving Resident #6 in soiled brief for 45 minutes.
Failed to provide clean, available linen draw-pads and maintain a safe, homelike environment with multiple maintenance issues.
Failed to administer medications as ordered and failed to draw labs as ordered for multiple residents.
Failed to provide appropriate incontinence care and supervision at meals for residents.
Failed to provide appropriate pressure ulcer care and prevent new ulcers for residents with history of pressure ulcers.
Failed to ensure basement door was alarmed and failed to supervise residents properly; medication carts left unlocked.
Failed to ensure residents were seen by their primary care physician at least every 60 days.
Failed to answer resident call lights within 15 minutes as required.
Failed to maintain accurate resident records in electronic system for multiple residents.
Failed to provide appropriate catheter care and hand hygiene supplies to prevent infections.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 4
Call light response time: 21.55
Call light response time: 19.5
Call light response time: 22.67
Call light response time: 73.67
Call light response time: 19.28
Pressure ulcer measurement: 4.2
Pressure ulcer measurement: 2.7
Pressure ulcer measurement: 0.1
Pressure ulcer measurement: 5.2
Pressure ulcer measurement: 5.4
Pressure ulcer measurement: 0.2
Pressure ulcer measurement: 5.5
Pressure ulcer measurement: 6.9
Pressure ulcer measurement: 0.1
Pressure ulcer measurement: 7.5
Pressure ulcer measurement: 6
Pressure ulcer measurement: 0.1
Pressure ulcer measurement: 0.8
Pressure ulcer measurement: 0.5
Pressure ulcer measurement: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nurses Assistant | Named in dignity and respect deficiency for Resident #6 |
| Staff H | Certified Nurses Assistant | Named in dignity and respect deficiency for Resident #6 |
| Staff A | Certified Nursing Assistant | Named in linen supply and incontinence care deficiencies |
| Staff B | Certified Nursing Assistant | Named in incontinence care deficiency |
| Staff F | Certified Medication Aide | Named in medication administration deficiency |
| Staff J | Registered Nurse | Named in pressure ulcer care and medication cart security deficiencies |
| Staff C | Housekeeper | Named in environmental and infection control deficiencies |
| Staff D | Regional Maintenance Director | Named in infection control and safety deficiencies |
| Facility Administrator | Named in multiple deficiencies including dignity, safety, and supervision | |
| Interim Director of Nursing | Named in multiple deficiencies including medication, supervision, and record keeping | |
| Regional Maintenance Director | Named in safety deficiency regarding basement door alarm |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 11
Date: Mar 14, 2024
Visit Reason
The inspection resulted from investigation of multiple complaints (#118497-C, #118591-C, #118561-C, #119063-C, #119122-C) and facility reported incidents (#117735-I, #119404-I, #119445-I) conducted from February 26, 2024 to March 14, 2024.
Complaint Details
Complaints #118497-C, #118591-C, #118561-C, #119063-C, and #119122-C were substantiated. Facility reported incident #119404-I was substantiated.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, inadequate linen supplies, failure to meet professional standards in medication administration, insufficient supervision and assistance for residents, inadequate infection control practices, and failure to maintain a safe and homelike environment. Several residents were affected by these deficiencies.
Deficiencies (11)
Failure to treat residents with respect and dignity, including incidents involving Resident #6 and Resident #17.
Failure to provide a safe, clean, comfortable, and homelike environment, including inadequate linen supplies and maintenance issues.
Failure to meet professional standards in medication administration, including failure to give medications as ordered and failure to follow physician orders.
Failure to provide adequate ADL care for dependent residents, including failure to assist with incontinence care.
Failure to provide quality care, including failure to promptly identify and intervene for residents at risk for pressure ulcers.
Failure to provide treatment and services to prevent and heal pressure ulcers, including inadequate wound care and skin assessments.
Failure to ensure a free of accident hazards environment, including failure to supervise residents and secure medication carts.
Failure to maintain sufficient nursing staff to meet residents' needs and to answer call lights timely.
Failure to maintain resident records accurately and confidentially, including incomplete medical records and lack of documentation.
Failure to maintain infection prevention and control program, including inadequate catheter care and hand hygiene.
Failure to ensure physician visits are timely and documented.
Report Facts
Facility census: 48
Number of residents reviewed: 20
Number of deficiencies cited: 11
Frequency of staff audits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nurses Assistant (CNA) | Named in dignity violation involving Resident #6 |
| Staff H | Certified Nurses Assistant (CNA) | Named in dignity violation involving Resident #6 |
| Staff A | Certified Nurses Assistant (CNA) | Interviewed regarding dignity and care for Resident #17 |
| Staff F | Certified Medication Aide (CMA) | Named in medication administration deficiencies |
| Staff E | Certified Nursing Assistant (CNA) | Reported linen supply issues |
| Staff C | Housekeeper | Named in housekeeping and environment deficiencies |
| Staff J | Registered Nurse (RN) | Named in wound care and pressure ulcer deficiencies |
| Interim Director of Nursing | Interviewed regarding multiple deficiencies and care expectations | |
| Maintenance Director | Named in environment and housekeeping deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 21, 2023
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective December 21, 2023.
Inspection Report
Routine
Census: 49
Deficiencies: 7
Date: Nov 21, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, environment, staffing, medication management, and food service at Azria Health Park Place.
Findings
The facility was found deficient in multiple areas including failure to provide privacy and adequate hygiene for residents, maintain a safe and homelike environment, implement comprehensive care plans, respond timely to call lights, secure medications properly, provide appropriate dental care, and serve food at safe temperatures.
Deficiencies (7)
Failed to complete activities of daily living and provide privacy during enteral feeding for residents #21 and #32.
Failed to maintain a clean, safe, and comfortable homelike environment; issues with unpainted spackle, peeled paint, water puddles, misaligned door magnets, and stained walls.
Failed to implement comprehensive care plans for residents #1, #4, and #25 including failure to monitor weights, catheter care, and dialysis vital signs.
Failed to provide needed medical services related to inadequate dental care and failure to follow physician orders for residents #34 and #4.
Failed to respond to residents' call lights within 15 minutes for residents #14 and #28.
Failed to keep all medications in a locked medication cart inaccessible to unauthorized staff and residents.
Failed to provide food at an appetizing temperature; pureed foods served at 119 degrees Fahrenheit instead of the required minimum of 135 degrees.
Report Facts
Residents affected: 49
Call light responses exceeding 15 minutes: 120
Call light responses exceeding 1 hour: 13
Pre-filled insulin pens/syringes observed: 5
Pureed food temperature: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Observed not checking gastrostomy tube placement and not providing privacy during enteral feeding |
| Staff P | Licensed Practical Nurse (LPN) - Unit Manager | Observed closing door for privacy and stated expectation for privacy during tube feedings |
| Director of Nursing (DON) | Director of Nursing | Stated expectations for privacy during tube feedings, resident grooming, and following care plans |
| Staff V | Regional Maintenance Supervisor | Reported maintenance surveillance and acknowledged delays in building repairs |
| Staff T | Certified Nurse Aide (CNA) | Performed catheter care improperly by lifting catheter tubing above bladder level and not applying dressing |
| Staff U | Certified Nurse Aide (CNA) | Assisted with catheter care |
| Staff P | Licensed Practical Nurse (LPN) | Stated expectation to follow up on dental issues and document refusals |
| Staff R | Regional Director of Operations | Stated expectation for medication carts to be locked when unattended |
| Staff I | Cook | Stated he never checks temperatures of pureed food prior to serving |
| Staff W | Observed responding to call light for Resident #29 | |
| Administrator | Stated expectation for timely follow-up on dental issues and proper food temperatures |
Inspection Report
Routine
Census: 49
Deficiencies: 25
Date: Nov 21, 2023
Visit Reason
Routine inspection of Azria Health Park Place nursing home to assess compliance with regulatory requirements including resident care, environment, staffing, and infection control.
Findings
The facility was found deficient in multiple areas including resident care (privacy, hygiene, care plan implementation), environmental maintenance, staff background checks, notification procedures, restorative therapy, medication management, infection control, dietary services, staffing, and quality assurance processes.
Deficiencies (25)
Failed to provide privacy during enteral feeding and assistance with activities of daily living for residents #21 and #32.
Failed to maintain a clean, safe, and homelike environment including unpainted walls, peeling paint, water puddles, and non-functioning heaters.
Failed to complete background checks prior to staff employment for Staff C.
Failed to notify Long-Term Care Ombudsman of resident hospital transfers for Residents #24 and #34.
Failed to obtain bed hold notifications for Residents #24 and #34 during hospitalizations.
Failed to implement comprehensive care plans for Residents #1, #4, and #25 including daily weight monitoring, catheter care, and dialysis vital sign monitoring.
Failed to provide assistance with oral hygiene for Resident #29.
Failed to follow physician orders and provide appropriate treatment for Residents #4 and #34 including dental care and weight monitoring.
Failed to provide restorative therapy as ordered for Residents #1 and #25.
Failed to apply initials and date/time to feeding tube formula bottles and verify gastrostomy tube placement before feeding for Residents #21, #45, and #47.
Failed to complete pre and post dialysis assessments and vital signs for Resident #25.
Failed to respond to resident call lights within 15 minutes for Residents #14 and #28.
Failed to post nurse staffing information daily in a readable format for residents and visitors.
Failed to complete monthly medication regimen reviews by a licensed pharmacist for Residents #14, #18, #31, and #37.
Failed to implement gradual dose reductions and timely physician review of PRN psychotropic medications for Resident #34.
Failed to keep medications locked and secure in medication carts.
Failed to provide needed assistance for dental services for Resident #34 including scheduling and follow-up.
Failed to provide well-balanced diet with correct serving sizes and appropriate portions for 18 residents.
Failed to employ a certified dietary manager or qualified dietitian.
Failed to serve food at safe and appetizing temperatures for Residents #6, #32, and #34.
Failed to store food properly with open dates, maintain chemical concentrations in dish machine, ensure proper hair restraints, and practice appropriate hand hygiene in kitchen.
Failed to have a comprehensive and effective Quality Assurance Performance Improvement (QAPI) program with consistent attendance and implementation.
Failed to provide appropriate infection prevention and control practices including hand hygiene, catheter care, enteral feeding, wound care, and staff COVID-19 protocols.
Failed to ensure working call system in resident bathroom and bathing area for Resident #14.
Failed to provide required annual in-service training for nurse aides including dementia care and abuse prevention for 5 employees.
Report Facts
Residents census: 49
Deficiencies with delayed call light response: 120
Deficiencies with call light response over 1 hour: 13
Medication Regimen Reviews missed: 9
Medication Regimen Reviews missed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Named in deficiency related to enteral feeding and privacy |
| Staff P | Licensed Practical Nurse (LPN) - Unit Manager | Named in deficiency related to enteral feeding privacy |
| Director of Nursing (DON) | Director of Nursing | Named in multiple deficiencies related to care expectations and infection control |
| Staff C | Named in deficiency related to background check | |
| Staff D | Named in deficiency related to background check | |
| Administrator | Administrator | Named in multiple deficiencies related to policy and expectations |
| Staff T | Certified Nurse Aide (CNA) | Named in deficiency related to catheter care |
| Staff U | Certified Nurse Aide (CNA) | Named in deficiency related to catheter care and restorative therapy |
| Staff I | Cook | Named in deficiency related to food portion sizes and hand hygiene |
| Staff J | Cook | Named in deficiency related to food portion sizes |
| Staff K | Dietitian | Named in deficiency related to food portion sizes and kitchen hygiene |
| Staff H | Named in deficiency related to medication regimen reviews | |
| Staff L | Named in deficiency related to dish machine chemical levels | |
| Staff N | Dietary Aide | Named in deficiency related to dish machine chemical levels |
| Staff O | Named in deficiency related to COVID-19 testing and infection control | |
| Staff Q | Registered Nurse (RN) | Named in deficiency related to wound care |
| Staff W | Registered Nurse (RN) | Named in deficiency related to wound care |
| Staff S | Director of Nursing (DON) | Named in deficiency related to COVID-19 testing and infection control |
| Staff A | Senior President of Clinical Services | Named in deficiency related to dietary manager qualifications and infection control |
| Staff R | Regional Director of Operations | Named in deficiency related to medication cart security and QAPI |
| Staff E | Named in deficiency related to dependent adult abuse training | |
| Staff F | Named in deficiency related to dependent adult abuse training | |
| Staff G | Named in deficiency related to dependent adult abuse training |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 23
Date: Nov 21, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey and included investigation of multiple substantiated complaints and a reported incident.
Complaint Details
Complaints #114233-C, #115667-C, #115918-C, #116408-C, #116528-C, #116916-C, #116940-C were substantiated. Facility reported incident #116113-I was not substantiated.
Findings
The facility was found to have multiple deficiencies including failure to provide privacy and dignity during care, unsafe and unclean environment, inadequate abuse and neglect policies implementation, failure to notify the Long-Term Care Ombudsman of hospital transfers, incomplete comprehensive care plans, insufficient assistance with activities of daily living, inadequate dental and dietary services, insufficient nursing staff, medication regimen review irregularities, infection control lapses, and resident call system malfunctions. The facility reported a census of 49 residents.
Deficiencies (23)
Failure to provide privacy and dignity during care for residents requiring assistance with gown change and enteral feeding.
Failure to maintain a safe, clean, comfortable, homelike environment with issues such as unpainted walls, water puddles, and misaligned door magnets.
Failure to develop and implement abuse and neglect policies including background checks for staff.
Failure to provide required notice before transfer or discharge to residents and representatives.
Failure to implement comprehensive care plans consistent with resident rights and needs.
Failure to provide adequate assistance with activities of daily living including oral hygiene.
Failure to ensure quality of care including dental services and weight monitoring.
Failure to provide restorative therapy as ordered and document therapy sessions.
Failure to ensure proper tube feeding management and labeling.
Failure to complete dialysis evaluations and treatments as required.
Failure to maintain sufficient nursing staff and post staffing information.
Failure to complete monthly drug regimen reviews and report irregularities.
Failure to provide psychotropic medication reviews and monitor PRN use.
Failure to label and store drugs and biologicals properly and secure medication carts.
Failure to provide routine and emergency dental services.
Failure to provide adequate food and nutrition services including correct portion sizes and food temperatures.
Failure to employ a qualified dietary staff and certified dietary manager.
Failure to maintain food safety and sanitation including proper hand hygiene and chemical levels in dishwashers.
Failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program.
Failure to maintain an infection prevention and control program including COVID-19 protocols.
Failure to maintain a functional resident call system.
Failure to provide abuse, neglect, and exploitation training for staff.
Failure to provide required in-service training for nurse aides.
Report Facts
Resident census: 49
Call light responses: 120
Call light responses exceeding 15 minutes: 13
Residents reviewed for medication regimen: 5
Residents reviewed for restorative therapy: 3
Residents reviewed for dialysis: 1
Residents reviewed for oral hygiene assistance: 1
Residents reviewed for dental services: 5
Residents reviewed for food portion accuracy: 18
Residents reviewed for infection control: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chris Danilson | Administrator | Signed the initial comments and plan of correction on 12/21/23. |
| Staff B | Licensed Practical Nurse (LPN) | Named in deficiency related to failure to provide privacy during enteral feeding. |
| Staff P | Interviewed regarding privacy and dignity expectations. | |
| Director of Nursing (DON) | Interviewed multiple times regarding expectations for privacy, grooming, restorative therapy, infection control, and other care practices. | |
| Staff C | Named in deficiency related to failure to complete background checks prior to employment. | |
| Staff A | Interviewed regarding hospital transfer notifications and dental services. | |
| Staff D | Interviewed regarding background checks and dependent adult abuse training. | |
| Staff F | Interviewed regarding dependent adult abuse training. | |
| Staff G | Interviewed regarding dependent adult abuse training. | |
| Staff H | Interviewed regarding medication regimen reviews and infection control. | |
| Staff I | Cook | Interviewed regarding food portion sizes and meal service. |
| Staff J | Interviewed regarding food portion sizes. | |
| Staff K | Dietitian | Interviewed regarding food safety and hand hygiene. |
| Staff L | Interviewed regarding dishwasher chemical levels. | |
| Staff N | Dietary Aide | Interviewed regarding dishwasher chemical levels. |
| Staff O | Interviewed regarding COVID testing and infection control. | |
| Staff Q | Registered Nurse (RN) | Interviewed regarding wound care and infection control. |
| Staff R | Regional Director of Operations | Interviewed regarding QAPI program and infection control. |
| Staff S | Interviewed regarding COVID testing. | |
| Staff T | Certified Nurse Aide (CNA) | Interviewed regarding catheter care. |
| Staff U | Certified Nurse Aide (CNA) | Interviewed regarding catheter care and restorative therapy. |
| Staff W | Registered Nurse (RN) | Interviewed regarding wound care and infection control. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
The document is a plan of correction submitted following a deficiency statement, indicating the facility's acceptance of compliance and corrective actions.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective July 27, 2023.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Date: Jul 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of abuse involving Resident #1.
Complaint Details
The complaint involved an allegation that Staff A held Resident #1's nose to force medication administration on 4/20/23. Staff B and Staff C reported the incident on 4/22/23. The facility investigation confirmed the incident and Staff A was suspended. The facility reported the incident to the Department of Health and Human Services hotline on 4/22/23, but initially to an incorrect number. Staff A denied the allegation. Staff B was re-educated on abuse reporting.
Findings
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals within 24 hours for one resident. The investigation revealed that Staff A held Resident #1's nose to force medication administration, which was deemed inappropriate and abuse. Staff A was suspended and re-education on abuse reporting was conducted for staff.
Deficiencies (1)
Failed to timely report an allegation of abuse to the state agency within 24 hours for one resident.
Report Facts
Census: 47
Morphine dosage: 0.25
Morphine wastage: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Agency Registered Nurse (RN) | Named in medication administration abuse allegation involving Resident #1 |
| Staff B | Certified Medication Aide (CMA) | Witness and reporter of the medication administration incident |
| Staff C | Licensed Practical Nurse (LPN) | Reported incident to HR Director and participated in investigation |
| Staff G | Interim Director of Nursing (DON) | Notified of incident and involved in investigation and staff re-education |
| Regional Director of Operations | Acting Administrator | Conducted mini-investigation and contacted staffing agency |
| HR Director | Received reports of incident and coordinated notifications |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 4
Date: Jul 6, 2023
Visit Reason
Investigation of complaints #109332-C and #112985-C and facility reported incidents #112544-I and #112625-I conducted from July 3 to July 6, 2023, including substantiated complaint #112985-C.
Complaint Details
Complaint #112985-C was substantiated. The complaint involved failure to report abuse allegations timely and improper medication administration to Resident #1.
Findings
The facility failed to report an allegation of abuse within 24 hours for one resident, Resident #1, involving inappropriate medication administration and holding the resident's nose to force medication intake. Additional findings included incomplete comprehensive care plans for two residents and failure to provide routine showers for two residents. The facility also failed to respond to call lights within 15 minutes for three residents.
Deficiencies (4)
Failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals within 24 hours for Resident #1 involving inappropriate medication administration.
Failed to fully develop a comprehensive care plan within the required time frame for two residents (Resident #7 and Resident #8).
Failed to provide showers on a routine basis for two residents (Resident #2 and Resident #4).
Failed to answer residents' call lights in less than 15 minutes for three residents (Resident #3, #4, and #5).
Report Facts
Census: 47
Call light uses: 55
Call light response time >15 minutes: 14
Call light uses: 48
Call light response time >15 minutes: 8
Call light uses: 86
Call light response time >15 minutes: 23
Baths received: 1
Baths received: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Agency Registered Nurse (RN) | Named in abuse allegation involving holding resident's nose to administer medication |
| Staff B | Certified Medication Aide (CMA) | Witnessed and reported abuse allegation involving Staff A |
| Staff C | Licensed Practical Nurse (LPN) | Reported abuse allegation to HR Director |
| Staff G | Former Director of Nursing (DON) | Not reachable for interview regarding abuse allegation |
| Staff H | Licensed Practical Nurse (LPN), Unit Manager | Reported knowledge of narcotic medication spill and abuse reporting |
| Staff J | Certified Nurse Aide (CNA) | Interviewed regarding resident bathing refusal and care |
| Staff K | Certified Nurse Aide (CNA) | Reported documentation of baths and care |
| Administrator | Provided statements on call light response education and staffing | |
| Regional Director of Operations (RDO) | Interviewed about abuse allegation investigation and reporting | |
| Human Resources Director | Received abuse reports and coordinated investigation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 12, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction, effective December 29, 2022.
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 8
Date: Nov 1, 2022
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaint #108668-C and facility-reported incident #108224-I from November 1 to November 9, 2022.
Complaint Details
Complaint #108668-C was substantiated. Facility-reported incident #108224-I was substantiated but not specific to the allegation.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, incomplete background checks for staff, inadequate referral for PASARR Level II residents, insufficient comprehensive care plans, failure to implement abuse and neglect policies, inadequate medication administration and pain management, and failure to maintain adequate staffing and timely response to call lights. The complaint and facility-reported incident were substantiated.
Deficiencies (8)
Failure to treat Resident #5 with respect and dignity, including rude staff behavior and ignoring resident requests.
Failure to complete Single Contact Repository (SING) background checks prior to hire for two staff members and failure to ensure dependent adult abuse training for one staff member.
Failure to refer one resident with a negative Level I PASARR result for Pre-Admission Screening and Resident Review (PASARR) Level II evaluation.
Failure to develop and implement comprehensive care plans for residents, including measurable objectives and timeframes.
Failure to develop and implement abuse, neglect, and exploitation prevention policies and procedures.
Failure to provide sufficient in-service training for nurse aides, including dementia management and abuse prevention.
Failure to ensure staff cardiopulmonary resuscitation (CPR) certification for all shifts reviewed.
Failure to provide adequate pain management for residents.
Report Facts
Census: 46
Residents reviewed: 16
Residents reviewed: 6
Residents reviewed: 5
Residents reviewed: 2
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Staff reviewed: 6
Staff reviewed: 31
Residents with CPR requested: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant (CNA) | Failed to complete background check prior to hire; involved in abuse prevention training deficiency. |
| Staff F | Certified Nursing Assistant (CNA) | Failed to complete background check prior to hire; involved in abuse prevention training deficiency; disciplinary action for phone use during resident care. |
| Staff L | Dietary Aide | Lacked documentation of dependent adult abuse training. |
| Staff H | Licensed Practical Nurse (LPN) | Reported on resident care plans, medication administration, and pain management deficiencies. |
| Staff M | Registered Nurse (RN) Consultant | Reported on medication administration and call light response time deficiencies. |
| Staff G | Licensed Practical Nurse (LPN) | Reported on medication administration and order processing deficiencies. |
| Staff I | Agency Registered Nurse (RN) | Reported medication error and training deficiencies. |
| Staff K | Agency Registered Nurse (RN) | Reported medication administration and resident monitoring deficiencies. |
| Staff J | Certified Medication Aide (CMA) | Reported on medication administration deficiencies. |
| Staff P | Certified Nursing Assistant (CNA) | Reported on resident care and medication administration deficiencies. |
| Staff O | Temporary Nurse Aide (TNA) | Assisted with resident care during pressure ulcer treatment. |
| Staff A | Registered Nurse (RN) | Reported on resident rights and dining assistance. |
| Staff N | Clinical Services | Reported on Quality Assessment and Assurance (QAA) committee deficiencies. |
| Staff Q | Licensed Practical Nurse (LPN) | Reported on medication administration deficiencies. |
| Staff E | Certified Nursing Assistant (CNA) | Involved in resident dignity and respect deficiency. |
| Staff B | Certified Nursing Assistant (CNA) | Observed ignoring resident requests and lack of door knock prior to entering rooms. |
| Staff F | Certified Nursing Assistant (CNA) | Disciplinary action for phone use during resident care. |
| Staff M | Registered Nurse (RN) Consultant | Reported on call light response time and medication administration. |
| Staff L | Dietary Aide | Lacked dependent adult abuse training documentation. |
| Staff D | Certified Nursing Assistant (CNA) | Failed to complete background check prior to hire. |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 8
Date: Nov 1, 2022
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaint #108668-C and facility-reported incident #108224-I from November 1 to November 9, 2022.
Complaint Details
Complaint #108668-C was substantiated. Facility-reported incident #108224-I was substantiated but not specific to the allegation.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, incomplete background checks for staff, failure to refer residents for PASARR Level II reviews, inadequate comprehensive care plans, insufficient pain management, and failure to maintain adequate staffing and timely response to call lights. Several residents had documented health issues such as pressure ulcers and mental health diagnoses that were not fully addressed.
Deficiencies (8)
Failure to treat Resident #5 with respect and dignity, including rude behavior by staff and ignoring resident requests.
Failure to complete Single Contact Repository (SING) background checks prior to hire for two staff members and failure to ensure training for one staff member.
Failure to refer Resident #39 for PASARR Level II review despite negative Level I result.
Failure to develop and implement comprehensive care plans for residents, including measurable objectives and timeframes.
Failure to provide adequate pain management for Resident #19, including lack of assessment and documentation.
Failure to maintain sufficient nursing staff and timely response to call lights for multiple residents.
Failure to ensure staff had completed required in-service training for nurse aides.
Failure to ensure staff on duty had current CPR certification.
Report Facts
Census: 46
Residents reviewed: 16
Residents reviewed: 6
Residents reviewed: 2
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 2
Residents reviewed: 3
Residents reviewed: 5
Staff background checks: 2
Staff CPR certification: 7
Residents with pressure ulcers: 1
Residents with pain management issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Named in findings related to rude behavior and disciplinary action for phone use during resident care. |
| Staff D | Certified Nursing Assistant (CNA) | Named in findings related to incomplete background check prior to hire. |
| Staff L | Dietary Aide | Named in findings related to lack of required Dependent Adult Abuse training. |
| Staff H | Licensed Practical Nurse (LPN) | Reported on resident care and medication administration issues. |
| Staff M | Registered Nurse (RN) Consultant | Reported on medication administration and call light response findings. |
| Staff G | Licensed Practical Nurse (LPN) | Reported on advanced directives and medication administration policies. |
| Staff P | Certified Nursing Assistant (CNA) | Reported on resident care and medication administration. |
| Staff K | Agency RN | Reported on medication administration incident. |
| Staff I | Agency RN | Reported on medication error and training deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 26, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance of the facility.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective October 26, 2022.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 30, 2022
Visit Reason
The inspection was conducted as an investigation of complaints #105658-C, #106355-C, #107830-C and a facility reported incident #107885-I from September 23, 2022 to September 28, 2022.
Complaint Details
Complaints #106355-C, #107830-C and facility reported incident #107885-I were substantiated. Complaint #105658-C was not substantiated.
Findings
The investigation substantiated complaints #106355-C, #107830-C and the facility reported incident #107885-I, while complaint #105658-C was not substantiated. Deficiencies were found related to failure to notify physicians of resident condition changes, failure to follow physician orders for care plans and medication administration, insufficient nursing staff, and delayed call light responses.
Deficiencies (5)
Failure to notify the physician for 1 of 3 residents reviewed regarding weight change notifications.
Failure to follow physician's orders for 1 of 3 residents reviewed related to comprehensive care plans and medication administration.
Failure to follow physician orders for weights for 3 of 5 residents reviewed.
Insufficient nursing staff to assure resident safety and care.
Delayed response to call lights for 2 of 7 residents reviewed.
Report Facts
Complaints investigated: 3
Complaints not substantiated: 1
Residents reviewed for physician notification: 3
Residents reviewed for care plan compliance: 3
Residents reviewed for weight order compliance: 5
Residents reviewed for call light response: 7
Dates of complaint investigation: September 23, 2022 to September 28, 2022
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 9
Date: Jul 13, 2022
Visit Reason
An investigation of multiple complaints and facility-reported incidents was conducted from May 31 to July 13, 2022, to determine compliance with federal regulations.
Complaint Details
The investigation was triggered by complaints #100965-C, #101285-C, #102250-C, #102451-C, #102585-C, #102615-C, #103978-C, #103996-C, #104342-C, #104892-C, #104895-C, #104982-C, and #105052-C and facility-reported incidents #102199-I, #102582-I, and #104962-I. Complaints #100965-C, #101285-C, #102250-C, #102451-C, #102585-C, #102615-C, #103996-C, #104342-C, #104892-C, #104895-C, and #105052-C were substantiated. Complaints #103978-C and facility-reported incidents #102199-I, #102582-I, and #104962-I were not substantiated.
Findings
The facility was found to have multiple deficiencies including failure to notify changes in resident condition, unsafe and unclean environment conditions, failure to implement comprehensive care plans, failure to meet professional standards of care, inadequate bathing and toileting assistance, insufficient restorative programs, inadequate infection control, and insufficient nursing staff. Several residents were identified as at risk or affected by these deficiencies.
Deficiencies (9)
Failure to notify resident, physician, and representative of significant changes in resident condition.
Unsafe, unclean, and uncomfortable environment including peeling paint and buildup of dirt and debris in resident bathrooms.
Failure to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes.
Failure to meet professional standards of care including medication administration errors and failure to follow physician orders.
Failure to provide adequate bathing, toileting, and perineal care to residents as scheduled and per care plans.
Failure to provide adequate restorative nursing programs and therapies as planned.
Failure to maintain infection prevention and control program and proper use of personal protective equipment.
Failure to maintain sufficient nursing staff with appropriate competencies and skills.
Failure to maintain safe operating condition of essential equipment.
Report Facts
Resident census: 50
Deficiencies cited: 9
Medication administration errors: 3
Residents reviewed for bathing/toileting: 4
Residents reviewed for restorative programs: 4
Residents with skin condition assessment failures: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant (CNA) | Named in observation of failure to use gait belt and ambulate resident safely |
| Staff B | Licensed Practical Nurse (LPN) | Observed setting up medications improperly |
| Staff C | Registered Nurse (RN) | Administered medications without observing setup |
| Staff D | Certified Nursing Assistant/Shower Aide | Described challenges completing showers due to staffing |
| Staff F | Certified Nursing Assistant (CNA) | Failed to provide scheduled baths/showers |
| Staff I | Certified Nursing Assistant/Certified Medication Aide | Failed to cleanse resident properly and removed saturated brief |
| Staff N | Certified Nursing Assistant (CNA) | Failed to retract resident's foreskin during cleansing |
| Staff E | Restorative Aide | Failed to perform restorative exercises as set up by therapy |
| Staff A | Certified Medication Aide (CMA) | Left medication cup unattended on resident's bedside table |
| Director of Nursing (DON) | Director of Nursing | Participated in observations and education sessions |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Nov 17, 2021
Visit Reason
The inspection was conducted as a Focused Infection Control Survey and investigation of complaint #100603-C.
Complaint Details
Complaint #100603-C was substantiated.
Findings
The facility failed to follow professional standards and ensure medications were given as ordered for 1 of 4 residents reviewed, specifically Resident #1. The complaint was substantiated.
Deficiencies (1)
Failure to follow professional standards and ensure medications were given as ordered for Resident #1.
Report Facts
Census: 48
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 30, 2021
Visit Reason
A revisit of the Recertification Survey and Complaints #96923-C, #96475-C, #95033-C and #98669-C ending July 28, 2021 and investigation of Complaint #98917 were conducted on September 28 - 30, 2021.
Complaint Details
Complaint #98917-C was investigated and found not substantiated.
Findings
All deficiencies have been corrected and the facility is in compliance effective August 20, 2021. Complaint #98917-C was not substantiated.
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 9
Date: Jul 28, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of complaints #96923-C, #98669-C, #96475-C, and #95033-C completed between 7/19/21 and 7/28/21.
Complaint Details
Complaints #98669 and #96475 were substantiated; complaints #96923 and #95033 were not substantiated.
Findings
The facility was found to have multiple deficiencies including failure to provide reasonable accommodations for residents, incomplete Medicare Liability Notices, incomplete comprehensive assessments and care plans, insufficient nursing staff, improper medication storage, and inadequate food safety practices. Corrective actions and education were implemented with specified completion dates.
Deficiencies (9)
Facility failed to place the resident's call light within reach for 1 of 19 residents.
Facility failed to provide 1 of 3 residents discharged from skilled level of care with required Medicare Liability Notices.
Facility failed to complete accurate admission Minimum Data Set (MDS) including Preadmission Screening and Resident Review (PASRR) for 1 of 12 residents reviewed.
Facility failed to complete a comprehensive care plan based on residents' needs for 1 of 12 residents reviewed.
Facility failed to provide bathing assistance at least weekly for 2 of 19 residents reviewed.
Facility failed to ensure call lights were answered in a timely manner for 3 of 19 residents.
Medication room contained expired medications and unlabeled items.
Facility failed to provide each resident with a nourishing, palatable, well-balanced diet meeting nutritional and special dietary needs.
Facility failed to label and store food items properly to reduce risk of contamination and foodborne illness.
Report Facts
Census: 55
Residents reviewed: 19
Residents reviewed: 12
Residents reviewed: 3
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 2
Residents reviewed: 3
Completion dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marsha James | Director of Nursing (DON) | Named in education and corrective action related to call light response, medication storage, and bathing schedule |
| Erin Melby | Regional Nurse Consultant | Named in education and corrective action related to PASRR and care plan reviews |
| Social Service Director | Named in relation to specialized services on care plan and PASRR oversight | |
| Business Office Manager | Named in education regarding Medicaid/Medicare Coverage and Liability Notices | |
| Administrator | Named in multiple interviews and responsible for auditing and monitoring corrective actions | |
| Dietary Manager | Named in relation to food safety, meal service, and dietary deficiencies | |
| Director of Nursing (DON) | Named in multiple interviews regarding call light expectations, bathing schedules, medication storage, and corrective actions | |
| Assistant Director of Nursing (ADON) | Named in documentation of fall incident and resident care |
Inspection Report
Abbreviated Survey
Census: 52
Deficiencies: 0
Date: Dec 21, 2020
Visit Reason
A 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.
Report Facts
Total Census: 52
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
A Focused Infection Control Survey and an investigation of Complaint #92588 was conducted by the Department of Inspections and Appeals from November 4 to 12, 2020.
Complaint Details
Complaint #92588 was investigated and found to be not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. Complaint #92588 was not substantiated.
Inspection Report
Routine
Census: 57
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals 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.
Report
Viewing
Loading inspection reports...
