Inspection Report Summary
The most recent inspection on January 8, 2026, found the facility certified in compliance with health requirements and did not list any specific deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to medication administration errors, resident supervision, and failure to report or investigate abuse allegations properly. Several complaint investigations substantiated issues such as mistreatment during care, delayed nursing responses, and inadequate supervision leading to resident harm, but no fines, immediate jeopardy findings, or license actions were noted in the available reports. Most complaints were substantiated when deficiencies were found, with some involving medication errors and resident safety incidents. The inspection history indicates ongoing challenges with medication management and resident care, though the most recent certification suggests corrective actions have been accepted and compliance achieved.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
115 residents
Based on a December 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 8, 2026
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance with health requirements, following acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was certified in compliance with health requirements effective December 31, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 1
Date: Dec 22, 2025
Visit Reason
The inspection was conducted as a result of investigation of complaints #2677953-C and #2689409-C from December 18, 2025 to December 22, 2025.
Complaint Details
Complaint #2677953-C resulted in a deficiency.
Findings
The facility failed to ensure residents were free of significant medication errors, specifically failing to follow physician orders for medication administration for Resident #1, resulting in a deficiency.
Deficiencies (1)
Facility failed to follow physician's order for medication administration causing a resident not to receive their diuretic medication as needed.
Report Facts
Census: 115
Correction date: Correction date set for 12/31/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Vogan | Administrator | Signed as laboratory director or provider/supplier representative on plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 8, 2025
Visit Reason
The document serves as a Statement of Deficiencies and Plan of Correction following a survey completed on December 8, 2025, related to regulatory compliance of the facility.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance with health requirements effective October 9, 2025. No specific deficiencies are detailed in this document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 8, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance with health requirements, indicating acceptance of a credible allegation of substantial compliance.
Findings
The facility will be certified in compliance with health requirements effective November 21, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction. No specific deficiencies are detailed in this document.
Report Facts
Certification effective date: Nov 21, 2025
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 3
Date: Nov 20, 2025
Visit Reason
The inspection was conducted as a result of complaints #2647186-C, investigated from October 27, 2025 to November 20, 2025, regarding alleged mistreatment and failure to protect resident rights at the facility.
Complaint Details
Complaint #2647186-C was substantiated, with findings of mistreatment and failure to report and investigate abuse allegations properly.
Findings
The facility failed to treat a resident with respect and dignity, failed to ensure all alleged violations involving mistreatment, neglect, or abuse were reported immediately, and failed to notify the Department of Inspection and Appeals and Licensing within required timeframes. The investigation found staff acted too quickly and carelessly during peri-care, causing discomfort and injury to Resident #1, and the facility did not properly document or report the incident.
Deficiencies (3)
Failure to treat Resident #1 with respect and dignity, resulting in mistreatment during peri-care.
Failure to report alleged violations of abuse, neglect, or mistreatment to the appropriate authorities within required timeframes.
Failure to thoroughly investigate and prevent further potential abuse or neglect during the investigation process.
Report Facts
Resident census: 120
Deficiency count: 3
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 1
Date: Oct 9, 2025
Visit Reason
The inspection was conducted as a result of complaints #1647088-C and #1647091-C alleging significant medication errors at the facility.
Complaint Details
Complaints #1647088-C and #1647091-C resulted in a deficiency related to medication errors. The complaint was substantiated as evidenced by the findings of incorrect medication administration and documentation failures.
Findings
The facility failed to ensure residents were free of significant medication errors, specifically involving Resident #1 who received incorrect medications. Multiple documentation and administration errors were identified, including incorrect dosing and failure to complete incident reports.
Deficiencies (1)
Facility failed to ensure residents were free of significant medication errors, including incorrect administration of Lorazepam and Clonazepam to Resident #1.
Report Facts
Census: 116
Complaint numbers: 2
Medication doses missed or incorrect: 4
Medication competency frequency: 3
Medication competency frequency: 2
Narcotic log review frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported medication errors and identified incorrect medication administration |
| Staff B | Reported medication errors and brought them to attention | |
| Director of Nursing | Director of Nursing (DON) | Provided verbal coaching and oversaw incident report completion |
| Psychiatric Nurse Practitioner | Reported Resident #1 was on a combination of benzodiazepine medications |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
The document serves as a statement of deficiencies and plan of correction, certifying the facility 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 will be certified in compliance effective June 25, 2025, based on the accepted plan of correction.
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Date: Jun 16, 2025
Visit Reason
The inspection was conducted as an investigation of facility reported incidents #128158-I and #129334-I, focusing on allegations of abuse and neglect involving two residents.
Complaint Details
The investigation of facility reported incident #128158-I resulted in a deficiency related to abuse and neglect. Incident #129334-I did not result in a deficiency. The substantiation status is that the facility was found not in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities due to the abuse incident.
Findings
The facility failed to adequately supervise Resident #1, who had a history of sexually inappropriate behavior, resulting in Resident #2 being found in a compromising sexual situation with Resident #1. The investigation found multiple instances of inappropriate sexual behavior by both residents, insufficient supervision by staff, and failure to keep the residents separated despite known risks.
Deficiencies (1)
Failure to adequately supervise Resident #1, resulting in a sexual incident with Resident #2.
Report Facts
Total census: 121
BIMS score Resident #1: 11
BIMS score Resident #2: 3
Medication dosage: 25
Audit frequency: 4
Audit frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Witnessed the incident and reported difficulty supervising residents. |
| Staff B | Certified Nursing Assistant | Discovered the sexual incident and assisted residents afterward. |
| Staff C | Registered Nurse | Assessed residents after the incident and reported lack of directives. |
| Staff D | Certified Nursing Assistant | Reported prior flirtatious behavior and lack of directives to keep residents apart. |
| Staff E | Certified Nursing Assistant | Verified difficulty supervising residents and lack of directives. |
| Director of Nursing | Director of Nursing | Verified expectations for supervision and acknowledged facility failure. |
| Administrator | Administrator | Verified expectations for supervision and acknowledged facility failure. |
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 0
Date: Feb 13, 2025
Visit Reason
The visit was conducted as the annual recertification survey for Bethany Life Nursing Home to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the applicable federal requirements following the annual recertification survey conducted from February 10 to February 13, 2025.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 24, 2024
Visit Reason
Investigation of complaints #125575 and #123094 conducted December 23-24, 2024.
Complaint Details
Complaints #125575 and #123094 were investigated and found to be unsubstantiated.
Findings
The Bethany Life Nursing Home was found to be in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. Complaints #125575 and #123094 were not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
The visit was conducted based on the department's acceptance of a credible allegation of compliance and plan of correction for Bethany Life Nursing Home.
Findings
The Bethany Life Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities effective 8/22/24, based on the department's acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 1
Date: Jul 25, 2024
Visit Reason
The inspection was conducted due to complaints #121547, #121834, and #122060, with complaints #121834 and #122060 substantiated. The visit aimed to investigate these complaints regarding nursing staff sufficiency and response times.
Complaint Details
Complaints #121834 and #122060 were substantiated. The complaint involved delayed response to call lights, with Resident #2 reporting wait times over 30 minutes and alarm response reports confirming delays of over 19 minutes.
Findings
The facility failed to provide sufficient nursing staff to ensure timely response to resident call lights, specifically failing to answer within 15 minutes for Resident #2. The investigation found that staff response times exceeded 15 minutes, with documented delays up to 19 minutes.
Deficiencies (1)
Facility staff failed to answer resident call lights in a timely manner (no longer than 15 minutes) for Resident #2.
Report Facts
Census: 117
Call light response time: 19.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Confirmed that call light response times could exceed 15 minutes. |
| Staff B | Certified Nursing Assistant | Confirmed that call light response times could exceed 15 minutes. |
| Administrator | Confirmed expectation that staff answer call lights within 15 minutes per State Rules and Federal Regulations. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
The inspection was conducted as a complaint investigation for complaint intakes #120800-C, #120830-C, #121075-C, and #121110-C, including an onsite revisit of surveys ending May 7, 2024.
Complaint Details
Complaint investigation intakes #120800-C, #120830-C, #121075-C, and #121110-C were conducted from June 3, 2024 to June 4, 2024. The facility was found in substantial compliance.
Findings
The Bethany Life Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities following the complaint investigation and onsite revisit.
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 1
Date: May 7, 2024
Visit Reason
The inspection was conducted following an investigation of complaints #120334-C and #120319-I regarding resident safety and care at Bethany Life Nursing Home.
Complaint Details
Complaint #120334-C was not substantiated. Facility reported incident #120319-I was substantiated.
Findings
The facility failed to ensure adequate supervision and use of gait belts during resident transfers, resulting in a resident fall with fractures and injuries. Staff noncompliance with gait belt policy led to termination of an employee.
Deficiencies (1)
Failure to ensure one of six residents received adequate supervision to prevent accidents, resulting in a fall and fractures.
Report Facts
Resident census: 125
Fine amount: 16500
Dates of survey: May 1, 2024 - May 7, 2024
Correction date: 5/14/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in the finding for not using a gait belt during resident transfer, leading to resident fall and termination |
| Director of Nursing (DON) | Director of Nursing | Signed Facility Investigation Summary Report and explained gait belt policy and staff termination |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Observed resident condition post-fall and participated in assessment |
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 3
Date: Apr 3, 2024
Visit Reason
The inspection was conducted due to substantiated complaints #119760-C and #119860-C and a facility reported incident #119740-I. The visit investigated deficiencies related to supervision and accident hazards following a resident choking incident.
Complaint Details
Complaints #119760-C and #119860-C were substantiated. Facility reported incident #119740-I was substantiated. The Immediate Jeopardy began on March 25, 2024 and was removed on March 28, 2024.
Findings
The facility failed to provide adequate supervision to a resident who choked on food, resulting in the resident's death and an Immediate Jeopardy situation. The facility implemented corrective actions including staff education on supervision, audits, and policy updates. Additional deficiencies were found related to nursing staff responsiveness and resident records.
Deficiencies (3)
Failure to supervise a resident who needed cues to slow down while eating, resulting in choking and death.
Failure to ensure sufficient nursing staff responded timely to call lights for 4 out of 4 residents reviewed.
Failure to maintain accurate and complete resident medical records, including documentation of the choking incident.
Report Facts
Resident census: 128
Residents reviewed for call light response: 4
Call light response failures: 4
Correction plan audit duration: 3
Correction plan call light follow-up: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse (LPN) | Noted in statements regarding resident supervision and choking incident |
| Staff D | Certified Nursing Assistant (CNA) | Observed resident choking and involved in supervision failure |
| Staff F | Homemaker | Involved in meal service and supervision observations |
| Staff H | Certified Medication Assistant (CMA) | Reported resident needed reminders to slow down while eating |
| Staff G | Registered Dietician | Met with resident's family and explained supervision needs |
| Director of Nursing (DON) | Director of Nursing | Provided multiple interviews about supervision policies and resident care |
Inspection Report
Annual Inspection
Census: 117
Deficiencies: 8
Date: Mar 4, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #118649-C, #119134-C, and facility reported incidents #117737-1 and #119029-1.
Complaint Details
Complaints #118649-C and #119134-C were substantiated. Facility reported incidents #117737-1 and #119029-1 were substantiated. The complaint investigation revealed verbal abuse by staff to Resident #91, failure to protect residents from abuse, and inadequate investigation and corrective actions by the facility.
Findings
The facility was found to have deficiencies related to resident rights, abuse and neglect, comprehensive care planning, quality of care, accident hazards, food and nutrition, infection control, and medication management. Several complaints and incidents were substantiated, including verbal abuse by staff and failure to protect residents from abuse. The facility failed to maintain adequate supervision, documentation, and staff training in multiple areas.
Deficiencies (8)
Facility failed to treat residents with dignity and respect, evidenced by verbal abuse of Resident #91 by staff.
Facility failed to protect residents from abuse and neglect, including verbal abuse and failure to intervene timely.
Facility failed to develop and implement comprehensive care plans for residents.
Facility failed to provide adequate quality of care, including skin assessments and pressure injury management.
Facility failed to ensure adequate supervision to prevent accidents for residents at risk of falls.
Facility failed to provide food and nutrition at safe and palatable temperatures.
Facility failed to maintain an effective infection prevention and control program.
Facility failed to properly label, store, and secure drugs and biologicals, including medication refrigerators.
Report Facts
Census: 117
Residents sampled: 26
Residents reviewed for pressure ulcers: 6
Residents reviewed for falls supervision: 2
Residents reviewed for abuse allegations: 5
Residents reviewed for medication refrigerator audit: 6
Residents reviewed for food temperature: 6
Residents reviewed for skin assessments: 3
Residents reviewed for accident supervision: 1
Residents reviewed for nutrition: 7
Residents reviewed for abuse investigation: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Certified Medication Aide (CMA) | Named in verbal abuse incident with Resident #91. |
| Staff L | Nurse Manager | Involved in abuse incident investigation and disciplinary action. |
| Staff N | Certified Nursing Assistant (CNA) | Alleged perpetrator of verbal abuse to Resident #91. |
| Staff M | Director of Nursing (DON) | Involved in abuse incident investigation and staff interviews. |
| Staff P | Assistant Director of Nursing (ADON) | Involved in abuse incident investigation and staff interviews. |
| Staff Q | Life Enrichment Aide | Witnessed verbal abuse incident. |
| Staff O | Certified Medication Aide (CMA) | Reported concerns about abuse incident. |
| Staff T | Homemaker | Witnessed resident behavior during abuse incident. |
| Staff F | Housekeeper | Reported uncertainty about medication refrigerator cleaning. |
| Staff G | Maintenance | Reported long delay in medication refrigerator repair. |
| Staff K | Certified Medication Aide (CMA) | Observed resident fall and medication administration. |
| Staff R | Certified Nursing Assistant (CNA) | Observed resident fall and provided care. |
| Staff S | Certified Medication Aide (CMA) | Reported staffing concerns and resident fall. |
| Staff J | Cook | Observed food preparation and pureed diet compliance. |
| Staff D | Homemaker | Observed food temperatures and meal service. |
| Staff A | Registered Nurse (RN) | Observed medication refrigerator and medication administration. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
The document is a plan of correction following a credible allegation of substantial compliance for Bethany Life Nursing Home.
Findings
The facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, and will be certified in compliance effective December 27, 2023.
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Date: Dec 4, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to complaint #117113-C from November 30, 2023 to December 4, 2023.
Complaint Details
Complaint #117113-C was substantiated.
Findings
The facility was found not in compliance with 42 CFR Part 483 requirements due to failure to follow a doctor's order for treatment of a Stage 3 pressure ulcer for Resident #3. The order was delayed in initiation and not acknowledged timely by nursing staff.
Deficiencies (1)
Failure to follow a doctor's order to start treatment on a pressure ulcer for Resident #3, with delayed initiation and lack of acknowledgment by nursing staff.
Report Facts
Census: 121
Correction date: Correction date set for 12/27/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Mentioned regarding failure to acknowledge and follow doctor's orders for Resident #3's pressure ulcer treatment |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 30, 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 credible allegation and Plan of Correction, resulting in certification effective November 22, 2023.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 2, 2023
Visit Reason
The inspection was conducted due to complaints #116479, #116491, and Facility Reported Incident #116480-I regarding compliance with 42 CFR Part 483 requirements for long term care facilities.
Complaint Details
Complaint #116479 was substantiated. Complaint #116491 and Facility Reported Incident #116480-I were not substantiated.
Findings
The facility was found not in compliance with regulations related to psychotropic drug use, specifically failure to have a physician review and/or discontinue PRN psychotropic medication within 14 days for one resident. Complaint #116479 was substantiated, while #116491 and incident #116480-I were not substantiated.
Deficiencies (1)
Failure to have a physician review and/or discontinue PRN psychotropic medication (Ativan) within 14 days for Resident #1.
Report Facts
Complaint numbers: 3
Dates of medication administration: 5
Dates of medication administration: 8
Date of death: Oct 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Named in medication error finding and interview about PRN Ativan use |
| ADON | Assistant Director of Nursing | Named in medication record review and monitoring plan |
| CEO Administrator | CEO/Administrator | Signed the plan of correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
The document reflects acceptance of a credible allegation of compliance and plan of correction for the facility, certifying it in compliance effective January 2, 2023.
Findings
The facility was found to be in compliance based on the accepted plan of correction and credible allegation of compliance, with no specific deficiencies detailed in this document.
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 4
Date: Dec 2, 2022
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the Iowa Department of Inspections and Appeals. The facility was found not to be in substantial compliance with 42 CFR 483 subpart B.
Complaint Details
The complaint investigation substantiated abuse of one resident (R64) who was bruised after staff held her arms during care. Staff involved were immediately suspended and subsequently terminated. The facility failed to timely report the alleged abuse to the Administrator. The investigation included interviews, record reviews, and staff interviews.
Findings
The facility failed to provide the required Notice of Medicare Non-coverage (NOMNC) at least two days prior to the end of covered services for one resident. The facility also failed to assure freedom from abuse for one resident who was found with bruising after staff held her by the arms during care. Additionally, the facility failed to ensure timely reporting of alleged violations and failed to meet professional standards for services provided, including catheter care and respiratory care.
Deficiencies (4)
Failed to provide required Notice of Medicare Non-coverage (NOMNC) at least two days prior to end of coverage for one resident.
Failed to assure freedom from abuse for one resident found with bruising after staff held her by the arms during care.
Failed to ensure timely reporting of alleged violations of abuse.
Failed to meet professional standards of care for catheter care and respiratory care for residents reviewed.
Report Facts
Survey Census: 100
Sample Size: 20
Survey Dates: Inspection conducted from 2022-11-29 to 2022-12-02
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Lake | Administrator | Signed the Plan of Correction and involved in oversight of corrective actions |
| Director of Resident Life Services | Interviewed regarding NOMNC notification and corrective actions | |
| Medicare Coordinator | Interviewed regarding NOMNC notification and corrective actions | |
| Certified Nursing Assistant (CNA)1 | Involved in abuse incident with resident R64 | |
| Certified Medication Aide (CMA)1 | Involved in abuse incident with resident R64 | |
| Certified Nursing Assistant (CNA)2 | Witnessed abuse incident and interviewed during investigation | |
| Director of Nursing (DON) | Conducted investigation of abuse incident and reported findings | |
| Chief Executive Officer and Director of Nursing | Re-introduced companion role for support and supervision | |
| Clinical Manager | Developed oxygen therapy management program and auditing schedules | |
| Infection Preventionist | Tracking catheter change compliance and infection control measures |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 10
Date: Sep 30, 2021
Visit Reason
A recertification health survey and investigation of multiple complaints and facility reported incidents was conducted on 09/30/2021.
Complaint Details
The investigation included substantiated complaints #98881, #99150, #99151, #99152, and #99176, and a not substantiated complaint #99443.
Findings
The facility was found to have multiple deficiencies related to residents' rights, care planning, accident prevention, food procurement, infection control, and discharge procedures. Several complaints and incidents were substantiated, and the facility failed to meet regulatory requirements in several areas including medication changes, care plans, supervision, and infection prevention.
Deficiencies (10)
Right to be informed and make treatment decisions was not met as the facility failed to notify the doctor of the family's preferences on a medication change for Resident #118.
The facility failed to complete a comprehensive person-centered care plan related to incontinence care for Resident #99.
The facility failed to have a physician order for a catheter for Resident #56.
The facility failed to have a discharge summary including a recapitulation of a resident's stay for Resident #118.
The facility failed to ensure safe transfer assistance and nursing supervision for 4 of 4 residents observed.
The facility failed to ensure proper use of gait belts and wheelchair use policies for residents with safety concerns.
The facility failed to store and prepare food in accordance with professional standards; personal unlabeled, uncovered, and expired items were disposed of.
The facility failed to ensure proper hand hygiene and glove usage during food service and resident care.
The facility failed to establish and maintain an infection prevention and control program meeting regulatory requirements.
The facility failed to ensure proper documentation and follow-up on residents' VA eligibility and admission procedures.
Report Facts
Facility census: 125
Residents reviewed: 29
Residents observed for safe transfer: 4
Residents with gait belt safety concerns: 5
Residents with catheter orders reviewed: 1
Residents reviewed for discharge summary: 1
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 2
Date: Jul 23, 2021
Visit Reason
The inspection was conducted as an investigation of Complaints #97224-C, #97472-C and multiple Facility Reported Incidents and a Mandatory report between 7/1/21 and 7/23/21.
Complaint Details
Complaint #97224-C and Complaint #97472-C were substantiated. Multiple Facility Reported Incidents were not substantiated. Mandatory report #97705-M was investigated with results pending.
Findings
The facility failed to promptly notify families or representatives of the use of cameras in resident rooms and monitors located in public areas for 2 of 5 residents (Resident #9 and Resident #3). This failure also resulted in a violation of residents' personal privacy and confidentiality rights.
Deficiencies (2)
Failed to promptly notify resident families and/or representatives of the use of cameras in resident rooms and monitors located in a public area.
Failed to ensure personal privacy of personal space and accommodations related to use of cameras in resident rooms and monitors located in a public area.
Report Facts
Resident census: 126
Camera placement duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed placement date of monitor for Resident #9 | |
| Assistant Director of Nursing | Confirmed failure to notify resident families and/or representatives prior to camera placement |
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 2
Date: Jul 23, 2021
Visit Reason
Investigation of multiple complaints and facility reported incidents related to the use of electronic monitoring devices in resident rooms and public areas.
Complaint Details
Complaint #97224-C and #97472-C were substantiated. Multiple facility reported incidents were investigated with most not substantiated. Mandatory report #97705-M was investigated with results pending.
Findings
The facility failed to promptly notify families or representatives of the use of cameras and monitors in resident rooms and public areas for 2 of 5 residents (Resident #3 and Resident #9). The facility also failed to ensure personal privacy related to the use of electronic monitoring devices. Informed consent was obtained after the fact for Resident #9 and similarly situated residents. The facility implemented policies and staff education to address these issues.
Deficiencies (2)
Failure to promptly notify resident families and/or representatives of the use of cameras in resident rooms and monitors in public areas.
Failure to ensure personal privacy of residents related to use of cameras and monitors.
Report Facts
Resident census: 126
Days camera placed: 6
Date monitor placed: Jun 14, 2021
Date of informed consent: Jul 16, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed placement date of monitor for Resident #9 via email. | |
| Assistant Director of Nursing | Confirmed failure to notify families prior to camera placement in resident rooms. |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 0
Date: Dec 31, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted along with investigation of Complaint #94390-C and Incident #94992-I during December 28-31, 2020.
Complaint Details
Complaint #94390-C and Incident #94992-I were investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation. Complaint #94390 and Incident #94992 were investigated and found not substantiated.
Report Facts
Total residents: 131
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 19, 2020
Visit Reason
The inspection was conducted as an investigation of complaint #87903-C and Incident #91682-I and #91681-I, completed between August 5-19, 2020.
Complaint Details
Investigation of complaint #87903-C and Incident #91682-I and #91681-I; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance during the investigation of the complaint and incidents.
Inspection Report
Routine
Census: 121
Deficiencies: 0
Date: Jun 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaint #91507-C was investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #91507-C was not substantiated.
Report Facts
Total residents: 121
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 1
Date: Apr 9, 2020
Visit Reason
Investigation of Incident #90389 related to a resident ingesting tea tree oil on a secured dementia unit.
Complaint Details
Incident #90389 was substantiated. Resident #1 ingested tea tree oil from another resident's room on the secured dementia unit, causing hypoxia and requiring emergency transfer. Staff failed to report or remove the hazardous item despite awareness.
Findings
The facility failed to ensure the resident environment was free from accident hazards, resulting in Resident #1 ingesting tea tree oil and requiring emergency room transfer. Staff were aware of the presence of the oil but failed to report or remove it.
Deficiencies (1)
Failure to ensure the resident environment remained free from accident hazards, specifically allowing access to tea tree oil which was ingested by Resident #1.
Report Facts
Census: 132
Wandering risk scale score: 12
Incident time: 1600
Incident date: Mar 7, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Documented incident and transferred resident to emergency room |
| Staff B | Certified Nurse Aide (CNA) | Found resident with tea tree oil bottle and reported incident |
| Staff C | Certified Nurse Aide (CNA) | Noticed tea tree oil in another resident's room but did not report or remove it |
| Director of Nursing (DON) | Acknowledged staff knowledge of tea tree oil presence and failure to report or remove it |
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