Inspection Reports for Rehabilitation Center of Des Moines
701 Riverview Street, IA, 503162312
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 24, 2025 found the facility in substantial compliance with no deficiencies cited. Prior inspections showed a mixed pattern with several periods of deficiencies related to resident care, including issues with assessments, infection control, nutrition, medication administration, and resident dignity. Complaint investigations were mostly unsubstantiated, though some earlier complaints were substantiated, including concerns about privacy, safety, and financial exploitation. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, with recent inspections showing correction of prior deficiencies and a return to compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
13.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
200% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
72 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 24, 2025
Visit Reason
A complaint investigation was conducted for complaints #2629644-C, #2675959-C, #2676018-C and a facility reported incident #2676040-I from November 24, 2025 to November 25, 2025.
Complaint Details
Investigation involved multiple complaints and a facility reported incident; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 15, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective October 15, 2025. No specific deficiencies are detailed in the report.
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 7
Date: Sep 16, 2025
Visit Reason
The inspection was conducted as an annual recertification survey including investigation of multiple complaints and facility-reported incidents between September 8, 2025 and September 16, 2025.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, quality of care related to neurological exams, nutrition and hydration, respiratory care, infection control, immunizations, and reporting of major injuries. Deficiencies were documented with detailed findings for specific residents and corrective plans were submitted.
Deficiencies (7)
Failure to accurately complete Minimum Data Set (MDS) assessments regarding pneumococcal vaccinations for multiple residents.
Failure to complete and document neurological exams (neurochecks) for residents after falls.
Failure to coordinate nutritional care for residents on dialysis, including communication with dialysis centers and dietitians.
Failure to provide ordered respiratory care including oxygen therapy for residents.
Failure to implement infection prevention and control program including hand hygiene and immunizations.
Failure to provide appropriate medication administration including hand hygiene during medication pass.
Failure to report major injury incidents timely to the department as required.
Report Facts
Facility census: 72
Residents reviewed: 18
Residents reviewed for dialysis: 2
Residents reviewed for respiratory care: 1
Residents reviewed for medication administration: 4
Residents reviewed for immunizations: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 24, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, confirming the facility's substantial compliance and certification effective May 24, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 3
Date: May 7, 2025
Visit Reason
The inspection was conducted as a result of investigations of complaints #128042-C, #128260-C, and #128274-C from April 18, 2025 to May 7, 2025, which resulted in deficiencies.
Complaint Details
The visit was complaint-related based on complaints #128042-C and #128260-C which resulted in deficiencies. The facility acknowledged concerns regarding dignity and resident rights, code status confusion, and safety hazards. The Licensed Nursing Home Administrator and Director of Nursing acknowledged the issues during the investigation.
Findings
The facility failed to provide privacy and dignity to Resident #5 by leaving window blinds open during care, failed to have clear code status direction for Resident #2 resulting in conflicting DNR and full code orders, and failed to ensure safety for Resident #8 who was pushed in a wheelchair without foot pedals causing risk of injury. The facility acknowledged these issues and implemented corrective actions including staff education, policy revisions, audits, and equipment adjustments.
Deficiencies (3)
Failure to provide privacy and dignity to Resident #5 by leaving window blinds open during care.
Failure to have clear direction for code status for Resident #2, resulting in conflicting DNR and full code orders.
Failure to ensure safety for Resident #8 who was pushed in a wheelchair without foot pedals, risking injury.
Report Facts
Census: 72
Deficiencies cited: 3
Date of survey completed: May 7, 2025
Correction date: May 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Lee Thomas | Administrator | Signed plan of correction on 5/24/25 |
| Staff D | Certified Nurse Aide (CNA) | Observed leaving blinds open and acknowledged concern |
| Staff E | Certified Nurse Aide (CNA) | Observed providing care to Resident #5 with blinds open |
| Licensed Nursing Home Administrator | LNHA | Acknowledged concerns regarding blinds and code status |
| Director of Nursing | DON | Acknowledged concerns regarding blinds and code status |
| Staff A | Certified Medication Aide (CMA) | Reported events related to Resident #2's code status and care |
| Staff B | Registered Nurse (RN) | Reported events related to Resident #2's code status and care |
| Staff C | Nurse Practitioner | Discussed code status with Resident #2's son and hospital |
| Staff F | Certified Nurse Aide (CNA) | Observed pushing Resident #8 in wheelchair without foot pedals |
| Staff H | Certified Nurse Aide (CMA) | Witnessed incident involving Resident #8 in wheelchair |
| Staff G | MDS Coordinator/Nurse | Acknowledged understanding of wheelchair safety concerns |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 6, 2025
Visit Reason
A complaint investigation was conducted for multiple complaints and a facility reported incident from January 29, 2025 to February 6, 2025.
Complaint Details
Investigation involved Complaints 125332-C, 125169-C, 124560-C, 124566-C, 124567-C, 124184-C (listed twice), 126392-C and Facility Reported Incident 124715-I. The facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the applicable regulations.
Report Facts
Complaint numbers: 9
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 17, 2024
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 17, 2024.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 20, 2024
Visit Reason
A revisit of the survey ending June 6, 2024 and investigation of Complaints #121956-C, #122163-C and Facility Reported incidents #122158-I was conducted on July 19, 2024 to July 20, 2024.
Complaint Details
Investigation of Complaints #121956-C, #122163-C and Facility Reported incidents #122158-I was conducted.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective June 28, 2024.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
A complaint investigation was conducted for multiple complaints (#116150-C, #116216-C, #117936-C, #118545-C, #118556-C, #118674-C, #118694-C, #118711-C) and a mandatory facility reported incident (#117961-M) from February 6, 2024 to February 14, 2024.
Complaint Details
Investigation covered multiple complaints and a mandatory facility reported incident; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance. A separate report will be sent later for the facility reported incident #117961-M.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 6, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on November 6, 2023, related to facility certification compliance.
Findings
Based on acceptance of the credible allegation of substantial compliance and the submitted Plan of Correction, the facility will be certified in compliance effective November 5, 2023.
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 13
Date: Oct 2, 2023
Visit Reason
The inspection was an annual recertification survey combined with complaint investigations and facility-reported incidents conducted from October 2, 2023 to October 5, 2023.
Complaint Details
Complaints #114735-C and #115209-C were substantiated. Facility reported incident #115885-I was substantiated.
Findings
The facility was found to have multiple deficiencies related to resident rights, dignity, abuse reporting, care planning, infection control, pain management, and other regulatory requirements. Several complaints and incidents were substantiated. The facility failed to meet requirements in areas such as dignity bags for catheter care, abuse investigation reporting, PASARR evaluations, care plan implementation, pain management, dialysis care, medication administration, infection control, and resident call systems.
Deficiencies (13)
Facility failed to treat residents with dignity and respect, including failure to provide dignity bags for indwelling urinary catheters.
Facility failed to report results of abuse investigations within required timeframes.
Facility failed to provide timely and accurate PASARR evaluations and referrals.
Facility failed to develop and implement comprehensive care plans consistent with residents' needs.
Facility failed to provide adequate pain management for a resident.
Facility failed to ensure adequate supervision and assistance devices to prevent accidents.
Facility failed to ensure residents receiving enteral nutrition were fed according to physician orders.
Facility failed to ensure dialysis assessments and treatments were completed and documented properly.
Facility failed to maintain complete and accurate medical records.
Facility failed to establish and maintain an effective infection prevention and control program.
Facility failed to ensure proper handling and donning/doffing of PPE by nursing staff.
Facility failed to ensure secure storage of medications and proper medication administration.
Facility failed to ensure call light systems were accessible and functioning for residents.
Report Facts
Residents reviewed: 17
Census: 68
Residents reviewed: 3
Residents reviewed: 2
Residents reviewed: 1
Residents reviewed: 17
Residents reviewed: 2
Medications administered: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Medication Aide (CMA) | Named in pain management and medication administration findings related to Resident #7. |
| Staff F | Mentioned in dignity bag and catheter care observations. | |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including pain management, PASARR, dialysis care, medication administration, and care plan updates. |
| Administrator | Administrator | Mentioned in relation to complaint investigations and reporting. |
Inspection Report
Annual Inspection
Census: 85
Capacity: 100
Deficiencies: 2
Date: Sep 15, 2023
Visit Reason
The inspection was conducted as the facility's annual survey to assess compliance with state and federal regulations.
Findings
The facility was found to be generally compliant with most regulatory requirements, with some deficiencies noted related to medication administration and documentation.
Deficiencies (2)
Medication administration errors identified during the inspection.
Incomplete resident care documentation.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jane Doe | Director of Nursing | Named in medication error finding |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
A Complaint Survey was conducted from July 31, 2023 to August 7, 2023 to investigate multiple complaints and facility reported incidents.
Complaint Details
The survey investigated Complaints #112108-C, #112528-C, #114463-C, #114514-C and Facility Reported Incidents #112913-I, #113875-I, #114461-I, #114162-I. The facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 20, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction for the facility, certifying compliance based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was certified in compliance effective April 20, 2023, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 2
Date: Mar 28, 2023
Visit Reason
The inspection was conducted as an investigation of self-report 110915-I and complaints 111013-C and 111752-C between March 20, 2023 and March 28, 2023.
Complaint Details
Self-report 110915-I was not substantiated. Complaint 111013-C was substantiated. Complaint 111752-C was substantiated.
Findings
The facility was found to have deficiencies related to quality of care and sufficient nursing staff, including failure to assess a wound weekly for one resident and failure to ensure timely response to call lights for two residents. Complaints 111013-C and 111752-C were substantiated while the self-report 110915-I was not.
Deficiencies (2)
Facility failed to assess a wound weekly for 1 of 3 residents reviewed (Resident #2).
Facility failed to provide adequate nursing supervision by failing to ensure call lights were answered timely for 2 of 3 residents reviewed (Resident #2 and #4).
Report Facts
Total Residents: 67
MDS score: 12
MDS score: 14
Wound measurement: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated nurses assess and document wounds weekly and addressed complaints about call light response times |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 10, 2023
Visit Reason
An investigation of intakes #107868-C, #109447-C, #109449-C, #109450-C, #109731-C, and #109635-I was conducted from December 14, 2022 to January 10, 2023.
Complaint Details
Investigation of multiple complaint intakes as listed; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance. The investigation results for the facility's self-reported incident #109084-M, completed December 14, 2022 to January 11, 2023, will be sent under separate cover.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 16, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and ensure compliance for certification.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification in compliance effective 12/16/2023.
Inspection Report
Annual Inspection
Census: 72
Capacity: 72
Deficiencies: 20
Date: Oct 4, 2022
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of complaints from September 26 to October 4, 2022.
Complaint Details
Complaints 99605-C, 100178-C, 100408-C, 100434-C, 101463-C, 101722-C, 101820-C, 102583-C, 102688-C, 104535-C were not substantiated. Complaints 99605-C, 100178-C, 100408-C, 100434-C, 101722-C, 101820-C, 105151-C, 105348-C, 105392-C, 105648-C, 105854-C, 105857-C, 106381-C, 106449-C, 106608-C, 106612-C and facility reported incidents 102304-I, 105699-I, 106221-I, 106456-I, 106614-I, 106621-I, 107237-I, 107640-I were substantiated.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' rights to self-determination, management of personal funds, abuse prevention training, care planning, nutrition and hydration maintenance, medication administration, and safety hazards. Some complaints were substantiated while others were not. The facility reported a census of 72 residents.
Deficiencies (20)
Failure to ensure resident's right to make choices about aspects of life, including bathing preferences.
Failure to ensure residents had access to their personal funds on weekends and holidays.
Failure to develop and implement abuse/neglect policies and procedures, including screening and behavioral monitoring of residents with criminal history.
Failure to develop and implement comprehensive person-centered care plans for residents, including measurable objectives and timeframes.
Failure to provide showers and baths for residents as requested and needed.
Failure to ensure medication orders were processed properly and timely, resulting in medication errors.
Failure to dispose of garbage and refuse properly, including unsecured dumpster lids.
Failure to maintain corridors with firmly secured handrails.
Failure to provide abuse, neglect, and exploitation training to staff within regulatory timeframes.
Failure to ensure residents were free of significant medication errors.
Failure to ensure residents received adequate nutrition and hydration, including weight monitoring and dietary interventions.
Failure to ensure residents received showers and baths as requested and needed.
Failure to ensure residents were free from abuse, neglect, exploitation, and misappropriation of property.
Failure to ensure residents at risk for elopement were properly monitored and protected.
Failure to ensure residents received care and services to maintain or improve activities of daily living.
Failure to ensure residents' care plans were updated to reflect current needs and preferences.
Failure to ensure staff followed policies and procedures related to medication administration and documentation.
Failure to ensure facility policies and procedures were followed related to resident safety and care.
Failure to ensure staff completed required training on dependent adult abuse within regulatory timeframes.
Failure to complete required baseline and follow-up tuberculosis screening for staff.
Report Facts
Deficiencies cited: 20
Census: 72
Total Capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff T | Certified Nursing Assistant (CNA) | Named in relation to shower scheduling and resident preference findings. |
| Staff S | Certified Nursing Assistant (CNA) | Named in relation to documentation of showers and bathing policy. |
| Staff W | Certified Nursing Assistant (CNA) | Named in relation to bathing policy and shower documentation. |
| Staff X | Certified Nursing Assistant (CNA) | Named in relation to shower documentation and resident care. |
| Staff F | Registered Nurse (RN) | Named in relation to shower scheduling and neglect findings. |
| Director of Nursing (DON) | Director of Nursing | Named in relation to shower preference, medication administration, and care plan findings. |
| Administrator | Administrator | Named in relation to resident preferences and care plan findings. |
| Staff A | Certified Nursing Assistant (CNA) | Named in relation to resident care and abuse prevention training. |
| Staff BB | Former Activity Director | Named in relation to resident elopement and wandering. |
| Staff CC | Staff | Named in relation to resident wandering and unfamiliarity with residents. |
| Staff GG | Former Administrator | Named in relation to resident elopement. |
| Staff G | Staff | Named in relation to tuberculosis screening and medication administration. |
| Staff P | Staff | Named in relation to tuberculosis screening and medication administration. |
| Staff Q | Staff | Named in relation to tuberculosis screening. |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 9
Date: Oct 16, 2021
Visit Reason
The inspection was conducted as the annual recertification survey and investigation of the Rehabilitation Center of Des Moines, including review of resident rights, care, and compliance with federal regulations.
Findings
The facility was found to have multiple deficiencies related to resident rights, care planning, medication administration, infection control, environment, and staffing. Several residents had unmet needs in areas such as cognitive assessments, personal funds management, nutrition, and safety. The facility implemented plans of correction and education to address these issues.
Deficiencies (9)
Failure to maintain resident rights including dignity, respect, and grievance resolution.
Inadequate care planning and failure to provide necessary treatments and assessments.
Failure to properly manage residents' personal funds and financial affairs.
Inadequate infection prevention and control program.
Failure to provide adequate nutrition and food safety.
Failure to ensure adequate staffing and staff training.
Failure to maintain a safe and clean environment.
Failure to properly administer medications and maintain medication records.
Failure to provide adequate supervision and assistance with activities of daily living.
Report Facts
Census: 64
Deficiencies cited: 9
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 15, 2021
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating acceptance of a credible allegation of compliance and certification of the facility in compliance effective 10/15/21.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Date: Apr 26, 2021
Visit Reason
The inspection was conducted following allegations of financial exploitation of Resident #4 and concerns related to quality of care for Resident #6, including an unwitnessed fall.
Complaint Details
The complaint investigation was substantiated for Resident #4 regarding financial exploitation. The facility reported the allegation to the state regulatory agency on 3/5/21. Resident #4's money was missing after being entrusted to staff for safekeeping during a facility evacuation. The facility failed to properly secure the money and delayed investigation. For Resident #6, the complaint involved failure to document and assess an unwitnessed fall on 3/29/21.
Findings
The facility failed to initiate an immediate investigation following the allegation of financial exploitation of Resident #4 and failed to safeguard the resident's money properly. Additionally, the facility failed to document and conduct follow-up assessments after an unwitnessed fall for Resident #6.
Deficiencies (2)
Failure to initiate immediate investigation following allegation of financial exploitation of Resident #4.
Failure to document and conduct follow-up assessments after an unwitnessed fall for Resident #6.
Report Facts
Resident census: 65
Missing money amount: 220
Date of alleged financial exploitation: Feb 11, 2021
Date of complaint report: Mar 5, 2021
Date of fall: Mar 29, 2021
Date of inspection completion: Apr 26, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Handled Resident #4's money and belongings before they went missing |
| Staff B | Licensed Practical Nurse (LPN) | Charge nurse on 2/10/21 who failed to secure Resident #4's money |
| Staff C | Certified Medication Assistant (CMA) | Placed Resident #4's coin purse in medication room |
| Staff D | Registered Nurse (RN) | Charge nurse who was informed of missing money and assessed Resident #6 after fall |
| Staff E | Certified Nursing Assistant (CNA) | Assisted Staff D with Resident #6 after fall |
| Director of Nursing (DON) | Director of Nursing | Interviewed staff and residents regarding the allegations and fall; provided education on fall documentation |
| Prior Administrator | Facility Administrator | Was notified of missing money but was suspended and terminated before investigation |
| Clinical Market Leader | Market Leader | Provided policy clarification on handling resident money |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 7
Date: Mar 16, 2021
Visit Reason
The investigation was conducted in response to multiple complaints (#94710-C, #95062, #95134, #95539, #95687, #95808, #96138, #96249) and a facility reported incident (#96094) completed between 2/9/21 and 3/16/21.
Complaint Details
Multiple complaints and a facility reported incident were investigated. Complaints #94710-C, #95062-C, #95539-C, #95687-C, #95808-C, #96138-C, #96249-C and Facility Reported Incident #96094-I were substantiated. Complaint #95134-C was not substantiated.
Findings
The facility was found to have multiple deficiencies including failure to maintain comfortable building temperatures, inadequate preparation for safe transfer/discharge of residents, failure to meet professional standards in care plans, insufficient assistance with activities of daily living, failure to ensure quality of care including lab tests and catheter care, unsafe environment related to fire watch documentation, and insufficient nursing staff. Several complaints and the facility reported incident were substantiated.
Deficiencies (7)
Facility failed to maintain comfortable building temperatures between 71 and 81 degrees in resident areas and failed to provide additional blankets or move residents to warmer areas.
Facility failed to ensure safe and orderly transfer/discharge for 1 out of 4 residents reviewed, resulting in a resident spending the night outdoors in subzero weather.
Facility failed to follow professional standards to ensure adequate blood sugar monitoring and failed to clarify insulin orders for a newly admitted resident.
Facility failed to complete baths for 3 out of 3 residents reviewed and failed to provide showers as scheduled.
Facility failed to ensure laboratory tests were completed as ordered and failed to provide appropriate catheter care and documentation.
Facility failed to ensure a safe environment related to fire watch during use of temporary heating system and falsified fire watch documentation.
Facility failed to have sufficient nursing staff with appropriate competencies and skills to assure resident safety and care.
Report Facts
Census: 70
Residents with temperatures below 97 degrees: 26
Residents reviewed for transfer/discharge planning: 4
Residents reviewed for baths: 3
Residents reviewed for call light response: 5
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff R | Maintenance | Verified facility temperatures and reported building surge pump issue |
| Staff D | Administrator | Acknowledged pump replacement and temperature issues; terminated employment related to falsification |
| Staff A | Social Worker | Involved in discharge and shelter placement of Resident #12 |
| Staff B | Activities Assistant | Assisted with Resident #12 discharge and involved in fire watch falsification |
| Staff C | Activities Assistant | Assisted with Resident #12 discharge |
| Staff M | Registered Nurse | Conducted rounds and checked blood sugar for Resident #13 |
| Staff N | Interim Director of Nursing | Reported no blood sugar checks prior to fall and assisted with insulin monitoring |
| Staff P | Nurse Consultant | Provided input on insulin monitoring and call light response |
| Staff K | Certified Nursing Assistant | Reported day shift bathing issues |
| Staff Q | Interim Director of Nursing | Reviewed bathing documentation and shower chair issues |
| Staff L | Certified Nursing Assistant | Reported no showers completed on 6-2 shift |
| Staff G | Certified Medication Aide | Reported residents felt cold |
| Charles Funk | Compliance Department Member | Educated staff on falsification of documents |
Inspection Report
Routine
Census: 72
Deficiencies: 13
Date: Sep 30, 2020
Visit Reason
Routine COVID-19 infection control survey and investigation of complaints and facility self-report.
Findings
The facility had multiple deficiencies including failure to complete admission paperwork and consents, failure to notify family of changes in condition, failure to follow care plans, incomplete care plans, failure to meet professional standards in admission assessments, failure to complete discharge summaries, inadequate bathing and hygiene care, incomplete wound care assessments and treatments, failure to check feeding tube placement before medication administration, insufficient nursing staff leading to delayed call light responses, failure to arrange transportation for podiatry appointments, and ineffective pest control resulting in maggot infestations.
Deficiencies (13)
Failure to complete necessary admission information and obtain proper consents for care and billing for Resident #18.
Failure to promptly notify family and physician of changes in condition for multiple residents.
Failure to follow interventions in comprehensive care plans for Residents #26 and #30, including transfer safety.
Failure to update and manage care plans to reflect physician orders and resident needs for Resident #12.
Failure to meet professional standards for admission assessments by not having RN complete initial assessments for multiple residents and failure to follow physician orders for Resident #12.
Failure to complete discharge summaries and communicate necessary discharge information for multiple residents.
Failure to provide necessary bathing and personal hygiene care resulting in maggot infestations for multiple residents.
Failure to meet professional standards of care for wound assessments and treatments for multiple residents, including delayed and incomplete documentation.
Failure to ensure safe transfers for Resident #30 resulting in a fracture due to lack of gait belt and mechanical lift use.
Failure to check feeding tube placement prior to medication administration for Resident #22.
Failure to ensure timely response to call lights for multiple residents.
Failure to maintain complete and accurate resident records including assessments, notifications, and documentation of incidents for Residents #9 and #10.
Failure to maintain an effective pest control program resulting in presence of flies and maggots in the facility and resident wounds.
Report Facts
Call light response delays: 169
Call light response delays: 16
Call light response delays: 60
Call light response delays: 105
Pest control visits: 11
Baths received: 5
Baths received: 3
Pain medication missed doses: 4
Residents reviewed: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff T | Certified Nursing Assistant | Named in fall incident for Resident #30, admitted failure to use gait belt. |
| Staff E | Certified Nursing Assistant | Named in fall incident for Resident #30. |
| Staff G | Licensed Practical Nurse | Administered medications without checking feeding tube placement for Resident #22. |
| Staff R | Licensed Practical Nurse | Wound nurse, confirmed failure to assess wounds timely and incomplete wound documentation. |
| Staff N | Certified Nursing Assistant | Observed maggots on Resident #11. |
| Staff Y | Certified Nursing Assistant | Observed maggots on Resident #11 and reported to nurse. |
| Staff BB | Certified Nursing Assistant/Certified Medication Aide | Observed maggots on Resident #12 and reported to nurse. |
| Staff TT | Licensed Practical Nurse | Responded to maggot incident on Resident #12. |
| Staff UU | Certified Nursing Assistant | Observed maggots on Resident #12. |
| Staff S | Registered Nurse | Charge nurse on duty during Resident #30 fall. |
| Staff J | Registered Nurse | On duty during Resident #9 fall and PICC line incident. |
| Staff F | Registered Nurse | Assessed Resident #9 after PICC line pulled out. |
| Staff LL | Occupational Therapist | Confirmed transfer assistance and gait belt use for Resident #30. |
| Staff PP | Certified Nursing Assistant | Confirmed gait belt use required for transfers. |
| Staff MM | Certified Nursing Assistant | Observed staff transferring residents without gait belts. |
| Staff OO | Certified Nursing Assistant | Observed staff transferring residents without gait belts. |
| Staff V | Registered Nurse/Corporate Nurse/Clinical Market Leader | Confirmed expectations for wound care documentation. |
| Staff P | Licensed Practical Nurse | Completed skin assessments and wound care for Resident #24. |
| Staff W | Registered Nurse/Cooperate Clinical Resource Nurse | Confirmed wound care orders and documentation gaps for Resident #24. |
| Staff R | Licensed Practical Nurse/Wound Nurse | Confirmed wound care procedures and documentation. |
| Staff UU | Certified Nursing Assistant | Observed maggots in Resident #12 wound. |
| Staff BB | Certified Nursing Assistant/Certified Medication Aide | Observed maggots in Resident #12 wound. |
| Staff TT | Licensed Practical Nurse | Responded to maggot incident on Resident #12. |
| Staff M | Certified Nurse Aide | Observed maggots in Resident #11 wound. |
| Staff N | Certified Nurse Aide | Observed maggots in Resident #11 wound. |
| Staff Y | Certified Nurse Aide | Observed maggots in Resident #11 wound. |
| Staff EE | Licensed Practical Nurse | Responded to maggot incident on Resident #11. |
| Staff D | Certified Nurse Aide | Reported call light delays. |
| Staff B | Certified Medication Aide | Reported call light delays. |
| Staff C | Certified Medication Aide | Reported call light delays. |
| Staff E | Certified Nurse Aide | Reported call light delays. |
| Staff G | Licensed Practical Nurse | Reported call light delays. |
| Staff A | Licensed Practical Nurse | Reported call light delays. |
| Staff X | Transportation Supervisor | Reported transportation communication issues. |
| Staff R | Licensed Practical Nurse | Reported podiatry records incomplete. |
| Staff S | Registered Nurse | Charge nurse on duty during Resident #9 fall. |
| Staff T | Certified Nursing Assistant | Named in fall incident for Resident #30. |
| Staff E | Certified Nursing Assistant | Named in fall incident for Resident #30. |
| Staff KK | Licensed Practical Nurse | Reported Resident #9 fall and fracture. |
| Staff PP | Certified Nursing Assistant | Confirmed gait belt use required for transfers. |
| Staff MM | Certified Nursing Assistant | Observed staff transferring residents without gait belts. |
| Staff NN | Certified Nursing Assistant | Observed staff transferring residents without gait belts. |
| Staff OO | Certified Nursing Assistant | Observed staff transferring residents without gait belts. |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Jun 9, 2020
Visit Reason
The inspection was conducted as a COVID-19 focused infection control survey and investigation of Complaint #91078-C from 6/8 to 6/9/2020.
Complaint Details
Complaint #91078-C was substantiated.
Findings
The facility failed to ensure staff followed infection control practices for 2 of 4 residents observed, including improper use and removal of personal protective equipment (PPE) and inadequate hand hygiene. The complaint was substantiated.
Deficiencies (1)
Failure to establish and maintain an infection prevention and control program including proper PPE use and hand hygiene.
Report Facts
Census: 68
Date of compliance: Jul 9, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Observed donning and doffing PPE improperly during resident care. |
| Staff E | Certified Nursing Assistant (CNA) | Observed assisting resident without proper hand hygiene and PPE use. |
| Staff D | Certified Nursing Assistant (CNA) | Observed removing gloves and gown without hand hygiene. |
| Staff F | Maintenance Staff | Observed entering resident rooms without proper PPE and hand hygiene. |
Inspection Report
Deficiencies: 0
Date: ScannedReport 1062 2024 07 17 022648
Visit Reason
Unable to determine from the provided text.
Findings
Unable to determine from the provided text.
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