Ramsey Village
Non profit - Corporation
78 Beds
Independent
Data: November 2025
Trust Grade
40/100
#295 of 392 in IA
Photo by Google Maps
Photo by Ramsey Village Continuing Care
Photo by Ramsey Village Continuing Care
Photo by Ramsey Village Continuing Care
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Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Ramsey Village in Des Moines, Iowa, has a Trust Grade of D, indicating below-average performance with several concerns. It ranks #295 out of 392 facilities in Iowa, placing it in the bottom half, and #18 out of 29 in Polk County, suggesting only a few local options are better. The facility is showing improvement in its trend, with issues decreasing from 10 in 2024 to just 1 in 2025. Staffing is average with a 3/5 rating, but the turnover rate is concerning at 57%, higher than the state average. While there have been no fines, which is a positive aspect, there are significant weaknesses, including a serious incident where staff failed to assess a resident's wound for 48 days and concerns regarding call light response times, indicating potential delays in resident care.
- Trust Score
- D
- In Iowa
- #295/392
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 57% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Iowa facilities.
- Skilled Nurses ○ Average
- Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for Iowa. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 25%
Needs review
10 → 1 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Iowa average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 57%
11pts above Iowa avg (46%)
Frequent staff changes - ask about care continuity
Staff turnover is elevated (57%)
9 points above Iowa average of 48%
The Ugly 29 deficiencies on record
1 actual harm
Apr 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to appropriately provide ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to appropriately provide assessments and interventions for necessary care and services for 1 of 4 residents reviewed (Resident #1). Clinical record review revealed the Assistant Director of Nursing notified the nursing staff of a wound on Resident #1's left foot after admission. The nurse failed to conduct an assessment and failed to notify the provider to acquire an intervention for 48 days after admission. The facility reported a census of 61 residents.
Findings include:
A Minimum Data Set (MDS) dated [DATE], documented that Resident #1 admitted to on 9/23/25 from Home/Community (e.g., assisted living). This MDS documented that Resident #1's diagnoses included diabetes, Alzheimer's disease, functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without damage to the spinal cord), bipolar disorder, and polyneuropathy (nerve damage that affects the hands and feet). A Brief Interview for Mental Status (BIMS) for Resident #1 revealed a score of 12 out of 15, which indicated moderately impaired cognitive functioning. Resident #1 required substantial/maximal assistance (Helper does more than half of the effort. Helper lifts or holds the trunk or limbs and provides more than half the effort.) for shower/bathing, upper body dressing and lower body dressing. Resident #1 was dependent (Helper does all of the effort, resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) on putting on/taking off footwear. Resident #1 required substantial/maximal assistance for rolling left to right in bed, sitting to lying in bed, Lying to sitting in bed, sitting to stand, chair/bed transfer and toilet transfer. This resident was dependent on staff for wheelchair assistance. This MDS documented that Resident #1 had no diabetic foot ulcers identified nor did she have an infection of the foot and was not on a turning repositioning program. It documented that Resident #1 had no other open lesions on the foot.
Care Plan dated 9/23/24 directed staff as follows:
Check all of the body for breaks in skin and treat promptly as ordered by the doctor.
Don't use over the counter remedies for corns and calluses, refer to a podiatrist to treat.
Educate the resident and family that diabetes is a chronic disease and that compliance is essential to prevent complications of the disease.
Review complications and prevention with the resident and family.
Elicit verbal understanding from the resident and family. The nails should always be cut straight across, never cut corners and file rough edges with emery board.
The Medication and Treatment Administration Record (MAR/TAR) for September and October 2024 failed to identify an intervention for Resident #1's wound to the left foot.
The progress notes for Resident #1 revealed:
1. On 9/23/24 at 12:56 admitted resident #1, an assessment completed by Staff D, MDS Coordinator, no skin issues were identified and no swelling in the feet.
2. A late entry on 9/23/24 at 12:57 PM, a wound on the left foot, resident #1 placed on enhanced barrier precautions and staff was notified. Documented by Staff E Assistant Director of Nursing (ADON).
3. On 9/27/24 Staff F, Medical Director (MD) conducted a in house visit for Resident #1 and ordered a Chest x-ray (CXR) due to resident wheezing.
4. On 10/26/24 at 2:11 PM Resident #1 fell to the floor.
5. On 10/29/24 Resident #1 was seen by Staff F and aware of the fall.
6. On 11/10/24 a Certified Nursing Assistant (CNA) reported to a nurse that there was blood on EZ stand platform (stand up lift) after a transfer of Resident #1 and blood on a sock. The CNA noted a wound bottom of Resident #1's left (lt)foot. The wound bed was black and foul smelling and measured 3 centimeters (cm) x 3 cm with a blood blister above this that was intact that measured 1.5 cm x 1 cm. The foot was cleansed, a protective foam boot was applied. The top of the lt foot was red, warm, and Resident #1 had a temperature of 97.1 and denied pain. The nurse notified Staff F, Physician and received a new order for (antibiotics) Cephalexin 500 milligrams (mg) given three times a day (TID) for 7 days. The daughter was notified.
7. On 11/12/24 Staff F examined the diabetic wound, continued betadine treatment two times a day (BID) and ordered a consult by the wound nurse. An X-ray was ordered to rule out osteomyelitis (Infection of the bone) and Levofloxacin 250 mg for 7 days, in addition to the Cephalexin antibiotic.
8. On 11/11/24 the wound nurse documentation of a diabetic wound that measured 3.5 x 3 cm, an in house acquired wound, unknown how long the wound was present, the odor had increased.
During an interview on 4/24/25 at 9:32 AM, Staff E, ADON stated she had worked in this facility for 1.5 years, and had taken over the wound nurse position recently. Staff E explained in the past, if a wound was identified, the nurse would notify the physician, receive an order for treatment, then notify the family. Staff E stated when Resident #1 was admitted in September 2024, Staff D, MDS Coordinator would have completed the admit assessments. Staff E stated she had identified the wound to Resident #1's left foot and notified the staff nurse. Staff E stated the expectation was that the nurse would have notified the physician, received an order for treatment and notified the family. Staff E stated it was the nurses responsibility at that time. Staff E stated she did not see the wound again until it was identified by a CNA in November 2024. Staff E stated that was when she had taken over the admit assessments, for early identification of wounds. Staff E stated the facility had a large number of agency nurses last fall, communication was difficult and she didn't want to see anyone get hurt due to that negligence. Staff E stated she was the current wound specialist and if staff finds a wound, she would assess it, all of the body parts, then scan the results to Staff G, Doctor of Nursing Practice (DNP) who will provide an assessment, order a treatment and monitor the wound until it is healed. Staff E stated nurses conduct weekly wound checks. Staff E stated Resident #1 was placed on skin assessments on Wednesday's during showers and was compliant with care.
During an interview on 4/24/25 at 10:09 AM, Staff G, DNP stated she became the wound nurse in November 2024. Staff G stated she had examined Resident #1 on 11/21/24. Staff G explained that when Staff E, ADON becomes aware of a wound, she would scan a note to Staff G's office and will put the resident on the wound sheet and if the resident had a consent on file then Staff G would come to the facility and examine the resident. Staff G stated Staff E had been her contact person since 11/2024. Staff G stated her assessment of Resident #1's left foot wound revealed 95% slough (a yellow, white devitalized tissue that accumulates in a wound bed) with moderate serosanguinous drainage and did not note an odor. Staff G stated she had ordered betadine moistened gauze, secured with tape two times a day (BID) and apply foam boots (Prevolone). Staff G explained the picture of Resident #1's left foot that she had initially reviewed could not have developed overnight. Staff G was not aware of when Resident #1 acquired the wound or she would have documented, staff did not advise her when it was first identified. Staff G stated Resident #1 was transferred with a mechanical lift at that time. Staff G stated she was not aware if the facility staff conducted daily diabetic foot checks. Staff G stated Resident #1's wound was healed, fully resolved, by 2/13/25. Staff G stated she feels the facility staff are making good progress.
A policy titled Procedure for Identifying a New Skin Area dated 11/9/20 revealed:
1. Assess the area and notify the physician by fax, phone or in person if the provider is in the facility.
2. Implement treatment if ordered.
3. Notify family, power of attorney (POA) or responsible party.
4. Complete an incident report in Point Click Care (PCC) computer.
5. Notify the DON if the skin area requires treatment at a higher level of care (hospital or ER).
A policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 2001 revealed:
1. The nurse and physician will assess significant risk factors (immobility, weight loss, history of ulcers).
2. The nurse shall describe and document a full assessment of the pressure sore, assess pain, the resident's mobility status, current treatments and all active diagnoses.
3. The staff will examine the skin of a new admission for ulcerations or altercations in skin.
4. The physician will assist to determine etiology and characteristics of the wound infection.
5. The physician will help identify the contributing factors to skin breakdowns (medical comorbidities such as diabetes).
6. The physician will help identify medical interventions related to wound management (treatment).
During an interview on 4/23/25 at 3:39 PM, The Director of Nursing (DON) stated the expectation of the nursing staff was that assessments are to be completed on a timely basis and temporary interventions put into place until the Interdisciplinary Team (IDT) can evaluate the situation. The DON stated he felt that the nurses can evaluate and respond quickly. Management had discussed annual competencies for nursing. The management conducted monthly inservices a daily huddle with therapy and dietary.
Oct 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and the Resident Assessment Instrument (RAI) Manual the facility failed to acc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and the Resident Assessment Instrument (RAI) Manual the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one of sixteen residents reviewed (Resident #4). The facility reported a census of 62 residents.
Findings include:
The Minimum Data Set (MDS) assessment completed on 9/13/24 revealed Resident #4 readmitted to the facility on [DATE] from the hospital and had a diagnosis of coronary artery disease. The MDS documented the resident took an anticoagulant medication during the 7-day look-back period.
The Care Plan initiated on 4/18/23 revealed the resident on anticoagulant therapy but the problem was resolved (removed) from the Care Plan on 4/30/23.
The Order Summary revealed Eliquis (Apixaban) (an anticoagulant) 5 milligrams (mg) by mouth two times a day for DVT (deep vein thrombosis) (blood clot) for three months started on 3/22/24 and discontinued on 6/22/24.
The Medication Administration Record (MAR) revealed Eliquis 5 mg by mouth two times a day related to coronary artery disease discontinued on 7/9/24 at 2:30 PM. The MAR dated 9/2024 revealed an order for aspirin 81 mg by mouth every morning.
During an interview 10/3/24 at 8:35 AM, Staff C, MDS Coordinator, reported she obtained information from the resident's record, interviewed the resident and family, and also gathered information about the resident while she provided cares in order to complete and update the resident's Care Plans. Staff C reported Resident #4 no longer took Apixaban. The medication was discontinued on 7/9/24.
The RAI Manual Version 3.0 revealed MDS assessment section N0410E marked when a resident took an anticoagulant such as warfarin, heparin, or a low- molecular weight heparin. Record the number of days the resident received an anticoagulant medication during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview, and policy review the facility failed to develop and implement a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview, and policy review the facility failed to develop and implement a comprehensive person-centered Care Plan for one of sixteen residents sampled (Residents #54). The facility reported a census of 62 residents.
Findings include:
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 admitted to the facility on [DATE] and had diagnoses of cancer and a pleural effusion. The assessment documented the resident took an antibiotic during the 7-day assessment look-back period and received IV (intravenous) (into a vein) medications during the 14-day look-back period.
The Care Plan initiated on 9/3/24 and revised on 9/30/24 revealed Resident #54 on IV antibiotic therapy. The Care Plan directed staff to administer antibiotic medications as ordered by the physician, and monitor for the effectiveness and side effects of the medication. The Care Plan lacked information about the resident's PICC (peripherally inserted central catheter) line or Mediport (port) (an implanted device that provides access to a vein for delivering medications and fluids), as well as the interventions to monitor and manage these devices.
The Order Summary Report revealed PICC and port dressing change every 7 days and PRN (as needed) started on 9/3/24.
Resident #54's Medication Administration Record (MAR) for October 2024 documented orders for cefazolin 15 milligrams (mg) IV in the morning, for a port infection, had a start date 9/4/24 at 6:00 AM. The MAR also instructed to administer cefazolin 2 grams (gm) IV twice a day for MSSA (methicillin-susceptible staphylococcus aureus) (a bacterial infection) started on 9/3/24 at 9:00 PM.
The Skilled Nursing assessment dated [DATE] revealed the resident had a diagnosis of multiple myeloma and took chemotherapy. The assessment documented the resident received IV antibiotic medications, and had a PICC line and an implanted port.
The Progress Notes dated 9/7/24 at 9:36 AM revealed the resident had a chest port to the right chest and a PICC line to his left upper arm.
During observation on 9/30/24 at 2:11 PM, Resident # 54 had a PICC line in his left arm and a port to his right chest.
During an interview 10/3/24 at 8:35 AM, Staff C, MDS Coordinator, reported she obtained information from the resident's record, interviewed the resident and the family member(s), and also gathered information about the resident while she provided cares in order to complete and update the resident Care Plans. Staff C reported the resident's Care Plan developed at admission and updated any time a resident had a change in status. Staff C reported the PICC line and Mediport should be listed on the Care Plan if a resident had these medical devices.
During an interview 10/3/24 at 9:02 AM, the Director of Nursing (DON) reported the resident's Care Plan updated whenever needed, and Care Plans reviewed during the resident's care conferences. An interdisciplinary team reviewed the Care Plans.
A Comprehensive Person-Centered Care Plan policy revised 3/2022 revealed a comprehensive care plan developed for each resident. The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment. The care plan included measurable objectives and time-frames and described the services furnished to attain or maintain the resident's highest practicable physical and psychosocial well-being.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interview, and policy review the facility failed to check and verify placem...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interview, and policy review the facility failed to check and verify placement of a gastrostomy tube (g-tube) before medications and enteral feeding administered through the gastrostomy tube for one of one residents reviewed with a gastrostomy tube (Resident #117). Facility staff also failed to flush the gastrostomy tube with water after each medication administered. The facility reported a census of 62 residents.
Findings include:
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 had diagnoses of sepsis due to e-coli (bacteria), gastroesophageal reflux disease (GERD), diabetes, and dysphagia. The MDS revealed the resident had coughing and choking during meals or when she swallowed medications, and had a tube feeding.
The Care Plan initiated 9/19/24 revealed the resident required tube feedings. The Care Plan directed staff to check tube placement, check gastric contents/residual volume before each feeding started and hold the feeding per the physician's orders depending upon the amount of aspirate.
The Order Summary Report dated 10/2024 revealed an order to crush medications as needed unless contraindicated but lacked directives for checking g-tube placement or residual.
During observation on 10/2/24 at 7:25 AM, Staff A, Licensed Practical Nurse (LPN) prepared medications for Resident #117.
Staff A crushed each medication in a clear plastic envelope then took the medications to the resident's room.
The medications included the following:
1. Diltiazem 60 milligrams (mg)
2. Aspirin 81 mg
3. Levothyroxine 100 micrograms (mcg)
4. Vitamin D3 5000 units
5. Vitamin B12 1000 mcg
6. Pregabalin 200 mg
7. Metformin 500 mg
8. Biotin 10000 mcg
9. Azithromycin 250 mg
10. Culturelle 1 package
Staff A donned gloves, obtained a glass of tap water and placed the glass on an over-bed table.
Staff A poured 300 milliliters (ml) of Glucerna 1.2 calories into a graduate container and placed the container on an over-bed table.
Staff A connected a syringe to the resident's g-tube and administered 60 ml of water. Staff A poured an envelope of crushed medication into a small plastic cup, added 10 ml water, and used the tip of the syringe to stir the medication and water. Staff A drew the medication solution into the syringe, attached the syringe to the g-tube, and administered the medication. Staff A continued to repeat the process of placing crushed medication into a plastic cup, adding water to the cup, stirring the medication, and administered each medication individually until all medications were administered.
On 10/2/24 at 7:52 AM, Staff A rinsed the syringe and plastic cup with water in the bathroom. Staff A changed her gloves, then connected the syringe to the resident's g-tube, poured 60 ml of water into the syringe, then poured Glucerna formula into the syringe. Staff A allowed the contents to gravity flow until all of formula instilled. Staff A then poured 60 ml of water into the syringe, removed the syringe, and plugged the g-tube port. Staff A removed her gloves and washed her hands.
Staff A did not check placement of the g-tube prior to administering medications, water flushes, and tube feeding through the g-tube. Staff A also did not administer a water flush between each medication administered.
During an interview 10/3/24 at 8:35 AM, Staff C, MDS Coordinator, reported placement of a g-tube checked prior to administration of medication and tube feedings. Staff C reported a stethoscope used to listen over the gastric area to hear air as it is pushed through the syringe to verify g-tube placement. Staff C stated a syringe attached to the g-tube and the handle of the syringe pulled back to check for residual or gastric contents. Staff C reported the g-tube should be flushed with 15 ml of water between each medication administered through a g-tube.
During an interview 10/3/24 at 9:02 AM, the Director of Nursing (DON) reported he expected a g-tube be checked for placement by listening with a stethoscope prior to administration of medications or tube feedings. The g-tube residual checked per physician's orders. The DON reported he expected g-tube medications be administered separately unless they had a physician's order to mix (cocktail) the medications. The DON stated a 15 ml water flush should be administered between each g-tube medication.
An Administering Medications through an Enteral Tube policy dated 2001 revealed guidelines for safe administration of medications through an enteral tube. Each medication administered separately and g-tube flushed between medications. Use warm, purified water for diluting medications and for flushing the g-tube. The procedural steps included:
a. Wash hands
b. Prepare the medications
c. Verify placement of feeding tube
d. Flush tubing with at least 15 ml warm water
e. Dilute the medication with at least 30 ml of water
f. Administer each medication separately
g. Flush with 15 ml warm water between medications if administering more than one medication.
h. Flush the g-tube with 15 ml of water after the last medication administered
i. Clamp the g-tube
j. Administer the feeding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to provide assessments and timely intervention regarding skin conditions and wound...
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Based on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to provide assessments and timely intervention regarding skin conditions and wounds for one of sixteen residents observed (Resident #15). The facility reported a census of 62 residents.
Findings include:
The quarterly Minimum Data Sample (MDS) for Resident #15, dated 09/06/2024, which documented relevant diagnoses of cancer, heart failure, diabetes mellitus (diabetes), cerebrovascular event, Non-Alzheimer's dementia, traumatic brain injury, anxiety disorder, and depression. It documented her brief interview for mental status (BIMS) score as 12, indicating moderate cognitive impairment.
The Care Plan, last revised 06/17/2024, revealed staff were to check all of the body for breaks in skin and treat promptly as ordered by doctor. It also revealed staff were to monitor and document any signs and symptoms of hyperglycemia, such as dry skin.
A direct observation on 09/30/2024 at 03:09 PM revealed Resident #15 had a red lesion with a dark colored scab in the center on her right cheek bone. Resident #15 was observed picking at the wound at this time.
A direct observation on 10/01/2024 at 12:11 PM revealed the wound had gotten visibly darker.
In an interview on 10/01/2024 at 02:51 PM with Staff D, Registered Nurse, stated she had been aware of the wound for a little over a week. She believed it had been documented either through a nursing Progress Note or placed on a skin assessment sheet in the skin assessment chart, located on the unit. Staff brought the book to this surveyor and could not find a skin assessment had been performed. Staff then stated she must have forgotten. She stated the medical director had not been made aware of this wound yet.
Review of nursing Progress Notes failed to document a skin assessment for this wound.
In an interview on 10/02/2024 at 09:33 AM with Staff E, Unit Manager, stated the skin issue was a recurrent patch of dry skin on Resident #15's face. She acknowledged the skin assessment had not been performed, and stated her expectation is for staff to fill out a skin assessment sheet when they notice a new or reopened wound and to place a note in the electronic health record (EHR) for tracking.
Review of a facility provided document titled Resident Assessments, last revised in March of 2022, documented all staff members are to participate in resident assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, and policy review, the facility failed to follow enhanced barri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, and policy review, the facility failed to follow enhanced barrier precautions (EBP) practices for residents with indwelling medical devices for two of three residents reviewed for infection control (Resident #54 and Resident #117). The facility also failed to ensure infection control policy & procedure manual updated on an annual basis. The facility reported a census of 62 residents.
Findings include:
1. Infection control manual review completed on 10/3/24 at 8:30 AM. The manual did not include a cover page to indicate the enclosed policies and procedures had been reviewed and approved annually.
An interview on 10/3/24 at 8:45 AM, the Director of Nursing (DON) reported policies and procedures are approved annually during the facility's January Quality Assurance and Performance Improvement (QAPI) meeting. The DON provided a copy of January's QAPI sign-in sheet as well as a copy of a Record of Adoption form, which was not completely filled out. The form provided no information as to what policies or procedures were approved, did not have the medical director signature, nor did it indicate a date of approval. The DON reported that January 2024 QAPI meeting minutes did not reflect approval of the infection control manual. All that was attached to the meeting minutes was the incomplete Record of Adoption form.
The undated policy Facility Policies and Procedures-Annual Review stated policies and procedures are reviewed and revised by the Quality Assurance and Assessment Committee:
a. When changes in regulations or professional standards of practice necessitate revisions.
b. When additional procedures are needed according to the facility assessment and/or individual resident needs.
c. At least annually.
The policy further stated administrators, the medical director, and department leaders are sent draft revisions with an opportunity to review and respond to changes. Final revisions are posted for staff with a summary of changes and effective date.
2. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 had a diagnosis of sepsis due to e-coli (bacteria). The MDS revealed the resident had a tube feeding.
The Care Plan initiated 9/19/24 revealed the resident required tube feedings. The Care Plan lacked directives for staff to use enhanced barrier precautions (EBP).
During observation on 10/2/24 at 7:25 AM, Staff A, Licensed Practical Nurse (LPN) prepared and administered medications and enteral feeding through Resident #117's gastrostomy tube (g-tube) (a tube in the stomach). Staff donned gloves and placed supplies and medications on an over-bed table without a barrier. Staff A did not wear a gown during the procedure when she handled the g-tube and when she administered medications and tube feeding through the g-tube.
During an interview 10/3/24 at 8:35 AM, Staff C, MDS Coordinator, reported EBP's still a new process. EBP's entailed wearing a gown and gloves whenever she touched or worked with a resident with a catheter, g-tube, or open wounds.
During an interview 10/3/24 at 9:02 AM, the Director of Nursing (DON) reported the facility didn't have a policy for EBP's, he expected staff to follow the CDC guidelines. EBP's should be used whenever a resident had a wound, catheter, and any medical devices such as a catheter, g-tube, or PICC line.
A Personal Protective Equipment (PPE) policy revised 10/2018 revealed PPE provided for personnel who perform tasks that may involve exposure to blood or body fluids. PPE included wearing a gown and gloves. The type of PPE required for a task was based on the risk of an exposure.
The Center for Disease Control (CDC) guidelines for Enhanced Barrier Precautions in Nursing Homes
(https://www.cdc.gov/long-term-care-facilities/media/pdfs/Letter-Nursing-Home-Staff-508.pdf)
revealed the CDC recommends EBP to prevent the spread of multi-drug-resistant organisms (MDROs) in healthcare settings. EBP guidelines include a gown and gloves worn during high-contact care activities with residents who are at higher risk of acquiring or spreading an MDRO. EBP used when cared for a resident with an indwelling medical device.
3. The MDS assessment dated [DATE] revealed Resident #54 had a diagnosis of cancer. The MDS indicated the resident took an antibiotic and had an IV access.
The Care Plan initiated 9/3/24 and revised on 9/30/24 revealed the resident on antibiotic therapy. The Care Plan directed staff to administer medication and monitor the IV site for signs of redness, warmth, drainage or swelling. The Care Plan lacked information about the resident's peripherally inserted central catheter (PICC) line and Mediport (port), and the need to use EBP.
During observations on 10/1/24 at 8:08 AM, Staff B, LPN, accessed and flushed Resident #54's PICC line with normal saline, and initiated an IV cefazolin (antibiotic) infusion through the resident's PICC line. At 8:20 AM, Staff B, flushed the resident's port with normal saline, then administered cefazolin into the port. At 8:53 AM, Staff B checked the IV cefazolin infusion and pump and reported the infusion completed. Staff B donned a pair of gloves, removed the IV tubing from the PICC line, cleansed the end of the PICC line with an alcohol swab, and flushed the PICC line with normal saline. Staff B cleansed the PICC line with an alcohol swab, and attached a new cap on the PICC line. Staff B removed her gloves and washed her hands. Staff B did not wear a gown during the procedure while she handled and cared for the PICC line and port.
During an interview 10/3/24 at 9:02 AM, the Director of Nursing (DON) reported the facility didn't have a policy for EBP's, he expected staff to follow the CDC guidelines. EBP's should be used whenever a resident had a wound, catheter, and any medical devices such as a catheter, g-tube, or PICC line.
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility policy review, and the Resident Assessment Instrument (RAI) Manual, a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, facility policy review, and the Resident Assessment Instrument (RAI) Manual, and policy review, the facility failed to complete and transmit a resident Minimum Data Set assessment upon a resident's discharge within the required timeframe for one of sixteen residents reviewed (Resident #58). The facility reported a census of 62 residents.
Findings include:
The Minimum Data Set (MDS) assessment tool dated 5/12/24 revealed the Director of Nursing (DON) signed the assessment as completed on 5/15/24.
The MDS assessment dated [DATE], revealed Resident #58 admitted to the facility on [DATE], and discharged from the facility on 5/22/24. The MDS assessment revealed the DON signed the assessment as completed on 6/2/24.
The Electronic Health Record (EHR) software program revealed the 5-day MDS assessment completed on 5/15/24 but not submitted to CMS (Center for Medicare Services). The EHR also revealed the discharge return not anticipated MDS assessment dated [DATE] was completed on 6/2/24 but not submitted to CMS.
During an interview 10/3/24 at 8:35 AM, Staff C, MDS Coordinator, reported she had worked at the facility in the MDS Coordinator role since 3/2024. Staff C reported the MDS assessments completed on each resident at least every 90 days. She obtained information from the resident's record, interviewed the resident and family, and also gathered information about the resident while she provided cares in order to completed the MDS assessments. Staff C reported she submitted the MDS assessment to CMS once all of the MDS sections were completed. Staff C reported Resident #58's discharge MDS not submitted when the discharge MDS assessment was completed because he had a private insurance plan. He did not have a Medicare Part A policy, so the MDS assessment did not need to be submitted. Staff C reported Resident #58's admission MDS assessment was submitted to CMS for tracking purposes only.
A Resident Assessments policy revised 3/2022 revealed assessments completed at intervals designated by OBRA (Omnibus Budget Reconciliation Act) (the Nursing Home Reform Act) and PPS (Prospective Payment System) requirements. The resident assessment coordinator ensured resident assessments completed timely. OBRA required discharge assessment completed for all residents including discharge return anticipated and return not anticipated.
The RAI Manual Version 3.0 revealed the discharge return not anticipated MDS assessment must be completed when the resident discharged from the facility and the resident not expected to return to the facility within 30 days. The discharge return not anticipated MDS must be completed within 14 days after the discharge date , and submitted within 14 days after the MDS completion date.
Aug 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on clinical record review, facility document review, and staff interview, the facility failed to treat a resident with respect and dignity when providing cares one of three residents reviewed fo...
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Based on clinical record review, facility document review, and staff interview, the facility failed to treat a resident with respect and dignity when providing cares one of three residents reviewed for dignity (Resident # 9). The facility reported a census of 61 residents.
Findings include:
A Quarterly Minimum Data Set (MDS) Assessment documented Resident#9 had the diagnoses including non- traumatic brain dysfunction, dementia, high blood pressure, and stroke. The Brief Interview for Mental Status (BIMS) documented the resident scored a 3 out of 15, which indicated severe cognitive loss for daily decision making skills. The MDS revealed the resident required maximum assist of two staff members for transfers from surface to surface, and total dependence for cares including toileting, and showers. The MDS indicated that the resident used a manual wheelchair for moving about the facility with total dependence of staff.
A facility Self Report dated 8/5/24 revealed Staff A, Certified Nurse Aide (CNA) reported an allegation that Staff B, Certified Medication Aide (CMA), while assisting a resident who became verbally aggressive and combative with cares, attempted to place a glove in the resident's mouth. The self report additionally documented Resident #9 stated he wished he wasn't in the facility and Staff B responded to the resident in an unkind and demeaning manner.
On 8/6/24 at 12:53 pm, Staff A, CNA stated she was in the room of Resident #7, which he shares with his spouse, on the evening of 8/4/24 with Staff B, CMA. She stated both residents have behaviors. She explained she and Staff B were getting both residents ready to go to dinner and Resident #7 was speaking about not wanting to live in the nursing facility. She reported Staff B replied to Resident #7 that his children don't care about him and that is why he lived there. She stated Staff B needed to change the resident's soiled clothing and after she was through, Staff B removed her soiled gloves and balled the gloves up into her hand and put them towards the mouth of Resident #7 while telling him to Shut up. She stated Resident #7 closed his lips. She stated she could not say if Staff B was trying to put the gloves in the resident's mouth but they were near his mouth. Staff A stated the rest of the shift was busy and the incident slipped her mind and she did not report this until the following day. She stated she reported it to Staff C, Licensed Practical Nurse (LPN) the morning of 8/5/24.
On 8/6/24 at 3:52 pm, Staff C, LPN stated Staff A reported her concerns regarding Staff B and Resident #7 to her, stating Staff B was being aggressive and mean to the resident. She stated she immediately called the manager on duty for the facility and reported this to her.
The facility provided an educational memo to all staff on 8/6/24. The memo included direction to staff as follows;
a. Emotional Abuse defined as verbal or non-verbal behavior that causes psychological harm.
b. Reports should be made even if you are unsure about the validity of the suspicion, it is better to report and let authorities investigate.
All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative.
The facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, revision date July 2019, documented the following:
Key Definitions:
Personal degradation of a dependent adult. Personal degradation means a willful act or statement by a caretaker intended to shame, degrade, humiliate, or otherwise harm the personal dignity of a dependent adult, or where the caretaker knew or reasonably should have known the act or statement would cause shame, degradation, humiliation, or harm to the personal dignity of a reasonable person. Personal degradation includes the taking, transmission, or display of an electronic image of a dependent adult by a caretaker, where the caretaker ' s actions constitute a willful act or statement intended to shame, degrade, humiliate, or otherwise harm the personal dignity of the dependent adult, or where the caretaker knew or reasonably should have known the act would cause shame, degradation, humiliation, or harm to the personal dignity of a reasonable person
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on clinical record review, pharmacy & hospital record review, and staff interview, the facility failed to notify the physician when medication was unavailable and was not administered for 1 of 3...
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Based on clinical record review, pharmacy & hospital record review, and staff interview, the facility failed to notify the physician when medication was unavailable and was not administered for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 61.
Findings include:
The Medical Diagnosis section of Resident #3 Electronic Health Record (EHR) reflected a diagnosis of Permanent Atrial Fibrillation (a condition where an irregular heartbeat can't be reset and no further treatments are attempted to restore a normal sinus rhythm).
The admission Orders to the facility from the hospital, dated 3/20/24 reflected the resident had orders for:
-Warfarin (a blood thinning medicine, used to treat and prevent blood clots, which can be caused by Atrial Fibrillation), 2.5 mg tablet, take 2 tablets each Monday.
-Warfarin, 2.5 mg tablet, take 1 tablet each Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday.
The Coumadin Flow Sheet for Resident#3 documented as follows;
The INR (international normalized ratio, a blood test to time how long it takes blood to clot) Result Report dated 3/21/24 documented an INR of 1.8. The physician responded to change the Warfarin orders to:
- Warfarin, 2.5 mg tablet, take 2 tablets each Monday and Friday.
- Warfarin, 2.5 mg tablet, take 1 tablet each Tuesday, Wednesday, Thursday, Saturday and Sunday.
The Medication Administration Record (MAR) of Resident #3, for March of 2024 reflected that the resident did not begin receiving Warfarin until the 21st of March rather than the 20th as ordered. Additionally, on March 23rd and 24th, the Warfarin was documented as not given and linked to a progress note.
The Progress Notes failed to reveal any documentation of the physician being notified on any of the dates of the resident not receiving her ordered Coumadin. The Progress Notes for March 23 and 24th reflected the medication to be on order from the pharmacy.
On 8/7/24 at 1:36 pm, the Director of Nursing (DON) stated Warfarin is not a medication that is stocked in the Emergency Kit of medications at the facility.
On 8/7/24 at 3:56 pm, the DON stated his expectation is for the physician to be notified when a medication is not administered as ordered. He stated the facility has no policy regarding physician notification.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on clinical record review, facility document review, and staff interview, the facility failed to report suspected dependent adult abuse within the required two hour time frame for one resident (...
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Based on clinical record review, facility document review, and staff interview, the facility failed to report suspected dependent adult abuse within the required two hour time frame for one resident (Resident # 9). The facility reported a census of 61 residents.
Findings include:
A Quarterly Minimum Data Set (MDS) Assessment documented Resident#9 had the diagnoses including non- traumatic brain dysfunction, dementia, high blood pressure, and stroke. The Brief Interview for Mental Status (BIMS) documented the resident scored a 3 out of 15, which indicated severe cognitive loss for daily decision making skills. The MDS revealed the resident required maximum assist of two staff members for transfers from surface to surface, and total dependence for cares including toileting, and showers. The MDS indicated that the resident used a manual wheelchair for moving about the facility with total dependence of staff.
A facility Self Report dated 8/5/24 revealed Staff A, Certified Nurse Aide (CNA) reported an allegation that Staff B, Certified Medication Aide (CMA), while assisting a resident who became verbally aggressive and combative with cares, attempted to place a glove in the resident's mouth. The self report additionally documented Resident #9 stated he wished he wasn't in the facility and Staff B responded to the resident in an unkind and demeaning manner.
The Self Report noted the approximate date and time of the occurrence was 8/3/24 at 5:00 pm.
The Amendment Details of the report documented the report was initially filed on Sunday, 8/4/24 but was filed in error regarding the Assisted Living portion of the facility. That was closed out and refiled on Monday 8/5/24 correctly for the nursing facility.
On 8/6/24 at 11:25 am the Administrator stated the incident happened on Saturday 8/3/24. The report was initially filed with the State Agency on Sunday 8/4/24 and amended on Monday 8/5/24. She stated Staff B, CMA was suspended immediately upon notification of the incident. She stated Staff B had been employed at the facility since mid June, 2024 and had no disciplinary action prior to this incident. The Administrator stated Staff A, CNA had been employed since 7/16/24 but had been a CNA since November of 2023. She stated education was given to Staff A of the need to report abuse concerns immediately.
On 8/6/24 at 12:53 pm, Staff A, CNA stated she was in the room of Resident #7, which he shares with his spouse, on the evening of 8/4/24 with Staff B, CMA. She stated both residents have behaviors. She explained she and Staff B were getting both residents ready to go to dinner and Resident #7 was speaking about not wanting to live in the nursing facility. She reported Staff B replied to Resident #7 that his children don't care about him and that is why he lived there. She stated Staff B needed to change the resident's soiled clothing and after she was through, Staff B removed her soiled gloves and balled the gloves up into her hand and put them towards the mouth of Resident #7 while telling him to Shut up. She stated Resident #7 closed his lips. She stated she could not say if Staff B was trying to put the gloves in the resident's mouth but they were near his mouth. Staff A stated the rest of the shift was busy and the incident slipped her mind and she did not report this until the following day. She stated she reported it to Staff C, Licensed Practical Nurse (LPN) the morning of 8/5/24.
On 8/6/24 at 3:52 pm, Staff C, LPN stated Staff A reported her concerns regarding Staff B and Resident #7 to her, stating Staff B was being aggressive and mean to the resident. She stated she immediately called the manager on duty for the facility and reported this to her.
The facility provided an educational memo to all staff on 8/6/24 with the definition of abuse and neglect and the need for immediate reporting of any such instances. The memo directed staff as follows;
All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative.
The facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, revision date July 2019, documented the following:
Reporting -
All allegations of Resident abuse shall be reported to the Iowa Department of Inspections and Appeals not later than two (2) hours after the allegation is made.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on clinical record review, pharmacy & hospital record review, staff interview, and facility policy review, the facility failed to transcribe and administer medication as ordered by the physician...
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Based on clinical record review, pharmacy & hospital record review, staff interview, and facility policy review, the facility failed to transcribe and administer medication as ordered by the physician for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 61.
Findings include:
The Medical Diagnosis section of Resident #3 Electronic Health Record (EHR) reflected a diagnosis of Permanent Atrial Fibrillation (a condition where an irregular heartbeat can't be reset and no further treatments are attempted to restore a normal sinus rhythm).
The Pharmacy Warfarin Consult, dated 3/19/24 documented the INR (international normalized ratio, a blood test to time how long it takes blood to clot) Goal to be 2-3.
The admission Orders to the facility from the hospital, dated 3/20/24 reflected the resident had orders for:
-Warfarin (a blood thinning medicine, used to treat and prevent blood clots, which can be caused by Atrial Fibrillation), 2.5 mg tablet, take 2 tablets each Monday.
-Warfarin, 2.5 mg tablet, take 1 tablet each Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday.
The INR Result Report dated 3/21/24 documented an INR of 1.8. The physician responded to change the Warfarin orders to:
- Warfarin, 2.5 mg tablet, take 2 tablets each Monday and Friday.
- Warfarin, 2.5 mg tablet, take 1 tablet each Tuesday, Wednesday, Thursday, Saturday and Sunday.
The Medication Administration Record (MAR) of Resident #3, for March of 2024 reflected that the orders from the hospital were originally transcribed correctly, but never administered. The order was changed on 3/21/24 to reflect:
- Warfarin, 2.5 mg tablet, take 2 tablets each Monday and Friday.
- Warfarin, 1 mg tablet, take 1 tablet each Tuesday, Wednesday, Thursday, Saturday and Sunday. This dose was a decrease of 1.5 mg each day from what the physician ordered.
The Coumadin Flow Sheet reflected an INR test result of 1.6 on the following test on 3/28/24, a decrease from 3/21/24 testing.
On 8/7/24 at 3:56 pm, the Director of Nursing (DON) stated the order was transcribed incorrectly into the EHR and there was no order for a 1 mg dose of Warfarin.
The Medication and Treatment Orders Policy, dated 2001, documented a Policy Statement of Orders for medications and treatments will be consistent with principles of safe and effective order writing.
Jul 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility policy review, the facility failed to notify the Long Term Care Om...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility policy review, the facility failed to notify the Long Term Care Ombudsman for 1 of 1 residents who transferred to the hospital (Resident #56). The facility reported a census of 67 residents.
Findings include:
The Minimum Data Set (MDS) dated [DATE] for Resident #56 documented diagnoses of fractures and other multiple trauma, hip fracture, Alzheimer's disease, non-Alzheimer's disease and anxiety disorder. The MDS documented a Brief Interview for Mental Status (BIMS) should not be conducted as the resident was rarely/never understood.
Review of MDS dated [DATE] documented Resident #56 was discharged to an acute hospital with return anticipated, unplanned. Review of MDS dated [DATE] documented Resident #56 had a re-entry to the facility 5/5/23.
Review of Progress Notes for Resident #56 revealed the resident transferred to the hospital on 4/30/23 and returned to the facility 5/5/23.
In an interview 7/20/23 at 8:30 AM, the Director of Nursing (DON) confirmed the facility did not notify the Ombudsman of the transfer to the hospital for Resident #56.
Review of undated facility form titled, Guidelines for Ombudsman Notification, directed staff to notify the State Ombudsman of all discharges for the previous month.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, direction from the Resident Assessment Instrument, and facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, direction from the Resident Assessment Instrument, and facility policy review, the facility failed to ensure each resident received an accurate Minimum Data Set (MDS) assessment, reflective of the resident's status at the time of the assessment for 1 of 17 residents reviewed for accuracy of assessment (Resident #16).
Findings include:
The Significant Change MDS dated [DATE] identified Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS documented the resident had a psychotic disorder. The MDS failed to document the resident received any antipsychotic medication during the 7 day look back period.
The Medicare 5 day MDS dated [DATE] failed to document the resident received any antipsychotic medication during the 7 day look back period.
The Discharge MDS dated [DATE] failed to document the resident received any antipsychotic medication during the 7 day look back period.
The Annual MDS dated [DATE] failed to document the resident received any antipsychotic medication during the 7 day look back period.
The Comprehensive Care Plan, review date of 7/7/23 failed to reveal documentation the resident had a diagnosis of a psychotic disorder. The Care Plan also failed to reveal documentation of the resident taking an antipsychotic medication.
The Medication Administration Records for May and June 2023 documented Resident #16 received Nuplazid every day.
On 7/17/23 at 11:34 am, Resident #16 stated she suffers hallucinations. She stated she wished the facility had not labeled her as being psychotic but stated it was because of the medication for the hallucinations.
On 7/19/23 at 2:26 pm, the MDS Coordinator stated it was an error that the Nuplazid was not documented on the MDS as an antipsychotic. She reviewed the orders and the Medication Administration Record (MAR) for Resident #16 and stated 4/20/23 was the start date for the Nuplazid order and 4/26/23 was the first date the resident received the medication.
The MDS 3.0 RAI (Resident Assessment Instrument) Manual v 1.17.1_October 2019, N-6 directed to record the number of days an antipsychotic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).
The policy Certifying Accuracy of the Resident Assessment, revision date December 2009, documented
•
All personnel who complete any portion of the MDS assessment, tracking form, or correction request form must sign a hard copy of such assessment certifying the accuracy of that portion of that assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS for Resident #16 dated 6/6/23 identified Resident #16 had a BIMS score of 15 out of 15 which indicated cognition inta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS for Resident #16 dated 6/6/23 identified Resident #16 had a BIMS score of 15 out of 15 which indicated cognition intact. The MDS documented the resident had a psychotic disorder.
The Comprehensive Care Plan, review date of 7/7/23 failed to reveal documentation the resident had a diagnosis of a psychotic disorder. The Care Plan also failed to reveal documentation of the resident taking an antipsychotic medication.
The Pre admission Screening Resident and Resident Review (PASRR) for Resident #16 dated 8/9/22 documented the resident had diagnoses of Major Depression, Anxiety, and Adjustment Disorder with Anxiety. The PASRR documented the resident had psychotropic medications of Duloxetine 60 milligrams (mg) a day (anti depressant medication) and lorazepam 0.5 mg a day (anti anxiety medication).
The Active Diagnosis List of Resident #16 documented the diagnoses of psychotic disorder with hallucinations due to known physiological condition was added to the resident record on 2/7/23.
The Active Orders for Resident #16 documented the resident received a new order for Nuplazid (an antipsychotic medication) on 4/19/23.
The Medication Administration Record (MAR) for April of 2023 documented the first dose of Nuplazid received was 4/26/23.
On 7/20/23 at 3:46 pm, the Administrator stated a new PASRR was not submitted for Resident #16 when she received the new diagnosis of psychotic disorder or when the antipsychotic medication order was received.
The Policy titled Behavioral Assessment, Intervention and Monitoring, revision date March 2019 documented new onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR Level II evaluation.
Based on clinical record review, staff interview and facility policy review, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 2 of 2 residents reviewed with a new mental health diagnosis (Residents #16 and #42). The facility reported a census of 67 residents.
Findings include:
1. The Minimum Data Set (MDS) dated [DATE] documented Resident #42 had a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating severely impaired cognition. The MDS further documented the resident had diagnoses including depression, anxiety and psychotic disorder.
The Care Plan for Resident #42 initiated 9/3/22 documented the resident had a diagnosis of depression. The Care Plan directed staff to administer antidepressant medications as ordered, monitor for side effects and monitor/document/report signs and symptoms of depression.
Clinical record review revealed Resident #42 had diagnoses of major depressive disorder effective 12/8/22. The clinical record further revealed the resident did not have a Level 2 PASRR evaluation submitted following the major depressive disorder diagnoses.
Review of the July 2023 Medication Administration Record (MAR) for Resident #42 revealed she received sertraline (antidepressant) daily effective 5/5/23 for major depressive disorder.
During an interview 7/19/23 at 3:46 PM, the Administrator revealed a Level II PASRR evaluation had not been submitted as expected for Resident #42 regarding her diagnoses of major depressive disorder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to update the Co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to update the Comprehensive Care Plan care for 1 of 17 (Resident #16) residents reviewed for care plan completion and revision.
Findings include
The Significant Change MDS dated [DATE] identified Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated cognition intact. The MDS documented the resident had a psychotic disorder.
The Comprehensive Care Plan, review date of 7/7/23 failed to reveal documentation the resident had a diagnosis of a psychotic disorder. The Care Plan also failed to reveal documentation of the resident taking an antipsychotic medication. The Care Plan documented the resident receives an anti anxiety medication.
The Active Diagnosis List of Resident #16 documented the diagnosis of psychotic disorder with hallucinations due to known physiological condition was added to the Resident Record on 2/7/23.
The Active Orders for Resident #16 documented the resident received a new order for Nuplazid (an antipsychotic medication) on 4/19/23. The Active Orders failed to document the resident takes an anti anxiety medication.
On 7/17/23 at 11:34 am, Resident #16 stated she suffers hallucinations. She stated she wished the facility had not labeled her as being psychotic but stated it was because of the medication for the hallucinations.
On 7/19/23 at 2:26 pm, the MDS Coordinator stated Resident #16 currently receives an antidepressant and an antipsychotic and does not take an antianxiety medication. She confirmed she signed the Care Plan Review as being completed on 7/7/23. She further stated this was the date she began the care plan review and was not complete on that date.
The policy Care Plans, Comprehensive, Person Centered, revision date of March 2022 documented
•
Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview and manufacturer's recommendation, the facility failed to administ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview and manufacturer's recommendation, the facility failed to administer insulin according to accepted standards of clinical practice for 1 of 2 residents reviewed for administration of insulin (Resident #37). The facility reported a census of 67 residents.
Findings include:
The Minimum Data Set (MDS) dated [DATE] documented Resident #37 had a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating severely impaired cognition. The MDS documented the resident had diagnoses including diabetes mellitus (DM), non-Alzheimer's dementia and cerebrovascular accident (CVA) and received insulin injections 7 out of the past 7 days.
The Care Plan revised 12/22/22 for Resident #37 revealed the resident had DM and was dependent on insulin and diabetes medication to manage it. The Care Plan directed staff to administer diabetes medication as ordered by the physician and to educate the resident and family the correct protocol for insulin injections.
Review of Resident #37's July 2023 Medication Administration Record (MAR) revealed the following order:
a. Lantus solution 100 unit/milliliter (ML) inject 35 units subcutaneously one time a day related to type 2 diabetes with hyperglycemia initiated 9/15/22.
Review of facility policy titled, Administering Medications, revised April 2019 revealed medications are administered in accordance with prescribers' orders.
Observation 7/19/23 at 8:21 AM, revealed Staff A, Licensed Practical Nurse (LPN) administered Resident #37, 35 units Lantus insulin using a Lantus single patient use prefilled pen. After administration, Staff A held the insulin pen in place in the skin for approximately 3 seconds. Following removal of the insulin pen, Staff A revealed the insulin pen was to stay in place 10-15 seconds following administration.
Review of the manufacturer's recommendation for the Lantus single patient use prefilled pen revealed following administering the insulin dose, slowly count to 10 before you withdraw the needle from the skin as this ensures the full dose of insulin will be delivered.
During an interview 7/19/23 at 9:33 AM, the Director of Nursing revealed it is an expectation the insulin pen be held in place as documented in the manufacture's recommendation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on clinical record review, observations, staff interviews and policy review, the facility failed to provide 1 resident (Resident #8) with sufficient fluid intake. The facility reported a census ...
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Based on clinical record review, observations, staff interviews and policy review, the facility failed to provide 1 resident (Resident #8) with sufficient fluid intake. The facility reported a census of 67 residents.
Findings include:
The Minimum Data Set (MDS) assessment of Resident #8 dated 5/26/23 reflected the resident had highly impaired vision. The MDS identified a Brief Interview of Mental Status (BIMS) score of 1 out of 15 which indicated severe cognitive impairment. The MDS coded the resident received hospice level of care services.
The Care Plan revised on 7/7/23 revealed Resident #8 to be legally blind. It directed staff to provide set up assistance for meals and to tell the resident where the items were at.
On 7/17/23 at 10:51 am observed Resident #8 resting in bed. No water observed anywhere in area of Resident #8's portion of the room.
On 7/18/23 at 10:00 am, observed Resident #8 again resting in bed with no water present.
On 7/19/23 at at 11:59, observed Resident #8 received her lunch tray with 3 drinks served to her on the tray.
On 7/19/23 at 3:13 pm, observed Resident #8 in her recliner in her room. No water seen in her portion of the room.
On 7/19/23 at 3:16 pm, Staff D, CNA stated fresh water is passed at the beginning of the 2:00 pm to 10:00 pm shift and again at bedtime and in between per resident request. She stated water had already been passed that shift. When asked why Resident #8 had no water in her room, she stated Resident #8 was asleep during water pass so she did not wake her up.
On 7/20/23 at 9:24 am, observed Resident #8 resting in bed with no water present.
On 7/20/23 at 9:29 am, the Assistant Director of Nursing stated her expectation is that all residents should have water available in their rooms at all times.
The facility policy Resident Hydration and Prevention of Dehydration, revision date December 2008 directed Nurse Aides will provide and encourage intake of bedside, snack and meal fluids on a daily and routine basis as a part of daily care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record and policy review the facility failed to answer call lights timely (wit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record and policy review the facility failed to answer call lights timely (within 15 minutes) for 3 of 5 residents reviewed (Resident #2, #31, and #68). The facility reported a census of 67 residents.
Findings include:
1.The Minimum Data Set (MDS) assessment for Resident #2, dated 6/6/23, identified the resident needed extensive assistance of 2 staff for bed mobility, transfers, dressing, and toilet use. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating mild cognitive impairment.
During an interview on 7/18/23 at 11:27 AM, Resident #2 stated it frequently takes more than 15 minutes for staff to answer her call light.
Review of facility document titled Ciscor OneSource, (facility call light log report) documented the following call light response times longer than 15 minutes from the time period of 7/3/23 - 7/18/23 for Resident #2:
a.7/4/23 5:16 AM - 36:18 minutes.
b. 7/6/23 4:19 PM - 31:57 minutes.
c. 7/11/23 3:49 AM - 34:21 minutes.
d. 7/12/23 4:31 PM - 36:54 minutes.
e. 7/15/23 9:43 AM - 33:34 minutes.
f. 7/16/23 1:40 PM - 27:43 minutes.
g. 7/18/23 5:33 AM - 34 minutes.
2.The MDS assessment for Resident #31, dated 5/19/23, identified the resident needed limited assistance of 1 staff for bed mobility, transfers, dressing, and extensive assist of 1 staff for toilet use. The MDS indicated the resident had a BIMS score of 12 out of 15, indicating mild cognitive impairment.
During an interview on 07/18/23 at 10:48 AM, Resident #31 stated it frequently takes more than 15 minutes for staff to answer the call light.
Review of facility document titled Ciscor OneSource, (facility call light log report) documented the following call light response times longer than 15 minutes from the time period of 7/3/23 - 7/18/23 for Resident #31:
a. 7/3/23 - 9:40 AM - 32:42 minutes.
b. 7/3/23 - 12:48 PM - 1 hour 5 minutes.
c. 7/3/23 - 8:28 PM - 35:53 minutes.
d. 7/3/23 - 9:20 PM - 23:44 minutes.
e. 7/4/23 - 4:46 AM - 21:39 minutes.
f. 7/7/23 - 9:48 AM - 24:58 minutes.
g. 7/8/23 - 9:30 AM - 42:15 minutes.
h. 7/8/23 - 8:01 PM - 22:44 minutes.
i. 7/9/23 - 4:43 AM - 24:31 minutes.
j. 7/9/23 - 7:37 AM - 21:20 minutes.
k. 7/9/23 - 1:14 PM - 37:16 minutes.
l. 7/10/23 - 8:42 AM - 27:03 minutes.
m. 7/12/23 - 4:33 AM - 23:14 minutes.
n. 7/12/23 - 7:09 AM - 21:49 minutes.
o. 7/12/23 -4:33 PM - 32:18 minutes.
p. 7/12/23 - 5:43 PM - 22:09 minutes.
q. 7/12/23 - 6:41 PM - 30:35 minutes.
r. 7/15/23 - 4:07 AM - 22:12 minutes.
s. 7/15/23 - 5:10 AM - 49:32 minutes.
t. 7/15/23 - 7:39 AM - 37:50 minutes.
u. 7/15/23 - 12:48 PM - 24:35 minutes.
v. 7/15/23 - 6:26 PM - 20:49 minutes.
w. 7/15/23 - 7:38 PM - 20:45 minutes.
x. 7/16/23 - 1:11 PM - 57:12 minutes.
w. 7/17/23 - 7:10 PM - 21:39 minutes.
z. 7/18/23 - 6:32 PM - 26:58 minutes.
3.The MDS assessment for Resident #68, in progress due to recent admission on [DATE], indicated the resident had a BIMS score of 15 out of 15, indicating no cognitive impairment.
The Care Plan for Resident #68, initiated 7/13/23, documented the resident needed assistance of 2 staff for bed mobility, transfers, toileting, and dressing.
During an interview on 7/17/23 at 2:23 PM, Resident #68 stated two days ago, it took 1 hour and 20 minutes for staff to answer the resident's call light, the resident needed to go to the bathroom but was able to hold it. The resident stated it frequently takes over 15 minutes but feels like the facility is short staffed.
Review of facility document titled Ciscor OneSource, (facility call light log report) documented the following call light response times longer than 15 minutes from the time period of 7/12/23 - 7/19/23 for Resident #68:
a. 7/12/23 - 7:54 PM- 34:06 minutes.
b. 7/12/23 - 8:40 PM - 28:29 minutes.
c. 7/12/23 - 9:13 PM - 17:23 minutes.
d. 7/13/23 - 4:49 AM - 46:33 minutes.
e. 7/14/23 - 11:42 AM - 30:05 minutes.
f. 7/15/23 - 5:08 PM - 20:17 minutes.
g. 7/16/23 - 6:00 AM - 28:36 minutes.
h. 7/16/23 10:14 PM - 26:18 minutes.
i. 7/17/23 - 1:04 AM - 20:01 minutes.
j. 7/17/23 - 6:25 AM - 22:38 minutes.
k. 7/17/23 - 7:36 AM - 43:40 minutes.
l. 7/18/23 - 6:33 PM - 27:50 minutes.
m. 7/19/23 - 3:45 AM - 23:36 minutes.
n. 7/19/23 - 5:37 AM - 21:33 minutes.
During an interview on 7/20/23 at 1:40 PM, Staff F, Certified Nurse Aide (CNA) stated day shift is to have 5 CNAs but work with 4 sometimes, and feels more often than not are working short staffed. Staff F stated expectation is to answer call lights within 15 minutes but not always able to answer within 15 minutes.
During an interview on 7/20/23 at 1:49 PM, Staff G, CNA stated usually have 5-6 CNAs on day shift but do work with less staff at times, feels able to answer call lights timely and the call lights are to be answered within 15 minutes.
Review of facility document titled, [NAME] Village Call Light Review Policy, documented the nursing leadership staff will review responses that are greater than 15 minutes in clinical standup, needs will be reviewed, and education to staff provided as needed.
During an interview on 7/20/23 at 2:11 PM, the Assistant Administrator stated expectation for call lights to be answered as soon as possible.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on clinical record review, facility document review, staff interviews and facility policy review, the facility failed to maintain accurate and complete records for controlled medications for 2 o...
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Based on clinical record review, facility document review, staff interviews and facility policy review, the facility failed to maintain accurate and complete records for controlled medications for 2 of 2 residents (Resident #8 & #57) reviewed for controlled medication review. Schedule II-V controlled medications have a potential for abuse and may also lead to physical or psychological dependence.
Findings include:
1. The Minimum Data Set (MDS) assessment for Resident #8 dated 5/26/23 identified a Brief Interview of Mental Status (BIMS) score of 1 out of 15 which indicated severe cognitive impairment. The MDS documented the resident received opioid medication on 3 out of 7 days of the assessment reference period. The MDS coded the resident received hospice level of care services.
The Care Plan revised on 7/7/23 revealed Resident #8 had pain with pain medication being managed by the hospice team.
The controlled drug record for Resident #8 revealed the order for the morphine sulfate was to administer 0.25 mls every 6 hours as needed for pain, dated 2/6/23.
The MAR for Resident #8 revealed her current order was to administer 0.5 mls every 1 hour as needed, dated 6/5/23.
The Controlled Drug Record for Resident #8 documented 29.75 milliliters (mls) remaining of a 30 ml bottle of Morphine Sulfate Solution liquid. The Record documented the last dose was given on 7/6/23.
The Medication Administration Record for Resident #8 for July of 2023 failed to reveal any documentation of the resident receiving Morphine on 7/6/23.
On 7/19/23 at 8:06 am, observation of liquid narcotic medications in the medication cart for Hall A revealed 2 bottles of morphine sulfate labeled for use by Resident #8. Bottle #1 was dated 2/6/23 with instructions of give 0.25 mls (5 mg) every 6 hours as needed. Bottle #2 was dated 3/20/23 with instructions give 0.5 mls (10 mg) every 2 hours as needed. The corresponding Controlled Drug Record in the narcotic count book documented dates of 3/17/23 and 3/20/23.
On 7/19/23 at 8:41 the Director of Nursing (DON) provided the morphine bottles which displayed the incorrect count as well as the Controlled Drug Sheets corresponding with the investigation. Upon observation it was noted the bottle for Resident #8 was dated 3/17/23 with instructions to give 0.5 mls (10 mg) every 2 hours as needed. The Controlled Drug Record provided by the DON was dated 2/6/23 with instructions to give 0.25 mls (5 mg) by mouth every 6 hours as needed.
On 7/20/23 at 8:40 am, the Pharmacist for the facility's Pharmacy stated the typical process for narcotic medications is to contact the facility to see if a new supply is needed prior to sending more. He verified the pharmacy records showed a 30 ml bottle of Morphine Sulfate for Resident #8 was sent on 3/17/23 and another 30 ml bottle for Resident #8 was sent three days later on 3/20/23. He stated there were no notes on the pharmacy records indicating that a pharmacy employee had discussed this with a facility employee and it was the error of the pharmacy to send 2 bottles so close together. No facility employee had requested this.
2. The MDS assessment of Resident #57 dated 7/30/23 identified BIMS score of 2 which indicated severe cognitive impairment. The MDS documented the resident received opioid medication on 1 out of 7 days of the assessment reference period. The MDS coded the resident received hospice level of care services.
The Care Plan revised on 7/10/23 revealed Resident #57 was on opioid medication therapy.
The Controlled Drug Record for Resident #57 documented 29.0 mls remaining of a 30 ml bottle of Morphine Sulfate Solution liquid.
The facility document titled Investigation, dated 7/10/23 documented the narcotic count on Hall A of the facility showed a discrepancy at 6:30 am. The facility document titled Investigation documented a visual count showed 26 mls in the bottle for Resident #8 and 27 mls in the bottle for Resident #57.
On 7/19/23 at 10:18 am, Staff B, Registered Nurse (RN) stated she arrived at the facility for her 6:00 am shift on 7/9/23 and counted controlled medications with the offgoing shift. She stated all looked correct so she signed the Narcotic Count Sheet and began her shift. She stated in the middle of her shift she noticed 3 blister packs of oral narcotic medications for 1 resident were incorrect. She stated one resident had 3 different blister packs of the same medication and the medication sheets did not match the correct numbers. She stated the total number of pills matched but the individual number against the Controlled Drug Record sheet did not match. She stated she counted again with another nurse on duty and they corrected the count so each sheet matched. She stated she did not administer any liquid narcotics during her sheet. At the end of her shift, Staff C, Registered Nurse was coming on duty. She stated Staff C took a long time to look at each bottle of morphine during count but eventually said all were ok. Staff C accepted the keys and signed the Narcotic Count Sheet. She stated she and Staff C visited for a short time then she left for the night. The following day she received a phone call regarding narcotic count having a discrepancy.
On 7/19/23 at 12:18 pm, Staff C, RN, stated she received report from Staff B, RN at 6:00 pm on 7/9/23. She stated when they did narcotic count, one of the bottles of morphine seemed off but Staff B told her she was looking at the incorrect bottle. She stated she looked at all the bottles and felt everything was correct and signed the Narcotic Count Sheet. She stated she had the keys the entire shift and the cart was locked when not in use. She stated she administered no liquid morphine during the shift. When she counted the narcotics the next morning with the oncoming shift, 2 of the bottles seemed to have the incorrect count. She stated she believed that when she counted the prior nights, she got the bottles mixed up during count. She stated there 5 bottles of liquid morphine in the cart to count. She stated at drug count she sat all of the bottles of morphine on top of the medication cart to allow the morphine to settle so she could visualize the level of the liquid at eye level for a correct count. She stated she thinks 2 of the bottles may have gotten mixed up and put in the wrong boxes. She also stated the lid of one of the bottles was saturated and feels the bottle may have been tipped and some of the morphine spilled.
The document Nursing Policies and Procedures, Controlled Substances, dated 6/2011 directs Controlled Drugs (Schedules II-V) will be properly stored and accounted for as outlined by State and Federal Regulations.
Apr 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on staff interviews and record review, the facility failed to ensure resident care and treatment was provided by competent staff and in accordance with professional standards of practice for 5 o...
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Based on staff interviews and record review, the facility failed to ensure resident care and treatment was provided by competent staff and in accordance with professional standards of practice for 5 of 5 residents reviewed. (Residents #1, #2, #3, #4, #5) The facility reported census was 60 residents.
Findings include:
According to the facility investigation, Staff A, RN (Registered Nurse) reported she and Staff B, RN were sitting at the nurse's station at around 11:00 p.m. on 3/22/23. Staff B was fidgeting and scratching all over, then made the comment that he was itching like crazy. Around 2:00 a.m. on 3/23/23 Staff C, CNA (certified nurse aide) stated to Staff A, he's (Staff B) not okay. Staff B was standing at the medication cart, being repetitive and staring at the medication. Staff B was looking at the pill and then the medication card and repeated this action several times. It was like he was in a trance. Staff B stated it is my obsessive compulsive disorder (OCD) rabbit hole and said he was unable to let go of the card. Staff A stated Staff B swayed a little bit and looked wobbly. Staff A stated I don't know what's wrong with you, but you're not going to fall on my shift. Staff A stated he was in a trance like state. Staff B sat near the bird cage and stated it was his OCD and he had been stressed. Staff A stated at around 3:30 a.m. Staff B was charting and his head was bobbing and she thought to just let him sleep. At around 4:00 a.m. Staff A asked Staff B about a log and repeated her question without a response. Staff A indicated she was worried about him and whether she could call his wife or whether he just needed sleep. Staff A stated at 4:37 a.m. Staff C stated something is not right. Staff A responded to the nurse's station to find Staff B diaphoretic, unresponsive, with purplish ears and fingers. Staff A got Staff B oxygen and had 911 called for an ambulance. The ambulance arrived by 4:50 a.m. and transported Staff B to the hospital. Staff A reported at 5:10 a.m. the hospital called inquiring what dosage the liquid oxycodone was as Staff B had admitted to ingesting 8 milliliters of it.
In an interview on 4/19/23 at 4:30 p.m. Staff B, RN, stated he worked a 6:00 p.m. to 6:00 a.m. shift on the evening of 3/22/23. During the shift he became stressed with staffing issues and eventually began withholding routine doses of controlled medications from several residents and ingesting the medications for himself. Staff B stated the statement he had sent to the facility admitting diversion of controlled medication involving 5 residents remains accurate to the best of his recollection. In that statement, Staff B admits to removing controlled medications from several residents who were mentally unable to know whether they received their medication. Staff B identified the residents and what was diverted by him and ingested. The residents included Resident #1, whom he admitted to taking (2) hydrocodone/APAP 5-325 and (1) Clonazepam 0.5 mg from, Resident #2 whom he admitted taking (3) hydrocodone/APAP 5-325 from, Resident #3 whom he admitted to taking (2) hydrocodone/APAP 5-325 from, Resident #5 whom he admitted to taking (1) Tramadol 50 mg from and Resident #4 whom he admitted to taking and ingesting 6-10 milliliters of liquid Oxycodone HCL oral concentrate 100 mg/5 ml from.
Jun 2022
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations, staff and resident interviews, and clinical record and document review, and the facility failed to address fears and honor preferences for 1 of 20 residents reviewed (Resident #...
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Based on observations, staff and resident interviews, and clinical record and document review, and the facility failed to address fears and honor preferences for 1 of 20 residents reviewed (Resident # 18). The facility reported a census of 71 residents at the time of the survey.
Findings include:
1. The Minimum Data Set (MDS) assessment tool dated 3/18/22 identified Resident # 18 scored 12 of 15 possible points on the Brief Interview for Mental Status (BIMS) score of 12 which that indicated the resident demonstrated moderately impaired cognitive abilities. The MDS indicated Resident # 18 needed extensive assist of 1 staff for toilet use, dressing, and personal hygiene.
Observation on 6/7/22 at 11:48 AM, revealed Resident # 18 in her room with the lights and television off eating lunch. The resident commented she preferred to eat in her room by herself.
A subsequent observation on 6/13/22 at 10:25 AM, revealed Resident # 18 also declined the Activity Director's invitation to join an activity. When asked about preferences, Resident # 18 answered she was not in the mood to talk at that time and also not motivated to do anything due to neck pain. She added all she cared about was pain medication and waiting for staff to provide it.
Interviews with staff on 6/13/22, showed inconsistencies with regard to handling Resident # 18's behavior pattern, preferences, and care needs, as follows:
- At 10:32 AM, Staff J Certified Medication Aide (CMA) described Resident # 18 as forgetful regarding where she placed her diapers and things like that and then would proceed to say somebody took them. Staff J reported Resident # 18 also did not like staff to wake her up to check her for toilet needs at night. Staff J said they (staff) could not let that happen (forgo checking Resident # 18 in the night. She added that with especially with the resident's recent falls, they check her more frequently now.
- At 10:45 AM, Staff G Certified Nursing Assistance (CNA) stated Resident # 18 could be forgetful, however, Staff G could not provide examples of any behaviors the resident displayed or add any details regarding Resident # 18's preferences and cares.
- At 10:48 AM, Staff D Registered Nurse (RN) reported Resident # 18 disliked male CNAs and stated, I don't know why, but [Resident # 18] does not like male caregivers. I think she's just more comfortable with female caregivers.
- At 1:20 PM, when asked if staff had reported anything to her related to a concern Resident # 18 had regarding male caregivers, the Director of Nursing (DON) replied, A mental health therapist that saw the resident told her that Resident # 18 said during counseling: an elderly CNA and her son worked a night shift and entered her room to check and change her brief. The DON responded that was bad because it triggered Resident # 18's childhood sexual abuse. The DON also said the psychiatrist advised for the counselor to stop sessions with Resident # 18 saying, she [counselor] had no right to dig into what happened 84 years ago and trigger those bad memories. However, the DON acknowledged that during the facility's internal investigation, Resident # 18 narrated the same story about an elderly woman and a teenage boy checking on her 2 nights ago and that she did not like it. The DON stated checking the staff schedule on 11/30/21 or the 2 nights ago per Resident # 18, but did not find any male staff who worked that night nor an elderly woman on facility staff. The DON stated they saw Resident # 18's statements as delusions.
- At 3:43 PM, the Social Services Director (SSD) stated, Something happened about or over 6 months ago [12/21] when Resident # 18 still lived on B Hall in a private room. She said the resident reported an adult female brought her son into the resident's room in the evening and she did not like that. The SSD said, I met with Resident # 18 on the following day and she verbalized she preferred female versus male caregivers. When asked how the facility ensured staff provided Resident # 18's reported preference, the SSD responded she did not know the schedules and assignments of caregivers because scheduling is the nursing department's responsibility.
On 6/14/22 at 6:59 AM, Staff L RN stated worked the night shift and cared for Resident # 18 at times and reported they had to ensure 2 staff members entered Resident #18's room to provide care, because she has accused staff before about something. Staff L denied they ensured only a specific gender entered the room, they just needed tow staff members. She added, that she thought the facility documented it on the care plan that way.
Review of Resident # 18's care plan revealed a lack of specific staff directives that specifically identified or assessed the residents fears or honored Resident # 18's preferences.
a. The care plan directed staff to greet the resident by name and ensure she is fully awake prior to touching her. The care plan also directed staff to assist the resident with personal hygiene and toilet use, to encourage her to use the bathroom, and to change Resident # 18's briefs at night only when she insisted on not using the bathroom.
B. The care plan identified Resident # 18's history of trauma related to childhood abuse from inappropriate touching by a male family member. The care plan directed staff to knock and announce themselves before entering the room.
C. The care plan also identified a psychosocial problem related to the resident isolating herself depending on mood, recurrent depression, anxiety, and PTSD. The care plan directed staff to provide opportunities for the resident and her family to participate in care.
D. The care plan documented Resident # 18 experienced bladder incontinence and directed staff to change the resident's incontinence garments per schedule and as needed and to clean the resident with each incontinence episode.
An investigation document provided by the facility and dated 12/2/22 revealed an interview with Resident # 18 following a report from a mental health counselor (MHC) that saw Resident #18. A handwritten witness statement dated 12/2/21 and attached to the facility's investigation documentation included Resident # 18's statement that showed the resident reported, They did it again, they checked to see if I was wet.
In an interview, the MHC reported they immediately told the facility about the residents' statements of fear indicating a possible potential for abuse so the facility could address the report right away. The MHC also verified DON's statement about reporting Resident # 18's story and statements with regard to not liking males to check her for incontinence at night.
On 6/14/22 at 8:38 AM, the Administrator said that counselors communicate with the facility verbally and the facility would conduct an internal investigation. The Administrator added that in this case, we took it as delusional signs on her [Resident # 18's] end. The Administrator verified Resident # 18's clinical records did not include specific documentation related to the delusional statements and how the facility addressed them. The Administrator said, unfortunately they do not always make it in the notes, and that is something we should be working on. The Administrator and the DON verified the absence of documentation related to Resident # 18's dislike of male caregivers at night time and/or staff directives to address that preference.
06/14/22 at 08:41 AM, the DON also verified that Resident # 18's care plan did not include her dislike of male caregivers at night time and/or staff directives to address that preference. The DON reported they still had male staff working with Resident # 18 and added, it is hard because she really likes some of them. The Administrator and the DON acknowledged that it is important for care plans to provide clear and individualized directions or interventions to meet resident's specific needs and to avoid harmful triggers. The Administrator and DON were in agreement for the need to update the care plan in order to address Resident # 18's fear of night time male care givers and to recognize Resident # 18's preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to provide the family/resident a 30 day notificat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to provide the family/resident a 30 day notification related to a discharge initiated by the facility for 3 of 3 residents sampled (Resident #71, 72 and 74). The facility reported a census of 71 residents.
1. According to the Minimum Data Set (MDS) assessment tool dated 7/21/22, Resident #71 scored 0 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which indicated the resident demonstrated severe cognitive impairment. The MDS documented diagnoses that included anxiety disorder, psychotic disorder and depression.
Census record review revealed a 6/18/2021 hospital transfer.
The Progress Notes dated 6/18/2021 at 1:15 PM, documented staff transferred Resident #71 to the emergency room and sent along a bed hold policy, which contained the option to hold the resident's bed while they were in the hospital.
Progress Notes dated 6/29/21 at 11:29 AM, documented the facility discharged Resident #71 from the building.
Review of the progress notes revealed they contained no documentation to show staff discussed the facility's inability to meet the resident's needs and/or a plan for emergency discharge with the resident or family.
2. An MDS dated [DATE] documented Resident #72 scored of 0 of 15 possible points on the BIMS test and had diagnoses that included depression, constipation and cognitive communication deficit.
Census record review revealed a 6/18/21 hospital transfer.
Progress notes dated 2/19/2022 at 1:21 PM documented staff transferred Resident #72 to the hospital for evaluation.
Progress notes failed to document discussion with family/resident regarding the facility's inability to meet the resident's needs and plan for emergency discharge.
3. An MDS dated [DATE] documented Resident #74 scored 0 of 15 possible points and had diagnoses that included anxiety disorder, Parkinson's Disease and weakness.
Census record review revealed the facility stopped billing Resident #74 on 6/13/21.
Progress Notes dated 6/13/21 at 4:47 AM document staff transferred Resident #74 to the hospital for an evaluation
An undated facility Resident Rights document directed residents have a right to a 30-day notice of discharge or transfer that includes the reason and effective date of transfer, location of discharge, notice of the right to appeal, and the contact information of the State Ombudsman.
During an interview on 6/14/22 at 10:00 AM, the social worker stated she was unsure who would directly be having the conversation with residents/or family related to end of bed hold and need for discharge
An interview on 6/14/22 at 1:00 PM, Administrator stated she did not feel the facility was able to meet the needs of the resident at the time of the referral from the acute care facilities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview the facility failed to provide the family/resident a bed hold notifica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview the facility failed to provide the family/resident a bed hold notification when they were transferred to the hospital for 2 of 3 residents reviewed (Resident #72 and 74). The facility reported a census of 71 residents.
1. An MDS dated [DATE] documented Resident #72 scored of 0 of 15 possible points on the BIMS test and had diagnoses that included depression, constipation and cognitive communication deficit.
Census record review revealed a hospital transfer on 6/18/21
Progress notes dated 2/19/2022 at 1:21 PM documented Resident #72 transferred to the hospital for evaluation.
2. An MDS dated [DATE] documented Resident #74 scored 0 of 15 possible points and had diagnoses that included anxiety disorder, Parkinson's Disease and weakness.
Census record review revealed the facility stopped billing Resident #74 on 6/13/21.
In an interview on 6/14/22 at 10:00 AM, the social worker stated she was not responsible for the bed hold policy notification.
Interview with the Assistant Director of Nursing on 6/14/22 at 12:30 PM revealed it was her expectation that the nurses would ensure the bed hold was sent at the time of transfer and document this in the progress notes.
Policy titled Bed-Holds and Returns dated 3/17 under Policy Interpretation and Implementation number 3, it is documented that prior to a transfer, written information would be given to the residents and resident representative that explain in detail the rights and limitations of the bed hold.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, Preadmission Screening and Resident Review (PASRR), and staff interviews, the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, Preadmission Screening and Resident Review (PASRR), and staff interviews, the facility failed to submit a Preadmission Screening and Resident Review when a resident had a newly diagnosed mental disorder for one of four residents reviewed for PASRR (Resident #16). The facility reported a census of 71 residents.
Findings include:
The annual minimum data set (MDS) assessment dated [DATE] revealed Resident #61 had diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, mood disorder, and psychotic disorder. The MDS documented the resident not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident took an antidepressant medication and had no psychological therapy during the seven day look-back period.
The MDS assessment dated [DATE] revealed the resident had diagnosis of dementia, anxiety disorder, depression, and psychotic disorder. The MDS revealed the resident had no psychosis or behavioral symptoms. The MDS indicated the resident took an antidepressant medication and had no psychological therapy during the look-back period.
The care plan updated 11/16/21 revealed the resident had depression and anxiety related to dementia and took routine antidepressant medication. The staff directives included to administer medications as ordered by the physician, observe for side effects and effectiveness of psychotropic medications, and arrange a psychiatric consult and follow up as indicated.
Review of the PASRR notice for nursing facility approval dated 8/10/20, revealed the resident had mental illness diagnoses of anxiety disorder. The PASRR directed the facility staff to submit a status change if the resident had a change in symptoms, behavior, or diagnoses.
The electronic health record (EHR) diagnoses report revealed anxiety disorder (added 8/5/20), delusional disorder (added 2/5/21), major depressive disorder (added 2/17/21), and mood disorder (added 2/17/21).
The order summary report dated 6/2022 revealed trazadone (an antipsychotic) twice a day started 1/20/22 for anxiety disorder and major depressive disorder, and venlafaxine (an antidepressant) twice a day for anxiety disorder and major depressive disorder started 1/6/22.
In an interview 6/15/22 at 8:25 AM, the social worker reported PASRR's completed upon admission, whenever a resident had a change in mental health diagnoses, and if a resident had a change in mental health status such as a psychiatric hospitalization. The SW confirmed the last PASRR completed on Resident #61 on 8/10/2020. The SW checked the EHR and Path tracker website and reported the last PASRR evaluation completed 8/10/2020.
On 6/15/22 at 11:00 AM, the social worker advised the surveyor she submitted Resident #61's information for a PASRR re-evaluation on 6/15/22. The PASRR dated 6/15/22 reflected Resident #61's mental health diagnoses included major depression, psychotic disorder, anxiety disorder, mood disorder, and major depressive disorder.
On 06/15/22 at 1:40 PM, the administrator reported the facility had no PASRR policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on documents review, interviews and observations, the facility failed to develop a care plan to include specific actions to address identified needs, problems, or preferences for 1 of 20 residen...
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Based on documents review, interviews and observations, the facility failed to develop a care plan to include specific actions to address identified needs, problems, or preferences for 1 of 20 residents reviewed (Resident # 18). The facility reported a census of 71 residents at the time of the survey.
Findings include:
Resident # 18's annual Minimum Data Set (MDS) assessment tool dated 3/18/22 showed a Brief Interview for Mental Status (BIMS) test score of 12, which meant the resident demonstrated moderately impaired cognitive abilities. The MDS documented Resident # 18's needed extensive assist of 1 staff for toilet use, dressing, and personal hygiene.
Resident # 18's electronic records contained medical diagnoses that included dementia with Lewy bodies, recurrent major depressive disorder, anxiety disorder, and post traumatic stress disorder (PTSD).
Multiple interviews on 6/13/22 and 6/14/22 revealed staff awareness of Resident # 18's history of childhood traumatic experiences that could potentially trigger the resident during staff provision of cares as follows:
- Staff J Certified Medication Aide (CMA) reported Resident # 18 disliked night time checks;
- Staff D Registered Nurse (RN) reported Resident # 18's disliked male Certified Nursing Assistants (CNAs) and felt more comfortable with female caregivers;
- The Director of Nursing (DON) verified a mental health counselor reported Resident # 18 voiced triggers about bad memories;
- The Social Services Director (SSD) verified that when Resident # 18 was still in a private room, she made delusional statements regarding a female caregiver that brought her son into her room in the evening that Resident # 18 did not like;
- The MHC confirmed they reported Resident # 18's concerning statements to facility staff;
- The DON verified the facility conducted an investigation
- Resident # 18 repeated the same story about the female care giver and son to inspector during the survey.
- Staff L stated 2 staff members needed to care for Resident # 18 due to past accusations.
Resident # 18's care plan lacked specific directions that addressed or identified resident's fears of male night time caregivers and failed to contain staff directives regarding how to honor that stated preference.
The Administrator and the DON acknowledged that Resident # 18's care plan needed an update to be individualized according to Resident # 18's needs.
The facility's undated document titled, Resident and Responsible Party Handbook indicates that the interdisciplinary care team meets up with residents develop plans of care that assesses, implements, and evaluates the care to be provided. The document also indicates provision of nursing services 24 hours daily to assess and monitor residents' direct care and individualized needs.
The facility's policy titled, Care Planning - Interdisciplinary Team revised on 9/13, provides that the interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident based on comprehensive assessments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documents review, observations, and staff interviews, the facility did not provide consistent implementation of planned...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documents review, observations, and staff interviews, the facility did not provide consistent implementation of planned interventions to prevent pressure wounds for 2 of 2 residents in the sample reviewed for pressure ulcers (Resident # 17 and Resident # 64). The facility reported a census of 71 at the time of the survey.
Findings include:
1. According to the admission Minimum Data Set (MDS) assessment tool dated 3/30/22, Resident # 17 had a Stage 3 pressure ulcer of the left hip, a Stage 1 pressure ulcer of the sacral region, and an unstageable pressure ulcer on the right ankle and right heel. The MDS revealed the resident had a diagnosis of peripheral vascular disease.
Resident # 17's care plan identified an actual/potential skin problem related to bowel incontinence and admission with pressure ulcers and moisture associated skin damage (MASD). The care plan directed staff to place a bordered foam dressing on the resident's coccyx prophylactically.
The physician order sheet included an order that directed apply sacral bordered foam to coccyx every 3 day(s) in the morning and as needed if soiled or dislodged. The sheets also directed staff to assess and chart on the area each time they replace the bordered foam.
On 6/9/22 at 10:15 AM, Staff G Certified Nursing Assistant (CNA) and Staff M (CNA) transferred Resident # 17 to bed. Staff G checked Resident # 17's briefs and said it's poopy. Observation revealed Resident # 17's buttocks were reddened and sheared and the coccyx area did not contain any type of dressing, which Staff G and Staff M verified.
On 6/09/22 at 10:31 AM, Staff N Registered Nurse (RN) entered the room to provide a dressing change and apply treatments to Resident # 17's buttocks. Staff N also verified there was no protective dressing on Resident # 17's coccyx area. Staff N said that a sacral bordered foam was supposed to be in place at all times and changed every couple of days and as needed when soiled and dislodged.
On 6/9/22 11:11 AM, the Assistant Director of Nursing (ADON) reported said Resident # 17's pressure ulcers had healed but acknowledged Resident # 17's skin condition and their high risk for pressure wounds. The ADON stated that the sacral guard was being used prophylactically and should be in place all the time.
2. Resident # 64's quarterly MDS dated [DATE] identified 1 unstageable pressure ulcer and documented medical diagnoses that included diabetes mellitus, candidiasis of skin and nail, and chronic venous peripheral insufficiency.
Resident # 64's care plan identified the resident had peripheral vascular disease related to diabetes. The care plan also identified a risk for circulatory complications and wounds, and also documented a pressure ulcer to the left inner heel. The care plan directed staff to apply pressure relieving boots on Resident # 64's bilateral lower extremities (BLE) and ensure they are on at all times.
The orders also directed staff to apply pressure relieving boots to BLE at all times except showers, and nurse to check placement and skin integrity BID (twice a day).
During observation on 6/9/22 from 11:12 to 11:20 AM, Resident # 64 was in the hallway by the nurses' medication cart, waiting for staff to administer her insulin wearing only one boot on their right lower extremity. Resident # 64 said she did have 2 pressure ulcers on both heels that have been healed. At 11:25 AM, the ADON put boots on both of Resident # 64's lower extremities and acknowledged the importance of having the boots in place at all times.
The facility's policy titled, Skin Assessments and Interventions dated 4/11 directed staff to implement ordered treatments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interviews, the facility failed to provide adequate nursing supervision ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interviews, the facility failed to provide adequate nursing supervision and assistance devices to prevent hazards for 2 of 8 residents reviewed (Resident #16 & 26). The facility reported a census of 71 residents.
Findings include:
The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had diagnosis of Alzheimer's disease, dementia, and muscle weakness. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. The MDS indicated the resident required extensive assistance of one staff for locomotion on and off the unit, and used a wheelchair for mobility.
Resident #16's care plan revised 2/24/22 revealed the resident had impaired cognition, required assistance with ADLs (activities of daily living), and had a risk for falls related to Alzheimer's Disease and poor safety awareness. The care plan intervention included staff propelled the wheelchair for resident locomotion.
During observation on 6/7/22 at 12:54 PM, Staff A, CNA pushed Resident #16 in a wheelchair down the hall, by the nurse's station, and to the resident's room [ROOM NUMBER] foot without foot pedals on the wheelchair. Resident # 16 wore slippers on her feet and the bottom of her feet skimmed the carpeted floor.
In an interview on 6/13/22 at 3:36 PM, the Administrator reported the facility had no policy for transfers with a wheelchair.
In an interview 6/15/22 at 10:55 AM Staff B, Unit Manager, reported she expected staff used wheelchair pedals whenever they pushed residents in a wheelchair due to safety concerns. Staff B stated if a resident unable to hold legs up during transport in a wheelchair due to fatigue, the resident's feet dropped toward the floor, and the resident potentially could tip out of the wheelchair.
2. According to an admission MDS dated [DATE], Resident #26 scored 10 of 15 possible points on the Brief Interview for Mental Status (BIMS), which meant the resident experienced moderately impaired cognitive abilities. The MDS identified Resident # 26 had medical diagnoses that included amyotrophic lateral sclerosis, adult failure to thrive, generalized muscle weakness, neuromuscular dysfunction of bladder, benign neoplasm of colon, unsteadiness on feet, lack of coordination, and need for assistance with personal care. The MDS documented Resident # 26 required extensive assist of 2 staff for transfers, ambulation (walking), toilet use, and personal hygiene.
Resident # 26's care plan identified Resident # 26 as at high risk for falls and documented she required assist of 1 staff and a four-wheeled walker to ambulate to the toilet. The care plan revealed Resident # 26 demonstrated incontinence of bowel and impaired visual function.
During interview on 6/7/22 at 12:44 PM, Resident # 26 said, At times they just do not answer the call lights, they put me on the toilet for an hour and I had to call my husband to get me off. Resident # 26 reported that call light can go un-answered for an hour. Resident # also said that sometimes it takes a long time to get help for transfers from her wheelchair to recliner chair.
The call light log showed that on 4/30/22 at 12:44 PM, Resident # 26's call light was on for 58 minutes and 2 seconds. The progress notes entered on 4/30/22 at 1:00 PM documented Resident # 26 fell while walking without assistance in the bathroom.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interviews and record review the facility failed to assess for correct enteral tube (g-tube) placement of 1 of 1 residents sampled. (Resident #40). The facility reported a census...
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Based on observation, interviews and record review the facility failed to assess for correct enteral tube (g-tube) placement of 1 of 1 residents sampled. (Resident #40). The facility reported a census of 71 residents.
A Minimum Data Set assessment tool dated 4/20/22 revealed Resident #40 scored 15 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident had no identified cognitive impairment. Diagnoses included gastroesophageal reflux disease (GERD) or ulcer, esophageal obstruction, malnutrition, and gastrostomy (g-tube).
Observation on 06/13/22 at 10:03 AM, revealed Staff D, RN failed to check g-tube placement prior to administering medication.
In an interview on 6/15/22 at 11:30 AM, Staff C, LPN identified the need to check placement of the gtube prior to use.
Interview with the ADON, 6/14/22 at 12:30 PM identified that standard of practice to check placement of the gtube prior to use.
A facility policy titled Administering Medications through an Enteral Tube dated 2/15/21 directed staff to confirm placement of the feeding tube.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Town Hall Meeting Minutes revealed the following:
a. Minutes dated 3/2/2022 documented concerns related long...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Town Hall Meeting Minutes revealed the following:
a. Minutes dated 3/2/2022 documented concerns related longer periods of time it takes to have call lights answered during the night.
b. Minutes dated 4/6/2022 documented a concern related to the length of time it takes for call lights to be answered on all shifts.
c. Minutes dated 5/4/2022 documented a resident remarked staff had requested residents to not put on their call light during the overnight shift.
In a confidential Resident Council meeting held 6/8/2022 at 3:00 PM, 3 of 5 interviewable residents stated call light response time it took an average 45 minutes.
Interview on 6/15/22 at 11:30 AM Staff C, LPN stated residents have verbalized frustration over long call light wait times.
Interview on 6/15/22 @ 1:00 PM, the Administrator verbalized call light response time as a concern. She acknowledged an improved system for communication would assist with call light response time.
Based on resident and staff interview, clinical record review, and call light logs the facility failed to answer call lights within a reasonable amount of time for 2 residents (#26 and #37) and a confidential Resident Council group of residents reviewed. Residents reported having to wait fifty-eight minutes to have the call light answered. Facility call-light logs revealed the call lights answered between one to fifty-eight minutes. The facility reported a census of 71 residents.
Findings include:
1. The MDS (Minimum Data Set) assessment tool dated 4/18/22 revealed Resident #37 scored 8 of 15 possible points on the BIMS (Brief Interview for Mental Status Score) test, which meant the resident demonstrated moderately impaired cognitive abilities. The MDS revealed Resident #37 required assist of two staff with bed mobility, transfers, and toilet use.
The Call Light Report dated 6/2/-6/9/22 revealed Resident #37 activated his call light and waited greater than 15 minutes for staff to assist him a total of 8 times during that period of time. The report revealed the longest Resident #37 waited for staff assistance was 50 minutes and 27 seconds.
Resident #37's Care Plan directed staff to place Resident #37's call light within reach so he may request assistance.
During an interview with Resident #37 on 6/7/22 at 12:30 p.m. reported he used his call light to tell staff he is ready to go to bed.
During an interview on 6/9/22 at 1:00 p.m., the Director of Nursing reported she expected staff to answer residents' call lights within 15 minutes.
On 6/13/22 at 10:56 a.m., the Director of Maintenance, reported activated call lights forward to the radios of staff working in that department. After 15 minutes, the radio alerts staff once per minute thereafter.
An interview with the Administrator on 6/13/22 at 3:37 p.m., revealed no call light policy.
2. According to an admission MDS dated [DATE], Resident #26 scored 10 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident experienced moderately impaired cognitive abilities. The MDS identified Resident # 26 had medical diagnoses that included amyotrophic lateral sclerosis, adult failure to thrive, generalized muscle weakness, neuromuscular dysfunction of bladder, benign neoplasm of colon, unsteadiness on feet, lack of coordination, and need for assistance with personal care. The MDS documented Resident # 26 required extensive assist of 2 staff for transfers, ambulation (walking), toilet use, and personal hygiene.
Resident # 26's care plan identified Resident # 26 as at high risk for falls and documented she required assist of 1 staff and a four-wheeled walker to ambulate to the toilet. The care plan revealed Resident # 26 demonstrated incontinence of bowel and impaired visual function.
During interview on 6/7/22 at 12:44 PM, Resident # 26 said, At times they just do not answer the call lights, they put me on the toilet for an hour and I had to call my husband to get me off. Resident # 26 reported that call light can go un-answered for an hour. Resident # also said that sometimes it takes a long time to get help for transfers from her wheelchair to recliner chair.
The call light log showed that on 4/30/22 at 12:44 PM, Resident # 26's call light was on for 58 minutes and 2 seconds. The progress notes entered on 4/30/22 at 1:00 PM documented Resident # 26 fell while walking without assistance in the bathroom.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Iowa facilities.
Concerns
- • 29 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (40/100). Below average facility with significant concerns.
- • 57% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Ramsey Village's CMS Rating?
CMS assigns Ramsey Village an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Iowa, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Ramsey Village Staffed?
CMS rates Ramsey Village's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 57%, which is 11 percentage points above the Iowa average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Ramsey Village?
State health inspectors documented 29 deficiencies at Ramsey Village during 2022 to 2025. These included: 1 that caused actual resident harm, 27 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Ramsey Village?
Ramsey Village is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 78 certified beds and approximately 60 residents (about 77% occupancy), it is a smaller facility located in DES MOINES, Iowa.
How Does Ramsey Village Compare to Other Iowa Nursing Homes?
Compared to the 100 nursing homes in Iowa, Ramsey Village's overall rating (2 stars) is below the state average of 3.0, staff turnover (57%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Ramsey Village?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Ramsey Village Safe?
Based on CMS inspection data, Ramsey Village has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Iowa. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Ramsey Village Stick Around?
Staff turnover at Ramsey Village is high. At 57%, the facility is 11 percentage points above the Iowa average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Ramsey Village Ever Fined?
Ramsey Village has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Ramsey Village on Any Federal Watch List?
Ramsey Village is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.