Parkview Care Center
For profit - Individual
70 Beds
OSBYCORP
Data: November 2025
Trust Grade
48/100
#291 of 392 in IA
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Parkview Care Center in Fairfield, Iowa, has a Trust Grade of D, indicating below-average performance with some significant concerns. Ranked #291 out of 392 facilities in Iowa, they fall in the bottom half, though they are the top choice among two facilities in Jefferson County. The center is improving; the number of reported issues decreased from 23 in 2024 to 8 in 2025. However, staffing is rated poorly at 1 out of 5 stars, although their turnover rate of 30% is better than the state average. Notably, there have been serious concerns, including a failure to properly assess a resident's needs after they suffered a fall and a mouse infestation that has troubled residents, highlighting both health and comfort issues. On a positive note, the facility has had no fines, which suggests they are not facing significant regulatory compliance issues.
- Trust Score
- D
- In Iowa
- #291/392
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 30% annual turnover. Excellent stability, 18 points below Iowa's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Iowa facilities.
- Skilled Nurses ○ Average
- RN staffing data not reported for this facility.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Bottom 26%
Needs review
23 → 8 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 23 issues
2025: 8 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (30%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (30%)
18 points below Iowa average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below Iowa average (3.0)
Below average - review inspection findings carefully
Chain: OSBYCORP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 31 deficiencies on record
1 actual harm
Jul 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on clinical record review, facility policy review, and staff interview, the facility failed to ensure resident code status were clear and consistent in the electronic health record as compared t...
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Based on clinical record review, facility policy review, and staff interview, the facility failed to ensure resident code status were clear and consistent in the electronic health record as compared to the documentation kept in binder at the nurses desk for 1 of 24 residents (Resident #33) reviewed for advance directives. The facility reported a census of 49 residents. Findings include:The Minimum Data Set (MDS) assessment tool, dated 5/2/25, listed diagnoses for Resident #33 which included non-Alzheimer's dementia, anxiety disorder, and depression and listed her Brief Interview for Mental Status (BIMS) score as 0 out of 15, indicating severely impaired cognition. The facility Resuscitation Policy, effective 8/17/17, stated the facility would maintain each resident's resuscitation status in the clinical record. On 7/1/25 at 12:50 p.m., a review of Resident #33's Iowa Physician Order for Scope of Treatment, dated 1/20/23 and scanned in the electronic health record (EHR), revealed the resident was a Full Code. The resident's IPOST, dated 9/24/24, located in a book at the nursing station, stated the resident was a Do Not Resuscitate (DNR). On 7/1/25 at 12:52 p.m., Staff C Licensed Practical Nurse (LPN) stated if he needed to determine a resident's code status, he would either look in the EHR or the book at the nursing station, whichever was the fastest. On 7/1/24 at approximately 1:00 p.m., the Director of Nursing (DON) stated that code statuses should match and she would remedy the situation.
CONCERN
(D)
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, facility policy review, and staff interview, the facility failed to notify the physician of a weight gain for 1 of 3 residents reviewed for nutrition (Resident #24). T...
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Based on clinical record review, facility policy review, and staff interview, the facility failed to notify the physician of a weight gain for 1 of 3 residents reviewed for nutrition (Resident #24). The facility reported a census of 49 residents.Findings include: The Minimum Data Set (MDS) assessment tool, dated 5/30/25, listed diagnoses for Resident #24 which included edema (swelling), non-Alzheimer's dementia, and major depressive disorder. The MDS listed the resident's cognition as severely impaired. A 9/4/24 Care Plan entry stated the resident would maintain a healthy weight. Review of Resident #24's Weight Report listed the following weights:a. 5/1/25 a weight of 158 lbs. (pounds)b. 6/26/25 180 lbs., a gain of 22 lbs. or 13.92 percent.A 5/26/25 Quarterly Nutritional Assessment stated the resident had a weight gain and recommended a reduction of the resident's supplement to 60 milliliters (ml) once daily. The facility lacked documentation of provider notification of the resident's additional weight gain from 5/26/25 until 6/26/25. On 7/3/25 at 9:27 a.m. Staff D Registered Nurse (RN) stated if a resident had a 22 lbs. weight gain in two months she would check the resident for swelling and make sure the weight was correct. She stated she would notify the provider. On 7/3/25 at 9:30 a.m., the Director of Nursing (DON) stated if a resident gained 22 lbs. in two months, she would notify the Registered Dietician and the provider. She stated she expected staff to address a weight gain.Review of the undated facility policy Change in Condition revealed the facility would consult with the resident's physician when there was a significant change in condition or a need to alter treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, policy review, and staff interview, the facility failed to provide an ongoing program of activities for 1 of 1 residents reviewed for activities (Resident...
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Based on observation, clinical record review, policy review, and staff interview, the facility failed to provide an ongoing program of activities for 1 of 1 residents reviewed for activities (Resident #24). The facility reported a census of 49 residents.Findings include:The annual Minimum Data Set(MDS) assessment tool, dated 11/29/25, listed diagnoses for Resident #24 which included edema (swelling), non-Alzheimer's dementia, and major depressive disorder. The MDS listed the resident's cognition as severely impaired and stated the resident preferred the following activities: listening to music and spending time outdoors. Review of the Care Plan, dated 3/3/22, revealed the resident was at ease in joining other residents in activities. The Care Plan identified the resident enjoyed Jewish singing and visiting with friends from the meditating community. The facility Activity Services Policy, revised 7/13/23, stated the facility would plan activities based on resident interests, abilities, and needs. The facility designed activities to promote physical, mental, and social well-being. The untitled monthly activity logs revealed the resident participated in the following activities:a. April 2025: exercise - participated 22 times, refused once; one-on-one visits - participated 23 times.b. May 2025: exercise - participated 17 times, refused 5 times; one-on-one visits - participated 22 times; games -refused 1 time; pretty nails - refused 1 time; bible study - participated 1 time.c. June 2025: exercise - ball toss, walking, target toss, bean bag toss - participated 16 times, refused 2 times; one-on-one visits -participated 19 times; games - participated 1 time; church - participated 1 time; party - refused 1 timeReview of the activity calendars revealed other activity offerings included: outing, bingo, movie, cooking, crafting, coffee club, help with cleaning/folding. The facility lacked documentation these activities were offered to Resident #24. The activity calendar lacked documentation of further activities offered to the resident. Observations of Resident #24 revealed the following:a. On 6/30/25 at 1:32 p.m., the resident sat on the edge of his bed.b. On 7/1/25 at 8:51 a.m., the resident laid in bed.c. On 7/1/25 at 11:37 a.m. and 12:10 p.m., the resident sat at the dining room table.d. On 7/2/25 from 8:44 a.m. until 9:48 a.m., the resident sat on the couch in the day room and watched a TV game show. e. On 7/2/25 at 11:09 a.m. and 11:46 a.m., the resident sat at the dining room table. f. On 7/2/25 at 1:38 p.m., the resident laid in bed. g. On 7/2/25 at 3:10 p.m., the resident sat in a recliner in the day room and watched a TV game show.h. On 7/3/25 at 8:59 a.m., the resident sat in a recliner in the day room. During an interview on 7/3/25 at 9:42 a.m., the Director of Nursing (DON) agreed that resident should be kept busy and stimulated with activities. During an interview on 7/3/25 at 9:03 a.m., the Life Enrichment Coordinator stated she completed an hour of activities in the memory care unit. She stated she was responsible for transportation also so when she was doing that, she could not spend time on activities. During an interview on 7/3/25 at 9:18 a.m., the Director of Activities stated she was new at the facility but stated in her old facility she conducted activities every hour to 2 hours, around 5 activities per day. She stated she would like to carry out that schedule at this facility eventually. She stated staff could complete an activity with the residents before lunch.
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 observation, clinical record review, policy review, and staff interview, the facility failed to ensure medications and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure medications and chemicals were secured and not accessible to 10 of 10 (which included Resident #11) cognitively impaired and independently mobile residents on the memory care unit. The facility reported a census of 49 residents. Findings include:1. The Minimum Data Set (MDS), dated [DATE], listed diagnoses for Resident #11 which included obesity, prediabetes, and a moderate intellectual disability The MDS stated the resident was independent with walking and listed her cognition as severely impaired. Review of the Care Plan, dated 10/24/24, revealed Resident #11 had cognitive loss and dementia and impaired decision making. The Care Plan directed staff to determine if her decisions would endanger her or others. The Care Plan documented the resident felt the need to touch different things and directed staff to allow this when safe to do so. During an observation on 6/30/25 at 1:47 p.m., while in the day room of the Memory Care Unit, Resident #11 pulled back the curtain covering the right-hand cubby and looked in. Other residents sat in the room but no staff were present. 2. Review of an untitled facility document revealed a list of 10 cognitively impaired, independently mobile residents in the locked Memory Care Unit. Observations on 7/2/25 revealed residents from the above list were unattended in the day room without staff at the following times: 8:52 a.m. to 8:55 a.m.; 9:02 a.m. to 9:08 a.m.; and 9:13 a.m. to 9:15 a.m.During an observation on 7/2/25 at 9:54 a.m., the right-hand cubby in the day room found to have contained the following:a. Staff B Certified Nursing Assistant's (CNAs) bag which contained an almost full bottle of ibuprofen 200 milligrams (mg)b. A spray bottle of Old English furniture polish in which the label stated it could cause eye irritationDuring an interview On 7/2/25 at 10:06 p.m., the Director of Nursing (DON) stated the resident environment should be free from medications and chemicals. She stated staff should lock up their personal items. The undated facility Hazard Communication Program stated the facility was committed to preventing chemical exposures.The undated facility policy [Facility Name Redacted] Medication Pass and Treatments directed staff to keep medications locked at all times.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, the facility failed to offer an annual influenza vaccine fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interview, the facility failed to offer an annual influenza vaccine for 2 of 5 residents (Residents #11 and #24) reviewed for immunization. The facility reported a census of 49 residents.Findings include:1. The Minimum Data Set (MDS), dated [DATE], listed diagnoses for Resident #11 which included obesity, prediabetes, and moderate intellectual disabilities and listed her cognition as severely impaired. An untitled document, dated 3/13/24, documented that the Resident #24's resident representative consented to an influenza vaccine. The facility lacked documentation the resident received an influenza vaccine during the 2024-2025 flu season. 2. The MDS assessment tool, dated 5/30/25, listed diagnoses for Resident #24 which included edema (swelling), non-Alzheimer's dementia, and major depressive disorder. The MDS listed the resident's cognition as severely impaired. An untitled document, dated 3/13/24, documented that the Resident #24's resident representative consented to an influenza vaccine. The facility lacked documentation the resident received an influenza vaccine during the 2024-2025 flu season. The undated facility Policy for Provision of Influenza and Pneumococcal Vaccines, stated the facility would screen residents to determine if they were current on their immunizations. The policy stated the facility would offer all residents the influenza vaccines. On 7/3/25 at 9:39 a.m., the Director of Nursing(DON) stated she was not sure how the facility missed the above resident's annual influenza shots.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, record review, staff interviews, and the facility policy, the facility failed to follow the menu for 1 of 1 meals observed and 2 of 2 residents sampled for a therapeutic diet (Re...
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Based on observation, record review, staff interviews, and the facility policy, the facility failed to follow the menu for 1 of 1 meals observed and 2 of 2 residents sampled for a therapeutic diet (Resident #21 and Resident #36). The facility reported a census of 49 residents.Findings include: 1. Review of the facility Spring/Summer 2025 Menu Week 1 revealed the following menu for Tuesday, July 1, 2025: a. Lemon chicken b. Garlic parmesan pastac. Roasted caesar vegetable [a substitute of California mix (generally a mixture of broccoli, cauliflower and carrots) made]d. Garlic toast
e. Sugar cookie barsDuring an observation of the puree process on 7/1/25 at 10:47 a.m., Staff E, Dietary Cook/Aide did not prepare the puree garlic toast menu item. During an observation 7/1/25 at 11:50 a.m., the lunch meal service started. Staff E prepared plates for the residents. No garlic toast served with the prepared plates throughout the lunch meal service. During an interview on 7/1/25 12:41 a.m., Dietary Manager confirmed no bread served and stated garlic bread was supposed to have been served. During an interview on 7/2/25 at 9:54 a.m., Staff G, Dietary Aide queried if bread was served for lunch yesterday and Staff G stated no, she thought they were supposed to have garlic toast. Staff G stated she guessed they didn't have enough, but no one told her that directly. During an interview on 7/3/25 at 12:28 p.m., the Dietary Manager queried on not having the garlic toast and the Dietary Manager stated [name redacted] hadn't been getting them supplies because sometimes they run out. The Dietary Manager asked about substitutes and the Dietary Manager stated he usually tried to come up one, but didn't always.
2. The Minimum Data Set (MDS) assessment for Resident #36, dated 3/28/25, identified the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 (indicative of severe cognitive impairment) and diagnoses of dementia and diabetes.The Care Plan for Resident #36, last revised 4/3/25, identified the resident was at risk for weight loss due to cognitive status.On 07/01/25 at 12:04 PM, dietary staff brought Resident 36's food out. The resident received mechanically ground lemon chicken with sauce, pasta, broccoli casserole. The resident ate 100 percent. The resident did not receive a piece of garlic bread per the facility menu and was not offered a bread substitute. 3. The MDS assessment for Resident #21, dated 5/2/25, identified the resident had a BIMS of 11 out of 15 (indicative of a moderate cognitive impairment) and diagnosis of cerebral vascular accident (stroke) and diabetes.The Care Plan for Resident #21, last revised 5/8/25, identified the resident received a therapeutic diet related to a diagnosis of diabetes. On 7/01/25 at 12:07 PM, dietary staff served Resident #21 her lunch which included lemon chicken with a sauce, pasta and a broccoli casserole. Resident #21 did not receive a piece of garlic bread per the facility menu and was not offered a bread substitute.The facility policy, titled Food and Nutrition Services, dated October 2017, identified the facility provided each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, and the facility policy, the facility failed to provide a pa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, and the facility policy, the facility failed to provide a palatable vegetable for 1 of 1 meal observed. The facility reported a census of 49 residents. Findings include:1. The Facility Spring/Summer 2025 Menu Week 1 revealed the following menu for Tuesday, July 1, 2025::a. Lemon chicken b. Garlic parmesan pastac. Roasted caesar vegetable [a substitute of California mix (generally a mixture of broccoli, cauliflower and carrots) made]d. Garlic toaste. Sugar cookie [NAME] 7/1/25 at 12:52 p.m., the State Agency received and tasted a lunch tray with the above menu items. The California mix sampled contained mostly broccoli pieces. The broccoli pieces were soft and mushy, and tasted and smelled like black pepper. During an interview on 7/2/25 at 8:28 a.m., Staff E, Dietary Aide/Cook queried if she followed a recipe for the menus stated she followed the recipes. Staff E stated the vegetable was a California mix. Staff E queried if the California mix had a recipe for how much seasoning to add and Staff E stated no, she didn't measure the seasoning, Staff E sprinkled the seasoning and tasted it and thought it tasted fine. Staff E stated some people said it was too spicy, but Staff E made sure she stirred it pretty good. Staff E stated she used a salt free seasoning blend in the California mix and might have had a big clump in it. During an interview on 7/3/25 at 8:43 a.m., the Dietician queried on using a salt free seasoning blend with the vegetables and she stated the cooks added the seasoning for taste. The Dietician stated if residents complained, it was a different story. She stated she wouldn't put spices on broccoli. The Dietician asked about the texture of the broccoli and she stated the broccoli should be tender and the spices withheld unless the vegetables were supposed to be spiced. During an interview on 7/3/25 at 12:28 p.m., the Dietary Manager queried on the broccoli served on 7/1/25 and he stated broccoli was difficult to hold and constantly wanted to turn pale. The Dietary Manager stated he would prefer they undercook the broccoli and let the steam table finishing cooking it, but there was no way to keep the broccoli from getting mushy. The Dietary Manager asked about the salt free seasoning blend to the vegetable dish and the Dietary Manager stated it was very possible the cook added too much.
2. During an observation on 07/01/25 at 12:04 PM, dietary staff brought Resident 36's food out. The resident received mechanically ground lemon chicken with sauce/gravy, pasta, and broccoli casserole. Staff A, Certified Nurses Aide (CNA), and Staff C, CNA, assisted the resident with sitting at the table. The resident started to eat and talk with his tablemates. At 12:12 PM, Staff A, CNA, sat at the resident's table. Resident #36 requested salt for his food. Staff A helped to apply salt to the resident's food and then offered to pepper the resident's food. Resident #36 responded that someone had already peppered it. Resident #36 told one of his tablemates that the food had too much pepper. 3. On 6/30/25 at 2:01 PM, Resident #21 reported the food was not good. She explained that it was either undercooked or overcooked.On 7/01/25 at 12:07 PM, dietary staff served Resident #21 her lunch which included lemon chicken with a sauce, pasta and a broccoli casserole. The broccoli casserole was mushy and overcooked in appearance. The resident ate 50 percent of the meal, and did not eat the broccoli casserole. The facility policy, titled Food and Nutrition Services, dated October 2017, identified the facility provided each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, facility policy review and staff interviews, the facility failed to maintain a sanitary kitchen which included safe refrigerator temperatures, consist daily refrigerator temperat...
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Based on observation, facility policy review and staff interviews, the facility failed to maintain a sanitary kitchen which included safe refrigerator temperatures, consist daily refrigerator temperature check documentation, target sanitization levels in the dishwasher, staff hand hygiene practices, and clean deep freeze equipment. The facility reported the census of 49 residents. Findings include:Review of the June 2025 Refrigerator Logs revealed temperatures logged during the evening shift on 6/25/25; 6/27/25; 6/28/25; 6/29/25; and 6/30/25. Review of the June 2025 Refrigerator Log for Refrigerator #2 revealed the following temperature documented during the evening shift: a. 6/25/25: 48 degrees Fahrenheit (F).b. 6/27/25: 48 degrees F.c. 6/28/25: 48 degrees F.d. 6/29/25: 48 degrees F.e. 6/30/25: 47 degrees F.During the initial kitchen observation on 6/30/25 at 10:18 a.m., the white deep freeze had a large amount of ice buildup along the inside of the freezer walls. During the initial kitchen observation on 6/30/25 at 10:38 a.m., the temperature logs on the refrigerator had a total of 5 entries for June. The Dietary Manager queried where the dishwasher logs were located and the Dietary Manager stated he didn't have them at the moment. The thermometers for two refrigerators in the main kitchen registered a temperature of 45 degrees F. The thermometer for the refrigerator on the counter by the handwashing sink log registered a temperature of 48 degrees F. During an observation on 7/1/25 at 8:52 a.m., Staff E, Dietary Aide/Cook queried where the test strips were located for the dishwasher and she stated she didn't know where they were. During an observation on 7/1/25 at 8:58 a.m., the Dietary Manager found the test strips for the dishwasher and after a cycle run for testing the strip read 25 parts per million (ppm). The color on the strip was light purple. The Dietary Manager stated [name redacted] was in a couple months ago and did some adjustments. The Dietary Manager asked about the dishwashing logs and he provided them. The Dietary Manager confirmed the refrigerator and freezers temperatures were not being completed even though he told his staff to do them. The Dietary Manager queried on providing the manufacture instructions for the dishwasher and he stated he couldn't because the dishwasher had been here longer than he was. The Dietary Manager asked if he would talk with someone about providing the manufacturer instructions and he stated yes, he would. During an observation on 7/1/25 at 11:10 a.m., Staff E temped the alternate main dish of smashed burgers. Staff E cleaned the thermometer and lifted the trash lid with her bare hands and placed the wipes in the trash can and then the lifted the trash can lid again to place another wipe in it and the side of the thermometer touched the top of the trash lid. Staff E continued to temp the smashed burgers and did not wash her hands or the clean the thermometer after it touched the trash lid. During an interview on 7/1/25 at 11:34 a.m., the Dietary Manager queried on the plan for the dishwasher and the Dietary Manager stated he placed a call to the company who fixed it and the staff would need to hand sanitize the dishes until the sanitizing up to a target 50 PPM. The Dietary Manager queried on problems with the dishwasher and he stated no, not until now. During an observation on 7/1/25 at 11:37 a.m., the thermometer for refrigerator on the corner by the handwashing sink temperature read 52 degrees F. During an observation on 7/1/25 at 11:45 a.m., the Dietary Manager used a different test strip roll and ran a dishwasher cycle and retested the sanitizer and the Dietary Manager stated the strips got darker. The color on the strip was between the 25 PPM and the 50 PPM. The Dietary Manager confirmed the test strip not dark enough and the staff would not use the dishwasher until it was fixed. During an observation on 7/1/25 at 12:10 p.m., the thermometer for the refrigerator on the counter of the kitchen by the handwashing sink temperature read 55 degrees F. During an interview on 7/1/25 12:41 p.m., Dietary Manager queried on the temperature of the refrigerator next to the handwashing sink and he stated the refrigerator settled down after meal services and he had the coils cleaned a few weeks ago. The Dietary Manager stated he instructed staff to limit their use of the refrigerator and keep the doors closed. The Dietary Manager stated he would keep an eye on it and would shuffle items to the other refrigerator. During an interview on 7/1/25 at 1:05 p.m., the Administrator notified of the dishwasher sanitizer strips not meeting the required level and the Administrator stated she would speak to the Dietary Manager and see what was going on.During an interview on 7/1/25 at 1:32 p.m., the Administrator stated the dishwasher strip was at 50 PPM and showed a picture on her phone that was close to 50 PPM on the strip. The Administrator stated the facility would use paper plates until [name redacted] came to the facility and looked at the dishwasher. During an interview on 7/1/25 at 1:45 p.m., the Dietary Manager stated he fixed the problem and the dishwasher was working, because he adjusted the tubing. During an interview on 7/1/25 at 1:53 p.m., the Dietary Manager tested a test strip on the dishwasher and the strip read under 50 PPM. The Dietary Manager checked the sanitizer again and the strip still did not read at least 50 PPM. The color of the strip continued to look light purple/lilac. While the Dietary Manager checked the dishwasher, staff put dishes away that were placed on the dishwasher racks. The Dietary Manager stated the facility would use paper plates and he instructed the staff to clean the dishes and put them away and they would rewash the dishes when the dishwasher was fixed. During an observation on 7/1/25 at 1:53 p.m., the thermometer for refrigerator by the handwashing sink temperature read 55 degrees F. The Dietary Manager confirmed the refrigerator not cooling down and they needed to move items out of it. The refrigerator door opened and observed the thermometer on the inside of the refrigerator, which registered a of 60 degrees F. During an observation on 7/1/25 at 2:56 p.m., no staff present in the kitchen. The refrigerator temperature by the handwashing sink read 56 degrees F. Opened the door to the refrigerator and the refrigerator still had cups and pitches with beverages in them. On 7/1/25 at 2:58 p.m., the Director of Nursing notified and observed the temperature of the refrigerator by the handwashing sink in the kitchen at 56 degrees F and beverages still in the refrigerator. On 7/1/25 at 3:03 p.m., the Dietary Manager stated the drinks in the refrigerator had been warm for too long and would be dumped and all the other items in the refrigerator had been moved to another refrigerator. On 7/2/25 at 8:22 a.m., the Dietary Manager stated [name redacted] came in last night and fixed the dishwasher and [name redacted] was also coming in today to check the dishwasher again. The sanitizer on the dishwasher checked and the strip read 50 PPM. The Dietary Manager stated he cleaned the coils on the refrigerator this morning and the temperature held steady at 38 degrees F. Upon observation, the refrigerator temperature 41 degrees F. The Dietary Manager stated he would watch the temperature and make sure it didn't go up before placing anything in it. During an interview on 7/2/25 at 8:28 a.m., Staff E, Dietary Aide/Cook queried on how the dishwasher sanitizer is checked and she stated she didn't know who checked it and Staff E never had checked it. Staff E asked what she did when she needed to lift the lid to the trash can and Staff E stated she would wash her hands. Staff E informed of the observation of her touching the trash lid with her hands and the thermometer touching the trash lid and Staff E did not deny she didn't wash her hands before temping the smashed burgers. Staff E queried on how completed the temperature logs on the refrigerators and Staff E stated the cooks did them. Staff E asked about the refrigerator by the handwashing sink and Staff E stated they moved everything out of it. and since the weather has been hot outside the temperature fluctuated. Staff E stated she didn't know exactly when the refrigerator temperatures started fluctuating. Staff E stated the staff informed the Dietary Manager when the temperature in the refrigerator went up. Staff E asked who did the deep cleaning the deep freeze and Staff E stated Staff F usually done it. During an interview on 7/2/25 at 9:54 a.m., Staff G, Dietary Aide queried on how the temperatures for the refrigerators are checked and logged and she stated usually the cooks do the checks. Staff G queried on the higher temperature of the refrigerator by the handwashing sink and she stated she noticed it in the last few weeks and in the cooler months they don't have issues. Staff G asked if she checked the sanitizer in the dishwasher and Staff G stated no, she never had and didn't know who did. Review of the invoice for the dishwasher repair dated 7/2/25 at 10:02 a.m. revealed the following: e-call sanitizer not hitting 50 ppm, came in found drain solenoid had dropped down not draining as it should, adjusted solenoid. Titration levels look good now, showed state 75 ppm.During an interview on 7/2/25 at 10:08 AM, Staff F, Dietary [NAME] queried on how checked and logged the temperatures on the refrigerators and she stated the temperatures needed done in the morning and the evening and she was not good at doing it. Staff F stated the temperature on the refrigerator always looked good in the morning and as the progressed the temperatures plummeted with the heat outside. Staff E stated the temperatures of the refrigerators should be at 34 degrees F. Staff F queried on who defrosted the freezer and Staff F stated it usually fell on the Dietary Manager. Staff F stated when she was the Dietary Manager, Staff F did it once a month. Staff F stated it had been at least 3 months since the last time the deep freeze was cleaned and it needed done. During an interview on 7/3/25 at 12:28 PM, the Dietary Manager asked about the temperature logs for the refrigerator and he confirmed they were not getting done. The Dietary Manager queried on the dishwasher log and he stated he didn't know if someone was color blind, but he explained to staff where the strip color should be. The Dietary Manager confirmed problems with the sanitizer in the dishwasher at the beginning of the week, but now everything worked properly. The Dietary Manager asked about the deep freeze cleaning schedule and the Dietary Manager stated it is cleaned once a month by him or one of the cooks. The Dietary Manager stated he believed they cleaned the freezer within the last month on a Wednesday but he didn't know the date or who cleaned it. The Dietary Manager informed of the cook touching the trash can lid with their hands and the thermometer touching it and the Dietary Manager stated staff need to wash their hands after touching the lid and he needed to reeducate the staff. The Dietary Manager asked about the refrigerator logs and one of the logs documented 48 degrees and the Dietary Manager stated the cooks were supposed to check and log the temperatures in the morning before they started using them and, in the evening, before they leave for the night. The Dietary Manager stated he instructed staff if a temperature is out of range not to write it down, but to come to him so the appliance could be looked at. Review of the facility policy titled Sanitization Policy, revised October 2008 revealed a Policy Statement which declared The food service area shall be maintained in a clean and sanitary manner. The Policy Interpretation and Implementation section directed the following, in part: 8. Dishwashing machines must be operated using the following specifications:Low-Temperature Dishwasher (Chemical Sanitization)a. Wash temperature (120 degrees F)b. Final rinse with 50 ppm hypochlorite (chlorine) for at least 10 seconds.17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Review of the facility policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices revised on October 2017 revealed a Policy Statement which declared Food and nutrition service employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The Policy Interpretation and Implementation section directed the following, in part: 6. Employees must wash their hands:f. After handling soiled equipment or utensilsh. After engaging in other activities that contaminate the handsReview of the facility policy titled Refrigerator and Freezers Policy revised December 2014 revealed a Policy Statement which declared This facility safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The Policy Interpretation and Implementation section directed the following, in part: 1. Acceptable temperatures ranges are 35 degrees F to 40 degrees F for refrigerators and less than 0 degrees F for freezers. 2. monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted.
Aug 2024
2 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews the facility failed to ensure a residents clothing f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews the facility failed to ensure a residents clothing fit properly and in good repair as to provide personal privacy while in common areas of the facility for 1 of 12 (Resident #6) residents reviewed. The facility reported a census of 47 residents.
Findings include:
The Minimum Data Sample (MDS), dated [DATE], for Resident # 6 revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognition. The MDS listed diagnoses included: non-Alzheimer's dementia, anxiety disorder, and depression.
During an observation on 8/13/24 at 12:21 PM, Resident # 6 used his wheelchair to propel the hallway near his room. Resident #6 had a tear in his pants from his groin to his knee, with an adult incontinence brief visible through the tear.
During an interview on 08/15/24 at 09:39 AM, Resident # 6 stated his clothes do not fit properly, most of them are torn, and need to be thrown out.
During an interview on 08/15/24 at 10:16 AM, Staff F, Certified Medication Aide (CMS), stated CMA's and Certified Nursing Assistants (CNA's) are look at a residents clothing when they are assisting with dressing , and report any clothing needs to nursing or Social Services. She acknowledged Resident # 6 required new clothing, and stated he is on the the list of people they look for clothes for when they get clothing donations from staff or the community. Staff F stated if the resident were to come out of his room undressed or with holes in his clothing staff are directed to assist the resident back to his room and help him dress appropriately. If the resident were to refuse, they are to tell the charge nurse and have them document the episode in the electronic health record's progress notes. She acknowledged that if there was no charting done, she believes that an episode of refusal did not occur.
During an interview on 08/15/24 at 10:21 AM . Staff G, CNA acknowledged Resident # 6 needs new clothes. She stated he had very few pairs of pants. She stated the expectation is for staff to assist a resident back to their room if they are not wearing clothes, wearing clothes improperly, or wearing clothes with revealing rips, holes, or tears. If the resident refused assistance they are to tell the nurse and have them document the behavior.
During an interview on 08/14/24 at 02:31 PM, Staff E, Social Services acknowledged Resident # 6 is in need of new clothing. She stated he is on their donations list, having received a donation of clothing and shoes earlier in the year. She stated the facility is responsible for contacting Resident # 6's Power of Attorney to inform them that he is in need of new clothes. She indicated she did not know when the last time a request for new clothing had been made. She stated there is no formal system to assess clothing needs for cognitively impaired residents. She noted housekeeping does an initial inventory of resident clothing and CNAs are then responsible for informing social services or nursing staff of a residents needs.
During an interview on 08/14/24 at 08:52 AM , the Administrator stated it is her expectation if a resident was moving around the facility with significant holes in their pants or shirts the CNAs or nursing staff would direct the resident to their room and assist them in dressing more appropriately. If the resident refuses, the expectation is that the CNAs or nursing staff document this refusal. She acknowledged the resident is on a clothing donation list.
A review of Nursing Progress Notes revealed a note, dated 6/12/23, documenting contact with Resident #6 Power of Attorney. No further documentation of contact with the Power of Attorney found in the clinical record.
The facility provided documentation indicating Resident #6 last received a clothing donation on 02/02/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected 1 resident
Based on document review, and staff interviews the facility failed to employ a Certified Dietary Manager to carry out the functions of the food and nutrition service. The facility reported a census of...
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Based on document review, and staff interviews the facility failed to employ a Certified Dietary Manager to carry out the functions of the food and nutrition service. The facility reported a census of 47 residents.
Findings include:
During an interview on 08/13/24 at 11:00 AM, the Dietary Supervisor stated she did not have education and training completed to be a Certified Dietary Manager. She stated she enrolled and began the class to be certified over a year ago but had not completeted the course work.
A review of the Dietary schedule for July 21, 2024 to August 3, 2024 revealed the Dietary Supervisor scheduled to work: 7/21/24, 7/23/24, 7/24/24, 7/28/24, 7/29/24, 7/30/24, and 8/3/24.
During an interview on 08/13/24 at 3:30 PM, the Administrator confirmed the facility did not employ a Certified Dietary Manager but had her enrolled in the program to become a Certified Dietary Manager.
Apr 2024
2 deficiencies
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
Based on facility record review, staff interviews, and hospital record review, the facility failed to ensure residents were appropriately assessed and provided interventions to maintain their optimal ...
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Based on facility record review, staff interviews, and hospital record review, the facility failed to ensure residents were appropriately assessed and provided interventions to maintain their optimal health and well being for 1 of 3 residents reviewed (Resident #1). The facility reported census was 44 residents.
Findings include:
According to a Minimum Data Set (MDS) with a reference date of 2/16/24, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognitive status. Resident #1 had been independent with ADL's, but following a fall with fracture, was dependent on staff with transfers (Hoyer), mobility (W/C), dressing, toilet use, and personal hygiene needs. Resident #1's diagnoses included fracture right femur, myopia.
A Progress Note dated 3/29/24 found Resident #1 returned from the hospital following a fall and fractured right femur. Resident #1 was placed on an opioid for pain control, and according to the VS.weight.BM document, had no recorded bowel movements since her return through 4/2/24.
A Progress Note written by Staff A, Registered Nurse, on 3/29/24, indicated Resident #1 had very active bowel sounds in all 4 quadrants upon re-admission.
A Progress Note written by Staff B, Registered Nurse, on 4/3/24 at 12:34 p.m. indicated Resident #1 refused to eat lunch and received a new standing order for constipation, Senna S 2 tabs twice daily and Bisacodyl suppository 10 mg rectally as needed daily.
In an interview on 4/16/24 at 1:15 p.m. Staff B, Registered Nurse, stated she usually works from 6:00 a.m. to 2:00 p.m. Staff B stated she recalls on 4/3/24, Resident #1 complaining of stomach discomfort, abdominal distention and constipation. Staff B stated she updated the physician of the resident's condition and wrote a standing order for Senna and a Bisacodyl suppository. Staff B stated the Senna and Bisacodyl suppository was not in stock, so they would have to wait for the pharmacy delivery that evening. Staff B stated she informed Staff C at shift change report. Staff B stated the next day (4/4/24), Resident #1 continued to have stomach discomfort and abdominal distention. Staff recalled being informed that the suppository administered was not effective, which prompted her to obtain an order for a fleets enema, which was again not in stock and was not administered during her shift. Staff B stated she did not attempt another suppository or assess Resident #1 for impaction.
A Progress Note written by Staff C, Licensed Practical Nurse, on 4/3/24 at 5:01 p.m. indicated Resident #1's abdomen was hardened, Resident #1 had an emesis and was complaining of stomach pain. Staff C indicated Resident #1 was found to be impacted and Staff C digitally removed the impaction, noting a large amount of hardened, dark stool was removed.
A Progress Note written by Staff C, Licensed Practical Nurse, on 4/3/24 at 5:54 p.m. indicated Resident #1 was delivered a room tray and Resident #1 only wanted drinks. Orange juice and prune juice were provided.
A Progress Note written by Staff D, Licensed Practical Nurse, on 4/4/24 5:30 a.m. indicated Resident #1 had a large liquid brown emesis last evening and her abdomen remained distended. Staff D administered a suppository (8:00 p.m. on Medication Administration Record (MAR)) indicating only a smear resulted.
In an interview on 4/16/24 at 1:00 p.m. Staff C, Licensed Practical Nurse, stated he generally works 6:00 a.m. to 6:00 p.m. and recalls Resident #1 having trouble with her bowels, stomach pain, and distention. On the evening of 4/4/24, Staff C checked Resident #1 for impaction and removed a large amount of hard stool. Staff C stated he remembered hearing in report that there was an order for Senna, but did not recall being informed of the order for a suppository. Staff C stated he had Resident #1 remain in bed during his shift.
A Progress Note written by Staff B, Registered Nurse, on 4/4/24 at 8:22 a.m. indicated Resident #1 was still complaining of discomfort to abdomen and abdomen remained distended. No emesis noted at breakfast. Staff B indicated she contacted the physician's office to update on Resident #1's condition. Resident #1 was encouraged to drink fluids.
A Progress Note written by Staff B, Registered Nurse, on 4/4/24 at 11:06 a.m. indicated Resident #1 had a small greenish emesis after lunch.
A Progress Note written by Staff B, Registered Nurse, on 4/4/24 at 1:18 p.m. indicated new orders received for Zofran ODT 4 milligrams every six hours as needed (nausea), Miralax twice daily (laxative), and a one time order for a fleets enema. Pharmacy notified to ensure Miralax and fleets enema would be delivered on evening run.
In an interview on 4/16/24 at 3:30 p.m. Staff F, Certified Medication Aide, stated she was working the evening shift on 4/4/24. Staff F stated Resident #1 was not feeling well and had reportedly vomited a couple of times that morning. Resident was complaining of her neck brace. Staff F recalls Resident #1 getting an enema, but she was not in the room.
In an interview on 4/16/24 at 3:19 p.m. Staff E, Certified Nurse Aide, stated she recalls Resident #1 having bowel discomfort on 4/3/24 and 4/4/24. Resident #1 was stating she needed to have a bowel movement. Staff E stated Resident #1 was questioning things as she always does. Resident #1's abdomen was hard and distended. Staff E stated they tried pushing fluids to help her out.
A Progress Note written by Staff H, Licensed Practical Nurse, on 4/4/24 at 9:15 p.m. indicated fleets enema delivered by pharmacy and administered with a moderate amount of soft stool expelled.
In an interview on 4/16/24 at 4:38 p.m. Staff H, Licensed Practical Nurse, stated she was working a 6:00 p.m. to 6:00 a.m. shift on 4/4/24. Resident #1 had been sick earlier with bowel issues. Staff H indicated Resident #1 had gotten up for supper, but didn't eat much. They were able to get her to drink some prune juice. Staff H stated she received the fleets enema from pharmacy and administered it, feeling like she had good results. Resident #1 had a medium amount of soft stool expelled and her abdomen was less rigid afterwards and stated she was feeling better. Staff H stated Resident #1's bowel issues was a high priority. Staff I, Registered Nurse, stated Resident #1 had no further bowel movements that evening and seemed to sleep ok. Staff I stated she did not assess Resident #1 before leaving that morning.
In an interview on 4/17/24 at 11:35 a.m. Staff G, Certified Nurse Aide, stated she worked 6:00 a.m. to 2:00 p.m. on 4/5/24 and provided care for Resident #1. Staff G stated that morning her and another aide changed and dressed Resident #1. Resident #1 had a small bowel movement. Resident #1 was awake and talkative, but mumbling and not speaking in full sentences. Staff G stated Resident #1 was not complaining of pain, but may have gotten a pain medication earlier. Resident #1 was transferred per Hoyer lift into her wheelchair and propelled to the dining room. Resident #1 took a few bites of food and drank all of her fluids. Resident #1 was having difficulties staying upright in her chair and was falling asleep, all of which was unusual. After breakfast at around 8:30 a.m. they laid Resident #1 back into bed. Staff G stated Resident #1's abdomen was very distended and hard. Staff G stated she informed the nurse, Staff A, of Resident #1's inability to stay upright and her mumbling. Staff G stated she thought Resident #1 had an enema that morning, but wasn't sure. At around 9:15 a.m. Resident #1 was playing with her call light and noticeably groggy and not making sense. Staff G stated she again reported this to their nurse, Staff A. At 10:30 a.m. Staff G checked on Resident #1, noting she remained dry, but was very warm and sweating. Staff G stated she removed Resident #1's long sleeve shirt and placed her in a gown. Staff G stated she also removed her socks and noticed her feet were slightly mottling. Staff G stated she reported Resident #1's condition to their nurse, Staff A, who agreed with Resident #1 remaining in bed for lunch. At around 11:30 a.m. Staff G stated she passed room trays. She stated she was able to get Resident #1 to eat a few bites of yogurt and dessert and a few sips of water. It was around this time the DON came in and asked how Resident #1 was doing. Staff G stated she reported her observations. At around 12:00 p.m. Staff G stated she checked on Resident #1 and she was dry and a tiny bit responsive. Her head of bed was at 45 degrees. From 12:30 p.m. to 1:30 p.m. Resident #1 remained in bed and unresponsive.
A Progress Note written by Staff A, Registered Nurse, on 4/5/24 at 1:30 p.m. indicated Staff A checked on Resident #1 after she had not come to the dining room for lunch. Resident #1' s vital signs were temperature 93.9, pulse 44, respirations 26, blood pressure 111/28 and unable to get an oxygen saturation level.
In an interview on 4/17/24 at 2:00 p.m. Staff A, Registered Nurse, stated she was working the day shift on 4/5/24 after being off a few days prior. Staff A stated it was reported to her that Resident #1 was having bowel issues and they had administered an enema to try and resolve the issue. Staff A stated that morning after breakfast she completed an assessment, including vital signs on Resident #1. Resident #1's abdomen was distended and hard, but not sore. Staff A stated she had no concerns and no further contact with Resident #1 until after lunch at about 11:30 a.m. It was at that time Staff A went to Resident #1's room because she did not come out for lunch. Staff A stated she checked her vital signs which were concerning and initiated oxygen, but noted Resident #1 was talkative and alert. Staff A stated the DON and Staff I also came into the room and together they dealt with Resident #1. At 2:10 p.m. the physician was notified and gave an order to send Resident #1 out for evaluation. When asked why there was a delay over a 2 hours before sending Resident #1 to the hospital, Staff A provided no explanation.
A Progress Note written by Staff I, Registered Nurse, on 4/5/24 at 1:36 p.m. indicated Staff I was called to Resident #1's room by the Director of Nursing (DON). Blood pressure again checked and was 80/20. Unable to obtain an oxygen saturation level. Oxygen administered at 2 liters per minute per nasal canula with head of bed elevated. Resident #1 had audible gurgling. Physician notified and updated and family notified of Resident #1's condition.
A Progress Note written by Staff A, Registered Nurse, on 4/5/24 at 2:30 p.m. indicated Resident #1's physician was updated on her condition and Resident #1 was requesting to go to the hospital. At 2:10 p.m. Staff A was given orders to send Resident #1 to the hospital.
A Progress Note written by Staff A, Registered Nurse, on 4/5/24 at 2:34 p.m. indicated the ambulance arrived at 2:30 p.m. Resident #1 vital signs were obtained and Resident #1 was placed on a gurney and left just prior to 3:00 p.m.
In an interview on 4/17/24 at 1:30 p.m. the Director of Nursing (DON), stated Resident #1 was not the same after her fall and fractured right femur. Resident #1 seemed more anxious and needy. The DON stated she met with Resident #1 in an attempt to relieve her anxiety. The DON stated Resident #1 had always had a pot belly, as if she was pregnant. On 4/3/24, Staff B, reported Resident #1 was constipated and having episodes of emesis. Resident #1 was encouraged to stay active, eat and drink plenty of fluids. Nothing seemed to be helping and on 4/4/24 they got an order for an enema. That evening Resident #1 was up for supper and ate a few bites. The enema was given with seemingly good results. The next morning the DON stated she spoke with Resident #1 and she seemed to be fine. The DON stated Resident #1 was having difficulties keeping her head up with her c-collar on, so she was searching for a high back wheelchair around lunch time. The DON stated Staff A reported Resident #1 was placed on oxygen and her vital signs were not good. The DON stated she got Staff I and together they checked Resident #1's blood pressure. Resident #1's feet were mottled and Staff I contacted Resident #1's son to report her condition. The son then spoke with the social worker and DON and decided he wanted his mother sent to the hospital. The DON stated when she observed the feet mottling, she felt death was imminent.
In an interview on 4/17/24 at 12:30 p.m. Staff K, Certified Medication Aide, stated on the morning of 4/5/24, she passed Resident #1's morning medications. Staff K stated the medications were crushed due to Resident having difficulties swallowing. Staff K stated Resident #1 stated she was in pain and ready to go. Staff K stated she did not recall anything else about that morning.
In an interview on 4/17/24 at 11:20 a.m. Staff J, Certified Nurse Aide, stated on 4/3/24 and 4/4/24 Resident #1 seemed her normal self. Resident #1 was talkative and stated her stomach felt hard and bigger. Staff J stated Resident #1's abdomen was very distended. Staff J stated Resident #1 had a medium bowel movement noted in her brief on the morning of 4/3/24 and a small bowel movement during a transfer on the morning of 4/4/24.
According to the Prehospital Care Report (Emergency Medical Services (EMS) dated 4/5/24, EMS was on scene at 2:22 p.m. They were dispatched on report of a resident (Resident #1) being cold and clammy with depressed oxygen and blood pressure levels. Resident #1 was lying in bed, supine with a c-collar on. Staff report resident was alert and oriented and acting her normal self at breakfast this morning. Staff reports placing Resident #1 on oxygen at 2 liters per minute per nasal canula. Resident #1 is unresponsive, breathing normally, but oxygen saturation is at 67% when removed from oxygen. Resident #1 is cool and clammy. Hands and feet are purple in color. Resident #1 is hypotensive, eyes fixed and not responsive. Placed on a gurney and oxygen added at 10 liters per minute.
According to the hospital Emergency Department (ED) Provider Note dated 4/5/24, Resident #1 was brought in for evaluation and was unresponsive and showing signs of mottling in her extremities. Resident #1 was felt to be in the dying process. Resident #1 was dramatically hypotensive, possible septic and mildly hypoxic. ED Course: It was decided given her current picture that comfort measures would be most appropriate, and these were initiated, but she ended up passing away in the ER.
CONCERN
(F)
📢 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 F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, the facility failed to provide an effective rodent control program within the facility. ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, the facility failed to provide an effective rodent control program within the facility. The facility reported census was 44 residents.
Findings include:
In an interview on 4/18/24 at 10:40 a.m. Staff N, Housekeeper, stated she has worked at the facility for three months and during that time mouse infestation has been an on-going issue. Staff N stated she had observed multiple mice in resident rooms and frequently sees droppings when sweeping. Staff N stated just today she swept up mouse droppings in room [ROOM NUMBER] on B-hall. Staff N stated they are to check the glue traps daily, but noted it had been so bad the mice are chewing on the traps and don't seem to be sticking to the glue. Staff N stated the residents in room [ROOM NUMBER] and 113 on B-hall have both complained about seeing mice in their room. Staff N stated she heard an aide, Staff M, witnessed seeing a mouse on the lap of a resident in room [ROOM NUMBER] on B-hall.
In an interview on 4/18/24 at 1:30 p.m. Staff M, Certified Nurse Aide, stated a couple of weeks ago, she witnessed a mouse on the lap of a resident sitting in his room.
In an interview on 4/18/24 at 11:00 a.m. Staff O, Housekeeping Supervisor, stated she had worked at the facility for several years and recently returned and had never seen the mice like they have seen this year. Staff O stated in early February they began seeing mice and contacted their pest control provider. The provider placed poison on the exterior of the building and glue traps were provided for the interior. Staff O stated initially they were catching 5-7 mice a day, mostly on B-hall. It has since slowed down. Staff O stated some of the issue is related to room [ROOM NUMBER]. The resident has food brought in, trash on his floor, and will not allow housekeeping in to clean his room routinely.
In an interview on 4/18/24 at 10:20 a.m. Staff P, Dietary Supervisor, stated in the last month she had a couple of dietary staff see mice in the kitchen area. Staff P stated she had also seen mouse droppings near the storage shelves and kitchen. Staff P stated about six weeks ago she saw a mouse in the break room and reported her concerns to their maintenance and housekeeping supervisor and was provided glue traps. Staff P stated she removed the food from the bottom shelf and has placed several glue traps in the kitchen area.
During an observation and interview on 4/18/24 at 10:50 a.m. Resident #4 (room [ROOM NUMBER]) was sitting up in his recliner with the TV on. Resident #4 stated he sees mice in his room all of the time and the staff does nothing about it. Resident #4 was agitated. A Minimum Data Set (MDS) completed 3/8/24 noted Resident #4 with a Brief Interview for Mental Status score of 15 out of 15, indicating an intact cognitive status.
During an observation and interview on 4/18/24 at 10:40 a.m. Resident #5 (room [ROOM NUMBER]) was lying on his bed. There was a noticeable odor in the room and the door was covered with trash, boxes, and belongings. Resident #5 stated he often hears and sees mice in his room. A Minimum Data Set completed 3/8/24 noted Resident #5 with a Brief Interview for Mental Status score of 13 out of 15, indicating an intact cognitive status.
Feb 2024
19 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
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, policy review, and staff interview, the facility failed to honor a resident's food and beverage preferences for 1 of 16 residents reviewed during dining s...
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Based on observation, clinical record review, policy review, and staff interview, the facility failed to honor a resident's food and beverage preferences for 1 of 16 residents reviewed during dining services (Resident #1). The facility reported a census of 47 residents.
Findings include:
The facility policy Resident Food Preferences, revised July 2017, stated individual food preferences would be assessed upon admission and communicated to the interdisciplinary team and the Food Services Department would offer a variety of foods at each scheduled meal.
The Care Plan approach dated 1/27/22 directed staff to encourage fluids throughout the day.
The Minimum Data Set (MDS) assessment tool, dated 11/24/23, listed diagnoses for Resident #1 which included cerebrovascular accident(stroke), schizophrenia, and hypertension(high blood pressure). The MDS stated the resident was independent with eating and listed her Brief Interview for Mental Status(BIMS) score as 5 out of 15, indicating severely impaired cognition.
On 2/13/24 at 8:30 a.m., observed the resident sitting at the breakfast table and she asked Staff E Certified Nursing Assistant(CNA) what was in one of her bowls and Staff E stated it was oatmeal. The resident stated she did not like oatmeal and Staff E told the resident she also had eggs. Staff E did not offer to bring the resident another breakfast item. At 8:34 a.m. observed Staff J CNA sit down at the table and the resident stated that she wanted a cup of coffee. Staff J smiled at the resident but did not provide her with a cup of coffee. The resident then took a bite of her eggs but said it was too hot and Staff J told the resident she also had oatmeal. The resident stated she did not like oatmeal. Staff J did not offer the resident an alternative to the oatmeal and the resident ate only eggs for her breakfast meal.
On 2/14/24 at 9:54 a.m., observed the resident sitting in an activity and drinking coffee.
On 2/19/24 at 2:08 p.m., the Director of Nursing(DON) stated if a resident did not like her meal, staff would offer them something different.
CONCERN
(D)
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 observation, clinical record review, staff interviews, and policy review the facility failed to notify a resident's responsible party and hospice provider in a timely manner when an injury oc...
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Based on observation, clinical record review, staff interviews, and policy review the facility failed to notify a resident's responsible party and hospice provider in a timely manner when an injury occurred for 1 of 3 residents reviewed (Resident #46) for notification. The facility reported a census of 47 residents.
Findings include:
The Minimum Data Set (MDS) for Resident #46 dated 1/5/24 indicated a significant change related to a decline in health and the start of hospice care. It included diagnoses of heart failure, post traumatic stress disorder, and chronic obstructive pulmonary disease. The Brief Interview for Mental Status documented a score of 7 which indicated severe cognitive impairment.
The Care Plan with a care conference date of 12/7/23 documented impaired decision making and a history of falling related to dementia with a hospice consult on 12/28/23.
On 2/12/24 at 1:07 PM observed the resident finished meeting with a hospice provider and laying in bed. Resident #46 stated his knee hurt. He pulled up the bottom of his covers and pant leg to show an open wound about the size of a dime on his knee. The wound appeared moist and there was dried blood on 3 separate sections of the sheet similar in size to the wound. The resident also had a wound to his right eye near his eyebrow.
On 2/12/24 at 1:11 PM Staff I, RN, stated she was not aware of the injury to the resident's knee and didn't know if it was related to the eye injury.
A hospice document titled Hospice IDG Comprehensive Assessment and Plan of Care Update Report faxed on 2/9/24 indicated symptoms being managed for the resident included pain and falls, and safety concerns included risk for falls.
The Progress Note dated 2/12/24 at 3:00 AM documented Resident #46 attempting to get out of bed when the nurse entered the room. He went to the bathroom alone and staff observed him using the toilet. The nurse noted the resident had blood in the bed, all over face and hands, and a small amount on the floor. A 2 cm x .2 cm laceration was noted on the resident's right eyebrow with mild purple bruising. The resident was unable to state the cause. Care provided and the provider notified. The note failed to indicate notification of family or hospice.
The Progress Note dated 2/12/24 at 3:34 PM noted blood on the resident's sheets. The resident had a skinned knee. When he pulled the sheets back it caused the sore to bleed. Care provided and the provider notified. The note failed to indicate notification of family or hospice.
An untitled document used to track wound treatment, dated 2/12/24, documented communication to the Director of Nursing (DON) regarding the eye injury. It failed to include notification of the family or hospice. The facility failed to create a skin document for the knee injury.
On 2/15/24 at 11:31 AM the DON stated staff should initiate neurological assessments for unwitnessed incidents. Staff should contact a responsible party, the provider, and in this case hospice. On 2/19/24 at 12:26 PM the DON confirmed by email that she was unable to find anything that documented the resident's wife was notified of the incident(s) leading to injury on 2/12/24.
An undated policy titled Falls documented the charge nurse, DON, and Administrator are responsible for falls. The policy ensured a thorough assessment was completed and appropriately documented with interventions to prevent future falls. Procedure #6 specified to notify the physician and family.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on clinical record review, policy review, facility document review, and staff interviews, the facility failed to ensure a resident was free from physical abuse for 1 of 2 residents reviewed for ...
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Based on clinical record review, policy review, facility document review, and staff interviews, the facility failed to ensure a resident was free from physical abuse for 1 of 2 residents reviewed for abuse (Resident #38). The facility reported a census of 47 residents.
Findings include:
The facility policy Abuse, revised 8/31/16, stated the facility would not permit residents to be subjected to abuse by any person and defined abuse to include willful infliction of injury.
The Minimum Data Set (MDS) assessment tool, dated 12/1/23, listed diagnoses for Resident #38 which included hypertension, depression, and hyperlipidemia (a high level of fat in the blood). The MDS stated the resident required partial to moderate assistance for bathing, dressing, and personal hygiene. The MDS stated the resident had physical behavioral symptoms directed toward others such as hitting and kicking 4-6 days during the 7 day review period and displayed rejection of care daily. The MDS listed the resident's cognition as severely impaired.
Care Plan entries, dated 12/7/23, documented the resident often became aggressive during cares and directed staff to use a calm voice and reassure her staff was taking care of her.
A 12/27/23 written statement by Staff M Certified Nursing Assistant(CNA) stated she and Staff N CNA walked Resident #38 into the shower room and asked her to start getting undressed. The resident started fighting and hit Staff N and attempted to bite both Staff N and Staff M. Staff N told the resident that was not nice and smacked the resident on the head. Staff N immediately apologized to the resident. Staff M then assisted the resident with showering while Staff N left the immediate area.
On 2/12/24 at 2:00 p.m., Staff M CNA stated on the day of the incident the resident tried to bite Staff N and Staff N hit her with an open hand and after Staff N said oh my God, I am so sorry. Staff M stated the hit was on the upper forehead and hair and made a smack sound when it happened. Staff M did not see any redness to the area and stated she reported this to the Director of Nursing (DON) and Staff N was subsequently fired.
On 2/13/24 at 10:00 a.m., Staff N CNA stated that she and Staff M CNA tried to get the resident's clothes off prior to a shower and the resident hit her on the arm multiple times. Staff N stated she hit the resident on the top of her head and described it as between a tap and a hit. She stated this was an immediate reaction and she felt frustrated. She stated the hit did not make a noise and did not cause any redness or bruising. She stated the hit was on the top of the resident's head on her hair. Staff N stated she never hit her before and she was very sorry this all happened.
On 2/19/24 at 2:08 p.m., the DON stated on the day of the incident a CNA reported that the resident bit Staff N and Staff N bopped her on the head. The DON stated she and the Administrator then assessed the resident and pulled Staff N off the floor. The DON stated she expected staff to treat residents with kindness, respect, and patience.
On 2/19/24 at 3:27 p.m., the Administrator stated regarding the incident that Staff N did not deny that she hit Resident #38. She stated they removed Staff N from the unit.
An undated written statement by the DON stated Staff N was immediately relieved of her duties at the time of the incident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual revised October 2023 documented an RAI must be completed for any resident residing in a facility (p. 2-3) and quarterly assessments must be transmitted no later than 14 days after the (Minimum Data Set) MDS completion date (p. 2-18).
The Resident Face Sheet for Resident #29 indicated the resident most recently admitted [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (stroke), generalized anxiety disorder, and essential (primary) hypertension.
A review of the resident's quarterly MDS assessments in the electronic health record revealed a quarterly assessment dated [DATE] remained in process and had not been submitted to CMS as of 2/15/24 at 2:42 PM.
An interview with the Director of Nursing on 2/15/24 at 12:42 PM confirmed there were resident MDS assessments they were trying to get done and this one should have been done. She stated this submission oversight was probably on her and they are getting there.
3. The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual revised October 2023 documented an RAI must be completed for any resident residing in a facility (p. 2-3) and quarterly assessments must be transmitted no later than 14 days after the (Minimum Data Set) MDS completion date (p. 2-18). Discharge Assessments with return anticipated must be transmitted no later than 14 calendar days after the MDS completion date (p. 2-19).
The Resident Face Sheet for Resident #41 indicated the resident admitted [DATE] with the latest return date of 10/11/23 and diagnoses of periprosthetic fracture around other internal prosthetic joint (hip fracture after repair), chronic atrial fibrillation (irregular often rapid heart rhythm), and dementia.
A review of the resident's MDS documentation in the electronic health record revealed a discharge MDS with return anticipated dated 10/1/23 and a quarterly assessment dated [DATE] remained in process and had not been submitted as of 2/15/24 at 2:41 PM.
An interview with the Director of Nursing on 2/15/24 at 12:42 PM confirmed these were additional assessments that needed to be completed.
Based on clinical record review, staff interviews, and facility policy review, the facility failed to complete Minimum Data Set (MDS) assessments on time for 3 of 14 residents reviewed for MDS assessments (Resident #2, #29, and #41). The facility reported a census of 47 residents.
Findings include:
1. The MDS Quarterly assessment dated [DATE] for Resident #2 revealed an assigned Assessment Reference Date (ARD) of 8/18/23 and the Omnibus Budget Reconciliation (OBRA) ARD date of 8/12/23, with a completion due date of 9/1/23. The record review revealed the MDS assessment had not been submitted as of 2/15/24.
During an interview on 2/15/24 at 9:08 AM, the MDS Coordinator queried on Resident #2 MDS assessment dated [DATE] and she stated she didn't do that assessment and someone started the assessment but didn't finish it. The MDS Coordinator stated her expectation for MDS assessments is to be completed within 14 days from the 8/18/23 date.
During an interview on 2/15/24 at 12:40 PM, the Director of Nursing (DON) queried on the expectation of MDS completion and she stated the MDS assessments needed completed within 14 days of the ARD date.
The Facility Resident Assessment Policy dated 11/2019 revealed the following information:
a. The Resident Assessment Coordinator is responsible for ensuring the Interdisciplinary Team conducted timely and appropriate resident assessments and reviews according to the following requirements:
1. Quarterly Assessments- conducted not less frequently than three months following the most recent OBRA assessment of any type
2. Discharge Assessment- conducted when a resident discharged from the facility
b. A comprehensive assessment included:
1. completion of the MDS
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 interviews, and facility policy review, the facility failed to accurately code the Minimu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) Assessment for a resident's (Preadmission Screening and Record Review) Level II PASRR for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 47 residents.
Findings include:
The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired.
The Annual MDS dated [DATE] revealed the resident wasn't currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition.
The record review revealed Resident #4 Level II PASRR completed on 9/22/22.
During an interview on 2/15/24 at 9:08 AM, the MDS Coordinator queried on Resident #4 MDS dated [DATE] and she confirmed the MDS needed coded to reflect the resident currently considered a PASRR Level II.
During an interview on 2/15/24 at 12:40 PM, the Director of Nursing (DON) queried on Resident #4 annual MDS and if the resident considered for a PASRR Level II and she stated she he should be, because he was a Level II and the MDS coded wrong.
The Facility Resident Assessment Policy dated 11/2019 revealed the following information:
a. All resident assessments completed within the previous 15 months maintained in the resident's active clinical record. The results of the assessments used to develop, review and revise the resident's comprehensive care plan.
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 and staff interviews the facility failed to submit a Preadmission Screening and Resident Review ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews the facility failed to submit a Preadmission Screening and Resident Review (PASRR) related to a new diagnosis for 1 of 3 residents reviewed for PASRR level II screening (Resident #41). The facility reported a census of 47 residents.
Findings include:
A Minimum Data Set (MDS) assessment for Resident #41, dated 9/22/23, documented a diagnosis of non-Alzheimer's dementia and did not include any psychiatric/mood disorders.
The MDS assessment dated [DATE] for the resident documented diagnoses of Parkinson's disease and unspecified dementia of unspecified severity without behavioral disturbance. It did not include any psychiatric/mood disorders.
The MDS assessment dated [DATE] documented diagnoses of non-Alzheimer's dementia, Parkinson's disease, and psychotic disorder other than schizophrenia.
The PASRR dated 10/11/23 indicated the outcome was Level 1 negative, no status change. It documented no mental health diagnosis was known or suspected, and no known mental health behaviors or symptoms existed. Seroquel Oral Product 25 mg/day was listed as current with a diagnosis of dementia behaviors.
A review of the electronic health record revealed no other PASRR screenings submitted.
On 2/15/24 at 10:52 AM the Administrator stated hopefully a diagnosis came before a medication.
An interview with the Director of Nursing (DON) on 2/15/24 at 11:31 AM revealed that the resident returned from a hospital stay on Seroquel due to behaviors at the hospital. They were originally on the medication at admission to the facility and it was discontinued 6/7/23. She stated the pharmacist asked for an approved diagnosis to go with the medication when a medication review was completed. The DON was not sure where the diagnosis came about. She stated she probably should have completed a new PASRR when they returned from the hospital.
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** 2. The MDS for Resident #41, dated 1/26/24, documented diagnoses of non-Alzheimer's dementia, Parkinson's disease, and psychotic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS for Resident #41, dated 1/26/24, documented diagnoses of non-Alzheimer's dementia, Parkinson's disease, and psychotic disorder other than schizophrenia. The Brief Interview for Mental Status revealed a score of 3 which indicated severe cognitive impairment.
The prior MDS assessment dated [DATE] documented diagnoses of Parkinson's disease and unspecified dementia of unspecified severity without behavioral disturbance. It did not include any psychiatric/mood disorders.
A Preadmission Screening and Resident Review (PASRR) dated 10/11/23 indicated the outcome was Level 1 negative, no status change. It documented no mental health diagnosis known or suspected, and no known mental health behaviors or symptoms existed. Seroquel Oral Product 25 mg/day listed as current with a diagnosis of dementia behaviors.
Progress notes from the resident's electronic health record dated 10/12/23 indicated the resident started on Seroquel 25 mg at the hospital according to the discharge records. The progress notes failed to indicate behaviors or diagnoses associated with the medication.
The Care Plan with a date range of 8/1/23 through 11/1/23 failed to include psychotropic drug use or psychotic disorder. The Care Plan printed 2/14/24 at 8:31 PM revealed psychotropic drug use and psychotic disorder with delusions were not addressed in the care plan until 2/14/24.
An interview with the DON on 2/15/24 at 11:31 AM revealed that the resident returned from a hospital stay on Seroquel due to behaviors at the hospital. They were originally taking the medication at admission to the facility on 5/12/23 and it was discontinued 6/7/23. She stated the pharmacist asked for an approved diagnosis to go with the medication when a medication review was completed. The DON was not sure where the diagnosis of psychotic disorder came about. She stated the resident did not have a therapy or counseling appointment.
A policy titled Comprehensive Assessment and the Care Delivery Process revised December 2016 indicated comprehensive assessments would be conducted to assist in developing person centered care plans. Assessing the individual would include gathering information from observation, hospital discharge summaries, and evaluations from other disciplines. An MDS would be completed after it was determined a resident had a significant change in physical or mental condition. The policy revealed completed assessments were used to develop, review, and revise the resident's comprehensive care plan.
Based on clinical record review, staff interviews, and facility policy review, the facility failed to revise the care plan for a resident with a significant weight loss and an opioid pain medication and didn't address an antipsychotic with a new diagnosis for 2 of 14 residents reviewed for care plans (Residents #34 and #41). The facility reported a census of 47 residents.
Findings include:
1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS revealed diagnosis of fracture of unspecified part of neck of left femur, subsequent encounter. The MDS revealed the resident received an opioid.
The Electronic Medical Record (EMR) revealed the following diagnosis:
a. pain, unspecified
b. fracture of unspecified part of left femur, subsequent encounter for closed fracture with routine healing.
The Physician Orders revealed the following orders:
a. Fentanyl patch 72 hour 12 mcg/hr (microgram/hour)- once a day every 3 days- start date 1/10/24
b. Med Pass 90 ml (milliliters) with breakfast and supper- twice a day- ordered on 1/30/24
The record review revealed the following information for weight loss:
a. On 10/26/2023, the resident weighed 112 lbs. On 12/06/2023, the resident weighed 105 pounds which is a -6.25 % Loss.
b. On 12/06/2023, the resident weighed 105 lbs. On 01/17/2024, the resident weighed 95 pounds which is a -9.52 % Loss.
c. On 01/17/2024, the resident weighed 95 lbs. On 02/09/2024, the resident weighed 84 pounds which is a -11.58 % Loss.
The Care Plan lacked documentation for a focus area or interventions for Resident #34 weight loss and the opioid medication.
During an interview on 2/15/24 at 9:16 AM, the MDS Coordinator queried if weight loss needed addressed on the care plan and she stated yes, it needed addressed on the care plan. When asked if a Fentanyl patch needed addressed on the care plan, she stated the Fentanyl patch didn't get addressed on the care plan but it needed to be.
During an interview on 2/15/24 at 12:58 PM, the Director of Nursing (DON) queried on the expectation of weight loss addressed on the care plan and she stated it needed to be addressed. When asked if pain medications such as Fentanyl patch should be on the care plan the DON confirmed pain medications needed addressed on the care plan and also the resident's pain.
The Facility Comprehensive Assessment and the Care Delivery Process dated 12/2016 revealed the following information:
a. comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.
b. assessment and information collection includes (what, where, and when).
1. assess the individual for symptom or condition -related assessments
2. assess the individual for evaluations such as dietary, respiratory, social services, etc.
c. information analysis
1. define issues, including problems, risk factors, and other concerns and determine Care Area Assessment (CAA) triggered during completion of the MDS
2. define conditions and problems that caused, or could cause other problems
d. monitored results and adjusted interventions
1. periodically reviewed progress and adjusted treatments.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record review, and facility policy review, the facility failed to use professio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record review, and facility policy review, the facility failed to use professional standards by not cleaning the rubber seal of an insulin pen with an alcohol pad or priming the insulin pen prior to administration for 1 of 2 residents observed for insulin administration (Resident #7). The facility reported a census of 47 residents.
Finding include:
The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS revealed the diagnosis of diabetes mellitus and the resident received insulin injections 7 out of 7 days.
The Care Plan revealed a focus area revised on 10/19/23 for diabetes mellitus.
The Electronic Medical Record (EMR) revealed the following diagnosis:
a. diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma
The Physician Orders revealed the following medication orders:
a. ordered 1/20/24- Lantus U-100 Insulin (insulin glargine) 100 unit/ml (milliliter)- 15 units in the evening
During an observation on 2/13/24 at 4:40 PM, Staff A, LPN (Licensed Practical Nurse) prepared to administer Lantus to Resident #7. Staff A took the cap off the Lantus pen and did not wipe the rubber seal of the pen with an alcohol wipe prior to placing the needle on the pen. Then Staff A turned the knob of the Lantus insulin pen to 15 units without priming the insulin pen prior to turning the knob to the correct dose for administration. Staff A then administered Lantus insulin into Resident #7 left arm.
During an interview on 2/13/24 at 4:45 PM, Staff A queried if he needed to do anything prior to placement of the needle on the insulin pen and he stated the insulin vials needed wiped with an alcohol pad. When asked Staff A if he needed to clean the rubber seal of the insulin pen before placing the needle on it, he stated he didn't recall ever being told to clean it with an alcohol pad. When asked Staff A if he needed to prime insulin pens, Staff A stated he didn't understand what it meant to prime the needle and he didn't know that was a thing.
During an interview on 2/15/24 at 1:19 PM, the Director of Nursing (DON) confirmed nurses needed to clean the rubber seal of the insulin pen and prime the insulin to 2 units prior to administration.
The Lantus Manufacturers Instructions dated 2022 revealed the following information:
a. Attach the needle.
1. Wipe the pen tip (rubber seal) with an alcohol pad.
b. Perform a safety test.
1. Dial a test dose of 2 units.
2. Hold pen with the needle pointed up and lightly tap the insulin reservoir so the air bubbles rise up to the top of the needle. This will help get the most accurate dose.
3. Press the injection button all the way in and check to see if insulin came out of the needle.
4. If no insulin came out, perform the test 2 more times. If no insulin came out, use a new needle and repeat the safety check.
The Facility Administering Medication Policy dated 4/2019 revealed the following information:
a. Staff followed established facility infection control procedures (example antiseptic technique) for the administration of medications, as applicable.
b. Each nurse's station had a current Physician's Desk Reference (PDR) and/or other medical reference as well as a copy of the surveyor guidance for F755-61 (Pharmacy Services) available. Manufacturer's instructions or user manual related to any medication administration devices kept with the devices or at the nurse's station.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE] revealed Resident #28 scored a 13 out of 15 on the BIMS exam which indicated cognition intact...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE] revealed Resident #28 scored a 13 out of 15 on the BIMS exam which indicated cognition intact. The MDS revealed the resident needed substantial/maximal assistance with showering/bathing, and with personal hygiene.
During an interview on 2/12/24 at 1:56 PM, Resident #28 stated the facility showered her twice a week and didn't clip her fingernails or clean under them. She stated she would like them clipped. She stated she didn't ask them to do it because she hated to ask for anything. She stated she wasn't brought up that way. Resident #28 stated since she arrived to the facility no one clipped or cleaned her fingernails.
During an observation on 2/13/24 at 1:42 PM, the resident's fingernails long and dirty under the nail beds.
During an interview on 2/13/24 at 2:54 PM, Staff O, CNA (Certified Nurse Aide) queried on who's responsible for fingernail care and she stated she tried to do them in the shower when the nails were soft. She stated for some reason they had a fail with fingernails getting clipped. She stated she clipped them as long as not diabetic but she didn't know who's job it was but she thought the nurses clipped them because she didn't know who took blood thinners or which residents diabetic.
During an observation on 2/14/24 at 9:00 AM, the resident sat in the dining room and ate her breakfast independently. Her fingernails dirty and not clipped.
During an observation on 2/15/24 at 7:51 AM, the resident's fingernails are long and dirty under the nails. Resident #28 stated no one looked at her nails and they were still long and dirty.
During an interview on 2/15/24 at 9:56 AM, Staff I, RN (Registered Nurse) queried on who trimmed the resident's fingernails and she stated the shower aides clipped them unless the resident diabetic. Staff I stated the CNA supposed to check the fingernails with every shower and clean them.
During an interview on 2/15/24 at 11:26 AM, Staff E, CNA queried on who clipped the resident's fingernails and she stated the CNAs clipped them unless the resident's diabetic.
During an interview on 2/15/24 at 1:14 PM, the Director of Nursing (DON) queried on when fingernail care completed and she stated it needed done with the resident's showers unless the resident diabetic.
During an interview on 2/15/24 at 3:41 PM, Staff O stated she clipped Resident #28 fingernails with her shower. Staff O confirmed the resident wanted them clipped and stated she felt happy after Staff O clipped them.
The Facility Fingernail Policy dated 2/2018 revealed the following information:
a. nail care included daily cleaning and regular trimming.
b. proper nail care aided in the prevention of skin problems around the nail bed
c. trimmed and smooth nails prevented the resident from accidentally scratching and injuring his or her skin.
Based on observation, clinical record review, policy review, resident interview and staff interviews, the facility failed to provide incontinence care for 1 resident (Resident #1) and nail care for 1 resident (Resident #28) for 6 residents reviewed for assistance with activities of daily living (ADLs). The facility reported a census of 47 residents.
Findings include:
1. The facility policy Perineal Care, revised February 2018, stated the purpose of perineal care, to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.
The Care Plan focus dated 1/27/22 stated Resident #1 had bladder incontinence related to decreased mobility and wore briefs. The Care Plan directed staff to provide incontinence care after each incontinent episode.
The Minimum Data Set (MDS) assessment tool, dated 11/24/23, listed diagnoses for Resident #1 which included cerebrovascular accident (stoke), schizophrenia, and hypertension (high blood pressure). The MDS stated the resident was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 5 out of 15, indicating severely impaired cognition.
Observation on 2/14/24 revealed the following:
At 8:25 a.m., the resident sat in her wheelchair at the breakfast table and remained there until Staff E Certified Nursing Assistant(CNA) asked the resident which movie she wanted to watch today and wheeled her to her room, turned the TV on, and gave her a sweater. Staff E did not offer to change the resident's brief. The resident remained in her room until 9:43 a.m. when the Activity Director asked her if she wanted to go to the activity and wheeled her to the dining room. The resident remained in the dining room for crafts and exercises until 11:22 a.m. when the Activity Director [NAME] her into the Assisted Dining Room. Staff did not offer to change the resident's brief as of 11:56 a.m.
When queried regarding the assistance of incontinence care on 2/14/24 at 11:56 a.m., the Director of Nursing (DON) stated staff should change the resident every 2 hours.
On 2/14/24 at 12:15 p.m., observed Staff J CNA wheel the resident from the dining room to her room and told the resident she would get her freshened up. Staff J and Staff K Certified Medication Aide (CMA) transferred her into bed. The staff pulled the resident's pants down and there was an odor of urine. Staff K stated the resident's pants were wet and the resident's incontinent brief was wet. The resident had red indentations on the top of her thighs. Staff J and K provided incontinence cares and a new brief.
On 2/19/24 at 2:08 p.m., the DON stated she did not know what happened with the situation where staff did not assist the resident with perineal care. She stated they should have toileted the resident and staff were aware of this.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, policy review, and staff interviews, the facility failed to regularly assess a wou...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, policy review, and staff interviews, the facility failed to regularly assess a wound and notify the provider of changes in the wound, and failed to intervene in a timely manner after a critical lab result for 1 of 4 residents reviewed for a change in condition (Resident #21). The facility reported a census of 47 residents.
Findings:
The facility policy Wound Care, revised October 2010, stated the policy provided guidelines for the care of wounds to promote healing and stated the resident's record should include characteristics such as the wound color, size, and drainage.
The facility policy Change in a Resident's Condition or Status, revised May 2017, stated the facility would promptly notify the physician of changes in the resident's medial condition.
A 6/30/22 Care Plan entry stated staff would assess the resident's skin on shower days with quarterly assessment, and as needed. The entries directed staff to report any reddened or compromised areas to nursing. A 3/10/23 Care Plan entry directed staff to follow treatment orders to the left foot.
A 6/1/23 Physician Communication Fax stated the resident's left foot, which was previously open and treated at the wound clinic, had a thin layer of skin slough off this site 1.5 centimeters(cm) in a circular shape. The area had open skin, was pink in color, and had no drainage.
The Minimum Data Set(MDS) assessment tool, dated 6/2/23, listed diagnoses for Resident #21 which included diabetes, non-Alzheimer's dementia, and anxiety disorder. The MDS stated the resident had an open lesion on the foot with dressings to the feet and listed his Brief Interview for Mental Status(BIMS) score as 4 out of 15, indicating severely impaired cognition.
The Progress Note for the resident documented the following:
On 7/11/23 the resident's left foot had a calloused area on the bottom where the bones protruded and the site had been sloughed off by the resident. There was an order in place to wrap with gauze and apply a non-adherent dressing daily to protect the area.
On 7/20/23 documented an area of the resident's left foot sloughed off in the night and had blood to the area. The area measured 1.1 cm x 1.3 cm x 0.2 cm(length x width x height).
On 8/1/23 the Advanced Registered Nurse Practitioner(ARNP) documented a nurse reported a concern. The resident had a diabetic foot ulcer on his left foot which was red and swollen with discharge and the current dressing was just padding. The note listed the following orders:
a. Mepilex Ag(a dressing which was antimicrobial and absorbed drainage) to the left foot and directed to change every 72 hours.
b. Keflex(an antibiotic) 500 milligrams(mg) four times daily for 7 days.
c. Bactrim DS twice daily x 5 days for diabetic foot wound with infection.
On 8/3/23 at 8:30 a.m. the resident transferred to the hospital for possible admission for IV therapy.
On 8/3/23 at 3:20 p.m. the resident admitted to the hospital and they drained the resident's abscess on his foot.
On 8/11/23 the resident discharged from the hospital.
The untitled wound assessment dated [DATE] documented the resident had a left foot surgical wound which measured 0.2 cm x 1.1 cm x 0.9 cm.
The facility lacked documentation of previous skin assessments prior to 8/11/23 and lacked documentation of provider notification of the wound's open and bleeding status from 7/11/23-8/1/23.
The Progress Notes for the resident documented the following:
On 8/14/23 at 12:30 p.m. the hospital lab called to report critical labs: hemoglobin(a blood protein which carries oxygen) 7.1 and hematocrit(the percentage of red cells in the blood) 22 and stated the facility had the lab fax the results to the physician.
On 8/15/23 at 1:16 p.m. the provider saw that the physician had not addressed the critical labs and requested the resident to be sent to the hospital for a blood transfusion.
On 8/15/23 the ARNP documented the resident was sent to the ER recently for a concern of sepsis secondary to diabetic foot ulcer. The resident had a left foot post I and D(incision and drainage) of an abscess. He received Unasyn(an antibiotic) and discharged on clindamycin(an antibiotic). The note stated his hemoglobin was 7.1 and he needed to go to ambulatory care for a blood transfusion.
On 8/15/23 at 2:32 p.m. the hospital called and stated the resident's labs were rechecked and had improved so a transfusion was no longer necessary. The resident received a dose of IV iron and would discharge from the ER at approximately 4:30 p.m.
The facility lacked documentation of further attempts to notify the provider of the critical lab between 8/14/23 at 12:30 p.m. and 8/15/23 at 1:16 p.m.
Via email communication on 2/15/23 at 10:35 p.m., the Director of Nursing (DON) stated the facility had no skin sheets prior to 8/11/23.
On 2/19/24 at 9:21 a.m., the DON stated staff should assess wounds every 7 days to be in compliance. She stated prior to him going into the hospital, it looked like he had a corn. She stated it was not lanced open until he went to the hospital. She stated with regard to the critical lab, she called the surgeon and asked him to return the call and she was not sure what to do in the instance that the physician did not call back. She stated she called him multiple times. She stated the ARNP (Staff L) was not the one handling the hemoglobin and hematocrit.
On 2/19/23 at 10:44 a.m. via phone, Staff L ARNP stated around June the resident had a calloused area on his left foot that had not been bothering him for a while. She stated she was not notified the wound opened up and was bleeding on 7/20/23 and would have wanted to know this. She stated she probably would have started a new dressing at that time.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and the facility policy review, the facility failed to supervise a resident in ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and the facility policy review, the facility failed to supervise a resident in their room while they sat in a shower chair which resulted in a fall from the shower chair for 1 of 4 residents reviewed for falls (Resident #2). The facility reported a census of 47 residents.
Finding include:
The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored a 15 out of 15 on the Brief Interview for Mental Status exam, which indicated cognition intact. The MDS revealed impairment of both sides of the lower extremities and resident used a wheelchair. The MDS revealed the resident dependent with toileting hygiene and while transferred from chair/bed to chair. The MDS revealed resident needed substantial/maximal assistance with shower and bathing. The MDS revealed a diagnosis of traumatic brain dysfunction.
The Care Plan revealed a focus area dated 12/4/23 for a history of falling related to weakness and needed assistance with transfers. The interventions dated 12//5/23 revealed resident not to be left unattended in shower chair.
The Event Report dated 2/5/24 at 2:00 PM revealed the following information:
a. Description: resident fell unwitnessed fall at 2:00 PM
b. Location of Fall: resident's room
c. Body Observation: ROM (Range of Motion) x 4 without pain/limitations.
d. possible contributing factors: recent decline in ADL (Activity of Daily Living) abilities
e. Orders:
1. Fall: Monitor status for 72 hours for bruising, change in mental status/condition, pain, or other injuries related to fall from 2/5/23 to 2/8/23
2. Fall: With suspected head trauma- neuro checks every 15 minutes for 4 hours, then every hour x 2 hours, then every 2 hours x 2 hours, and then every 4 hours x 2 hours, and then every shift x 3 ordered from 2/5/24 to 2/6/24
f. Notes dated 2/5/23: CNA (Certified Nurse Aide) called this nurse to resident's room and found resident on floor in sitting position by toilet. CNA came and got writer. Resident stated he needed to use the bathroom for a bowel movement and tried to transfer himself from the shower chair onto the toilet. CNA stated she told him she would be back after he completed shaving and he needed to pull his call light when done. Resident pulled the call light but didn't wait for help. Neuro checks initiated and all intact. Grips equal and strong. PERRL (pupils equal, round, reactive to light) and medium size. See attachment of vital signs and stable baseline. DON (Director of Nursing) in house. Intervention was to not leave resident on shower chair unattended. Resident denied any pain or discomfort at this time. AROM (Active Range of Motion) without difficulty. Assisted up with assist of two and gait belt onto toilet. No cuts, abrasions, or scraps noted by this writer.
g. Evaluation: N/A (not available): Event still open
During an interview on 2/14/24 at 5:22 PM, Staff C, RN (Registered Nurse) queried if appropriate to leave a resident unattended in a shower chair and she stated no, you don't leave residents alone in shower chairs.
During an interview on 2/15/24 at 10:39 AM, Staff D, RN queried about the incident when Resident #2 fell out of the shower chair and she stated the resident needed reminded not to self transfer and the CNA told him to turn on the call light when he finished shaving. Staff D stated the CNA and her both went to answer the light and when they arrived to his room they observed him on the floor. Staff D stated the CNA new and the resident wanted to shave and she said she would be right back. Staff D asked if the resident could shave in his wheelchair and she stated yes he could after he dressed.
During an interview on 2/15/24 at 11:30 AM, Staff E, CNA queried on the incident when Resident #2 fell out of the shower chair and Staff E stated the resident asked to shave himself in the shower chair and he needed a new razor and she would be right back. Staff E stated she locked the wheels on the shower chair and instructed him to turn on his call light when he was done shaving. Staff E stated Resident #2 turned on his light and by the time her and Staff D came to the room the resident on the floor. Staff E asked why the resident left in the shower chair and she stated the resident requested to stay in the shower chair to shave and didn't want to transfer to his wheelchair, he wanted to go straight to bed after he shaved. Staff E stated no one told her he didn't normally do that, and it was a mistake on her behalf.
During an interview on 2/15/24 at 1:11 PM, the Director of Nursing (DON) queried the expectation when residents sat in the shower chair and she stated for the residents not to be left alone in the shower chair and the intervention after the fall was to not leave the resident alone in the shower chair. She stated the CNA told him she would be right back but the resident could be impulsive. The DON confirmed she wouldn't leave him alone in the shower chair.
The Facility Fall Policy (no date identified) revealed the following information:
a. The purpose of the policy: to ensure if a resident fell, a thorough assessment completed and appropriately documented with interventions identified to prevent future falls.
b. Procedure: document in the nurse's notes
1. event witnessed
2. location of the event
3. physical description of resident
4. assessment for injury
5. assess for cause such as statement by the resident; environmental issues; personal care issues (last toileted) and adaptive equipment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and facility policy review the facility failed to address a res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and facility policy review the facility failed to address a resident weight loss in a timely manner and offer different options at meal times to encourage adequate nourishment for 1 of 2 residents reviewed for weight loss (Resident #34). The facility reported a census of 47 residents.
Findings include:
The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired.
The Care Plan revealed a focus area for a therapeutic regular mechanical soft diet dated 9/19/23. The interventions dated 9/19/23 revealed the resident provided with as much control as possible in routine and food preferences.
The Record Review revealed the following information for weight loss:
a. On 10/26/2023, the resident weighed 112 lbs. On 12/06/2023, the resident weighed 105 pounds which is a -6.25 % Loss.
b. On 12/06/2023, the resident weighed 105 lbs. On 01/17/2024, the resident weighed 95 pounds which is a -9.52 % Loss.
c. On 01/17/2024, the resident weighed 95 lbs. On 02/09/2024, the resident weighed 84 pounds which is a -11.58 % Loss.
The Vitals Results for weight revealed the following dates weights taken or not taken:
a. 10/26/23 at 1:15 AM: 112 pounds
b. 11/15/23 at 4:03 PM: not taken
c. 12/6/23 at 8:13 AM: 105 pounds
d. 12/28/23 at 12:32 AM: not taken
e. 1/4/24 at 4:08 PM: not taken
f. 1/6/24 at 6:39 PM: not taken
g. 1/10/24 at 7:41 PM: not taken
h. 1/17/24 at 7:41 PM: 95 pounds
i. 1/25/24 at 12:36 PM: not taken
j. 2/1/24 at 3:37 PM: 85 pounds
h. 2/9/24 at 2:38 PM: 84 pounds
The Care Plan lacked documentation for a focus area or interventions for Resident #34 weight loss.
The Dietary Progress Note dated 12/31/23 at 3:20 PM revealed the resident at 105 pounds with weight loss since admission from 114 pounds. Diet Order: Regular. Estimated needs (ABW (Adjusted body weight) 50 kg (kilograms)) determined and met but secondary to weight loss, would add 90 ml (milliliters) Med Pass Supplement bid (twice a day). Will continue to follow.
The Physician Notes dated 1/2/24 at 9:52 AM revealed the following information:
a. Appetite not great, proximally 25%. preferred sweets and then didn't feel like eating meals
b. Plan: Use where lift and get patient up to a recliner, if that goes well can work on getting her in a chair to come out for meals.
The Dietary Progress Note dated 1/22/24 at 3:08 PM revealed the resident is at 95 pounds with weight loss since admission from 114 pounds. Diet Order: Regular. Estimated needs determined and met but secondary to weight loss, would add 90 ml Med Pass Supplement BID. Unless intake improved, weight loss likely to remained unavoidable.
Will continue to follow.
The Physician Orders revealed the following orders:
a. Med Pass 90 ml (milliliters) with breakfast and supper- twice a day- ordered on 1/30/24
During an observation on 2/13/24 at 8:35 AM, staff sat at the table and talked with the resident and assisted her with eating and encouraged her to eat.
During an observation on 2/13/24 at 8:47 AM, the resident's cream of wheat not touched and her scrambled eggs didn't get ate, neither did the sausage and the coffee cake barely touched. Resident drank a small amount of tomato juice. The resident ate less than 25% of her meal.
During an observation on 2/14/24 at 8:59 AM, staff served her meal of scrambled eggs, sausage, and french toast. A glass of water placed in front of her.
During an observation on 2/14/24 at 9:02 AM, the resident stated she didn't want anything. She stated she wasn't hungry and refused to eat. The CNA (Certified Nurse Aide) stated okay and didn't ask if she wanted anything different. The resident ate less than 25% of her meal.
During an interview on 2/15/24 at 9:52 AM, Staff I, RN (Registered Nurse) queried on Resident #34 weight loss and she stated Resident #34 a picky eater and she stopped eating after her husband died.
During an interview on 2/15/24 at 10:35 AM, Staff D, RN queried on Resident #34 eating habits and she stated Resident #34 ate in the assisted dining room to help with cueing and encouragement of eating or at least drinking. She stated they got her up for meals and she received Med Pass so she didn't eat much. Staff D asked how she knew of a weight loss and she stated she looked at the weights and looked in progress notes and the dietician reviewed the weights and progress notes for weight loss and asked the aides if they knew of any concerns. She stated weight loss documented on the communication board also. She stated she also looked at the care plan and spoke to the DON (Director of Nursing) and looked in the progress notes to make sure the weight loss charted.
During an interview on 2/15/24 at 11:34 AM, Staff E, CNA queried on Resident #34 eating habits and she stated she ate her bed when she first started and then she stopped eating. She stated the family requested we get her up to the chair in her room to eat and she still didn't eat so the facility asked the family if they could take her to the dining room to socialize to see if that helped. Staff E stated Resident #34 didn't like the dining room either and didn't eat and requested to go back to bed as soon as she left the dining room. Staff E stated Resident #34 told her family she ate. Staff E stated she offers the resident food but told her she wasn't hungry.
During an interview on 2/15/24 at 12:58 PM, the Director of Nursing (DON) queried on the resident's significant weight loss and she stated in January the dietician charted the resident's weight loss but didn't send her the reports and they happened to see the orders for the Med pass and ordered it. She stated the facility went through all the dietician notes, and pulled all the orders. The DON stated she notified the provider and they signed all the orders. The DON stated the Administrator notified the dietician the orders could have been missed and she needed to inform them of the orders. She stated they usually received notes about these issues from the dietician. Reviewed the weights and the dates the weights not taken for the resident and the DON confirmed the weights should of been taken.
The Facility Food Preference Policy dated 2/2017 revealed the following information:
a. The dietician and nursing staff, assisted by the physician, identified any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences.
b. The nursing staff documented the resident's food and eating preferences in the care plan.
c. The dietician discussed with the resident or representative the rationale of any prescribed therapeutic diet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
Based on clinical record review, policy review, and staff interview, the facility failed to ensure a resident was seen by a physician every 60 days for 1 of 14 residents reviewed for physician's visit...
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Based on clinical record review, policy review, and staff interview, the facility failed to ensure a resident was seen by a physician every 60 days for 1 of 14 residents reviewed for physician's visits (Resident #45). The facility reported a census of 47 residents.
Findings include:
The facility policy Attending Physician Responsibilities revised August 2014, stated the physician would see resident every 60 days.
The Minimum Data Set (MDS) assessment tool, dated 12/15/23, listed diagnoses for Resident #45 which included non-Alzheimer's dementia, tachycardia (fast heart beat), and pain and listed the resident's Brief Interview for Mental Status (BIMS) score as 7 out of 15, indicating severely impaired cognition.
Review of the resident's clinical record revealed a lack of documentation of a provider visit from May 2023 to 2/14/24.
On 2/14/24 at 11:23 a.m., the Director of Nursing (DON) stated she called the clinic and the provider did not see the resident since May of 2023. The DON stated the frequency should be every 60 days and the provider would see the resident tonight.
On 2/19/24 at 2:08 p.m., the DON stated Resident #45's provider visit was taken care of. The provider saw the resident and wrote a new order. She stated this was an oversight.
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to administer a Risperidone i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to administer a Risperidone injection when ordered, which resulted in a behavioral change with the resident for 1 of 8 residents reviewed for medication administration (Resident #4). The facility reported a census of 47 residents.
Findings include:
The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS revealed diagnoses of anxiety disorder, bipolar disorder, and schizophrenia. The MDS revealed the resident received antianxiety, antidepressant, and antipsychotic medications.
The Care Plan revealed a focus area dated 3/28/22 and revised on 9/21/23 for resident took Buspar, Mirtazapine, Risperdal Consta, Zoloft, Wellbutrin related to the diagnoses of schizophrenia and bipolar disorder. The interventions dated 3/28/22 revealed to monitor for any behaviors, and monitor for effectiveness and adverse side effects.
The Physician Orders revealed the following:
a. Risperdal Consta (Risperidone microspheres) suspension,extended release reconstitute; 50 mg (milligrams)/2 ml (milliliters); amount to administer: 2 ml intramuscular (IM); once every 14 days- ordered on 1/6/24 and discontinued on 1/30/24
b. Risperdal Consta (Risperidone microspheres) suspension,extended release reconstitute; 50 mg/2 ml; amount to administer: 2 ml; intramuscular-once - one time - 01/22/2024 - 01/22/2024 (start and end date)
c. Risperdal Consta (Risperidone microspheres)-suspension,extended release reconstitute 50 mg/2 ml- ordered on 1/30/24
The Progress Note dated 1/06/24 at 2:55 PM, revealed pharmacy recommendation signed by provider for Risperdal Consta 50 mg every 2 weeks with staff to monitor behaviors closely. Noted, faxed, and scanned.
The Progress Note dated 1/22/24 at 9:28 PM, revealed the resident pulled his call light multiple times, told staff to drink his Gatorade and yelled at staff to drink his Gatorade for him. Resident very angry with staff this evening and tried to sell his guitar to the housekeeper. Resident acting very not himself since injection changed to every 2 weeks instead of every 10 days. Resident resistive to taking showers and refused them. Resident refused to take shower tonight and yelled at staff to go take a shower themselves. Resident did not have his Risperdal Consta injection this past weekend when scheduled. Noted it was unavailable from the pharmacy on Saturday the 20th. Medication available tonight. On call services notified of resident needed to have injection. Stated they notified on call and to check our fax machine for orders.
The Progress Note dated 1/22/24 at 10:56 PM, revealed received fax stating May resume schedule for Risperdal Consta-give tonight and then every 14 days as ordered. Risperdal injection given at this time in left buttock. Resident took injection well.
The January 2024 Medication Administration Record (MAR) revealed the resident received the Risperdal Consta on 1/6/24, 1/22/24, and 1/30/24.
The January 2024 MAR revealed the Risperdal Consta not administered on 1/20/24 between 6 PM and 10 PM due to item unavailable with a comment of N/a (not available).
The facility lacked documentation of a Progress Note for reasoning or interventions taken for the medication not given on 1/20/24.
During an interview on 2/14/24 at 4:02 PM, Staff P, RN (Registered Nurse) queried on Resident #4 Risperdal injection and she stated at first they gave it every 10 days and then the pharmacy recommended a reduction of the dosage and the provider spaced out the current dosage from 10 days to 2 weeks and ordered to monitor for behaviors. Staff P stated he started having behaviors and now she believed the medication ordered for every 10 days again. Staff P stated resident is sweet and never had behaviors prior to the medication change. She stated when they spaced out the medication the resident turned rude and nasty with staff and wouldn't come to supper or out of his room. Staff P asked about the medication not given on the scheduled date and she stated the medication didn't come in. She stated when you give the medication you are supposed to order the medication from pharmacy. Staff P asked what she did when a medication not available and she stated she put a note that the medication not available and fax it to the pharmacy. Staff P stated the pharmacy usually came twice a day but not everyday if they didn't order anything.
During an interview on 2/15/24 at 12:52 PM, the Director of Nursing (DON) queried on Resident #4 Risperdal injection and she stated the medication previously scheduled for 10 days, then they received a gradual reduction dose (GDR) and to 14 days and then the provider switched it back to 10 days. When asked the DON about the medication not given on 1/20/24, she stated the medication didn't come from the pharmacy and the staff should have reordered it after given the previous time. When asked how long it took to receive from the pharmacy when ordered, she stated it shouldn't take 2 days and she didn't know what nurse reordered it. When asked the expectation when a medication not available to administer, she stated to chart you didn't give it, notify the provider of the missed dose, and call the pharmacy. She stated she would also call the provider and ask to give something in its place.
The Facility Administering Medication Policy dated 4/2019 revealed the following information:
a. Medications administered in accordance with prescriber orders, including any required time frame.
b. Medication errors documented, reported, and reviewed by the Quality Assurance Performance Committee) QAPI to inform process changes and/or the need for additional staff training.
c. Medications administered within 1 hour of their prescribed time, unless otherwise specified.
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 observations, staff interviews, and facility policy review, the facility failed to keep medication carts locked when not in use and staff not around the medication cart and not keeping medica...
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Based on observations, staff interviews, and facility policy review, the facility failed to keep medication carts locked when not in use and staff not around the medication cart and not keeping medication storage rooms keys kept on their persons for 1 of 2 medication carts and 1 of 2 medication storage rooms reviewed. The facility reported a census of 47 residents.
Findings include:
During an observation on 2/14/24 at 1:48 PM, the medication cart in Hallway A left unlocked and no nurse or residents around the cart. The cart located behind the nurse's desk. A set of keys placed in the medication storage room doorknob.
During an observation on 2/14/24 at 1:49 PM, a resident came up in front of the nurse's desk and picked up the cordless phone and made a phone call and walked away.
During an observation on 2/14/24 at 1:50 PM, a CNA (Certified Nurse Aide) went behind the nurse's desk and went to the bathroom and walked by the medication cart and didn't lock it.
During an observation on 2/14/24 at 1:53 PM, the DON (Director of Nursing) walked behind the nurse's desk and walked by the medication cart and didn't lock it.
During an observation on 2/14/24 at 1:54 PM, CMA (Certified Medication Aide) stood in front of the nurse's desk with medication cart visible and stood for a few seconds and then walked away.
During an observation on 2/14/24 at 1:56 PM, no residents in the Hallway A and three staff members down Hallway A and not able to visualize the nurse's desk or the medication cart.
During an observation on 2/14/24 at 1:59 PM, Staff B, RN (Registered Nurse) walked by the medication cart and locked it and opened the medication room with the keys in the door knob lock and then put the keys in her pocket.
During an interview on 2/14/24 at 2:00 PM, Staff B queried if medication carts needed locked and she stated yes all the time. When asked Staff B if the medication storage rooms needed to be locked, she stated yes, at all times. When asked where the medication storage keys needed kept, she stated in their pockets.
During an interview on 2/14/24 at 2:08 PM, the Director of Nursing (DON) queried when medication carts needed locked and she stated they needed to be locked unless within eye sight of staff. When asked if the medication storage room keys could be in the lock of the door knob, she stated no.
The Facility Storage of Medication Policy dated 4/2019 revealed the following information:
a. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals locked when not in use.
b. Unlocked medication carts were not left unattended.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on the clinical record review, staff interviews, and facility policy review, the facility failed to offer the COVID (Coronavirus disease) booster vaccination to 2 out 5 residents reviewed for CO...
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Based on the clinical record review, staff interviews, and facility policy review, the facility failed to offer the COVID (Coronavirus disease) booster vaccination to 2 out 5 residents reviewed for COVID-19 vaccinations (Resident #2 and #4). The facility reported a census of 47 residents.
Findings include:
1. The Preventative Health Care Report revealed the following information for Resident #2:
a. COVID vaccine administered on 11/18/22
The facility lacked documentation of the COVID booster vaccine been offered to Resident #2 in 2023.
2. The Preventative Health Care Report revealed the following information for Resident #4:
a. COVID vaccine administered on 11/18/22
The facility lacked documentation of the COVID booster vaccine been offered to Resident #4 in 2023.
During an interview on 2/14/24 at 2:10 PM, the Director of Nursing (DON) queried on how they track vaccines and she stated they received a report from IRIS. When asked the DON how often they offered the COVID booster/vaccine, she stated the pharmacy came down and administered them, they sent a sheet out and the facility conducted monthly consents. When asked the DON if all the residents offered the vaccine and she stated yes, but some declined.
During an interview on 2/15/24 at 12:48 PM, the DON stated the pharmacy conducted a COVID clinic at the facility.
The Facility COVID-19, Prevention and Control Policy (no date identified) revealed the following information:
a. COVID-19 Prevention
1. Vaccination: All residents offered the vaccine unless a medical contraindication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, policy review, and staff interviews the facility failed to prepare foods under sanitary conditions for 1 of 2 days of kitchen observation. The facility reported a census of 47 r...
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Based on observations, policy review, and staff interviews the facility failed to prepare foods under sanitary conditions for 1 of 2 days of kitchen observation. The facility reported a census of 47 residents.
Findings include:
On 2/13/24 at 11:15 AM observed Staff F, Dietary, put her hand in her left pocket and take out a pen and a marker while wearing a serving glove. She wrote on the foil covering a pan of hot food. Still wearing the glove, Staff F placed the marker back in her left pocket. She then picked up a pan of rice with her gloved hand and her bare right hand. She opened the oven with her bare right hand and placed the pan in the oven. She picked up another pan her gloved hand and opened a drawer with her her right hand. Staff F then picked up cooked chicken pieces with the same glove and put them in another pan. She covered the pan with foil and carried it to the stove. Staff F then threw the glove away and used hand sanitizer. She then put her hand back in her pocket and took out a marker which she used to label more tinfoil. She put her left hand back in her pocket with the marker. Staff F picked up a piece of paper and 3 pans and the paper rested against the lip of one pan. She held the bottom of another pan against her clothing while carrying it to the sanitized counter. She failed to use soap and water hand hygiene during this observation. At 11:48 AM Staff F collected a package of spaghetti from dry storage and carried it to the counter by holding it against the front left side of her shirt.
On 2/13/24 at 11:25 AM observed Staff G, Dietary, picked up the lid to the garbage can with her left hand to dispose of a piece of plastic wrap. She then reached over to pick up a bowl of pureed food to place it in the microwave. She picked up the thermometer with her left hand to temp the pureed food. She failed to use soap and water hand hygiene between touching the garbage can lid, the bowl of food, and the thermometer.
On 2/13/24 at 11:57 AM observed Staff H, Dietary, leaned against a sanitized surface drinks were being served from. She labeled drinks with a black marker while she leaned forward with the front of her clothing touching the edge and the top surface of the island counter. The length of her bare left forearm also rested on the surface. Her right shoe rested on the surface of the lower shelf next to a box labeled potatoes. When Staff H moved on to the next task, the surface of the counter was not sanitized.
02/15/24 at 9:51 AM the Dietary Supervisor stated staff are trained at orientation on sanitation and cleaning expectations. It included proper procedure for dishes, clearing tables, hand hygiene, and charting. She provided an example of washing hands timed to the length it takes to sing happy birthday and stated she expected staff to wash their hands this way between kitchen tasks. She indicated they do not usually have the lid on the garbage.
A policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, revised October 2017, documented employees must wash their hands before coming in contact with any food surfaces, during food preparation as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and after engaging in other activities that contaminate hands. The policy noted hand gel cannot be used in place of handwashing in the food service area. Gloves were considered single-use items that must be discarded after completing the task for which they were used and the use of disposable gloves did not substitute for proper handwashing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on clinical record review, staff interviews, and facility policy review, the facility failed to offer the influenza vaccine annually to 2 out of 5 residents reviewed; and failed to offer the pne...
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Based on clinical record review, staff interviews, and facility policy review, the facility failed to offer the influenza vaccine annually to 2 out of 5 residents reviewed; and failed to offer the pneumococcal vaccine at recommended times to 4 out of 5 residents reviewed for influenza and pneumococcal vaccinations (Resident #1, #2, #4, #24). The facility reported a census of 47 residents.
Findings include:
1. The Preventative Health Care Report revealed the following information for Resident #4:
a. pneumococcal vaccine administered 9/4/20 from an outside source.
The Iowa Registry Immunization Record revealed resident received the Pneumococcal 23 on 9/4/20. The IRIS revealed 1 of 2 dose series.
The facility lacked documentation of consent or declination forms for Resident #4 for the pneumococcal vaccine.
2. The Preventative Health Care Report revealed the following information for Resident #2:
a. Influenza administered on 11/8/22
The facility consent form for influenza and pneumococcal signed on 11/8/22 by Resident #2 revealed resident consented for influenza and pneumococcal vaccinations.
The facility lacked documentation for a pneumococcal vaccine offered or administered to the resident.
3. The Preventative Health Care Report revealed the following information for Resident #24:
a. pneumococcal vaccine administered on 12/2/18 from an unknown source
The facility consent form for influenza and the pneumococcal vaccine signed on 11/1/22 for Resident #24 revealed consent for both the pneumococcal influenza vaccine.
The facility lacked documentation the pneumococcal vaccine offered or administered to Resident #24 in 2023.
4. The Preventative Health Care Report revealed the following information for Resident #1:
a. influenza vaccine administered on 12/15/22
b. pneumococcal vaccine refused on 11/10/21
The facility consent/declination form revealed Resident #1 refused the pneumococcal vaccine on 11/1/22.
The facility lacked documentation the influenza or the pneumococcal vaccinations offered to Resident #1 in 2023.
During an interview on 2/14/24 at 2:10 PM, the Director of Nursing (DON) queried on how they track vaccines and she stated they received a report from IRIS. When asked the DON how often they offer the pneumococcal vaccine, she stated they didn't do the pneumococcal vaccines at the facility. She stated the clinic kept track of them and when someone received a vaccine it was uploaded to IRIS. She stated the pharmacy let them know who needed the vaccine.
During an interview on 2/14/24 at 2:10 PM, when asked the DON how often influenza vaccines offered, she stated over time the pharmacy comes in and did the flu vaccine clinic. When asked the DON about consent and declinations for the flu vaccines, she stated the pharmacy kept the consents for them.
The Facility Influenza and Pneumococcal Vaccine Policy reviewed on 6/8/22 revealed the following information:
a. All residents admitted to the facility screened to determine if they current on adult immunizations. Documentation of the resident's immunization status maintained in the medical record. Consent for annual vaccination obtained from resident or family member at the time of admission or anytime afterwards.
b. Any resident admitted to our facility after medical clinics have done influenza vaccinations will be offered the influenza vaccine unless documented they already received vaccine for that year or documented contraindication.
c. Pneumococcal immunization status will be determined on admission regardless of date. Vaccination provided by medical clinics.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on the clinical record review, staff interviews, and facility policy review, the facility failed to implement a Legion Water Management Program. The facility reported a census of 47 residents.
...
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Based on the clinical record review, staff interviews, and facility policy review, the facility failed to implement a Legion Water Management Program. The facility reported a census of 47 residents.
Findings include:
During an interview on 2/13/24 at 10:24 AM, Staff Q, Maintenance queried on documentation for water temperatures and he stated the water heaters only went up to 110 degrees. Staff Q stated he only visualized the temperatures and never documented them. When asked Staff Q what he did for Legion, he stated no one spoke to him about Legion. Staff Q stated he received a policy from another facility a couple of days ago. When asked Staff Q what he did when rooms vacant, he stated he checked them out before someone moved into them.
The Legion Map Surveillance (no date identified) revealed the following information:
a. where the water located
b. the direction of the water flow
c. where the water heaters located
The Legion Map Surveillance lacked documentation of where showerheads, hoses, fountains, and filters located.
The facility lacked documentation for locations of possible water stagnation and inadequate disinfection.
The facility lacked documentation for water temperature fluctuations or water temperature changes.
The facility lacked documentation on specific measures to control the introduction or the spread of Legion.
During an interview on 2/13/24 at 10:24 AM, when asked Staff Q for a map of the water system and areas for possible stagnation of water, he stated they didn't have a map that he was aware of and the recirculation pumps worked. Staff Q stated they didn't have a diagram of the pipes they just went down the halls and the water heaters set at a certain temperature so they only went so high.
During an interview on 2/14/24 at 2:10 PM, the Director of Nursing (DON) queried on how they assessed for Legion and she stated she knew she was supposed to. When asked the DON if they did anything for Legion, she stated not they didn't. When asked the DON if they tested the water for Legion or other water-borne pathogens and she stated the maintenance man would know if they did, but she didn't know.
The Facility Legion Water Management Program Policy dated 7/2017 revealed the following information:
a. The water management team consist of at least the following personnel:
1. The Infection Preventionist
2. The Administrator
3. The Medical Director
4. The Director of Maintenance
5. The Director of Environmental Services
b. The purpose of the water management program were to identify areas in the water system where Legion bacteria could grow and spread, and to reduce the risk of Legionnaire's disease.
c. The water management program included the following elements:
1. An interdisciplinary water management team
2. A detailed description and diagram of the water system in the facility, including the following:
aa. receiving;
bb. cold water distribution;
cc. heating;
dd. hot water distribution; and
ee. waste
3. The identification of area in the water system that could encourage the growth and spread of Legion or other waterborne bacteria, including:
aa. storage tanks;
bb. water heaters;
cc. filters;
dd. aerators;
ee. showerheads and hoses:
ff. misters, atomizers, air washers and humidifiers;
gg. hot tubs
hh. water fountains; and
ii. medical devices such as CPAP (continuous positive airway pressure) machines, hydrotherapy equipment, etc.
4. The identification of situations that can lead to Legion growth such as:
aa. construction;
bb. water main breaks;
cc. changes in municipal water quality
dd. the presence of biofilm, scale or sediment;
ee. water temperature fluctuations;
ff. water pressure changes;
gg. water stagnation;
hh. inadequate disinfectant
5. Specific measures used to control the introduction and/or spread of Legion (example: temperature, disinfectants)
6. Control limits or parameters acceptable and monitored
7. A diagram of where control measures applied;
8. A system to monitor control limits and the effectiveness of control measures;
9. A plan for when control limits not met and/or control measure not effective; and
10. documentation of the program.
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
- "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.
- • 30% annual turnover. Excellent stability, 18 points below Iowa's 48% average. Staff who stay learn residents' needs.
Concerns
- • 31 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Parkview Care Center's CMS Rating?
CMS assigns Parkview Care Center 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 Parkview Care Center Staffed?
CMS rates Parkview Care Center's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 30%, compared to the Iowa average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Parkview Care Center?
State health inspectors documented 31 deficiencies at Parkview Care Center during 2024 to 2025. These included: 1 that caused actual resident harm and 30 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Parkview Care Center?
Parkview Care Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by OSBYCORP, a chain that manages multiple nursing homes. With 70 certified beds and approximately 50 residents (about 71% occupancy), it is a smaller facility located in FAIRFIELD, Iowa.
How Does Parkview Care Center Compare to Other Iowa Nursing Homes?
Compared to the 100 nursing homes in Iowa, Parkview Care Center's overall rating (2 stars) is below the state average of 3.0, staff turnover (30%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Parkview Care Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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 below-average staffing rating.
Is Parkview Care Center Safe?
Based on CMS inspection data, Parkview Care Center 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 Parkview Care Center Stick Around?
Staff at Parkview Care Center tend to stick around. With a turnover rate of 30%, the facility is 16 percentage points below the Iowa average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 29%, meaning experienced RNs are available to handle complex medical needs.
Was Parkview Care Center Ever Fined?
Parkview Care Center 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 Parkview Care Center on Any Federal Watch List?
Parkview Care Center 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.