Azria Health Winterset

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to carry out appropriate food safety practices to prevent foodborne illness for 1 of 1 meal services observed. The facility reported a census of 51.

Inspectors wroteBased on clinical health record review, observations, resident interviews, staff interviews, and policy review, the facility failed to supervise resident medication administration for 2 of 3 residents reviewed (Residents #2 and #3). The facility reported a census of 51.

Inspectors wroteBased on facility document review, resident interview, staff interviews, and policy review, the facility failed to ensure residents free from abuse for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 51.

Inspectors wroteBased on facility document review, staff interviews, and policy review, the facility failed to report to the state agency within the required time frame a suspected case of resident abuse and neglect for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 51.

Inspectors wroteBased on facility document review, staff interviews, and policy review, the facility failed to investigate suspected resident abuse and neglect for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 51.

Inspectors wroteBased on observations, staff interview, and policy review the facility failed to sanitize a mechanical lift during use between 4 residents. In addition, the facility failed to transport linen in a manner to prevent contamination. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review the facility failed to provide a homelike environment by not placing sheets on residents' beds for 2 of 5 residents (Resident #22 and #28) reviewed. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, staff interview, guidance from the October 2025 Resident Assessment Instrument (RAI) 3.0 User's Manual, and facility policy review, the facility failed to accurately reflect the status of 1 of 2 sampled residents on hospice care in the Minimum Data Set (MDS) Assessment (Resident #35). The deficient practice created the potential for the resident to not receive appropriate treatment and services. The facility reported a census of 50 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review the facility failed to provide adequate oral care for 1 of 3 residents (Residents #9) reviewed. The facility reported a census of 50 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review, the facility failed to provide supplemental oxygen as ordered for 1 of 1 resident reviewed for respiratory care (Resident #48). The facility reported a census of 50 residents.

Inspectors wroteBased on observations, clinical record review, policy review, resident, and staff interviews, the facility failed to provide non-pharmacologic pain management for 1 of 1 resident reviewed (Resident #7). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, document review, resident interview, staff interview, and policy review the facility failed to provide an adequate amount of nursing staff to assure residents safety by not responding to call lights in a timely manner for 3 of 6 residents reviewed (Residents #15, #20, and #22). The facility reported a census of 50 residents.

Inspectors wroteBased on observation, interview, facility policy review, and United States (US) Food and Drug Administration (FDA) 2022 Food Code review, the facility failed to serve food in a manner that complied with safe food handling practices during one of two observed meal services. The facility reported a census of 50 residents.

Inspectors wroteThe Minimum Data Set (MDS) of Resident #35 dated 2/11/25 identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated his cognition was intact. The MDS coded Resident #35 needed partial/moderate assistance to eat. The MDS listed Resident #35 as dependent on staff for hygiene tasks, dressing, transfers, to shower or bathe, and used a manual wheelchair. The MDS described Resident #35 as always incontinent of both bowel and bladder. The MDS included diagnoses of cerebral palsy, Cerebral palsy (CP) (a disorder of movement and posture caused by damage or abnormal brain development, usually before birth, resulting in varied impaired muscle control and coordination.), dysphagia (difficulty swallowing), diabetes mellitus, and cognitive communication deficit. The MDS failed to identify his terminal prognosis (J1400) and hospice care (O0110. K1). [...]

Inspectors wroteBased on observation, Electronic Health Records (EHR), Medication Administration Records-Treatment Administration Record (MAR-TAR), document review, policy review, and staff interview the facility failed to provide adequate sanitization to shower chair between residents, failed to provide influenza testing and communicate with public health during outbreak and failed to provide appropriate infection prevention practices during administration of medications to 2 of 7 residents reviewed (Resident #8, and #33), and contact with Resident#31 whom had a dressing. The facility reported a census of 50 residents.

Inspectors wroteBased on Electronic Health Records (EHR) review, observations, policy review, resident interview and staff interview the facility failed to provide the residents with a comfortable homelike environment by not repairing damages in resident rooms for 5 of 17 residents (Resident #11, #31, #33, #43 and #47). The facility reported a census of 50 residents.

Inspectors wroteBased on Electronic Health Record (EHR) review, staff interview, policy, and Medication Administration Records - Treatment Administration Records (MAR-TAR) review the facility failed to provide needed services in accordance with professional standards by leaving medications in the residents room for self administration without visualization of the nurse for 4 of 12 residents (Resident #8, #31, #33 and #41). The facility reported a census of 50 residents.

Inspectors wroteBased on Electronic Health Record (EHR), policy review, observation, and staff interviews the facility failed to protect residents from hazards, accidents and injuries by not securing 2 shower rooms with the presence of chemicals, sharp razors, and biohazard containers, inappropriate ambulation assistance and failed to secure the wheelchair while dining for 4 of 17 residents (Resident #16, #32, #39, and #43). The facility reported a census of 50 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling and dating open food items, by not completing chemical sanitization checks appropriately for a low temperature dish machine, completion of hand hygiene by staff, completion of hand hygiene with the residents, and by not sanitizing surfaces in the kitchen with the appropriate chemical concentration. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, the facility failed to provide the resident with proper notice when the facility initiated a discharge before the resident had exhausted their Medicare Part A benefit days for 1 of 3 residents reviewed (Resident #20). The facility reported a census of 50.

Inspectors wroteBased on Medication Administration Record (MAR) - Treatment Administration Record (TAR), Electronic Health Records (EHR), policy review, and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the MDS by not accurately assessing the use of a wander guard for 1 of 3 residents reviewed (Resident #43). The facility reported a census of 50 residents.

Inspectors wroteBased on electronic record review, resident interview and staff interviews the facility failed to provide a comprehensive care plan for 1 of 8 residents reviewed (Resident #11). The facility reported a census of 50 residents.

Inspectors wroteBased on record review, observation, and staff interviews the facility failed to assist residents with activities of daily living by not completing grooming tasks for 2 of 8 residents reviewed (Resident #11 and #26). The facility reported a census of 50 residents.

Inspectors wroteBased on Electronic Health Records (EHR), staff interview, and observation the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by pushing enteral formula with a piston syringe into feeding tube for 1 of 1 residents (Resident #5). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure staff documented non-pharmacological interventions attempted prior to the administration of an as needed (prn) medication for 1 of 1 residents reviewed for prn anti-anxiety medications(Resident #6). The facility reported a census of 50 residents.

Inspectors wroteBased on observations, staff interviews, policy, Electronic Health Records (EHR) and Medication Administration Records - Treatment Administration Records (MAR-TAR) the facility failed to ensure the residents were free of significant medication errors to 1 of 6 residents reviewed (Resident #8). The facility reported a census of 50 residents.

Inspectors wroteBased on observations, staff interviews, documents, Electronic Health Records (EHR), Medication Administration Records - Treatment Administration Records (MAR-TAR) and policy review the facility failed to ensure medications at the facility were labeled in accordance with currently accepted professional principles when the label for a medication did not match the order and the medication was administered to 1 of 6 residents reviewed (Resident #33). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, staff interview, employee file review, and policy review the facility failed to ensure two staff present while using a mechanical lift for a resident transfer, and staff failed to ensure sling straps removed from a mechanical lift when transferred a resident from the wheelchair to the bed for one of three residents reviewed for falls (Resident #3). The facility reported a census of 51 residents.

Inspectors wroteBased on record review, staff interviews, and facility job description review, the facility failed to ensure the dietary service manager met the required qualifications of a Dietary Manager, in the absence of a full-time dietitian. During initial kitchen walk through on 5/6/24, at 9:28 am, Staff F, Dietary Manager stated she had not taken the course to become a certified dietary manager. She said her prior background was working as a Certified Nurse Aide (CNA) and a Dietary Aide. The facility provided a certificate of Staff F having completed ServSafe training on 3/14/24. On 5/8/24 at 3:11 pm, the Administrator stated Staff F is enrolled in an Iowa Food Manager Certification Course which she will be completing through the healthcare association. She stated it is a self paced course and she anticipated Staff F would have completed within the month. [...]

Inspectors wroteBased on observations, staff interviews, the 2022 Food and Drug Administration (FDA) Food Code, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to develop comprehensive care plans for 1 of 8 residents reviewed (Resident #30). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review the facility failed to follow physician's orders and ensure interventions in place to prevent pressure ulcer development for one of three residents reviewed for pressure ulcer risk (Resident #2). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, observation, and staff interview, the facility failed to ensure residents provided a diet with finger foods per resident preference to maintain nutrition and weight for one of three residents reviewed for nutrition maintenance (Resident #1). The facility reported a census of 51 residents.

Inspectors wroteBased on observation and staff interview the facility failed to post required notifications of survey agencies, and other support for advocacy. The facility also failed to provide accessibility of the survey results. The facility reported a census of 51.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to refer 4 of 4 residents (#1, #3, #4, and #5) to the appropriate state-designated authority for a Level I Pre-admission Screening and Resident Review (PASRR) prior to admission or after a possible newly diagnosed serious Mental Disorder, Intellectual Disability, or other related condition. The facility reported a census of 48 residents.