Community Memorial Health Center

Inspectors wroteBased on resident and staff interviews, record review and facility policy review the facility failed to accommodate an appropriate bathing time to honor residents preference for 1 of 17 residents (Resident #6) reviewed. The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents (Resident #4) reviewed for PASRR requirements. The facility reported a census of 47 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infection for 1 of 2 residents reviewed (Resident #1). The facility reported a census of 47 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to accurately transcribe physician orders for psychotropic medications, including documenting the correct medication end dates in the electronic medical record, for 2 of 2 residents reviewed (Resident #3 and #22). The facility reported a census of 47 residents

Inspectors wroteBased on observation, clinical record review, staff interview, and per the current Centers for Disease Control and Prevention (CDC) guidelines the facility failed to use Enhanced Barrier Precautions (EBP) to prevent the spread of multidrug-resistant organisms (MDROs) during catheter care for 1 out 2 resident reviewed (Resident #24). The facility reported a census of 47 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a residents right in self determining a time to get dressed/up for 5 of 5 residents reviewed with dementia (Resident #1, #2, #3, #4, and #5). The facility reported a census of 45 residents.1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 3 on the Brief interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for toileting hygiene, upper and lower body dressing. The resident's diagnoses included Alzheimer's disease and insomnia. The Care Plan revised 8/4/25 identified the resident had a diagnosis of insomnia and she took scheduled Melatonin for it. Interventions included monitoring the resident for any change in sleep pattern, and staff would encourage a consistent routine each night. On 11/25/25 at 4:12 a.m. [...]

Inspectors wroteBased on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 residents reviewed for abuse (Resident #1). The facility reported a census of 46 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to provide and maintain accurate resident records to reflect an incident occurring in the facility for 1 of 4 residents (Residents #1). The facility reported a census of 46 residents.

Inspectors wroteBased on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility for 2 of 2 residents reviewed (Residents #8 and #9). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, facility investigation review, staff interviews, and facility policy review the facility failed to conduct a thorough investigation of an allegation of abuse. On 4/3/24, the nurse learned of a Certified Nurse Aide (CNA) slapping Resident #1 on the leg. After learning of this allegation of abuse, the facility allowed the CNA to finish working the scheduled night shift and to continue to work unattended behind closed doors with other residents. This failure resulted in residents living at the facility to be exposed to the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of April 9, 2024 on June 30, 2024 at 3:32 p.m The facility staff removed the IJ on July 3, 2024 through the following actions: a. [...]

Inspectors wroteBased on record review, interview, and facility policy the facility failed to have the Infection Preventionist at quarterly meetings for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 50.

Inspectors wroteBased on clinical record review, facility record review, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 1 out of 3 residents (Resident #1) reviewed from physical abuse. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 residents reviewed for abuse (Resident #1). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, facility record review, staff interviews and facility policy review the facility failed to provide accurate resident records for 1 of 4 residents (Residents #1). The facility reported a census of 50 residents.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to update the resident's care plan to accurately reflect the resident for 4 of 13 reviewed (Residents #2, #16 #20, #41). The facility reported a census of 50 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to have a facility assessment updated. The facility reported a census of 50 residents. Findings Include: Review of the facility assessment revealed an updated date of 6/2/22. The facility does not hvae a policy on facility assessment or revision. Interview on 11/02/23 at 8:54 a.m., with the Administrator revealed the facility did not have the facility assessment updated for 2023 and everyone was working on their parts to get it updated. He further revealed it should be completed yearly.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to incorporate specialized services into resident ' s care with a Level II Preadmission Screening and Resident Review (PASRR) for 1 out of 2 residents (Resident #16). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, policy and procedures, resident and staff interviews, the facility failed to implement measures to ensure the personal alarm sounded when a resident arose from the chair for 1 out 1 residents reviewed (Resident #41). The facility reported a census of 50.