Correctionville Specialty Care

Inspectors wroteBased on clinical record review, facility record review, resident and resident family interviews, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 4 out of 4 residents (Resident #3, #4, #6 & #8) reviewed from abuse. The facility reported a census of 35 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 2 of 4 residents reviewed for abuse (Resident #3 & #6). The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview the facility failed to revise and update care plans to include appropriate interventions for residents to prevent repeated falls and resident to resident altercations for 2 out of 3 residents reviewed (Resident #1 and #4). The facility reported a census of 35 residents.

Inspectors wroteBased on observation, clinical record review, and resident and staff interviews, the facility failed to ensure that a resident who experienced a fall received the necessary care and services to maintain their highest practicable physical well-being. For 1 of 3 residents reviewed (Resident #1), nursing staff failed to conduct a thorough assessment, implement immediate interventions, perform required neurological checks, or notify the resident's physician and family following an unwitnessed fall for 1 of 3 residents reviewed (Resident #1).

Inspectors wroteBased on observation, clinical record review, family and staff interviews, the facility failed to provide appropriate supervision to ensure each resident's individual safety while using the commode for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 35 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide and maintain accurate resident records to reflect incidents that occurred in the facility for 2 of 3 residents (Residents #1 and #6). The facility reported a census of 35 residents.

Inspectors wroteBased on observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 5 residents (Residents #3, #9, and #12) reviewed. The facility reported a census of 35 residents.

Inspectors wroteBased on clinical document review, staff interview, and policy review the facility failed to provide a comprehensive care plan related to oxygen use for 1 of 5 residents (Resident #9) reviewed. The facility reported a census of 35 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide thorough and timely assessment and intervention for 1 of 16 residents reviewed. Resident #24 was diagnosed with Covid-19 and was admitted to the hospital with pneumonia. The resident returned to the facility on 11/25 and the staff failed to assess the resident's Vital Signs (VS; heart rate, oxygen saturation, blood pressure and respirations) until 12/4/25 when she was found to have a change in condition, including low blood pressures. The resident was sent back to the hospital on [DATE]. The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, observations, staff interview, and policy review the facility failed to provide a professional standard of quality of care by not completing catheter cares for 1 of 2 residents reviewed (Resident #3). The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, observations, resident interviews, staff interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 4 residents reviewed (Residents #9) requiring the use of oxygen. The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance as scheduled for 3 of 4 residents reviewed for bathing (Resident #2, #6 and #9). The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to complete assessments for the necessary care and services to maintain the residents' highest practical physical well- being. Clinical record review revealed the nursing staff failed to perform neurological assessments for 1 out 3 residents reviewed for falls (Resident#1). The facility reported a census of 32 residents.

Inspectors wroteBased on observation, clinical record review, resident, family and staff family interviews, the facility failed to provide an environment that is free from accidents and hazards for 2 of 2 residents reviewed (Resident #1 and #10). The facility reported a census of 32 residents.

Inspectors wroteBased on facility record review and resident and staff interviews, the facility staff did not consistently answer call lights within a reasonable amount of time. Residents reported having to wait over 15 minutes for call lights to be answered for 3 of 3 residents reviewed (Resident #6, #7 and #9). The facility reported a census of 32 residents.

Inspectors wroteBased on observations, interview, and record review, the facility failed to review and revise care plans for four out of four residents reviewed (Residents #3, #11, #21 and #26). Specifically, the facility failed to identify the targeted behaviors for residents that received anti-psychotic, antidepressant and psychotic medications. The facility reported a census of 27 residents.

Inspectors wroteBased on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (July 1 - September 30) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 27 residents.

Inspectors wroteBased on observation, infection control policy, clinical record review and staff interview, the facility failed to conduct blood sugar tests in a manner that protected the resident from blood borne pathogens for 2 out of 2 residents reviewed (Resident #3 and #15). The facility reported a census of 27 residents.

Inspectors wroteBased on clinical record, facility policy, resident, and staff interview, the facility failed to follow dentist referral to obtain specialty dental services for 1 of 3 residents reviewed (Resident #93). The facility reported a census of 24 residents.

Inspectors wroteBased on clinical record review, law enforcement incident review, facility policy review, resident and staff interviews, the facility failed to keep residents safe from sexual abuse and financial exploitation for 1 of 3 residents (Resident #1). Resident #1 reported a male Certified Nurse Aide (CNA) forced her to perform sexual acts on him. In addition, that male CNA and another CNA transferred money from her account using an electronic money transferring service. Despite the allegation of sexual abuse from the male CNA to Resident #1, the facility failed to prevent him from working with other vulnerable residents in the corporation.

Inspectors wroteBased on clinical record review, facility policy review, staff, and resident interviews, the facility failed to report allegations of abuse within 2 hours for 1 of 3 residents reviewed (Resident #1). Resident #1 reported to staff on 10/23/23 that a staff member sexually abused her, in addition to transferring money from her account to staff. The facility did not report the incident to the appropriate authorities until the evening of 10/24/23.

Inspectors wroteBased on interviews with residents, staff and law enforcement, record review and policy review the facility failed to adequately investigate allegations of abuse for 1 of 3 residents reviewed (Resident #1). After Resident #1 reported allegations of sexual and financial abuse, the administration only addressed the exchange of money but minimized and failed to fully investigate the allegations of sexual abuse.

Inspectors wroteBased on clinical record review, interviews with staff and residents and policy review the facility failed to meet a resident's needs related to adequately planned transfers for 1 of 3 residents reviewed (Resident #1). The facility discharged Resident #1 abruptly after allegations of abuse to a homeless shelter that did not know of her transfer. The homeless shelter did not have nurses on staff to meet her medical needs and they did not have any staff overnight. The homeless shelter transferred Resident #1 to the hospital as she could not safely remain in the homeless shelter. After arriving to the homeless shelter, Resident #1 began to stumble and fall.

Inspectors wroteBased on interviews, record review and policy review the facility failed to prevent retribution to a resident and a staff member for 1 of 3 residents (Resident #1). Resident #1 reported that a male Certified Nurse Aide (CNA) sexually abused her. After the facility learned of the allegations on 10/24/23, they discharged Resident #1 to a homeless shelter on 10/25/23 with only approximately 30 minutes to pack. In addition, Staff P reported that the facility suspended her after she confronted the Administrator regarding the need to report the abuse. The facility suspended Staff Q from work for not reporting abuse within 2 hours after she learned about the allegation. At the time she reported the allegation, the facility already knew from other staff. The facility asked her to share information related to the abuse to speed up their investigation so she could return to work sooner. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure they provided adequate administration services. Upon allegations of abuse, the administrator failed to conduct a thorough investigation, failed to report the allegations to the proper authorities, and abruptly discharged the resident who made the allegation (Resident #1). The facility reported a census of 30 residents.

Inspectors wroteBased on clinical record review, interviews with staff and residents and policy review the facility failed to meet a resident's needs related to discharge planning for 1 of 3 residents reviewed. Resident #1 was discharged abruptly after allegations of abuse and was sent to a homeless shelter that was unaware that she was coming and could not meet her medical needs. The facility reported a census of 30 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to adequately monitor residents that had a high-risk for pressure ulcers for one of two residents reviewed (Resident #16). Resident #16 had a facility-acquired pressure on the bottom of his foot that was not discovered or documented until it measured over 7 centimeters in total area and was blackened. Despite Resident #16 receiving a bath the day before the discovery of the unstageable pressure wound, the staff denied knowledge of the wound. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that staff accounted for narcotic medications upon shift change. The facility reported a census of 29 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to protect a resident's right to privacy for one of one resident reviewed (Resident #1). Due to the resident's treatment of Staff H, Certified Nurse Aide (CNA), he recorded an interaction with Resident #1 without her permission.

Inspectors wroteBased on observations, electronic record review, policy review, and staff interviews the facility failed to provide a comprehensive care plan for 2 of five resident reviewed (Residents #3 and #33). Resident #3's Care Plan lacked her use an opioid (controlled pain medication) to manage her pain or that she had pain. Resident #33's Care Plan lacked that she used TED hose (stockings to prevent blood clots and swelling).

Inspectors wroteBased on observation, interview and record review the facility failed to include pertinent physician information in the Care Plan for 1 of 15 residents reviewed (Resident #33). On 7/25/23 Resident #33 admitted to the facility and the staff did not know that he had a penile implant. According to a hospital report on 10/17/23, Resident #33 went to the emergency room with penile pain and concerns with his urinary catheter. The hospital report indicated that Resident #33's implant malfunctioned.

Inspectors wroteBased on observations, interviews, record review, and policy review the facility failed to follow physician's orders for one of two residents' reviewed (Resident #33). In addition to not following the physician's orders, the facility documented that they completed Resident #33's order.

Inspectors wroteBased on observations, interviews, clinical record reviews, and facility policies, the facility failed to change the urinary catheter for a resident for one of two residents reviewed for catheter care (Resident #16). Resident #16 had an order to change his catheter every thirty days. In August 2023, the facility failed to change Resident #16's urinary catheter, his clinical record lacked documentation until 10/15/23 that his catheter got changed. On 10/19/23, Resident #16 went to the hospital for groin pain, while there the Urologist discovered a kidney stone and cystitis (inflammation of the bladder). Due to the possibility of the bladder stone blocking the kidney's ureter that brings the urine to the bladder, Resident #16 received a stent. The Urologist indicated that the kidney stone developed due to no one changing his urinary catheter.

Inspectors wroteBased on clinical record review, policy review, resident interview and staff interview, the facility failed to prevent a significant medication error for one of 3 residents reiviewed (Resident #87). Resident #87 admitted to the facility with orders for insulin gargaline (slow acting insulin) to receive once a day with breakfast the day after her admission. That morning on 2/21/23, the nurse gave Resident #87 her 16 units of insulin gargline. That afternoon, another nurse added the same order for insulin gargaline but for the hour of sleep (HS). At bedtime, Resident #87 received her second dose of 16 units of insulin gargaline that day, bringing the total insulin to 32 units for the day (double her dose).

Inspectors wroteBased on observations, interviews, facility policy review, and clinical record reviews the facility failed to secure medications in a locked compartment for 2 of 3 residents reviewed (Residents #3 and #1).

Inspectors wroteBased on document review, observation, record review, and staff interview the facility failed to prepare food in a form designed to meet the resident's individual needs by sending the incorrect consistency for a modified diet ordered for 2 of 2 residents reviewed (Resident #4, and #26).