Oskaloosa Care Center

Inspectors wroteBased on staff interviews, resident interview and policy review, the facility failed to be respectful and provide care with dignity for 1 of 3 residents reviewed (Residents #2). The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review the facility failed to ensure 1 of 3 (Resident #1) residents reviewed for transfers was repositioned and kept clean and dry. Resident #1 sat for a prolonged time in a wheel chair without repositioning and with urine-soaked clothing. The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review, staff interviews, resident interview and policy/competency review, the facility failed to ensure safety precautions for 1 of 3 residents reviewed when used a mechanical lift was used to transferred from chair to bed (Resident #2), Two staff were required to assist the resident transfer when a mechanical lift is used for safety. The facility reported a census of 78 residents.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to provide services that met professional standards regarding following physician's treatment orders (Resident #4) and monitoring for adverse reactions to immunizations (Resident #1, #2, #3, #5, #6, #7, #9, #11, #13, #14) for 11 of 13 residents reviewed. The facility reported a census of 75 residents.

Inspectors wroteBased on record review, staff interview, and facility policy the facility staff failed to administer medications correctly related to omission of medications, residents getting the wrong medications, and tube feeding not started timely, for five of five residents reviewed for physicians orders. (Residents #4, 12, 13,14, and 15). The facility reported a census of 75 residents.

Inspectors wroteBased on clinical record review, interviews, and policy review the facility failed to report a resident to resident altercations involving (R#1) and failed to report allegation of abuse involving (R#5) to the State Agency. The facility reported a census of 75 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to provide a thorough investigation into allegations of abuse for 1 of 1 residents (Resident #5) reviewed. The facility reported a census of 75 residents.

Inspectors wroteBased on Electronic Record Review (EHR), staff interviews and facility policy review, the facility failed to assess, intervene, and monitor interventions per the facility's Bowel Regulatory Program for four of four residents (Resident #1, #2, #3, and #4) reviewed for increased risk of constipation. The facility reported a census of 82 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to carry out cardiopulmonary resuscitation(CPR) in accordance with the resident's wishes, and follow the physician's orders for 1 of 1 residents reviewed for cardiopulmonary resuscitation status(Resident #1). The facility failed to correctly identify that Resident #1 desired CPR related to discrepancies in code status listed in multiple locations and a staff member incorrectly reading the resident's chart. Approximately 7 minutes after Resident #1 was last seen alive, the Advanced Registered Nursing Practitioner(ARNP) issued an order to withhold CPR due to the facility staff's delays. The facility staff also lacked knowledge of how to locate the facility's crash cart. This failure resulted in Immediate Jeopardy(IJ) to the health, safety, and security of the resident. [...]

Inspectors wroteBased on interviews, clinical record review, and facility policy review, the facility failed to carry out timely assessments and interventions after a resident complained of chest pain for 1 of 3 residents reviewed for a change in condition(Resident #9). The facility reported a census of 76 residents.

Inspectors wroteBased on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to implement training for multiple topics for 6 of 6 staff reviewed (Staff B, M, N, O, P, Q). The facility reported a census of 76 residents.

Inspectors wroteBased on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to ensure staff completed training in Quality Assurance and Performance Improvement(QAPI) for 6 of 6 staff reviewed(Staff B,M, N, O, P, Q). The facility reported a census of 76 residents.

Inspectors wroteBased on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to ensure staff completed training in infection control for 4 of 6 staff reviewed (Staff B,O, P, Q). The facility reported a census of 76 residents.

Inspectors wroteBased on personnel file review, the facility in-service attendance calendar, and staff interview, the facility failed to ensure staff completed training in compliance and ethics for 6 of 6 staff reviewed(Staff B, M, N, O, P, Q). The facility reported a census of 76 residents.

Inspectors wroteBased on observation, staff interviews, record review and policy review, the facility failed to ensure open items were dated, covered and labeled and food was stored under sanitary conditions to prevent cross contamination. The facility further failed to test twice daily the dishwasher to ensure the low temperature dishwasher was getting to the correct temperatures and chemical solution to appropriately sanitize dishes. The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to limit a PRN (as needed) psychotropic drug (drugs that affect a person's mental state) to 14 days and failed to ensure the resident had an appropriate diagnosis for the psychotropic drug for 1 of 6 residents reviewed (Resident #28). The facility reported a census of 81 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to develop and implement a comprehensive person centered Care Plan for 1 of 19 residents reviewed for Care Plans (Resident #28). The facility reported a census of 81 residents.

Inspectors wroteBased on observations, interviews record review and policy the facility failed to follow professional standards during medication administration observation, left medications with a resident, unsupervised administration for 1 of 7 observed (R#45). The facility reported a census of 81.

Inspectors wroteBased on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to perform perineal care for incontinent residents in a hygienic manner for 3 of 3 residents observed (Resident #1, #38, and #63). The facility reported a census of 81.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure a resident with physical aggression tendencies towards other residents was adequately supervised to prevent reoccurrences. (Residents #2, #3, #4, #7) The facility reported census was 81.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to treat a resident in a dignified manner when they used excessive force to restrain the resident to obtain a urine sample. (Resident #1) The facility reported census was 81.

Inspectors wroteBased on clinical record reviews and staff interviews, the facility failed to meet professional standards and practices as documentation was intentionally falsified and clinical records removed for 2 of 8 residents reviewed. (Resident #1, #2) The facility reported census was 81.

Inspectors wroteBased on clinical record reviews and staff interviews, the facility failed to meet professional standards and practices as documentation was intentionally falsified and clinical records removed for 2 of 8 residents reviewed. (Resident #1, #2) The facility reported census was 81.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure residents are appropriately assessed and provided interventions to maintain their optimal health and well being for 1 of 8 residents reviewed. (Resident #1) The facility reported census was 81.

Inspectors wroteBased on facility record review and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 77 out of 83 residents. The facility incorrectly coded physical restraints were used on 77 residents. The facility reported a census of 83 residents.

Inspectors wroteBased on direct observation, staff interview, and family interview, the facility failed to provide sufficient staff to provide needed cares and supervision to ensure safety of residents at the facility. The facility reported a census of 83 residents with 10 of those residents in the Chronic Confusion or Dementing Illness Unit (CCDI).

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASARR) evaluation for 1 of 2 residents reviewed with new mental health diagnoses and medication revisions (Resident #53). The facility reported a census of 83.

Inspectors wroteBased on record review, observations, staff interviews, and policy review, the facility failed to carry out therapy recommendations and provide restorative exercises for 1 of 4 residents reviewed for rehabilitation services and/or limited range of motion (Resident #64). The facility reported a census of 83 residents.

Inspectors wroteBased on record review, staff interview, and policy/guidance review the facility failed to ensure accuracy on residents' Minimum Data Set (MDS) assessments. Residents reviewed in the sample were coded incorrectly indicating restraints were used on 18 of 20 residents reviewed in the sample (Residents' #3, #6, #11, #19, #22, #26, #32, #40, #45, #52, #53, #59, #63, #64, #65, #66, #73, #74, #82, and #233.) Resident #11 was also inaccurately coded for pneumonia. The facility reported a census of 78 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update a Care Plan for 1 of 18 residents reviewed for Care Plans (Resident #73). Resident #73 was observed ambulating in the facility without a walker. Review of Resident #73's Care Plan revealed that resident was to use a walker. The facility reported a census of 78 residents.

Inspectors wroteBased on observation, Resident interview, staff interview and clinical record review the facility failed to ensure accurate order transcribed on the Medication Administration Record (MAR) for oxygen for 1 of 3 residents sampled for respiratory (Resident #233). The facility reported a census of 78. The Entry Minimum Data Set (MDS) dated [DATE] documented Resident #233 was admitted on [DATE] from a Hospice facility. The admission MDS dated [DATE] revealed resident diagnoses which included Debility, Cardiorespiratory Conditions, anxiety and depression. A Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated cognition intact. The Care Plan with initiated date 1/4/23 documented a diagnosis of Chronic Obstructive Pulmonary disease (COPD). The Care Plan did not address the resident's oxygen needs. [...]

Inspectors wroteBased on clinical record review, staff interview, the facility failed to limit a As Needed (PRN) psychotropic medication to fourteen (14) day limit without physician rationale to extend the order for 3 of 5 (Resident #40, #52, and #59) reviewed. The facility reported a census of 78 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to clean the countertop surface and/or place a clean barrier under a rubber spatula that was placed on the counter while pureeing food. The facility reported a census of 78.