Stacyville Community Nursing Home

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure 1 of 3 sampled residents on antipsychotic medications had diagnoses to support the justification and use of the medication and the negative side effects it can cause in the elderly (Resident #19). The facility reported a census of 24 residents.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 3 residents reviewed for catheters (Resident #6). The facility reported a census of 24 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure one of 3 residents (Resident #2) remained free from a medication error, failed to document the error in the clinical record, and failed to follow professional standards for reconciling controlled drugs (medications with a high potential for abuse). The facility reported a census of 23 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure one of one residents (Resident #2) remained free from a medication error and failed to document the error in the clinical record. The facility reported a census of 23 residents.

Inspectors wroteBased on electronic health record (EHR)review, policy review, resident, and staff interviews the facility failed to report an allegation of abuse within the required time frame to the Iowa Department of Inspection, Appeals, and Licensing (DIAL) for 1 of 1 resident reviewed (Resident #9). The facility reported a census of 22 residents. Findings Include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of renal (kidney) insufficiency (poor functioning), stroke and end stage renal disease (ESRD). The MDS documented Resident #9 received dialysis services outside of the facility. During an interview on 6/2/25 at 12:10 PM, Resident #9 reported he had money missing and someone took his money. [...]

Inspectors wroteBased on electronic health record (EHR) review, clinical record review, the Centers for Medicare and Medicaid Services (CMS) Long term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview the facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) assessment after a resident elected to start hospice for 1 of 1 residents (Resident #17) reviewed on hospice services. The facility reported a census of 22 residents.

Inspectors wroteBased on clinical record review and staff interviews the facility failed to accurately document and submit an accurate Minimum Data Set (MDS) Assessment for 1 of 6 residents reviewed (Resident #6). The facility reported a census of 22 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to follow physician's orders for 2 of 6 residents reviewed (Resident #6 and #11). The facility reported a census of 22 residents.

Inspectors wroteBased on facility record review and staff interviews, the facility failed to have an effective quality assurance (QA) program in place to assist in the provision of quality care for residents. The facility identified a census of 27 residents.

Inspectors wroteBased on observations, clinical record review, resident interview, staff interviews and the Resident [NAME] of Rights the facility failed to allow a resident to make his own decisions and follow physician orders for 1 resident reviewed (Resident #4). The facility reported a census of 27 residents.

Inspectors wroteBased on observation, clinical record review, resident interview, staff interview and facility policy review the facility failed to maintain a complete and accurate Care Plan based on the individual resident needs for 4 residents of residents reviewed (Residents #2, #3, #4, and #5). The facility identified a census of 27 residents.

Inspectors wroteBased on observation, clinical record review and staff interview the facility failed to provide restorative services to residents as a means to maintain their highest level of functioning (Residents #2, #3, and #5). The facility identified a census of 27 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review the facility staff failed to follow professional standards of practice as they allowed staff to compound (mix together) treatment ointments/creams prior to application for one (1) resident reviewed (Resident #1). The facilities identified a census of 27 residents.

Inspectors wroteBased on staff provide photograph, resident, and staff interviews, the facility failed to have a licensed nurse awake and capable of rendering nursing service for 1 day reviewed. On 1/22/24, residents and the facility saw observed Staff C, Licensed Practical Nurse (LPN), sleeping in the front lounge. The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record reviews, staff interviews, the Iowa Nursing Board Chapter 6 regarding the Nursing Practice For Registered Nurses (RN)/Licensed Practical Nurses (LPN), the Iowa Department of Inspections, Appeals, and Licensing (DIAL) website page related to the RN/LPN Role & Scope, audio of a submitted video, and employee records, the facility failed to have competent staff to work at the facility. The facility had an LPN perform intravenous (IV) medications via a peripherally-inserted central catheter (a IV that provide medications into a large vein that can stay in for multiple months) for 1 of 1 residents reviewed (Resident #15) without an Iowa approved certification. [...]

Inspectors wroteBased on schedule review, time card review, staff interview and facility policy review the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day as required by the Federal Regulations. In addition, the facility failed to designate a RN as the Director of Nursing. The facility reported a census of 28 residents.

Inspectors wroteBased on interviews, employee records reviews, and clinical record reviews, the facility failed to provide an effective leadership to follow the required Federal Regulations and state rules of a long-term care nursing facility. The facility failed to follow the Federal Regulation to have a Registered Nurse (RN) designated as the Director of Nursing (DON). The provisional Administrator designated Staff B, Licensed Practical Nurse (LPN), as the Interim DON knowing she didn't have her RN. In addition, the facility failed to ensure proper chain of command regarding concerns with the DON. The facility reported a census of 28 residents.

Inspectors wroteBased on facility record review and staff interviews, the facility failed to have an effective quality assurance (QA) program in place to assist in the provision of quality care for residents. See F727 for additional information regarding RN coverage. The facility identified a census of 28 residents.

Inspectors wroteBased on clinical record review, resident interview, staff statements and review of Resident Rights, the facility staff failed to treat one (1) resident with dignity and respect while speaking with them (Resident #9). The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review the facility staff failed to follow professional standards of practice for 1 resident reviewed (Resident #1). Staff A, Registered Nurse (RN), drew up liquid morphine, Roxanol (pain medication), without a witness in a 1 milliliter (ml) syringe. Staff B, the Interim Director of Nursing (DON)/Licensed Practical Nurse (LPN), took the syringe from Staff A and administered it to Resident #1. The facility identified a census of 28 residents.

Inspectors wroteBased on observation, clinical record review, staff interview and equipment invoices, the facility failed to maintain patient care equipment in safe operating condition. The facility identified a census of 28 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to report missing narcotics from the facility's emergency narcotic box within the required 24 hours. The facility identified a census of 28 residents.

Inspectors wroteBased on observations, clinical record review, staff interview, and facility policy review, the facility failed to provide adequate assessments and interventions in a timely manner for 1 of 3 residents reviewed (Resident #3) following a change of condition. The facility identified a census of 28 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to maintain a safe environment for one (1) resident residents reviewed (Resident #15). While assisting Resident #15, the nurse found a marijuana pipe and a medication bottle labeled Lasix (diuretic) with contents unknown in his drawer. Instead of removing the items, the nurse allowed Resident #15 to keep the items in his room with direction for his family to pick up. The facility reported a census of 28.

Inspectors wroteBased on record review, facility provided education, policy review, staff and Pharmacist interviews the facility failed to provide 1 of 6 residents (Resident #1) their prescribed medications. After Resident #1 received another resident's medications, she went to the local hospital. Due to Resident #1's level of sedation, the hospital admitted her. The facility reported a census of 31 residents.

Inspectors wroteBased on time card review, schedule review, and staff interviews, the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) consecutive hours per day as required by the Federal Regulations. The facility reported a census of 31 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to submit a new Pre admission Screening and Resident Review (PASRR) for 1 of 1 resident (Resident #11) for review when he received new diagnoses documented in his medical record. The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, and staff interview and policy review, the facility failed to accurately complete a comprehensive Care Plan 3 of 14 residents reviewed (Resident #9, #25 and #28). The facility reported a census of 31 residents.

Inspectors wroteBased on record review and staff interview the facility failed to revise 1 of 1 Residents (Resident #11) Care Plan when Diagnoses of Psychosis and depression were documented in his medical record to ensure proper interventions were in place. The facility reported a census of 31 residents.

Inspectors wroteBased on record review, policy review, resident, and staff interview the facility failed to implement discharge planning upon admission for 1 of 1 resident reviewed (Resident #28). Resident #28 voiced she would like to discharge upon admission to a different facility. The facility reported a census of 31 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure 1 of 1 resident (Resident #28) received an anti psychotic medication (Olanzapine) for only the diagnoses related to psychiatric/mood disorders upon admission. The facility reported a census of 31 residents.

Inspectors wroteBased on observations, staff interviews, the Centers for Medicare and Medicaid Services (CMS), and the Assure Prism Manual, the facility failed to adequately sanitize the blood sugar meter and use barrier when doing blood sugar checks and insulin for 3 of 3 residents reviewed (Resident #25, #10,and #26). The facility reported a census of 31.

Inspectors wroteBased on staff interviews, the facility failed to provide a qualified Infection Preventionist to monitor and provide oversight to the facility infection prevention program. The facility reported a census of 31 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to have a system in place for residents to decline vaccinations if desired for 3 of 4 residents (Resident #16, #5, and #20). The facility reported a census of 31 residents.

Inspectors wroteBased on nursing time card review and staff interview, the facility failed to accurately report the Payroll Based Journal (PBJ) for licensed nursing staff during the second quarter of fiscal year 2024. The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) manual the facility failed to accurately document and submit accurate resident Minimum Data Set (MDS) Assessment for 4 of 7 residents reviewed (Resident #9, #20, #29 and #3). The facility reported a census of 31 residents.

Inspectors wroteBased on clinical record review, staff and provider interviews, facility investigation records, and policy review the facility failed to implement root cause analysis and provide interventions for 1 of 3 residents reviewed (Resident #8) to prevent future falls. Resident #8 had a Fall on [DATE] that resulted in admission to the hospital for a subdural hematoma (brain bleed) that may have been an injury caused from the fall or the reason the fall occurred, Resident #8 passed away on [DATE]. The facility reported a census of 22 residents.

Inspectors wroteBased on resident and staff interviews, and policy review the facility failed to ensure 1 of 3 residents reviewed (Resident #4) was spoken to respectfully and in a dignified manner by facility staff. The facility reported a census of 22 residents.