The Village of Ackley

Inspectors wroteBased on record review and staff interviews the facility failed to accurately code 1 of 1 Minimum Data Set (MDS) assessments for residents with a Pre-admission Screening and Resident Review (PASRR) Level II outcome (a formal determination that confirms if an individual with suspected serious mental illness or intellectual disability requires Medicaid-certified nursing facility care and defines their need for specialized services) (Resident #2). The facility reported a census of 27 residents. Findings Include:Resident #2's MDS assessment dated 12/11//25 identified she didn't have a state level II PASRR serious mental illness and/or intellectual disability or related condition. The MDS documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS included diagnoses of depression, schizophrenia and cognitive communication deficit. [...]

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to clean the kitchen convection oven, griddle on the stove, sink, cabinet under sink, and electric griddle. The facility reported a census of 27 residents.

Inspectors wroteBased on electronic health record (EHR) review, facility records, policy review, resident and staff interviews the facility failed to ensure residents are free from neglect following a fall for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 32. Findings Include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS documented Resident #2 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts, holds, and supports trunk or limbs, but provides the efforts) from sit to stand (The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed). The MDS documented Resident #2 had been dependent (Helper does all of the effort. [...]

Inspectors wroteBased on electronic health record (EHR) review, facility records, 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 (Resident #2) reviewed. The facility reported a census of 32. Findings Include:Resident #2 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS documented Resident #2 required substantial/maximal assistance (Helper does more than half the effort. [...]

Inspectors wroteBased on clinical record review and staff interview the facility failed to inform the Long Term Care (LTC) Ombudsman office of a resident transfer from the facility for 1 of 1 resident's reviewed (Resident #9) for hospitalization. The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to treat residents with dignity and respect in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 1 residents reviewed (Resident #14). The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed with a new mental health diagnosis (Resident #19). The facility reported a census of 28 residents.

Inspectors wroteBased on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal Staffing Data Report (July 1, 2024 - September 30, 2024) 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 28 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 4 residents reviewed (Resident #1) for falls. Resident #1 had four falls in the month of June. Resident #1 experienced a right ankle injury and a skin tear/bruise to right elbow when a fall resulted from the facility not providing the appropriate level of assistance per therapy recommendations. The facility reported a census of 32 residents.

Inspectors wroteBased on staff interviews, clinical record review, hospital record review, family interviews, and policy review the facility failed to conduct appropriate assessments, interventions and timely Physician notification for 1 of 4 resident reviewed (Resident #1). Resident #1 experienced difficulty swallowing, poor oral intake, and mouth pain that resulted in weight loss and a hospitalization from 7/1/24 to 7/8/24 for acute kidney injury, dehydration (inadequate fluid intakes) and pharyngitis/MRSA (Methicillin - resistant Staphylococcus Aureus - staph infection resistant to several antibiotic to the throat). Resident #1 started having difficulty swallowing on 6/20/24, went to the ER (emergency room) on 6/21/24 and returned to the facility. Resident #1 continued to have difficulty with swallowing with decreased oral intakes after returning from ER. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to notify the physician and family for a significant change in condition for 2 of 4 residents reviewed (Residents #1 and #4). The facility reported a census of 32 residents.

Inspectors wroteBased on observations, staff, and family interviews the facility failed to provide a safe, clean, comfortable environment for 1 of 4 residents reviewed (Resident #1) for a homelike environment. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to provide Speech Therapy (ST) as ordered by the Physician order for 1 of 1 resident reviewed (Resident #1) for therapy services. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to accurately document a fall and the required assessment related to a fall in the medical record for 1 of 4 residents reviewed (Resident #4). The facility failed to complete thorough incident reports for 3 out 4 residents (Residents #4, #1, and #2). The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview, the facility failed to have a system in place to ensure residents who use Coumadin (blood thinner) received their therapeutic monitoring as ordered by the physician for 3 of 3 residents reviewed (Residents #5, #13, #16). The facility failed to get Resident #5 and Resident #13's lab draws completed for at least 6 days. Resident #13 had an elevated lab level that required the facility to hold his medication for 2 doses. When Resident #5 missed her lab draw, the facility failed to get her lab draw completed resulting in her missing 8 days of her coumadin. The facility failed to follow the Physician's order for Resident #16 and drew their lab early resulting in a low therapeutic level for their convenience. [...]

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to follow the approved diet menu and failed to measure accurate servings for residents who received pureed diets. The facility reported a census of 34 residents.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 34.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by (a) improperly storing food, (b) failing to maintain correct dishwasher operation, and (c) failing to prevent cross contamination during food service. The facility reported a census of 34 residents.

Inspectors wroteBased on observation, staff interviews, document reviews, and policy review, the facility failed to develop a comprehensive water management program and identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. The facility also failed to evaluate where hazardous conditions may occur in the water systems and implement measures to prevent waterborne pathogens. In addition, the facility failed to provide hand hygiene supplies for each resident and/or visitor. The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review, policy review and staff interviews, the facility failed to ensure code status between the facility and hospice were congruent for 1 of 2 residents reviewed for advanced directives (Resident #10). The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review, staff and family interviews, and policy review, the facility failed to provide family notification in a timely manner when changes occurred in the resident's physical or mental condition for 1of 1 resident reviewed (Resident #23). The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to transmit a discharge Minimum Data Set (MDS) assessment in a timely manner for 1 of 1 resident reviewed for resident assessment (Resident #32). The facility reported a census of 34 residents.

Inspectors wroteBased on resident interview, clinical record review, policy review and staff interview, the facility failed to invite a resident or a resident's representative to an initial Care Conference for one of one (Residents #38). The facility reported a census of 34 residents.

Inspectors wroteBased on observation, staff interviews, record review, and policy review, the facility failed to provide appropriate treatment and services to prevent a urinary tract infection for 1 of 3 residents (Resident #23). The facility reported a census of 34 residents.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to evaluate and manage an as needed psychotropic medications between fourteen days of use for 1 of 1 resident sampled (Resident #34). The facility reported a census of 34.

Inspectors wroteBased on document review and staff interview, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a certified dietary manager. The facility reported a census of 34 residents.

Inspectors wrote481-58.20(135C) Duties of health service supervisor. Every nursing facility shall have a health service supervisor who shall: 58.20(13) Evaluate in writing the performance of each individual on the health care staff on at least an annual basis. This evaluation shall be available for review in the facility to the department; (III) Based on personnel record review and staff interview, the facility failed to conduct annual staff evaluations for 5 of 5 employee records reviewed (Staff B, Registered Nurse (RN); Staff C, Maintenance Supervisor; Staff G, RN; Staff H, Licensed Practical Nurse (LPN); Staff I, RN). The facility reported a census of 34 residents.

Inspectors wroteBased on interviews, record reviews, and policy review the facility failed to update a resident's Care Plan following their admission to Hospice Services for 1 of 1 resident reviewed for hospice services (Resident #23). The facility reported a census of 34 residents.

Inspectors wroteBased on record review, policy review and staff interview, the facility failed to ensure the required members were present at quarterly Quality Assurance Performance Improvement (QAPI) meetings. The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview, the facility failed to ensure Dependent Adult Abuse Mandatory Training recertification training was completed timely for 2 of 5 staff personnel files reviewed (Staff B, Registered Nurse (RN) and Staff C, Maintenance Supervisor). The facility reported a census of 34 residents.

Inspectors wroteBased on staff schedule review, facility assessment review, nurse written statement and staff interview the facility failed to provide professional nursing coverage 24 hours a day, 7 days a week. The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to notify the physician and family of a significant weight loss for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to recognize, assess and investigate the cause of a weight loss and implement appropriate interventions based on the assessment and investigation for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 33 residents.