Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Correctionville Specialty Care during CMS and state inspections, most recent first.
Failure to Protect Residents from Abuse: A resident reported sexual touching by another resident in the dining area, another resident reported that a male resident entered her room while she was sleeping and kissed her, a third resident reported being struck with a bedpan by overnight staff, and another resident reported that an LPN yelled at her and was verbally abusive when she needed help using the bathroom. Staff statements and facility records documented the allegations and resident distress, with one resident also noted to have scratches after the bedpan incident.
Failure to timely report abuse allegations: Two residents reported mistreatment, including one resident who said another resident entered her room while she was sleeping unclothed, kissed her, and asked for sex, and another resident who reported an overnight nurse aggressively pulled her legs to move her out of bed. Staff documented the reports, but the facility did not notify DIAL within the required 2-hour timeframe.
Care plans were not revised to include interventions after repeated falls and a resident-to-resident altercation. One resident with Parkinson's disease, moderate cognitive impairment, and a history of falls had an unwitnessed fall, but the care plan had no fall interventions documented. Another resident with depression, anxiety, and HF reported that a male resident tried to touch her breast, yet the revised care plan still lacked interventions after the incident.
A resident with Parkinson's disease, moderate cognitive impairment, and a history of falls was found on the floor near his wheelchair after an unwitnessed fall. Staff reported the resident denied injury, but the RN could not recall completing the required assessment or neuro checks, and the record had no fall assessment, VS, head-to-toe exam, progress note, care plan intervention, or incident report. The Administrator confirmed the nurse did not complete required assessments, identify the cause, or notify the MD, family, or administration.
Failure to supervise a resident on the commode. A resident with dementia, anxiety, repeated falls, and non-ambulatory status was left on the commode for an extended period after staff forgot a timer alert. Staff acknowledged the resident could not always reach the call light because the cord was too short and that the call light was sometimes tucked away. An LPN did not assess the resident or complete incident documentation after being told about the event, and the resident later reported butt pain and a deep indentation.
Failure to document resident incidents accurately and timely. A resident with Parkinson’s disease and cognitive impairment had a reported fall, but the chart lacked documentation in the care plan, progress notes, clinical assessment, and incident reports. Another resident with moderate cognitive impairment reported that a peer entered her room while she was unclothed, kissed her, and asked for sex; staff statements confirmed the report, but the documentation was delayed and did not accurately reflect the event when it occurred.
Food was not consistently served at an appetizing temperature for several residents. Two cognitively intact residents reported that meals were often cold or not hot when delivered, and a third resident with BIMS 15/15, neurogenic bladder, paraplegia, and post polio syndrome said hot food was served cold and room trays were often cold or incorrect. Surveyors observed hot items held at proper temps in the steam table, but a sampled room tray showed chicken at 131.7 degrees and mashed potatoes at 139 degrees, below the facility policy requirement to keep hot foods above 135 degrees F.
Incomplete Care Plan for Oxygen Use: A resident with intact cognition, HTN, renal insufficiency, and anxiety disorder had a physician order for continuous O2 at 2 L to maintain saturation above 90% for SOB and hypoxemia, but the care plan contained no focus, goals, or interventions for oxygen use. The DON stated that oxygen use should have been included on the care plan, and the facility policy required a comprehensive person-centered care plan describing services to support the resident’s highest practicable well-being.
Failure to Monitor Vital Signs After Hospital Return: A resident with multiple comorbidities, recent Covid-19, pneumonia, and respiratory failure returned from the hospital with orders for continued O2 and monitoring, but the chart lacked documented VS for several days. Staff later found repeated low BP readings with weakness and increased confusion, and the resident was sent to the ED for hypotension.
Failure to provide required catheter care and monitoring: A resident with a suprapubic catheter, recurrent UTIs, and bladder infections reported that staff did not consistently empty the catheter every shift or clean it properly after emptying. Record review showed missed or inconsistent documentation of catheter emptying, and observation found the drainage bag full with 1500 cc of urine and sediment in the tubing. The DON and Administrator stated catheter care and emptying should occur every shift and that the bag should be emptied at least every 8 hours.
Failure to provide respiratory care for a resident requiring O2. A resident with intact cognition, HTN, renal insufficiency, and anxiety disorder was observed on 2 L NC with undated tubing, and the resident was unsure when the tubing was last changed. The EHR showed orders for continuous O2 to keep SpO2 above 90% and for oxygen tubing and nebulizer mask to be changed weekly. The DON stated tubing should be dated when changed and changed per the order.
The facility failed to provide scheduled bathing assistance to three residents due to staffing shortages. A resident with diabetes and a diabetic ulcer was not offered a bath since admission, while another with muscle wasting did not receive weekly baths as scheduled. A third resident with legal blindness also missed scheduled baths. Staff admitted to inaccurately documenting refusals due to previous instructions, highlighting discrepancies in care records.
A resident with polyneuropathy and moderate cognitive impairment experienced multiple unwitnessed falls, but the facility failed to complete required neurological assessments. Staff interviews indicated that the increased workload from recent admissions hindered their ability to perform necessary care.
The facility failed to maintain a safe environment for two residents, as TV cords were observed hanging close to call light strings, posing a potential hazard. A CNA and a resident's family member reported that a resident mistook the TV cords for the call light, nearly causing the TV to fall. The facility's policy did not address these hazards, and the Administrator acknowledged the issue upon observation.
The facility experienced delays in answering call lights, with residents waiting over 15 minutes for assistance due to staffing shortages. A resident reported waiting over an hour for bedtime care, while another expressed frustration over repeated delays. Staff interviews confirmed that insufficient staffing, particularly with new admissions, hindered timely responses. The facility's policy lacked a specified response time, though the Administrator indicated a 15-minute expectation.
The facility failed to update care plans for residents on psychotropic medications, omitting targeted behaviors and non-pharmacological interventions. This affected residents with conditions like anxiety, depression, and dementia, as their care plans lacked necessary details for monitoring behaviors. The DON was unaware of the requirement to include targeted behaviors in care plans.
The facility failed to submit accurate staffing reports to CMS, resulting in a one-star staffing rating. The DON worked extra shifts on nights and weekends, and an employee from the attached assisted living facility also worked hours that were not reported. This led to discrepancies in the reported staffing data.
An LPN failed to follow infection control protocols during blood sugar testing for two residents. The LPN did not use a protective barrier for testing supplies, neglected hand hygiene after glove removal, and did not sanitize the glucometer. The facility's policy requires these measures to prevent blood borne pathogen transmission.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to appropriately implement interventions to protect residents from abuse for 4 of 4 residents reviewed. The report describes separate incidents involving verbal abuse, sexual abuse, and physical abuse or neglect concerns, with resident interviews, staff statements, facility records, and incident reports showing that the residents reported harmful conduct by staff or another resident and that the facility did not appropriately prevent or respond to the events as described in the record. Resident #4 had diagnoses of depression, anxiety disorder, and heart failure, and a BIMS score of 15 indicating no cognitive impairment. The resident reported that a male resident touched her breast area under her shirt while they were in the dining room, and she told him to stop because people were watching and they would get into trouble. Staff statements reflected that the resident reported the male resident put his hand up her shirt more than once. The male resident acknowledged touching her breast area once but denied touching her under her blouse. The resident later stated she did not feel unsafe in the facility but wanted him to stay away from her. Resident #6 had diagnoses of hypertension, muscle weakness, and depression, with a BIMS score of 12 indicating moderate cognitive impairment. The resident reported that another male resident entered her room while she was sleeping, kissed her on the neck or face, asked her to have sex with him, and remained in her room for about 10 minutes before leaving. Staff statements confirmed that the resident came to the nurses’ station upset and reported that the male resident had come into her room while she was naked and sleeping. Staff also noted that she declined an offer to sleep in another room and later barricaded her door. Resident #8, who had diagnoses including difficulty walking, muscle weakness, and respiratory failure and a BIMS score of 11, reported that overnight staff used a bedpan on her when she wanted to use the toilet and that a staff member struck her hip and thigh with the bedpan. The resident later described that the bedpan hurt her and that she did not want to use it. Facility notes documented scratches on her back and the allegation that staff had hit her with the bedpan. Resident #3 had diagnoses including muscle wasting, abnormal posture, and morbid obesity, and a BIMS score of 15. The resident reported that an LPN yelled at her while she needed help getting up to use the bathroom and that the staff member made her feel sad, uneasy, and afraid. Staff statements described the LPN as rude and verbally abusive toward residents, including yelling at Resident #3 and refusing to help her at first when she needed to use the restroom. The sheriff’s report documented that the resident said the worker was rude and mean but that no physical assault occurred. Across these incidents, the record shows resident reports, staff observations, and facility documentation of abuse-related allegations involving inappropriate conduct toward residents.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing within 2 hours for two residents. One resident had diagnoses of hypertension, muscle weakness, and depression, with a BIMS score of 12 indicating moderate cognitive impairment. That resident stated that another resident entered her room while she was sleeping unclothed, kissed her around the mouth and cheek area, and asked her to have sex with him. She reported the incident to staff at the nurses’ station, but staff did not treat it as an abuse allegation at the time. Written statements from CNAs documented that the resident came to the nurses’ station upset and reported that the other resident had entered her room, kissed her while she was naked, and asked her to have sex with him. Staff acknowledged the report and discussed keeping an eye on the other resident, but the incident was not reported to DIAL within the required timeframe. The facility’s incident report was submitted the next day, and an RN later documented that the nurse on duty did not think it was an incident and therefore did not call anyone. A second resident had diagnoses including muscle wasting, abnormal posture, and morbid obesity. An outside care provider emailed the facility that the resident reported mistreatment by an overnight nurse, stating the nurse opened the resident’s door, told her to get up, and aggressively pulled her legs to move her out of bed. The administrator interviewed the accused nurse later that evening, but the facility did not submit the abuse report to DIAL within 2 hours of the allegation. The facility policy required allegations involving abuse or serious bodily injury to be reported within 2 hours to local, state, and federal agencies as required by regulation.
Care plans not updated after falls and resident altercation
Penalty
Summary
The facility failed to revise and update care plans to include appropriate interventions for repeated falls and a resident-to-resident altercation for 2 of 3 residents reviewed. Resident #1 had diagnoses of Parkinson's Disease, symptoms of and signs with cognitive functions and awareness, and a history of falling, with a BIMS score of 10 indicating moderate cognitive impairment. Staff recalled a fall in April 2026 when the resident attempted to walk from the bathroom to his wheelchair and fell by the wheelchair, and the RN stated that for an unwitnessed fall, risk management information, a head-to-toe assessment, an intervention, neurological assessments, and documentation were required per facility policy. However, the care plan for Resident #1 contained no documentation of interventions for the April 2026 fall, and the Administrator stated she had no knowledge of the fall and acknowledged that because it was not identified, no interventions were determined to prevent future falls. Resident #4 had diagnoses of depression, anxiety disorder, and heart failure, with a BIMS score of 15 indicating no cognitive impairment. A late entry progress note documented that the resident reported to a CNA that a male resident tried to touch her breast while eating supper, and the resident stated she told him to stop because people were going to see and they would get into trouble. The facility incident report stated the resident wanted boundaries with the male resident and would tell him to stay away or ask someone to help her. Although the care plan was revised on 4/14/26, it lacked interventions following the incident on 4/9/26. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident, and the Administrator stated the care plans should be updated with interventions as they are implemented.
Failure to Assess and Document After Resident Fall
Penalty
Summary
The facility failed to ensure appropriate treatment and care after an unwitnessed fall for a resident with Parkinson's disease, cognitive impairment, and a history of falling. The resident's MDS documented a BIMS score of 10, indicating moderate cognitive impairment. Staff reported that the resident was found on the floor near his wheelchair after walking from the bathroom, and the resident stated he lost his footing and fell. The RN recalled the resident denied hitting his head or having other injuries, but she could not remember whether she completed and documented the required assessment or neurological checks and stated she would have hoped so. The record contained no documentation of a fall assessment, vital signs, head-to-toe evaluation, neurological assessment, progress note, care plan intervention, or incident report for the fall. The facility's policies required staff to investigate and report accidents and incidents, document the resident's condition and vital signs, notify the physician and family, and identify possible causes within 24 hours. During interview, the Administrator stated she was unaware of the fall until later and confirmed the nurse failed to complete required assessments, neurological checks, cause identification, immediate interventions, and notification of the physician, family, or administration.
Failure to Supervise Resident on Commode
Penalty
Summary
The facility failed to provide appropriate supervision to ensure a resident’s safety while using the commode. The resident had diagnoses of dementia, anxiety disorder, and repeated falls, and the MDS documented a BIMS score of 14, indicating no cognitive impairment. The care plan identified a fall risk related to increased restlessness and anxiety. The resident was non-ambulatory and required assistance with a stand lift, but preferred to use the commode. Staff left the resident on the commode for an extended period after placing her there around 8:30 PM. A CNA stated that a timer was set to remind staff to assist the resident off the commode, but she forgot the alert while in another resident’s room. The resident was later found still on the commode around 10:00 PM to 10:30 PM. The resident stated she had been on the commode for about an hour, while staff estimated she had been left there for roughly 30 to 45 minutes or longer. The roommate recalled that the resident was waiting on the commode near bedtime and that staff did not return promptly. The report also showed that the resident could not reliably access the call light while on the commode because the cord was too short. Staff acknowledged that the call light was sometimes out of reach and that it had been tucked behind the bed or otherwise made unreachable. An LPN stated she knew the resident could not reach the call light and admitted she did not assess the resident after being told about the incident, did not complete incident documentation, and did not file a risk management report. Another staff member stated the resident had a deep indentation and later reported butt pain and inability to feel her feet. The Administrator stated she was unaware of the incident and that staff must always provide the resident with a call light, regardless of how often she requested assistance.
Failure to Document Resident Incidents Accurately and Timely
Penalty
Summary
The facility failed to maintain accurate resident records to reflect incidents that occurred in the facility for 2 of 3 residents reviewed. For one resident with Parkinson’s disease, cognitive impairment, and a history of falls, staff described a fall in the resident’s room area when the resident was walking from the bathroom to the wheelchair and ended up on the floor near the wheelchair. The CNA said the resident reported losing his footing, and the RN recalled the resident saying his legs gave out and denying head injury or other injuries. However, the resident’s care plan, progress notes, clinical assessment, and April incident reports contained no documentation of the fall, and the RN could not clearly recall whether required assessments and documentation were completed. For another resident with hypertension, muscle weakness, depression, and moderate cognitive impairment, the resident reported that another resident entered her room while she was sleeping unclothed, kissed her around the mouth and cheek area, and asked her to have sex with him. She said she told him no and to leave, then later reported the incident to staff at the nurses’ station. Written statements from CNAs confirmed that the resident appeared upset, reported the other resident had entered her room, kissed her, and asked her to have sex with him, and that staff discussed keeping an eye on him and offered a different room, which she declined. Although the incident was reported to the state and a progress note was later entered, the documentation did not accurately reflect the event when it occurred. The progress note described physical aggression received by another resident and was entered several days after the incident. Facility policy required documentation to be accurate, timely, and professional, and to validate late entries with the source of additional information when needed. The Administrator stated staff should have documented the incident when it happened and that the nurse working at the time should have documented it that night.
Food Served at Improper Temperature
Penalty
Summary
The facility failed to provide food at an appetizing temperature for 3 of 5 residents reviewed, including Residents #3, #9, and #12. Resident #9, whose MDS showed a BIMS score of 15 indicating intact cognition, stated during interview that food is not always hot when delivered on the meal tray. Resident #12, whose MDS also showed a BIMS score of 15, stated that the food was "absolute garbage" and was always cold. Resident #3's quarterly MDS showed a BIMS score of 15/15, diagnoses of neurogenic bladder, paraplegia, and post polio syndrome, and that the resident was independent with eating and had gained weight during a physician-prescribed weight gaining program. The care plan identified independent eating and a regular diet with thin liquids, with interventions to provide diet within consistencies, meal preferences, and diet monitoring. During dining room observation, pre-temp meal items in the steam table were measured at acceptable hot holding temperatures, including gravy at 161 degrees, mashed potatoes at 170.9 degrees, spinach with mushrooms at 164.4 degrees, and chicken dijon at 152 degrees. However, when room trays were prepared and sent from the kitchen, a sampled tray checked at 12:28 PM showed chicken at 131.7 degrees and mashed potatoes at 139 degrees. The Certified Dietary Manager stated she would expect food temperatures to be appropriate at the time of service and confirmed the chicken temperature from the room tray was low. The facility's Food Preparation and Service Policy stated that hot foods must be maintained above 135 degrees F.
Incomplete Care Plan for Oxygen Use
Penalty
Summary
The facility failed to provide a comprehensive care plan related to oxygen use for Resident #9. The resident’s MDS showed a BIMS score of 15, indicating intact cognition, and listed diagnoses of hypertension, renal insufficiency, and anxiety disorder. A physician’s order dated 11/13/25 directed oxygen continuously at 2 liters to keep oxygen saturation above 90% every shift for shortness of breath and hypoxemia, but the resident’s care plan, revised on 11/13/25, contained no focus, goals, or interventions for oxygen utilization. During interview, the DON stated that oxygen use should have been included on the care plan. The facility policy on comprehensive person-centered care plans stated that the care plan will describe the services to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.
Failure to Monitor Vital Signs After Hospital Return
Penalty
Summary
The facility failed to provide thorough and timely assessment and intervention for a resident who had multiple serious medical conditions, including anemia, coronary artery disease, heart failure, pneumonia, diabetes mellitus, chronic respiratory failure, and a history of oxygen use as needed. After the resident returned from the hospital following treatment for respiratory failure with hypoxia, the record showed a plan for continued supplemental oxygen at 2 L to keep saturations above 90% and to monitor heart rate and rhythm. However, the clinical record lacked documented vital signs from 11/26/25 through 12/3/25, despite the resident’s recent hospitalization and ongoing respiratory concerns. The resident had tested positive for Covid-19, developed pneumonia, had increased confusion and several falls, and on 11/20/25 was noted to have difficulty breathing, oxygen saturations that dropped to 66% without supplemental oxygen, and a blood pressure of 70/48, prompting transfer to the hospital. After returning to the facility, the NP noted on 12/1/25 that the chart still lacked vital signs from the prior days, and nursing later received an order to check daily vital signs. On 12/4/25, the nurse found the resident’s blood pressure continued to drop despite repeated checks, with weakness and increased confusion, and the resident was sent to the emergency room where hypotension as low as 76/46 was documented. Staff interviews confirmed that the resident had been very sick with Covid, was unsteady, had falls, and that ongoing vital signs would have been important during that time.
Failure to Provide Required Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate catheter care and monitoring for a resident with a suprapubic catheter and a history of urinary tract infections and bladder infections. The resident’s record showed diagnoses including post polio syndrome and neuromuscular dysfunction of the bladder, with care plan interventions for catheter monitoring, fluids, enhanced barrier precautions, and monitoring for signs and symptoms of UTI. The resident stated that staff were supposed to empty the catheter every shift, but it did not always happen, and also stated staff did not consistently clean the catheter with alcohol swabs after emptying or wear PPE. Review of the electronic record showed multiple antibiotic treatments for UTIs and cystitis during the year, along with a report of low output and dark urine. The point-of-care record for catheter care and urine output showed only three dates in the prior month where catheter care or emptying was documented twice in one day, and on the day of record review there was no documentation that the catheter had been emptied during the first shift. Observation later that day showed the catheter bag contained 1500 cc of urine with sediment in the tubing, and the resident stated the first shift had not emptied the bag. Staff observations and interviews confirmed the concern. A CNA then emptied 1500 cc from the bag and stated she was concerned it might be leaking and would notify the nurse. An LPN later assessed the catheter and found no leakage but noted sediment in the tubing and the need to monitor the catheter. The DON and Administrator stated catheter care and emptying should occur every shift and PRN, and that if documentation was absent they could not say the task had been completed. The facility’s catheter care policy stated the collection bag should be emptied at least every 8 hours.
Failure to Date and Change Oxygen Tubing per Order
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for one resident who required oxygen. Resident #9 had a BIMS score of 15 indicating intact cognition and diagnoses including hypertension, renal insufficiency, and anxiety disorder. The resident was observed using oxygen via concentrator at 2 liters by nasal cannula, and the oxygen tubing was not dated. The resident stated they were unsure when staff last changed the oxygen tubing. The EHR showed an order for oxygen continuously at 2 liters to keep oxygen saturation above 90% every shift for shortness of breath and hypoxemia, along with an order for oxygen tubing and nebulizer mask to be changed every Tuesday. The DON stated that oxygen tubing should be dated when changed and changed per the orders. The facility policy on Oxygen Administration stated that after completing oxygen setup or adjustment, the date and time the procedure was performed should be recorded in the resident's medical record.
Failure to Provide Scheduled Bathing Assistance Due to Staffing Issues
Penalty
Summary
The facility failed to provide scheduled bathing assistance to three residents, leading to a deficiency in care. Resident #2, a new admission with diabetes mellitus and a diabetic ulcer, reported not being offered a bath since admission, despite being scheduled for baths twice a week. Documentation showed that baths were marked as not applicable on the scheduled days, indicating a lack of care provided. Resident #6, who has difficulty walking and muscle wasting, was scheduled for weekly baths but reported not receiving them consistently. Although staff documented refusals on two occasions, the resident denied refusing baths during the relevant period. This discrepancy suggests that the resident's needs were not met as per the care plan. Resident #9, with legal blindness and muscle weakness, also reported not receiving a bath since a specific date, despite being scheduled for assistance. Interviews with staff revealed that short staffing and the need for two-person assistance for many residents contributed to the failure to provide scheduled baths. Staff admitted to documenting refusals inaccurately due to instructions from a previous DON, further complicating the accuracy of care records.
Failure to Complete Neurological Assessments After Falls
Penalty
Summary
The facility failed to complete necessary neurological assessments for a resident who experienced multiple unwitnessed falls. The resident, who had diagnoses of polyneuropathy, muscle weakness, and repeated falls, was documented to have moderate cognitive impairment with a BIMS score of 9. Despite the facility's policy requiring specific intervals for neurological assessments following a fall, the assessments were either not completed or improperly completed on several occasions. Interviews with staff revealed that the nursing team was struggling to keep up with the necessary care due to an increased workload from recent admissions. A registered nurse mentioned the difficulty in completing tasks due to the influx of new residents. The facility's administrator acknowledged the issue, noting that the staff needed time to adjust to the additional workload, which included eight new admissions over three weeks.
Hazardous TV Cord Placement in Resident Rooms
Penalty
Summary
The facility failed to provide an environment free from accidents and hazards for two residents. Staff and family interviews revealed that one resident repeatedly pulled on TV wires, mistaking them for the call light, which almost resulted in the TV being pulled off the wall. Observations confirmed that the TV cords were hanging close to the call light strings in both residents' rooms, with the TVs positioned over their beds. The facility's Homelike Environment policy, last revised in February 2021, did not address these environmental hazards. The Administrator acknowledged the potential hazard upon observation and indicated that maintenance would address the issue.
Delayed Call Light Response Due to Staffing Shortages
Penalty
Summary
The facility failed to consistently answer call lights within a reasonable amount of time, as reported by three residents. Resident #6, who had intact cognition and required assistance with transfers, reported waiting over 15 minutes for call lights 1-4 times a day. Resident #7, also with intact cognition, reported waiting over an hour most nights before 10 PM for assistance with bedtime care. Resident #9, who required partial assistance for daily activities, stated that call lights were answered after more than 15 minutes 2-3 times every evening, leading to frustration. Staff interviews revealed that the facility was short-staffed, contributing to delays in responding to call lights. Staff C, a CNA, mentioned that only two staff members were available on the floor, which was insufficient to meet the needs of new residents requiring two-person assistance. Staff A, an RN, confirmed that call lights took over 15 minutes to answer due to a lack of help, especially with recent admissions. The facility's policy on answering call lights did not specify a required response time, although the Administrator stated it should be within 15 minutes.
Failure to Revise Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to review and revise care plans for four residents who were receiving antipsychotic, antidepressant, and psychotic medications. Specifically, the care plans did not identify the targeted behaviors for these residents, nor did they include non-pharmacological interventions or specify which behaviors staff should monitor. This deficiency was identified through observations, interviews, and record reviews, affecting residents with various diagnoses such as anxiety disorder, depression, dementia, bipolar disease, schizophrenia, and delirium. Resident #3, with a BIMS score indicating no cognitive impairment, was taking medications like Duloxetine and Aripiprazole but lacked a comprehensive care plan addressing targeted behaviors. Similarly, Resident #26, also with no cognitive impairment, was on medications such as Mirtazapine and Seroquel without a detailed care plan. Another resident, also identified as #3 in a separate instance, was on multiple medications including Clozapine and Quetiapine, yet their care plan was incomplete. Lastly, Resident #21, with severe cognitive impairment, was on medications like Escitalopram and Trazodone, but their care plan did not include necessary behavioral monitoring details. The Director of Nursing was unaware that targeted behaviors needed to be included in the care plans, which contributed to the oversight.
Inaccurate Staffing Reports Submitted to CMS
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the period of July 1 to September 30. The report triggered for excessively low weekend staffing and a one-star staffing rating. Upon review, it was found that the facility scheduled an extra CNA on weekdays to complete baths, and the Director of Nursing (DON) worked additional shifts on nights and weekends. However, these additional hours worked by the DON and an employee from the attached assisted living facility were not reported to CMS. The facility's policy, established in October 2017, requires that staffing and census information be reported electronically to CMS through the PBJ system in compliance with the Affordable Care Act. The policy outlines that direct-care staffing information should include staff hired directly by the facility, those hired through an agency, and contract employees. Despite this, the facility failed to include all worked hours in their reports, leading to inaccurate data submission. This discrepancy was confirmed during an interview with the Administrator and DON, who acknowledged the failure to report the worked hours accurately.
Infection Control Deficiency in Blood Sugar Testing
Penalty
Summary
The facility failed to conduct blood sugar tests in a manner that protected residents from blood borne pathogens, as observed in two separate incidents involving Resident #3 and Resident #15. In the first incident, Staff A, an LPN, entered Resident #15's room with a bag of supplies for a blood sugar test and placed the testing supplies directly on the bedside table without using a protective barrier. After performing the blood sugar test, Staff A placed the glucometer back on the table without a barrier, failed to perform hand hygiene after removing gloves, and did not sanitize the glucometer before placing it back into the bag. In the second incident, Staff A used a wheelchair to transfer Resident #3 to the nurse's station and placed the blood sugar testing supplies directly on the countertop without a barrier. Similar to the first incident, Staff A failed to perform hand hygiene after removing gloves and did not sanitize the glucometer before placing it back into the bag. The facility's policy, dated October 2011, requires staff to clean reusable equipment per manufacturer instructions and perform hand hygiene after removing gloves. The Director of Nursing confirmed that staff should place a protective barrier between testing supplies and surfaces and perform hand hygiene immediately after glove removal.
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Illustrative
What surveyors actually found near you
We read the 72 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Correctionville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Holstein | 11.5 mi | ★★★★★ | 13 | 0 |
| Kingsley Specialty Care | 12.5 mi | ★★★★★ | 7 | 1 |
| Willow Dale Wellness Village | 14.7 mi | ★★★★★ | 2 | 0 |
| Careage Hills Rehabilitation And Healthcare | 22.2 mi | ★★★★★ | 9 | 0 |
| Maple Heights | 22.3 mi | ★★★★★ | 17 | 0 |
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