Azria Health Winterset

In the surveyor’s words

From the most serious findings on record at Azria Health Winterset, in the surveyor’s own words.

• Immediate jeopardy, patternF880Feb 8, 2021

  Based on interview and record review, the facility failed to implement CMS and CDC recommended infection control practices in order to control and prevent the potential spread of COVID-19 between residents and staff. The facility allowed staff to work and provide care to residents after they reported signs and symptoms of COVID-19 and subsequently tested positive for COVID-19. Additionally, the facility failed to ensure all staff were thoroughly screened before beginning their scheduled shifts, failed to ensure staff adhered to facility policy which prohibited staff from screening themselves, and failed to ensure all staff completed education regarding proper screening for COVID-19. These findings constituted an Immediate Jeopardy to resident health and safety. […]

• Immediate jeopardy, isolatedF686Feb 8, 2021

  Based on observation, interview and record review, the facility failed to adequately provide wound care to prevent worsening of ulcers for 4 of 5 residents reviewed (Residents #10, #12, #11 and #24.) The facility failed to implement a consistent system for communication between staff for monitoring wounds for residents of residents that were at risk or had developed ulcers and there were gaps in the record that failed to contain required information related to wound measurements, assessments, and descriptions. This situation constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 43 residents. […]

• Actual harm, isolatedF689May 9, 2024

  Based on clinical record review, staff interview, employee file review, and policy review the facility failed to ensure two staff present while using a mechanical lift for a resident transfer, and staff failed to ensure sling straps removed from a mechanical lift when transferred a resident from the wheelchair to the bed for one of three residents reviewed for falls (Resident #3). The facility reported a census of 51 residents. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had diagnoses of cerebral palsy, deep vein thrombosis (DVT), and muscle weakness. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. […]

• Actual harm, isolatedF692Feb 8, 2021

  Based on observation, record review, and staff interview, the facility failed to assist and supervise residents that required dining assistance for 2 of 7 residents reviewed (Residents #1 and #3). The facility had identified Resident #3 as at risk for inability to maintain nutritional status and malnutrition due to a [DIAGNOSES REDACTED]. Meal observations on 1/6/21 and 1/7/21 revealed the resident lay in bed in her room with her unopened meal in front of her. Staff had not set up the meal or offered assistance during the meal. On 1/11/21, Resident #3 weighed 101.4 lbs. When staff weighed her again on 2/1/21, she weighed 92 pounds: a 9.2% weight loss. The facility reported a census of 43 residents. […]

• No harm, potential for more than minimal, widespreadF880Mar 10, 2025

  Based on observation, Electronic Health Records (EHR), Medication Administration Records-Treatment Administration Record (MAR-TAR), document review, policy review, and staff interview the facility failed to provide adequate sanitization to shower chair between residents, failed to provide influenza testing and communicate with public health during outbreak and failed to provide appropriate infection prevention practices during administration of medications to 2 of 7 residents reviewed (Resident #8, and #33), and contact with Resident#31 whom had a dressing. The facility reported a census of 50 residents. Findings include: 1. The Annual Minimum Data Set (MDS) dated [DATE] for Resident #31 documented a Brief Interview for Mental Status (BIMS) of 13 which indicated no cognitive impairment. […]