Dunlap Specialty Care

In the surveyor’s words

From the most serious findings on record at Dunlap Specialty Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF849Nov 9, 2023

  Based on clinical record review, hospital document review, staff interviews, family interviews, hospice documents, hospice agreement and facility policy review the facility failed to notify in a timely manner 1 of 3 resident's hospice provider when she had a fall with injury (Resident #1). On [DATE] at 8:30 AM the nurse was called to the resident's room by another staff member. Resident #1 was lying on the floor on her left side. The resident reported she was getting up to go to the bathroom and fell . An assessment was completed and found skin tears to her left arm and next to her left eye. Bruising was noted to start over her left eye. At 10:07 AM the hospice nurse was notified that the resident had a fall and sustained an injury. […]

• Immediate jeopardy, isolatedF600May 4, 2023

  Based on record review, observation, resident and staff interviews and facility policy review the facility failed to keep a resident (Resident #27) from physically abusing other residents while living at the facility. Review of Resident #27 record revealed documentation in the past she has open handed slapped another resident in the face, hit a resident in the back of the head, and threw water at a resident. During the survey Resident #27 threw a full pop can at a resident causing mental anguish and pain. The facility was unable to produce documentation of nursing risk management incident report investigations potentially placing all residents at risk for resident to resident abuse due to failure to review incidents. […]

• Immediate jeopardy, isolatedF609May 4, 2023

  Based on record review, resident and staff interviews, and facility policy review the facility failed to report continued resident to resident altercations for 1 of 3 residents reviewed to the State Agency (Iowa Department of Inspections and Appeals (DIA)), (Resident #27). The facility reported Resident #27 initial resident to resident physical altercation for an incident that occurred on 12/14/2022, however the facility failed to report subsequent resident to resident physical altercations by Resident #27 that occurred on 12/23/22 and 3/5/2023. During the facilities annual survey Resident #27 had an additional resident to resident physical incident that could of potentially been avoided if the State Agency would have been aware of Resident #27 continued aggression towards other residents. […]

• Immediate jeopardy, isolatedF689May 4, 2023

  Based on record review, resident and staff interviews, and facility policy review the facility failed to implement safety measures and interventions for Resident #27 to protect residents from her physical resident to resident altercations for 2 of 3 residents reviewed (Residents #11 and #24). The facility failed to identify the root cause and implement interventions for Resident #27 aggression towards other residents potentially placing all residents at risk. The Iowa Department of Inspections and Appeals (DIA) informed the facility of the Immediate Jeopardy (IJ) that began as of December 14, 2022 on April 27, 2023 at 11:45 AM the Facility Staff removed the Immediate Jeopardy on April 27, 2023 through the following actions: a. […]

• Actual harm, isolatedF684Jan 16, 2024

  Based on clinical record review, staff interviews, and policy review, the facility failed to provide assessment and intervention timely for the necessary care and services after a resident fall for 1 of 6 residents reviewed (Resident #1). The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15 of 15; indicating no cognitive impairment. It also listed diagnoses of Cerebrovascular accident (stroke), Non-Alzheimer's dementia, anxiety disorder, Chronic Obstructive Pulmonary Disease (COPD), and neoplasm of bronchus and lung. […]