Elkader Care Center

In the surveyor’s words

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

• Actual harm, isolatedF686Oct 24, 2024

  Based on observations, clinical record review, Nurse Practitioner/Providers interview, resident and staff interviews, and facility policy and procedure review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from developing or worsening on residents with a history of pressure ulcers for one of three residents reviewed (Resident #3). The facility reported a census of 28 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• No harm, potential for more than minimal, patternF803Jun 16, 2022

  Based on observations, record review, and staff interview the facility failed to provide the correct serving amount as planned on the menu. The facility census was 37 residents. Findings include: During observation of the noon meal preparation on 6/14/22 at 11:00 a.m. the Dietary Supervisor placed 4 servings of the roast beef in the Robot Coupe to puree for the 3 residents with orders for a pureed diet, the Dietary Supervisor then added 3 slices of bread and about 1/2 cup of beef gravy to achieve the proper consistency for residents on a pureed diet, she then placed the mixture into a steam table pan, covered, and put in the oven without measuring the final product volume. During observation on 6/14/22 at 12:03 p.m. […]

• No harm, potential for more than minimal, isolatedF684Oct 24, 2024

  Based on observations, clinical record review, Nurse Practitioner/Physician/Providers interviews, resident and staff interviews, and facility policy review, the facility failed to provide proper assessments and interventions in a timely manner for 2 of 3 residents following a change of condition (Residents #3 & #2). The facility reported a census of 28 residents. Findings include: 1. The facilities Pressure Ulcer Prevention Program policy (not dated) directed the facility staff should have a system in place that assured assessments were completed timely and appropriate; interventions implemented, monitored and revises as appropriate; and changes in condition recognized, evaluated, reported to the resident's attending practitioner and other healthcare professionals, ie.wound nurse and etc… […]

• No harm, potential for more than minimal, isolatedF835Oct 24, 2024

  Based on observations, clinical record review, Nurse Practitioner/Providers interviews, resident and staff interviews and facility policy review, the facility staff failed to follow their own policy and procedures as a means to prevent and or minimize pressure ulcers from developing on residents with history of pressure ulcers for one of three residents reviewed (Resident #3). The facility reported a census of 28 residents. Findings include: The facilities Pressure Ulcer Prevention Program policy (not dated) directed the facility staff the facility should of had a system in place that assured assessments were completed timely and appropriate; interventions implemented, monitored and revises as appropriate; and changes in condition recognized, evaluated, reported to the resident's… […]

• No harm, potential for more than minimal, isolatedF607Aug 30, 2023

  Based on facility record review, employee file review, staff interview, and policy review the facility failed to ensure 1 of 5 staff members (Staff A) completed the two hour Dependent Adult Abuse training within 6 months of their hire date. The facility further failed to complete the Single Contact Repository (SING) background checks prior to hire on 2 of 5 staff members (Staff B & Staff C). The facility reported a census of 29 residents. Findings include: 1. Review of an employee hire list provided by the facility during the survey week, revealed Staff A, certified nursing assistant (CNA), had a documented hire date of 8/2/22. The employee file lacked documentation of Iowa Department of Public Health (IDPH) approved Dependent Adult Abuse Mandatory Reporter training completed. […]