Exira Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 8, 2024

  Based on observations, clinical record review, facility document review, staff and resident interviews, and facility policy review the facility failed to supervise a cognitively impaired resident. Staff were unaware Resident #1 left the building on 10/31/24. Staff last saw Resident #1 at approximately 12:45 PM. The door alarm sounded at 1:01 PM, staff responded, took approximately 5 steps outside, did not see anyone, walked back in the facility, disarmed the door alarm and went back to work. At 1:30 PM a different staff member came into the back-parking lot, saw a car backed up against the curb and was blocking the parking lot. Staff realized it was Resident #1 in the driver's seat with the car running and the doors locked. […]

• Actual harm, isolatedF676May 12, 2022

  Based on observations, clinical record reviews, and staff interviews the facility failed to maintain, restore, or improve the functional ability of a residents's range of motion (ROM) for 3 of 4 residents reviewed (Residents #21, #23, and #45). On 1/4/21, Resident #45 went to a specialty hospital clinic due to pain in their right shoulder with a right upper extremity contracture. The specialty hospital identified Resident #45 couldn't continue private outpatient physical therapy in October 2020 due to the novel Coronavirus 2019 (COVID) outbreak. The facility failed to provide Resident #45 a restorative nursing ROM during that time to maintain their ability and/or prevent a decline. […]

• Actual harm, isolatedF689May 12, 2022

  Based on clinical record, facility investigations, staff interview, and facility policy, the facility failed to prevent falls for 3 out of 7 residents reviewed (Resident #0, #244, and #254). The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5, indicating severely impaired cognition. Resident #244's diagnoses included [CONDITION(S)], [CONDITION(S)], and cardiac arrhythmia. The same MDS revealed that Resident #244 required limited assistance of 2 persons with bed mobility, extensive assistance of 2 persons for transfers and toilet use. Fall Risk Assessments review, a total score of 10 or greater equaled a high risk for falls a. 4/9/21 - score of 17 b. […]

• No harm, potential for more than minimal, widespreadF922Jul 13, 2023

  Based on interviews, observations, and review of facility policies the facility failed to ensure procedures were developed to ensure water was available when normal water supply was lost. This failure had the potential to affect all 36 residents. Findings include: On 7/11/23 at 11:00 AM observed an emergency water supply consisting of two gallons and two 24 packs of eight-ounce water bottles in a closet in the closed dementia unit. In addition, noted 20 gallons of water and four cases of 16.9-ounce bottled water in the front storage area. […]

• No harm, potential for more than minimal, patternF725May 6, 2026

  Based on observations, resident interviews, family interviews, staff interviews, and policy review, the facility failed to respond to resident call lights within 15 minutes for 4 of 4 residents (#1, #2, #5, #6). The facility also assigned an uncertified nursing aide to direct resident care alone, used agency staff to orientate a newly hired Certified Nurse Aide, and failed to respond timely to a request for assistance in a locked memory-care unit. The facility reported a census of 35 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 01 out of 15 which indicated severely impaired cognition. It included diagnoses of non-Alzheimer's dementia, anxiety, and hospice. […]