Lamoni Specialty Care

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 29, 2022

  Based on observations, clinical record review, and staff interviews, the facility failed to provide adequate nursing supervision and assistance devices to prevent accidents for 2 of 2 residents reviewed (Resident #4 and #9). On 11/16/21, staff attempted to remove the Hoyer sling under Resident #4 after their shower while the resident was still sitting in the shower chair. This caused Resident #4 to slide forward in the shower chair as the resident's leg started to bend to the side. Although staff kept the resident from falling to the floor, the resident sustained a right lower leg fracture. On 6/2/22, staff found Resident #9 on the floor in their room. The fall resulted in a left wrist fracture that required a cast, an orthopedic consult, and pain control. […]

• No harm, potential for more than minimal, patternF812Aug 19, 2021

  Based on observation, policy review and staff interview the facility failed to label and store food items appropriately, in order to reduce the risk of contamination and food-borne illness. The facility reported a census of 34. Findings included; During initial tour of the kitchen on 8/16/21 at 09:16 AM included the following items; a. bag of frozen fried chicken 12 piece not dated or labeled. b. bag of frozen dough 32 pieces not dated or labeled. c. part bag of frozen diced chicken not dated or labeled ( approximately 1 pound). d. bag of 12 frozen pre made omelets not dated or labeled. e. part bag of frozen cooked sausage 5 lbs 1/4 full not dated or labeled. f. bag of frozen fish 12 piece not date or labeled. g. 16 glasses of water in refrigerator not covered or dated. h. […]

• No harm, potential for more than minimal, patternF880Aug 19, 2021

  Based on observation, facility policy review, and staff interview, the facility failed to provide Covid-19 screening for visitors, failed to ensure staff properly wore the face covering (mask covering mouth and nose) while in the facility. The facility reported a census of 34 residents. Findings Include: On arrival to the facility, staff took the state survey team team through the facility without conducting a Covid-19 screening prior to entering the building. Policy review of the facility's Covid-19 Employee/Visitor Screening Process directed staff to screen all staff and visitors before they entered the building. An interview with the Director of Nursing (DON) stated she expected staff to screen all visitors and employees Covid-19 before they entered the building. […]

• No harm, potential for more than minimal, isolatedF609Apr 30, 2025

  Based on clinical record review, Individual Narcotic Records, Controlled Drugs-Count Records and staff interviews, the facility failed to report 4 milliliters of morphine missing from a resident's supply. (Resident #5) The facility reported census was 31. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive status. Resident #5 was Independent with transfers, mobility, dressing, toilet use and personal hygiene needs, occasionally incontinent of bladder and always incontinent of bowel. […]

• No harm, potential for more than minimal, isolatedF755Apr 30, 2025

  Based on clinical record review, Individual Narcotic Records, Controlled Drugs-Count Records and staff interviews, the facility failed to ensure an accurate reconciliation of all controlled medications. (Resident #5) The facility reported census was 31. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitive status. Resident #5 was Independent with transfers, mobility, dressing, toilet use and personal hygiene needs, occasionally incontinent of bladder and always incontinent of bowel. […]