Northern Mahaska Specialty Care

In the surveyor’s words

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

• Immediate jeopardy, patternF880Jul 16, 2022

  Based on observations, record and document review, staff interviews, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program to prevent the transmission of Coronavirus Disease 2019 (COVID-19). Specifically, 1. The facility failed to implement and monitor an effective screening process for staff to prevent a COVID-19 outbreak. The failure to follow facility policy resulted in a staff member being able to work on 07/11/2022 while having signs and symptoms of COVID-19 after having direct exposure to a COVID-19 positive staff member. 2. […]

• Immediate jeopardy, patternF600Dec 9, 2021

  Based on observations, resident, family and staff interviews and record review, the facility failed to ensure that residents had the right to be free from abuse, and exploitation for 6 of 8 residents reviewed, (Resident #2, #13, #15, #17, #19 and #22). The facility must not allow verbal, mental, physical or sexual abuse which resulted in an immediate jeopardy to residents' health and safety. The facility reported a census of 77 residents, 53 of the 77 residents were female. Findings include: 1. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/4/21, documented Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Brief Interview for Mental Status (BIMS) score was 7 which indicated severe cognitive impairment. […]

• Immediate jeopardy, patternF689Dec 9, 2021

  Based on observations, staff and resident interviews and clinical record review, the facility failed to provide supervision to ensure that 6 female residents of the facility were free from sexual advances from 2 male residents identified in the sample allowing opportunities for exploitation of female residents. Female residents, ( Resident #2, #13, #15, #17, #19 and #22) were identified as having been groped and/or propositioned by Resident #1 and/or Resident #18. The interventions put in to place after the incidents were either non-existent or ineffective and did not prevent Resident #1 from groping and or propositioning female residents. […]

• Immediate jeopardy, isolatedF689Jul 6, 2024

  Based on observations, record review, and staff, resident and resident responsible party interviews, the facility failed to ensure the environment remained free of hazards, and failed to ensure employees reported hazards that posed an immediate threat to the safety of all residents when at least 3 employees failed to report an employee had a loaded handgun in her purse that she brought into the facility stored at the Nurse's Station, unsecured, where a cognitively impaired resident gained access to the purse (Resident #1). The facility reported a census of 79 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/3/24 at 1:15 p.m. The IJ began on May 5, 2024. Facility staff removed the Immediate Jeopardy on 7/6/24 by implementing the following actions; a. […]

• Actual harm, isolatedF689May 10, 2023

  Based on observations, interviews and record review, the facility failed to ensure safety for 1 out of 3 residents reviewed (Resident #2). Resident #2 was transferred from her bed into her wheelchair without removing/moving the leg rests/foot pedals from Resident #2's wheelchair. This resulted in a large skin tear, which required the need to transfer Resident #2 out to the emergency room (ER). The facility reported a census of 68 residents. Findings include: A Minimum Data Set, dated dated dated [DATE], documented that diagnoses for Resident #2 included heart failure, diabetes, and malnutrition. This resident's Brief Interview for Mental Status revealed a score of 14 out of 15, which indicated intact cognition. This resident was an extensive assist of 2 for bed mobility, and transfers. […]