The Village of Ackley

In the surveyor’s words

From the most serious findings on record at The Village of Ackley, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 16, 2023

  Based on observation, record review, staff interviews, and facility policy review the facility failed to provide adequate nursing supervision and assistive devices to ensure the environment was as free of hazards as possible for a resident at risk for elopement (when a resident leaves the building without staff knowledge or consent) for 5 of 5 residents reviewed. Resident #1 was identified with unspecified dementia, cognitive impairment, poor safety awareness, and recently had her wander guard (personal alarm sensor bracelet) removed. Investigation revealed facility staff failed to intervene on 5/2/23 when Resident #1 was observed wandering during the night fully clothed and had put her coat on. […]

• Immediate jeopardy, isolatedF757Apr 9, 2024

  Based on clinical record review, policy review and staff interview, the facility failed to have a system in place to ensure residents who use Coumadin (blood thinner) received their therapeutic monitoring as ordered by the physician for 3 of 3 residents reviewed (Residents #5, #13, #16). The facility failed to get Resident #5 and Resident #13's lab draws completed for at least 6 days. Resident #13 had an elevated lab level that required the facility to hold his medication for 2 doses. When Resident #5 missed her lab draw, the facility failed to get her lab draw completed resulting in her missing 8 days of her coumadin. The facility failed to follow the Physician's order for Resident #16 and drew their lab early resulting in a low therapeutic level for their convenience. […]

• Actual harm, isolatedF689Jul 11, 2024

  Based on clinical record review, staff interviews, and policy review the facility failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 4 residents reviewed (Resident #1) for falls. Resident #1 had four falls in the month of June. Resident #1 experienced a right ankle injury and a skin tear/bruise to right elbow when a fall resulted from the facility not providing the appropriate level of assistance per therapy recommendations. The facility reported a census of 32 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #1 was independent with bed mobility. […]

• Actual harm, isolatedF692Jul 11, 2024

  Based on staff interviews, clinical record review, hospital record review, family interviews, and policy review the facility failed to conduct appropriate assessments, interventions and timely Physician notification for 1 of 4 resident reviewed (Resident #1). Resident #1 experienced difficulty swallowing, poor oral intake, and mouth pain that resulted in weight loss and a hospitalization from [DATE] to [DATE] for acute kidney injury, dehydration (inadequate fluid intakes) and pharyngitis/MRSA (Methicillin - resistant Staphylococcus Aureus - staph infection resistant to several antibiotic to the throat). Resident #1 started having difficulty swallowing on [DATE], went to the ER (emergency room ) on [DATE] and returned to the facility. […]

• No harm, potential for more than minimal, patternF623Feb 27, 2025

  Based on clinical record review and staff interview the facility failed to inform the Long Term Care (LTC) Ombudsman office of a resident transfer from the facility for 1 of 1 resident's reviewed (Resident #9) for hospitalization . The facility reported a census of 28 residents. Findings include: The Nursing Note dated 5/27/24 at 11:28 PM, reflected the hospital admitted Resident #9. The Nursing Note dated 5/30/24 at 11:44 AM, identified Resident #9 returned to the facility. The facility lacked documentation showing the required notification to the LTC Ombudsman of Resident #9's admission to the hospital. During an interview on 2/26/25 at 9:20 AM, the Administrator acknowledged he had the responsibility for sending the notifications to the LTC Ombudsman beginning in June 2024. […]