Azria Health Longview
Azria Health Longview in Missouri Valley, IA — inspection on November 25, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
super odd to her.
Staff C stated she did not see her that often because their working days were different, it was random when they worked together.
She heard of Staff A taking longer breaks and disappearing but a lot of people do that.On [DATE] at 9:14 AM Staff B stated they provide emergency medications to long term facilities via a med bank. A med bank is a tower of compartments with drawers (cubie) that dispense medications after signing in to the med bank. On [DATE] they were contacted by the facility about one of the cubies having issues with opening to get the medication out.
They contacted med bank support and they were unable to find a solution to open the cubie.
When they removed the cubie from the med bank to inspect it further two things were noted: the cubie was tampered with or broken and the medication packets had been tampered with as well. He looped in the other pharmacy staff on what was found and they made the decision to break the cubie to see what was inside.
Once it was opened, the medication packets were labeled as 5mg oxycodone but the packaging had been tampered with.
The oxycodone pills had been removed and replaced with Carvedilol pills; there were 13 packets: 1 packet was empty and 12 packets had been replaced with Carvedilol.
Staff B called the facility to inform them what he had found and he started to dig in and narrow down a timeframe on who had accessed this specific cubie.
The facility also started their own investigation.
When asked why they thought the cubie had been tampered with, Staff B stated there is a little black rectangle piece on top of the cubie. He stated there were pry marks on it and once they opened it, they noticed there was adhesive on the lid to reseal it to close it.
Both of these things indicate the cubie was broken or tampered with.
When asked how they were able to determine the oxycodone pills had been replaced in the pill packets.
The back of the packets has a while cover label and some had corners that were pulled back.
Once the packets were flipped over you can see the backing had pulled open and that's when they noticed the markings on the pills and used those markings to identified the replaced pills.
The pills that were used to replace the oxycodone pills looked just like oxycodone pills, small white round pills.
The only difference were the markings.
When staff need to get a medication from the med bank they would log in, select the resident that needs the medication, select the medication that is to be administered.
After the medication is selected the cubie (drawer) that [TRUNCATE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Azria Health Longview
1010 Longview Road Missouri Valley, IA 51555
SUMMARY STATEMENT OF DEFICIENCIES
Based on the previous Centers for Medicare and Medicaid Services (CMS) form 2567 review, staff interviews and facility policy review the facility failed to ensure they provided a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program.
The facility reported a census of 80 residents.Findings include:A review of the Department of Inspections, Appeals, and Licensing website revealed the facility had repeat deficient practices identified during the annual survey and complaint investigations from 2/27/2024 through 10/1/2025.
The repeat deficiencies cited include:-6/12/2025 during an annual survey and complaint investigation: 865 QAPI plan.-10/1/2025 during a complaint investigation: 602 exploitation.On 11/25/2025 at 12:17 PM the Administrator stated after deficiencies have been identified they educate all staff on the process change prior to their next working shift.
They will bring the same information to the huddle meetings to ensure staff understand.
When asked how they ensure the issue has been resolved she stated they will complete audits for about three months or until they are in compliance.
When asked about the repeated 602 deficiency from the 10/1/2025 and current surveys, she indicated she felt both issues were ethical issues with staff.
She felt their processes were in place and worked successfully but staff involved too advantage of the situation.The facility provided a document titled Quality Assurance and Performance Improvement (QAPI) Program, with a revision date of February 2020.
The policy statement included: this facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents.The objectives of the QAPI program are to:1. provide a means to measure current and potential indicators for outcomes of care and quality of life.2. provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators.3. reinforce and build upon effective systems and processes related to the delivery of quality care and services.4. establish systems through which to monitor and evaluate corrective actions.Implementation:1.
The QAPI committee oversees implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee.2.
The QAPI plan describes the process for identifying and correcting quality deficiencies.
Key components of this process include: a. tracking and measuring performance; b. establishing goals and thresholds for performance measurement; c. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systemic quality deficiencies; e. developing and implementing corrective action or performance improvement activities; and f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed.3.
The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and makes adjustments to the plan.
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