Southeast Iowa Regional Medical - Klein Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
acute fracture. The PA stated he could only go by what the Radiologist documented. During the interview on 10/30/25 at 12:12 PM, the Director of Nursing (DON) queried on the purpose of the bed/chair alarms and
she stated the purpose was for the residents who could not communicate or know to use the call light. The DON stated the bed/chair alarms went through the staff phones to notify them when a resident was getting up or where set to audible. The DON confirmed Resident #1 bed alarm did not alarm when Resident #1 got up and fell. The DON asked what the expectation of the bed/chair alarms and she stated they would be tasking the nurse to check the bed alarms to make sure they were working properly every shift just like a wander guard (device used to alarm staff if a resident is wandering to a potentially unsafe location.) During
an interview on 10/30/25 at 1:30 PM, the Staff C, RN (Registered Nurse) Unit Manager queried on the incident with Resident #1 and she confirmed the bed alarm did not sound and they trouble shot the alarm and changed the batteries, even though the batteries were not completely dead and the bed alarm worked again. Staff C stated Resident #1a bed alarm started out going through the staff phone, but after the fall,
they switched it to audible. During an interview on 10/30/25 at 1:40 PM, Staff B, RN queried on Resident #1 fall in the bathroom and she stated she found Resident #1 in the bathroom on the floor. Staff B stated Resident #1 didn't remember why she was in the bathroom. Staff B stated Resident #1's bed alarm did not sound on her phone and when Staff B checked the bed alarm, Staff B noticed if you wiggled the cord, the bed alarm came back on. Staff B stated she told the day shift to switch out the bed alarm because Staff B didn't have access to the new bed alarms. Review of the facility Fall Procedure dated 3/2024 revealed the following:a. Note any environmental factors that may have contributed to fall. b. Review the care plan for current fall prevention interventions and add new interventions or edit current interventions. New or edited interventions need to be tried to prevent recurrence of falls. Review of the undated [Brand name redacted] Sensor Pad Monitors instructions revealed: a. Place the user on the pad surface to activate system and test to ensure function. (If placed properly, the monitor will sound an alarm to notify staff if the user removes weight from the pad.
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Southeast Iowa Regional Medical - Klein Center in West Burlington, IA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in West Burlington, IA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Southeast Iowa Regional Medical - Klein Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.