Altoona Nursing And Rehabilitation Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

F, reported that just know to stay away. On 10/29/25 at 2:40 PM Staff B, Licensed Practical Nurse (LPN) reported she could not recall who the other resident was for the 10/06/24 or the 3/22/25 incidents. Staff B reported she could not recall if the resident on 3/22/25 hit the table or not. Staff B reported she did not fill out an incident report but if the resident would have been hurt, she would have. Staff B verbalized Resident #6 is possessive of her spot in the dining room/main lobby area. Staff B reported Resident #6 doesn't want anyone to sit at her spot ever. The Nursing Abuse Prevention, Identification, Investigation and Reporting Policy dated 7/8/24 directed staff as follows: Rational: All Residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that result in person degradation, including the taking or using photographs or recording in any manner that would demean or humiliate a resident, and prohibits using of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep or distribute photographs and/or recording on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. -Physical abuse includes, but not limited to hitting, slapping, pinching, and kicking. It also includes corporal punishment when used to correct or control behavior, including but not limited to, pinching, spanking, slapping hands, flicking, or hitting with an object. - Resident-to-resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and results in physical harm, pain or mental anguish is considered resident-to-resident abuse.

Resident-to-resident sexual harassment, sexual coercion, or sexual assault is also considered abuse. The facility will presume that instances of abuse caused physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary. An example would be a resident slapping another resident who is physically or cognitively impaired, even though the resident who was slapped showed no reaction (e.g., yelp or grimace), it is presumed the resident experienced pain. 2.

Resident #7's MDS assessment dated [DATE REDACTED] documented a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition. The MDS included diagnoses of dementia and hypertension (high blood pressure). On 10/30/25 at 11:00 AM Resident #7 reported he had an altercation in the dining room on the other end recently with Resident #6 due to Resident #6 being mean toward him. Resident #7 reported Resident #6 is crazy. Resident #7 reported he was not doing anything but sitting at a table enjoying his afternoon. Resident #7 reported he never wants to go back to that area because Resident #7 is crazy to deal with.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Altoona Nursing and Rehabilitation Center

200 Seventh Avenue SW Altoona, IA 50009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm

on but does not stop. At 11:35 AM a CNA went in with the EZ stand machine and left the machine. CNA reported he would be back when he got another staff member. At 11:39 AM staff came back in to assist the resident. On 10/30/25 at 11:37 AM Resident #11 reported to this surveyor it is sometimes two to three hours for her call light. She then pointed to the clock under her tv and said she times it. This was while in

the Ez stand waiting for the staff to return.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Altoona Nursing and Rehabilitation Center

200 Seventh Avenue SW Altoona, IA 50009

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, policy review and staff interview, the facility failed to complete incident reports or document for 2 of 3 resident-to-resident altercations reviewed (Resident #6). The facility reported a census of 97 residents. Findings include: Resident #6's Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented

a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition. The MDS included diagnoses of dementia and diabetes. Resident #6's Progress Notes documented the following:a. 10/6/24 at 12:08 PM Resident #6 has been noted the last two days, picking on another female resident. If

she is in her way of getting thru to her table, she shoves her wheelchair to move her so she can get through. Today Resident #6 shoved her again and stated You dumb bitch, get out of my way. Staff spoke with Resident #6 about the way she was treating the other resident and reminded her that she cannot put her hands on anyone or anyone's wheelchair and not shove her or anyone else. Resident #6 stated well you think she can get out of the way, what do you want me to do, go all the way around? Staff reported to Resident #6 that she could do that or even ask the individual to move so she could get thru. b. 3/22/25 at 2:39 PM Resident #6 was verbal toward another resident. Telling the other resident to shut up, and you don't belong here. Resident #6 then proceeded to push the other resident (in her wheelchair) into the table

the other resident was sitting at. Resident #6 was reminded by staff it was inappropriate and not to touch another resident or tell them to shut up. On 10/29/25 at 10:40 AM the Director of Nursing (DON) reported

they did not have incident reports for the 10/6/24 and 3/22/25 resident-to-resident altercations due to no one being hurt. On 10/29/25 at 1:25 PM the DON reported the 10/24/25 incident where Resident #6 hit another resident, the intervention was separation. She reported there was no other inventions put in place because they could not remove Resident #6 from the dining room because of her rights. She reported the facility did not look at any other inventions. On 10/29/25 at 2:40 PM Staff B, Licensed Practical Nurse (LPN) reported the 10/6/24 and the 3/22/25 incidents she cannot recall who the other resident was. Staff B reported she did not chart or follow up with other residents involved in either of incidents. Staff B reported

she could not recall if the resident on 3/22/25 hit the table or not. Staff B reported she did not fill out an incident report but if the resident would have been hurt she would have. Staff B verbalized Resident #6 is possessive of her spot in the dining room/main lobby area. Staff B reported Resident #6 doesn't want anyone to sit at her spot ever. Staff B reported looking back she should have charted on both residents. The Accident and Incidents-Investigating and Reporting Policy dated July 2017 directed staff as follows: Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: a. The Nurse Supervisor/ Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. b. The following data, as applicable shall be included on the Report of Incident/Accident form: date and time of accident or incident , circumstances surrounding the accident or incident, where the accident or incident took place, who was involved, condition of who was affected, corrective action taken, and follow-up information.c. The Incident/Accident report will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.

Event ID:

Facility ID:

If continuation sheet