Caring Acres Nursing & Rehab Center

F-F609, Reporting of Abuse Allegations. All suspected violations and all substantiated incidents of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, abuse, including injuries of unknown source, and misappropriation of resident property. Should a suspected violation or a reasonable suspicion or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse, or suspected crimes, or suspected evidence of humiliating or demeaning photographs or recordings) be reported, the facility Administrator, or his/her designee in their absence.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 165217

F-F610 with an origination date of July 2023. The document indicated residents will be protected from further abuse, neglect, exploitation or mistreatment while the investigation is in process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 165217 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165217 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caring Acres Nursing and Rehab Center 1000 Hillcrest Drive Anita, IA 50020

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37074 safety Based on clinical record review, facility investigative file review, resident and staff interviews, and facility Residents Affected - Few policy review the facility failed to report 1 of 3 resident's (Resident #1) allegation of abuse to the appropriate staff members to ensure timely reporting to the State Agency. On 7/23/24 at roughly 8:30 PM Staff A and Staff B had assisted Resident #1 with getting ready for bed. Resident #1 told staff she was upset and yelling that she had asked two hours prior to be put to bed. Staff explained to her they were assisting others with baths, passing the snack cart out and assisting others to bed. Resident #1 yelled I asked you two f***ing hours ago. Staff A replied with I am not putting up with your shit tonight. Resident #1 replied I am not dealing with your attitude either. Staff B reported this to the Assistant Director of Nursing (ADON) (Staff A's mother) and she indicated she would go talk to Resident #1. After speaking with Staff A and Resident #1, the ADON continued with her duties: neuro checks on a resident and found that another resident had fallen on the floor.

On 7/24/24 at 3:00 PM Staff C Licensed Practical Nurse (LPN) went to the Administrator's office with Resident #1 to talk about the concerns that was reported to her by Staff D CNA. The facility then reported the allegation to the State Agency (SA) on 7/24/24 at 5:13 PM. The facility reported a census of 26 residents.

The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/30/24 at 5:00 PM. The IJ began

on 7/23/24, the day Resident #1 reported her concerns. The facility removed the Immediate Jeopardy on 7/31/24 through the following actions:

-Staff A, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were suspended on 7/30/24.

-On 7/30/24 the facility began additional re-education for all employees relating to abuse, neglect, and exploitation as well as reporting requirements. The facility originally began reeducation on 7/24/24 following

the initial report All employees currently working will be educated immediately. All other employees will be educated prior to their next scheduled shift.

-When new team members begin employment, they will receive Dependent Adult Abuse Prevention and Reporting training as part of their initial onboarding. All other employees will receive Dependent Adult Abuse Prevention training annually, and with any allegation or investigation regarding abuse.

-The facility has interviewed all alert residents related to abuse.

-The Administrator will interview five random residents about abuse weekly for the next 12 weeks.

-The Administrator will interview five random staff members per week for 12 weeks to verify knowledge related to abuse and reporting policies.

-Regional Director of Clinical Services had reviewed documentation of current residents, retrospectively back to 12:00 AM on 7/19/24 with no findings of abuse evident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 165217 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165217 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caring Acres Nursing and Rehab Center 1000 Hillcrest Drive Anita, IA 50020

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 0609 The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure. Level of Harm - Immediate jeopardy to resident health or Findings include: safety According to the Admission Minimum Data Set (MDS) assessment tool with a reference date of 6/24/24, Residents Affected - Few documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairments. Resident #1 had an admitted [DATE REDACTED]. The MDS documented she did not display any physical, verbal, or other behavioral symptoms during the review period. The MDS documented she was frequently incontinent of urine and was always incontinent of bowel. The MDS listed

the following diagnoses for Resident #1: acute cystitis with hematuria, anemia, neurogenic bladder, multidrug resistant organism, septicemia, urinary tract infection (UTI), cerebral palsy, anxiety, depression, psychotic disorder (other than schizophrenia), post-traumatic stress disorder (PTSD), borderline personality disorder, and mild intellectual disabilities.

The Care Plan focus area with an initiation date of 6/19/24 documented Resident #1 had activities of daily living (ADL) performance deficit related to cerebral palsy and musculoskeletal impairment.

The Care Plan focus area with an initiation date of 6/24/24 documented she has the potential to have manipulative behaviors at times. Staff are encouraged to explain all procedures to Resident #1 before starting and allow the resident to adjust to changes.

Review of the facility's grievances revealed the following grievance was filed on Resident #1's behalf:

a) Resident stated when staff entered room, she got upset stated I've been waiting for two hours to go to bed. Resident #1 stated Staff A said we have 20 something residents, please be considerate. Resident stated she continued to be agitated then stated Staff A said I'm not doing this, then walked out. The form was signed and dated by the SSD on 7/23/24.

The following Progress Note was documented on 7/24/24 at 5:37 PM by Staff C Licensed Practical Nurse (LPN): this nurse spoke with resident and spent much of the afternoon discussing her feelings about an incident that occurred last night. Resident #1 was visibly upset and had asked this nurse to go with her to talk to the Administrator. Staff C and Administrator told resident that she was heard and that the matter will be looked into. Resident #1 told this nurse that she felt safe at this time and that she did not want a certain person to take care of her. Staff C reassured resident that other staff could meet her needs and she would not have to have cares provided by the person who made her feel uncomfortable. She was informed a bit later by Staff C that there is an investigation and it has been turned in. Resident #1 thanked this nurse for giving her support and reassured that she could come to Staff C at any time and she could tell her anything that was bothering her. They all want her to feel safe.

The facility investigation included the following statements:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 165217 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165217 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caring Acres Nursing and Rehab Center 1000 Hillcrest Drive Anita, IA 50020

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 0609 a) Staff A Certified Nursing Assistant (CNA) wrote: she was working 2:00 PM-10:00 PM on 7/23/24. She had just finished the nurse's orders of passing snacks, ice water, doing rounds, and hourly check-ups on certain Level of Harm - Immediate residents. She went to assist another resident when a CNA told her that the resident they need to lay down jeopardy to resident health or was upset. When Staff A arrived to the resident's room she said: hello, I heard that you were upset and I was safety wondering if there was anything I could do? Immediately the resident started screaming and yelling, I am not f***ing upset (said that two times), you guys waited forever to come lay me down. Staff A explained the Residents Affected - Few resident, I am sorry, myself and the other CNA just got done with nurse's orders and both of us are getting tired, so we understand. After transporting the resident to bed, Staff A went to assist the CNA with rolling the resident. As soon as Resident #1 saw Staff A was touching her, she started yelling and scream don't f***ing touch me (was said about five times) with the occasional word bitch thrown in. After Staff A ensured the other CNA was at a good stopping point, Staff A told that staff member I can't handle this shit. Staff A then walked over to the other side of the room and grabbed a pillow for the resident's head, then stood around the other CNA, staying there to make sure she did not need any other assistance other than touching the resident.

b) Staff B CNA wrote the following statement: on 7/23/24 Staff A and I went to assist Resident #1 to bed. At

the time we went in, she was very upset and was yelling at the fact that she did ask two hours prior to be put

in bed. Staff B and her were busy doing baths, passing snack cart out and putting other residents to bed. Resident #1 yelled I asked you two f***ing hours ago. Staff A replied with I'm not putting up with your shit tonight. Resident #1 then replied with I am not dealing with your attitude either. Resident #1 was screaming while being put in bed due to her being in pain. After being put in bed, Resident #1 looked at Staff A and said you are not f***ing touching me. Staff B told Resident #1 she had to help roll her to get the sling out from under her. Resident #1 rolled her eyes. Due to the resident screaming while being put in bed, Staff B did ask Resident if she was ok. Resident #1 replied, it didn't matter. Resident #1 was assured she did care if she was ok. Resident #1 did not say anything after that, so Staff B walked out. Staff B told the nurse and she said

she would go talk to Resident #1 about it. The ADON (nurse on duty that night) did talk to her and Staff A about the next time letting Resident #1 calm down then reproach her. She signed and dated her statement

on 7/25/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 165217 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165217 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caring Acres Nursing and Rehab Center 1000 Hillcrest Drive Anita, IA 50020

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 0609 c) The ADON wrote the following statement: on the night of 7/23/24 at 9:30 PM she was passing medications down hall 2 when Staff B came to her and stated Resident #1 was upset, she was screaming at staff when Level of Harm - Immediate entering her room about how long she had been waiting for staff to put her to bed. Staff A and Staff B jeopardy to resident health or apologized for the delay and that they were with other residents and doing the best they could. Resident #1 safety continued screaming at both CNA's telling them how much bullshit it was and that they were terrible. Staff B then stated Staff A made the comment, I can't deal with this right now. Resident #1 then began screaming at Residents Affected - Few Staff A, don't f***ing touch me, don't f***ing touch me, don't f***ing touch me. Staff B she let Resident #1 know Staff A would not be doing her cares, that Staff B would but still needed Staff A's assistance to roll the resident so Staff B could provide cares. Resident #1 then stated why does that matter, no one cares. Staff B reassured her that they indeed do care. The ADON finished her medications a few minutes later and returned to the nurse's station when the Social Service Director (SSD) informed her that Resident #1 made a grievance that she waited two hours to put to bed and that Staff A was rude to her. The SSD stated she had just talked with Resident #1 and had not had a chance to write it up yet. The ADON questioned Staff A and

she stated, Resident #1 was screaming at us for taking so long. She tried to explain why and they couldn't really help it but were trying the best they could. Resident #1 continued to scream at them, saying how awful

they were. When they got her into bed, Resident #1 started screaming don't f***ing touch me like five times and Staff A said ok Staff B told Resident #1 that she needed her help rolling her to do cares. The ADON asked why the resident was yelling at Staff A not to touch her. Staff A stated because she was mad and does not like me, never has, she is like that with staff she does not like when she is upset. The ADON asked if she stated that she wasn't or can't going to deal with this right now and she indicated she had not made that statement. After question Staff A, the ADON went to speak with Resident #1. Upon entering the resident's room it was noted that resident was not in distress and was in a calm mood. The ADON stated that she had heard the resident was upset and asked what had happened. Resident #1 stated she was upset because

she waited two hours to be laid down and told the staff it was bullshit. She added she should not have to wait that long, then Staff A told her she can't deal with this. Resident #1 indicated she did not like people talking like that to her. The ADON stated she understood and that she would speak with Staff A about the way she spoke to Resident #1 and they apologized. The ADON also took accountability for the staff taking so long to lay her down as she tasked them with passing snacks, fresh ice water, and the baths for the evening to ensure all duties were completed in a timely manner. Resident #1 stated that she understood stuff like that happens sometimes. The ADON then reiterated that this did not excuse Resident #1's comment and that it will be addressed. Resident #1 thanked the ADON, stated no when asked if there was anything else she would like to talk about or needed. Resident #1 still seemed to be in a calm, pleasant mood. After the conversation with Resident #1, the ADON went to the nurse's station and realized a resident needed a neuro check completed and went to find another resident on the floor. This nurse instructed Staff A to complete her charting and take out the trash before leaving as it was already 10:00 PM. Staff A was educated on importance of professionalism and instructed that in situations that are overwhelming, she needs to ensure resident safety then leave the room, go to the charge nurse and allow the charge nurse to intervene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 165217 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165217 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caring Acres Nursing and Rehab Center 1000 Hillcrest Drive Anita, IA 50020

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 0609 d) The Administrator's statement indicated Staff C entered his office shortly before 3:00 PM on 7/24/24. She stated that she had heard from Staff D CNA had reported a concern to her and that Resident #1 wanted to Level of Harm - Immediate talk with him. Resident #1 requested Staff C to be with her. Resident #1 came in and said she was very jeopardy to resident health or upset with Staff A and the way she's been treatment her. Resident #1 stated Staff A was rude to her but did safety not want to say what Staff A had said to her. She indicated she reported the incident to the ADON and the SSD. We continued talking but she did not feel comfortable saying anymore. She was assured that is was Residents Affected - Few absolutely find bringing her concerns to him and that he really wanted to help. The Administrator told her that

he wanted her to be happy here because it's her home. Resident #1 asked if Staff A could not be present in her room or provide her care, he agreed. Resident #1 left the room and Staff C returned after and told him that Resident #1 said Staff A said she was not putting up with her shit tonight and that Staff B heard it too.

e) The SSD statement indicated she entered Resident #1's room to do assessments with her. Resident was lying in bed. Once the first assessment was completed, Resident #1 stated she was rude. When asked who was rude, she stated Staff A. When they came in, Resident #1 was upset because she waited two hours to be put to bed. Resident #1 stated Staff A told her there's 20 something other residents and to be considerate. She then stated that Staff A said more but did not state what else was said. Resident #1 stated Staff A said I'm not doing this and walked out of the room. The SSD stated she would write up a grievance and that they would talk to Staff A. Resident #1 thanked her and they finished the assessments. When the SSD left the room, Resident #1 was smiling and appeared content.

The facility investigative file included the following summary:

a) Resident #1 is a [AGE] year-old cognitively impaired female who was admitted to the facility on [DATE REDACTED] with a primary diagnosis of acute cystitis without hematuria and spastic diplegic cerebral palsy.

b) At 3:00 PM on 7/24/24, Resident #1 reported to the Administer that Staff A had been verbally abusive to her at approximately 9:30 PM on 7/23/24. She could not verbalize the actual statements that Staff A had made to her at that time. When asked if anyone else was present or aware, she stated that Staff B witnessed

the incident and that she had reported it to the ADON and SSD the night prior. The DON was immediately notified, and the Administrator initiated an abuse investigation.

c) Investigation Findings:

1) On 7/24/24 at approximately 2:00 PM during care, Resident #1 told Staff D that Staff A had yelled at her

the night before and that she told her to shut up. She also stated that Resident #1 had reported this to the ADON and the SSD. Staff D immediately reported this to Staff C charge nurse.

2) Staff C followed up with Resident #1 after she finished her talk therapy, at approximately 2:45 PM. Resident #1 told Staff C that Staff A had cursed at her. According to Resident #1's statement to her, Staff A had told her they did not have time for her shit. At that time, she brought Resident #1 to the Administrator, initiating the abuse investigation. Resident #1's initial statement to the Administrator was that Staff A had been verbally abusive to her. When asked what she had said, Resident #1 stated she could not repeat it.

She stated it was too terrible for her to report. She also stated that she told Staff A to not touch her after she assisted her to bed. Resident #1 repeated that she no longer felt comfortable with Staff A providing her care. Resident #1 stated she reported her concerns to the ADON and the SSD and Staff B had witnessed all their interactions that night.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 165217 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165217 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caring Acres Nursing and Rehab Center 1000 Hillcrest Drive Anita, IA 50020

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 0609 3) Staff B stated that Resident #1 was upset and yelling at both staff as they entered her room. They had a hectic night and she had to wait longer than she wanted to be assisted to bed. Staff B confirmed that Staff A Level of Harm - Immediate told Resident #1 that she wasn't putting up with her shit tonight. She reported this to her charge nurse, jeopardy to resident health or ADON that night. safety 4) The ADON stated that Staff B did inform her of the incident but that Staff A had said she could not deal Residents Affected - Few with this right now to the resident. Staff B stated to her that Resident #1 was upset throughout her cares, but

they had tried to reassure her. The ADON followed up with Resident #1 and found her to be calm and not in distress. The ADON let her know that if Staff A had been rude to her that that was not acceptable and that

she would follow up with Staff A to address the incident. Resident #1 had no further concerns at that time and stated stuff like that happens sometimes. At no time was Resident #1 upset or voicing concerns about verbal abuse.

5)The SSD stated that the evening of 7/23/24, Resident #1 had brought concerns that Staff A had been rude. When she asked what had happened, Resident #1 told her she had to wait two hours to be put to bed and that Staff A had told her that she needed to be more considerate of the other residents. She also stated that Staff A had said, I am not doing this and walked out of the room. The SSD told her she would fill out a grievance form for her and the team would follow up with Staff A. Resident #1 voiced no other concerns at that time and SSD left her smiling and content.

On 7/30/24 at 2:18 PM Resident #1 stated she turned Staff A in because she has been very abusive to a lot of people at the facility, herself included. She works the evening shift, 2:00 PM-10:00 PM, is only 16 and the daughter of the ADON. The ADON will cover Staff A's butt and a lot of her family works here too so they will also cover up for her. She gets special treatment because of that. Resident #1 stated from her stand-point Resident #1 is very verbally abusive. When asked what has happened, she indicated Staff A has called her a whore, bitch and white trash. She has called her these things to her face. Staff A has also told Resident #1 is not allowed to have feelings or emotions. Staff A has told her she is not allowed to get her in trouble or say anything. When asked how this made her feel, Resident #1 said it pisses her off when Staff A acts like this.

This is supposed to be her home, she's not supposed to feel this way about anyone that works here. When Resident #1 does peri-care she does it very hard. She's never been told of any injuries but is sore after Staff

A cares for her. She has asked her to please not care for her. Staff A's response to that was I don't f***ing care, I'll f***ing do it anyway's. Last week, while Staff A and Staff B were assisting her to bed, Staff B told the resident I am not dealing with your shit. Resident #1 indicated she has talked with the Administrator, the ADON, DON and SSD about her concerns. All staff tell her when she reports concerns is, they will talk with her. Staff A is back to working at the facility but she is not allowed to care for Resident #1. Resident #1 reported feeling uncomfortable around her presence, does not want her looking at her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 165217 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165217 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caring Acres Nursing and Rehab Center 1000 Hillcrest Drive Anita, IA 50020

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 0609 On 7/30/24 at 3:34 PM the ADON stated she was passing medications on hall 2 when Staff B came to her and said just a heads up, Resident #1 is not in a good mood. She was upset because they took so long to Level of Harm - Immediate get her to bed. Resident #1 was screaming at them and Staff A made a comment that upset her further. jeopardy to resident health or When asked what comment it was, she stated I don't know, something along the lines of I can't deal with this safety shit right now. Resident #1 screamed back at her don't f***ing touch me, don't touch me. Once she was done with her medication pass, she spoke to Staff A. She reported Resident #1 was yelling at them, saying this Residents Affected - Few place was awful, literally screaming in their faces how long she had been waiting. Resident #1 was yelling at Staff A to not touch her. Staff A was asked if she made the comment can't deal with this shit, she could not remember if she cussed. The ADON told her you can't talk like that to residents, if you get frustrated you can't talk like that. The ADON stated it sounds like it was a slip of the tongue kind of thing. She told Staff A to take the trash out and finish charting. The ADON went in to speak with Resident #1. She indicated she was upset because she waiting forever to get to bed. Staff A told Resident #1 she can't deal with this shit right now and Resident #1 told Staff A to not touch her. The ADON explained to the resident what Staff A said was not ok and it would be handled. The ADON explained she told the staff members to get snacks passed and baths done before getting residents to bed. Resident #1 voiced understanding, was fine and did not want to talk about anything else. When asked who she reported this alleged incident to, she stated to be honest

she intended to let the DON know but when she got to the nurse's station two other residents needed her attention. She had one resident that had fallen and one that was crawling in and out of bed. She indicated

she was notified of the allegation on 7/23/24 roughly at 9:30-9:40 PM. The DON found out about the allegation the next morning but not from her, from someone else. When asked what she should have done with the information that Staff B shared with her, she acknowledged she should have contacted the DON right away.

On 7/30/24 at 2:59 PM Staff B stated she worked the night of the alleged incident. Resident #1 reported she was ready for bed. Staff B informed her she will need to get help, Staff A was doing a bath at that time. Resident #1 then stated, I told you two f***ing hours ago I wanted to go to bed. Staff A stated I am not dealing with your shit. Resident #1 stated and I am not dealing with your f***ing attitude. Once they got her to bed, Staff B asked if she was ok and Resident #1 stated it does not f***ing matter. She then looked at Staff A and said you are not f***ing touching me. Staff B indicated Resident #1 did not need her brief changed. Once

they left the room, Staff B told the ADON what had happened. The ADON told her she would talk to her. She works with Staff A and there are times she thinks she is joking but she's not. Staff B stated she did not think

the comment she made to Resident #1 had meaning behind it. She was having a tough day that day.

On 7/31/24 at 2:54 PM the SSD stated when Staff A and B exited Resident #1's room, she went in to her room to complete assessments for her MDS. Resident #1 told the SSD that her and Staff A got in to it. When asked what happened, the resident told her, Staff A and Staff B came in and she was upset. The resident indicated she yelled because she had to wait to be put to bed. Staff A told her to please be considerate of the 20 other residents in the facility. The resident reported more words were exchanged. Staff A said I am not doing this tonight and left the room. The SSD stated she filled out a grievance on it as she did not think it was abuse. She informed Resident #1 that she would fill out a grievance and let the ADON know. The SSD denied that Resident #1 reported Staff A had cursed that day.

On 7/31/24 at 12:51 PM the DON stated she was made aware of the alleged incident on 7/24/23, it had taken place on the evening shift of 7/23/24. Staff C had reported to her that Resident #1 was in the Administrators office informing him of the events that took place on 7/23/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 165217 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165217 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Caring Acres Nursing and Rehab Center 1000 Hillcrest Drive Anita, IA 50020

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 0609 On 8/2/24 at 2:39 PM the Administrator stated a CNA had reported that Resident #1 complained about Staff

A being rude to her the night before. After Resident #1 completed talk therapy, she came to his office and Level of Harm - Immediate talked with her. She was very nervous and could not give a lot of information at that time. She indicated Staff jeopardy to resident health or A was rude, very upset by it and did not want her taking care of her anymore. After they spoke with Resident safety #1 she reported Staff A was not going to put up with her shit. This cued him to start looking in to this. The DON was not aware of this and the only thing they knew of was a grievance on Resident #1's behalf. The Residents Affected - Few SSD completed the grievance and said it was filed the night before but it did not have, not putting up with her shit, on the form. They had confirmed that Staff A had used very inappropriate language. Staff A denied saying this but to her co-worker out of frustration because the nurse was riding them hard that night. The next day Resident #1's story changed when she spoke with the DON and Staff E. She had denied Staff A had said she was not going to put up with her shit but added new allegations of verbal stuff. Resident #1 stated Staff A told her she wished she was, not born. The Administrator stated in his mind at this point, he was convinced something had happened. Whatever happened was inappropriate and not intended to be abusive. What happened was affecting Resident #1 so they educated Staff A and gave her a final warning

before returning back to work. When asked if the ADON should have reported this on 7/23/24 he stated in retrospect, she should have dug more in to what had happened. He stated no matter what, if someone has a concern, he should be contacted directly.

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