North Crest Living Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

results were sent back through the fax machine but now it is her understanding it is sent through an email.

Staff A acknowledged she was still figuring out the processes at the facility. Staff A stated everything that

she received and processed she signed when she processes them. Staff A stated she had not received the faxed UA for Resident #1 on 8/7/25. On 8/26/25 at 9:00 AM Staff B, MD stated the main cause of hospitalization for Resident #1 was due to respiratory failure due to aspiration and does not believe knowledge of the lab or starting antibiotics would have prevented the hospitalization. Staff B, MD explained

the results of the UA and Bacteria Culture Results should have been sent to him, that was a professional standard. Review of the email dated 8/22/25 from Staff C, Medical Records Staff to the DON documented Staff C understood she was a part of the fail safe for lab results processing. Results with no signatures get printed out and given to the nurses.On 8/26/25 at 8:31 AM the Director of Nursing (DON) acknowledged

she could not find when the lab results were sent to the physician once received by the facility from the lab.

The DON stated as the results come back from the lab the results should be sent off to the doctor for review. The DON stated she had noticed the missed physician notification on 8/22/25 and started educating

the nurses at the facility about physician notification and handling of lab results. The DON stated she had updated the nurses on the follow up portions for the lab results to the physician. The DON explained it was

a situation that warranted a mass audit to be sure nothing was missed in the process. Review of policy updated 9/24 titled, Physician Order Guideline documented it was the policy of the facility to secure physician orders for care and services for residents as required by state and federal law. Physician orders will be dated and signed according to state and federal guidelines. Unclear or incomplete written orders will be reviewed with the physician. Any order clarification will be documented on the physician's telephone order form. Faxed orders will be accepted under the following conditions: the physician signs and retains

the original copy of the faxed order and the physician provides the original copy, if requested.Review of document updated 8/22/25 titled, Labs documented when lab results are received the receiving nurse was to send to the physician and update the awaiting physician section.

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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

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

North Crest Living Center

34 Northcrest Drive Council Bluffs, IA 51503

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

stated she felt like the concern was a documentation issue. The DON stated if there was a decrease in output the nurse should have been notified. The DON acknowledged no output from Resident #1's catheter could indicate dysfunction or the catheter was clogged.Review of policy updated 10/24 titled, Catheters documented the policy was to provide guidance in the preventive measures for controlling common infections for residents with a urinary catheter as part of the overall infection control policy. The facility was committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infection. Catheters are to be changed per orders.

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

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

North Crest Living Center

34 Northcrest Drive Council Bluffs, IA 51503

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter, that was on Enhanced Barrier Precautions (EBP) for 1 of 3 reviewed (Resident #3). The facility reported a census of 57 residents.Findings include:The Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented utilization of an indwelling catheter.Review of Resident #3's EHR titled, Orders documented a physician's order started 8/4/25 to change indwelling catheter with 16 French monthly and as needed. Review of Resident #1's EHR titled, Orders documented a physician's order started 7/29/25 to change indwelling catheter with 16 French monthly and as needed. Observation on 8/25/25 at 3:10 PM of catheter care completed on Resident #3 by Staff H, Certified Nursing Assistant (CNA) and Staff I, CNA with EBP signage posted in Resident #3's room revealed Staff H present in the room with Resident #3 sitting on the commode. Staff H left the room and asked another staff member to help with peri care. Staff H returned to Resident #3's room with Staff I. Staff H and Staff I applied gloves, neither staff completed hand hygiene or applied a gown, Staff H utilized a gait belt to assist Resident #3 with standing, Staff I obtained wipes, Staff I removed peri wipes from the bag, cleansed catheter and penis while standing behind Resident #3, cleansed buttocks with 2 peri wipes, pulled Resident #3's brief up, pulled Resident #3's pants up, Staff H assisted Resident #3 with transfer to the wheelchair, Staff H removed gloves, Staff H completed hand hygiene, Staff I removed gloves, Staff I gathered trash in trash bag, Staff I removed the trash bag, Staff I exited Resident #3's room, Staff I walked down the hall to the soiled utility room, Staff I opened the door, placed garbage in the trash barrel and Staff I completed hand hygiene in the hall outside the soiled utility room. On 8/25/25 at 3:30 PM Staff H stated he was not required to wear a gown when Resident #3 was on the commode. Staff H stated when he was not working directly with the bodily fluids the gown would not be expected. Staff H acknowledged that other CNA was not wearing the gown at the time of catheter care and peri care. Staff H explained Resident #3 was having a BM there is no expectation for gown application. Staff H stated with Enhanced Barrier Precautions (EBP) he was supposed to gown and glove for catheter and peri cares but not required when Resident #3 was having a bowel movement. On 8/25/25 at 3:56 PM Staff I, stated the only time she would apply a gown was when she emptied Resident #3's catheter. On 8/25/25 at 4:05 PM the DON stated the facility's expectation was that gowns would be worn by the staff that transferred the resident and the staff completing care on the resident. On 8/26/25 at 2:16 PM Staff F, Licensed Practical Nurse (LPN) stated when there was any care provided to a resident with catheters the staff are required to wear a gown, gloves and complete hand hygiene before and after application of gloves or resident contact. On 8/26/25 at 4:17 PM the DON stated hand hygiene should be completed prior to resident care, after resident care, before applying gloves and after removal of gloves. The DON stated the staff should have worn gowns with the resident cares on Resident #3. Review of policy updated 11/24 titled, Enhanced Barrier Precautions (EBP) documented EBP was used to prevent the spread of Multi-Drug Resistant Organisms (MDRO) to residents.

EBP precautions apply when a resident is not known to be infected or is known to be infected with a CDC-targeted MDRO and has a wound or indwelling medical device. Indwelling medical devices include urinary catheters.Review of policy updated 8/24 titled, Hand Hygiene documented hand hygiene will be completed before anticipated contact with resident, after contact with a resident, after contact with blood, body fluids, visibly contaminated surfaces, after contact with objects in the residents room, after removing Personal Protective Equipment (PPE).

Residents Affected - Few

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

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