Kahl Home For The Aged & Infirmed

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

complete order with form, dosage, route, frequency and indication, the name of the physician or health care provider and nurse sign off of the electronic order as per the software system guidelines. 5. The physician or provider will authenticate the order within the time limit set by state regulations.6. Preferred method for provider signatures: Physician or provider should authenticate the order within Point Click Care's order portal.7. If necessary, the order may be printed out for the physician or provider to sign in wet ink within state identified time limit. If the order is signed in this manner, the actual signed order should be scanned into Point Click Care, and the order should be marked as ‘signed in wet ink' in the orders portal as soon as reasonably able to be completed.8. Follow through with orders by making appropriate contact or notification (e.g., lab or pharmacy).

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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

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kahl Home for the Aged & Infirmed

6701 Jersey Ridge Road Davenport, IA 52807

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, clinical record review and staff interviews, the facility failed to utilize isolation gowns when providing resident care that require the use of Enhanced Barrier Precautions (EBP) for 1 of 3 residents (Resident #3) in the sample. The facility reported a census of 104 residents.Findings include:Review of the Minimum Data Set (MDS), dated [DATE REDACTED] identified Resident #3 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS list of diagnoses included pressure ulcer to the sacral region. The MDS indicated Resident #3 dependent on staff for assistance with toileting and transfers

in and out of bed/chair, and required substantial/maximal assistance with showers.Review of Resident #3 Care Plan, dated 2/12/25, the Care Plan revealed a Problem to address The resident requires enhanced barrier precautions (EBP) to reduce the spread or potential spread of multi-drug resistant organisms R/T (related to) a pressure injury. Interventions included, in part:a. Nursing staff to wear gown and gloves during wound cares. Date Initiated: 2/12/25.b. Staff are to wear gown and gloves with ADL (activities of daily living) cares such as: dressing, bathing/showering, catheter or ostomy cares, and toileting tasks including changing briefs, and toileting hygiene. Date Initiated: 2/12/25.During an observation on 12/23/25 at 1:22 PM, an Enhanced Barrier Precautions sign posted on the room of Resident #3 door. During an observation

on 12/29/25 at 11:25 AM, Staff G, Licensed Practical Nurse (LPN) and Staff H, Registered Nurse (RN) each wore isolation gown and gloves while they assisted Resident #3 with toileting. Staff F, CNA entered

the bathroom wearing gloves but did not wear a gown. During an interview on 12/29/25 at 1:46 PM, Staff F, CNA reported when providing cares to Resident #3, staff should be wearing a gown and gloves. She admitted she gave Resident #3 a shower earlier and took the isolation gown off afterward and forgot to put another one when she dried her back.During an interview on 12/29/25 at 2:03 PM, Staff G, LPN reported

before staff provide care for Resident #3, they should wear an isolation gown and gloves as she is on EBP.

Staff G stated Staff F, CNA should have worn an isolation gown during cares today.During an interview on 12/30/25 at 11:28 AM, the Director of Nursing reported she would expect staff to wear an isolation gown and gloves prior to providing care to Resident #3 as she is in EBP. Review of the facility policy titled, Enhanced Barrier Precautions Policy dated 3/27/25 included, in part:a. Policy statement: It is the policy of

this home to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. b. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.c. Policy Explanation and Compliance Guidelines section: 3. Implementation of Enhanced Barrier Precautions b. PPE (Personal Protective Equipment, i.e gloves and gowns) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact care activities include: Dressing, Bathing, Transferring Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters), Wound care: any skin opening requiring a dressing

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet