Sunnycrest Manor

F-F812 and documented in part that the facility failed to meet professional standards of food service safety and food had not been prepared under sanitary conditions.

The current survey, conducted between [DATE REDACTED] and [DATE REDACTED], revealed concerns in the same areas including

in part undated open foods, not monitoring refrigerator and freezer temperatures, not monitoring sanitizer chemical levels, dented cans, expired food, and a dusty vent.

The facility QAPI Plan titled Facility Assessment and reviewed ,d+[DATE REDACTED] documented information from the Facility Assessment was used to inform the QAPI process and the description of care, services, and resources provided both areas for monitoring of processes and outcomes as well as information for investigation of root causes of adverse events and gaps in performance. The section titled Policy and Procedure for Quality Assurance Performance Improvement indicated QAPI was integrated into responsibilities and accountability of top management, with the QAPI steering committee setting SMART goals each year reported on monthly.

On [DATE REDACTED] at 10:59 AM the Certified Dietary Manager (CDM) reported that he was working on a goal for a new ticketing system for meal service in the dining room. When asked about the concerns observed in the kitchen, he reported they did audits.

During an interview on [DATE REDACTED] at 11:52 AM the Administrator explained the QAPI committee met every two months. Residents, family members, staff, and departments heads could share concerns with the committee verbally, through resident council meetings, or in writing. All department heads were expected to set SMART goals that would be followed for at least a year. Safety, resident needs, and deficiencies from surveys were considered priority. The Administrator indicated the current dietary SMART goal was related to a dietary ticket system that would help with budgeting, ordering, and more accurately representing resident food needs. She reported the CDM provided audits every QA meeting and issues were immediately fixed with corrective actions. When asked about prior survey concerns in the kitchen, the Administrator stated she understood why there was a QAPI concern and the committee had been trying hard.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 165556 Department of Health & Human Services Printed: 09/07/2025 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 165556 B. Wing 02/27/2025

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

Sunnycrest Manor 2375 Roosevelt Street Dubuque, IA 52001

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 0865 On [DATE REDACTED] at 12:11 PM the CDM provided a document titled 2024 deficiency audits with tabs for food temperature, hairnets, glove usage, date marking, and portion size. In the date marking tab, 13 of 44 entries Level of Harm - Minimal harm or indicated food was not labeled properly. The audits did not include education provided to staff regarding potential for actual harm results.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 165556 Department of Health & Human Services Printed: 09/07/2025 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 165556 B. Wing 02/27/2025

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

Sunnycrest Manor 2375 Roosevelt Street Dubuque, IA 52001

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 37072 potential for actual harm Based on observation, staff interview, and record review the facility failed to provide proper hand washing Residents Affected - Few and wound care to prevent the spread of infection in 1 out of 1 wound care observed (Resident #34). The facility identified a census of 73 residents.

Findings include:

Review of Resident #34 physician visit/consult form dated 11/14/24 revealed the resident had a left heel blister drained on 10/29/24 and indicated the area positive for Methicillin-resistant Staphylococcus aureus (MRSA) bacteria.

Review of the Care Plan for Resident #34 with a revision date of 12/17/24 revealed an open area to right great toe and left heel. The Care Plan revealed resident had an active infection to left heel and left lower extremity cellulitis. The Care Plan directed staff during active infection institute CONTACT ISOLATION: Wear gowns when changing contaminated linens and prior to entering residents room, gowns and gloves should be removed prior to exiting the room, staff should use good hand-washing before entering and prior to exiting room. Place soiled linens in bags prior to exiting room and place in proper laundry bins . Bag linens and close bag tightly before taking to laundry.

Observation on 02/25/25 at 10:37 AM, Staff A, Licensed Practical Nurse (LPN) provided wound care to Resident # 34. Staff provided a dressing change to the left heel and right great toe to Resident #34. Staff donned personal protective equipment (PPE) and stated he washed hands prior to me coming to the room. Staff A double gloved both hands, removed soiled dressing from right great toe and then from the left heel.

He did not wash hands or change gloves after removed dressings. He then proceeded to cleanse the wound

on left heel and then right great toe wound with soap and water, rinsed each area and then dried first the left heel and then the right great toe. Staff A did not remove gloves or wash hands between the wounds. Staff A removed outer gloves and donned another pair of gloves and then provided treatment to both wounds without changing gloves or washing hands between the wounds. After the treatment completed he removed gloves, cleaned up supplies, removed trash from room and took to utility room next door to residents room and disposed of trash and removed personal protective equipment. Staff A did not wash hands, he returned betadine to medication room on the unit touching medication cart, door knobs and then came out and washed hands.

During an interview on 02/27/25 at 08:10 AM Staff H, Registered Nurse ( RN) states I would take care of one wound at a time. First wash hands and don gloves, then cleanse wound and again wash hands and don clean gloves. Complete the treatment and then remove gloves and wash hands again. I would then take my gloves off and wash my hands and then go to the next wound and complete one wound at a time and complete the wound care the same way. I would wash my hands before leaving the room. You should not leave the room with gloves on hands.

On 02/27/25 at 8:30 AM Staff I, RN stated to keep wounds separate when providing a treatment. You should not go between wounds. I would wash my hands between steps of wound care and changes my gloves.

Before you leave the room put the bed down, place call light in reach, and remove gloves and wash your hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 165556 Department of Health & Human Services Printed: 09/07/2025 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 165556 B. Wing 02/27/2025

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

Sunnycrest Manor 2375 Roosevelt Street Dubuque, IA 52001

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 On 02/27/25 at 10:26 AM the Infection Preventionist stated if staff are providing wound cares they need to change gloves and wash hands before treating wounds, should only complete wound care on one wound at Level of Harm - Minimal harm or a time or you risk spreading infection from one wound to another. Staff should use barriers making sure area potential for actual harm is clean, between cleansing the wound and removal of the dirty dressing staff should take off gloves and complete hand hygiene. Staff definitely need to use personal protective equipment and change gloves Residents Affected - Few between wounds. Staff should never come out of the room with gloves on and should be completing hand hygiene. Staff should dispose of PPE in the room and hand hygiene in the room not after you have left the room.

On 02/27/25 at 10:37 AM the Co Director of Nursing (Co DON) stated the expectation of staff would be they should do one extremity when providing wound care. They should remove dressing, wash hands and don new gloves then do the treatment and complete hand hygiene. Staff should complete one wound before starting another. They should take off their gloves and complete hand-washing before leaving the room.

The facility provided a policy titled Hand Washing reviewed 2024 which directed staff hand hygiene would be required before and after changing a dressing. The policy revealed hand hygiene continues to be the primary means of preventing transmission of infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 165556