Bishop Drumm Retirement Center

were not obtained for the following dates: 3/9, 3/16, 4/6, 5/11, 5/25, 6/8, 7/6, 7/27, 8/3, 8/17, 8/31 and 9/14.

On 9/16/25 at 11:54 AM, the Dietician reported she expected residents with feeding tubes to have weights completed weekly to monitor their nutritional status.

She said she had noticed obtaining weekly weights had been a problem.

She reported she believed the Director of Nursing (DON) and Administrator were aware of the issue.

She said some of the scales had been broken and needed to be repaired.

She said a weight scale had been added to the shower room.

She said there had also been concerns with staff obtaining accurate weights.

On 9/16/25 at 10:45 AM, the Administrator in training/ Infection Preventionist said she expected staff to obtain weights according to physician orders.

A facility policy titled Weight Monitoring revised 11/28/22 documented weights could be a useful indicator of nutritional status.

Significant unintended changes in weight or insidious weight loss may indicate a nutritional problem.

The policy directed staff to implement a weight monitoring schedule upon admission for all residents and weights should be recorded at the time they are obtained.

• The Quarterly MDS for Resident #15, dated 7/24/25, included diagnoses of Muscular Dystrophy,

respiratory failure, dysphagia (difficulty swallowing food or liquids), and malnutrition.

The MDS identified the resident had a feeding tube (tube into the stomach to provide liquid nutrition) and was dependent on staff for eating, toilet hygiene. and transfers.

The MDS indicated the resident had a suprapubic catheter (tube into the lower abdomen to drain urine from the bladder) and a tracheostomy (opening with tube into the windpipe to maintain an airway for breathing).

The MDS indicated the resident had a BIMS score of 12, indicating mild cognitive impairment. Resident #15's Medication Administration Record (MAR) for 8/1/25 - 8/31/25 and 9/1/25 – 9/30/25 revealed the following physician orders: a. daily weights X 3 and then weekly for nutrition monitoring, on time a day every Sunday with start date of 5/4/25. b. weight monitoring every day shift every Friday with start date 6/13/25. Resident #15's MAR for 8/1/25 – 8/31/25 and 9/1/25 – 9/30/25 revealed only 1 weight on 8/31/25 of 124.4 pounds. Resident #15's Weights and Vitals record revealed weights documented on 7/4/25, 8/31/25, and 9/3/25 only.

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Bishop Drumm Retirement Center 5837 Winwood Drive Johnston, IA 50131

addition the policy documented licensed nurses would conduct a full body skin assessment on all

finding of the skin assessment would be documented in the medical record.

After completing a

measurable goals for prevention and management of pressure injuries with appropriate interventions.

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Bishop Drumm Retirement Center 5837 Winwood Drive Johnston, IA 50131

Observation on 9/15/25 at 2 PM, Staff A, Registered Nurse with the same pair of gloves on completed the 2 wound treatments, removing the old dressings, cleansing the wounds, and applying new dressings on Resident #15.

Staff A then proceeded to remove the old suprapubic catheter dressing on Resident #15, applied wound cleanser to a gauze pad and wiped around the suprapubic catheter insertion site 4 times continuing to wipe in the same areas with the same area of the gauze pad.

Staff A continued with the same gloves on, and proceeded to apply a new dressing around the suprapubic catheter. Resident #15's electronic health record progress notes revealed the following:a.

Nurse's Note 8/16/25 at 6:09 AM- Nurse was summoned to the resident's bedside for complaints of blood in the urine, blood observed in the tubing of the indwelling suprapubic catheter and large sediment in the catheter tubing.

Resident transferred to the hospital emergency room (ER). b.

Encounter Note, 8/21/25 - resident seen for an acute visit, recent ER visit for hematuria (blood in urine) in foley catheter bag.

Resident returned to the facility.

Received urinalysis culture and sensitivity (C&S) (test for bacteria and antibiotic that bacteria is sensitive to) report indicating a urinary tract infection.

Order left in facility for antibiotic medication. Resident #15's lab report from the hospital revealed a urinalysis completed on 8/16/25 and C&S resulted on 8/19/25 with Enterococcus species(bacteria) count over 100,000.

The facility Suprapubic Catheterization policy approved 9/17/25 revealed wash and dry hands, apply gloves, and clean the stoma (insertion site in abdomen of suprapubic catheter), cleansing outward from for the stoma in a circular motion using only 1 cotton ball or applicator for each stroke.

Interview on 9/16/25 at 9 AM, the Infection Control Preventionist stated expectation when changing the dressing and cleaning the suprapubic catheter site to remove the old dressing, complete hand hygiene, apply new gloves and cleanse around the catheter working from the insertion site outward with the gauze pad or cotton ball, not wiping over the same area again.

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Bishop Drumm Retirement Center 5837 Winwood Drive Johnston, IA 50131

provide appropriate care for a resident with a feeding tube.

flush an enteral gastrostomy tube (g-tube) (tube surgically inserted into the stomach to provide

for 1 of 3 resident (Resident #15) reviewed.

The facility reported a census of 114 residents.

Findings include:The Quarterly Minimum Data Set (MDS) for Resident #15, dated 7/24/25, included diagnoses of Muscular Dystrophy, respiratory failure, dysphagia (difficulty swallowing food or liquids), and malnutrition.

The MDS identified the resident had a g-tube and was dependent on staff for eating, toilet hygiene. and transfers.

The MDS indicated the resident had a suprapubic catheter (tube into the lower abdomen to drain urine from the bladder) and a tracheostomy (opening with tube into the windpipe to maintain an airway for breathing).

The MDS indicated the resident had a BIMS score of 12, indicating mild cognitive impairment.Observation on 9/15/25 at 2:30 PM, Staff A, Registered Nurse was sitting on the side of Resident #15's bed and applying tape to the g-tube adaptor port (end of g-tube that attaches to the tubing from the container that provides the feeding product).

Staff A had a syringe with approximately 25 milliliters (ml) of pink liquid.

Staff A proceeded to attach the syringe to the g-tube and administered the liquid into the resident's g-tube, without flushing the g-tube before or after administering the liquid in the syringe.

Staff A stated the pink liquid was 3 of the resident's medication and an unknown amount of water, as there was no set amount for the water flush so it didn't really matter.The facility's Medication Administration via Enteral Tube policy revised 9/16/25, revealed flush enteral tube with at least 15 ml. of water prior to administering medications, dilute the solid or liquid medication as appropriate and administer, and flush tube again with at least 15 ml. water.Interview on 9/16/25 at 9 AM, the Director of Nursing stated her expectation to follow the physician's order for flushing a g-tube before and after medication administration, and if no order to follow the protocol which is 30 or 60 ml. of water to flush before and after medications given.

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Bishop Drumm Retirement Center 5837 Winwood Drive Johnston, IA 50131

residents to call for assistance and staff will ensure the call light is within reach of resident and

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Bishop Drumm Retirement Center 5837 Winwood Drive Johnston, IA 50131

have an effective quality assurance program in place to assist in the provision of quality of care for

reported a census of 114 residents.

Findings include:

Review of the Department of Inspections Appeals and Licensing (DIAL) website under the facility's visit history revealed the facility had the following concerns identified at the current revisit and complaint survey, that were also cited at past surveys in the last two and half years. a. F-F686- Pressure Sores b. F-F658- Services to Meet Professional Standardsc. F-F725- Sufficient Nursing Staffingd. F-F880- Infection ControlThe following surveys revealed repeated deficiencies from 6/29/23 to current survey:7/21/25- Recertification, Complaint, Incident Survey: F-F725, F-F8804/3/25- Complaint, Incident: F-F7259/19/24- Recertification, complaint, Incident: F-F8808/18/24- Complaint revisit: F-F6866/27/24- Complaint: F-F686, F-F7255/3/24- Complaint: F-F6582/27/24- Complaint, Incident: F-F658, F-F686, F88010/9/23- Complaint, Incident, Recertification revisit, Complaint Revisit, Incident Revisit: F-F725, F-F8806/29/23- Recertification, Complaint, Incident: F-F725, F880A Quality Assurance and Performance Improvement Plan (QAPI) dated 2/26/25 documented the facility used a systematic approach to determine when in-depth analysis was needed to fully understand identified problems, causes of the problems, and implications of a change.

The policy further documented that to prevent future events and promote sustained improvement the facility would develop actions to address the identified root cause and/or contributing factors of an issue/event that would affect change at the systems level. To ensure the planned changes/interventions are implemented and effective in making and sustaining improvements, the facility would choose indicators/measures that tie directly to the new action and conduct ongoing periodic measurement and review to ensure that the new action has been adopted and was performed consistently.In an interview on 9/17/25 at 1:45 PM, the surveyor asked the Administrator what the facility had done to improve and address the repeat deficiencies from the current survey and prior surveys.

The Administrator acknowledged the repeated deficiencies and stated that the facility had put in place quite a few things to improve and address the deficiencies. He said the facility had implemented new wound assessments/tracking and had hired a wound nurse.

The Administrator reported he thought the facility had a good process in place for pressure wounds until the current survey identified concerns. He said the facility was tracking infection control in a different way so trends could be identified easier. He said the facility was conducting routine audits and reviewing resident infections.

The Administrator reported the facility was working with an outside quality of care coalition on a monthly basis to share information, resources and review quality of care outcomes. He said the facility had been tracking call lights and had made some changes on how the staff were scheduled and supported. He said he felt call lights had improved.

The Administrator reported the concerns identified through the survey process would be reviewed and discussed through QAPI.

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Bishop Drumm Retirement Center 5837 Winwood Drive Johnston, IA 50131

ensure use of enhanced barrier precautions (EBP)when required and failed to complete hand hygiene

Findings include:1.The Quarterly Minimum Data Set (MDS) for Resident #15, dated 7/24/25, included diagnoses of Muscular Dystrophy, respiratory failure, dysphagia (difficulty swallowing food or liquids), and malnutrition.

The MDS identified the resident was dependent on staff for eating, toilet hygiene. and transfers.

The MDS indicated the resident had a gastrointestinal feeding tube (g-tube) (tube into the stomach to provide liquid nutrition) a suprapubic catheter (tube into the lower abdomen to drain urine from the bladder) and a tracheostomy (opening with tube into the windpipe to maintain an airway for breathing).

The MDS indicated the resident had a BIMS score of 12, indicating mild cognitive impairment. Resident #15's Care Plan with revision date 11/13/24 documented the resident required Enhance Barrier Precautions (EBP) with close contact due to presence of catheter. 2.Observation on 9/15/at 1:59 PM, the Infection Control Preventionist (ICP)was in Resident #15's room providing oral care with only gloves on, no gown on. 3.Observation on 9/15/25 at 2 PM, Staff A, Registered Nurse (RN) applied a gown and gloves and entered Resident #15's room.

Staff A removed an old dressing off the resident's left buttock, cleansed an open wound with wound cleanser and a gauze pad, and applied a new dressing with an ordered treatment paste.

Staff A continued with the same gloves on and remove an old dressing from the resident's right buttock, cleansed the wound area and applied a new dressing.

Staff A then proceeded with the same gloves on and removed the old suprapubic catheter dressing on the resident, cleansed the catheter insertion site, and applied a clean dressing to the site.

Staff A, still with the same gloves on, removed the old dressing from the g-tube site, cleansed the site area with wound cleanser and gauze, and applied a new dressing.

Staff A continued with the same gloves on and removed the tracheostomy dressing, cleansed around the tracheostomy, and applied a clean dressing. 4.Observation on 9/15/25 at 2:30 PM, Staff A, was sitting on the side of Resident #15's bed administering to the resident per g-tube, without a gown or gloves on.

Facility Enhanced Barrier Precautions policy, revised 9/16/25, revealed 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 with high-contact resident care activities include device care of feeding tubes, tracheostomy tubes, urinary catheters, and wound care.

Facility Hand Hygiene policy, revised 9/16/25, revealed hand hygiene is indicated and will be performed under the conditions listed: after handling contaminated objects and before and after handling clean or soiled dressings.

Interview on 9/16/25 at 9 AM, the ICP acknowledged she observed Staff A not complete hand hygiene or change gloves when completing dressing changes for Resident #15 and stated expectation to complete hand hygiene and change gloves when going from dirty to clean when completing dressing changes.

The ICP additionally stated her expectation for staff to wear gown and gloves with high contact care such as administering medications per a g-tube.