Good Neighbor Home

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on observation, clinical record review, video footage, family interview, staff interview, and facility policy review the facility failed to maintain a resident's dignity by failing to remove a gait belt assistive device

after usage for 1 of 3 residents reviewed (Resident #3). The facility identified a census of 99 residents.

Findings include: Resident #3's MDS assessments dated 7/11/25 and 7/22/25 identified a Brief Interview for Mental Status (BIMS) score of 1, severely impaired cognition. The MDS indicated Resident #3 had fluctuating inattention, disorganized thinking, and wandered daily. Resident #3 required partial to moderate assistance with transfers and ambulation. The MDS included diagnoses of a non-traumatic brain dysfunction, Alzheimer's Disease, and anxiety. The Care Plan Approach dated 8/1/25 identified Resident #3 needed everyone to know he required assistance from 1 staff member with a walker and a gait belt for transfers and/or ambulation. Review of the facility's video footage along with the management staff documentation indicated on 9/26/25 at 7:14:08 p.m. Resident #3 stood at the front door with a gait belt around his waist, without staff present. During an interview on 10/9/25 at 3:49 p.m. Staff A, Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA), confirmed it has never been acceptable to have leave a gait belt around a resident's waist when not in use. A Dignity policy and procedure form revised February 2021 indicated each resident should receive care in a manner the promoted and enhanced their sense of well-being, level of satisfaction with life and feelings of self-work and self-esteem.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Good Neighbor Home

105 McCarren Drive Manchester, IA 52057

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 0689 Level of Harm - Actual harm Residents Affected - Few

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

facility didn't have other staff members in the living room area with the residents. When she completed cares with the resident, she assisted them out of their room and still heard the alarm as it sounded but thought it odd nobody responded to the alarm. So, she walked towards the main entrance with the resident and as she approached, she observed the family member with Resident #3 inside the building close to the front door. The staff member sat the resident down she assisted out of her room on the bench located close to the alarm, shut it off, and approached the family member with Resident #3 and asked if she knew what had been going on. The family member told her she came to the building to spend some time with her family member after supper, as she did daily and stayed at the door for approximately 5 minutes as she waited for some staff to open the door. She mentioned she didn't observe any staff out in the common area, so she decided to stay there and waited until her family member stood up, walked to the door, held the door handle for approximately 15 seconds until it unlocked and she walked in. The staff member recalled that

she checked the clock at the time of the incident and it had been between 7:20 p.m. and 7:30 p.m. The staff member didn't know the location of Staff F and Staff A at the moment of the incident but they both claimed to be in resident's rooms.

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

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Good Neighbor Home

105 McCarren Drive Manchester, IA 52057

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

unit. b. 7:10:30 p.m. - Resident #3 could be seen as he looked at the family member/visitor at the door.

Note: 10 residents present in the lounge area which included Resident #3 and without staff present. c. 7:13:22 p.m. - Resident #3 stood from the table in the lounge area. d. 7:14:08 p.m. - Resident #3 stood at

the front door with a gait belt around his waist and no staff present. e. 7:14:19 p.m. - Staff A, Certified Medication Aide (CMA), into the common dining area as she ambulated towards the kitchen with her back to the front door. f. 7:16:15 p.m. - Resident #3 opened the door without staff present and the door alarm sounded. g. 7:17:04 p.m. - The visitor/family member walked into the common area beside the resident.

Note: 10 residents remained in the lounge area without staff present. h. 7:17:22 p.m. - Staff B, Certified Nursing Assistant (CNA) present in the common dining area as she assisted another resident. The staff member had her back to the front door and/or lounge area in the video still shot. i. 7:18:49 p.m. - Staff B at door and turned off the alarm as typed by management however video revealed Staff B as she looked towards the door and an unknown family member ambulated away from the door as if he just entered (the Director of Nursing Services identified the family member via email 10/15/25 at 2:59 p.m.).During an

interview on 10/8/25 at 4:25 p.m., Staff F, CNA, indicated sometimes she felt they had enough staff in [NAME] and sometimes the didn't. In addition, she had times she indicated she felt overwhelmed. Staff F declined anything else. During an interview 10/8/25 at 4:35 p.m. Staff G, CNA, indicated the facility didn't have enough staff in [NAME] to meet the individual needs of the residents. The staff member stated, a lot of our residents sun down real strong. The staff member felt if the facility had more staff to keep an eye on people maybe people would not get up by themselves.During an interview 10/8/25 at 3:54 p.m. Staff H, RN indicated there had not been enough staff scheduled in [NAME] because there so many of the residents required at least one staff assistance with cares and both aides could have been busy and someone in the lounge area wants to get up or has behaviors that person had to wait. During an interview 10/8/25 at 3:05 p.m. Staff E, CNA/CMA indicated she felt sometimes there had been enough staff in [NAME] and sometimes no rather it depended on the impulsivity of the residents back in the unit. The staff member stated in a perfect world it would have gone OK if the residents exhibited no behaviors however it had not been like that. During an interview 10/8/25 at 3:39 p.m. Staff D indicated she felt sometimes the facility had enough staff in the CCDI [NAME], but it depended on the clientele.Review of the facility's Town Talk Minutes included the following as dated per month: a. June 2025 - Long wait time for call lights but they received good care. The staff responded slow to call lights. An unknown resident had to use his urinal several times and wet the bed as he waited for staff to respond. b. September 2025 - Short staffed, especially on weekends.The Answering the Call Light policy revised September 2022 directed the facility staff to responded timely to the resident's requests and needs. The Procedure instructed to have staff to answer Resident #3 call system immediately.

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If continuation sheet