Southridge Specialty Care

F 0580 The Incident, Accident, Unusual Occurrence Progress Note dated 3/17/25 at 7:10 PM, documented a Certified Medication Aide (CMA) requested Staff E, Licensed Practical Nurse (LPN), go to Resident #8's Level of Harm - Minimal harm or bathroom. Upon entering the bathroom, they noted Resident #8 lying on the floor with the lower left extremity potential for actual harm by the foot riser and her right knee bent and lower extremity by the base of the toilet. In addition, Staff E found Resident #8 lying on the wheelchair cushion with a disposable incontinence pad under her head and Residents Affected - Few back. When asked Resident #8 what happened, she couldn't reply due to her increased confusion. At the time, Resident #8 didn't wear any non skid socks. Three staff members assisted Resident #8 to her feet with

the use of a gait belt. Resident #8 stood up by the hand rail while the nurse did a head-to-toe assessment, that revealed no bruising or injuries. The staff then assisted Resident #8 to sit on the toilet. Resident #8 complained of right hip pain and bilateral knee pain. The assessment showed no redness or any swelling to her extremities. Resident #8 stood without any complaints of pain. A staff member transferred Resident #8 off of the toilet to her wheelchair then transferred her to the recliner. Resident #8 voiced no complaints of pain at that time. The nurse-initiated neuro (neurological) checks and measured within normal limits. Resident #8 had equal and strong grips with symmetrical legs.

On 5/15/25 at 8:57 AM, Resident #8's Daughter reported her mother fell on [DATE REDACTED]. She added the facility didn't notify her of her mother's fall until the next day at 3:45 PM. Resident #8's Daughter said Staff E called her the following day. Staff E told her daughter, her mother fell late at night the night before and she didn't want to call her. Resident #8 fell around 7:10 PM.

On 5/15/25 at 10:42 AM, the Assistant Director of Nursing (ADON), reported the nurse didn't notify Resident #8's family after she fall on 3/17/25. The ADON said they found out the next morning the staff didn't notify the family. They educated the nurses that very day they needed to notify a family after a fall.

The Accidents and Incidents Investigating and Reporting policy revised July 2017, directed to document the date/time when the staff notified the injured person's family and by whom.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 8 165209 Department of Health & Human Services Printed: 08/26/2025 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 165209 B. Wing 05/29/2025

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

Southridge Specialty Care 309 West Merle Hibbs Boulevard Marshalltown, IA 50158

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 0658 The Medication and Treatment Orders policy, revised July 2016, instructed to have consistent orders for medications and treatments, with principles of safe and effective order writing. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 8 165209 Department of Health & Human Services Printed: 08/26/2025 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 165209 B. Wing 05/29/2025

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

Southridge Specialty Care 309 West Merle Hibbs Boulevard Marshalltown, IA 50158

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 0684 On 5/20/25 at 3:28 PM, the Nurse Consultant acknowledged the bruises in the pictures. The Nurse Consultant stated she couldn't find any documentation of bruising on Resident #8's legs or knees. When the Level of Harm - Minimal harm or surveyor showed the Nurse Consultant The NSG: Skin Observation Tool V 2 indicated the Certified Nurse potential for actual harm Aide (CNA) marked no new skin issues for the dates of 3/3/25, 3/10/25 and 3/17/25. The Nurse Consultant stated they started the form for the CNAs to alert the nurses when they find a new skin concern. When they Residents Affected - Few mark yes, the nurses become aware. They need to go and assess the new skin area. She stated what happened is that the CNAs felt the nurses already assessed the resident after a fall, therefore they knew about the skin area. The Nurse Consultant stated that after a fall, bruising may not show up right away, therefore the nurse would not see an area during their initial assessment. She stated they would provide education on that matter.

A Skin Tears Abrasions and Minor Breaks policy revised September 2013, defined the purpose of the procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. Preparation:

a. Obtain a physician's order as needed. Document physician notification in medical record.

b. Review the resident's Care Plan, current orders, and diagnoses to determine resident needs.

c. Check the treatment record.

d. Generate Non Pressure form and complete.

e. Assemble the equipment and supplies as needed.

Documentation - Record the following information in the resident's medical record:

a. Complete in house investigation of causation.

b. Generate Non Pressure form.

c. Document physician and family notification, and resident education (if completed) in medical record.

d. How the resident tolerated the procedure.

e. Any problems or resident complaints related to the procedure.

f. Any complications related to the abrasion (e.g., pain, redness, drainage, swelling, bleeding, decreased movement).

g. Interventions implemented or modified to prevent additional abrasions (e.g., clothes that cover arms and legs).

h. When an abrasion/skin tear/bruise is discovered, complete a Report of Incident/ Accident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 165209 Department of Health & Human Services Printed: 08/26/2025 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 165209 B. Wing 05/29/2025

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

Southridge Specialty Care 309 West Merle Hibbs Boulevard Marshalltown, IA 50158

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 0805 On 5/14/25 at 2:00 PM, the Nurse Consultant and the LNHA acknowledged the concern of serving the incorrect diet. They stated they would look for more documentation. Level of Harm - Minimal harm or potential for actual harm At the time of survey, the facility couldn't provide further documentation.

Residents Affected - Few A Therapeutic Diets policy revised October 2017, directed the attending physician to prescribe therapeutic diets to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Policy Interpretation and Implementation a. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet.

b. If a mechanically altered diet is ordered, the provider will specify the texture modification.

c. The resident has the right to not comply with therapeutic diets.

d. The Dietitian, nursing staff, and attending physician will regularly review the need for, and resident's acceptance of, prescribed therapeutic diets.

e. The dietitian and nursing staff will document significant information relating to the resident's response to his/her therapeutic diet in the resident's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 165209