Story Medical Senior Care

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

member, steps need to be taken to ensure the resident's safety and a report of suspected abuse would need to be made to the State within two hours. The DON stated after reading the email the following morning and noting the report of a staff member at the facility pushed, shoved and yelled at the resident,

she had Staff B interview the resident. The DON acknowledged a report was not made to the State agency regarding the resident stating she was shoved, pushed and yelled at by a staff member. During an interview

on 10/14/25 at 10:30 AM, a family member of Resident #1 stated on 7/20/25 a visit took place at the facility with the resident, in the early afternoon. While the family member stepped out of the resident's room, the resident talked to another family member still in the room. When the family member returned to the room,

the resident was crying and holding the hand of the other family member. The family member asked if everything was okay and the other family member said something happened. The resident then stated a CNA was mean to her and yelled at her, they got into a yelling match. The resident said she had used her call light to go to the bathroom and when the CNA came into her room she had gone in her brief. She said

the CNA screamed that she had to clean up the resident. The resident said the CNA jerked her up out of her recliner chair and the resident yelled at her that she was hurting her. The resident said the CNA pushed her back into her chair. The family member asked the resident who the CNA was, the resident said she did not know her name, it was a staff member who did not work at the facility very often. The resident told the family member the CNA then got her up out of the recliner and took her to the bathroom and then dropped her down on the toilet. The resident said she told the CNA she was hurting her and the CNA yelled at her.

The family member asked the resident more questions about the staff member and the resident said she had been working over the past few days, but did not work there very often. The resident said it happened within the last day or two. The family member said the resident was crying while reporting what happened.

The resident said maybe the staff member was having a bad day and didn't know what she was doing, the resident said she felt helpless. The family member went to find the charge nurse and reported this to the charge nurse. Review of the facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, with a revision date of November 2024, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury.

Event ID:

Facility ID:

16E277

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

16E277

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Story Medical Senior Care

710 S 19th St Nevada, IA 50201

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

reading the email the following morning and noting the report of a staff member at the facility pushed, shoved and yelled at the resident, she had Staff B interview the resident. The DON acknowledged a report was not made to the State agency regarding the resident stating she was shoved, pushed and yelled at by

a staff member. The DON acknowledged staff were not interviewed, including Staff C, and no other steps were taken regarding the reported concerns of suspected abuse. Review of the Electronic Health Record (EHR) revealed 14 of the 21 residents on the unit where Resident #2 resided in July of 2025 required assistance of 1 or more staff for completion of cares, such as toileting and transferring. During an interview 10/14/25 at 10:30 AM, a family member of Resident #1 stated on 7/20/25 a visit took place at the facility with the resident, in the early afternoon. While the family member stepped out of the resident's room, the resident talked to another family member still in the room. When the family member returned to the room,

the resident was crying and holding the hand of the other family member. The family member asked if everything was okay and the other family member said something happened. The resident then stated a CNA was mean to her and yelled at her, they got into a yelling match. The resident said she had used her call light to go to the bathroom and when the CNA came into her room she had gone in her brief. She said

the CNA screamed that she had to clean up the resident. The resident said the CNA jerked her up out of her recliner chair and the resident yelled at her that she was hurting her. The resident said the CNA pushed her back into her chair. The family member asked the resident who the CNA was, the resident said she did not know her name, it was a staff member who did not work at the facility very often. The resident told the family member the CNA then got her up out of the recliner and took her to the bathroom and then dropped her down on the toilet. The resident said she told the CNA she was hurting her and the CNA yelled at her.

The family member asked the resident more questions about the staff member and the resident said she had been working over the past few days, but did not work there very often. The resident said it happened within the last day or two. The family member said the resident was crying while reporting what happened.

The resident said maybe the staff member was having a bad day and didn't know what she was doing, the resident said she felt helpless. The family member went to find the charge nurse and reported this to the charge nurse. Review of the facility policy Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, with a revision date of November 2024, documented it shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. The facility will identify, through ongoing assessment, high-risk situations where abuse, neglect, or misappropriation of resident property may occur and provide appropriate intervention in such occasions. Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents.

Event ID:

Facility ID:

16E277

If continuation sheet