Park View Rehabilitation Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based record

review and staff interview, the facility failed to notify the resident's representative of a change in condition for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 43 residents. Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE REDACTED] Resident #1 demonstrated long and short term memory problems and severely impaired cognitive skills for daily decision making. The resident had diagnoses including a stroke with hemiplegia of the right dominant side.The Care Plan identified the resident at risk for alteration in skin integrity related to immobility, right sided weakness Status Post (S/P) stroke, anticoagulant and antiplatelet usage. On 7/30/25 pressure ulcer right buttock, and 8/15/25 pressure ulcer left buttock. A Concern Form dated 8/29/25 documented Resident #1's family member gave a verbal in person report. She felt the facility had not notified her of the resident's wound worsening.The Progress Notes dated 8/21/25 at 3:54 p.m. documented the weekly skin assessment revealed a reddish-purplish colored area remained on the left upper buttock with some yellow slough and measured 2.7 cm x 2 cm. She also had an open area measuring 8 cm x 10.5 cm that had deteriorated on her right buttock, with yellow slough around the edges and brown discolored skin in the center. The fax with

the above information returned by the Primary Care Provider on 8/22/25 showed physician notification. The clinical record lacked documentation the resident representative received notification of the change in the wound.On 9/3/25 at 12:20 p.m. Staff C Licensed Practical Nurse (LPN) stated she normally did wound assessments on Thursdays and then she would fax the doctors with the results. She said the resident's wounds had been deteriorating.The facility Notification for Change of Condition policy revised 6/2023 identified the facility would provide care to residents and provide notification of resident change in status.

The facility must immediately inform the resident; consult with the resident's physician, and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status.

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park View Rehabilitation Center

601 Park Avenue Sac City, IA 50583

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 Level of Harm - Actual harm Residents Affected - Few

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

talked to her at that time about the wound, and the family member was going to her next appointment with her. On 94/25 at 9:10 a.m. the Provisional Administrator confirmed the resident did not have an appointment on 8/22/25 at the wound center.The facility undated Skin Management policy documented the potential ongoing management strategies may include risk factor management interventions including management of acute changes in the resident's condition.

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park View Rehabilitation Center

601 Park Avenue Sac City, IA 50583

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

search for him which didn't take very long because he was across the hall. She didn't even know he could walk. She said his alarm did not sound that morning. Staff G said she didn't know why the alarm didn't go off that morning she never found out. On 9/3/25 at 1:51 p.m. Staff H CNA stated she did not hear the alarm sound, and she did not know why it did not.On 9/4/25 at 9:29 a.m. Staff G Licensed Practical Nurse (LPN) stated the resident had the alarm in place on 7/11/25 but it did not sound. She said either they did not turn it

on the night before or the resident had turned it off himself. She said she thought he had learned how to turn it off. She said he now had another alarm hooked to him that sounded if he pulled away from it. She said the alarm was in place so when he was getting up they would know, and respond.The undated facility Fall Occurrence policy documented the purpose to ensure residents were evaluated for fall risks and implemented interventions to minimize the risk for falls and/or the risk for injury from falls.

Event ID:

Facility ID:

If continuation sheet