Pioneer Valley Living And Rehab

F-F637- Comprehensive Assessment After a Significant Change

3.

F-F656- Develop and Implement Comprehensive Care Plan

6.

F-F658- Services Provided Meet Professional Standards

7.

F-F880- Infection Prevention and Control

The QAPI Facility Plan dated December 2024 identified the governing body and\or the facility administration shall provide general oversight for QAPI activities related to resident care and services throughout the facility. The governing body is responsible and accountable for ensuring that:

1. An ongoing QAPI program is defined, intimate, maintained and addressed identified priorities.

2. Policies are established to ensure the QAPI program is sustained during transitions and leadership and staff turnover.

3. The QAPI program is adequately resourced, including ensuring staff, time, equipment and technical training as needed to conduct its work.

4. The QAPI program identifies and prioritizes problems and opportunities that reflect organizational processes, functions, and services to residents based on performance indicator data, resident and staff input, and other information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 50 165615 Department of Health & Human Services Printed: 09/09/2025 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 165615 B. Wing 02/06/2025

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

Pioneer Valley Living and Rehab 400 Sergeant Square Drive Sergeant Bluff, IA 51054

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 0865 5. Corrective actions adjust gaps in systems in our evaluation for effectiveness.

Level of Harm - Minimal harm or 6. Clear expectations are set around safety, quality, rights, choice and respect. potential for actual harm 7. One or more persons are designated to be accountable for QAPI. Residents Affected - Many 8. Leadership and facility wide training is conducted on QAPI.

9. An atmosphere exists in which staff members are encouraged to identify and report quality problems, as well as opportunities for improvement.

In an interview on 2/6/25 at 8:57 AM, the Administrator stated, we are working on MDS (Minimum Data Set) and resident falls with a performance improvement plan (PIP). They both started in December. When asked about repeated deficiencies the Administrator explained last year the facility hired two different staff that no longer work for the facility. For MDS needs the facility hired a third party to manage MDS and care plans.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 50 165615 Department of Health & Human Services Printed: 09/09/2025 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 165615 B. Wing 02/06/2025

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

Pioneer Valley Living and Rehab 400 Sergeant Square Drive Sergeant Bluff, IA 51054

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41785 potential for actual harm Based on observation, interview and record review the facility failed to implement infection control practices Residents Affected - Few for 2 of 22 residents reviewed, (Resident #149 and #24). While staff provided nutrition and medications through a feeding tube, she failed to wear all of the required Personal Protective Equipment (PPE). The nurse stood on the resident's oxygen tubing while providing care to Resident #149. The urinary catheter bag for Resident #24 was laying on the floor. The facility reported a census of 47 residents.

Findings include:

1) According to the Minimum Data Set (MDS) dated [DATE REDACTED] Resident #149 had a Brief Interview for Mental Status (BIMS) score of 15. She had an abdominal feeding tube and was on medications that included antipsychotic, antidepressant, diuretic, antiplatelet and continuous oxygen.

The Care Plan updated on 8/30/24, showed that Resident #149 had orders for nothing by mouth (NPO). She was at risk for aspirations, staff were to monitor for signs and symptoms of aspiration, assess evaluate report significant changes to physician as needed.

On 1/27/25 at 4:55 AM, Staff O, Licensed Practical Nurse (LPN) explained that a cup of dark fluid that was sitting on the medication cart, was the medication for Resident #149 that she had mixed earlier that morning. Staff O donned disposable gloves but failed to put on a gown. She prepared the Glucerna nutritional supplement, poured it in the bag on the pole next to the resident's bed and held the tubing while the fluid flowed down the tubing. Once the fluid reached the end of the tubing, she took the tip of the tubing and hung

it inside the bag of fluid while she prepared and administered the medications via feeding tube. The resident was lying in bed with supplemental oxygen via nasal cannula and the oxygen tubing was laying across the floor beside the bed. Staff O stepped on and off the oxygen tubing twice while administering the medications.

On 2/6/25 at 8:02 AM, Staff J, Director of Nursing said that Staff O realized that she should have had a gown

on when she did the tube feeding. Staff J agreed that placing the tip of the tubing in the bag of nutritional supplement and stepping on the oxygen tubing were infection control concerns.

According to the undated facility policy titled: Enhanced Barrier Precautions Enhanced Barrier Precautions (EBP) the facility would expand the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids were anticipated and refer to the use of the gown and gloves during high-contact resident care activities that provide opportunities for transfer of pathogens to staff hands and clothing. EBP apply to: wounds and/or indwelling medical devices (central line, urinary catheter, feeding tube, tracheostomy)

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2. Observation on 2/3/25 at 10:50 a.m, included observation of Resident #24's catheter bag laying directly on

the floor. The catheter bag lacked a privacy cover.

Facility did not provide a policy on catheter bags not touching the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 50 165615 Department of Health & Human Services Printed: 09/09/2025 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 165615 B. Wing 02/06/2025

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

Pioneer Valley Living and Rehab 400 Sergeant Square Drive Sergeant Bluff, IA 51054

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 0880 Interview on 2/6/25 at 9:11 a.m., with the Director of Nursing revealed the catheter bag should not ever be on

the floor. 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 50 of 50 165615