Pioneer Valley Living And Rehab

F-F658 indicated that 4 files a week would be audited. Just 2 files a week had been audited for the first 4 weeks.

b. POC for

F-F684 indicated that 4 files a week would be audited. Just 2 files a week had been done.

c. POC for

F-F689 indicated that 4 charts a week would be audited for accidents and hazards, safe transfers. Just 2 files a week had been audited for 7 weeks.

On 4/3/25 at 11:30 AM the Administrator indicated that they had made progress in many areas and they continued to monitor successes along with the areas that still need work. She acknowledged that there was a misunderstanding on the POC and the number of files that would be audited weekly.

The QAPI Facility Plan dated December 2024, identified the governing body and/or the facility administration would provide general oversight for QAPI activities related to resident care and services throughout the facility. The governing body was responsible and accountable for ensuring that: The QAPI program identified and prioritized 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 20 of 21 165615 Department of Health & Human Services Printed: 08/31/2025 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 04/03/2025

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 41785 potential for actual harm Based on observation, interview and record review the facility failed to ensure that staff followed Enhanced Residents Affected - Few Barrier Precautions (EBP) while providing wound treatments for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 45 residents.

Findings include:

According to the Minimum Data Set (MDS) date 2/14/25, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit.) The resident was totally dependent on staff for toileting and transfers, and required substantial assistance with putting on and taking off footwear and lower body dressing. The resident had a stage 2 pressure injury and treatments included pressure ulcer care, application of ointments/medications and application of dressings to feet. The resident was on Hospice care.

The Care Plan updated on 2/19/25, showed that Resident #1 had impairment to skin integrity related to fragile skin and a decline in his cognition and physical condition. He was admitted to Hospice services on 1/25/25. He had padded, protective boots that he was to wear as allowed. A wound specialist, Nurse Practitioner (NP) was seeing the resident for wound care.

On 3/31/25 at 12:51 PM, Staff BB, Certified Nurse Aide (CNA) and Staff Y, CNA, assisted Staff DD, Registered Nurse (RN) with a wound treatment dressing change to the right foot of Resident #1. The three staff members failed to wear gowns during the cares.

On 4/3/25 at 6:55 AM, Resident #1 did not have EBP signs on his door to alert staff to wear full Personal Protective Equipment (PPE.)

On 4/3/25 at 11:30 AM the Administrator said that they had just posted the signage on the door for Resident #1. She acknowledged that they failed to implement EBP while caring for the residents open wound.

According to the undated facility policy titled: Enhanced Barrier Precautions (EBP), the facility would expand

the use of 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 165615