Stone Cottage Care Center

staff he is receiving it routinely, he did report he has had several UTIs. Resident #8 also reported the

She would expect staff to provide oral cares to the residents least every morning and evening.

There should not be any reason why this is not being done. It's addressed on the all the Kardex which all the staff have access to.

She would expect staff to provide peri care to the residents after every incontinent episode and upon rising and before they go to bed.

When asked why Resident #8 did not have any peri care for 5 days, she reported he just had peri care just before he made that statement.

A review of the Facility Policy titled: Oral Care with the last revision date of 5/15/20 had documentation of the following: For a patient who can't expectorate or is dependent for oral care If necessary, insert a bite block or mouth prop to hold the patient's mouth open during oral care.

Brush the patient's teeth, gums, and tongue with a soft compact-head toothbrush and toothpaste at least twice per day but ideally four times per day.

Brush the teeth for at least 2 minutes at each session using the brushing method described above.

A review of the Facility Policy titled: Perineal Care dated as last revised February 2018 had documentation of the proper procedure, but failed to direct staff on the frequency that perineal care should be provided.

165381 05/28/2026

Stone Cottage Care Center 900 South Stone Street Sigourney, IA 52591

she declined.

165381 05/28/2026

Stone Cottage Care Center 900 South Stone Street Sigourney, IA 52591

During the day shift on weekends, there is usually just two CNAs to take are of 30+ residents.

They will schedule agency, but most of the time they will call in sick or just a no call, no show.

One of the aides has worked 14 days in a row to help out on the weekends. At least half of the residents require two aides for cares.

In an interview on 5/26/26 at 1:58 PM, Staff A, CNA reported staff should answer call lights within 15 minutes and that Resident #8 will complain daily that it takes too long for staff to answer his call light.

In an interview on 5/26/26 at 3:02 PM, Staff D, CNA reported staff should answer a resident's call light within 15 minutes, but it takes at least 30 to 45 minutes, this is part of the reason she left.

Typically on day shift, there is one nurse, one CMA (Certified Medication Aide) and 3 CNAs but there are quite a few call offs.

She also said she has worked by myself with over 35 residents before they could find someone to come in.

People would call in sick at least once every weekend. A few weekends ago, she worked 6:00 AM to 6:00 PM, they were short, she ended up working until 2:00 AM as no one came in to relieve her at 10:00 PM.

She did not feel there was enough staff to give residents the are they need as at least half of the residents require cares in pairs and eleven residents require transfers with a mechanical lift.

In an interview on 5/28/26 at 9:15 AM, the Administrator reported she would expect staff to answer call lights within 15 minutes.

She reported she looked through all the grievances, resident council meeting minutes and could not find any complaints about call lights.

A review of the Facility Policy titled: Answering the Call Light dated as last revised September 2022 had documentation of the following: Answer the resident call system immediately.

If the resident needs assistance, indicate the approximate time it will take for you to respond.

If the resident's request requires another staff member, notify the individual.

If the resident's request is something you can fulfill, complete the task within five minutes if possible.

If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance.

165381 05/28/2026

Stone Cottage Care Center 900 South Stone Street Sigourney, IA 52591

for one ofone residents reviewed for occupational therapy services. (Resident#8).

The facility

identified Resident #8 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 and had the following diagnoses: Traumatic Spinal Cord Dysfunction, Quadriplegia, Neurogenic Bladder and Diabetes Mellitus.

The MDS also identified Resident #8 to be totally dependent on staff for assistance with all activities of daily living and had an indwelling urinary catheter. A review of the Physician Orders revealed an order dated 11/6/25 for Occupational Therapy to evaluate and treat as ordered. A review of Occupational Therapy progress notes revealed the last entry was dated 4/2/26.

The Care Plan with the last revision date of 3/4/26 identified Resident #8 with the problem of being a quadriplegic, however, failed to address the order for Occupational Therapy dated 11/6/25. On 5/20/26 at 11:30 AM Resident#8 reported that he had not received occupational therapy for activities of daily living. In an interview on 5/26/26/ at 1:03 PM, Staff B, RN reported the following: Resident was getting OT and getting a TENS unit, however the Occupational Therapy Assistant has not worked with him for at least several weeks and could not explain why the OTA has not seen him when he continues to get physical therapy. In an interview on 5/26/26 at 3:43 PM, the Occupational Therapy Assistant reported it has been a month she worked with Resident #8 last on upper body, muscle to get him to do a grasp and maintain tone in his muscles.

The visits stopped because the recertification was not done and she cannot provide services until the Occupational Therapist completes the recertification.

The Occupational Therapist had a family illness which is why they are behind on the recertifications. Resident #8 is on her schedule definitely for tomorrow. In an interview on 5/28/26 at 9:15 AM, the Administrator reported regarding Resident #8's occupational therapy, the Occupational Therapist does need to write up a recertification.

The facility did not have full time in house therapy staff, they are as needed (PRN) for but work for the facility.