Casa De Paz Health Care Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

services as needed. She had the potential for impaired skin integrity and was at risk for edema, swelling and pain. Staff were to administer treatments as ordered.On 8/20/25 at 2:18 PM, Resident #9 was sitting in her room in her wheel chair watching a video. When asked if she had ever been treated disrespectfully by any of the staff she said that earlier that day, Staff A, Certified Nurse Aide (CNA) got in my face and talked down to me. she felt like Staff A was talking down to her and didn't treat her respectfully.On 8/20/25 at 3:09 PM, the Director of Nursing (DON) said that Resident #9 told her about the interaction with Staff A. She said that the staff member had gotten frustrated, but Staff A didn't think her tone was rude to the resident.

DON said she was given coaching she will get me a copy.On 8/21/25 at 8:34 AM, Staff B, Certified Medication Aide (CMA) said that all catheters should have a privacy bag even when the residents are in their rooms.According to a Corrective Action note dated 8/20/25, Staff B was instructed to step away from

the residents when frustrated, and to be mindful of her tone of voice when speaking to the residents.

According to the facility policy titled: Dignity, revised on February 2021, staff promote maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Demeaning practices and standard of care that compromise dignity were prohibited. Staff were expected to promote dignity and respect and help the residents to keep urinary catheter bags covered.

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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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Casa DE Paz Health Care Center

2121 West 19th Street Sioux City, IA 51103

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

disease, heart failure, dementia, seizure disorder and anxiety disorder.The Care Plan updated on 4/24/25, showed that Resident #9 had the potential for impaired skin integrity and was at risk for edema, swelling and pain. Staff were to administer treatments as ordered. The August MAR/TAR for Resident #9 showed the following orders and missed treatments:Order dated 6/27/24 at 7:30 AM, methol-zinc oxide ointment apply to gluteal crease one time day for skin care. The treatment was not completed on the 3rd, 16th and 17thOrder dated 6/24/24 at 7:30 AM, [NAME] hose apply in the morning and elevate legs when resting. Not done on 3rd, 16th or 17th.Order dated 3/24/25 at 7:00 PM, Biofeeze gel apply to back and knee twice a day. Not done on 3rd, 16 or 17th.4) According to the MDS dated [DATE REDACTED], Resident #10 had a BIMS score of 13 (moderate cognitive deficit.) She was totally dependent on staff for dressing, hygiene, toileting and transfers. She had an indwelling catheter and her diagnoses included: neurogenic bladder, dementia, anxiety disorder, schizophrenia, and respiratory failure.The Care Plan for Resident #10 last updated on 6/3/25, showed that the resident was on hospice services due to terminal condition. Staff were to administer medications as ordered, indwelling catheter, provide catheter care per policy. She had the potential for impaired skin integrity, administer treatments as ordered and monitor for effectiveness. The August MAR/TAR for Resident #10 showed the following orders and missed treatments:Order dated 7/19/25 at 7:00 AM, apply Steri-strip to skin tear on left forearm twice a day. The treatment was only done once a day on the 3rd, 10th, 16th and 17thOrder dated 2/26/25 at 7:30 AM, apply lotion to areas affected by incontinence daily. Not completed on 3rd, 16th and 17th.Order dated 6/3/25 at 7:30 AM, apply lotion to dry areas on both feet daily. Not completed on 3rd, 16th or 17th.On 8/21/25 at 9:20 AM, Staff C. Licensed Practical Nurse (LPN) demonstrated that many options the nurses had in the electronic chart, to indicated

the reason if/when a treatment or medication was not given. The choices then transferred over into the nursing notes. She said that with those options, the space on the MAR/TAR should never be left blank with no explanation.8/21/25 at 10:40 AM the Director of Nursing (DON) said that they had a new nurse that she suspected did not understand the documentation of treatments. She had a charge nurse that was responsible for supervising the new staff member and she would be providing some education to the nurses.A facility policy titled: Medication and Treatment Orders, dated July 2016, showed that orders for medications and treatments would be consistent with principles of safe and effective order writing.A facility policy titled: Indwelling Catheter Insertion, Female Resident; Preparation, Review the residents record and verify physicians order for the procedure.

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