Casa De Paz Health Care Center

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

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

of Visit medication listed in the summary did not include an extended release;a. CD/LD 25/100 one tab 4 times a day with end date of 8/7b. CD/LD 25/100 2.5 tab five times daily PRNAn order entered at the facility

on 8/8/25 at 8:18 AM, included CD/LD 25-100 mg one tab four times a day (until cartridge comes from pump) AND give 2.5 tab ever 5 hours PRN. According to the Medication/Treatment Administration Record (MAR/TAR) From 8/8/25- 8/20/25, the PRN dose was used 31 times. During the same timeframe, Resident #5 did not get any extended release tabs. A Nursing Progress Note dated 8/7/25 at 5:11 PM, showed Resident #5 returned from appointment with change to the CD/LD, ER 25/100 changed to 4 times a day.

The nurse called for verification and they indicated they would fax the doctor's dictation notes. A Fax was received and MAR updated. A Nursing Progress Note dated 8/18/25 at 3:01 PM, showed that they called to

the neurologist to request more of the medication scheduled rather than having the PRN as bigger dose.

Documentation of telephone messages at the neurologist office showed the Director of Nursing (DON) called on 8/18/25 at 3:01 PM, regarding the Sinemet 25/100 and that Resident #5 was getting 1-tab scheduled 4x a day and the PRN wasn't enough. The DON was hoping that he can get 2.5 tabs scheduled 4x day with 1-tab 5x a day PRN. The DON stated that the resident was super stiff with this order. A follow up telephone message dated 8/19/25 at 7:21 PM, from the neurologist to the nursing home said why is he getting 1 tab 4 times a day? He should be getting 2.5 tabs 5 times a day and Sinemet Extended Release 50/200 one tablet 5 times a day. On 10/28/25 at 8:05 AM, the Administrator acknowledged that the summary from the neurologist on 8/7/25 had conflicting information regarding medications. The narrative said one thing, and the initial medication list was different and the ending list. She said staff saw the entry that said no changes to the medications so it did seem contradictory. The Administrator said that the staff would not pay attention to the section of the summary titled Plan. The DON said she called back to clinic

after the resident was using so much of the PRN and thought he should have an extended-release tablet.

The DON said that they did not call back for clarification orders after the 8/7/25 visit. A facility policy titled; Medication Orders, (no date of implementation) showed that a written transfer order did not require further validation if it was signed and dated by the residents attending physician, unless the order was unclear or incomplete.

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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

10/30/2025

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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

flushing. She said that would be a question for the neurologist who prescribed it. She said that the company has trainers come out to teach the nursing home staff how to use it. On 10/30/25 at 9:40 AM, the nurse from the neurologist office said they do not manage the pump tubing after the resident was no longer getting medication administered through the Duopa. They gave orders for flushing related to administration of the medication but once he was no longer using the pump, that would have been the PCP responsibility to monitor or give orders for maintenance. No one from the facility called to get clarification on continued flushing or maintenance while not in use. On 10/30/25 at 8:40 AM, the Gastroenterologist (GI) doctor that had applied the G-j tube for Resident #5 in January said that the tubing for the Duopa was much narrower than a regular feeding tube and he wasn't sure how long it would stay functional. When informed that part of

the tubing had passed through the resident's stool in June, the doctor said that he usually recommended that tubing be replace every 6 months. He said that it was possible that the tubing could have started to breakdown. The plastic can become corroded. He said that whoever was monitoring/managing the medications should have given orders for maintenance on the pump and tubing. On 10/30/25 at 9:15 AM,

the Director of Nursing and Administrator acknowledged that none of the doctors had taken responsibility for orders or directions on maintenance for the Duopa pump tubing when it was not being used. According to the facility policy titled: Care and Treatment of Feeding Tubes Direction for staff on how to provide the following care would be provided: frequency of and volume used for flushing, including flushing for medication administration, and what to do when a prescriber's order does not specify. Direction for staff regarding the conditions and circumstances under which a tube was to be changed will be provided. When to replace and/or change a feeding tube (generally as ordered/scheduled by the physician when a long term feeding tube comes out unexpectedly, or when the tube was worn or clogged)

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Facility ID:

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