Westwood Specialty Care

Certified Nursing Assistant (CNA) reported several CNAs have recently resigned after being held

implemented in which some resident baths are assigned to day shift and others to night shift.

Staff E

them.

Staff E is now expected to complete those missed baths during the day in addition to her regularly scheduled assignments and baths often don't get done.

The Bath, Shower/Tub policy last revised February 2018 identified for documentation the date and time the shower/tub bath was performed.

The name and title of the individual(s) who assisted the resident with the shower/tub bath.

All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath.

How the resident tolerated the shower/tub bath. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken.

The signature and title of the person recording the data.

For reporting, notify the supervisor if the resident refuses the shower/tub bath.

Notify the physician of any skin areas that may need to be treated.

Report other information in accordance with facility policy and professional standards of practice.In an interview on 12/31/25 at 8:12 AM, the Administrator reported that he expected shower schedules to be followed as planned. He explained that, in an effort to improve shower completion, the process had been changed to provide some residents with evening showers.

The Administrator indicated no knowledge of issues with evening showers not completed.

165271 12/31/2025

Westwood Specialty Care 4201 Fieldcrest Drive Sioux City, IA 51104

physician ordered daily weights 1 of 1 residents reviewed (Resident #2).

The facility reported a

Resident #2 documented heart failure, hypertension and coronary artery disease.

The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment.

Review of the physician order dated 7/17/25 at 3:21 p.m., revealed an order for daily weights if weight gain of greater than 3 pounds in one day or greater than 5 pounds in one week fax weights weekly.

Review of daily weight records lacked daily weights on the following days:October 11, 17 and 31November 8, 9, 20, 21, 22, 28 and 30December 5 and 12

Review of the clinical record lacked any documentation the physician had been notified daily weights were not being completed and monitored as ordered.

Review of the facility provided policy titled Physician Services with a revised date of February 2021 revealed supervising the medical care of residents includes monitoring changes in resident's medical status, providing consultation or treatment when called by the facility and overseeing a relevant plan of care for the resident.

Interview on 12/30/25 at 2:01 p.m., with Regional Nurse Consultant revealed the facility should be doing daily weights if they are ordered and they should notify the physician if they are not being completed or per the order with weight gains.

165271 12/31/2025

Westwood Specialty Care 4201 Fieldcrest Drive Sioux City, IA 51104

Observation on 12/29/25 at 1:41 p.m., of Staff D, Certified Nursing Assistant (CNA) assisting Resident #4 into the bathroom.

Staff D assisted Resident #4 to the grab bar.

Resident proceeded to grab the bar and Staff D grabbed under resident's right armpit with her forearm and pulled her up to a standing position.

When the resident was completed in the bathroom Staff D assisted the resident to a standing position by using her forearm pulling under her left armpit to a standing position.

Review of the care plan with a revision date of 10/31/25 revealed Resident #4 required 1 assist with toileting and personal hygiene.

Review of the MDS dated [DATE] revealed Resident #4 is dependent on staff assistance for toileting, requires partial to moderate assistance with personal hygiene and requires partial to moderate assistance with toilet transfers.

Review of the facility provided policy titled Safe Lifting and Movement of Residents revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.

Staff responsible for direct resident care will be trained in the use of manual ([NAME]/transfers belts) and mechanical lifts.

Safe lifting and movement of residents is part of an overall facility employee health and safety program.

Interview on 12/29/25 at 2:26 p.m., with Regional Nurse Consultant revealed when staff are assisting a resident with a 1 assist transfer she expects staff to use a gait belt and not to pull on their arms.

• The MDS assessment dated [DATE] for Resident #13 documented diagnoses of seizure disorder,

anxiety disorder and chronic obstructive pulmonary disorder.

The MDS showed the Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment.

The care plan with an initiation dated of 8/22/18 identified Resident #13 required assistance to the bathroom and required the mechanical stand lift with assistance of one for transfers.

Observation on 12/16/25 at 12:35 PM revealed Staff E, a Certified Nursing Assistant (CNA), transferred Resident #13 from the bed to the toilet using a mechanical stand lift.

While raising the resident from the toilet, Staff E failed to lock the lift brakes, paused when the resident was mostly standing, then locked the brakes and continued raising the resident to a fully standing position.

Staff E then pushed the resident out of the bathroom and positioned the mechanical stand lift at the wheelchair.

Staff E again failed to lock the brakes before lowering the resident into the wheelchair.

The mechanical stand operators manual instructed staff to lock the stand brakes prior to lifting the resident or lowering the resident into a seated position.

In an interview on 12/29/25 at 12:55 PM, the Administrator reported staff should follow the operators manual when using the mechanical stand lift.

165271 12/31/2025

Westwood Specialty Care 4201 Fieldcrest Drive Sioux City, IA 51104

Observation on 12/29/25 at 1:41 p.m., of Staff D, CNA assisting Resident #4 to the bathroom.

When resident #4 was completed in the bathroom, Staff D assisted her to a standing position and then took a disposable wipe and wiped from front to back with the first wipe, used the same side and wiped the rectum 3 times and disposed of it into the trash.

Took another wipe and wiped from front to the back and with the same side of the wipe on the rectum 2 times and disposed of it into the trash.

Took another clean wipe and wiped from the front to the back and with the soiled side wiped the residents rectum 3 times and disposed of it into the trash.

Staff with soiled gloves on pulled up the residents brief, and with the soiled gloves on pulled up the residents pants and adjusted her sweater and pulled the wheelchair closer to the resident.

After the resident was in the chair, removed gloves and performed hand hygiene.

Interview on 12/29/25 at 2:26 p.m., with Regional Nurse Consultant revealed she expected staff to perform peri care properly and to use a clean part of the wipe when doing care.

She further revealed staff should be using an alcohol swab after emptying the catheter tubing.

165271 12/31/2025

Westwood Specialty Care 4201 Fieldcrest Drive Sioux City, IA 51104

services of a licensed pharmacist.

record review and staff interviews the facility failed to provide and maintain accurate resident

reported a census of 77 residents.Findings include: The MDS assessment dated [DATE] for Resident #4 documented diagnoses of muscle wasting, dependence on a wheelchair and nerve damage.

The MDS showed moderate cognitive impairment for daily decision making.

The Clinical Physician Orders for Resident #4 dated 7/18/23 showed tramadol 50 milligram (MG) three times a day ordered for pain.

The Controlled Drug Count Record dated 9/16/25 for Resident #4 showed Staff F, Certified Medication Assistant (CMA) failed to sign the count record at 6 AM.

The Individual Narcotic Record for Resident #4 showed that on 9/16/25 PM shift the tramadol tablet count to be 30 tablets.

The 9/17/25 AM tramadol showed the count to be 28 tablets.

The September Medication Reconciliation for 2025 showed Staff F, CMA administered Tramadol 50 mg at bedtime to Resident #4. In an interview on 12/30/25 at 12:00 PM, Staff G, a Licensed Practical Nurse (LPN), reported that on 9/16/25, after bedtime medications were administered, Staff G assumed responsibility for Staff F's assigned medication cart and residents.

Staff G reported that at the end of their shift, during the AM narcotic count with Staff F, they discovered two tramadol tablets missing.

Staff G could not specifically recall the number of tablets.

When asked what happened next, Staff G reported that Staff F refused to sign the Drug Count Record and immediately left the building.

When asked whether they had previously encountered issues with incorrect narcotic counts involving Staff F, Staff G reported that she and Staff F were new and that Staff F no longer worked at the facility after the tramadol went missing.

When asked if she reported the missing medication, Staff G stated that she immediately contacted the Regional Nurse Consultant.

The Storage of Medications policy last revised April 2020 identified Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments.

Access to controlled medication is separate from access to non-controlled medications.

Controlled medications that are part of a single unit dose distribution system may be stored with non-controlled medications when the supply is minimal and shortages are readily detectable.

The policy failed to address directions specific to narcotic counting, destruction of narcotics or action to be taken in the case of missing medication. In an interview on 12/29/25 at 12:55 PM, the Regional Nurse Consultant reported she received notification of missing tramadol the morning of 9/17/25 and arrived at the building shortly after.

The Regional Nurse Consultant confirmed two tramadol 50 mg tablets went missing.

She reported the facility is unable to determine the cause of the missing tramadol.

The Regional Nurse Consultant reported the investigation concluded when Staff F did not come back to the facility or answer their calls.

165271 12/31/2025

Westwood Specialty Care 4201 Fieldcrest Drive Sioux City, IA 51104

medication errors for 1 of 3 resident reviewed (Resident #1).

The facility reported a census of 77

documented a diagnosis of heart failure, renal insufficiency and stroke.

The MDS showed a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment.

The Medical Diagnosis report for Resident #2 showed no diagnosis of Diabetes [NAME].

The Clinical Physician Orders for Resident #2 showed no orders of jardiance or gabapentin.

The Progress Note dated 11/3/25 at 7:30 AM for Resident #1 documented the following:Resident received wrong AM medications this AM.

Spit out most of all medications.

Received jardiance and gabapentin, but medications not ordered.

Resident verbalizes understanding of receiving wrong medications.

Denying pain and no signs of pain observed.Vitals within normal limits. No abnormal new assessment findings.

Nurse from a supporting agency called.

Nurse Practitioner explains to proceed with scheduled AM medications.

Family updated.

Administrator updated.

The Progress Note dated 11/3/25 at 5:30 PM for Resident #1 indicated a nurse from a supporting agency present in the facility when the resident's family reported concerns regarding increased drowsiness.

Upon assessment, the nurse observed new stroke-like symptoms not noted during prior evaluations.

The nurse instructed facility staff to initiate emergency response.

Emergency medical services contacted. In an Interview on 12/17/25 at 1:04 PM, Staff H, Licensed Practical Nurse (LPN) reported on the morning of 11/3/25 Resident #1 received another resident's medications.

Staff H reported because of swallowing issues Resident #1 spat out most of the other resident's medications.

Staff H indicated after identifying the individual medications spat out the resident ingested two or three medications.

Staff H failed to recall the specific names of the medications swallowed, however identified one of the pills as diabetic medication.

When asked whether she reported the specific names of the medications swallowed to the provider during notification, the Staff H reported that she did.

When asked what orders were given, Staff H stated that the provider instructed her to monitor the resident and administer her scheduled medications.

When asked whether she received specific monitoring parameters, Staff H stated that she did not.

When asked if she received orders to check blood glucose levels, Staff H stated no.

Staff H added, Looking back, I know I should have checked them, but I didn't. I checked on her several times. I thought the half life of jardiance was long acting.

When asked whether she assessed vital signs, Staff H stated that she completed vital signs and cognitive checks.

When asked if she documented the assessments, Staff H stated that she did not recall and acknowledged that she did not document all assessments.

Staff H reported emergency medical services (EMS) transferred the resident to the emergency room.

The Fire Rescue report dated 11/3/25 indicated upon arrival Resident #1 opened eyes in response to pain, not alert or orientated. EMS found Resident #1 very diaphoretic and hot.

The report noted Resident #1 received the wrong medication of gabapentin and jardiance at 6:45 AM along with regularly scheduled tramadol.

The report also noted a blood glucose level of 64 milligram per deciliter. Resident #1 transferred to the emergency room via ambulance.

The Administering Medication policy last April 2019 identified:9.

The individual administering medications verifies the resident's identity before giving the resident his/her medications.

Methods of identifying the resident include:a.

Checking identification band;b.

Checking photograph attached to medical record; andc. If necessary, verifying resident identification with other facility personnel.10.

The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. In an interview on 12/29/25 at 12:55 PM, the Regional Nurse Consultant reported staff should follow policy when administering medications.

When asked if she would have expected staff to respond differently when Resident #1 received the jardiance and gabapentin, the Regional Nurse Consultant reported the staff notified the provider and followed physician orders.

165271 12/31/2025

Westwood Specialty Care 4201 Fieldcrest Drive Sioux City, IA 51104

records, the Regional Nurse Consultant stated something should have been documented.

165271 12/31/2025

Westwood Specialty Care 4201 Fieldcrest Drive Sioux City, IA 51104

Observation on 12/23/24 at 9:11 a.m., revealed Staff A, LPN preparing medications for Resident #4.

The nurse pushed pantoprazole (medication to decrease stomach acid) out of the pill card and the medication dropped onto the top of the medication cart.

Staff A without performing hand hygiene applied a glove, picked up the medication and placed it into the medication cup with the other medication.

Staff A removed the glove and performed hand hygiene and administered the medications to Resident #4. 3.

Observation on 12/23/25 at 9:27 a.m., of Staff B, Registered Nurse (RN) preparing Resident #1's medication.

Staff B took out a pill cutter out of the medication cart to cut the Guaifenesin tablet (medication to relieve chest congestion) tablet.

The pill cutter was observed to have a white power substance on the top and bottom of the pill cutter.

Staff B did not clean the pill cutter and poured the tablet out of the bottle onto the pill cutter and without doing hand hygiene applied gloves.

Staff B with a gloved hand placed the tablet in the correct spot to cut the tablet.

Staff B cut the tablet and placed half into the medication cup and the other half into the sharps container, removed her glove and did not perform hand hygiene.

Staff B placed the pill cutter back into the medication cart and finished preparing the medications.

Staff B administered Resident #1's medications and returned to the medication cart and proceeded to the next resident. 4.

Observation on 12/23/25 at 9:40 a.m., with Staff B, RN with Resident #7's medication pass.

Staff B brought in residents Fluticasone-Salmeterol (an inhaler to reduce lung inflammation) inhaler into his room and laid it directly on the bedside table with no barrier.

Staff administered medications and inhaler and when completed exited the room with the inhaler and without wiping down the inhaler placed the inhaler back into the box and placed into the medication cart.

Review of facility provided policy titled Administering Medications with a revised date of April 2019 revealed staff follows established facility infection control procedures for the administration of medications as applicable.

Review of the facility provided policy titled Handwashing and Hand Hygiene revised August 2019 revealed the use of an alcohol-based hand rub or soap and water for the following before and after handling medications and before applying gloves and after removing gloves.

Interview on 12/23/25 at 10:10 a.m., with the Regional Nurse Consultant revealed staff should be following infection control measures at all times.