Stacyville Community Nursing Home

F-F727 regarding sufficient nursing staff.

The facility's submitted Plan of Correction listed a correction date as 8/16/24. The plan indicated the facility failed to schedule a Registered Nurse for at least 8 consecutive hours a day for 10 days out of 90. The facility reviewed the RN coverage for the rest of the schedule with the Staffing Coordinator for lack of RN coverage. The Administrator created advertisements, with the local newspaper, flyers in local businesses, posted to social media, and raised the starting wage for an RN. The facility requested RN coverage through staffing agency until the RN/ADON could start employment. The monitoring section indicated the Administrator, DON, or Staffing Coordinator would monitor the daily schedule to ensure the facility had 8 hours of RN coverage. After 8/16/24 the facility would use an audit tool weekly for 8 weeks. The DON applied for an RN waiver as of 8/14/24.

The QA / Quality Assurance Performance Improvement (QAPI) meeting minutes dated 8/16/24 listed the facility census as 30 residents with 51 staff. The staffing section reflected the facility had 51 staff and they had flyers hung up to recruit.

The August 2024 Quality Improvement Plan of Action forms lacked a plan regarding nursing staff.

The QA / QAPI meeting minutes dated 9/9/24 indicated the facility's census as 31 residents with 55 staff.

The section labeled Old Business reflected a review of the previous deficiencies progress. The documentation lacked documentation related to the nursing staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 165438 Department of Health & Human Services Printed: 09/09/2025 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 165438 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Stacyville Community Nursing Home 413 South Broad Street Stacyville, IA 50476

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 25854 potential for actual harm Based on observation, clinical record review, staff interview and equipment invoices, the facility failed to Residents Affected - Some maintain patient care equipment in safe operating condition. The facility identified a census of 28 residents.

Findings include:

1. Resident #2's clinical record reflected he had a code status (what to do in an emergency when resident's heart rate stops) of do not resuscitate (DNR).

The Call Summary Report dated 11/14/24 included a call remark at 9:57 AM that indicated Resident #2 choked on peanut butter and the suction didn't work.

The Health Status Note dated 11/14/24 at 10:00 AM reflected the writer got a call to go to the living room stat (immediately). When they arrived the found Resident #2 blue and purple with his eyes rolled back into his as

he tried to gasp for air. When the Heimlich didn't work, the writer tried to suction his throat, sweeping it clean with their pointer finger. Staff D, assisted after her morning meeting with trying to get the suction machine to work. Then, Staff F, Maintenance, worked on the suction machine to find why it wouldn't work.

The Health Status Note dated 11/14/24 at 10:53 AM indicated the staff observed Resident #2 in the communal area (living room) eating peanut butter crackers, when he started to choke. The staff performed finger sweeps and attempted to suction in order to dislodge the peanut butter crackers without success.

On 1/17/25 at 4:00 PM Staff D reported the suction machine didn't function when a resident choked, but the staff responded appropriately.

2. An undated typed statement written by Staff D, Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON), they indicated Resident #1 was drowning in her aspirations (inhaled secretions into the lungs) and the suction machine didn't work properly. When the nurse consultant investigated the suction machine, she determined the machine had the wrong canister used and it couldn't create a suction. The staff received education and the facility corrected the issue.

According to an invoice from the facility's equipment provider dated 11/14/24 the facility purchased new plastic suction canisters for their suction machine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 165438