F 0582 On 5/19/25 at 2:22 PM, the Administrator reported it was an expectation for the SNF ABN Form CMS 105 to be completed when a resident was discharged from Medicare Part A and remained in the facility. Level of Harm - Minimal harm or potential for actual harm The facility policy titled Medicare Advanced Beneficiary Notice dated April 221 documented it was the facility policy to inform residents in advance when changes will occur to their bills. The policy directed that if the Residents Affected - Few admission coordinator or business office manager believed that Medicare would not pay for an otherwise covered skilled service, the resident or representative would be notified in writing why the service may not be covered and the resident's potential liability for payment of the non covered service. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage CMS 105 to the resident prior to providing care that Medicare usually covers, but may not pay for because the care was considered not medically reasonable and necessary, or custodial. The resident or representative may choose to continue receiving the skilled services that may not be covered, and assume financial responsibility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 22 165270 Department of Health & Human Services Printed: 08/26/2025 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 165270 B. Wing 05/21/2025

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

Stratford Specialty Care 1200 Highway 175 East Stratford, IA 50249

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 0684 On 5/20/25 at 9:57 PM, Staff C, RN (Registered Nurse) reported on the evening of 5/15/25, she was down

the center hall passing medications. She said Staff A, CNA approached her and told her that Resident #13 Level of Harm - Minimal harm or had taken herself to the BR, had a BM and Staff A had cleaned her up on the toilet. Staff C said Staff A told potential for actual harm her that she had gone to check the room number and call for assistance. She said in the meantime Resident #13 decided to self-transfer from the toilet to the wheelchair and Staff A saw that Resident #13 was not going Residents Affected - Few to make it so she assisted Resident #13 by lowering her to the floor to prevent a fall. Staff C reported she was in the middle of passing medication along with giving insulin and she did not want to make a medication error so she finished up with that resident before going to Resident #13's room. She acknowledged and reported that there was a delay in response. She said she made the decision based on the facts that she knew Resident #13 was lowered to the floor, did not actually fall and had not hit her head. She reported when she completed the medications for the one resident, she secured her lap top and med cart and went to Resident #13's room. She said by then there was a 2nd staff member present (Staff B) and the staff had gotten Resident #13 up off the floor and into the wheelchair. She verified Resident #13 had not been assessed before she was moved off the floor. When asked how much time had passed from when she was first told Resident #13 was on the floor by the time she got to the room, she said she did not feel like it was longer than 10 minutes. She said she assessed Resident #13 which included her vital signs and range of motion. She reported she had been notified Resident #13 had an injury on her back. She said she did not look at her lower back at that time. She said she was going to go back when Resident #13 was in bed to look at her back and she did not. She stated she had forgotten and got busy. She said the next day the day shift nurse evaluated Resident #13's back.

On 5/21/25 at 11:15 AM, the DON reported she would expect the nurse to complete a nursing assessment

before the resident was assisted off the floor. In addition, the DON reported she would expect the nurse to assess Resident #13 back after the fall. The DON said she had identified Resident #13 did not have an assessment completed of her back until the following day. She acknowledged when a staff member lowers a resident to the floor that it was still considered fall and the staff would complete the required fall documentation. The DON reported she was aware and acknowledged there had been a delay in the nurse assessing Resident #13 after a fall. She said she expected the nurse to stop the medication pass and assess

the resident after the fall. She said she was in the process of completing a write up for the nurse and would provide the surveyor with a copy.

A facility form titled Corrective Action Form dated 5/21/25 documented Resident #13 had a witnessed fall on 5/15/25 in which she was lowered to the floor by Staff A. The form documented that it was reported Staff C did not respond to the fall to complete an assessment timely on 5/20/25 to the DON. The form documented Resident #13 was found to have an abrasion to her spine on 5/16/25 by the day shift nurse. The form revealed the corrective action documented, it was an expectation that Staff C do a full head to toe assessment including skin checks and vital on any resident that has a fall prior to the resident being moved from the position they are in. In addition, if Staff C was completing the medication pass, it was an expectation that Staff C stop what she was doing and attend to the resident.

The facility policy titled Change of Condition/Hot Chart Protocol dated January 2015 documented the purpose of the policy was to provide care to residents through nursing assessment, interventions and appropriate follow up. The policy documented a change in condition was an alteration from normal status with could include but not limited to an accident, incidents with or without injury, and skin changes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 22 165270 Department of Health & Human Services Printed: 08/26/2025 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 165270 B. Wing 05/21/2025

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

Stratford Specialty Care 1200 Highway 175 East Stratford, IA 50249

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 0689 The Incident Report dated 8/26/24 at 4:34 PM indicated a peer reported to the nursing staff Resident #14 fell

on the floor. The nursing staff proceeded to check rooms and found Resident #14 lying on the floor on his left Level of Harm - Minimal harm or side. Resident #14 stated as he came back from the bathroom and attempted to go from the wheelchair to potential for actual harm bed, he got dizzy and fell down. He added he bumped his head on the side of the bed. Two staff assisted Resident #14 to a standing position with a gait belt. Residents Affected - Few

The Care Plan with an initiated date of 4/4/17 lacked an intervention for the fall on 8/26/24.

On 5/20/25 at 2:15 PM the Director of Nursing (DON) stated that she didn't work at the facility during that time, but acknowledged she couldn't find an intervention for the fall on 8/26/24. The DON stated she expected an intervention put in place at the time of the fall.

The policy named QA & A Falls Protocol dated January 2015 instructed the facility would investigate all falls to identify possible causative factors and interventions for prevention. The medical record would reflect the occurrence, findings, action taken, and outcome as appropriate. The charge nurse is responsible for the following interventions at the time of the fall. The nurse must immediately evaluate the resident for injury, complete head-to-toe assessment with vital signs, neurological checks, and orthostatic blood pressures. The charge nurse should provide emergency first aid, document in the clinical record, notify the physician, and

the family. In addition, the charge nurse should complete the incident form, when they have completed all areas, place the form in the DON's mailbox. The DON had the responsibility for conducting further investigation and reviewing data, including interviews with staff or others knowledgeable about the event.

The DON would review the information to determine if major injury occurred and if they needed to file a self-report. The Care Plan will be reviewed and revised with recommended actions, then communicated to direct care staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 22 165270 Department of Health & Human Services Printed: 08/26/2025 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 165270 B. Wing 05/21/2025

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

Stratford Specialty Care 1200 Highway 175 East Stratford, IA 50249

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 The policy titled Medication Administration through a Feeding Tube dated December 2011

Level of Harm - Minimal harm or - Crush all tablets. Mix powder with 15 30 ML of water depending on tube diameter potential for actual harm - Verify tube placement Residents Affected - Few - Check for gastric residual

- Flush tube with 15 30 ML of water before administering medications

- Administer each medication separately and flush the feeding tube with 5-10 ML of water between the administration of each medication.

- Flush the feeding tube with at least 15 30 ML of water after the completion of the medication administration

On 5/20/25 at 12:45 PM, the DON reported she expected staff to follow the facility policy regarding checking placement, residuals, and water flushes with medication administration. The Corporate Nurse reported all homes in the Corporation she went to used the same policies. The Corporate Nurse reported checking placement/residual was not a requirement anymore. The DON reported when Resident #35 first admitted the Physician said they didn't require residual checks but she didn't have documentation to prove that.

On 5/20/25 at 2:58 PM, the DON reported the staff received verbal education regarding feeding tubes when Resident #35 first came to the facility but she didn't think she documented anything. When asked if the nurses had access to the feeding tube policies, the DON reported they used to have a folder at the nurses' station with the policies but the staff couldn't find it yesterday when they looked for it. When asked if the medication cart had policies for the nurses to follow, she said no.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 22 165270 Department of Health & Human Services Printed: 08/26/2025 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 165270 B. Wing 05/21/2025

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

Stratford Specialty Care 1200 Highway 175 East Stratford, IA 50249

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46875 potential for actual harm Based on observations, record review, staff interviews, resident interview and policy review, the facility failed Residents Affected - Few to change nebulizer tubing for 1 of 1 resident reviewed (Resident #33) for respiratory services. The facility reported a census of 36 residents.

Findings Include:

The Minimum Data Set (MDS) assessment for Resident #33 dated 4/3/25 identified a Brief Interview for Mental Status (BIMS) score of 00, which indicated severely impaired cognition. The MDS included diagnoses of hypertension, cerebrovascular accident (CVA), aphasia (difficulty speaking) and dysphagia (difficulty swallowing). The MDS documented Resident #33 used a feeding tube while a resident in the last 7 days.

On 5/18/25 at 9:24 AM, observed Resident #33's nebulizer machine sitting on the bed side table with the tubing connected to the machine and mask/chamber sitting behind the machine on the table. The nebulizer mask/chamber was marked/dated 10/14/24. The nebulizer mask was dirty with dust particles and had dried liquid spots on it.

Review of Resident #33's May 2025 Medication Administration Record (MAR) revealed there were no current orders for nebulizer treatments.

Review of the clinical record revealed Resident #33 was admitted on [DATE REDACTED] with an order to administer albuterol sulfate nebulization 3 ml (milliliters) every 4 hours as needed.

A Progress Note dated 2/28/25 documented the albuterol nebulizer solution was discontinued due to non use.

Review of the clinical record and the January 2025 MAR revealed Resident #33 had received three nebulizer treatments on 1/6, 1/10 and 1/11.

On 5/20/25 at 8AM, observed Resident #33's nebulizer machine with mask/tubing dated 10/14/24 remained at the bed side.

On 5/20/25 at 8:05 AM, the ADON went to Resident #33 ' s room with the surveyor. The ADON acknowledged the date on the nebulizer mask/chamber was dated 10/14/24 and the mask was dirty with dust particle/dried spots. The ADON threw the tubing, mask/chamber in the garbage and removed the nebulizer machine from Resident #33's room. The ADON reported she would sanitize the machine. She said

she thought the machine was being rented. The ADON reported the expectation was to change the nebulizer tubing and masks weekly on Sunday and document either on the MAR or TAR.

A facility policy titled Inhalation Treatment with Machine dated January 2015 documented to replace the tubing apparatus weekly. In addition, the policy documented nightly cleaning consisted of cleaning the equipment per manufacturer's instructions, label, date and bag after cleaning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 22 165270 Department of Health & Human Services Printed: 08/26/2025 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 165270 B. Wing 05/21/2025

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

Stratford Specialty Care 1200 Highway 175 East Stratford, IA 50249

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 0725 On 5/20/25 at 3:45 PM, Staff B, CNA, reported being mentally and physically exhausted due to the lack of staff on the evening shift. She reported the facility had a lot of times with only 2 aides between 2:00 PM - Level of Harm - Minimal harm or 4:00 PM and after supper in the main area. She said she tried to get baths done from 2:00 PM - 4:00 PM but potential for actual harm that it was very difficult at times. She reported having the memory care unit open made staffing more difficult.

She said it could get stressful at bed time as they had a lot of call lights on and residents wanting to go to Residents Affected - Some bed. She said some of the residents exhibited behaviors and yelled at her. Staff B described the shift as overwhelming and overstimulating because of everything going on. She reported she talked to the DON about the staffing and the DON responded all shifts hurt for help. She said the facility hired staff but some of them don't stay and then others are not reliable. She reported she thought the facility's location made it difficult to find staff. She said on weekends it could be worse when the management staff are not there. She said the staff are more likely to call in on the weekends because they can get away with it. She said it is left up to the nurses to find replacements when the facility had call ins and at times the nurse can't find replacements. She said some staff will come in an hour early.

On 5/20/25 at 9:57 PM, Staff C, RN (Registered Nurse),, reported usually on the evening shift there are 2.5 CNAs in the main area and once in a while if they are lucky they will have 3 CNAs. She reported staffing was challenging at times. She reported sometimes it can be hard to get to the call lights in a timely manner. She said she tried to respond and help as much as possible but if the resident required the assistance of 2 people

she couldn't do it by herself. When asked if any residents had complaints regarding long call lights, she said, I'm sure we do.

On 5/21/25 at 11:15 AM, the DON reported they expected the staff to answer call lights within 15 minutes per

the policy. She reported when the facility had a call-in during business hours, the ADON and herself help find replacements. She said on the schedules they have a designated staff member scheduled stay over 4 hours if the facility had a call in on the next shift. The DON gave an example: if they have a call in on the 2 - 10 shift, a designated day shift aide would have to stay over until 6 PM. She reported staff members who call in are to try to find their own replacement but it didn't always happen. When asked about after hours or on the weekend, she said the nurses are to attempt to try to find replacements and if they're not able, then they must notify the on call nurse. When asked about the expectation of the on-call nurse, she said it depended

on the staffing situation at the time. She said if the facility had 2 or less CNAs, then they expect the on call nurse to come in. She reported 1 nurse and 2 CNAs in the main area was not ideal but manageable. She said she has worked the shift herself and it was doable. When asked about getting baths done with 2 CNAs,

she said they usually only have 4 - 5 baths scheduled. She said if they have a call in on the evening shift then the day shift would try to help out to get the baths done. She said her ideal staffing pattern is 3 CNAs in

the main area with 1 CNA in the unit on the day and evening shift. For the overnight shift, 2 CNAs in the main area and 1 CNA in the unit.

The facility policy titled Answering the Call Light revised March 2021 documented the purpose of the policy as to ensure timely responses to the resident's requests and needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 22 165270 Department of Health & Human Services Printed: 08/26/2025 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 165270 B. Wing 05/21/2025

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

Stratford Specialty Care 1200 Highway 175 East Stratford, IA 50249

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 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 49056 potential for actual harm Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facility's past Residents Affected - Many surveys, and staff interview, the facility failed to correct their own deficiencies for 1 of concern. The facility reported a census of 36 residents.

Findings include:

The Quality Assurance and Performance Improvement (QAPI) Program revised March 2020 is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the Administrator and governing body. The Administrator, whether a member of the QAPI Committee or not, is ultimately responsible for the QAPI program and for interpreting its results and findings to the governing body. The governing body is responsible for ensuring that the QAPI program is implemented and maintained to address identified priorities; is sustained through transitions of leadership and staffing; is adequately resourced and funded, including the provision of money, time, equipment, training and staff coverage sufficient to conduct

the activities of the program; is based on data, resident and staff input and other information that measures performance and focuses on problems and opportunities that reflect processes, functions and services provided to the residents

The facility had the following concerns identified at the current survey, previously cited at surveys in the past year:

a. Sufficient Nursing Staff

On 5/21/25 at 1:22 PM the Administrator reported they did interviews with the residents. The Administrator stated that we all have community connections and the residents didn't tell the staff their concerns with the call lights. The Administrator explained the residents tell the surveyors their concerns. Even if they had one time six months ago the staff didn't get to their call light soon enough, some residents didn't forget. The Administrator verbalized the one thing that residents don't bring up anymore is call lights. The Administrator stated regarding staff, she felt they would never say they had enough help. The more you have, didn't necessarily mean the work got done faster or more efficiently, and the staff have proved that. The Administrator stated she did call light audits within the last year. The Administrator stated any deficiency they received for staffing, resulted because of resident's interviews and not observation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 22 165270 Department of Health & Human Services Printed: 08/26/2025 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 165270 B. Wing 05/21/2025

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

Stratford Specialty Care 1200 Highway 175 East Stratford, IA 50249

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 0880 - Contact with patient's intact skin

Level of Harm - Minimal harm or - Contact with environmental surfaces in the immediate vicinity of patients potential for actual harm - After glove removal. Residents Affected - Few

A facility policy titled Gloves dated April 2018 instructed handwashing as necessary even if using gloves were used.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 165270