**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, the Centers for Medicare and Medicaid Services (CMS) Long term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) Assessment timely upon hospice election for 1 of 2 residents reviewed on hospice services (Resident #2). The facility reported a census of 45 residents. Findings include: An Electronic Healthcare Record (EHR) Progress Note dated 3/3/25 at 12:18 PM revealed a referral had been made for hospice care services. The hospice care provider scheduled an onsite visit for 3/4/25. An EHR Progress Note dated 3/3/25 at 2:00 PM documented family agreeable to hospice consultation. The EHR census detail page failed to document hospice as the primary payer for Resident #2 effective 3/4/25. An EHR Progress Note on 3/10/25 at 9:03 AM documented Resident #2 had been admitted to hospice care services. The MDS 3.0 Summary page in Resident #2 EHR revealed the facility failed to complete the SCSA MDS when hospice services had been elected within the required timeframe. A review of the hospice clinical record revealed the following: * The Hospice Election Packet signed by Resident #2's family member documented the start of service date as 3/4/25. * The hospice Interdisciplinary Group Meeting dated 3/19/25 at 1:00 PM documented a current admission status for Resident #2 admitted on [DATE]. * The physician Progress Note dated 03/17/25 at 11:57 AM documented the certification of terminal illness for hospice admission. The Progress Note had been electronically signed by the physician on 3/17/25 at 12:13 PM. During an interview on 3/26/25 at 11:09 AM with Staff A, Licensed Practical Nurse (LPN) acknowledged Resident #2 had been on hospice care services. During an interview on 03/26/25 at 11:12 AM, the MDS Coordinator, acknowledged she is responsible for completing all required MDS assessments. The MDS Coordinator revealed Resident #2 elected hospice services on 3/12/25. The MDS Coordinator revealed SCSA MDS had been in process and would be completed on 3/26/25. The MDS Coordinator revealed she follows the RAI manual when completing required assessments. During an interview on 03/26/25 11:20 AM the Director of Nursing (DON) acknowledged Resident #2 had been admitted to hospices services on 3/4/25. The DON revealed she did not know when the SCSA MDS had to be completed and would need to check with the MDS Coordinator. During an interview on 3/26/25 at 11:24 AM with the DON and MDS Coordinator, the MDS Coordinator acknowledged hospice care services had been elected on 3/4/25. The MDS Coordinator acknowledged she failed to complete the SCSA MDS within the required timeframe. The MDS Coordinator revealed the SCSA MDS should have been completed by 3/17/25. The LTC RAI 3.0 User's manual Version 1.19.1 October 2024 documented the RAI states an SCSA is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The RAI Manual specified the SCSA MDS completion date is 14 days from the determination that a significant change in resident status occurred (determination date plus 14 calendar days). The Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(2)(ii) states the facility must conduct a comprehensive assessment of a resident in accordance with the time frames specified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to revise and implement interventions on the comprehensive Care Plan to include hospice services for 1 of 2 residents reviewed on hospice services (Resident #2). The facility reported a census of 45 residents. Findings include: Resident #2 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 09 out of 15, indicating moderate cognitive impairment. The MDS documented non-traumatic brain dysfunction (damage to the brain that does not result from a blow or external force to the head, but rather from internal factors like illness, stroke, or lack of oxygen), heart failure, diabetes mellitus, and non-Alzheimer's dementia. A Hospice Election Packet signed by Resident #2's family member documented the start of service date as 3/4/25. The Care Plan initiated on 4/5/24 for Resident #2 failed to include a focus area for a terminal prognosis with election of hospice care services to include interventions directing staff on cares provided. During an interview on 3/26/2025 at 11:12 AM, the MDS Coordinator acknowledged the Care Plan should have been updated on election of hospice care services. The MDS Coordinator revealed she updates the Care Plan. During an interview on 3/26/25 at 11:20 AM, the DON revealed the MDS Coordinator is responsible for updating/revising the Care Plan.

Based on observation, record review, and staff interview the facility failed to utilize proper food handling to prevent potential cross contamination of food to prevent risk of food borne illness for 3 out of 3 meals observed. The facility reported of census 45 residents. Findings include: A review of the Diet Type Report dated 3/24/25 revealed three residents with a diet texture of pureed. During observation of preparation of pureed meals on 3/25/25 at 9:00 AM, Staff B, Dietary [NAME] placed a single glove on her left hand. Staff B removed a green lid from a clear plastic container with her left gloved hand. The container held buttered bread slices. Staff B reached into the container with her left gloved hand and removed 4 slices of buttered bread and placed the bread slices into the food processor and blended them with green beans. Staff B failed to utilize proper food handling to prevent cross contamination to prevent food borne illness. When blended, Staff B placed the blended bread slices and green beans into a steam table pan. During an interview on 3/25/25 at 9:43 AM with Staff B and Staff C, Dietary Manager, Staff C acknowledge she observed Staff B remove the green lid from the clear container containing buttered bread slices with her left gloved hand, reach in and remove 4 slices of buttered bread, placing them into the food processor. Staff C revealed Staff B should have used tongs to remove the bread from the container. Staff B acknowledged she had been instructed to use tongs when handling bread. During an interview on 3/25/25 at 5:13 PM, Staff C, Dietary Manager revealed the facility failed to have a policy for food handling and follows the current Iowa Food Code. A review of the Iowa Administrative Code website (https://www.legis.iowa.gov/law/administrativeRules/rules?agency=481&chapter=34&pubDate=03-19-2025) revealed rule 481-34.6(137D) food preparation and protection. * 34.6(1) Food protection. Foods shall be processed, stored, and distributed in a manner that protects food from contamination, including cross contamination from the environment, and allergen cross contact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family and staff interview, and document review, the facility failed to complete a Minimum Data Set (MDS) significant change assessment for a resident discharged from hospice care for 1 of 1 residents reviewed for a significant change (Resident #2). The facility reported a census of 49 residents. Findings include: The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had diagnoses including hip fracture, non-Alzheimer's dementia, and encounter for palliative care. The MDS documented a Brief Interview for Mental Status (BIMS) of 5 indicating severely impaired memory and cognition. The MDS revealed the resident required total dependence of 2 staff for bed mobility and personal hygiene and total dependence of 1 staff member with eating. The MDS further documented the resident received hospice care in the past 14 days. The quarterly MDS assessment dated [DATE] revealed Resident #2 required extensive assistance of 2 staff with bed mobility, extensive assistance of 1 staff member with personal hygiene and required set-up help only with eating. The MDS did not document the resident received hospice care in the past 14 days. Review of Progress Notes dated 4/21/22 revealed Resident #2 was on the floor and could not move her right leg without pain and had a possible fracture of the right hip. The Progress Notes further documented an order was received to transfer the resident to the hospital where the resident was noted to have a broken right hip. Review of the clinical record for Resident #2 revealed she received an order for Hospice referral 4/23/22. A Hospice form dated 5/9/22 at 9:42 PM discharged Resident #2 from Hospice documenting the patient to revoke service due to level of care (LOC) change and signed by the licensed practitioner 5/10/22. The physician orders in the Electronic Health Record (EHR) documented Hospice was discontinued 5/12/22. Review of the MDS schedule for Resident #2 documented the following: 4/21/2022- Discharge Return Anticipated 4/23/2022- Entry 4/28/2022- Significant Change 7/27/2022- Quarterly Review of The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019 stated in Chapter 2, pages 23-24, directed the following: A Significant Change in Status Assessment (SCSA) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The Assessment Reference Date (ARD) must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill. During an interview 3/15/23 at 1:11 PM the Director of Nursing (DON) acknowledged a significant change had not been completed after Resident #2 was discharged from hospice level of care. The DON further revealed the facility does not have a policy for MDS significant changes as they follow the Resident Assessment Instrument (RAI) manual.