Careage Hills Rehabilitation and Healthcare

Inspectors wroteBased on observations, staff interviews, and facility policy reviews the facility failed to ensure food was prepared under sanitary conditions. The facility identified a census of 38 residents. Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was prepared under sanitary conditions. The facility identified a census of 38 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital and a discharge to home for 2 of 3 residents (Resident #38 and Resident #43) reviewed. The facility reported a census of 38 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #7) reviewed for PASRR requirements. The facility reported a census of 38 residents.

Inspectors wroteBased on clinical record review, facility record review and staff interviews the facility failed to document blood sugars and insulin on the medication administration record (MAR) for 1 out of 1 residents reviewed (Resident #4). The facility reported a census of 38 residents.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to ensure a safe transfer using a mechanical lift for 1 of 2 residents (Resident #11) according to facility policy and manufacturer guidelines. The facility reported a census of 38 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and per the current Centers for Disease Control and Prevention (CDC) guidelines the facility failed to use Enhanced Barrier Precautions (EBP) to prevent the spread of multidrug-resistant organisms (MDROs) and failed to provide proper hand hygiene after catheter care for 1 out 1 resident reviewed (Resident #2). The facility reported a census of 38 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision to prevent injuries with transfers using a mechanical lift for 1 of 3 residents reviewed (Residents #1). The facility reported a total census of 33 residents.

Inspectors wroteBased on observations, resident and staff interviews and facility policy the facility failed to provide an adaptive call light for Resident #4 to call for assistance. The facility reported a census of 33 residents. Observation on 12/3/25 at 3:22 p.m., of Resident #4 transferring from her bed to her wheelchair with a mechanical lift. During the transfer Resident #4 revealed she did not have a call light she was able to operate. Resident #4 verbalized she had a button call light but was unable to operate that due to her multiple sclerosis. Resident #4 revealed the facility had given her a pad call light but sometime last week that broke. Resident #4 explained the facility came and took the call light pad and was going to fix the call light and it has not come back. Observation in the room revealed there was no call light or way for Resident #4 to call for assistance in the room. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews and policy review, the facility failed to complete a wound treatment for 1 of 3 residents reviewed (Resident #1) and failed to complete an assessment for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 34 residents.

Inspectors wroteBased on observation and staff interview the facility failed to prepare food in accordance with professional standards for food service safety for 1 meal. The facility reported a census of 35 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to obtain bed hold notifications for 1 of 1 resident reviewed (Resident #6). The facility reported a census of 35.

Inspectors wroteBased on clinical record review, staff interviews, and the facility policy, the facility failed to follow the facility policy regarding significant weight loss in 1 out of 1 residents reviewed for nutrition needs (Resident #33). The facility reported a census of 35 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents were free from abuse for 1 of 4 residents. Resident #1 fell to the floor and sustained a hematoma on the back of his head after another resident pushed him down. The facility reported a census of 33 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to thoroughly investigate alleged abuse for 1 of 3 residents, and failed to investigate an injury of unknown origin for 1 of 1 resident reviewed. The facility reported a census of 33 residents

Inspectors wroteBased on observations, interviews, record and policy review the facility failed to ensure that residents were properly supervised, and interventions were utilized to prevent accidents for 5 of 5 residents reviewed, (Residents #1, #2, #3, #4 and #5), . Staff failed to use safe transfer practices for Residents #1, and #5. Resident #3 slid off of the [NAME] pool seat, and Resident #4 sustained a broken toe when a staff's dog tripped her. Staff failed to follow care plan interventions established to prevent further falls for Resident #2. The facility reported a census of 38 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to follow interventions established in the care plan to prevent falls for 1 of 5 residents reviewed. Resident #2 had a history of falls and observations revealed that staff failed to implement two of those interventions. The facility reported a census of 38 residents

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to provide proper transfer techniques while transferring a resident to prevent accidents for 1 of 3 residents (Resident #21) reviewed. The facility reported a census of 30 residents.

Inspectors wroteBased on resident and staff interviews and policy review the facility failed to have ready and reasonable access to personal funds upon request for 2 of 12 residents reviewed (Resident #25 and #30). The facility reported a census of 30. Findings Included: In an interview on 3/25/24 at 1:32 PM, Resident #30 stated, We can't get money when we want it because the person isn't here. We can plan for the weekend and they will leave money but only if we make plans. In an interview on 3/25/24 at 1:59 PM, Resident #25 stated, I haven't asked for money because that staff isn't here on the weekend. If I need money I would have to call my son. In an interview on 3/26/24 at 1:13 PM, the Operations Manager (OM) reported personal funds were available to residents after business hours and weekends by making predetermined arrangements with the social worker. [...]

Inspectors wroteBased on personnel file reviews, staff interviews, and policy reviews the facility failed to complete the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information prior to employment for 2 of 5 employees reviewed (Staff E and Staff F). The facility census was 30.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to obtain bed hold notifications for 1 of 3 residents (Residents #21) reviewed. The facility reported a census of 30.