Embassy Rehab and Care Center

Inspectors wroteBased on observations, staff interviews, and policies reviewed the facility failed to store, prepare, serve, and distribute food in accordance with professional standards. The facility failed to provide hygiene practices during food preparation, prevent cross contamination during meal service, complete temperature logs for resident snack refrigerator, and serve food at the appropriate temperatures. The facility reported a census of 42 residents.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to maintain an effective infection prevention and control program and provide specific policies related to all employees' hand hygiene during meal service (Resident #5, #24 and #25). The facility reported a census of 42 residents.indings include:1. Observations on 5/19/26 at 12:24 PM showed that Staff F, Dietary Aide, wore the same pair of gloves during the entire dining room service. Staff F picked up food plates and cups from resident tables and placed the dishware into the dirty dish room. Staff F then immediately returned to the dining room and failed to remove the soiled gloves or perform hand hygiene. During the observation, Staff F touched the residents' cups before asking if they were finished. Staff F also retrieved condiments for the residents while still wearing the same gloves.2. [...]

Inspectors wroteBased on observations, facility policy review and staff interview the facility failed to provide dignity with speaking to residents in the dining room and provide privacy during resident treatments. The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to address dementia care for 1 out of 4 residents reviewed (Resident #5). The facility reported a census of 43 residents.

Inspectors wroteBased on record review, staff interviews and facility provided policy the facility failed to maintain accurate and verified documentation of task completion. Specifically, staff signed off on assigned duties as complete without actually performing the work or communicating with assigned personnel to confirm completion. The facility reported a census of 42 residents.

Inspectors wroteBased on clinical records, facility policy and staff interviews the facility failed to provide a safe environment free from physical abuse for 1 of 3 (Resident #1) residents. The facility reported a census of 45 residents. Findings Include:1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of neurogenic bladder, anxiety disorder and dementia with other behavioral disturbances. The MDS showed the Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. The Progress Note dated 7/5/25 at 6:45 AM for Resident #1 showed Staff C, Registered Nurse (RN) documented the following: At about 3:45 AM one of the night CNA's notified me that she met another CNA yelling, restraining and hitting a resident inappropriately in his room during rounds. [...]

Inspectors wroteBased on observations, staff interviews and policy review the facility failed to provide a clean homelike environment free from offensive odors. The facility reported a census of 45.

Inspectors wroteBased on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility. The bed hold notice also failed to notify the amount per day the resident or representative agreed to pay for 2 of 4 residents reviewed (Residents #13, # 21 and #40). The facility failed to notifiy the Long Term Care Ombudsman of discharge from facility for 1 of 4 residents reviewed (Resident #46). The facility reported a census of 45 residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to post accurate nurse staffing data in a prominent location and visible to residents and visitors. The facility reported a census of 45 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area. The facility identified a census of 45 residents.

Inspectors wroteBased on clinical record review, facility record review, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 1 out of 12 residents (Resident #34) reviewed from physical abuse. The facility reported a census of 45 residents. The deficiency cited at F600 is considered past non-compliance. The Workplace Violence, HIPAA, Abuse Recap facility education and sign-in sheets dated 4/2/25 showed the facility performed education regarding abuse. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 documented diagnoses of dementia, muscle weakness and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The facility Incident Report dated 3/25/25 at 8:45 AM for Resident #34 documented the following: [...]

Inspectors wroteBased on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 2 out of 5 sampled residents reviewed (Resident #13 and #38). The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 1 residents reviewed for abuse (Resident #34). The facility reported a census of 45 residents.

Inspectors wroteBased on observation, record and chart review the facility failed to accurately update a physician's order in the electronic chart and failed to update the resident's chart to show a diagnosis of anxiety for 1 of 12 residents reviewed (Resident #39). The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer 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 2 out of 2 residents (Resident #38 and #39) reviewed for PASRR requirements. The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to address dementia/Alzheimer's Disease care for 1 out of 12 residents reviewed (Resident #39). The facility reported a census of 45 residents.

Inspectors wroteBased on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (January 1-March 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 38 residents.

Inspectors wroteBased on observation, document review, policy review, and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs of the residents at the facility on regular diets. The facility reported a census of 38 residents.

Inspectors wroteBased on resident interview, policy review, and staff interview the facility failed to provide snacks to residents who wanted to eat at non-traditional times or outside of scheduled meal service times. The facility reported a census of 38 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling and dating open items of food. The facility reported a census of 38 residents.

Inspectors wroteBased on observation, staff and resident interview the facility failed to provide privacy during incontinence care and dressing change for 1 out of 4 residents reviewed (Resident #4). The facility reported a census of 38 residents.

Inspectors wroteBased on electronic health records review, policy review, and staff interview the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for 2 of 3 residents reviewed (Resident #8, and #10). The facility reported a census of 38 residents.

Inspectors wroteBased on electronic health record review, staff interview, and policy review the facility failed to obtain bed hold notifications for 2 of 2 residents reviewed (Residents #8 and #10). The facility reported a census of 38 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #8 had a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. Review of Resident #8 ' s electronic health records revealed Resident #8 was hospitalized [DATE], 12/25/23, 2/13/24, 4/25/24, and 6/4/24. 2. The MDS dated [DATE] documented Resident #10 had a BIMS of 15 indicating no cognitive impairment. Review of Resident #10 ' s electronic health records revealed Resident #10 was hospitalized [DATE] and 7/7/23. Review of the facility policy for bed holds revealed there was no policy. [...]

Inspectors wroteBased on observation, record review, document review, and staff interview the facility failed to provide appropriate infection prevention practices by not completing hand hygiene during resident care and failed to follow guidelines for enhanced barrier precautions for 2 out of 4 resident reviewed (Resident #4 and #39). The facility reported a census of 38 residents.

Inspectors wrote2. On 1/16/24 at 12:11 PM observed the staff pass the lunch in the dining room. The observation revealed the staff placing a fluted cup of butterscotch pudding on the plate with other food. The butterscotch touched the food ready for consumption, the staff continued to serve the meal to the residents. The Food Preparation policy revised September 2017 instructed to prepare all foods in accordance with the Food & Drug Administration (FDA) Food Code. Interview on 1/17/24 at 11:11 AM, the Administrator reported the pudding cup should not be on the dinner plate. 3. On 1/16/24 at 12:39 PM, witnessed the linen cart in the hallway with the front cover up and clean linen laying in the cart. Staff A, Housekeeping, walked up to the linen cart and pushed it down to the next room with the linen cover up exposing the clean linen. [...]

Inspectors wroteBased on record review, facility policy review, resident, and staff interviews, the facility failed to maintain the resident's dignity by not providing bathroom assistance in a timely manner to prevent incontinence for 2 out of 3 residents reviewed (Residents #1 and #3).

Inspectors wroteBased on facility record review and resident and staff interviews, the facility staff do not consistently answer call lights within a reasonable amount of time. Residents reported having to wait for staff to answer their call light for over 15 minutes for 2 of 3 resident reviewed (Residents #1 and 3#).