Every finding on record at AMS Memorial-Greene

Based on clinical record review, staff interview, policy review, and CDC guidelines review the facility failed to provide COVID-19 education and vaccinations for 5 of 5 residents (residents #1, #2, #3, #4 and #5) reviewed for immunizations. Additionally, the facility failed to track the immunization status of their staff. The facility reported a census of 5 residents.Findings include: Resident #1's immunization (vaccination) record lacked documentation of the 2025-2026 COVID-19 vaccination. Resident #2's immunization record lacked documentation of the 2025-2026 COVID-19 vaccination. Resident #3's immunization record lacked documentation of the 2025-2026 COVID-19 vaccination. Resident #4's immunization record lacked documentation of the 2025-2026 COVID-19 vaccination. Resident #5's immunization record lacked documentation of the 2025-2026 COVID-19 vaccination. The current Centers for Disease Control and Prevention (CDC) guidelines recommended everyone age 6 months and older receive the 2025-2026 COVID-19 vaccination. The CDC documented this as especially important for individuals [AGE] years of age or older. On 7/16/26 at 9:05 AM Staff F, Director of Nursing (DON), confirmed the facility didn't provide informed consent, declination, or education to residents regarding the 2025-2026 COVID-19 vaccination. A review of personnel files for Staff A, Registered Nurse (RN), Staff B, Licensed Practical Nurse (LPN), Staff C, Certified Nursing Assistant (CNA), Staff D, CNA, and Staff E, Cook, showed all files lacked vaccination information. In an email written on 7/15/26 at 6:01 PM, Staff G, Administrator, confirmed the facility didn't have a system in place to track staff vaccination status.

Based on clinical clinical record review, staff interviews, and facility policy review the facility failed to complete a baseline care plan for 1 out of 5 (Resident #5) residents reviewed for baseline cares. The facility reported a census of 5. Findings include:The facility census documented Resident #5 entered the facility on 7/10/26. Resident #5's medical diagnoses documented dementia (memory loss) and depression (mood disorder). Resident #5's History and Physical (H&P) documented Resident #5 took citalopram (antidepressant medication) and trazodone (sleep aid medication). Resident #5's Brief Interview for Mental Status (BIMS) evaluation listed a score of 10, indicating moderately impaired cognition. A record review on 7/13/26 at 2:21 PM showed no care plan, and tasks contained no triggered items (instructions for providing care). A record review on 7/13/26 at 2:33 PM showed Resident #5 didn't have a completed Baseline Care Plan. Resident #5's Baseline Care Plan dated 7/14/26 at 10:11 AM showed completion and signatures on 7/14/26. On 7/16/26 at 9:54 AM Staff A, Director of Nursing (DON), acknowledged staff hadn't completed the Baseline Care Plan. Staff A reported she called the nurse to complete it. The undated Planning and Implementing Care Policy instructed to develop and implement a baseline care plan for each resident, including instructions needed to provide effective, person-centered care meeting professional standards of quality care. The facility would develop the baseline care plan within 48 hours of a resident's admission.

Based on observation and interview, the facility failed to ensure staff offered or served water to residents with or during meals for 2 of 3 meals observed. The facility reported a census of 5 residents. Findings include:On 7/13/26 at 12:10 PM 3 residents sat at the dining room table. Staff didn't offer or serve water to any of the 3 residents with or during the meal. On 7/14/26 at 11:45 AM 5 residents sat at the dining room table. Staff didn't offer or serve water to any of the 5 residents with or during the meal. On 7/15/26 at 9:17 AM Resident #2 stated during an interview Resident #2 didn't have water at meals. On 7/15/26 at 9:30 AM Staff A, Dietary Manager (DM), acknowledged staff didn't serve residents water with meals. Staff A further explained not knowing staff needed to serve water at every meal.

Based on observation, staff interview, and policy review the facility failed to change gloves between touching surfaces and food. Additionally, the staff failed to adequately wash their hands during the meal service. The facility reported a census of 5 residents. Findings include: On 7/13/26 at 11:24 AM witnessed Staff E, Cook, wearing gloves at the start of the observation when entering the kitchen. Staff E opened the oven, removed a foil packet, and opened the foil containing mechanical soft (altered texture) bread. Staff E placed the bread on a plate and held the bread in place with a gloved hand while checking the temperature of the bread. Staff E checked the temperature of the spaghetti noodles and sauce, cleaning the thermometer between items with an alcohol wipe. Staff E then opened the refrigerator, took out a prepared glass of apple juice, checked the temperature of the juice, and rinsed the thermometer under a running faucet, turning the water on and off with gloved hands. Staff E checked the temperature of the coffee and rinsed the thermometer off under running water, turning the faucet on and off with gloved hands. Staff E checked the temperature of the lettuce salad in an individual serving bowl, touching the lettuce to insert the thermometer to obtain an accurate temperature. Staff E moved the cups of apple juice and coffee from the counter near the coffee pot to the counter near the stove and placed them on a tray. Staff E carried the cups of apple juice and coffee by gripping the rims, placing her palm over the open top of the glasses. Staff E delivered the tray to a resident and served the meal. Staff E removed her gloves for the first time during the observation upon returning to the kitchen after serving the resident. After removing her gloves, Staff E washed her hands at the handwashing sink. Staff E turned off the water with wet hands before dispensing and using a paper towel. Staff E applied a new set of gloves, took a tray off the serving cart, and placed the tray on the counter. Staff E took a small plate with a peanut butter sandwich off the tray, placed the plate on the counter, removed the wrapper, picked up the sandwich to separate the precut halves, and returned the sandwich to the plate. Staff E touched a plate on the stove, decided the plate felt too hot, went to the plate rack to get another plate, placed the plate on the tray, picked up the sandwich with gloved hands, and placed the sandwich on a larger plate on the tray. Staff E opened the refrigerator, took out orange juice while holding the cup by the drinking rim, and placed the cup on the tray with the peanut butter sandwich. Staff E delivered and served the tray to a resident. Staff E removed her gloves upon entering the kitchen. Staff E washed her hands at the handwashing sink. Staff E turned off the water with wet hands before dispensing and using a paper towel. After the meal, Staff E loaded the dishwasher and attempted to run it. Staff E washed her hands at the handwashing sink. Staff E turned off the water with wet hands before dispensing and using a paper towel. While Staff A, Dietary Manager (DM), troubleshot the dishwasher, Staff E again washed her hands at the handwashing sink. Staff E turned off the water with wet hands before dispensing and using a paper towel. The undated facility policy titled Food and Nutrition instructed the appropriate use of utensils, such as gloves, tongs, deli paper, and spatulas, as essential to prevent foodborne (food-caused) illness. The policy instructed gloved hands count as a food contact surface capable of contamination or soiling. The policy instructed disposable gloves represent single-use items requiring disposal after each use, and glove use doesn't substitute for proper handwashing with soap and water. The facility policy titled Infection Prevention and Control Manual under Standard Precautions dated 2020 instructed staff to thoroughly dry hands with a disposable towel and turn off the faucet using a disposable paper towel. On 7/15/26 at 9:30 AM Staff A acknowledged staff shouldn't touch food with the same gloves used to touch nonfood surfaces.

Based on clinical record review, staff interview and policy review, the facility failed to screen, educate, and offer the pneumonia vaccine to 1 of 5 residents (Resident #4) sampled for vaccines. The facility reported a census of 5 residents.Findings include:Resident #4's Minimum Data Set (MDS) dated [DATE] documented an admission date of 7/1/26. The MDS documented Resident #4's pneumococcal vaccination didn't meet up-to-date status and staff didn't offer the immunization (vaccine). Resident #4's immunization record in the electronic health record lacked documentation of staff giving the pneumococcal vaccination. On 7/16/26 at 9:05 AM Staff A, Director of Nursing (DON), confirmed the facility didn't have informed consent (written permission), declination (refusal) of vaccine, or education provided to Resident #4. The policy titled Pneumococcal Vaccine Program dated 2020 instructed staff to screen every admission, educate the resident regarding the vaccine, and give the vaccine.

Based on nursing schedule reviews, and staff interviews, the facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. Review of nurse coverage schedules revealed 3 days in a 4 week period were without RN coverage. The facility reported a census of 22. Findings include: The Nursing Schedule 2022 dated 1/23/22 to 2/19/22 the facility did not have an RN working on 2/5/22, 2/6/22 and 2/12/22. On 2/14/22 at 12:30 PM, the Nursing Home Administrator (NHA) stated that the facility used to have a waiver for eight hour RN coverage but the facility no longer had the waiver. The NHA stated they are looking to pursue getting the waiver again. On 2/17/22 at 12:47 PM, the Director of Nurse (DON), confirmed the facility did not have eight hours of RN coverage every day since one RN retired on 2/1/22. She stated the Nursing Home Administrator (NHA) was looking at getting a waiver again as the facility used to have one. She stated the NHA lived right across the street and was a RN.

Based on facility email correspondence with families, staff interviews, and policy review the facility failed to document notification to residents. The facility also notify resident representatives and families by 5:00 PM the next calendar day following the occurrence of a single confirmed novel Coronavirus 2019 (COVID-19) staff or resident positive for 7 of 8 positive cases in January 2022. The facility reported a census of 22 residents. Findings include: The undated paper labeled Staff Positive Cases for January 2022 provided by the facility Office Manager documented eight positive cases of COVID-19 for staff for the month of January. The indicated that the following staff tested positive on the following dates: 1. Staff A 1/11/22 2. Staff B 1/17/22 3. Staff C 1/17/22 4. Staff D 1/21/22 5. Staff E 1/22/22 6. Staff F 1/23/22 7. Staff G 1/23/22 8. Staff H 1/30/22 Record review of an email provided by the facility regarding family notification of COVID-19 positives in the facility dated 1/21/22 at 9:46 AM documented notification to families all the positive cases for the month of January so far. During an interview on 2/21/22 at 2:50 PM, the Director of Nursing (DON) revealed that the facility didn't document in any resident record or on paper of resident notification for staff that tested positive for COVID-19 in January 2022. She revealed that staff talked to the residents that they could, but did not document it anywhere. The document provided by the facility of the current residents' BIMS scores for 2/17/22 documented 15 of 21 residents with moderate to severely impaired cognition. During an interview on 2/17/22 at 2:53 PM with the Office Manager commented that the facility did not notify families with every positive staff case for the month of January 2022. She revealed she thought families were informed once in the month of January. The record review of an email provided by the facility regarding family notification of COVID-19 dated 2/18/22 at 12:18 PM documented notification to families of positive staff cases at the end of January 2022 and a single positive staff case on 2/17/22. The undated facility policy titled COVID Testing and Reporting Procedures indicated the facility would inform staff members, residents, resident representatives, and/or families of those residing in the facilities by 5:00 PM the next calendar day following the occurrence of a single confirmed COVID-19 infection.

Based on employee files review, staff interviews and abuse policy review, the facility failed to complete a background check for 1 of 5 employees (Staff I) prior to hire. The facility reported a census of 22 residents. Findings include: The record review of a document titled Archived Time Card Report revealed Staff I, Certified Nurse Aide (CNA), was hired on 3/15/18. The record review of Staff I's Certified Nurse Aide active license revealed the following: Certification date: 11/22/1993 Expiration date:1/31/24 The record reviewed on 2/17/22 at 11:00 AM of Staff I's employee file lacked a background check prior to hire. On 2/17/22 at 1:33 PM the facility provided a background check they found in the basement dated 3/19/07 for Staff I. The Office Assistant revealed it was completed at Staff I's prior place of employment, she then revealed Staff I's prior place of employment was not affiliated with this facility, but did have the same Administrator at the time. On 2/17/22 at 1:34 PM, the facility provided a background check dated 2/17/22 for Staff I indicating that Staff I was ok to work. During an interview on 2/17/22 at 1:35 PM, the Office Manager revealed she did not run a background check prior to Staff I starting at the facility. The Office Manager reported she was instructed not to as the employee transferred to this facility from another one the Administrator worked at. During an interview on 2/21/22 at 4:50 PM, the Administrator declared he should of ran a background check prior to hiring Staff I and not treated it as a transfer between facilities since he owned them both. He explained that since they were different providers he should of treated Staff I as a new employee. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated July 2019 instructed the facility to complete the following: 1. The facility will conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire, in the manner prescribed under Iowa Administrative Code. 2. The facility will conduct a criminal record check and dependent adult/child abuse registry check on all current employees and other individuals engaged to provide services to resident who have criminal convictions or founded abuse determination after hire, or where the facility received credible information that an employee has had a criminal conviction or founded abuse determination subsequent to hire. See Iowa Code.

Based on record review, staff interviews, and policy review, the facility failed to develop and implement a comprehensive person-centered care plan as directed by the Resident Assessment Instrument (RAI) manual and ongoing as needed with resident changes for 2 of 12 residents reviewed (Resident #20 and #18). The facility reported a census of 22 residents. Findings include: 1. The Minimum Data Assessment (MDS) dated [DATE] for Resident #20 documented an entry date to the facility as 1/17/22. The MDS documented Resident #20 needed limited assistance of one (1) person to assist him with bed mobility, transfers, ambulation, dressing and personal hygiene. The MDS also documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #20's Electronic Health Record (EHR) on 2/21/22 documented the MDS was transmitted and accepted to the Centers of Medicare and Medicaid Services (CMS) on 1/24/22. Resident #20's Electronic Health Record (EHR) on 2/21/22 documented an overdue need for a care plan review on 1/30/22. Resident #20's current Care Plan printed on 2/21/22 revealed that the residents goals were past due for review with a target date of 1/30/22. During an interview on 2/21/22 at 5:19 PM the Director of Nursing (DON) revealed she was currently in the process of reviewing all care plans and that was something she was behind on. 2. Resident #18's MDS dated [DATE], documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status documented a score of 8, indicating moderate cognitive impairment. This resident required extensive assistance of two people for bed mobility, transfers, and personal hygiene. Resident #18's admitted was documented as 9/28/21. Resident #18's admission assessment MDS dated [DATE] documented an admitted [DATE]. The MDS section recorded the usage of an anticoagulant for seven out of seven days in the lookback period. Resident #18's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18's Care Plan, included a review of discontinued problems and interventions since his admission. The Care Plan lacked documentation of the resident using the anticoagulant. On 2/17/22 at 4:03 PM, the Director of Nursing (DON), stated she was concerned that Resident #18's [MEDICATION(S)] was not care planned. The DON stated that her expectation would be that all high risk drugs would be care planned. An undated Comprehensive Person-Centered Care Planning-Comprehensive Care Plan directed staff that a comprehensive person centered care plan was to be developed and implemented, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observations, clinical record review, facility policy review, and staff interview, the facility failed to review and revise care plans for 2 out of 12 residents reviewed (Residents #15 and #18). The facility failed to update the care plan after each episode following a fall by Resident #15 and after an antipsychotic medication was added for Resident #18. The facility reported a census of 22. Findings include: 1. Resident #15's Minimum Data Set (MDS) assessment dated [DATE], included the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS), documented a score of 15, indicating intact cognition. Resident #15 required extensive assistance of one person for transfering and toilet use. Resident #15 required limited assistance of one person for ambulation in room. A review of Resident #15's progress notes recorded falls on 7/25/21, 12/7/21, 1/29/22, 2/3/22 and 2/7/22. A review of incident reports for Resident #15 documented falls on 7/25/21, 12/7/21, 1/29/22, 2/3/22 and 2/7/22. Resident #15's Care Plan revised on 6/14/21, documented that they were at a high risk for falls related to confusion, gait (walking) balance problems, and unaware of their safety needs. The goal was Resident #15 wouldn't fall. The intervention dated 7/25/21 documented that education was provided to Resident #15 regarding safety with transfers and reminder to put his foot rest down before getting up. The Care Plan lacked additional interventions related to fall after 7/25/21. 2. Resident #18's MDS dated [DATE], documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The BIMS documented a score of 8, indicating moderate cognitive impairment. Resident #18 required an extensive assist of two people for bed mobility, transfers, and personal hygiene. Resident #18 received an antipsychotic 7 out of 7 days during the observation period. Resident #18's admitted was documented as 9/28/21. Resident #15's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18's Care Plan, included a review of discontinued problems and interventions since his admission. The discontinued problems lacked care planning for the antipsychotic medication. On 2/17/22 at 4:03 PM, the Director of Nursing (DON), stated that a fall intervention should be added to a care plan after each fall. The DON stated she noticed that on Resident #15 that interventions were not added. The DON stated she planned to do some education with the nurses, that they need to add an intervention on the care plans after falls. The DON stated she was concerned that an antipsychotic was not care planned. The DON stated that her expectation would be that high risk drugs should be care planned. An undated Care Plan Assessment policy, documented that as the resident's status changes, the facility must review and/or revise the care plan goals and treatment choices.

Based on record reviews and interviews, the facility failed to ensure that properly trained personnel certified in CPR (cardiopulmonary resuscitation) were available 24 hours per day. The review of CPR certified staff along with the review of the schedules for the nursing staff revealed that the facility went without a CPR certified staff member on 2 shifts in a 4 week period. During the review of 16 residents, 3 residents clinical records indicated the resident requested CPR at the time of the survey (Resident #13, #18, and #73). The facility reported a census of 22 residents. Findings include: The Nursing Schedule 2022 dated [DATE] to [DATE], documented that the Nursing Home Administrator (NHA), Registered Nurse (RN), worked as the nurse from 10:00 PM to 6:00 AM on [DATE] and [DATE]. The facility lacked additional staff certified in CPR working that night. The facility was unable to provide a current CPR certificate for the NHA when it was requested on [DATE]. On [DATE] at 11:15 AM, the Director of Nursing (DON), stated the NHA was now certified. The DON stated that the NHA obtained his CPR certification on [DATE], because the facility noted he didn't have a current certification. The DON stated the NHA had said he did get recertified before this date but he could not find the certificate, so he went ahead and became recertified again. An undated CPR Resuscitation Policy, directed staff that upon determination that a resident was in cardiopulmonary or respiratory arrest CPR would be immediately initiated by nursing staff. 911 would be called for advanced cardiac life support unless one of the exceptions applies: a. When the resident or the Resident's Representative indicated that resuscitation was not desired in writing and/or the attending physician has issued a written do not resuscitate (DNR) order that was maintained in the facility's clinical record; or b. When there is the presence of obviously clinical signs of irreversible deatch (defined as rigor mortis or dependent lividity); or c. There was no physiologic benefit expected because the vital functions have deteriorated despite maximal therapy for such conditions such as progressive septic shock or cariogenic shock d. When an attempt to perform CPR would place the rescuer at risk of personal injury. The facility provided an online Certificate of CPR Completion (eligible for skills session within 90 days) for the NHA, dated [DATE]. On [DATE] at 12:08 PM, the DON reported they understood that the NHA would need the skills session before he was considered fully certified.

Based on clinical record review, staff, and resident interviews, the facility failed to ensure staff provided and followed the individualized restorative programs for 2 of 3 residents reviewed (Residents #10 and #21). The facility reported a census of 22 residents. Findings include: 1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE], documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10's Brief Interview for Mental Status (BIMS) score was a 10 out of 15, indicating moderate cognitive impairment. Resident #10 required extensive assistance of two people for transfers, ambulation, and toileting. An OT Restorative Program form dated 9/30/20, directed that 3-6 times a week, Resident #10 was to have upper extremity passive range of motion (PROM) and active range of motion (AROM). A PT Restorative Program form dated 12/30/20, directed that 3-6 times a week Resident #10 was to have seated exercises, the nustep, and ambulation. A POC (Plan of Care) Response History printed on 2/17/22 for the previous 30 days, documented the task labeled Nursing Rehab/Restorative: Active ROM Program #1 Upper Extremity PROM. On 1/22/22 it was documented that resident refused. On 1/31/22 it was documented that this resident had 7 minutes of exercise. The task lacked additional documentation of completion, unavailability, not applicable, or refusals. A POC Response History printed on 2/17/22 for the previous 30 days, documented the task labeled Nursing Rehab/Restorative Active ROM program #2 Seated Exercise/Nustep. The documentation on 1/22/22 indicated that the resident refused. The documentation for this task showed 15 minutes of exercise on 1/23/22, 1/24/22, and 1/30/22. The task documented that on 1/31/22 the resident had 8 minutes of exercise. 2. Resident #21's MDS assessment dated [DATE], documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21's BIMS score was 8 out of 15, indicating moderate cognitive impairment. Resident #21 required an extensive assist of two people for bed mobility, transfers, toilet use, and personal hygiene. On 2/15/22 at 10:32 AM, Resident #10 remarked that she would like to do the bike (Nustep). Resident #10 stated that her legs bother her and don't work as good as they used to. Resident #10 explained that the lady retired on 2/6/22 so she hadn't been able to ride the bike. Resident #10 imagined the facility will be replacing the retired staff. A PT Restorative Program form dated 5/12/21, directed that 3-6 times a week Resident #21 was to have PROM of a single knee to chest, lower trunk rotation, and heel slides. An OT Restorative Program form dated 5/12/21, directed that 3-6 times a week, Resident #21 was to have upper extremity PROM or AROM. A POC Response History for the task of Nursing Rehab/Restorative: Active ROM Program #1 Bilateral Upper Extremity AROM or PROM printed on 2/17/22 for the previous 30 days, documented no data found, indicating there was no documentation that this exercise was provided. A POC Response History for the task of Nursing Rehab/Restorative: Active ROM Program #1 Bilateral Lower Extremity PROM printed on 2/17/22 for the previous 30 days, documented no data found, indicating there was no documentation that this exercise was provided. On 2/15/22 at 3:20 PM, the Director of Nursing (DON) commented that she now wore the restorative hat as well. She reported that they did have a Restorative Aide that retired a couple of weeks ago. The DON stated that on Monday 2/21/22, they have one of their Certified Nurse Aide's (CNA) lined up to take over the Restorative Aide responsibilities. The DON stated that this CNA did the restorative aide responsibilities before and that the DON didn't think it would be too hard of a transition for the CNA. The DON stated the residents have not received restorative services in the meantime while they put together their plan. On 2/15/22 at 3:33 PM, the DON provided restorative program sheets for Resident #10 and Resident #21. She stated how she would check to see if exercises were done was to go into the kardex (POC). The DON said that the old Restorative Aide did not like computers, so she did not always document on the kardex the exercises that the residents did. The DON added that she knew documentation was something that needed to be fixed. On 2/16/22 1:41 PM Staff J, Registered Nurse (RN), Restorative, stated she wasn't sure if she could say she was in charge of restorative, she just did her job. Staff J did RN coverage on weekends and then she did restorative on Mondays. Staff J explained that she would do restorative on Saturdays and Sundays too. Staff J stated that she would give everyone 15 minutes of her time, then she would document what she had done in the POC. Staff J added that most of the residents wanted to do the Nustep. Staff J stated that she retired and that her first day of retirement was 2/1/22. Staff J stated she did stay on to help as needed. Staff J explained that Resident #10 liked to do the Nustep and then do the upper body. Staff J reported that she really didn't know if any CNAs or other staff worked restorative with the residents. Staff J stated that she used to work with Resident #21 in her room. Staff J stated that Resident #21 went on Hospice care, then it became harder and harder to work with her related to Resident #21's anxieties. Staff J stated she could do general ROM with Resident #21. Staff J stated that she would start to work with Resident #21 and then Resident #21 would become emotional. Staff J explained that she just tried to give Resident #21 some tender love and care (TLC). Staff J said that Resident #21 was a religious person so sometimes Staff J would read to her as that calmed her down. Staff J explained that was how she spent her 15 minutes with Resident #21. Staff J stated no one really watched her do restorative and there were days she couldn't get to it. She declared that no one was doing a monthly progress note regarding restorative care, as they had not put the monthly progress note into play. Staff J stated that 3 or 4 years ago she got the books and she would ask who was to do it. We never got to documenting the monthly progress note. Staff J stated there was not a monthly evaluation by a nurse to see if the program was effective, if it should be continued, or if the program should be altered. Staff J would talk with therapy and let them know if she really needed something for the residents. Staff J explained that she would say that some residents had a significant decline because they did not receive a restorative program. Staff J did not name any specific residents. Staff J felt Resident #21's decline could not have been avoided and felt that Resident #10 didn't have a decline. Staff J remarked that most residents were on her caseload for restorative. An undated Rehabilitation Services Policy, documented that restorative services referred to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and as safely as possible. The concept actively focused on achieving and maintaining optimal physical, mental, and psychosocial functioning. The policy documented that a resident could start on a restorative nursing program when he or she was admitted to the facility with restorative needs but wasn't a candidate for formalized rehabilitation therapy, or when restorative needs arise during the course of a longer-term stay, or in conjunction with formalized rehabilitation therapy. The policy recorded that the restorative nursing programs generally were initiated when a resident was discharged from formalized physical, occupational, or speech rehabilitation therapy.

Based on clinical record review, pharmacy reviews, staff interviews, and policy review; the facility failed to ensure an As Needed (PRN) medication order for an anti-anxiety drug was limited to 14 day use. The facility failed to ensure a physician documented it was appropriate for the PRN order to be extended beyond the 14 days. The facility failed to a documented rationale in the resident's medical record to indicate the duration for the PRN order was required for 1 of 5 residents reviewed (Resident #1). The facility also failed to routinely monitor residents receiving anti-psychotic medications for potential adverse consequences for 2 of 5 residents reviewed (Resident #1 and #10). The facility reported a census of 22 residents. Findings include: 1. The Minimum Data Assessment (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of two (2), indicating severe cognitive decline. The MDS recorded that Resident #1 diagnoses included stroke, cancer, diabetes mellitus, and dementia. The Note to Attending Physician/Prescriber dated 2/4/21 for Resident #1 documented an order for [MEDICATION(S)], [MEDICATION(S)] (an anti-anxiety medication), one (1) milligram (MG) every 4 hours PRN with a start date of 12/17/20. The doctor signed a 6 month continuation on 2/5/21. Resident #1's Medication Administration Record (MAR) for the month of December 2020 documented a new order for: [MEDICATION(S)] 1 MG, take one (1) tablet by mouth every four (4) hours PRN started on 12/17/20. The MAR documented Resident #1 only received the medication for the first 14 days after ordered in the month of December. Resident #1's MAR for the month of January 2021 documented an order for: [MEDICATION(S)] 1 MG, take one (1) tablet by mouth every four (4) hours PRN started on 12/17/20. Resident #1 received the medication on the following dates past the 14 day start date. 1. 1/7/21 2. 1/12/21 3. 1/14/21 4. 1/18/21 5. 1/19/21 6. 1/22/21 7. 1/24/21 8. 1/26/21 During an interview on 2/21/22 at 2:35 PM the Director of Nursing (DON) revealed that she was not the DON in January 2021 and revealed the medication should of only been given for 14 days. 2. Definitions are provided to clarify terminology related to the evaluation and treatment of residents: Extrapyramidal symptoms (EPS) are neurological side effects that can occur at any time from the first few days of treatment with anti-psychotic medication to years later. EPS includes various syndromes such as: a. Akathisia, which refers to a distressing feeling of internal restlessness that may appear as constant motion, the inability to sit still, fidgeting, pacing, or rocking. b. Medication-induced Parkinsonism, which refers to a syndrome of Parkinson-like symptoms including tremors, shuffling gait, slowness of movement, expressionless face, drooling, postural unsteadiness and rigidity of muscles in the limbs, neck and trunk. c. [CONDITION(S)], which refers to an acute, painful, spastic contraction of muscle groups (commonly the neck, eyes and trunk) that often occurs soon after initiating treatment and is more common in younger individuals. Neuroleptic Malignant Syndrome (NMS) is a syndrome related to the use of medications, mainly anti-psychotics, that typically presents with a sudden onset of diffuse muscle rigidity, high fever, labile blood pressure, tremor, and notable cognitive dysfunction. It is potentially fatal if not treated immediately, including stopping the offending medications. Tardive dyskinesia refers to abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movements of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk or other parts of the body may also be affected. Resident #1's Order Recap Report for the time period of 8/26/21 to 2/28/22 revealed she received an order for [MEDICATION(S)], [MEDICATION(S)] (anti-psychotic medication), started on 7/6/21. The order was discontinued but also restarted on the same date of 8/26/21. Resident #1's MAR for the month of February 2022 documented an order for: [MEDICATION(S)] 25 milligrams, take one (1) tablet by mouth two (2) times a day starting on 8/26/21. Resident #1's Electronic Health Record (EHR) on 2/15/22 lacked initial and routine assessments for anti-psychotic medications for adverse consequences such as Extraphyramidal Symptoms (EPS), Neuroleptic Malignant Syndrome (NMS), and tardive dyskinesia. During an interview on 2/16/22 at 11:10 AM, the Director of Nursing (DON) revealed she was not aware she was to complete AIMS (Abnormal Involuntary Movement Scale) evaluations on residents. The DON added that she just got done completing her first one on Resident #1. Resident #1's EHR on 2/16/22 documented an AIMS initial assessment completed by the facility that included monitoring of adverse consequences such as Extraphyramidal Symptoms (EPS), Neuroleptic Malignant Syndrome (NMS), and tardive dyskinesia. The undated policy titled Medication Regimen Review lacked direction on assessments to be completed for the evaluation of residents when starting an anti-psychotic medication and throughout the time the resident is on the medication. 3. Resident #10's MDS dated [DATE], documented diagnoses that included non-Alzheimer's dementia, anxiety, and depression. Resident #10's BIMS score was 10 out of 15, indicating moderate cognitive impairment. Resident #10 required an assistance of 2 people for transfers, ambulation, and toilet use. The MDS documented Resident #10 used an antipsychotic for 7 out of 7 days during the observation period. Resident #10's Care Plan initiated on 3/19/20, documented that she used the [CONDITION(S)] medication [MEDICATION(S)] related to depression. Resident #10's goal was to remain free of [CONDITION(S)] drug related complications, including movement disorder, discomfort, [CONDITION(S)], gait disturbance, constipation/impaction or cognitive/behavioral impairment through the review date. The interventions directed staff to consult with pharmacy, medical provider to consider dosage reeducation when clinically appropriate at least quarterly and to monitor/document and report as needed any adverse reactions of [CONDITION(S)] medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, [CONDITION(S)], social isolation, blurred vision, diarrhea, fatigue, [CONDITION(S)], loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Resident #10's AIMS Evaluation dated 2/16/22, documented that she was admitted on [DATE]. The facility was unable to provide another AIMS assessment or any other assessment to show Resident #10 had been assessed and monitored for unwanted side effects of an antipsychotic medication. The MAR dated March 2020, documented that [MEDICATION(S)] (an anti psychotic medication) was started for Resident #10 on 3/12/20. The MAR dated February 2022, documented that [MEDICATION(S)] was administered daily. On 2/16/22 at 2:40 PM, the Director of Nursing (DON) stated they didn't do an AIMS assessment or a baseline assessment regarding antipsychotic usage. The DON provided an AIMS assessment that was done the day of the interview. The DON remarked they had not done the AIMS or baseline antipsychotic side effect assessment for this resident prior to the one done that day.

Based on resident and staff interviews and facility document review, the facility failed to ensure staff offered residents a snack at bedtime each night. The facility census was 27 residents. Findings include: During group interview on 3/3/20 at 1:00 p.m., four of four residents present reported not being offered bedtime snacks every night. Residents stated they do not get snacks after 2:30 p.m. The January 2020 Snack Flow Sheet Valley View revealed no documentation of bedtime snacks being offered to residents. The February 2020 Snack Flow Sheet Valley View had two documented entries of snacks being offered. During interview on 3/3/20 at 2:16 p.m., Staff E stated snacks were not always passed after supper and it has been a problem for a while. Staff E helped prepare the snacks and finds the snacks not passed when she comes back in the morning. During interview on 3/4/20 at 11:15 a.m., the Director of Nursing stated the snack records were not being filled out consistently.

Based on observation, facility policy review and staff interview, the facility failed to maintain a clean and sanitary kitchen and failed to serve resident food items utilizing proper hair/beard coverings. The facility census was 27 residents. Findings include: 1. During observation of the breakfast meal on 3/2/20 at 8:48 a.m., Staff C, Dietary Aide, wore a beard net. However, the net did not contain all of their beard. Staff C had approximately 3 inches of beard exposed on the sides of his face and on is neck. Staff C was standing over food in the kitchen while it was being dished. Staff C transported dished food in and out of the kitchen. 2. During observation of the noon meal on 3/2/20, at 12:14 p.m., Staff C, Dietary Aide, wore hair and beard restraints. However, the beard restrain failed to fully restrain the beard. The beard net covered Staff C's nose, covering the mustache. Staff C had approximately 3 inches on each side of the beard not covered by beard net. Approximately 2 inches of beard on Staff C's neck was not restrained in the beard net. Staff C transported food from the kitchen to tables on a cart. Staff C returned to the kitchen for each table service. 3. Observation on 3/3/20 at 12:05 p.m., revealed a thick layer of dust on a standing fan. The fan was blowing in the direction of the food preparation counter. Staff D, Cook, buttered bread at the counter. The counter was approximately 10 feet from the fan. Observation revealed a thick layer of dust on a wall mounted air conditioner. The undated Prevention of Foodborne Illness Policy stated Dietary Staff must wear hair and/or beard restraints to prevent their hair from contacting exposed food. During interview on 3/3/20 at 12:46 p.m., Staff D, Cook, stated Maintenance cleans the fan and air conditioner. Staff D stated they did not know how often it was cleaned. During interview on 3/3/20 at 2:03 p.m., the Dietary Manager acknowledged the fan and air conditioner needed cleaned. The Dietary Manager stated Maintenance cleaned them monthly but it needed done more frequently. The Dietary Manager stated hair and beard restraints should be worn by all staff in the kitchen.

Based on observation, resident and staff interviews, the facility failed to make available information on how to make a grievance and who the grievance Official was. The facility census was 27 residents. Findings include: 1. Observation throughout the survey on 3/2-4/20, revealed no posting regarding the facility designated Grievance Officer or the contact information for the Grievance Officer. During the group interview on 3/3/20 at 1:00 p.m., residents responded they were not aware of the grievance officer in the facility. During interview on 3/3/20 at 2:02 p.m., the Administrator stated resident's would come to her if they had a grievance, but acknowledged the designated grievance officer information was not posted. During record review of the Resident Handbook no grievance officer was identified in the handbook.

Based on personnel file review, facility policy review and staff interview, the facility failed to provide dependent adult abuse training for one of five employees reviewed. (Staff A) The facility census was 27 residents. Findings include: 1. The personnel file for Staff A, certified nurse aide, CNA documented a completed date of Dependent Adult Abuse training on [DATE]. During interview on [DATE] at 9:30 a.m., the Business Office Manager stated Staff A's Dependent Adult Abuse training was not current, and she was working on it right now. During interview on [DATE] at 9:45 a.m., Staff A verified she did not have a current Dependent Adult Abuse certificate. During interview on [DATE] at 11:00 a.m., the Director of Nursing stated she did not have knowledge that Staff A's Dependent Adult Abuse had expired. Review of a document titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting policy revealed each employee will take a one hour recertification training within 3 years of the initial training.

Based on observation, clinical record review and and staff interviews, the facility failed to ensure one resident had a safe transfer as planned. (Residents #16) The facility census was 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had [DIAGNOSES REDACTED]. The Care Plan dated 1/21/20, revealed the resident required assistance of one staff for transfers and a gait belt was to be used. The Care Plan indicated the resident was at high risk for falls. During observation on 3/3/20 at 7:30 a.m., Staff B transferred the resident from the recliner to the wheelchair with no gait belt used. During interview at the time, Staff B acknowledged he did not use a gait belt and should have. During interview at the time, the Director of Nursing stated staff should follow the Care plan and a gait belt should have been used.

Based on observation, clinical record review and staff interviews, the facility failed to follow proper infection control practices for one resident reviewed with a catheter. (Resident #13) The facility census was 27 residents. Findings include: 1. The Minimum Data Set Assessment ((MDS) dated [DATE], revealed Resident #13 had [DIAGNOSES REDACTED]. The Care Plan revised on 8/12/19, revealed the resident had an Indwelling Foley Catheter. The Care Plan directed staff to monitor for symptoms of urinary tract infection [MEDICAL CONDITION]. During observation on 3/3/20 at 7:50 a.m., Staff B, Certified Nurse Aide, CNA knocked and entered Resident 13's room and left to get alcohol swabs. Staff B again knocked and entered the residents room and put on gloves, but failed to wash hands. Staff B took a trash bag containing the resident's catheter supplies from the bathroom and sat it on the floor, with no barrier. Staff B removed their gloves and left the room to get a new leg bag. Staff B did not wash their hands. Staff B returned to the resident's room and put on new gloves without completing hand hygiene. Staff B removed gloves and left room to get hand sanitizer. Staff B returned and placed a bottle of hand sanitizer on resident's bedside table, put on clean gloves without completing hand hygiene. Staff B using gloved hands retracted foreskin and cleansed around catheter tubing with disposable wipes and removed gloves. Without completing hand hygiene Staff B put on new gloves, used an alcohol wipe to clean around the catheter tubing and connected leg bag to the catheter and removed gloves. During interview on 3/4/20 at 11:17 p.m., the Director of Nursing (DON) acknowledged hand hygiene should be completed before and after catheter care.

Based on observation, manufacturers recommendations and staff interview, the facility failed to ensure staff followed manufacturers guidelines for sanitizing resident equipment. (Resident #1) The facility census was 25 residents. Findings include: 1. On 3/19/19 at 9:23 a.m., Staff A, Certified Nurse Aide, CNA and Staff B, CNA assisted Resident #1 to transfer from a wheel chair to the toilet. During the transfer the resident voided a large amount of urine onto the wheel chair cushion. At 9:28 a.m., Staff A sprayed Century 256 (disinfectant) on the wheel chair cushion and immediately wiped it with a dry cloth. Observation at 9:29 a.m., revealed the chair cushion was visibly dry. At 1:30 p.m., the Director of Nursing (DON) verified Staff A had not sanitized the cushion according to manufacturers guidelines. The DON stated Staff A should have allowed the cushion to remain wet with sanitizer for three minutes. The DON stated Staff A was counseled on how to properly use the sanitizer after the observation. On 3/21/19 at 9:38 a.m., the DON stated the surface of the wheel chair cushion should have remained visibly wet for 3 minutes in order for it to have been sanitized properly. A review of the manufacturer guidelines for 256 Century Q disinfectant cleaner included a section for sanitizer. The directions for sprayer application directed to spray 6-8 inches from surface, rub with brush, cloth or sponge and let stand for 3 minutes and allow to air dry.

Based on record review and facility policy, the facility failed to develop provision in their abuse policy to address resident to resident abuse. Record review revealed staff had documented incidents of Resident #2 being sexually inappropriate with other residents. The facility abuse policy lacked any provision related to resident to resident abuse. The findings constitute an immediate jeopardy to the residents health and safety. The facility identify the census of 20 residents. Findings include: The undated facility Abuse Prevention/Identification Training policy noted all employees; families and care review volunteers would be trained and oriented regarding the facility policies and procedures regarding resident Abuse Prevention. Staff would be trained regarding all aspects of the Abuse Prevention policies and procedures within 6 months of hire. At least annually the facility would send and or review the Abuse prevention policy with families. The facility would follow the rules outlined in the Iowa Code for training for Mandatory Reporters. The Nurse's Notes for Resident #2 included the following: 8/11/2014 at 10:10 a.m. - staff notified the resident ' s family regarding the resident kissing another resident. Family asked staff to discourage the behavior if witnessed. 8/12/2014 at 11:55 a.m. - Returned to facility then noted kissing a resident of opposite sex. Redirected patient to own room. 8/17/2014 at 8:30 a.m. - Resident seen holding hands with resident of opposite sex when both walking back from break. Lasted only a few seconds then sat beside each other in recliners. No further episodes. 8/23/2015 at 10:30 a.m., documented on 8/24/2015 at 3 p.m. - Resident found having inappropriate contact/touching with resident of opposite sex, easily redirected. Family and physician notified. Resident started on [MEDICATION NAME] for depression. 1/25/2016 at 10 a.m. - Resident kept touching another resident's leg (Resident #4). Staff asked Resident to move to another recliner. After activity, Resident moved to chair next to spouse, (Resident #3). Staff witnessed Resident's hand inside of spouse's pants (Resident #3). Staff reminded Resident of inappropriate behavior and it would not be tolerated. Staff asked Resident to move to another recliner and wash hands. 1/31/2016 at 10 a.m. - CNA came to nurse and asked him/her to look at Resident #2 in the TV room. Resident #2 had his/her hands down front of spouse's pants (Resident #3) with a blanket over the top. Staff reminded Resident #2 of inappropriate behavior and asked Resident to move across room. 2/14/2016 at 9:30 a.m. - Resident #2 sat in the TV room, staff had moved other recliners away from Resident #2's chair. Staff observed resident had pulled his/her recliner next to spouse (Resident #3) and had hand in groin area underneath a blanket. When Resident observed staff walking towards him/her, Resident removed hand and leaned in opposite direction. Staff asked Resident to move to another recliner and reminded Resident that behavior was inappropriate. An incident/unusual occurrence form dated 4/2/16 documented staff noted Resident #2 had been in the day room touching another resident (Resident #4). Resident #2 had his/her hand in between the resident ' s legs (outside of clothes). The staff told the resident to stop and told the charge nurse. The nurse asked Resident #2 to go to his/her room. Resident #2 reported he/she did not remember touching another resident. The nurse asked Resident #2 not to sit by resident female residents and the resident agreed. Resident #2 stayed in his/her own room for about 15 minutes before he/she left the room and went down the living room and sat across the room from other residents. A written statement by a nursing assistant, Staff C dated 4/5/16 noted she had seen Resident #2 with his/her hand down another resident's brief, and holding another resident's hand that was not his/her spouse. Staff E, a nursing assistant documented on 4/7/16 she observed the resident hold hands with other residents and maybe a hand under a blanket. Review of the facility's Abuse Policies and Procedures revealed the facility failed to develop a policy related to Resident to Resident Abuse. The facility abated the IJ on 4/8/16 when they educated staff on protecting resident from resident to resident abuse with plans to develop a resident to resident abuse policy. The facility amended their abuse policy on 4/13/16 with provisions to address resident to resident abuse including: In the event of any evidence or cause to believe a resident had suffered any abuse, staff are to directly report to the Administrator or DON. Suspected abuse must be reported immediately and no later than two hours after the alleged incident. Upon report of any allegation or violation, the Administrator or DON will provide protection to keep residents free from harm during the investigation and thoroughly investigate the situation and report any incident deemed reportable to the Department immediately. All staff were educated on the policy with the development date of 4/2016. The facility provided documentation of an all staff meeting held on 4/27/16 and identified staff were educated on the revised abuse policy which addressed resident to resident abuse. Newly hired staff would receive abuse training upon hire. The IJ was lowered from L to F severity level with ongoing education to staff of the facility revised abuse policy.

Based on record review, interviews, and facility policy, the facility failed to protect residents from resident to resident abuse. Record review and interviews identified the facility failed to develop interventions to protect residents including Resident #3 and Resident #4 from being abused by Resident #2. Interviews revealed staff had seen Resident #2 inappropriately touching Resident #3 and Resident #4 prior to the abuse incident on 4/2/16 and staff redirected Resident #2 after the incidents occurred. Resident #2's record identified a history of inappropriately touching his/her spouse (Resident #3) in a public area with directives for staff to discourage the inappropriate behavior; and no provision in place to protect Resident #4 or other residents from abuse. The findings constitute an immediate jeopardy to the resident's health and safety. The facility identified a census of 20 residents. Findings include: 1. The undated facility Abuse Prevention/Identification Training policy noted all employees, families and care review volunteers would be trained and oriented to the facility policies and procedures regarding resident Abuse Prevention. Staff would be trained in all aspects of the Abuse Prevention policies and procedures within 6 months of hire. At least annually, the facility would send and/or review the Abuse prevention policy with families. The facility would follow the rules outlined in the Iowa Code for training for Mandatory Reporters. Review of the facility's Abuse Policies and Procedures revealed the facility failed to develop and implement a policy to prevent Resident to Resident Abuse. According to a Minimum Data Set (MDS) assessment dated [DATE], the facility staff's assessment of Resident #2 included: the resident scored 9 out of 15 on the BIMS (Brief Interview for Mental Status) which indicated moderate cognitive impairment. The resident ambulated (walked) independently. The Nurse's Notes for Resident #2 included: a. 8/11/2014 at 10:10 a.m. - staff notified the resident's family as the resident was kissing another resident. Family asked staff to discourage the behavior if witnessed. b. 8/12/2014 at 11:55 a.m. - the resident returned to facility then was noted kissing a resident of the opposite sex. Staff redirected the patient to their own room. c. 8/17/2014 at 8:30 a.m. - Resident seen holding hands with resident of opposite sex when both were walking back from break. This lasted only a few seconds, then the residents sat beside each other in recliners. No further episodes noted. d. 8/23/2015 at 10:30 a.m., documented on 8/24/2015 at 3 p.m. - Resident found having inappropriate contact/touching with resident of opposite sex, easily redirected. Family and physician notified. Resident started on [MEDICATION NAME] for depression. e. 1/25/2016 at 10 a.m. - Resident moved recliners in the TV room by themselves, then kept touching another resident's leg (Resident #4). Staff asked Resident #2 to move to another recliner. After activity, Resident moved to a chair next to their spouse, (Resident #3). Staff witnessed Resident's #2's hand inside of spouse's pants. Staff reminded Resident of inappropriate behavior and asked Resident to move to another recliner and wash his/her hands. f. 1/31/2016 at 10 a.m. - CNA came to nurse and asked him/her to look at Resident #2 in the TV room. Resident #2 had his/her hands down the front of spouse's pants with a blanket over the top. Staff reminded Resident #2 of inappropriate behavior and asked him/her to move across the room. g. 1/31/16 staff sent a facsimile report to the resident's physician that documented the resident was started on [MEDICATION NAME] 50 mg (milligrams) on 8/24/15 due to increased drinking and behaviors. The staff noted the resident would become more agitated when he/she could not have another alcoholic beverage due to a limit of three. The resident exhibited an increase of inappropriate sexual behaviors, not only with his/her spouse, but with other residents. h. 2/2/16 at 6:15 p.m. noted Resident #2 seated in the television room. The nurse attempted to help the resident find a program on television. The resident asked the nurse if there was any porn, because he/she would like to watch porn. The nurse reminded the resident it was an inappropriate statement. g. 2/14/2016 at 9:30 a.m. - Resident #2 sat in the TV room. Staff had moved other recliners away from Resident #2's chair. Staff observed resident had pulled his/her recliner next to spouse and had a hand in the spouse's groin area underneath a blanket. When Resident #2 observed staff walking towards him/her, the Resident removed his/her hand and leaned in the opposite direction. Staff asked Resident to move to another recliner and reminded Resident that behavior was inappropriate. h. 4/2/2016 at 3:30 p.m. - Resident found placing hand between clothed legs of resident of opposite sex. CNA told Resident to stop, and reported this to the nurse. The nurse asked the Resident to go to the room. When asked, Resident #2 failed to recall the incident. Staff asked Resident not to sit by residents of the opposite sex. When Resident went to the TV room, he/she did not need reminder not to sit by residents of opposite sex. At 9:45 p.m. staff documented the resident had been cooperative, had not attempted to touch another resident, but had to ask Resident #2 to move to a different recliner. The Care Plan initiated on 1/24/2014 revealed Resident #2 had an ADL (Activities of Daily Living) self care performance deficit and indicated the resident ambulated (walked) independently in room with a cane and a wheeled walker in the hallway, and dressed, ate and used the toilet independently. On 10/21/2015, the Care Plan added: Monitor for side effects of antidepressant medication, notify nursing/physician as needed. The physician ordered [MEDICATION NAME] daily, an antidepressant. On 8/12/2014 the Care Plan added, with a revision on 1/13/2016: Resident hand holding/kissing another resident in the facility; family would like behavior discouraged if witnessed. Attempting to place hand in spouse's clothing. Redirect if behaviors observed. The resident's care plan dated 3/31/16 noted on 8/12/14 the resident held hands and was kissing another resident in the facility. The family would like the behavior discouraged. The resident also attempted to place his/her hand in spouse's clothing; redirect if behaviors occur. On 4/2/16, the facility immediately separated Resident #4 from Resident # 2; and placed Resident #2 on 15 minute checks and updated his/her care plan. On 4/4/16, the resident was encouraged to stay in his/her room between meals/activities and escorted by the staff. Motion sensor placed in doorway of room to alert staff when the resident exited room. The facility abated the IJ on 4/8/16 when they educated staff on protecting residents from resident to resident abuse with plans to develop a more permanent policy. The facility amended their abuse policy on 4/13/16 to include reporting abuse provisions so facility residents will not be subject to abuse by any person, including other residents: In the event anyone in the facility identified any evidence or cause to indicate a resident suffered abuse, staff are to directly report to the Administrator or DON. Suspected abuse must be reported immediately and no later than two hours after the alleged incident. Upon report of any allegation or violation, the Administrator or DON will provide protection to keep residents free from harm during the investigation and thoroughly investigate the situation and report any incident deemed reportable to the Department immediately. All staff were educated on the policy with the development date of 4/2016. The facility provided documentation of staff training for an all staff meeting held on 4/27/16, and staff were educated on the revised abuse policy which addressed resident to resident abuse. Newly hired staff would receive abuse training upon hire. The IJ was lowered from K to E with need for ongoing monitoring resident to resident interactions including newly admitted residents.

Based on record review, interviews, and facility policy, the facility failed to implement strategies to prevent Resident #2 from abusing other Residents. Record review revealed staff had documented incidents of Resident #2 being sexually inappropriate with other Residents. The facility abuse policy failed to establish provisions for residents whose personal histories render them at risk of abusing other residents. The findings constitute an immediate jeopardy to the residents health and safety. The facility identify the census as 20 residents. Findings Include: 1. The undated facility Abuse Prevention/Identification Training policy noted all employees; families and care review volunteers would be trained and oriented regarding the facility policies and procedures regarding resident Abuse Prevention. Staff would be trained regarding all aspects of the Abuse Prevention policies and procedures within 6 months of hire. At least annually the facility would send and or review the Abuse prevention policy with families. The facility would follow the rules outlined in the Iowa Code for training for Mandatory Reporters. According to the Admission Record, Resident #2 admitted to the facility on [DATE]. According to the MDS (Minimum Data Set), dated 3/25/2016, Resident #2 had moderately impaired cognitive skills for daily decision making, transferred and ambulated without staff assistance, and had [DIAGNOSES REDACTED]. The Care Plan initiated on 1/24/2014 revealed Resident #2 had an ADL (Activities of Daily Living) self-care performance deficit and indicated the resident ambulated independent in room with a cane and a wheeled walker in the hallway. On 8/12/2014 the Care Plan added, with a revision on 1/13/2016: Resident hand holding/kissing another resident in the facility; family would like behavior discouraged if witnessed. Attempting to place hand in spouse's clothing. Redirect if behaviors observed. On 10/12/15 the Director of Social Services documented Resident #2 struggled most with recall and demonstrated indicators of [MEDICAL CONDITION], per delusions. The resident also demonstrated sexual behaviors. On 1/6/16 the Director of Social Services documented Resident #2 reported trouble concentrating. The resident demonstrated indicators of [MEDICAL CONDITION], per delusion. Resident #2 demonstrated sexual behaviors with occasional comments of a sexual nature towards staff. The Nurse's Notes for Resident #2 included the following: 8/11/2014 at 10:10 a.m. - staff notified Resident's family regarding the resident kissing another resident. Family asked staff to discourage the behavior if witnessed. 8/12/2014 at 11:55 a.m. - Returned to facility then noted kissing a resident of opposite sex. Redirected patient to own room. 8/17/2014 at 8:30 a.m. - Resident seen holding hands with resident of opposite sex when both walking back from break. Lasted only a few seconds then sat beside each other in recliners. No further episodes. 8/23/2015 at 10:30 a.m., documented on 8/24/2015 at 3 p.m. - Resident found having inappropriate contact/touching with resident of opposite sex, easily redirected. Family and physician notified. Resident started on [MEDICATION NAME] for depression. 1/25/2016 at 10 a.m. - Resident kept touching another resident's leg (Resident #4). Staff asked Resident to move to another recliner. After activity, Resident moved to chair next to spouse, (Resident #3). Staff witnessed Resident's hand inside of spouse's pants (Resident #3). Staff reminded Resident of inappropriate behavior and it would not be tolerated. Staff asked Resident to move to another recliner and wash hands. 1/31/2016 at 10 a.m. - CNA came to nurse and asked him/her to look at Resident #2 in the TV room. Resident #2 had his/her hands down front of spouse's pants (Resident #3) with a blanket over the top. Staff reminded Resident #2 of inappropriate behavior and asked Resident to move across room. 2/14/2016 at 9:30 a.m. - Resident #2 sat in the TV room, staff had moved other recliners away from Resident #2's chair. Staff observed resident had pulled his/her recliner next to spouse (Resident #3) and had hand in groin area underneath a blanket. When Resident observed staff walking towards him/her, Resident removed hand and leaned in opposite direction. Staff asked Resident to move to another recliner and reminded Resident that behavior was inappropriate. An incident/unusual occurrence form dated 4/2/16 documented staff noted Resident #2 had been in the day room touching another resident (Resident #4). Resident #2 had his/her hand in between the resident ' s legs (outside of clothes). The staff told the resident to stop and told the charge nurse. The nurse asked Resident #2 to go to his/her room. Resident #2 reported he/she did not remember touching another resident. The nurse asked Resident #2 not to sit by resident female residents and the resident agreed. Resident #2 stayed in his/her own room for about 15 minutes before he/she left the room and went down the living room and sat across the room from other residents. 2. A written statement by a nursing assistant, Staff C dated 4/5/16 noted she had seen Resident #2 with his/her hand down another resident's brief, and holding another resident's hand that was not his/her spouse. Staff E, a nursing assistant documented on 4/7/16 she observed the resident hold hands with other residents and maybe a hand under a blanket. During an interview on 4/12/2016 at 4:05 PM, Resident #2 stated had been asked if anyone spoke with him/her about touching others and responded his/her hand had been on the other resident ' s leg. Resident #2 reported it only occurred one time. When interviewed on 4/8/16 at 9:00 a.m. the resident's family members stated the resident had been inappropriately touching other residents of the opposite sex ever since admission to the facility. They reported they believe the resident knew what he/she was doing due to he/she would place a blanket over the other residents to prevent staff from seeing his/her hand. When they talk to the resident about the incidents the resident denied recalling the incidents. Review of the facility's Abuse Policies and Procedures revealed the facility failed to develop and implement a policy to prevent Resident to Resident Abuse. On 4/2/16, the facility immediately separated Resident #2 from other residents and monitored his/her whereabouts. The facility abated the IJ on 4/8/16 when they educated staff on protecting resident from resident to resident abuse with plans to complete a more permanently policy. The facility amended their abuse policy on 4/13/16 with reporting abuse provisions to address residents will not be subject to abuse by any person including other residents: In the event of any evidence or cause to believe a resident had suffered any abuse, staff are to directly report to the Administrator or DON. Suspected abuse must be reported immediately and no later than two hours after the alleged incident. Upon report of any allegation or violation, the Administrator or DON will provide protection to keep residents free from harm during the investigation and thoroughly investigate the situation and report any incident deemed reportable to the Department immediately. All staff were educated on the policy with the development date of 4/2016. The facility provided documentation of staff training for an all staff meeting held on 4/27/16, and staff were educated on the revised abuse policy which addressed resident to resident abuse. Newly hired staff would receive abuse training upon hire. The IJ was lowered from K to E severity with need for ongoing monitoring to ensure policy implementation by staff for resident to resident abuse.

Based on record review, observation, interviews, and facility policy, the facility failed to provide adequate supervision related to resident to resident abuse. Record review identified Resident #2 had a history of [REDACTED]. Staff interviews established Resident #2 had inappropriate sexual contact with other residents. Resident #2 ' s care plan did not address approaches related to his/her risk of abusing residents or monitoring him/her until [DATE]. The findings constitute an immediate jeopardy to the residents health and safety. The facility identify a census of 20 residents. Findings include: 1. According to the MDS (Minimum Data Set), dated [DATE], Resident #2 had moderately impaired cognitive skills for daily decision making, transferred and ambulated without staff assistance, and had [DIAGNOSES REDACTED]. The Care Plan initiated on [DATE] revealed Resident #2 had an ADL (Activities of Daily Living) self care performance deficit and indicated the resident ambulated independent in room with a cane and a wheeled walker in the hallway, and dressed, ate and used the toilet independently. The Care Plan revealed the resident had a psychosocial well-being potential problem related to recent admission to the facility initiated on [DATE]. The Care Plan directed staff to orient to the facility, encourage to attend activities, and provide opportunities for the resident and family to participate in cares. The resident could have mixed alcohol drinks with one ounce of alcohol, up to three times per day. The Care Plan directed Social Services to visit with the resident quarterly. On [DATE], the Care Plan added: Monitor for side effects of antidepressant medication, notify nursing/physician as needed. The physician ordered Sertraline daily, an antidepressant. On [DATE] the Care Plan added, with a revision on [DATE]: Resident hand holding/kissing another resident in the facility; family would like behavior discouraged if witnessed. Attempting to place hand in spouse's clothing. Redirect if behaviors observed. The behavior flow sheets dated February, March and April, 2016 revealed staff monitored for increased signs and symptoms of depression. The Nurse's Notes for Resident #2 included: [DATE] at 10:10 a.m. - staff notified Resident's family regarding the resident kissing another resident. Family asked staff to discourage the behavior if witnessed. [DATE] at 11:55 a.m. - Returned to facility then noted kissing a resident of opposite sex. Redirected patient to own room. [DATE] at 8:30 a.m. - Resident seen holding hands with resident of opposite sex when both walking back from break. Lasted only a few seconds then sat beside each other in recliners. No further episodes. [DATE] at 10:30 a.m., documented on [DATE] at 3 p.m. - Resident found having inappropriate contact/touching with resident of opposite sex, easily redirected. Family and physician notified. Resident started on Sertraline for depression. [DATE] at 10 a.m. - Resident moved recliners in TV room per self. Resident kept touching another resident's leg (Resident #4). Staff asked Resident to move to another recliner. After activity, Resident moved to chair next to spouse, (Resident #3). Staff witnessed Resident's hand inside of spouse's pants. Staff reminded Resident of inappropriate behavior and it would not be tolerated. Staff asked Resident to move to another recliner and wash hands. [DATE] at 10 a.m. - CNA came to nurse and asked him/her to look at Resident #2 in the TV room. Resident #2 had his/her hands down front of spouse's pants with a blanket over the top. Staff reminded Resident #2 of inappropriate behavior and asked Resident to move across room. [DATE] at 9:30 a.m. - Resident #2 sat in the TV room, staff had moved other recliners away from Resident #2's chair. Staff observed resident had pulled his/her recliner next to spouse and had hand in groin area underneath a blanket. When Resident observed staff walking towards him/her, Resident removed hand and leaned in opposite direction. Staff asked Resident to move to another recliner and reminded Resident that behavior was inappropriate. [DATE] at 3:30 p.m. - Resident caught placing hand between clothed legs of resident of opposite sex. CNA told Resident to stop and reported this to the nurse. The nurse asked Resident to go to the room. When asked, Resident #2 failed to recall the incident. Staff asked Resident not to sit by residents of opposite sex. When Resident ambulated to TV room, he/she did not need reminder not to sit by residents of opposite sex. At 9:45 p.m. staff documented the resident had been cooperative, not attempted to touch another resident, but had to ask Resident #2 to move to a different recliner. An incident/unusual occurrence form dated [DATE] documented staff noted Resident #2 had been in the day room touching another resident (Resident #4). Resident #2 had his/her hand in between the resident ' s legs (outside of clothes). The staff told the resident to stop and told the charge nurse. The nurse asked Resident #2 to go to his/her room. Resident #2 reported he/she did not remember touching another resident. The nurse asked Resident #2 not to sit by resident female residents and the resident agreed. Resident #2 stayed in his/her own room for about 15 minutes before he/she left the room and went down the living room and sat across the room from other residents. The nurse implemented 15 minute checks and told the other resident (Resident #4) to watch TV in his/her own room. Resident #2 ' s care plan contained no updates until [DATE], when the resident ' s Care Plan added: On [DATE] at 3:30 p.m. Resident #2 had hand between resident of opposite sex clothed legs (Resident #4). Staff redirected and implemented 15 minute checks. On [DATE] staff encouraged the resident to stay in room between meals and activities unless escorted by staff. Motion sensor in doorway of room to alert staff if resident exited room. The resident ' s family and physician were notified. Nurses Notes documented the following: [DATE] at 10:45 a.m. - Resident #2 needed one reminder after breakfast not to sit by resident of opposite sex in TV room. 15 minute checks continued. At 6:00 p.m., Resident needed reminders not to sit by resident of opposite sex in the TV room. [DATE] at 6:00 p.m. - Motion sensory alarm placed at resident's door to know when resident leaves room, or other resident enters. [DATE] at 3:30 p.m. - Floor mat alarm per nursing judgement by door. Requested discontinued order for motion sensor alarm. At 4:00 p.m. - Resident #2 stepped around mat and came to writer and asked what they were serving for supper. Staff took the resident to his/her room and observed the resident step around the alarm. Staff placed a second mat alarm in front of the door. At 6:30 p.m. - Staff received an order to discontinue 15 minute checks. [DATE] at 12:45 p.m. - Instituted motion alarm over Resident's room. Observation on [DATE] at 7:55 a.m. revealed Resident #2 seated in the far back small dining room. The resident sat in a regular dining room chair. Observation revealed residents of the opposite sex seated next to the resident. Observation on [DATE] at 8:45 a.m. revealed the resident seated in a chair in his/her bedroom. Observation revealed the resident's family members exited the resident's bedroom with one staff member. Observation revealed the staff member failed to turn the motion detector alarm on. The staff member left the resident alone in his/her bedroom and failed to utilize the motion detector as planned. An observation on [DATE] at 1:15 p.m. three female residents were in TV room. At 1:25 p.m. three females still in TV room. Observation on [DATE] at 1:30 PM revealed Resident #2 ambulate from his/her room with Staff J, CNA present. The sensor alarm sounded when the resident exited the room. The resident ambulated without staff assistance. 2. According to the MDS dated [DATE], Resident #3 had severely impaired cognitive skills for daily decision making and long and short term memory impairment. The resident transferred with extensive assistance of two staff and did not ambulate. The resident had [DIAGNOSES REDACTED]. The Care Plan directed staff to transfer Resident #3 with a mechanical lift. The Physician's Progress Note dated [DATE] indicated staff had no questions or concerns in regards to the resident. The resident in nonverbal. 3. According to the MDS dated [DATE], Resident #4 had severely impaired cognitive skills for daily decision making and long and term memory impairment. The resident required extensive assistance of two staff to transfer and ambulate and had [DIAGNOSES REDACTED]. Interviews: During an interview on [DATE] at 4:05 PM, Resident #2 stated had been asked if anyone spoke with him/her about touching others and responded his/her hand had been on the other resident ' s leg. Resident #2 reported it only occurred one time. During an interview on [DATE] at 12 o'clock, the DON (Director of Nursing) indicated all resident sexual behaviors would be documented in the Nurse's Notes, the facility had no incident reports regarding the resident to resident incidents. The DON reviewed the Resident #2's Nurse's Notes with the surveyor: The Nurse's Notes dated [DATE], Staff H, LPN (Licensed Practical Nurse) informed the DON that on [DATE], Resident #2 had his/her hand inside the brief of a now deceased resident's brief. The DON said staff could see part of the hand. After that incident Resident #2 received a physician's orders [REDACTED]. The DON revealed on [DATE], Resident #2 had his/her hand down the pants of spouse's (Resident #3) pants with a blanket over the top. On [DATE], the resident touched Resident #4's leg, and proceeded to move next to Resident #3 and put his/her hand down the resident's pants. On [DATE] staff found Resident #2 in the TV room with his/her hands underneath a blanket with his/her hand in Resident #3's groin area. On [DATE] staff found Resident #2 with his/her hand in between Resident #4's legs, over clothing. Staff separated the residents and started 15 minute checks. Staff also added a motion detector alarm which the resident removed. Staff added a floor mat alarm which the resident stepped over and then staff added another floor mat alarm. On [DATE] staff added a motion sensor alarm on the ceiling outside the resident's room that sounded at the Nurse's Station. A written statement by a nursing assistant, Staff C dated [DATE] noted she had seen Resident #2 with his/her hand down another resident's brief, and holding another resident's hand that was not his/her spouse. Staff E, a nursing assistant documented on [DATE] she observed the resident hold hands with other residents and maybe a hand under a blanket. During an interview on [DATE] at 2 o'clock PM, Staff G, RN (Registered Nurse) revealed on [DATE] in the afternoon, Staff A, CNA reported that he/she witnessed Resident #2 with his/her hand in between Resident #4's legs, over clothing, while seated in the TV room. Staff G separated the residents and initiated 15 minute checks. During an interview on [DATE] at 2:10 p.m., Staff A, CNA reported on [DATE], he/she observed Resident #2 seated in the TV room next to Resident #4. Resident #2 had his/her hand in between Resident #4's legs, over the resident's clothing. Staff A reported Resident #4 had been awake and does not really know what ' s going on. Staff A told Resident #2 to stop and he/she quickly removed his/her hand. Staff A reported the incident to the nurse. In the past, Staff A had also witnessed Resident #2 with his/her hand inside the brief of a now deceased resident. Staff A reported that incident to the charge nurse. Staff A reported no monitoring of Resident #2 until now, and the facility added a sensor alarm. Prior to the last incident, the staff attempted to keep an eye on Resident #2 who ambulates independently. Staff A had not witnessed Resident #2 go into other residents ' rooms. During an interview on [DATE] at 9:00 a.m., Staff F, Certified Nurse Aide, CNA reported Resident #2 had become friendlier towards other residents in the TV room during the evening. Staff F reported she had not witnessed Resident #2 ' s inappropriate behavior in the past and just heard about it. During an interview with Staff H, Register Nurse on [DATE] at 2 p.m., reported Staff A stated she had seen Resident #2 ' s hand in between Resident #4 ' s legs. Staff H went to the TV room and by this time, she did not see anything and asked Resident #2 to go to his/her room. Staff H reported two staff had assisted Resident #4 up and transferred him/her to the recliner, and Resident #2 had not been there and the staff would not have placed Resident #4 next to Resident #2. Staff H reported she had not seen Resident #2 be inappropriate and was not aware of his/her history. Staff H reported she worked 6 p.m., to 6 a.m. Staff H reported when she worked prn (as needed) Resident #2 made a comment about wanting to watch porn on TV. During an interview on [DATE] at 3:45 p.m., Staff B, RN revealed no observations of inappropriate behavior. Staff knew not to allow Resident #2 to sit next to Resident #3, who had a lap blanket. Resident #2 would put his/her hand underneath the blanket and rub between Resident #3's legs. Staff B would move Resident #2's recliner away from residents of the opposite sex. They tried a floor mat alarm, but Resident #2 could step over it so they added another floor mat alarm next to it, but it had a space in between and the resident could step between them. When they had one mat down, Resident #2 demonstrated how to step over it. That's when they added another floor mat alarm. Recently the facility added a sensor alarm which works well. Staff did 15 minute checks and then discontinued them. When interviewed on [DATE] at 9:00 a.m. the resident's family members stated the resident had been inappropriately touching other residents of the opposite sex ever since admission to the facility. They reported they believe the resident knew what he/she was doing due to he/she would place a blanket over the other residents to prevent staff from seeing his/her hand. When they talk to the resident about the incidents the resident denied recalling the incidents. During an interview on [DATE] at 4:30 PM, Resident #2's family member indicated the facility notified family when the resident touched his/her spouse, and the facility was going to watch the resident to keep them apart. Then it happened to someone else. The facility said they had moved the resident's chair and then he/she moved it back. Then the facility added all the alarms and there is always someone with him/her. The new alarm worked. The facility abated the IJ on [DATE] completed the following: On [DATE] the Care Plan added: 1:1 supervision in hallways, at meals and activities. 15 minute checks discontinued, motion sensor discontinued, floor mat alarm with magnet shut of implemented. Training sheets implemented. Second floor mat implemented due to resident jumping over one mat. On [DATE] the Care Plan added: motion sensor camera (no visual) hard wired in. Shut off at nursing station. Continue 1:1 supervision in hallways, meals and activities. Floor mats discontinued. On [DATE], the facility educated all staff on the double mats and alarm system at the doorway in addition to the hall monitoring. Staff are specially assigned to the resident's hallway, monitoring his/her movement and provides 1:1 supervision in the hallways; and supervised him/her during meals and activities. These actions lowered the IJ from K severity level to and E with the ongoing monitoring to ensure residents receive adequate supervision.

Based on observation, clinical record review, staff and family interviews, the facility failed to ensure a safe and orderly discharge from the facility with sufficient preparation, orientation, and a 30 day notice prior to enforcing an involuntary discharge to Resident #2. The facility moved Resident #2 out of the nursing home to an apartment without any considerations for the resident ' s safety and or wellbeing. Family interviews revealed the resident had been moved out of the nursing home due to his/her inappropriate touching other residents and would not be safe living on their own in an apartment. The DON reported the facility did not provide any discharge planning or orientation prior to moving the resident to the apartment. Onsite observation revealed the resident being moved out of the nursing home. The findings constitute an immediate jeopardy to the resident ' s health and safety. The facility reported a census of 20 residents. Concerns noted for 1 of 1 resident who were discharged involuntarily (Resident #2). Findings include: 1. According to the Admission Record, Resident #2 admitted to the facility on [DATE]. A physician's progress note dated 2/4/14 noted the resident moved to the facility within the past month. The resident had been living independently in an apartment on his/her own; however he/she was not taking medications the way he/she should and was not eating. He/she had lost a significant amount of weight. A physician's progress note dated 4/1/14 noted when the resident first moved to the facility it was for strengthening and the family thought he/she might return home. They now have decided that he/she needs to stay in the facility. On 10/12/15 the Director of Social Services documented Resident #2 struggled most with recall and demonstrated indicators of [MEDICAL CONDITION], per delusions. The resident also demonstrated sexual behaviors. On 1/6/16 the Director of Social Services documented Resident #2 reported trouble concentrating. The resident demonstrated indicators of [MEDICAL CONDITION], per delusion. The facility staff reported the resident believed he/she had somewhere to be or to go, although he/she did not. On 2/9/16 the resident's physician signed she certified the resident required the level of care. The clinical note dated 2/9/16 identified the physician had seen the resident today (2/9/16) for routine nursing home rounds. The nurses reported they had seen an increase in Resident #2's depressive symptoms. The physician identified the plan to continue the current treatment and the physician would see the resident at the next routine nursing home round (approximately 60 days later). A facsimile report to the resident's physician dated 2/25/16 at 2:11 p.m. requested a physical therapy evaluation due to falls. According to a Minimum Data Set (MDS) assessment dated [DATE], the facility staff's assessment of Resident #2 included: the resident scored 9 out of 15 on the BIMS (Brief Interview for Mental Status) which indicated moderate cognitive impairment. The resident did not exhibit any behavior symptoms during the seven-day assessment period. The resident ambulated independently. The resident's Active [DIAGNOSES REDACTED]. The resident sustained [REDACTED]. The MDS indicated active discharge planning was not occurring for the resident to return to the community. The resident's care plan dated 3/31/16 identified the resident had a self-care performance deficit related to weakness as resident had poor nutrition and was not taking medication prior to admission. The care plan lacked documentation regarding discharge plans. A facsimile report dated 4/2/16 identified Resident #2 had inappropriately touched another resident. The returning fax from the physician dated 4/4/16 at 9:09 a.m. documented thanks for the update, no new orders . A facsimile report sent to the resident's physician on 4/7/16 at 6:30 p.m. read, Resident discharging to apartment on 4/8/16. Review of the resident's clinical record revealed a lack of discharge plans and/or discharge planning. Nurse ' s Notes documented the following: On 4/7/16, at 3:30 faxed sent to the physician regarding discharge to apartment. On 4/7/16 at 5:30 fax received from the physician regarding discharge to apartment on 4/78/16. Observation on 4/8/16 at 8:45 a.m. Resident #2 had been in his/her room with their family members. A family member left the room with staff for a cart. When interviewed on 4/8/16 at 9:00 a.m. the resident's family members stated the owner of the nursing home informed them last night (4/7/16) they had to move the resident into the facility's Assisted Living this morning. The owner told them the resident had to move to the Assisted Living (independent living apartment) due behaviors. The family member stated they were told in the Assisted Living (independent living apartment) if the resident inappropriately touched tenants in a sexual manner, those tenants could tell the resident to stop it. The family members stated they did not have a choice about the resident's move to the Assisted Living (independent living apartment). They were only informed they had to move the resident this morning, and one of the family members left to get a cart with staff. The family stated they did not want the resident to move to the Assisted Living due to they did not believe he/she would be safe in the Assisted Living due to the facility placed the resident on medication due to his/her behaviors and the medication made the resident begin falling. They also voiced fear the resident might fall in the shower if showering independently. The family reported the resident required assistance with his/her showers. The family also stated the resident could not put his/her shoes and could only put slippers on independently which was unsafe due to recent falls. The family reported the resident first admitted to the facility due to he/she was not taking his/her medications and he/she liked to drink alcohol. The nurse ' s notes documented the following: On 4/8/16 at 11:00 resident went over to apartment with family members. 4/8/16 at 11:15 a.m., Resident returned to facility. Vitals and assessment completed. On 4/8/16 at 12:10 resident left facility with family. At 1:30 p.m., resident returned to facility. At 3:30 on 4/8/16, floor mat alarm per nursing judgement. A written statement by a housekeeping staff dated 4/8/16 included the following information: Staff had been asked by the DON to show Resident #2 ' s family the apartment and after doing the prior, she later obtained a cart. The STATE lady stated she wanted to talk with the resident ' s family. All of the resident ' s things were moved over to the apartment and another staff assisted with moving a bed to the apartment. Later the DON stated all of the resident ' s things needed to be returned to the nursing home right away. When interviewed on 4/8/16 at 10:30 a.m. the Director of Nursing stated the resident's family had voiced their fear about the resident being moved to the apartments. The family reported they were afraid the resident would fall. The Director of Nursing stated prior to informing the family they had to move the resident out of the nursing home to the apartment, owned by the nursing home, they did not have physical therapy perform an evaluation to see if the resident would be safe living independently in an apartment. She stated they did not document any discharge planning. She denied knowing how much it would cost the resident to receive the facility's home health care services. The Director of Nursing stated the owner would have to let the family know how much the services would cost. The Director of Nursing stated they did not provide any orientation to the resident or the family in the apartment. They did not instruct the resident/family how the resident would receive mail. She reported the facility did not give the resident, nor the family a 30-day involuntary discharge notice. They did not give the resident and/or the family a written notice. The Director of Nursing stated the owner informed the family the night before the resident would be discharged in the morning. She stated they did not ask the family if they wanted the resident to discharge from the facility and they did not give the family a choice about the discharge. The Director of Nursing stated the only choice they gave the family was for the resident to move into the facility's apartment, the owner's other nursing home in the locked dementia unit or the psych ward of the hospital. When interviewed on 4/8/16 at 11:00 a.m. the Director of Nursing stated the facility had not set up any arrangements to provide the resident with medications or meals. The Director of Nursing stated it was up to the family to make those arrangements with home health care it was not up to her and she had nothing to do with home health care. The facility abated the IJ when they returned Resident #2 to the facility on [DATE] and staff were educated on safety interventions. The IJ was lowered from J level to D severity level with the need to monitor resident/s discharges to ensure resident ' s safety.