Every finding on record at Lutheran Retirement Home

Based on observations, interviews, and record reviews, the facility failed to ensure residents were protected from physical abuse and mental anguish, and failed to provide adequate supervision and effective behavioral interventions to prevent resident-to-resident altercations and intrusions for 4 of 4 residents reviewed for behaviors and safety (Resident #1, Resident #2, Resident #3, and Resident #4). The facility reported a census of 34 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severely cognitively impaired. Resident #1 demonstrated an ability to understand and be understood by others with no vision problems. Resident #1 displayed physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing), verbal behavioral symptoms directed towards others (threatening, screaming, cursing at others), other behavioral symptoms not directed towards others (hitting or scratching self, pacing, rummaging, disruptive sounds like screaming), rejection of care, and wandering. Resident #1 required staff supervision for dressing, toileting, and personal hygiene, and maintained independence with ambulation without assistive devices. Resident #1's MDS listed diagnoses including Alzheimer's disease (progressive memory loss disorder), non-Alzheimer's dementia (brain disorder causing memory loss), and a sleep disorder (disrupted sleep pattern). The Care Plan dated 7/23/26 documented Resident #1 holding potential for physical aggressiveness (hitting, kicking, grabbing) and wandering related to agitation and Alzheimer's disease. Interventions directed staff to assess and anticipate needs including food, thirst, toileting, comfort, positioning, and pain; distract Resident #1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books; and provide structured activities including toileting, indoor and outdoor walking, and reorientation strategies using signs, pictures, and memory boxes. Following physical abuse towards another resident when Resident #1 pushed another resident to the floor, interventions directed staff to separate Resident #1 immediately, move Resident #1 to a safe, quiet area away from other residents, keep residents separated, and initiate one-on-one (1:1) supervision for Resident #1. Interventions directed staff to guide Resident #1 away from distress sources during agitation, engage calmly in conversation, walk calmly away and reapproach later during aggressive responses, and redirect Resident #1 if entering wrong rooms. A Behavior Monitoring and Intervention Report dated 4/11/26 at 3:40 AM, 1:00 PM, and 6:21 PM documented behaviors of wandering, pacing, anger towards others, entering other resident rooms or personal space, agitation, anxiety, and restlessness, noting redirection as an intervention resulting in no change in behavior. A Nurse Progress Note dated 4/11/26 at 8:01 PM documented Resident #1 wandering throughout the unit. The note documented Resident #1 becoming agitated during evening medication administration, throwing objects, seeking exits, and refusing redirection. A Nurse Progress Note dated 4/13/26 at 5:08 AM documented Resident #1 displaying severe anger at the beginning of the shift and wandering throughout the night. A Behavior Monitoring and Intervention Report dated 4/13/26 at 1:15 PM, 1:44 PM, and 7:33 PM documented behaviors of accusing others, agitation, delusions, and wandering, noting redirection as an intervention resulting in no change in behavior. A Behavior Monitoring and Intervention Report dated 4/14/26 at 3:06 AM, 9:37 AM, and 8:44 PM documented behaviors of grabbing, kicking, accusing and threatening others, delusions, refusing care, and wandering, noting redirection and meaningful activity as interventions resulting in no change in behavior. A Nurse Progress Note dated 4/14/26 at 7:00 PM documented a late entry for approximately 6:10 PM, where a nursing assistant requested nurse presence on the unit. Upon arrival, the nurse observed Resident #1 and a nursing assistant standing in the hallway while Resident #1 yelled at staff, stating ownership of the building and cursing at staff. The nurse requested Resident #1 continue walking down the hall to allow conversation with staff, prompting Resident #1 to yell at the nurse and enter a personal bedroom to sit on the bed. The nurse instructed staff to leave Resident #1 alone and proceed to the nurse's station, where a nursing assistant reported attempting to redirect Resident #1 out of another resident's room when Resident #1 became physically and verbally aggressive, attempted re-entry, and held the door shut. A Progress Note dated 4/14/26 written by the Nurse Practitioner documented Resident #1 displaying significant wandering, pacing, and restlessness at home, contributing to the need for a secure residence with nursing home supervision for care and safety. The note documented Resident #1 struggling to fall asleep and wandering during overnight hours since admission, outlining an assessment and plan for advanced severe Alzheimer's dementia with agitation, anxiety, behavioral disturbances, poor sleep, wandering, pacing, irritability, uncooperativeness, argumentativeness, verbal and physical abuse directed at others, redirection difficulty, and sundowning. A Nurse Progress Note dated 4/15/26 at 1:10 AM documented Resident #1 entering another resident's room at the shift start and refusing to exit, following reports of combative behavior on the prior shift. The nurse entered the unit and redirected Resident #1 out of the room to Resident #1's bedroom, where Resident #1 remained angry without physical aggression towards staff. An Orders-Administration Note dated 4/15/26 at 10:28 AM documented Resident #1 entering other resident rooms and taking items. Staff attempted redirection without success, observing Resident #1 move in and out of rooms to ensure item safety and prevent increased agitation, noting Resident #1 displayed pleasantness while repeatedly expressing a desire to leave. A Behavior Monitoring and Intervention Report dated 4/15/26 at 1:23 PM and 7:21 PM documented behaviors of entering other resident rooms or personal space, anxiety, restlessness, and wandering, noting redirection as an intervention resulting in no change in behavior. A Behavior Monitoring and Intervention Report dated 4/16/26 at 9:11 PM documented physical behavior directed toward others, grabbing, hitting, kicking, physical aggressiveness, and entering other resident rooms, noting redirection as an intervention resulting in no change in behavior. An Incident Note dated 4/16/26 at 10:28 PM documented a nurse called to the unit due to Resident #1 occupying another resident's bed. Upon arrival, Resident #1 cursed and swung at the nurse, grabbed and squeezed the nurse's hand to cause cuts and bruising to the left middle and ring fingers, twisted the nurse's wrist, slapped a nursing assistant on the face and arm, and attempted to kick the nurse and nursing assistant before staff removed Resident #1 to Resident #1's bedroom. A Nurse Progress Note dated 4/16/26 at 10:30 PM documented reports from the prior shift indicating Resident #1 occupied another resident's room and displayed combativeness. A nursing assistant reported attempting room removal before Resident #1 cursed, prompting staff to step away to prevent escalation. The nurse entered the room, where Resident #1 cursed and instructed the nurse to leave, and after the nurse explained the room belonged to a female resident and offered assistance to Resident #1's room, Resident #1 agreed, walked to Resident #1's room, and lay down. A Progress Note dated 4/18/26 written by the Nurse Practitioner documented evaluating Resident #1 via an after-hours triage call for acute behavioral changes with increased agitation and aggression, including hitting others. The note documented escalating agitation requiring additional management, evaluation, referral to psychiatric services, close nursing monitoring, and reporting of worsening behaviors or safety concerns. A Psychiatry New Evaluation dated 4/20/26 at 10:00 AM documented examining Resident #1 due to increased aggression. The note documented sundowning behaviors and verbal aggression prompting family admission to the nursing home, with staff observing aggressive behaviors since admission including hitting and slapping a nursing assistant, shoving a nurse to the ground, wandering into other resident rooms, refusing to leave, swinging items in the air, irritability, anger, and pacing. The evaluation documented Resident #1 declining, displaying verbal and physical aggression in the afternoon and evening, and posing a risk of harm to self or others. A Physician Round Worksheet dated 4/20/26 documented nursing concerns regarding Resident #1 displaying physical and verbal behaviors since admission, occurring most often around 6:00 PM. A Progress Note dated 5/4/26 written by the Nurse Practitioner documented Resident #1 requiring anti-anxiety medications due to severe agitation, anxiety, and exit seeking. The note documented Resident #1's baseline including significant confusion, disorientation, restlessness, near-constant wandering, and poor nighttime sleep. A Progress Note dated 5/26/26 written by the Nurse Practitioner documented Resident #1 displaying extreme restlessness, near-constant wandering and pacing, agitation, and exit seeking to return to a farm following return to the facility. A Progress Note dated 5/29/26 at 10:40 AM written by the Nurse Practitioner documented Resident #1 appearing restless, pacing in the hallway, sitting briefly for conversation before resuming pacing, and displaying 6:00 PM sundowning behaviors with aggression posing harm to self or others. A Nurse Progress Note dated 6/5/26 at 11:49 AM documented Resident #1 wandering hallways all day and entering other resident rooms, causing distress to one resident in particular, with multiple redirection attempts failing. A Nurse Progress Note dated 6/7/26 at 4:34 PM documented Resident #1 becoming aggressive and demanding with staff, entering other resident rooms, refusing redirection, moving furniture, and requiring close observation due to continuous movement. A Behavior Monitoring and Intervention Report dated 6/7/26 at 6:20 PM documented behaviors of accusing and cursing at others, rummaging, pacing, and refusing care, noting redirection as the only intervention resulting in no change in behavior. An Incident Report dated 6/8/26 at 8:15 AM documented staff calling the writer to the unit following a resident on the floor after another resident struck her. Staff explained Resident #1 forced entry into Resident #2's room and struck Resident #2 on the shoulder with a fist, causing Resident #2 to fall and sustain skin tears on her right hand, prompting Resident #2 to question why a man she did not know struck her. A Behavior Monitoring and Intervention Report dated 6/8/26 at 10:47 AM documented behaviors of grabbing, hitting, pushing, physical aggressiveness towards others, cursing, anger, screaming, threatening others, entering other resident rooms or personal space, agitation, pacing, and wandering, noting redirection as an intervention resulting in no change in behavior. A Nurse Progress Note dated 6/8/26 at 10:24 PM documented Resident #1 entering another resident's room after supper and pushing the door to keep the resident out, noting a nursing assistant would document observations. A Progress Note dated 6/8/26 written by the Nurse Practitioner documented Resident #1 becoming irritable, agitated, argumentative, hostile, and verbally and physically abusive towards staff when staff attempted redirection from pacing, wandering, care, medications, or meals. The note documented Resident #1 becoming irritable, argumentative, agitated, hostile, and verbally and physically abusive towards other residents in proximity or personal spaces. The note documented Resident #1 repeatedly entering another resident's room despite redirection attempts, becoming angry and combative when the female resident expressed distress, physically assaulting the resident by pushing her to the floor, and displaying verbal and physical assaultiveness towards staff. The practitioner provided orders to contact a psychiatrist, who provided orders and planned a visit to evaluate alternatives or dose increases. A Nurse Progress Note dated 6/9/26 at 11:31 AM documented Resident #1 continuing on 15-minute checks due to hitting and pushing Resident #2 the previous day. A Nurse Progress Note dated 6/9/26 at 10:51 PM documented Resident #1 becoming easily agitated with staff and other residents, wandering throughout the unit, entering other resident rooms to yell at residents, and yelling at residents and staff in dining and living areas. A Psychiatry Return Visit note dated 6/10/26 at 1:00 PM documented Resident #1 pacing hallway floors during an urgent visit following an episode of aggression towards Resident #2, noting Resident #1 remained irritable with minor improvement reported by staff. A Health Status Note dated 6/12/26 at 9:43 PM documented Resident #1 wandering into other resident rooms, causing agitation among other residents. A Nurse Progress Note dated 6/14/26 at 8:00 PM documented Resident #1 wandering around the facility unit, entering other resident rooms, becoming physical with staff during redirection, and prompting complaints from other residents regarding presence in their rooms. A Behavior Note dated 6/16/26 at 9:30 PM documented Resident #1 continuing to wander into other resident rooms, picking up another resident's water bottle, squirting water at two residents, and attempting to hit staff during intervention. A Progress Note dated 6/17/26 written by the Nurse Practitioner documented evaluating Resident #1 following physical aggression towards another resident the previous week and subsequent kissing of the same female resident on the forehead. The note documented evening crew distress regarding Resident #1's restlessness, agitation, anxiety, irritability, and significant evening sundowning, creating difficulty containing and redirecting Resident #1 to prevent bothering other residents, elopement attempts, or entering other resident rooms despite psychiatric medication adjustments. A Plan of Care Note dated 7/24/26 at 3:09 PM documented staff reporting mood and behavioral symptoms during the assessment period including cussing, entering wrong rooms, spitting, anxiety, elopement seeking, pacing, and wandering, noting redirection as an intervention. On 8/4/26 at 11:30 AM an observation showed Resident #1 sitting at the dining room table dressed in appropriate clothing. One staff member remained in the bathroom with another resident while another staff member assisted another resident with hallway ambulation. On 8/4/26 at 3:30 PM an observation showed Resident #1 walking up and down hallways without staff supervision while one staff member remained in a resident room and another staff member remained in the medication room. On 8/5/26 at 9:30 AM Staff A, Certified Nursing Assistant (CNA), stated on 6/8/26 around breakfast time, Staff A assisted another resident with breakfast while Staff B, Certified Nursing Assistant (CNA), worked in the kitchenette. Staff A reported hearing commotion and yelling coming from Resident #2's doorway. Upon arrival, Staff A observed Resident #1 in the doorway attempting entry while Resident #2 yelled requesting Resident #1 leave. As Resident #2 attempted door closure, Resident #1 turned and pushed Resident #2's shoulder, causing Resident #2 to stumble and fall backwards. Resident #1 shut the door by pulling the knob, and Staff A and Staff B attempted redirection away from the door to assess Resident #2. Resident #1 displayed agitation, hollering, and refusal to move away until releasing the knob after encouragement to walk to the dining room. Staff C, Licensed Practical Nurse (LPN), arrived to complete an assessment on Resident #2. Staff A reported difficulty keeping continuous eyes on Resident #1, noting Resident #1 enters other resident rooms to cause resident distress, and noted redirection does not always work, requiring additional activities and interventions. On 8/5/26 at 10:30 AM an observation showed Resident #1 walking down the hallway holding hands with another female resident without staff supervision or redirection attempts. On 8/5/26 at 11:10 AM Staff B stated working in the kitchenette on 6/8/26 when hearing commotion and yelling from Resident #2's room. Staff B and Staff A proceeded to the room, observing Resident #1 in the doorway and Resident #2 attempting to push Resident #1 out by pushing the door. Resident #1 displayed anger towards Resident #2, pushed Resident #2 back with a hand, and caused Resident #2 to stumble and fall on her bottom. Resident #1 pulled the door closed, and Staff B left to call the charge nurse stat while hearing Resident #2 behind the door. Staff B returned, and following multiple attempts and encouragement, Staff A and Staff B moved Resident #1 away from the door to the dining room. Staff B reported difficulty maintaining continuous eyes on Resident #1, noting redirection does not always work. On 8/5/26 at 2:22 PM Staff C, Certified Nursing Assistant (CNA), stated difficulty maintaining continuous supervision of Resident #1 at all times. Staff C reported Resident #1 enters other resident rooms, causing residents to yell or scream, and noted redirection attempts do not always succeed. On 8/6/26 at 10:00 AM the Director of Nursing (DON) acknowledged redirection does not always work with Resident #1, stating Resident #1 requires continuous supervision due to entering and exiting other resident rooms. 2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented an ability to understand and be understood by others with no vision problems. Resident #2's MDS documented a Brief Interview for Mental Status (BIMS) score of 6, indicating severely cognitively impaired. Resident #2's MDS documented physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing), verbal behavioral symptoms directed towards others (threatening, screaming, cursing at others), other behavioral symptoms not directed towards others (hitting or scratching self, pacing, rummaging, disruptive sounds like screaming), and wandering. Resident #2's MDS documented requiring staff supervision for dressing, toileting, and personal hygiene, and maintaining independence with ambulation without assistive devices. Resident #2's MDS listed diagnoses including Alzheimer's disease (progressive memory loss disorder), non-Alzheimer's dementia (brain disorder causing memory loss), anxiety (excessive worry), and depression (mood disorder). The Care Plan dated 7/30/26 documented Resident #2 holding an actual psychosocial well-being problem related to physical abuse by another resident. Interventions directed staff to consult pastoral care, Social Services, and psychiatric services as needed. Following physical abuse by another resident on 6/8/26, staff separated Resident #2 immediately, completed a head-to-toe assessment, identified two skin tears on the right hand, cleansed areas with wound cleanser, and covered areas with bandages. Staff received instructions to keep residents separated until further notice, and during conflicts, to remove residents to a calm, safe environment to vent or share feelings. An Incident Report dated 6/8/26 at 8:15 AM documented staff calling the writer to the unit following a resident on the floor after another resident struck her. Staff explained Resident #1 forced entry into her room and struck her shoulder with a fist, causing her to fall and sustain skin tears on her right hand, prompting Resident #2 to question why a man she did not know struck her. An Incident Note dated 6/8/26 at 9:34 AM documented staff calling the writer to the memory care unit following a resident on the floor after another resident struck Resident #2. A nursing assistant reported another resident forced entry into her room and struck her shoulder with a fist, causing her to fall and sustain skin tears on her right hand, prompting Resident #2 to question why a man she did not know struck her. Staff checked vital signs, cleansed two skin tears with wound cleanser, covered areas with bandages, and escorted Resident #2 to the dining room to sit with nursing assistants to ensure residents remained separated. A Progress Note dated 6/8/26 written by the Nurse Practitioner documented follow-up care for Resident #2 after Resident #1 pushed Resident #2 to the floor. The note documented Resident #2 residing in her personal room on the memory care unit when highly agitated Resident #1 attempted entry, prompting Resident #2 to request Resident #1 leave and yell at Resident #1. Resident #1 became hostile, verbally and physically abusive, and pushed Resident #2, causing her to fall and sustain skin tears on her right hand. Nursing staff addressed skin tears, provided reassurance, and noted Resident #2 returned to baseline without memory of the event while staff maintained separation efforts. The practitioner planned follow-up as needed if skin tears failed to heal or if staff noted concerning symptoms or baseline functional changes. A review of Resident #2's Clinical Record showed a lack of documentation regarding skin sheets for the skin tears on Resident #2's hand. 3. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented an ability to understand and be understood by others. Resident #3's MDS documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #3's MDS documented no behaviors, rejection of care, or wandering. Resident #3's MDS documented requiring staff supervision for all activities of daily living (ADLs) including dressing, toileting, and personal hygiene, and utilizing a wheelchair or walker for mobility. Resident #3's MDS listed diagnoses including Alzheimer's disease (progressive memory loss disorder), non-Alzheimer's dementia (brain disorder causing memory loss), depression (mood disorder), and psychotic disorder (loss of contact with reality). The Care Plan dated 8/6/26 documented Resident #3 holding a behavior problem related to depression as evidenced by suicidal comments. Interventions directed staff to encourage public area presence, administer medications as ordered, monitor and document side effects and effectiveness, anticipate and meet needs, provide opportunities for positive interactions and attention, and stop to converse when passing by. A Nurse Progress Note dated 4/16/26 at 9:30 PM documented Resident #3 refusing room entry due to fear of the male resident residing next door. The nurse attempted to explain the resident would not harm Resident #3 and encouraged bed return, but Resident #3 continued refusal, accepting an offer to remain in the commons area with staff. A Nurse Progress Note dated 4/17/26 at 1:09 PM documented Resident #3 displaying severe distress regarding Resident #1 entering her room, reporting to staff intent to stab Resident #1 with scissors or shoot Resident #1 with a friend's gun. Resident #3 blocked her bedroom door with furniture and expressed severe distress, stating a desire to prevent entry. Staff gained entry, and staff received instructions to maintain separation, monitor the situation, and re-evaluate as needed. A Nurse Progress Note dated 4/18/26 at 2:31 AM documented a late entry showing Resident #3 resting quietly in bed after pushing furniture in front of her door to prevent resident entry. Staff reassured Resident #3 of safety, noting Resident #1 made no attempts to enter Resident #3's room during the shift. A Nurse Progress Note dated 4/19/26 at 1:08 AM documented Resident #3 resting in her room while her daughter slept in a bedside recliner. The nurse discussed concerns with Resident #3 and her daughter, noting Resident #1 made no attempts to enter rooms. A Progress Note dated 4/27/26 written by the Nurse Practitioner documented Resident #3 expressing fear of memory care unit residents, specifically a loud, uncooperative male resident intruding upon personal spaces, and expressing distress regarding a restless, anxious female resident pacing constantly. On 8/5/26 at 9:00 AM an attempt to interview Resident #3 revealed Resident #3 could not recall or remember an incident involving Resident #1. On 8/5/26 at 11:10 AM Staff B stated holding awareness regarding the incident where Resident #3 barricaded her room with furniture due to fear of Resident #1 entering. 4. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented an ability to understand and be understood by others with no vision problems. Resident #4's MDS documented a Brief Interview for Mental Status (BIMS) score of 7, indicating severely cognitively impaired. Resident #4's MDS documented no physical behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others, no wandering, and no rejection of care. Resident #4's MDS documented requiring partial to moderate staff assistance for dressing, toileting, and personal hygiene, and requiring staff supervision for ambulation. Resident #4's MDS listed diagnoses including Alzheimer's disease (progressive memory loss disorder), non-Alzheimer's dementia (brain disorder causing memory loss), and anxiety (excessive worry). On 8/5/26 at 10:45 AM Resident #4 stated Resident #1 enters her room frequently, prompting Resident #4 to yell at Resident #1 to exit, and expressed a need for additional activities to keep Resident #1 occupied. On 8/6/26 at 1:10 PM the Director of Nursing (DON) reported the facility lacked a policy or procedure for residents with behaviors on the memory care unit. The DON reported expecting staff to follow care plan interventions, document attempted interventions, and record whether interventions altered resident behaviors.

Based on clinical record review, facility investigation, staff interview and review of policy and procedures, the facility failed to ensure all alleged violations involving mistreatment, neglect, and physical abuse were reported to the Department of Inspection, Appeals and Licensing (DIAL) within 2 hours for 2 of 2 residents reviewed (Resident #1 and Resident #2). The facility reported a census of 34 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented an ability to understand and be understood by others, with no vision problems. Resident #1's MDS documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severely cognitively impaired. Resident #1's MDS documented physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing), verbal behavioral symptoms directed towards others (threatening, screaming, cursing at others), other behavioral symptoms not directed towards others (hitting or scratching self, pacing, rummaging, disruptive sounds like screaming), rejection of care, and wandering. Resident #1's MDS documented requiring staff supervision for dressing, toileting, and personal hygiene, and maintaining independence with ambulation (walking) without assistive devices. Resident #1's MDS listed diagnoses including Alzheimer's disease (progressive memory loss disorder), non-Alzheimer's dementia (brain disorder causing memory loss), and a sleep disorder (disrupted sleep pattern). Resident #1's Care Plan with a target date of 7/23/26 identified potential for physical aggressiveness (hitting, kicking, grabbing) and wandering related to agitation and Alzheimer's disease. Interventions directed staff to assess and anticipate needs including food, thirst, toileting, comfort, positioning, and pain; distract Resident #1 from wandering using pleasant diversions, structured activities, food, conversation, television, or books; and provide structured activities including toileting, indoor and outdoor walking, and reorientation strategies using signs, pictures, and memory boxes. Following physical abuse towards another resident when Resident #1 pushed another resident to the floor, interventions directed staff to separate Resident #1 immediately, move Resident #1 to a safe, quiet area away from other residents, keep residents separated, and initiate one-on-one (1:1) supervision for Resident #1. Interventions directed staff to guide Resident #1 away from distress sources during agitation, engage calmly in conversation, walk calmly away and reapproach later during aggressive responses, and redirect Resident #1 if entering wrong rooms. An unsigned Incident Summary dated 6/8/26 documented staff paged a nurse to report to the memory care unit at approximately 8:20 AM. At approximately 8:23 AM the charge nurse requested the writer report to the memory care unit for an incident. Upon arrival, the writer observed Staff A, Certified Nursing Assistant (CNA), standing outside Resident #2's room, and observed Resident #2 and the Social Worker sitting on the bed. The Social Worker and Staff A reported a resident-to-resident incident occurring a few minutes prior, causing Resident #2 to fall to the floor. Staff C, Licensed Practical Nurse (LPN), met the writer outside Resident #2's room to report the incident, stating Resident #1 entered Resident #2's room without consent. Resident #1 yelled and screamed at Resident #2, while Resident #2 yelled requesting Resident #1 leave the room, leading to Resident #1 hitting and pushing Resident #2. Resident #2 fell, struck the wall, and slid to the floor. Staff A and Staff B, Certified Nursing Assistant (CNA), attempted to enter Resident #2's room, but Resident #1 slammed the door shut and held the door closed. Following encouragement, Staff A entered the room while Staff B called for staff assistance. Staff C reported arriving at the scene, assisting Resident #2 to bed, and assessing Resident #2 for injuries, noting two small cuts on Resident #2's right hand. The Social Worker consoled Resident #2 while Staff C completed an assessment. Staff C ordered Staff A and Staff B to keep residents separated and initiate 15-minute checks. Following notification of the incident, staff changed 15-minute checks to one-on-one (1:1) supervision for Resident #1 until further notice and instructed Staff C to notify both families. Staff A and Staff B reported Resident #1 displayed increasing irritability, agitation, swearing, and attempts to hit staff prior to the incident. Staff C reported Resident #1 demonstrated difficulty taking morning medications. At approximately 8:35 AM staff notified the Director of Nursing (DON) regarding the incident. A Corrective Action Description record undated documented staff immediately separating Resident #1 and Resident #2 and completing full assessments on both residents. Staff initially initiated 15-minute checks on Resident #1 and received instructions to keep residents separated. Following notification to the Provisional Administrator, staff placed Resident #1 on one-on-one (1:1) supervision until further notice. Due to severe cognitive impairment and constant wandering throughout the locked unit for both residents, facility leadership determined neither resident could move out of the memory care unit. Staff notified both families and the DON regarding the incident. Record documentation noted Resident #2 involved in prior physical altercations, including hitting another resident and walking away on 12/21/25, hitting a family member on 12/24/25, and hitting a staff member on 12/28/26. Interventions for prior incidents included increasing second shift staffing until rounds occurred, with incidents outlined on the care plan. An undated written statement by Staff A documented as they helped a resident eat, they heard yelling between two residents. When Staff A and Staff B ran over to de-escalate the situation, they observed Resident #1 attempt to push into Resident #2's room. Resident #1 slammed the door, reopened the door, and shoved Resident #2, causing Resident #2 to stumble and fall into the wall. When Staff A and Staff B attempted to redirect Resident #1 toward the sitting area, Resident #1 struck both Staff A and Staff B in the shoulder area. Staff B left to call the charge nurse while Staff A continued attempting to direct Resident #1 away from Resident #2's door to allow entry. Resident #1 angrily followed Staff A toward the sitting area while continuing to strike Staff A, slammed the fire door, and proceeded to an empty room. Staff A and Staff B entered Resident #2's room, finding Resident #2 on the floor crawling toward the bed. Staff A sat with Resident #2 while Staff B checked Resident #1's location to ensure nurse proximity. Resident #2 sustained a cut on the hand and displayed fear. The nurse examined Resident #2, and staff brought Resident #2 to the sitting area while Resident #1 continued swearing and yelling. A written statement by Staff B dated 6/8/26 at 8:24 AM documented putting items away in the kitchen while residents ate breakfast and Staff A fed a resident. Staff B heard yelling down the hall and immediately investigated, observing Resident #1 outside Resident #2's room, pushing the door to force entry, and swearing at Resident #2. Resident #2 expressed distress regarding Resident #1's attempts to enter the room. Resident #1 hollered, swung arms, struck Resident #2, and pushed Resident #2, causing Resident #2 to lose their balance and bump the wall inside the room. Staff B could not enter the room because Resident #1 held the door and slammed the door shut. Staff B called for a nurse stat (immediately) while Staff A attempted to direct Resident #1 away from the door. After Resident #1 left the area, Staff B entered the room and found Resident #2 on her knees near the door. Staff A, the nurse, and the Social Worker assisted Resident #2 and ensured their safety while Staff B checked on other residents in the dining room. An undated written statement by Staff C documented they arrived at the memory care unit after they received a call, where Staff B reported Resident #1 forced entry into Resident #2's room and struck Resident #2 on the shoulder, causing Resident #2 to fall backwards onto the floor. Staff C noted Resident #2 sustained two small cuts on the right hand from the fall. Staff C notified the Provisional Administrator and both families, separated the residents, placed Resident #1 on 15-minute checks, and subsequently transitioned Resident #1 to one-on-one (1:1) supervision until further notice. 2. Resident #2's MDS assessment dated [DATE] documented an ability to understand and be understood by others, with no vision problems. Resident #2's MDS documented a BIMS score of 6, indicating severely cognitively impaired. Resident #2's MDS documented physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing), verbal behavioral symptoms directed towards others (threatening, screaming, cursing at others), other behavioral symptoms not directed towards others (hitting or scratching self, pacing, rummaging, disruptive sounds like screaming), and wandering. Resident #2's MDS documented requiring staff supervision for dressing, toileting, and personal hygiene, and maintaining independence with ambulation (walking) without assistive devices. Resident #2's MDS listed diagnoses including Alzheimer's disease (progressive memory loss disorder), non-Alzheimer's dementia (brain disorder causing memory loss), anxiety (excessive worry), and depression (mood disorder). Resident #2's Care Plan with a target date of 7/30/26 identified an actual psychosocial well-being problem related to becoming a victim of physical abuse by another resident. The Interventions directed staff to consult with pastoral care, Social Services, and psychiatric services as needed. Following the physical abuse by another resident on 6/8/26, staff separated Resident #2 from the other resident immediately, completed a full head-to-toe assessment, identified 2 skin tears to the right hand, cleansed the areas with wound cleanser, and covered the areas with bandages. Staff received notification to keep residents separated until further notice and, during conflicts, to remove residents to a calm, safe environment and allow residents to vent or share feelings. An Incident Report dated 6/8/26 at 8:15 AM documented staff calling Staff C to the unit following an incident where Resident #1 struck Resident #2, causing Resident #2 to fall to the floor. Staff explained Resident #1 forced entry into Resident #2's room and struck Resident #2 on the shoulder with a fist, causing Resident #2 to fall and sustain two skin tears on the right hand. The note reflected Resident #2 questioned why he hit her; she didn't even know him. An Incident Note dated 6/8/26 at 9:34 AM documented the staff called Staff C to the memory care unit following an incident where Resident #1 struck Resident #2, causing Resident #2 to fall to the floor. Upon arrival, a nursing assistant explained Resident #1 forced entry into Resident #2's room and struck Resident #2 on the shoulder with a fist, causing Resident #2 to fall and sustain two skin tears on the right hand. Resident #2 stated questioning why a man Resident #2 didn't know struck Resident #2. Staff checked vital signs, cleansed the two skin tears with wound cleanser, covered the areas with bandages, and escorted Resident #2 to the dining room to sit with nursing assistants to ensure residents remained separated. A Progress Note dated 6/8/26 written by the Nurse Practitioner documented follow-up care for Resident #2 after Resident #1 pushed Resident #2 to the floor. The note documented Resident #2 residing in the memory care unit in a personal room when highly agitated Resident #1 attempted entry. Resident #2 requested Resident #1 leave the room and yelled at Resident #1, prompting Resident #1 to become hostile, verbally and physically abusive, and push Resident #2 to the floor, causing skin tears on the right hand. Nursing staff addressed the skin tears, provided reassurance, and noted Resident #2 returned to usual baseline without memory of the event. Staff maintained efforts to keep both residents separated, and the Nurse Practitioner planned follow-up as needed if skin tears failed to heal or if staff noted concerning symptoms or baseline functional changes. On 8/4/26 at 10:00 AM the Administrator reported the facility didn't report the incident in a timely manner as the incident happened on her first day at the facility. The Administrator explained she expected all staff to report resident allegations or accusations immediately, noting requirements to report to the Department of Inspections, Appeals, and Licensing (DIAL) within a 2-hour time frame. The undated Prevention/Identification policy instructed staff to protect residents from verbal, sexual, physical, financial, and mental abuse, corporal punishment, or involuntary seclusion perpetrated by staff, visitors, family members, or other residents. The policy defined physical abuse as including hitting, slapping, pinching, and kicking, and directed the facility to ensure residents remain free from neglect, mistreatment, and misappropriation of property. The policy directed staff to report all alleged violations involving abuse immediately, but no later than 2 hours after an allegation occurs, to the Department of Inspections and Appeals.

Based on observations, staff interviews, policy review, and the 2022 Food Code of the US Food and Drug Administration the facility failed to prevent the risk of cross contamination to potential bacterial accumulation and spread from jewelry worn while meal prepping and serving in the kitchen. The facility reported a census of 36 residents. Findings include: On initial walk through of the kitchen on 2/23/26 at 10:20 AM observed Staff D, Cook, with multiple rings on 8 of her fingers. On both wrists she wore bracelets while working in the kitchen prepping the meal. On 2/23/26 at 12:20 PM observed Staff D serving the noon meal. She continued to wear the rings on 8 of her fingers and bracelets on both wrists. On 2/24/26 at 11:00 AM observed Staff D pureed pork chops, sweet potatoes, and broccoli for the noon meal. The observation revealed Staff D still wore rings on 8 fingers, with some of her fingers having multiple rings on them. She wore a bracelet on both wrists. On 2/24/26 at 12:00 PM watched Staff D serve the noon meal wearing all the jewelry from the previous observations. On 2/24/26 at 12:30 PM Staff D reported she knew she wore more jewelry than she should based on the regulations and policy. On 2/24/26 at 1:00 PM the Dietary Manager reported the staff can't wear jewelry, except a plain wedding band when working in the kitchen. The facility policy titled Employee Sanitary Practices dated 2005 directed to keep jewelry to a minimum of wedding rings, plain watches, and no dangle earrings. The Food Code Manual January 18, 2023, Version documented jewelry is prohibited except for a plain ring such as a wedding band; while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.

The requirement is not met as evidenced by: Based on clinical record review, staff interview and facility policy, the facility failed to properly assess and provide treatment as ordered to promote healing of, and prevent infection in, existing pressure ulcer for 1of 1 resident reviewed (Resident #12). Resident #12 area started on 9/16/25 and the facility failed to do the treatment as ordered 15 times from 1/27/25 to 2/24/26 in which the area deteriorated.The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues.Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister.Stage III Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Resident #12's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 7 (severe cognition impairment). He required total assistance with toileting, dressing, transfers and repositioning. The MDS lacked documentation of unhealed pressure injuries.The Care Plan Focus revised 2/25/26 documented Resident #12 had actual impairment skin integrity of the right heel area related to a Stage 2 pressure ulcer to the right heel. The Interventions directed the following: a. Carry out skin treatments per orders. b. Weekly treatment documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue and exudate and any other notable changes or observations.The Physicians' Progress Note dated 1/7/26 instructed to continue the betadine daily to the right heel and start to apply a foam border dressing.Resident #12's February 2026 TAR (Treatment Administration Record) included the following orders:Mepilex to right heel. Change on shower days (Tuesdays and Fridays) on the day shift. Povidone-iodine solution 10% apply topically to affected area once daily.The documentation indicated Resident #12 received the Mepilex and iodine treatments on bath days.The Pressure Ulcer/Injury: Stage 3 Pressure Ulcer/Injury: Full-thickness Skin Loss documentation reviewed 2/25/26 at 10:35 AM reflected the following assessments of Resident #12's right lateral malleolus (heel) from 1/28/26 - 2/24/26:a. 1/28/26 i. Progress - Improving: overall wound characteristics improved ii. Measured - 0.52 centimeters (cm) length (L) by 1.51 cm width (W) by 0 (cm) depth (D) by 0.67 cm area (A)b. 2/2/26: i. Progress - Improving: overall wound characteristics improved ii. Measured - 1.54 cm L by 0.74 cm W by 0 cm D by 0.91 cm Ab. 2/11/26: i. Progress - Improving: overall wound characteristics improved ii. Measured - 1.65 cm L by 1.3 cm W by 0 cm D by 1.63 Ac. 2/24/26: i. Progress: Deteriorating: wound characteristics deteriorated. ii. Measure - 1.45 cm L by 1.62 cm W by 0 D by 2.03 A The chart lacked documentation of a wound measurement for the week of 2/18/26.On 2/25/26 at 8:20 AM Staff A, Registered Nurse (RN), described the treatment to Resident #12's right heel as to paint the area with Betadine on shower days and cover with a foam border dressing or Mepilex. He is to wear his Podus (brand name) boots (boots designed to eliminate pressure on the heel of the foot) at all times and treatment only done on bath days.On 2/25/26 at 10:40 AM Staff C, Certified Nurse Aide (CNA), verbalized Resident #12 has to have their boots on their feet at all times. They tried a foot board but Resident #12 likes to propel themselves in the facility and so they discontinued the board. He said the nurse did daily betadine but didn't know if that changed. They tried to lay him down during the day, but he is a farmer and needs to be up doing things so it never really worked for him to lay down as he tried to get up.On 2/25/26 at 1:22 PM Staff B, Licensed Practical Nurse (LPN), verbalized the process of Resident #12's heel treatment as to cleanse area to right heel with wound cleanser to area on shower days, paint with Betadine solution, and cover with a foam dressing. The Advanced Registered Nurse Practitioner (ARNP) is updated weekly regarding Resident #12's wound on visits.On 2/25/26 at 2:15 PM the Director of Nursing (DON) verbalized he expected the staff to follow the physician orders as written or notify the physician of the need to change treatment.The undated Policy Titled Skin Assessment/Ulcer Sore Prevention reflected the documentation for a pressure sore will be initially in the interdisciplinary notes as well as weekly pressure sore progress report sheet. The form needed completed weekly until the area is resolved. The facility would notify the physician sooner than weekly with any decline in the wound. The TAR will direct the treatments and initiated when completed.

Based on clinical record review and staff interviews the facility failed to provide adequate supervision for a resident identified as a fall risk resulting in an unwitnessed fall in the shower room for 1 of 1 resident reviewed (Resident #13). The facility reported a census of 36 residents. Findings include:Resident #13's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severe cognitive impairment. The MDS indicated Resident #13 needed substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds the trunk or limbs and provides more than half the effort) for transfers and toileting. The MDS further documented the resident had diagnoses of Alzheimer Disease, anxiety, history of falling and unsteady on feet. Resident #13's undated Care Plan documented they had limited physical mobility, unsteadiness on their feet and had a risk for falls. The Care Plan included the following Interventions in place prior to the fall to have a pressure alarm at all times, is dependent on staff for transfers and toileting and documented he fell four times prior to the fall in the shower room. Review of the facility's Incident Report for Resident #13 on 1/24/26 documented they had an unwitnessed fall in the shower room. Prior to the fall the staff saw him in the sitting room in his wheelchair and somewhat anxious. It documented as Resident #13 was in the shower room, the Certified Nurses' Aide (CNA) left the resident unattended to retrieve the lift for assistance. On 2/24/26 at 3:05 PM Staff E, CNA, reported on the day Resident #13 fell in the shower room, he needed to use the bathroom, so she took him to the shower room to change him because the standing mechanical lift is usually in the shower room. She reported when she took him in the shower room there was no standing mechanical lift, so she left him in the shower room to go get the equipment. Staff E reported when she came back, she heard the alarm in his wheelchair going off with Resident #13 on the floor. In addition, she saw Staff F, Licensed Practical Nurse (LPN), and Staff G, CNA, in the room assessing Resident #13. Staff E reported she didn't know what she was thinking leaving him by himself in the shower room. Staff E reported she knew better but was in a hurry. On 2/24/26 at 3:18 PM Staff F, LPN, reported as she talked with Staff G in the hallway, they heard an alarm going off. Once they figured out the alarm was in the shower room, they went to go see what was going on. When they entered the shower room, they found Resident #13 on the floor in front of his wheelchair and yelling for help. Resident #13 had no injuries from the fall. Staff F reported Staff E didn't receive education following the fall. They added, it is just common knowledge to not leave a fall risk resident alone in the shower room. On 2/24/26 at 3:49 PM Staff G, reported she was working the day Resident #13 fell. Staff G reported she was not far from the shower room talking to the nurse after coming out of a room. Staff G heard an alarm going off and once she figured out it was the shower room she told Staff F, that she was going to check the alarm. When Staff F and Staff G entered the shower room, they found no staff present and Resident #13 on the floor in front of his wheelchair. Staff G reported the staff should know residents with alarms should not be left in the shower room unattended. Staff G reported they didn't receive education on leaving residents in the shower room she is aware of after the incident. On 2/25/26 at 1:40 PM the Director of Nursing (DON) reported staff are not to leave residents unattended in the shower room at any time.

Based on facility record review, staff interview and policy review, the facility failed to have the minimum required members necessary at the Quality Assessment and Assurance (QAA) meetings to identify issues with respect to which quality assessment and assurance activities. The facility reported a census of 36 residents. Findings include:Review of the facility QAA sign in sheets revealed the July and October 2025 quarterly meetings didn't have the Director of Nursing (DON) present.On 2/26/26 at 11:05 AM the Administrator reported the DON didn't attend the quarterly meetings for July and October because they were gone that day. She reported she didn't try to reschedule the meeting so the DON could attend. The undated facility policy titled Quality Assurance Program documented all staff members of the quality assurance team will meet quarterly with the Medical Director. The policy failed to define the quality assurance team members.

Based on resident interview, staff interviews and grievance policy the facility failed to provide prompt effort to resolve a grievance and failed to complete a grievance form related to missing items for 1 of 1 resident reviewed for missing property (Resident #34). The facility reported a census of 36 residents. Findings include: Resident #34's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of debility and cardiorespiratory conditions. On 1/28/25 at 8:50 AM, Resident #34 reported they had a missing black sweatshirt with an emblem that he received from family members prior to his retirement from employment. He added he reported it about three weeks before. He explained he had the same shirt in another color that he showed to the staff so they knew what to look for. He reported he had waited 3 weeks and still didn't have follow up on this from any staff. On 1/29/25 at 10:53 AM Staff G, Laundry, explained the process for missing items if she knew, she would search in other residents' rooms, closets, and drawers during about a week's time frame. Staff G reported if they didn't find the item she would alert Staff C, Social Services, who takes it from there, they probably contacts the family and determines if they need a replacement or some other resolution. On 1/30/25 at 9:30 AM Staff C explained they knew about Resident #34's missing sweat shirt and that he had another one just like it. She added that she didn't have a completed grievance form. Staff C explained they complete the form for items such as wallets, rings, and valuables, but they wouldn't complete the form for items such as a T shirt. On 1/30/25 at 10:50 AM the Administrator stated someone completed a Lost and Found item report that day, dated 1/22/24. The Administrator confirmed no one completed a grievance intake form per the facility policy. The Grievance, Missing Property policy dated 8/30/18 directed, all residents have the right to report property/items that may be missing. If unable to resolve immediately, follow the grievance procedure. 1. Grievances may be presented to any staff who will then report the issue utilizing the grievances form.

Based on observations, record review, staff interviews and policy review, the facility failed to follow physician orders to prevent further contractors for 1 of 1 residents reviewed (Resident #19). The facility reported a census of 36 residents. Findings include: Resident #19's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS included diagnoses of joint disorder, depression, arthritis, and anxiety. A Physician Order for Resident #19 dated 9/26/24 included the following orders: a. Palm grip to right hand at all times when in bed to prevent contractors b. Tubi grip to left hand daily to reduce moisture and prevent injury from her nails digging into her palm. Change on shower days and as needed (PRN). Resident #19's clinical record lacked documentation of notification with the physician on not doing the treatment nor that they voiced pain while providing the treatment order for their hands. The Plan of Care Note dated 1/7/25 at 2:48 PM reflected the facility had a Care Conference with Resident #19's family. They voiced wanting more staff encouragement to remind Resident #19 to move their right hand to minimize the risk of contracture to that hand. Observation on 1/27/25 at 3:00 PM, Resident #19 laid in bed with no palm grip to her right hand and no tubi grip to her left hand. Observation on 1/28/25 at 3:10 PM, Resident #19 laid in bed with no palm grip to her right hand and no tubi grip to her left hand. Observation on 1/29/25 at 2:37 PM Resident #19 laid in bed with no palm grip to her right hand and no tubi grip to her left hand. During an interview on 1/29/25 at 2:44 PM Staff F, Certified Nurses' Aide (CNA), reported the CNAs didn't do anything with Resident #19 hands, only the nurses did. In an interview on 1/29/25 at 2:46 PM Staff E, Licensed Practical Nurse (LPN), reported the only thing the nurses did for Resident #19's hands was to have a tubi grip to the right hand at all times. During an interview on 1/29/25 at 2:52 PM the Director of Nursing (DON) reported Resident #19's order for her hands got transcribed to the Treatment Administration Record (TAR) wrong and if it is not on there she assumed they didn't do it and not sure why it is documented if she refused. During an interview on 1/29/25 at 2:55 PM Staff D, Registered Nurse (RN), reported the staff tried in the past to put a wash cloth in Resident #19's right hand but she complained of pain so they stopped doing anything for her right hand. Staff D reported she didn't notify the physician at any time about Resident #19's hands. The facility policy Following Physician Orders revised 11/27/24 directed staff to follow the physician orders as ordered.

Based on observation, clinical record review, policy review, resident, and staff interview, the facility failed to ensure a resident received dental services for 1 of 1 Resident's (Resident #20) reviewed for dental services. The facility reported a census of 36 residents. Findings include: Resident #20's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included a diagnosis of dental caries (cavities). The Interdisciplinary Progress Note dated 2/22/22 at 1:58 PM documented on admission, Resident #20 didn't have any missing or broken teeth. The Care Plan Intervention initiated 5/19/22 directed to refer to professions as needed (PRN), if indicated by Primary Care Physician (PCP), or Psych services. Arrange for appointments with PCP, dental, eye professionals, and podiatrist, per government regulation, family, and at Resident #20's request. Resident #20's Medical Diagnosis included a diagnosis dated 7/29/22 of dental caries, unspecified. On 1/27/25 at 11:40 AM observed Resident #20 had a broken front tooth with the appearance of dental caries on her bottom teeth. During an interview on 1/27/25 at 11:41 AM Resident #20 reported her front tooth continued to chip away, and another piece of her top front tooth came out that morning. Resident #20 explained the front tooth started to chip after it came in contact with a bar during a transfer several months ago. She alerted Staff A, Certified Nursing Assistant (CNA). Resident #20 stated they haven't seen a dentist in a very long time, certainly not since she admitted to the nursing facility (2/23/22). Resident #20 stated she would like to see a dentist but, didn't know how to go about that or how to pay. She didn't know of options for dental services. During an interview on 1/29/25 at 12:10 PM Staff A recalled when Resident #20 alerted her of their chipped tooth, she didn't see any breakage. Staff A informed Staff B, Licensed Practical Nurse (LPN). During an interview on 1/29/25 at 12:20 PM Staff B recalled when Resident #20 complained of a chipped tooth. They assessed and didn't see signs of chipping or breaking of the tooth. Resident #20 didn't have any further complaints until now. During an interview on 1/29/25 at 12:29 PM Staff C, Social Services, explained Resident #20's insurance as a factor inhibiting their dental services. Staff C added they had difficulty finding a provider. Acknowledged they could have set up transportation available with the state insurance. Staff C reported Resident #20 needed accompanied and they didn't have supportive family. They added having staff accompany residents to outside providers in the past with the Administrator's approval. During an interview on 1/29/25 at 2:20 PM, the Director of Nursing (DON) reported Resident #20 lacked family support and felt they wouldn't be willing to pay for dental or assist with transportation. The DON explained in the event of an emergency dental situation, the emergency room could manage Resident #20 until they find a dental provider. The DON added Resident #20's dental services probably consisted of out of town providers only and they lacked family participation. During an interview on 1/29/25 at 4:45 PM the Administrator, explained they would consult with Resident #20's family and look at options for dental services. They didn't know of any dental options investigated for Resident #20. The facility provided a Denture policy and procedure dated 2022 directed, the nurse would assist the resident with both routine and 24 hour emergency dental care. Social Services would assist residents who are eligible and wish to participate to apply for reimbursement of dental services as incurred medical expense under the state plan if applicable.

Based on clinical record review, staff interviews and policy review the facility failed to provide a bed hold notice to 2 of 3 residents reviewed (Residents #7 and #18). The facility reported a census of 36 residents. Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. Resident #7's Clinical Census reflected a discharge to the hospital on 5/28/24. They returned to the facility on [DATE]. The clinical records lacked documentation of a bed hold notification provided to Resident #7 or Resident #7's Representative when discharged to the hospital on 5/28/24. On 1/28/25 at 2:01 PM, the Director of Nursing (DON) reported the facility didn't complete a bed hold for the hospitalization on [DATE]. The undated Reserve Bed Policy instructed to provide the resident or the resident's representative a Notice of Bed hold Policy upon transfer. 2. Resident #18's MDS assessment dated [DATE] identified a BIMS score of 9, indicating moderate cognitive impairment. Resident #18's Clinical Census indicated they discharged to the hospital on 11/19/24 and returned to the facility on [DATE]. Resident #18's clinical records lacked documentation that the facility provided a bed hold notification to Resident #18 or Resident #18's Representative when she discharged to the hospital on 11/19/24. On 1/28/25 at 2:48 PM, the DON reported the facility didn't complete a bed hold for the hospitalization on [DATE].

Based on clinical record review, staff interview, policy and procedure review, the facility failed to provide an environment free from sexual abuse for residents who didn't have the mental capacity to consent to sexual contact for 1 of 30 residents Resident #1). In addition, the facility failed to prevent a cognitive resident from having sexually aggressive behavior, such as inappropriate touching, grabbing, and fondling for 1 of 30 residents (Resident #2). On three separate occasions reflected Resident #2 fondled and touched Resident #1 underneath her clothes with the staff unaware of the situation. The facility failed to separate the 2 residents after the first and second incidents (4/15/24, and 5/1/24 in the common area). The facility failed to put in interventions in place until 4/15/24. The implemented interventions of continuous 15-minute checks lacked multiple areas of documentation following the 5/1/24 incident, reflecting the staff didn't monitor the residents' location as indicated. In addition, the facility failed to update Interventions on the Care Plan until 4/15/24. As the facility failed to ensure the safety interventions, this resulted in the likelihood of a serious adverse outcome to occur. It can be determined that the reasonable person in their position would have experienced severe psychosocial harm (e.g., embarrassment, humiliation) as a result of the abuse. This resulted in an immediate need for the facility to take steps to ensure the protection for all residents from the risk of abuse. The facility reported a census of 36 residents. On 8/14/24 at 3:15 PM, the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on 8/15/24 after the facility staff completed the following: a. Education on the expected care for residents who have the tendency to show public displays of sexual behavior on 8/14/24 via text and on 8/15/24 at 10:00 AM at the all staff in-person in-service. b. Leadership staff understand the importance of completing an investigation regarding any resident on resident behaviors to include those sexual in nature. c. The staff intervened within 5 minutes after the incidents to ensure the safety of Resident #1. The staff talked with Resident #2 about his inappropriate behaviors. d. Implemented Inappropriate Behavior Protocol (to include sexual in nature behaviors) to aid staff in addressing any inappropriate behaviors. e. The facility updated both Care Plans. f. Resident #1 moved to the locked memory care unit on 5/8/24 g. The facility contacted other facilities for placement of Resident #2. h. Resident #2 discharged to another care facility in on 6/11/24. The facility lowered the Immediate Jeopardy to an E level deficiency prior to the survey exit. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. Resident #1 required total assistance with toileting hygiene and transfers. Resident #1 didn't walk and used a wheelchair for mobility. The MDS included diagnoses of Alzheimer's disease, and non-Alzheimer's dementia. The Care Plan dated 5/7/24 indicated Resident #1 had a potential for a psychosocial well being problem related to inappropriate touch by another male due to experienced inappropriate touch from another male resident. Interventions included: *15-minute checks initiated for safety. *Family notified of incident. *(5/8/24) moved to locked unit in The locked memory care unit for her safety until perpetrator's behaviors subside and/or discharges to another facility. The family okayed the room change and the facility notified them the room change is short term. *(6/27/24) When conflict arises, remove resident to a calm safe environment and allow to vent/share feelings. The Communication with Family Note on 4/15/24 at 1:49 PM indicated the facility spoke with Resident #1's son about an incident of a male resident touching his mother inappropriately. The staff reported they removed her to a safe area. The facility planned to continue to monitor and provide safe environment for Resident #1. The Self-Report dated 5/1/24 at 12:34 PM, documented an allegation of abuse. A Certified Nurse Aide (CNA) reported to the charge nurse Resident #2 went to Resident #1 in the commons area and put his hand down her shirt. The CNA responded quickly and when they told him to keep his hands to himself, Resident #2 responded, no. The CNA redirected Resident #2 away from Resident #1 to the dining area. The facility started 15-minute checks for 24-hours and updated the Care Plan. The facility indicated the corrective action as 15 minutes checks indefinitely for the time being. Resident #2 added to the provider rounds on 5/7/24 and 5/9/24. The facility educated the staff to keep the residents apart. The Advanced Registered Nurse Practitioner returned the facility's notification fax with the response for the facility to supervise Resident #2 at all times around female residents. The Social Services Note on 5/1/24 at 4:55 PM documented a discussion with Resident #1 that afternoon regarding the report of another male resident reaching down her shirt and touching her inappropriately. The staff reported they separated the residents immediately. The facility didn't observe any immediate changes in mood, anxiety, and affect (emotions). When inquired about Resident #1's feelings, she replied she had so much to do and expressed concern that she couldn't get all the work done. When asked if she specifically felt safe, Resident #1 responded she felt safe as she didn't worry about getting hurt, because she had just so much to do as it's a big event. The Social Services Note dated 5/1/24 at 5:05 PM indicated the facility called Resident #1's son regarding another male resident reached down his mother's shirt. The caller explained that the staff immediately separated the residents and started new intervention of frequent visual checks for the male resident. The call reviewed the comments with his mother as well as the staff observations. Informed the facility took the interactions seriously and they would maintain communication with him. The son reported he needed to think and would call with any questions or concerns. The Self-Report dated 5/7/24 at 4:12 PM documented an allegation of abuse. A CNA observed Resident #2 put his hands down Resident #1's shirt while in the lobby, as Resident #1 waited in the lounge/lobby area to go for supper. The CNA redirected Resident #2 to the dining room and made sure Resident #1 was ok and not exposed. The facility indicated the corrective action as the following: a. 5/7/24 Interventions: i. Education provided to Resident #2 on the importance of not touching other residents. ii. Education provided to the staff to keep Resident #2 away from other female residents. iii. 15-minute checks continued indefinitely on Resident #2. iv. Initiated 15-minute checks on Resident #1. v. The provider saw Resident #1 on rounds. vi. Resident #2 saw the provider on 5/7/24 and had an increase of his antidepressant medications. vii. Resident #2 scheduled to see the Psychiatry provider on 5/9/24. b. 5/8/24 Interventions: i. The facility visited with Resident #2's son about his recurrent behaviors and new interventions. ii. The facility discussed referral options with Resident #2's son. iii. Son requested referral sent to previous facility. iv. Facility initiated referral. v. The facility transferred Resident #1 to another area within the facility away from Resident #2, a locked Alzheimer's wing. The Nurse Progress Note dated 5/7/24 at 7:25 PM reflected the facility called and spoke with Resident #1's son, about a male resident inappropriately touched his mother before supper that evening. When he asked the facility, what they planned to do about the male resident, the writer replied at the time they started interventions. The Director of Nursing (DON) planned a call to both families the next day. When the writer spoke with Resident #1 about the incident, she stated she didn't remember anything happening and felt fine. The staff ensured Resident #1 had her call light within reach. The facility placed Resident #1 on 15-minute checks at that time. The Social Services Note on 5/8/24 at 12:11 PM indicated the facility called Resident #1's son to discuss the on-going concern related to a male resident having inappropriate contact with his mother. The facility updated the other resident's family assisted relocating that resident. The facility inquired as to whether family would consider moving his mother to the locked memory care unit for the time being until situation can be resolved. Resident #1's son verbalized agreement with the plan. In addition, the staff initiated 15 minute checks for both residents, and provided staff supervision to his mother when she left her room. The facility's Self-Report submitted 5/8/24 at 3:40 PM reflected an allegation of abuse following a Certified Nurse Aide (CNA) reporting he saw Resident #2 put his hands down Resident #1's shirt while in the lobby of the facility. When the CNA told Resident #2 to keep his hands to himself, Resident #2 replied no. The CNA redirected Resident #2 from Resident #1 and started 15-minute checks for 24 hours. The facility notified the interim Director of Nursing (DON), Administrator, and Social Worker. In addition, they added Resident #2 to the nursing home rounds. The facility notified the staff to keep the 2 residents separated. The Social Services Note dated 5/8/24 at 4:51 PM reflected Resident #1 had a room change. Resident #1 moved to a room in The locked memory care unit for as a short-term safety precaution. Resident #1 continued with a pleasant demeanor, smiles and answered direct questions. When asked if she had anything on her mind, she replied it's beautiful, nice, and sunny. The staff noted her mood, behavior, and affect unchanged/stable. The facility called Resident #1's son to inform him of her new room. He reported he understood the reasons for the move and verbalized he appreciated the facility implemented strategies to maximize his mother's safety. The facility and clinical record lacked documentation of any incident reports/investigations related to the incidents. 2. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 14, indicating intact cognition. The MDS listed Resident #2 as independent with activities of daily living and used a walker for mobility. Resident #2 exhibited behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days in the lookback period. In addition, the MDS indicated he significantly intruded on the privacy or activity of others. The MDS included diagnoses of coronary artery disease (impaired arteries of the heart), heart failure, hypertension (high blood pressure), non Alzheimer's dementia and chronic kidney disease. The Care Plan initiated 4/16/24, identified Resident #2 as resident of the facility. The Care Plan included the following problems: a. Hand-written documentation: 4/15/24 that he inappropriately touched a female resident. The staff intervened and redirected him. Provided education to Resident #2 on keeping his hands to himself. Educated the staff on resident not being around female residents. Monitor behaviors and added to the provider rounds. The goal reflected he would maintain his current level of function in all activities of daily living (ADLs) safety and thoroughly through the review date. The additional hand-written information indicated he saw the provider on rounds and started an antidepressant. b. Resident #2 attempted to touch female residents inappropriately at times. Additional hand-written documentation indicated 5/7/24: Inappropriate touching of a female resident. Education provided to Resident #2 and the staff. Provide direct supervision when out of his room. Continue 15-minute checks. Antidepressant increased. Added hand-written documentation 5/10/24: Current antidepressant discontinued and new antidepressant started with Depakote per the Psychiatric provider. The Goal reflected he would verbalize the need to control behavior through the review date. Hand-written documentation 5/8/24: Voluntary discharge process underway. Referral initiated to previous facility per son's request. 5/14/24: Previous facility completed their evaluation with a plan to transfer Resident #2 to new location beginning the next week. *(4/16/24) Monitor and document observed behaviors and attempted interventions in behavior log. *(4/16/24) Provide close supervision when Resident #2 is around female residents. *(5/2/24) Provide redirection as needed: Past Interests /Conversation Starters: Resident enjoys reading the newspaper, he used to work with scrap iron junking, and drove truck to the scrap yard. Favorite television shows include Gunsmoke and old westerns. *(5/2/24) Resident to be seen on Dr Rounds 5/7/24. Referral to Psychiatry as recommended. Referral for Talk Therapy as needed (PRN). *(5/2/24) Redirect when wandering, invading other resident's personal space, and monitor/report behaviors to charge nurse. *(5/9/24) Hand-written: Saw Psychiatry provider and recommendations sent to the ARNP. *(5/17/24) Hand-written: Facility visited with Resident #2's son and he didn't know when he would transfer to his previous facility. The family requested referrals sent to additional facilities. The Social Services Note dated 4/9/24 at 3:09 PM recorded a staff member notified the writer Resident #2 held another female resident's hand during the movie and popcorn activity. During this time, he attempted to take Resident #1's hand and place it on his chest underneath his denim bibs. The writer spoke with Resident #1 about inappropriate behavior and reminded him to respect peers and not to touch anyone inappropriately. The writer notified the Charge Nurse of the incident. The facility would continue to monitor for those types of behaviors. The Social Services Note dated 4/10/24 at 12:19 PM reflected the staff saw Resident #2 inappropriately touch another resident. After the staff moved Resident #2 to a safe place, they contacted the social worker and charge nurse. The Nurse Progress Note dated 4/14/24 at 6:31 PM, labeled Late Entry reflected the writer saw Resident #2 outside of another resident's room. The writer redirected him to his room. The Nurse Progress Note dated 4/15/24 at 10:16 AM, indicated the staff found Resident #2 in the commons area visiting with another resident with his hand down the resident's shirt. The staff moved the resident to a safe area. The staff spoke to Resident #2 about his inappropriate behaviors and left a voicemail his son to call back at his convenience. The staff planned to continue watching for behaviors. The Nurse Progress Note dated 4/15/24 at 10:49 AM, recorded the nurse informed Resident #2's son of Resident #2's inappropriate behaviors when he returned the call. Resident #2's son stated he would have a face to face conversation with Resident #2 when he had time the next day. The Nurse Progress Note dated 4/15/24 at 3:35 PM, reflected the CNA's reported Resident #2 outside of another resident's room. He looked at the door, then he attempted to try and open the door. The staff redirected him. The Nurse Progress Note dated 4/15/24 at 8:30 PM indicated Resident #2 didn't have further attempts to enter the woman's room and no behaviors noted. The Nurse Progress Note dated 4/16/24 at 10:50 AM, reflected Resident #2 attempted to enter a female resident's room while she slept. The staff redirected him to the commons area. Resident #2 cooperated with the staff. The Nurse Progress Note dated 4/17/24 at 11:13 AM, documented after Resident #2 finished listening to the music, he left the chapel, and stood in the commons area. Resident #2 walked over to a female resident and started to rub her shoulder. The staff redirected Resident #2 immediately. Resident #2 requested to go to the dining room for lunch. The Social Services Note dated 4/17/24 at 3:27 PM recorded the writer spoke with Resident #2 about not invading the privacy of peers. Resident #2 voiced understanding. In addition, encouraged him to keep his hands to himself and not touch peers inappropriately. The Nurse Progress Note dated 4/18/24 at 1:19 PM reflected Resident #2 didn't make any inappropriate comments, inappropriate touching of any of the staff or residents at the facility, or wondering into any other rooms. The facility planned to monitor him. The Nurse Progress Note dated 5/1/24 at 12:34 PM, reflected a CNA reported to the charge nurse Resident #2 went up to a female resident in the commons area and put his hand down her shirt. The CNA responded quickly and when they told him to keep his hands to himself, Resident #2 responded, no. The CNA redirected Resident #2 away from Resident #1 to the dining area. The facility started 15-minute checks for 24-hours and updated the Care Plan. The Self-Report dated 5/1/24 at 12:34 PM, documented an allegation of abuse. A Certified Nurse Aide (CNA) reported to the charge nurse Resident #2 went to Resident #1 in the commons area and put his hand down her shirt. The CNA responded quickly and when they told him to keep his hands to himself, Resident #2 responded, no. The CNA redirected Resident #2 away from Resident #1 to the dining area. The facility started 15-minute checks for 24-hours and updated the Care Plan. The facility indicated the corrective action as 15 minutes checks indefinitely for the time being. Resident #2 added to the provider rounds on 5/7/24 and 5/9/24. The facility educated the staff to keep the residents apart. The Advanced Registered Nurse Practitioner returned the facility's notification fax with the response for the facility to supervise Resident #2 at all times around female residents. The Nurse Progress Note dated 5/1/24 at 1:47 PM indicated the facility updated the 15- minute checks to continue indefinitely for the time being and added to rounds. The staff educated to keep residents apart. The Nurse Progress Note dated 5/1/24 at 2:28 PM documented the staff reported Resident #2 touched another resident in an inappropriate manner. The staff visited with Resident #2 regarding the concern and explained he couldn't touch another resident in an inappropriate manner. In addition, the staff wrote the message on his whiteboard. Resident #2 voiced he understood he shouldn't touch and respect other residents. Staff initiated 15 minute checks indefinitely. The staff contacted Resident #2's son by telephone to update on the situation, the son voiced agreement with the plan of care. The Nurse Progress Note dated 5/7/24 at 4:12 PM indicated the staff observed Resident #2 putting his hand down another resident's shirt while in the lobby. The CNA redirected him to the dining room. The Self-Report dated 5/7/24 at 4:12 PM documented an allegation of abuse. A CNA observed Resident #2 put his hands down Resident #1's shirt while in the lobby, as Resident #1 waited in the lounge/lobby area to go for supper. After redirecting Resident #2 to the dining room, the CNA checked to see if Resident #1 was ok and not exposed. The facility indicated the corrective action as the following: a. 5/7/24 Interventions: i. Education provided to Resident #2 on the importance of not touching other residents. ii. Education provided to the staff to keep Resident #2 away from other female residents. iii. 15-minute checks continued indefinitely on Resident #2. iv. Initiated 15-minute checks on Resident #1. v. The provider saw Resident #1 on rounds. vi. Resident #2 saw the provider on 5/7/24 and had an increase of his antidepressant medications. vii. Resident #2 scheduled to see the Psychiatry provider on 5/9/24. b. 5/8/24 Interventions: i. With the family's consent, the facility transferred Resident #1 to another area within the facility away from Resident #2, into a locked Alzheimer's wing. The Communication with Family Note dated 5/7/24 at 4:20 PM documented the facility called Resident #2's son to update of him inappropriately touching another resident in the lobby. The Communication with Physician dated 5/7/24 at 4:26 PM labeled Late Entry reflected the CNA reported to the nurse that he observed Resident #2 touching another resident inappropriately in the lobby. The situation is recurrent behaviors of the same nature with these two residents. The CNA redirected Resident #2 to the dining room for the evening meal and educated him on the importance of not touching other residents. The facility placed both residents on 15-minute checks by staff again. The facility educated the staff to keep the two residents separated. The Nurse Progress Note dated 5/8/24 at 12:21 PM reflected a follow-up regarding the report of another incident of Resident #2 inappropriately touching another resident. Visited with Resident #2 who denied recollection of the incident from the day before. The author reiterated to Resident #2 that behavior is not acceptable. The facility called Resident #2's son and explained the facility couldn't tolerate Resident #2's behavior. The author informed him the facility had a goal to keep all residents safe. For that reason, they recommended he review relocating his father for his benefit as well as the benefit for the other resident. The 15 Minutes Resident Checks Form lacked documentation on the following dates and times of Resident #2's whereabouts: *5/1/24 from 8:30 PM 10:00 PM *5/2/24 from 7:00 AM 8:00 AM and 2:30 PM 3:30 PM *5/3/24 from 2:30 PM 10:00 PM *5/6/24 from 2:00 PM 10:00 PM *5/10/24 from 6:30 AM 10:00 PM Interview on 8/13/24 at 1:50 PM, Staff A, Social Worker/Admission Coordinator, said Resident #2 and Resident #1 knew each other from being neighbors in the community. They sat by each other at activities and in the dining room. They held hands and Resident #2 would rub Resident #1 shoulders. Staff A described the interactions as friendly gestures, then it escalated to inappropriate touching/behaviors with Resident #2. Staff A verified the incident on 4/9/24 as the same incident as 4/10/24. Staff A said after the first incident she didn't think anyone directed to watch Resident #2 and Resident #1. In addition, she didn't believe they put any interventions or instructions in place to prevent further incidents. Staff A said to her knowledge no other incidents happened to any other residents, only with Resident #1. Staff A said she didn't report the 4/9/24 incident to anyone due to it being a friendly gesture between two old friends. Now when she looked back at it, she should have separated them right away, and added interventions to the Care Plan. Interview on 8/13/24 at 3:20 PM Staff B, Activity Director, said the incident on 4/9/24 happened in the chapel, during a movie Resident #2 and Resident #1 held hands. Then nonchalantly Resident #2 took Resident #1 hand and put it inside of Resident #2 bib overalls. She went to Resident #2 and told him that it was not appropriate for him to place Resident #1's hand inside of his bibs. Staff B, took Resident #1's hand out from under his bibs. Staff B said she didn't remember if anyone told the Administrator or Director of Nursing (DON) about the incident. Staff B, said she now knew any allegation of abuse needs reported right away. She verified the facility didn't report the incident to the DIAL and/or update the Care Plan. Interview on 8/13/24 at 3:50 PM, Staff C, Licensed Practical Nurse (LPN), said she didn't know of the incident on 4/9/24. Staff C said after the 4/15/24 incident, Staff D, Registered Nurse (RN), and Staff A told the staff to make sure and keep a closer eye on Resident #2 and Resident #1. In addition, make sure Resident #2 is nowhere near Resident #1. Staff C, said the 5/1/24 incident they started a directive to do 15-minute checks on Resident #2 and Resident #1. Staff C described the 5/7/24 incident as Resident #2 came out of the chapel and Resident #1 sat in the rock n go chair facing towards the television on the south wall. Resident #2 walked up to Resident #1 and put his hands down her shirt. The CNA, said he had his back towards Resident #1 talking with another staff member. When he turned around Resident #2 had his hand down her shirt. They went over right away, removed Resident #2 from the area, and told Resident #2 that was very inappropriate. Interview on 8/13/24 at 4:00 PM, Staff D, RN, said she spoke to Resident #2 about the incidents on 4/9/24 and 4/10/24. Staff D explained to Resident #2 the facility didn't allow inappropriate touching. They just told the staff to keep an eye on both residents when out of their rooms. Staff D confirmed she didn't put anything on the Care Plan about the incident. Interview on 8/14/24 at 9:30 AM, Staff E, RN, said that he didn't know about the 4/9/24 or 4/10/24 incident. The facility directed the staff on 4/15/24 to just keep Resident #1 and Resident #2 away from each other, they didn't get any other communication to prevent any further incidents from happening. Interview on 8/14/24 at 11:50 AM, Staff F, CNA, said didn't know about the incident between Resident #2 and Resident #1 until after she found Resident #2 with his hand down Resident #1's shirt on 5/1/24. Staff F said Resident #2 stood next to Resident #1 in the common area, with one hand down Resident #1's shirt. Staff F said the facility didn't give any directive on the 4/9/24 or 4/15/24 incident and they didn't have a communication book to look at. After the 5/1/24 incident the facility told them to keep a close eye on Resident #2. If he tried to go to Resident #1, they should redirect and navigate him to another area of the facility. The undated Abuse Prevention/Identification Policies and Procedure defined the purpose as to protect residents from other human beings (staff, visitors, family members or other residents) who may perpetrate verbal, sexual, physical, financial, and mental abuse, corporal punishment or involuntary seclusion. The Policy directed no resident is subjected to abuse through words of deeds of any person, from within or out of the facility. The facility will assure that all residents are free from neglect, mistreatment, and misappropriation of their property. The facility will do all within its control to prevent actions from occurring. That included doing whatever possible to control resident-on-resident altercations from occurring.

Based on clinical record review, staff interview, and facility policy/procedure the facility failed to report an allegation of abuse to the Department of Inspections, Appeals, and Licensing (DIAL) following the observation of a male resident putting a female resident's hand inside his bib overalls or the continued instances of him putting his hand down the female resident's shirt for 2 of 5 residents reviewed (Residents #1 and #2). The failure to report the incident resulted in an immediate jeopardy situation. See citation F600 for additional information. The facility reported a census of 36 residents. On 8/14/24 at 3:15 PM, the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on 8/15/24 after the facility staff completed the following: a. Education on the expected care for residents who have the tendency to show public displays of sexual behavior, including reporting on 8/14/24 via text and on 8/15/24 at 10:00 AM at the all staff in-person in-service. b. Leadership staff understand the importance of completing an investigation regarding any resident on resident behaviors to include those sexual in nature. c. Implemented Inappropriate Behavior Protocol (to include sexual in nature behaviors) to aid staff in addressing any inappropriate behaviors. The facility lowered the Immediate Jeopardy to an E level deficiency prior to the survey exit. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. Resident #1 required total assistance with toileting hygiene and transfers. Resident #5 didn't walk and used a wheelchair for mobility. The MDS included diagnoses of Alzheimer's disease, and non-Alzheimer's dementia. Resident #1's clinical record reflected a male resident (Resident #2) continued to make sexual advances to her on the following days: a. 5/1/24 b. 5/7/24 c. 5/8/24 2. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 14, indicating intact cognition. The MDS listed Resident #2 as independent with activities of daily living and used a walker for mobility. Resident #2 exhibited behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days in the lookback period. In addition, the MDS indicated he significantly intruded on the privacy or activity of others. The MDS included diagnoses of coronary artery disease (impaired arteries of the heart), heart failure, hypertension (high blood pressure), non Alzheimer's dementia and chronic kidney disease. Resident #2's clinical record reflected he continued to touch a resident (Resident #1) with impaired cognition and without the ability to consent on the following days: a. 4/9/24: Resident #2 took Resident #1's hand and placed it inside his bib overalls. b. 4/10/24: Staff observed Resident #2 with his hand down Resident #1's shirt. c. 4/15/24: Staff observed Resident #2 with his hand down Resident #1's shirt. d. 5/1/24: Staff observed Resident #2 with his hand down Resident #1's shirt. e. 5/7/24: Staff observed Resident #2 with his hand down Resident #1's shirt. f. 5/8/24: Staff observed Resident #2 with his hand down Resident #1's shirt. The Self-Report dated 5/1/24 at 12:34 PM, documented an allegation of abuse. A Certified Nurse Aide (CNA) reported to the charge nurse Resident #2 went to Resident #1 in the commons area and put his hand down her shirt. The CNA responded quickly and when they told him to keep his hands to himself, Resident #2 responded, no. The CNA redirected Resident #2 away from Resident #1 to the dining area. The facility started 15-minute checks for 24-hours and updated the Care Plan. The facility indicated the corrective action as 15 minutes checks indefinitely for the time being. Resident #2 added to the provider rounds on 5/7/24 and 5/9/24. The facility educated the staff to keep the residents apart. The Advanced Registered Nurse Practitioner returned the facility's notification fax with the response for the facility to supervise Resident #2 at all times around female residents. The Self-Report dated 5/7/24 at 4:12 PM documented an allegation of abuse. A CNA observed Resident #2 put his hands down Resident #1's shirt while in the lobby, as Resident #1 waited in the lounge/lobby area to go for supper. The CNA redirected Resident #2 to the dining room and made sure Resident #1 was ok and not exposed. The facility indicated the corrective action as the following: a. 5/7/24 Interventions: i. Education provided to Resident #2 on the importance of not touching other residents. ii. Education provided to the staff to keep Resident #2 away from other female residents. iii. 15-minute checks continued indefinitely on Resident #2. iv. Initiated 15-minute checks on Resident #1. v. The provider saw Resident #1 on rounds. vi. Resident #2 saw the provider on 5/7/24 and had an increase of his antidepressant medications. vii. Resident #2 scheduled to see the Psychiatry provider on 5/9/24. b. 5/8/24 Interventions: i. The facility visited with Resident #2's son about his recurrent behaviors and new interventions. ii. The facility discussed referral options with Resident #2's son. iii. Son requested referral sent to previous facility. iv. Facility initiated referral. v. The facility transferred Resident #1 to another area within the facility away from Resident #2, a locked Alzheimer's wing. The facility, Resident #1, and Resident #2's clinical records lacked documentation of the facility reporting any incidents to the DIAL until 5/1/24 and then not again until 5/7/24. This reflected incidents not reported for the 4/9/24, 4/10/24, or the 4/15/24. Interview on 8/13/24 at 1:50 PM, Staff A, Social Worker/Admission Coordinator, said Resident #2 and Resident #1 knew each other from being neighbors in the community. They sat by each other at activities and in the dining room. They held hands and Resident #2 would rub Resident #1 shoulders. Staff A described the interactions as friendly gestures, then it escalated to inappropriate touching/behaviors with Resident #2. Staff A verified the incident on 4/9/24 as the same incident as 4/10/24. Staff A said she didn't report the 4/9/24 incident to anyone due to it being a friendly gesture between two old friends. Now when she looked back at it, she should have separated them right away, and added interventions to the Care Plan. Interview on 8/13/24 at 3:20 PM Staff B, Activity Director, said the incident on 4/9/24 happened in the chapel, during a movie Resident #2 and Resident #1 held hands. Then nonchalantly Resident #2 took Resident #1's hand and put it inside of his bib overalls. She went to Resident #2 and told him that it was not appropriate for him to place Resident #1's hand inside of his bibs. Staff B, took Resident #1's hand out from under his bibs. Staff B said she didn't remember if anyone told the Administrator or Director of Nursing (DON) about the incident. Staff B, said she now knew any allegation of abuse needs reported right away. She verified the facility didn't report the incident to the DIAL and/or update the Care Plan. Interview on 8/13/24 at 4:00 PM, Staff D, RN, said she spoke to Resident #2 about the incidents on 4/9/24 and 4/10/24. Staff D explained to Resident #2 the facility didn't allow inappropriate touching. Staff D said she didn't do an investigation on the incidents and/or didn't report it to DIAL. She added the 4/15/24 incident didn't get report to the DIAL either. Interview on 8/13/24 at 4:45 PM, the Administrator said they expected the staff to start an investigation into any allegation of abuse. He verified no one told him of the 4/9/24, 4/10/24, and 4/15/24 incidents. The Administrator said the staff knew the policy to notify DIAL within a certain time frame, to start/initiate, and investigate. The facility went over the information during in-services, the new staff orientation policy, and procedures. The Administrator confirmed they expected the staff to follow the facility policy/procedures for reporting/investigating allegations. Interview on 8/14/24 at 11:50 AM, Staff F, CNA, said didn't know about the incident between Resident #2 and Resident #1 until after she found Resident #2 with his hand down Resident #1's shirt on 5/1/24. Staff F said Resident #2 stood next to Resident #1 in the common area, with one hand down Resident #1's shirt. Staff F said the facility didn't give any directive on the 4/9/24 or 4/15/24 incident and they didn't have a communication book to look at. After the 5/1/24 incident the facility told them to keep a close eye on Resident #2. If he tried to go to Resident #1, they should redirect and navigate him to another area of the facility. Staff F explained if they had an allegation of abuse, they are told to tell upper management. They will start an investigation, conduct interview, and notify the DIAL. The undated Abuse Prevention/Identification Policies and Procedure directed to report abuse allegations per Federal and State law. The facility will ensure that all alleged violations involving abuse are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the event that caused the allegation didn't involve abuse and didn't result in serious bodily injury. The staff must immediately report within 2 hours to the DON or Administrator or their designee any violations concerning mistreatment, neglect or abuse, including injuries of unknown source or misappropriation of resident property, no later than 24 hours if the events that cause the allegation didn't involve abuse or didn't result in serious bodily injury. The undated Abuse Investigation Policy instructed to assure all residents are protected from any form of abuse. To assure anyone committing any form of abuse is identified and removed from further opportunity to inflict. Any staff, who observes or are aware of an abuse situation occurring from staff and /or families, will report it immediately to the Administrator of Director of Nursing. In the event that the Administrator of Director of Nursing are not available staff should report any allegation to the Supervisor of duty. *When a report of suspected or alleged abuse is made to a supervisor, the person to whom it is reported will immediately begin the investigation process. *Staff will immediately report within 2 hours to the DON or Administrator or their designee any violations concerning mistreatment, neglect or abuse, including injuries or unknown source, or misappropriation of resident property or not later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury.

Based on clinical record review, policy review, staff interview, the facility staff failed to thoroughly investigate all allegations of abuse, and separate a possible abuser from other residents. The facility lacked documentation of thorough investigations. In addition, the facility failed to conduct resident and staff interviews to determine the extent of the allegations, and if other residents were involved. The facility failed to separate the two residents until the incident occurred a third time and the family had to request something be done. After the facility added an intervention to monitor first Resident #2, then Resident #1's location, the facility failed to document as indicated. The facility's failure to investigate and separate the alleged abuser from the alleged victim resulted in an immediate jeopardy situation. It can be determined that the reasonable person in their position would have experienced severe psychosocial harm (e.g., embarrassment, humiliation) as a result of the abuse. See citations F600 and F609 for additional information. The facility reported a census of 36 residents. On 8/14/24 at 3:15 PM, the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on 8/15/24 after the facility staff completed the following: a. Education on the expected care for residents who have the tendency to show public displays of sexual behavior on 8/14/24 via text and on 8/15/24 at 10:00 AM at the all staff in-person in-service. b. Leadership staff understand the importance of completing an investigation regarding any resident on resident behaviors to include those sexual in nature. c. Implemented Inappropriate Behavior Protocol (to include sexual in nature behaviors) to aid staff in addressing any inappropriate behaviors. d. Resident #1 moved to the locked memory care unit on 5/8/24 e. The facility contacted other facilities for placement of Resident #2. f. Resident #2 discharged to another care facility in on 6/11/24. The facility lowered the Immediate Jeopardy to an E level deficiency prior to the survey exit. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. Resident #1 required total assistance with toileting hygiene and transfers. Resident #1 didn't walk and used a wheelchair for mobility. The MDS included diagnoses of Alzheimer's disease, and non-Alzheimer's dementia. The Communication with Family/NOK/POA Note dated 4/15/24 at 1:49 PM reflected the facility contacted Resident #1's son to notify him a male resident touched his mother inappropriately. The facility told the son they moved Resident #1 to a safe area. The Care Plan dated 5/7/24 indicated Resident #1 had a potential for a psychosocial well being problem related to inappropriate touch by another male due to experienced inappropriate touch from another male resident. Interventions included: *15-minute checks initiated for safety. *Family notified of incident. *(5/8/24) moved to locked memory care unit for her safety until perpetrator's behaviors subside and/or discharges to another facility. The family okayed the room change and the facility notified them the room change is short term. *(6/27/24) When conflict arises, remove resident to a calm safe environment and allow to vent/share feelings. Resident #1's clinical record lacked documentation to keep the male resident away from her. The facility and clinical record lacked documentation of any incident reports/investigations related to the incidents. 2. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 14, indicating intact cognition. The MDS listed Resident #2 as independent with activities of daily living and used a walker for mobility. Resident #2 exhibited behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days in the lookback period. In addition, the MDS indicated he significantly intruded on the privacy or activity of others. The MDS included diagnoses of coronary artery disease (impaired arteries of the heart), heart failure, hypertension (high blood pressure), non Alzheimer's dementia and chronic kidney disease. The Care Plan initiated 4/16/24, identified Resident #2 as resident of the facility. The Care Plan included the following problems: a. Hand-written documentation: 4/15/24 that he inappropriately touched a female resident. The staff intervened and redirected him. Provided education to Resident #2 on keeping his hands to himself. Educated the staff on resident not being around female residents. Monitor behaviors and added to the provider rounds. The goal reflected he would maintain his current level of function in all activities of daily living (ADLs) safety and thoroughly through the review date. The additional hand-written information indicated he saw the provider on rounds and started an antidepressant. b. Resident #2 attempted to touch female residents inappropriately at times. Additional hand-written documentation indicated 5/7/24: Inappropriate touching of a female resident. Education provided to Resident #2 and the staff. Provide direct supervision when out of his room. Continue 15-minute checks. Antidepressant increased. Added hand-written documentation 5/10/24: Current antidepressant discontinued and new antidepressant started with Depakote per the Psychiatric provider. The Goal reflected he would verbalize the need to control behavior through the review date. Hand-written documentation 5/8/24: Voluntary discharge process underway. Referral initiated to previous facility per son's request. 5/14/24: Previous facility completed their evaluation with a plan to transfer Resident #2 to new location beginning the next week. *(4/16/24) Monitor and document observed behaviors and attempted interventions in behavior log. *(4/16/24) Provide close supervision when Resident #2 is around female residents. *(5/2/24) Provide redirection as needed: Past Interests /Conversation Starters: Resident enjoys reading the newspaper, he used to work with scrap iron junking, and drove truck to the scrap yard. Favorite television shows include Gunsmoke and old westerns. *(5/2/24) Resident to be seen on Dr Rounds 5/7/24. Referral to Psychiatry as recommended. Referral for Talk Therapy as needed (PRN). *(5/2/24) Redirect when wandering, invading other resident's personal space, and monitor/report behaviors to charge nurse. *(5/9/24) Hand-written: Saw Psychiatry provider and recommendations sent to the ARNP. *(5/17/24) Hand-written: Facility visited with Resident #2's son and he didn't know when he would transfer to his previous facility. The family requested referrals sent to additional facilities. Resident #2's son to update of him inappropriately touching another resident in the lobby. Resident #2's clinical record lacked direction to keep him separated from Resident #1 on the typed information of the Care Plan last revised 4/17/24. The facility added handwritten information for 4/15/24 on that same Care Plan. The 15 Minutes Resident Checks Form lacked documentation on the following dates and times of Resident #2's whereabouts: *5/1/24 from 8:30 PM 10:00 PM *5/2/24 from 7:00 AM 8:00 AM and 2:30 PM 3:30 PM *5/3/24 from 2:30 PM 10:00 PM *5/6/24 from 2:00 PM 10:00 PM *5/10/24 from 6:30 AM 10:00 PM The facility failed to keep Resident #1 safe from Resident #2 by failing to ensure he stayed away from Resident #1 following the first incident on 4/9/24 or the second incident on 4/15/24. Resident #2 continued to have access to Resident #1 before staff intervened on the following days: a. 4/9/24: Resident #2 took Resident #1's hand and placed it on his chest inside his bib overalls during an activity. b. 4/15/24: Resident #2 reached down Resident #1's shirt in commons area c. 4/17/24: After leaving the chapel, Resident #2 walked over to Resident #1 and started to rub her shoulder. d. 5/1/24: Resident #2 put his hand down Resident #1's shirt in the commons area. e. 5/7/24: Resident #2 observed putting his hand down Resident #1's shirt in the lobby. Interview on 8/13/24 at 1:50 PM, Staff A, Social Worker/Admission Coordinator, said after the first incident she didn't think anyone directed the staff to watch Resident #2 and Resident #1. In addition, she didn't believe they put any interventions or instructions in place to prevent further incidents. Staff A said to her knowledge no other incidents happened to any other residents, only with Resident #1. Staff A said she didn't report the 4/9/24 incident to anyone due to it being a friendly gesture between two old friends. Now when she looked back at it, she should have separated them right away, and added interventions to the Care Plan. Interview on 8/13/24 at 3:50 PM, Staff C, Licensed Practical Nurse (LPN), said she didn't know of the incident on 4/9/24. Staff C said after the 4/15/24 incident Staff D, Registered Nurse (RN), and Staff A told the staff to make sure and keep a closer eye on Resident #2 and Resident #1. In addition, make sure Resident #2 is nowhere near Resident #1. Staff C, said the 5/1/24 incident they started a directive to do 15-minute checks on Resident #2 and Resident #1. Staff C described the 5/7/24 incident as Resident #2 came out of the chapel and Resident #1 sat in the rock n go chair facing towards the television on the south wall. Resident #2 walked up to Resident #1 and put his hands down her shirt. The CNA, said he had his back towards Resident #1 talking with another staff member. When he turned around Resident #2 had his hand down her shirt. They went over right away, removed Resident #2 from the area, and told Resident #2 that was very inappropriate. Interview on 8/13/24 at 4:00 PM, Staff D, RN, said she spoke to Resident #2 about the incidents on 4/9/24 and 4/10/24. Staff D explained to Resident #2 the facility didn't allow inappropriate touching. Staff D said she didn't do an investigation on the incidents and/or didn't report it to DIAL. They implemented the intervention to redirect Resident #2 away from Resident #1. Staff D stated that she didn't do a thorough investigation on the incident, as she didn't interview staff or other residents. They just told the staff to keep an eye on both residents when out of their rooms. Staff D confirmed she didn't put anything on the Care Plan about the incident. She didn't think the facility had a paper incident/accident report made out. Interview on 8/13/24 at 4:45 PM, the Administrator said they expected the staff to start an investigation into any allegation of abuse. He verified no one told him of the 4/9/24, 4/10/24, and 4/15/24 incidents. The administrator confirmed the facility didn't have, as he couldn't find, a completed thorough investigation with staff or resident interviews in the facility. The facility went over the information during in-services, the new staff orientation policy, and procedures. The Administrator confirmed they expected the staff to follow the facility policy/procedures for reporting/investigating allegations. Interview on 8/14/24 at 9:30 AM, Staff E, RN, said that he didn't know about the 4/9/24 or 4/10/24 incident. The facility directed the staff on 4/15/24 to just keep Resident #1 and Resident #2 away from each other, they didn't get any other communication to prevent any further incidents from happening. Interview on 8/14/24 at 11:50 AM, Staff F, CNA, said didn't know about the incident between Resident #2 and Resident #1 until after she found Resident #2 with his hand down Resident #1's shirt on 5/1/24. Staff F said Resident #2 stood next to Resident #1 in the common area, with one hand down Resident #1's shirt. Staff F said the facility didn't give any directive on the 4/9/24 or 4/15/24 incident and they didn't have a communication book to look at. After the 5/1/24 incident the facility told them to keep a close eye on Resident #2. If he tried to go to Resident #1, they should redirect and navigate him to another area of the facility. Staff F explained if they had an allegation of abuse, they are told to tell upper management. They will start an investigation, conduct interview, and notify the DIAL. The undated Abuse Prevention/Identification Policies and Procedure defined the purpose as to protect residents from other human beings (staff, visitors, family members or other residents) who may perpetrate verbal, sexual, physical, financial, and mental abuse, corporal punishment or involuntary seclusion. The facility will assure that all residents are free from neglect, mistreatment, and misappropriation of their property. The facility will do all within its control to prevent actions from occurring. That included doing whatever possible to control resident-on-resident altercations from occurring. The Procedure instructed the facility to take actions necessary to provide a safe, secure environment that will protect the right of all residents who reside in the facility. The facility will ensure staff, visitor, family members or other residents do not use verbal, mental, sexual, financial or physical abuse, corporal punishment or seclusion toward a resident. The facility supervisors will routinely monitor the facility staff to assure the delivery of resident care and services and to assure the potential for abuse or neglect is minimized.

Based on clinical record review, policy and procedure review, and staff interviews the facility failed to recognize a resident as a victim prior to transferring them to a different unit, instead of their alleged abuser for 1 of 5 residents reviewed (Resident #1). It can be determined that the reasonable person in the resident's position would have experienced severe psychosocial harm (e.g., embarrassment, punishment, humiliation, anxiety) as a result of having to move after getting violated by another resident. The facility identified a census of 36 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. Resident #1 required total assistance with toileting hygiene and transfers. Resident #1 didn't walk and used a wheelchair for mobility. The MDS included diagnoses of Alzheimer's disease, and non-Alzheimer's dementia. The Communication - with Family Note dated 4/15/24 at 1:49 PM indicated the facility discussed the incident with Resident #1's son about a male resident touching her inappropriately. The staff explained they moved Resident #1 to a safe area and addressed all questions, who voiced no concerns. The staff planned to monitor and provide safe environment for Resident #2. The Social Services Note on 5/1/24 at 4:55 PM documented a discussion with Resident #1 that afternoon regarding the report of another male resident reaching down her shirt and touching her inappropriately. The staff reported they separated the residents immediately. The facility didn't observe any immediate changes in mood, anxiety, and affect (emotions). When inquired about Resident #1's feelings, she replied she had so much to do and expressed concern that she couldn't get all the work done. When asked if she specifically felt safe, Resident #1 responded she felt safe as she didn't worry about getting hurt, because she had just so much to do as it's a big event. The Social Services Note dated 5/1/24 at 5:05 PM indicated the facility called Resident #1's son regarding another male resident reached down his mother's shirt. The caller explained that the staff immediately separated the residents and started new intervention of frequent visual checks for the male resident. The call reviewed the comments with his mother as well as the staff observations. Informed the facility took the interactions seriously and they would maintain communication with him. The son reported he needed to think and would call with any questions or concerns. The Self-Report dated 5/7/24 at 4:12 PM documented an allegation of abuse. A CNA observed Resident #2 put his hands down Resident #1's shirt while in the lobby, as Resident #1 waited in the lounge/lobby area to go for supper. After redirecting Resident #2 to the dining room, the CNA checked to see if Resident #1 was ok and not exposed. The facility indicated the corrective action as the following: a. 5/7/24 Interventions: i. Education provided to Resident #2 on the importance of not touching other residents. ii. Education provided to the staff to keep Resident #2 away from other female residents. iii. 15-minute checks continued indefinitely on Resident #2. iv. Initiated 15-minute checks on Resident #1. v. The provider saw Resident #1 on rounds. vi. Resident #2 saw the provider on 5/7/24 and had an increase of his antidepressant medications. vii. Resident #2 scheduled to see the Psychiatry provider on 5/9/24. b. 5/8/24 Interventions: i. With the family's consent, the facility transferred Resident #1 to another area within the facility away from Resident #2, into a locked Alzheimer's wing. The Nurse Progress Note dated 5/7/24 at 7:25 PM reflected the facility called and spoke with Resident #1's son, about a male resident inappropriately touched his mother before supper that evening. When he asked the facility, what they planned to do about the male resident, the writer replied at the time they started interventions. The Director of Nursing (DON) planned a call to both families the next day. When the writer spoke with Resident #1 about the incident, she stated she didn't remember anything happening and felt fine. The staff ensured Resident #1 had her call light within reach. The facility placed Resident #1 on 15-minute checks at that time. The Care Plan dated 5/7/24 indicated Resident #1 had a potential for a psychosocial well being problem related to inappropriate touch by another male due to experienced inappropriate touch from another male resident. Interventions included: *15-minute checks initiated for safety. *Family notified of incident. *(5/8/24) moved to locked unit in The locked memory care unit for her safety until perpetrator's behaviors subside and/or discharges to another facility. The family okayed the room change and the facility notified them the room change is short term. *(6/27/24) When conflict arises, remove resident to a calm safe environment and allow to vent/share feelings. The Social Services Note on 5/8/24 at 12:11 PM indicated the facility called Resident #1's son to discuss the on-going concern related to a male resident having inappropriate contact with his mother. The facility updated the other resident's family assisted relocating that resident. The facility inquired as to whether family would consider moving his mother to the locked memory care unit for the time being until situation can be resolved. Resident #1's son verbalized agreement with the plan. In addition, the staff initiated 15 minute checks for both residents, and provided staff supervision to his mother when she left her room. The facility's Self-Report submitted 5/8/24 at 3:40 PM reflected an allegation of abuse following a Certified Nurse Aide (CNA) reporting he saw Resident #2 put his hands down Resident #1's shirt while in the lobby of the facility. When the CNA told Resident #2 to keep his hands to himself, Resident #2 replied no. The CNA redirected Resident #2 from Resident #1 and started 15-minute checks for 24 hours. The facility notified the interim Director of Nursing (DON), Administrator, and Social Worker. In addition, they added Resident #2 to the nursing home rounds. The facility notified the staff to keep the 2 residents separated. The Social Services Note dated 5/8/24 at 4:51 PM reflected Resident #1 had a room change. Resident #1 moved to a room in The locked memory care unit for as a short-term safety precaution. Resident #1 continued with a pleasant demeanor, smiles and answered direct questions. When asked if she had anything on her mind, she replied it's beautiful, nice, and sunny. The staff noted her mood, behavior, and affect unchanged/stable. The facility called Resident #1's son to inform him of her new room. He reported he understood the reasons for the move and verbalized he appreciated the facility implemented strategies to maximize his mother's safety. On 8/14/24 at 12:30 PM, the facility's DON confirmed they expected the staff, residents, and visitors must always treat all residents with dignity and respect. The undated Resident Rights brochure directed resident's rights included *Being treated with respect and dignity *Being free from abuse *Making independent choices

Based on clinical record review and staff interviews the facility failed to provide adequate supervision and follow physicians order's which resulted in a fall with injury for 1 of 1 residents reviewed (Resident #1). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 4/27/23 documented a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate impaired cognition. The MDS revealed diagnoses of anemia, dementia, hypertension, generalized muscle weakness and chronic kidney disease stage 3. A Care Plan focus area revised 4/26/23 documented Resident #1 to be assist of one with front wheeled walker as of 3/30/23 and to have a motion sensor when in bed or in recliner as of 3/27/23. A document titled Physician's Telephone Orders revealed a signed physician's order dated 3/28/23 for the motion sensor while in bed and recliner for Resident #1. During an interview on 11/20/23 at 10:18 AM, Staff A, Certified Nurse's Assistant (CNA) reported he was in a near by resident's room when he heard the sound of what he thought sounded like someone crashing against the closet door in a room. He voiced the closet doors make a certain sound so he knew it had to be that. He stated once he was finished in the resident's room he then headed down the hallway to make sure the residents were safe. When he went by Resident #1's room he saw her laying on the floor on her back with her head by the closet door and feet out in front of her. The resident's walker was by her bed and he did not see or hear a motion sensor alarm going off. He reported prior to the fall he had seen the resident resting in bed when passing ice water and snacks. During an interview on 11/20/23 at 10:35AM, Staff B, CNA verbalized after lunch on the day of the incident he assisted Resident #1 to the bed. He was unsure of the time but reported the resident's walker and call-light were both in reach. He reported he did not remember to put the motion alarm on when assisting her to bed. During an interview on 11/20/23 at 12:35 PM, Staff C, Licensed Practical Nurse (LPN) reported she worked as the nurse on the day of the incident. She verbalized she was at the nurse's station getting report and Staff A, CNA came and reported Resident #1 fell . When she entered the room the resident's head was by the bathroom door and her feet facing toward the windows laying on her back without her walker. She reported the floor alarm was not down or on at the time. She reported no visible signs of a fracture but the resident reported pain at 10 out of 10. The Advanced Nurse Practitioner (ARNP) was doing round in the building so she went and got her to further assess. The ARNP gave the order to send to the emergency room for further evaluation. She reported she later received a call from the hospital reporting Resident #1 sustained a right hip fracture from the fall. She then notified the acting DON at the time of the fracture. During an interview on 11/20/23 at 2:16 PM, Staff D, Director of Nursing (DON) reported she expected staff to follow physician's orders and the care plan. She reported the facility does not have a policy on physician's orders.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure a resident's dignity was respected by removing facial hair timely for 1 (Resident #16) of 8 sampled residents observed for facial hair. Findings included: Review of a facility policy titled, Shaving the Resident, dated 06/2013, specified, This is a daily activity. A review of an Admission Record indicated the facility admitted Resident #16 with diagnoses that included vascular dementia, rheumatoid arthritis, and macular degeneration (vision loss). The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident required setup help of staff for personal hygiene. A review of Resident #16's Care Plan, initiated 06/07/2021, revealed the resident needed help with activities of daily living (ADLs). Interventions included the resident needed set-up assistance with ADLs and assist as needed. On 12/05/2022 at 11:56 AM, Resident #16 was observed with facial hair. During an interview at this time, Resident #16 indicated they needed to be shaved, and that it bothered them. Resident #16 said they had gotten a shower but did not get shaved. On 12/06/2022 at 9:44 AM, Resident #16 was observed ambulating in the hall with a walker. The facial hair was still present. Resident #16 indicated they had been in therapy. On 12/06/2022 at 12:25 PM, Resident #16 was observed in the dining room eating. Resident #16 remained unshaven. During an interview on 12/07/2022 at 10:11 AM, Certified Nursing Assistant (CNA) #1 indicated residents were shaved when whiskers were seen for male and female residents. CNA #1 indicated residents were shaved at least two times a week. CNA #1 said Resident #16 got a shower on Monday (12/05/2022) and should have been shaved then. During an interview on 12/07/2022 at 10:49 AM, Registered Nurse (RN) #2 indicated Resident #16 should be shaved on shower days. RN #2 indicated Resident #16 should not have to ask to be shaved. RN #2 indicated the CNAs were responsible for shaving. During an interview on 12/07/2022 at 11:20 AM, RN #2 confirmed Resident #16's facial hair was pretty long. During an interview on 12/07/2022 at 1:55 PM, the Director of Nursing (DON) revealed she had seen Resident #16's facial hair and meant to get staff to take care of it. The DON indicated the frequency to be shaved was different for everybody. The DON indicated the resident being unshaven was a dignity issue. During an interview on 12/08/2022 at 8:39 AM, the DON indicated her expectation was for facial hair to be shaved if staff saw it while they were getting the residents ready. During an interview on 12/08/2022 at 8:40 AM, the Provisional Administrator indicated her expectation was that residents should be assessed daily for care and to follow the shaving policy.

Based on observation, clinical record review and staff interview, the facility failed to review risks versus benefits with residents and/or the resident representative for the use of grab bars for nine of thirteen residents reviewed (Resident #20, #7, #13, #17, #27, #33, #5, #21 & #3) The facility census was 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #20 had [DIAGNOSES REDACTED]. On 6/17/19 at 10:10 a.m., observation revealed the top 1/2 grab bars to bilateral sides of the bed in place. On 6/17/19 at 3:00 p.m., observation revealed the top 1/2 grab bars to bilateral sides of the bed in place. The Care Plan with a revision date of 3/8/2018, included a problem that indicated the resident needed help with activities of daily living, at risk for falls and skin breakdown. Intervention included padded bilateral grab bars to aide with bed mobility. The Clinical Record lacked documentation of the risk/benefit or consent given to the resident and/or family representative. 2. The MDS assessment dated [DATE], documented Resident #17 had [DIAGNOSES REDACTED]. On 6/17/19 at 11:47 a.m., observation revealed bilateral grab bars in place on the residents bed. On 6/17/19 at 2:56 p.m., observation revealed the grab bars remained in place on the residents bed. The Care Plan dated 9/20/18, included the resident had an ADL self-care performance deficit. Interventions included bilateral grab bars to aid with bed mobility. The Clinical Record lacked documentation of the risk/benefit or consent given to the resident and/or family representative. 3. The MDS assessment dated [DATE], documented Resident #13 had [DIAGNOSES REDACTED]. On 6/17/19 at 11:22 a.m., observation revealed bilateral grab bars on the residents bed. On 6/17/19 at 3:04 p.m., observation revealed the grab bars remained in place on the residents bed. The Care Plan revised on 11/29/16, indicated the resident had ADL self-care performance deficit related to progressing disease process of dementia/[MEDICAL CONDITION]. An intervention stated bilateral grab bars to aid with bed mobility. The Clinical Record lacked documentation of the risk/benefit or consent given to the resident and/or family representative. 4. The MDS assessment dated [DATE], documented Resident #27 had [DIAGNOSES REDACTED]. During observation on 6/18/19 at 7:30 a.m., the resident was in the bed with the grab bars in the upright position on both sides of the bed. A care plan with initiated date of 6/07/2018, indicated bilateral grab bars were to be used to aide with bed mobility. During interview on 6/18/19 at 2:17 p.m., Staff A stated the resident does use the bars on her bed to help reposition. During interview on 6/18/19 at 2:27 p.m., the Director of Nursing, DON stated they do not have the necessary consents and assessments for the side rails. 5. The MDS assessment dated [DATE], documented Resident #17 had [DIAGNOSES REDACTED]. A care plan with initiated date of 2/01/18, indicated bilateral grab bars were to be used to aide with bed mobility. During observation on 6/18/19 at 2:12 p.m., the resident was lying in bed with the top quarter rail in the upright position on the bed. During observation on 6/19/19 at 7:34 a.m., the resident was lying in bed with the top half rails in the upright position. The Clinical Record lacked documentation of the risk/benefit or consent given to the resident and/or family representative. 6. The MDS assessment dated [DATE], documented Resident #33 had [DIAGNOSES REDACTED]. Observation on 6/18/19 at 9:45 a.m., revealed the residents bed had 2 bed rails in an upright position at the head of the bed. The care plan with a revision date of 6/5/19, revealed an intervention for use of bilateral grab bars to aid with bed mobility. The clinical record lacked a signed informed consent by the resident or the resident's representative discussing the risks and/or benefits of the use of side rails. During interview on 6/19/19 at 8:35 a.m., the DON confirmed the facility had not completed a consent for use of bed rails for the resident. 7. The MDS assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. Observation on 6/17/19 at 2:38 p.m. revealed the residents bed had 2 bed rails in an upright position at the head of the bed. The care plan with a revision date of 6/13/19, included an intervention for bilateral grab bars to aid with bed mobility. The clinical record lacked a signed informed consent by the resident or the resident's representative discussing the risks and/or benefits of the use of side rails. During interview on 6/19/19 at 8:35 a.m., the DON confirmed the facility had not completed a consent for use of bed rails for the resident. 8. The MDS assessment dated [DATE], documented Resident #3 had [DIAGNOSES REDACTED]. Observation on 6/17/19 at 2:01 p.m., revealed the residents bed had 2 bed rails in an upright position at the head of the bed. The care plan with a revision date of 6/13/19, included an intervention for bilateral grab bars to aid with bed mobility. The clinical record lacked a signed informed consent by the resident or the resident's representative discussing the risks and/or benefits of the use of side rails. During interview on 6/19/19 at 8:35 a.m., the DON confirmed the facility had not completed a consent for use of bed rails for the resident. 9. The MDS assessment dated [DATE], documented Resident #21 had [DIAGNOSES REDACTED]. Observation on 6/17/19 at 2:21 a.m., revealed the residents bed had 2 bed rails in an upright position at the head of the bed. The care plan with a revision date of 5/8/19, included an intervention for bilateral grab bars to aid with bed mobility. The clinical record lacked a signed informed consent by the resident or the resident's representative discussing the risk and/or benefits of the use of side rails. During interview on 6/19/19 at 8:35 a.m., the DON confirmed the facility had not completed a consent for use of bed rails for the resident.

Based on facility policy review and staff interview, the facility failed to develop and implement abuse policies and procedures that included reporting of all alleged allegations of abuse to the Department within mandatory timeframes. The facility census was 35 residents. Findings include: 1. The facility's undated Abuse Investigation policy documented the purpose of the policy was to assure all residents remain protected from any type of abuse and to assure identification and removal of any person committing abuse. The policy directed staff to immediately investigate any allegations of abuse and to report the potential abuse to the Administrator, Director of Nursing (DON), or the Supervisor on duty. The DON or Administrator, and staff person needed to report allegation to the appropriate authorities within 24 hours of the report. The policy directed that upon completion of the investigation, but no more that 2 hours after the incident, the Administrator needed to notify the Department of Inspection and Appeals. The facility's undated Abuse Prevention/Identification policy documented the purpose of the policy was to protect residents from staff, visitors, family members, or other residents from verbal, sexual, physical, financial, and mental abuse, corporal punishment, or involuntary seclusion. The Prevention/Identification policy directed staff to immediately report to the DON, Administer, or their designee any violations concerning mistreatment, neglect or abuse, including injuries of unknown origin, or misappropriation of the resident's property. The DON, Administrator, and staff person needed to report allegations to the appropriate authorities within 24 hours of the report. The facility policies failed to document that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property was reported immediately, and no later than 2 hours after the allegation made if the events that caused the allegation involve abuse or result in serious bodily injury, or no later that 24 hours if the event that caused the allegation did not result in abuse or serious bodily injury to the State Survey Agency, and adult protective services where state law provides for jurisdiction in long term care facilities in accordance with state law. The policy had no direction related to reporting the results of the complete investigation to the administrator or his/her designee and to other officials in accordance with state law, including the State Survey Agency, within 5 working days of the incident. During interview on 3/19/18 at 11:00 a.m., the Administrator verified he expected all staff to report any allegation of potential abuse to him or the DON and staff needed to follow up with investigating and reporting to the proper authorities.

Based on clinical record review, facility policy review and staff interviews, the facility failed to ensure one of 12 residents reviewed remained free from abuse. (Resident #26) The facility census was 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #26 ha a [DIAGNOSES REDACTED]. An Interdisciplinary Progress Note dated 2/9/18 at 11:00 p.m., documented before the evening meal a Certified Nurses Aide, CNA observed the resident's [MEDICATION NAME] (a topical opioid pain medication) patch was no longer in place. The nurse applied a new [MEDICATION NAME] at 7:50 p.m., per schedule and at 8:30 p.m., the CNA reported the [MEDICATION NAME] was no longer in place. An Interdisciplinary Progress Note dated 3/11/18 at 7:15 p.m., for 3/9/18 at 8:00 p.m., revealed the nurse placed a new [MEDICATION NAME] 25 mcg. (microgram) patch to the resident's mid back due to the inability to find the patch applied on 3/8/18 on the resident's body. The nurse notified pharmacy and updated the resident's medication record. During interview on 3/14/18 at 1:15 p.m., the Director of Nursing (DON) stated she was unaware of the missing [MEDICATION NAME]es on 2/9/18 and 3/9/18 and that no investigations/incident report for missing [MEDICATION NAME]es was completed. During interview on 3/14/18 at 10:18 p.m., Staff A, Registered Nurse, RN stated she was working on 2/9/18 when the resident's [MEDICATION NAME] was missing. Staff A stated 2 [MEDICATION NAME]es had been found missing during the shift. Staff A believes Staff C, CNA brought the resident to her to apply a new [MEDICATION NAME] on 2/9/18. Staff A stated she and Staff C were not able to find the [MEDICATION NAME] applied on 2/6/18. Staff A applied the [MEDICATION NAME] that was due to be applied and instructed Staff C to notify her if the patch applied on 2/6/18 was found when getting the resident ready for bed. Staff A stated one or two CNA's got the resident ready for bed that night and reported to her that the patches applied on 2/6/18 and 2/9/18 were not found. Staff A stated she reported the incident to the night nurse that came on duty and but not to the DON. Staff A stated she did not fill out an incident report. During interview on 3/15/18 at 7:52 a.m., Staff B, RN, stated she worked on 3/9/18 and observed the resident's [MEDICATION NAME] applied on 3/8/18 was not located on the resident's body. Staff B stated she waited until the resident went to bed to make sure the [MEDICATION NAME] was not located on the resident and then applied a new patch when the patch was not found. Staff B stated she checked for [MEDICATION NAME]es on her shift to make sure they were in place as the resident liked to pick at the patches. Staff B stated she wrote a late entry about the patch missing, wrote a note for pharmacy, informed the night nurse the patch was missing, but failed to inform the DON of the missing patch. During interview on 3/19/18 at 11:00 a.m., the Administrator verified he expected all staff to report any allegation of potential abuse to him or the DON and staff needed to follow up with investigating and reporting to the proper authorities. The facility undated abuse Prevention/Identification policy identified the meaning of abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish and financial abuse included misappropriation of funds, stealing funds, or corrosion of funds. The policy directed the facility to ensure that staff, visitors, family members, and other residents to not abuse residents in any form.

Based on clinical record review and staff interview, facility staff failed to report potential abuse to the Department of Inspection and Appeals timely for one of 12 residents reviewed. (Resident #26) The facility census was 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #26 ha a [DIAGNOSES REDACTED]. An Interdisciplinary Progress Note dated 2/9/18 at 11:00 p.m., documented before the evening meal a Certified Nurses Aide, CNA observed the resident's [MEDICATION NAME] (a topical opioid pain medication) patch was no longer in place. The nurse applied a new [MEDICATION NAME] at 7:50 p.m., per schedule and at 8:30 p.m., the CNA reported the [MEDICATION NAME] was no longer in place. An Interdisciplinary Progress Note dated 3/11/18 at 7:15 p.m., for 3/9/18 at 8:00 p.m., revealed the nurse placed a new [MEDICATION NAME] 25 mcg. (microgram) patch to the resident's mid back due to the inability to find the patch applied on 3/8/18 on the resident's body. The nurse notified pharmacy and updated the resident's medication record. During interview on 3/14/18 at 1:15 p.m., the Director of Nursing (DON) stated she was unaware of the missing [MEDICATION NAME]es on 2/9/18 and 3/9/18 and that no investigation/incident report for the missing [MEDICATION NAME]es was completed. During interview on 3/14/18 at 10:18 p.m., Staff A, Registered Nurse, RN stated she was working on 2/9/18 when the resident's [MEDICATION NAME] was missing. Staff A stated 2 [MEDICATION NAME]es had been found missing during the shift. Staff A believes Staff C, CNA brought the resident to her to apply a new [MEDICATION NAME] on 2/9/18. Staff A stated she and Staff C were not able to find the [MEDICATION NAME] applied on 2/6/18. Staff A applied the [MEDICATION NAME] that was due to be applied and instructed Staff C to notify her if the patch applied on 2/6/18 was found when getting the resident ready for bed. Staff A stated one or two CNA's got the resident ready for bed that night and reported to her that the patches applied on 2/6/18 and 2/9/18 were not found. Staff A stated she reported the incident to the night nurse that came on duty and but not to the DON. Staff A stated she did not fill out an incident report. During interview on 3/15/18 at 7:52 a.m., Staff B, RN, stated she worked on 3/9/18 and observed the resident's [MEDICATION NAME] applied on 3/8/18 was not located on the resident's body. Staff B stated she waited until the resident went to bed to make sure the [MEDICATION NAME] was not located on the resident and then applied a new patch when the patch was not found. Staff B stated she checked for [MEDICATION NAME]es on her shift to make sure they were in place as the resident liked to pick at the patches. Staff B stated she wrote a late entry about the patch missing, wrote a note for pharmacy, informed the night nurse the patch was missing, but failed to inform the DON of the missing patch. During interview on 3/19/18 at 11:00 a.m., the Administrator verified he expected all staff to report any allegation of potential abuse to him or the DON and staff needed to follow up with investigating and reporting to the proper authorities.