Every finding on record at Sibley Specialty Care

Based on observation, staff interviews, and policy review, the facility failed to maintain the kitchen in a sanitary condition. The facility reported a census of 39 residents.Findings include:During observation on 6/28/26 at 9:39 AM the initial kitchen tour revealed:a. Food debris scattered around small appliances on the shelving unit under the prep table and beneath the food warmer.b. Melted ice cream present on the drip tray of the ice cream machine.c. Food debris present within two refrigerator units and a freezer unit.d. Crumbling white lime buildup on the dishwashing unit.During the tour, the Certified Dietary Manager (CDM) acknowledged the refrigerator and shelving units should be free of food debris and that lime buildup should be sanitized prior to deterioration. Observation on 6/30/26 at 11:54 AM, revealed cooking tongs falling into chicken broth during food preparation. The CDM retrieved clean tongs, failed to discard the contaminated broth, subsequently adding cooked chicken to the both.The Sanitization policy revised October 2018 identified the food service area shall be maintained in a clean and sanitary manner. The policy also identified that all utensils, counters, shelves shall be kept clean. During an interview on 6/30/26 at 12:49 PM, the Registered Dietitian stated that kitchen staff are expected to maintain sanitary conditions throughout all food service operations. She further acknowledged that the chicken broth should have been disposed of immediately following the contamination event.

Based on observation, resident and staff interviews, and a review of facility policy, the facility failed to ensure room trays were served at an appetizing temperature for 2 of 12 residents reviewed (Residents #1 and #6). The facility reported a census of 39 residents.Findings include: During an interview on 06/29/2026 at 10:50 AM, Resident #6 reported inconsistent meal temperatures, stating that food served in their room was frequently cold. During an interview on 6/30/26 at 8:51 AM, Resident #1 reported that meals served in their room were frequently cold. On 06/30/2026 at 12:13 PM, the Certified Dietary Manager (CDM) measured the temperature of the final room tray delivered. The readings were as follows:Chicken at 132 degrees Fahrenheit Broccoli at 123.3 degrees Fahrenheit The CDM acknowledged that these temperatures were unacceptable. When queried regarding expected food temperatures, the CDM stated the temperatures should be significantly higher. The Food Preparation and Service policy last revised April 2018 identified food temperatures should be held at a minimum of 135 degrees Fahrenheit. During an interview on 06/31/2026 at 9:03 AM, the Administrator acknowledged the facility was aware of issues regarding room tray temperatures. The Administrator noted that a previous attempt to mitigate the issue using supplementary heat packs was unsuccessful. The Administrator stated the facility is now considering pre-warming dining plates as a corrective measure.

Based on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 1 of 3 residents reviewed for abuse. The facility reported a census of 35 residents. The facility provided education to all staff on the types of abuse and process and protocol of reporting suspected abuse on 5/27/26 prior to DIAL entering the building on 6/3/26 so the deficiency is past non-compliance and no plan of correction is required.Findings include:Interview on 6/3/26 at 11:32 a.m., with Staff A, Certified Nursing Assistant (CNA) revealed on 5/23/26, she was working with Staff B, CNA getting residents up for the day. Staff B was assisting Resident #1 out of bed and Resident #1 was yelling at Staff B. Staff A tried to get Staff B to switch caring for the residents but she would not. Staff B got Resident #1 up quickly by putting her hand on the back of her neck and under her legs and swung her up quickly into a sitting position as Resident #1 was yelling at her. Staff A revealed later during the day Staff B was assisting Resident #4 to her room and stated she didn't want to go to the bathroom. Staff A stated she was outside the room doing some charting and she could see into Resident #4's room. Staff B took Resident #4 to the bathroom and slammed the door as she went out of the bathroom as the resident was saying no. Staff B went and assisted Resident #4 out of the bathroom and told her she needed to lay in her bed and Resident #4 told her she wanted to sit in her recliner and Staff B told her no. Staff B told Resident #4 to keep going and Resident #4 is very hard of hearing and she replied with, what? Staff B stated in a normal voice I don't know why I even bother talking to you anyway you can't hear anything. Staff A told Staff B that she cannot be doing that and Staff B replied I don't care, she can't fucking hear me anyway. Staff A revealed she did not report her concerns to the charge nurse but talked to Staff C about her concerns about Staff B. Staff A revealed she should have reported it to the charge nurse right away as they have 2 hours to report allegations of abuse. Staff A revealed she had received education on reporting any allegation of abuse right away to a supervising staff. Review of written statement by Staff A dated 5/27/26 revealed the following information:What do you mean by forced when you say Staff B forced Resident #2 to go to bed. She doesn't like to lay down in bed, so she told her she was going to lay down, and then just transferred her to her bed when she didn't want to. Forced was just the word I could use. It was more like firm vocally. What do you mean by rough when working with Resident #1.I was helping the roommate and Staff B, like, basically just responded negatively when trying to get her sat up in bed, had her hand on the back of her neck and kinda quickly sat her up when she was crying out and stuff. Review of written statement by Staff C, CNA dated 5/28/26 revealed what happened this weekend? Staff C revealed it was Sunday 5/24/25 at approx 1:45p.m., maybe, something like that, I was in the soiled utility room cleaning up, and Staff A came in and said I need to tell you something, I don't know what to do, Staff B was being snarky with residents. Staff C said what the heck is wrong. We discussed what was going on with Staff B and she told me that Staff B had moved the lift kind of hard working with residents. Staff C told Staff A to talk to Staff B and if you don't feel comfortable you need to report it. Apparently she did report it, but I should have done it first. It was an overwhelming weekend. Review of facility reported incident revealed submission date of 5/26/26 at 5:38 p.m Review of the facility provided document titled 5.26.26 Self Report, 5 day summary revealed the description of report : On the morning of 5/23/26, Staff B was reported by Staff A to be frustrated, using loud and at times inappropriate language with 3 residents. She was in a hurry and rough while transferring Resident #1 from supine to sitting bedside. Staff B was argumentative with Resident #2 while going to the bathroom. Staff B told Resident #4 to shut up and quit talking as she is very hard of hearing and speaks loudly during conversation. On 5/24/26 Staff B was witnessed being untruthful to a 4th Resident #3 as she tried to coerce him into participating with cares. Review of facility provided policy titled Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating with a revision date of April 2021 revealed if resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within 2 hours of an allegation involving abuse. Interview on 6/3/26 at 3:57 p.m., with the Assistant Director of Nursing (ADON) revealed the facility staff should have reported the incident right away. Allegations of abuse need to be reported to DIAL within 2 hours.

Based on clinical record review, staff interviews, facility record review and facility policy review the facility failed to provide adequate nursing supervision to prevent a resident from exiting the building for 1 of 3 residents reviewed (Residents #1). The facility reported a total census of 40 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of diabetes mellitus, Non-Alzheimer's Dementia and need for assistance with personal care. The MDS showed the Brief Interview for Mental Status (BIMS) was a 4 indicating severe memory impairment. Review of the Progress Notes dated 8/10/25 at 6:30 a.m., revealed at 6:35 a.m., the charge nurse received a phone call from the local hospital. Staff at the local hospital stated they witnessed a man thought to be Resident #1, clothed with a blanket in hand walking on the sidewalk. At 6:36 staff was immediately altered and resident head count conducted. Staff searched the entire facility and facility ground and Resident #1 was not found on the premises. Resident #1's roommate stated when he was last in the room, that Resident #1 grabbed a blanket and was going home. During the head count Staff A, Dietary Aide told staff she let Resident #1 out of the facility about five minutes prior because he wanted to check the weather. At approximately 6:40 a.m., the local Sheriff's office was notified and explained the situation, last known location, address of previous home as he was most likely going home. At 6:53 a.m., Resident #1 and wife arrive at the facility with the local Sheriff's office. Resident assessed for injuries, no injuries noted. Vital signs taken and within normal limits. The resident is noted to not recollect any details related to the incident. Review of the local Sheriff's Department report dated 8/10/25 revealed the facility called and reported that one of the residents was let out by accident and walked away. The facility provided Resident #1's previous address and he might be trying to find his way home. Officer patrolled the area and was unable to locate him. At 6:51 AM Officer seen a vehicle back out of the resident's former address and officer followed into facility parking lot and assisted Resident #1 back into the facility. Review of written statement from Staff A signed and dated 8/10/25 revealed I walked into work at 6:27 a.m., and grabbed the table clothes and napkins and realized I did not punch in yet so I punched in at 6:33 a.m., that is when Resident #1 asked me if he could go outside. I asked him what he was going to do and he said he wanted to check the weather. He was fully dressed with shoes and carrying 2 throw blankets. So then I let him out and continued to put the table clothes on. At about 6:40 a.m., I was asked if I knew where Resident #1 is and I told the nurse that I let him outside. Interview on 10/22/25 at 12:40 p.m., with Staff B, Registered Nurse (RN) revealed the incident was during a day shift between 6:30 a.m., and 7:00 a.m Staff B was in the hallways giving medications when the phone rang and when it was answered it was the local hospital calling and said there was a gentleman walking by the hospital that looked like Resident #1. While still on the phone with the local hospital Staff B announced over the radio to the staff to split up and look through the facility for Resident #1. Staff B asked the hospital staff what his last known location was. The staff searched inside and outside with no luck then called the local sheriff's office. Stated that at times he will verbalize he wants to go home and has a history of dementia. Staff B stated that when she went to call Resident #1's wife told her she already had him and that the sheriff's office was following them back to the facility. Once Resident #1 returned to the facility she assessed him for injuries and none were noted. Assessed his vital signs and all were within normal limits and had no further episodes of exit seeking that day. Staff B revealed she had asked Staff A if she had seen Resident #1. Staff A revealed she had left him out a few minutes ago and he had his blankets in his hand. She put the code in and let him out. She didn't let the staff know she let him out. Review of facility provided policy titled Wandering and Elopements with a revised date of March 2019 revealed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Interview on 10/22/25 at 12:23 p.m., with the Administrator revealed Staff A should not have let the resident out and all staff have received extensive training on 8/10/25 since the incident.

Based on review of the menu, observation, and staff interviews the facility failed to serve the full portions of food when preparing meals for residents (Residents #7, #16, #19, #22 and #28). The facility identified a census of 39 residents. Findings include: The facility's Cycle Day 4 Menu identified the following items as part of the planned menu for the lunch meal on 5/7/25 for residents on a regular diet: Pork chop Gravy Roasted Red Potatoes Squash (replaced with carrots) Wheat roll with Margarine The facility's Cycle Day 4 menu identified the following items as part of the planned menu for the lunch meal on 5/7/25 for residents on a mechanical diet: Pork chop chopped Gravy Mashed Potatoes Squash (replaced with carrots) blended Wheat roll with Margarine Observation on 5/7/25 at 12:10 PM, revealed Staff B, [NAME] used a size #6 scoop to serve a full portion of ground pork chop to residents. Staff B failed to fill the entire scoop of ground pork to Residents #7 and #28. Staff B used a size #8 scoop to serve a full portion of red potatoes. Staff C failed to fill the entire scoop of potatoes to Residents #16, #19, #22 and #28. In an interview on 5/7/25 at 12:51 PM, the Dietician reported Staff B should have served a full #6 scoop of pork and a full #8 scoop of red potatoes to residents in order to provide the proper portions per the menu. The Dietician reported the facility planned to provide additional education to the new kitchen staff. The Kitchen Weights and Measures policy dated April 2007 identified food services staff will be trained in proper use of cooking and serving measurements to maintain portion control. Policy Interpretation and Implementation 1. Cooks and Food Services staff will be trained in weights and measures, volume and weights, appropriate utensil use, and food can sizes. 2. Staff will be trained in the comparison of volume and weight measures (e.g., 2 cups (volume) water = 1 pound (weight), 1 oz. weight = 1 oz. volume, etc.). 3. Staff will be trained in size conversion of food cans to improve accurate measurements. Can size tables will be prominently posted for reference. 4. Recipes will specify consistent use of metric or U.S. measurement guidelines. 5. Serving utensils used will be consistent with choice of metric or U.S. measure used. 6. Staff will be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators (e.g., color-coded) on utensils will be prominently displayed for reference. 7. The Food Service Supervisor will ensure cooks prepare the appropriate amount of food for the number of servings required.

Based on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area where staff prepared food, and failed to keep utensils on a sanitary surface during meal service. The facility identified a census of 39 residents. Findings included: The initial kitchen walkthrough on 5/5/25 at 10:35 AM with the Dietary Manager (DM) revealed the following: a. The sugar bin showed a build up of debris around the opening and under the cover of the container. Hair present on the container. b. The flour bin showed a build up of debris around the opening and under the cover of the container. c. A snack cart contained a variety of scattered food debris at the bottom of the cart. d. A storage dish cart contained a variety of scattered food debris at the bottom of the cart. e. A shelving unit across from the oven showed dirt, grease and hair. f. The floor contained an accumulation of food debris and a variety of dried liquid. g. Two stand up freezer units with a variety of food debris in the bottom of the units. h. Two refrigerator units with a variety of food debris in the bottom of the units. i. The DM reported that she expected the environment to be clean, free of food debris and hair. The DM reported the freezer and refrigerator units should be free for food debris. Observation of lunch service on 5/7/25 at 12:10 PM showed the following: a. Staff B, [NAME] pureed pork, stopped the blender, removed the cover, set the cover face down directly on the countertop. Staff B stirred the food with a spatula, set the spatula directly on the countertop, replaced the cover and restarted the blender. Staff B further pureed the pork, stopped the blender, removed the cover, set the cover face down directly on the countertop. Staff B used the spatula to remove the food from the blender. b. Staff B, [NAME] pureed carrots in a blender, stopped the blender, removed the cover, set the cover face down directly on the countertop. Staff B donned gloves, removed bread from the bread bag, added the bread to the blender, replaced the cover and restarted the blender. Staff B doffed gloves, placed soiled gloves directly on the countertop and failed to perform hand hygiene. Staff B stopped the blender, stirred the food using the same spatula, replaced the cover and restarted the blender. Staff B discarded the soiled gloves from the countertop into the trash. Staff B failed to perform hand hygiene. Staff B then removed the blender cover, set the cover face down directly on the countertop where soiled gloves were previously placed. c. During food service Staff B, [NAME] used her hands to place and remove hot table food covers. Later in the food service Staff B utilized the tongs, previously used for the food, to move the covers. Staff B failed to remove tongs from service then utilized the tongs again for food. In an interview on 5/7/25 at 12:51 PM, the Dietician reported during food service she stopped Staff B and instructed her to perform hand hygiene. The Dietician acknowledged Staff B would have continued and failed to perform hand hygiene when necessary. The Dieticain reported she expected Staff B to use the blender cover, spatula and food tongs in a manner that prevented contamination. The Dietician also reported soiled gloves should be placed directly into the trash and hand hygiene should be performed immediately following. The Dietician reported the facility planned to provide additional education to the new kitchen staff. The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy dated October 2017 identified food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation 1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. 6. Employees must wash their hands: a. After personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); b. After using tobacco, eating or drinking; c. Whenever entering or re-entering the kitchen; d. Before coming in contact with any food surfaces; e. After handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; f. After handling soiled equipment or utensils; g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h. After engaging in other activities that contaminate the hands. 7. Antimicrobial hand gel CANNOT be used in place of handwashing in food service areas. 8. Contact between food and bare (ungloved) hands is prohibited. 9. Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. 10. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing.

Based on observation, infection control policy and staff interview, the facility failed to provide proper hand hygiene with wound care with 1 of 2 residents observed (Resident #18). The facility reported a total census of 39 residents. Findings include: Observation on 5/7/25 at 10:19 AM Staff A, Registered Nurse (RN) changed a dressing on the left second toe. Staff A, Entered into Resident #18's room and performed hand hygiene and applied gloves. Staff A removed soiled dressing off Resident #18's toe and with the soiled gloves took clean gauze out of the package, applied wound cleanser and cleansed the area on the toe. With the same soiled gloves, Staff A opened the ointment, took a piece of clean gauze and placed a dab on the gauze and dabbed the ointment onto the toe. With the soiled gloves on Staff A took the bandaid she was going to apply to the toe. The bandaid stuck to itself and Staff A removed the soiled gloves and performed hand hygiene. Staff A then completed the wound dressing. Interview on 5/7/25 at 10:30 AM the Director of Nursing (DON) revealed she should have changed her gloves during the wound dressing change. Review of the facility provided policy titled Handwashing Hand Hygiene with a revised date of August 2019 revealed the following information: a. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. b. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. c. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: i. Before handling clean or soiled dressings, gauze pads, ect ii. After contact with the resident ' s intact skin iii. After moving from a contaminated body site to a clean body site during resident care iv. After handling used dressings v. After removing gloves d. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on clinical record review, facility record review, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 1 out of 3 residents (Resident #1) reviewed from physical abuse. The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of hypertension, non- Alzheimer's dementia and anxiety disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of the Progress Notes revealed: On 6/6/24 at 10:02 a.m., at approximately 5:45 a.m., nurse aid reports to nurse manager while resident was being assisted to the bathroom with 2-assist, per plan of care, nurse aid's partner struck resident in the upper left arm. Reporting nurse aid stated the resident was being very rude and physically and verbally aggressive towards the two nurse aids, and the other nurse aid appeared to become upset and hit the resident after she had hit him. Resident stated you can't hit me, and verbalized the nurse aid hit her in the upper left arm, and she wanted to report him. Nurse aid was immediately separated from resident and was kept away from all other residents. Administrator updated, and assessment completed on resident. Assessment completed on resident; no redness, bruising, discoloration, swelling noted to affected extremity. Vital signs within normal limits. No emotional distress noted to the resident; the resident was sitting calmly in a chair with eyes closed when nursing entered the room. Resident denied pain to the area during assessment, but statedit hurt when it happened, he got me good. Active range of motions within normal limits. Family, provider, and appropriate agencies also updated regarding the situation. Review of Facility Reported Incident Investigation revealed the following information: a. Statement by Staff D, Certified Nursing Assistant (CNA) dated 6/6/24 revealed: at approximately 5:45 a.m., the nurse requested my partner and I to take Resident #1 to the bathroom so Staff E, CNA and I walked to Resident #1's room and opened the bathroom door and put her gait belt on. Resident was yelling at the staff seemingly unprovoked and when it was time to stand the resident up, Staff E seemed to forcefully stand her up by himself. Resident then yelled at Staff E and called him names and then hit him. At that time, Staff E then used a closed fist and hit her on her left upper arm and seemed to tighten the gait belt in his right hand by using a twisting motion. Resident #1 stated you don't hit me and Staff E responded to her with well you hit me first. Resident told Staff E not so tight and that she was going to report him. Staff E did not lessen the twisting motion on the gait belt until we got to the bathroom doorway. Staff D had a hold of her going towards the toilet and then Staff E went on the right side of her and held the gait belt while Staff D pulled her pants down to the toilet. Resident sat on the toilet and Staff D helped take off her soiled depends and clothing. Resident then started yelling at Staff D asking what I was doing, and Staff D told her that her pants were soiled and that I was just trying to help her. Resident responded with I know you are, but that bastard isn't and I am going to report him. Resident was then assisted with getting clean underwear on and wanted to sit on the toilet for a few minutes to finish. Staff D then went to the nurse manager that was on duty and told her what happened. b. Statement by Staff F, Registered Nurse (RN) dated 6/624 revealed: Resident #1 stated that Staff E better watch out. Staff F asked why. Resident #1 replied he hit me with his fist right here (points to left upper extremity). He's naughty. Staff F replied Thank you for letting me know. Resident responded you're welcome. c. Statement by Staff G, Social Worker and Administrator dated 6/6/24 at 2:00 p.m., revealed; Staff G joined Administrator to interview Resident #1. Resident #1's husband was present in the room. Administrator asked Resident #1 about an incident this morning, she could not recall anything. Administrator asked Resident #1's husband if she reported anything to him when he arrived this morning. He responded no. Resident #1 was then asked if she has had any trouble with any staff over the past couple of days, she identified Staff E. When asked what happened, Resident #1 revealed Staff E made a fist at her this morning. Staff G asked if Staff E hit her and she replied no. Staff G asked Resident #1 to lift her arm and if she has any pain. Resident #1 was able to move without pain. Staff G asked Resident #1 if she was afraid of Staff E and she said no but does not want him to work with her anymore. d. Review of text message screen shot from Staff E's phone number a message dated 6/6/24 at 6:34 a.m., stated sorry you had to see me lose my temper with Resident #1. Interview on 6/27/24 at 10:34 a.m., with Staff F revealed it was the beginning of her shift and she was working on doing vital signs and assessments. She needed to get Resident #1's vitals. When she entered Resident #1's room she was awake so she started talking to her and explained she was going to get her vital signs. Resident #1 told Staff F that Staff E better watch out. Staff F asked her why. Resident #1 revealed Staff E hit me right here (pointed to her left upper arm) with his fist. Staff E told Resident #1 ok thank you for letting me know. Staff E assessed the area and revealed no redness, swelling, bruising noted to the area. Resident #1 had no restrictions on her range of motion (ROM). After Staff F exited the room she told Staff C about the incident. Interview on 6/27/24 at 11:58 a.m., with Staff C, RN, Assistant Director of Nursing (ADON) revealed she had come in that morning and around 5:30 a.m., Staff D came into her office and looked upset so she asked her what was going on. Staff D reported when her and Staff E were assisting Resident #1 to the bathroom, Resident #1 had smacked Staff E and he hit her back. Resident #1 stated you can't hit me, Staff D reported she froze in the room for a minute and finished assisting Resident #1 to the toilet and exited the room. Staff C watched Staff E leave the facility and then called the Director of Nursing (DON) and the Administrator. Approximately an hour later Staff C went into Resident #1's room and she was sitting in a recliner with her eyes closed. Staff C asked Resident #1 how her arm was feeling. Resident #1 stated Staff E got me good. He hit me. Staff C assessed the area at that time and there was no redness, swelling or pain noted. Resident #1 stated it hurt then he got me good. Interview on 6/26/24 at 12:14 p.m., with Staff H, RN revealed she had come in after the incident had occurred. She was asked by Staff C to do an assessment of Resident #1 as there was an allegation of Staff E striking her. Staff H assessed Resident #1 and seemed to be in good spirits, denied pain, had good ROM and no hematoma present. Resident #1 told Staff H that Staff E had struck her in her arm. Resident #1 was upset when she was talking about it and was upset that a situation like this could occur. Staff H did reassess the area throughout the day and if indication of bruising, inflammation or hematoma was present. Interview on 6/27/24 at 5:38 p.m., with Staff D revealed Staff F asked Staff D and Staff E to assist Resident #1 to the bathroom. Staff D explained Staff E applied the gait belt and when Resident #1 was ready to stand up. Staff E took the gait belt and picked her up aggressively by himself. Staff D did not assist in the transfer to stand. Staff E further revealed when they were walking Resident #1 to the bathroom Resident #1 appeared to be mad at Staff E and Resident #1 hit Staff E. Staff E with a closed fist hit Resident #1 in her left upper arm. Resident #1 told Staff E you don't hit me, I am going to report you. Staff E replied in an aggressive tone you hit me first, Staff D explained she said to Resident #1 let's continue to the bathroom. Staff D explained Staff E was getting impatient with Resident #1 and started twisting the gait belt and it was getting tighter. Staff D explained once Resident #1 was on the toilet and she assisted her with care. Staff D revealed Resident #1 told her she knew she was trying to help her but that bastard isn't. Staff D and Staff E finished assisting Resident #1 and left her in the restroom to finish. Staff D went and reported to Staff C about the incident when she left the room. Staff D stated she received a text message from Staff E saying sorry you had to see me lose my temper with Resident #1. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of April 2021 revealed residents have the right to be free from abuse. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. Provide staff orientation and training or orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Review of the facility policy titled Identifying Types of Abuse with a revision date of April 2021 revealed abuse of any kind against residents is strictly prohibited. Physical abuse includes but is not limited to hitting. Interview on 6/28/24 at 9:54 a.m., with The Administrator revealed during his investigation he knows something happened but does not know exactly what happened. The Administrator further revealed the facility takes all allegations of abuse seriously.

Based on personnel file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal Background check and dependent adult/child abuse registry check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff A). The facility reported a census of 40 residents. Findings include: Review of facility provided document titled Employee New Hire by Time Period dated 4/14/24 at 8:13 a.m., revealed Staff A, non-certified nursing assistant documented a hire date of 3/26/24. The personnel file for Staff A revealed documentation of a criminal background check through a third-party vendor with a completed date of 3/21/24. The file lacked documentation of the Iowa Criminal Background Check. Review of facility provided policy titled Background Screening Investigations revised March 2019 revealed the facility conducts employment background screening checks, reference checks and convictions investigation checks on all applicants for positions with direct access to residents. The purpose of this policy direct access employee means any individual who has access to a resident or patient of a long term care facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the State for purposes of the National Background Check Program. Interview on 4/17/24 at 3:13 p.m., with the Business Office Manager revealed the background checks are done at the corporate level and the facility is provided the information after it has been completed.

Based on clinical record review and staff interview, the facility failed to obtain the resident or resident representative signature for consent on notification of the Notice of Medicare Non-Coverage (NOMNC) Centers of Medicare & Medicaid (CMS)-10055 and CMS form CMS-10123 for 2 of 3 sampled residents (Resident #15 and #36). The facility reported a census of 40 residents. Findings Include: 1. Record review for Resident #15 revealed form CMS 10055 with a services end date of 12/6/23. Resident #15 ' s representative gave verbal consent for signature on 12/1/23 however the form lacked a signature of resident or resident representative and date. Review of form CMS 10123-NOMNC with a services end date of 12/6/23 showed Resident #15 ' s representative gave verbal consent for signature on 12/1/23 however the form lacked a signature of patient or patient representative and date. Review of Resident #15 ' s Progress Notes dated 11/30/23 at 10:31 AM, revealed Resident #15 had met treatment goals, had achieved maximal progress with therapy and her last day of covered services is 12/6/23. 2. Record review for Resident #36 revealed form CMS 10055 with a services end date of 1/31/24. Resident #36 ' s representative gave verbal consent for signature on 1/29/24 however the form lacked a signature of resident or resident representative and date. Review of form CMS 10123-NOMNC with a services end date of 1/31/24 showed Resident #36 ' s representative gave verbal consent for signature on 1/29/24 however the form lacked a signature of patient or patient representative and date. Review of Resident #36 ' s Progress Notes dated 1/29/24 at 4:40 PM, revealed Resident 36 had met treatment goals, had achieved maximal progress with therapy and her last day of covered services is 1/31/24. Review of the Centers (CMS) Medicare Claims Processing Manual Chapter 30 with a revision date of 1/21/22 revealed the following information under ABN options for Delivery other than in-person revealed ABNs should be delivered in-person and prior to the delivery of medical care which is presumed to be non-covered. In circumstances when in-person delivery is not possible, notifiers may deliver an ABN using another method. Examples include: Direct telephone contact; Mail; Secure fax machine; or Internet e-mail. All methods of delivery require adherence to all statutory privacy requirements under HIPAA. The notifier must receive a response from the beneficiary or his/her representative in order to validate delivery. When delivery is not in-person, the notifier must verify that contact was made in his/her records. In order to be considered effective, the beneficiary should not dispute such contact. Telephone contacts should be followed immediately by either a hand-delivered, mailed, emailed, or a faxed notice. The beneficiary should sign and retain the notice and send a copy of this signed notice to the notifier for retention in the patient ' s record. The notifier must keep a copy of the unsigned notice on file while awaiting receipt of the signed notice. If the beneficiary does not return a signed copy, the notifier should document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the notice itself. Review of the CMS NOMNC form instructions for the NOMNC CMS-10123 revealed the signature line: beneficiary/enrollee or the representative must sign this line and the date line: The beneficiary/enrollee or the representative must fill in the date that he or she signs the document. If the document is delivered, but the enrollee or the representative refuses to sign on the delivery date, then annotate the case file to indicate the date that the form was delivered. CMS requires that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. Notification to the representative may be problematic because that person may not be available in person to acknowledge receipt of the required notification. Providers are required to develop procedures to use when the beneficiary/enrollee is incapable or incompetent, and the provider cannot obtain the signature of the enrollee ' s representative through direct personal contact. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee ' s services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative ' s address signs (or refuses to sign) the receipt is the date of receipt. Place a dated copy of the notice in the enrollee ' s medical file. When notices are returned by the post office with no indication of a refusal date, then the enrollee ' s liability starts on the second working day after the provider ' s mailing date. In an interview on 4/16/24 at 9:23 AM, the Administrator and Social Worker reported they were unaware that a resident or resident representative ' s signature was needed on forms CMS-10055 and CMS-10123 despite verbal consent obtained or that if the resident or resident representative does not return a signed copy, the notifier should document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the notice itself.

Based on clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 2 of 2 residents reviewed who transferred to the hospital (Resident #24 and #27). The facility reported a census of 40 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnoses of hypertension, diabetes mellitus, and need for assistance with personal care. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. Review of Resident #24 ' s Progress Notes revealed the following information: a. 5/8/23 at 1:15 p.m., Resident admitted to hospital. b. 5/12/23 at 10:57 a.m., Readmission from the hospital. c. 8/2/23 at 10:00 p.m., Resident transferred to emergency department. d. 8/3/23 at 12:04 a.m., Resident admitted to hospital. e. 8/5/23 at 5:41 p.m., Resident returned to facility with daughter. Review of Resident #24 ' s Census tab revealed the following: a. 5/8/23- hospital paid leave b. 5/12/23- active c. 8/2/23- hospital paid leave d. 8/5/23- active Review of MDS listing revealed the following: a. 5/8/23- discharge return anticipated b. 5/12/23- Entry c. 8/2/23- discharge return anticipated d. 8/5/23- Entry Review of the facility document titled Notice of Transfer Form to Long Term Care Ombudsman dated May and August lacked Resident #24 ' s name. 2. The MDS assessment dated [DATE] for Resident #27 documented diagnoses of fracture of the right femur, hypertension and diabetes mellitus. The MDS showed the BIMS score of 00 indicating severe cognitive impairment. Review of Resident #27 ' s Progress Notes revealed the following information: a. 2/4/24 at 9:59 a.m., family here to wheel resident to hospita.l b. 2/7/24 at 4:55 p.m., resident back in facility . Review of Resident #27 ' s Census tab revealed the following: a. 2/4/24- hospital paid leave b. 2/7/24- active Review of MDS listing revealed the following: a. 2/4/24- discharge return anticipated b. 2/7/24- Entry Review of the facility document titled Notice of Transfer Form to Long Term Care Ombudsman dated Feburary lacked Resident #27 ' s name. Interview on 4/18/24 at 7:57 a.m., with the Administrator revealed the facility does not have a policy on ombudsman notification. Interview on 4/17/24 at 4:01 p.m., with the Administrator revealed he was unaware he needed to add hospital transfers to the ombudsman notification.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the PreAdmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #5) reviewed for PASRR requirements. The facility reported a census of 60 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of major depressive disorder, anxiety disorder and psychotic disorder. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the clinical record included a Notice of Negative Level I Screen Outcome dated 2/14/2016 that revealed the PASRR level 1 screen remains valid for your stay at the nursing facility and should be transferred with you if you relocate. No further level 1 screening is required unless you are known to have or are suspected of having a major mental illness or an intellectual or developmental disability and exhibit a significant change in treatment needs. Further review revealed question #1- Does the individual have any of the following Major Mental Illnesses, which major depression and psychotic disorder. The box was marked no. Review of the MDS dated [DATE] revealed an active diagnosis of major depressive disorder, anxiety disorder and psychotic disorder. Review of Order Summary Report signed by the Physician dated 3/9/23 revealed active diagnosis of major depressive disorder, anxiety and alcohol dependence with alcohol- induced psychotic disorder. Review of Resident #5's chart lacked a follow-up and resubmission of a PASRR with the diagnosis of major depressive disorder and psychotic disorder. Interview on 3/15/23 at 9:01 a.m., with the Director of Nursing revealed there is no policy for PASRR. Interview on 3/15/23 at 9:09 a.m., with the MDS coordinator revealed the PASRR should have been re-submitted.

Based on clinical record and staff interview the facility failed to include side effects of anti-depressant medication on a care plan for 1 of 5 residents reviewed (Resident #25). The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #25 revealed a Brief Interview of Mental Status (BIMS) score of 06 which indicated moderately impaired cognition. The same MDS revealed the resident had a diagnosis of depression and received antidepressant medication. The Order Summary Report dated 2/19/23 signed by a physician revealed orders for the following antidepressants: 1. Duloxetine 60 milligrams (MG) daily. 2. Trazodone 25 mg daily. The Care Plan with an initiated date of 07/19/22 lacked specific side effects of antidepressant prescribed to the resident. In an interview on 03/15/23 at 1:45 PM, the Director of Nursing (DON) reported that when the facility's computer program for Electronic Health Records (EHR) updates, sometimes data is moved and that she would expect specific side effects for the resident's anti depressant be listed on the care plan. In the same interview, the DON reported that the facility does not have a care plan policy.

Based on observation, record review, and staff interview, the facility failed to assure a resident with a indwelling urinary catheter maintained dignity and privacy by not placing the catheter bag in a privacy bag or by placing the catheter in a ripped privacy bag that failed to conceal the catheter bag for 1 out of 3 residents reviewed (Resident #28). The facility reported a census of 38 residents. Findings include: A Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, dressing and toilet use. The resident had an indwelling urinary catheter. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Care Plan revised 9/16/21 identified the resident had an indwelling catheter due to urine retention, limited mobility and skin breakdown. Observation showed on 10/11/21 at 11:55 AM, Resident #28 sat in the dining room with the catheter bag visible due to a ripped privacy bag. Observation showed on 10/12/21 at 8:20 AM, Resident #28 sat in the dining room with the catheter bag visible due to a ripped privacy bag. The privacy bag rested on the dining room floor. Observation showed on 10/12/21 at 12:01 PM, Resident #28 sat in the dining room with the catheter bag totally exposed without use of a privacy bag. Observation showed on 10/13/21 at 8:55 AM, Resident #28 sat in the dining room with the catheter bag visible due to a ripped privacy bag. The privacy bag rested on the dining room floor. In an interview on 10/13/21 at 9:25 AM, Staff C, Certified Nursing Assistant (CNA), assisted Resident #28 back to her room from breakfast. When asked if the privacy bag appeared to be ripped she replied yes, I ' ll get a new one then she placed a request using her walkie-talkie for a new privacy bag. In an interview on 10/13/21 at 1:38 PM, the Director of Nursing (DON), relayed it is her expectation the catheter bag be concealed in a privacy bag, a ripped privacy bag showing the catheter bag would not be acceptable and the bag should not be touching the floor. The document titled Skills Checklist #27 Catheter Care and Empty Drainage Bag revised on 10/13 instructed to replace outer covering over the catheter bag.

Based on observation, facility policy, Center for Disease Control and Prevention (CDC), and staff interview, the facility failed to ensure the kitchen had dishware and utensils stored to prevent contamination and ensure kitchen staff had hygienic practices to prevent the spread of infection. The facility reported a census of 38 residents. Findings include: During observation on 10/11/21 at 9:37 AM, noted a stainless steel table of plate covers with the side facing up that would cover a plate, a clear plastic storage container filled with serving scoops with no lid covering the container, plates with serving side facing up stacked on the end of the steam table, scoop with handle in the powder of a [MEDICATION(S)] Instant Whey Protein Supplement with an open date of 9/21/21. Observation on 10/13/21 at 9:15 AM, noted Staff A, Dietary Aide, and Staff B, Dietary Aide, not wearing eye protection with source control not covering their nose and mouth. Observation on 10/13/21 at 10:20 AM, noted Staff A in the hallway not wearing eye protection. In an interview on 10/12/21 at 11:29 AM, the Dietary Manager (DM) reported the [MEDICATION(S)] Instant Whey Protein Supplement powder was used every morning on a resident's cereal. In an interview on 10/12/21 at 12:16 PM, the DM reported the plates stacked on the end of the steam table are always there serving side up. She also reported that since the facility had a COVID-19 outbreak, the plate covers have been stored with the surface that is used to cover the food up. During the same interview, the DM reported the scoop was always there and that she did not think to cover the clear plastic storage container with the serving scoops. In an interview on 10/13/21 at 10:22 AM, the DM reported she expected all kitchen staff to wear a N95 mask and eye protection. In an interview on 10/13/21 at 1:37 PM, the Administrator reported the DM has directed kitchen staff to wear eye protection and N95 masks, but that the DM's directives were not followed by the kitchen staff. The Storage Dishes in Daily Use facility policy dated 02/16 revealed dishes shall be stored in a manner that protects them from contamination and breakage. The Core Principles of COVID-19 Infection Protection facility policy with no date revealed staff was to wear a face covering or mask and that appropriate staff would wear Personal Protective Equipment (PPE). The CDC COVID Data Tracker transmission rate from 10/3/21 to 10/9/21 revealed [NAME] county was at a high rate of COVID-19 transmission. The Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Summary of Recent Changes dated 9/10/21 revealed that counties with a substantial or high transmission rate of COVID-19 should wear PPE to include eye protection and consider use of N95.

Based on observations, interviews and record reviews, the facility failed to complete hand hygiene while doing a dressing change for one of two residents reviewed, (Resident #14). The facility reported a census of 39. Findings include: The Minimum Data Set completed, with Assessment Reference Date of 8/6/19, showed a Brief Interview for Mental Status score of 5, indicating severe cognitive impairment. The resident had pressure ulcer/injury care completed in the seven days look back period. The resident had [DIAGNOSES REDACTED]. During an interview on 10/7/19 at 5:01 PM, the resident's representative stated the resident had an area to his bottom. The Treatment Administration Record (TAR), showed the resident had an order for [REDACTED]. The nurse was to monitor twice daily until healed, complete a weekly skin assessment, and discontinue when healed for two weeks. According to the TAR, the resident also had an order for [REDACTED]. The dressing change could decrease to do on bath days if the drainage was minimal. The nurse to monitor twice daily until healed, complete a skin watch weekly and discontinue when healed for two weeks. During an observation on 10/08/19 at 9:36 AM, Staff A, RN, verified order, sanitized her hands and put on gloves. Then Staff A prepared the supplies to complete the treatment. Staff A, cleansed the area with wound cleanser, then without hand hygiene and with the same gloves, Staff reached into the re-sealable zipper storage bag to get gauze to dry the suprapubic area. With the same gloves Staff A, then used a q-tip to insert a strip into the space around the suprapubic catheter. Staff A, changed her gloves without completing hand hygiene and placed a drain gauze to the area and secured the dressing with tape. During an observation on 10/8/19 at 9:46 AM, Staff A, cleansed hands and put a new bag in the garbage can. Without completing hand hygiene, Staff A applied new gloves. Staff A removed the dressing to the resident's left buttock, exposing a large red area approximately the size of the dressing and cleansed the area with gauze. After wiping, noted some bowel movement (BM) on the gauze. Staff A then moved out of the way to allow Staff C, Certified Nurses' Aide (CNA) and Staff D, CNA, to cleanse the resident's buttock due to the resident having a BM. Staff A did not complete hand hygiene or change gloves while waiting for the CNAs to complete the resident's peri-care. Wearing the same gloves used cleansing the area, the nurse placed a new absorbent, atraumatic dressing made from [MEDICATION NAME] foam to the wound. During an interview on 10/9/19 at 9:20 AM, the Director of Nursing reported she would expect that if the nurse had dirty hands, she would not touch anything clean with them. The policy labeled, Dressing Change Clean, dated 1/15 stated the purpose was to prevent infection, prevent the spread of infection if possible, and to protect the wound and enhance the healing process. The guidelines indicated for the nurse to remove the soiled dressing and discard into a plastic bag at the foot of the bed and remove gloves, then discard. The nurse was to wash hands, put on clean gloves, and then cleanse the wound with the prescribed solution if ordered.

Based on review of personnel records, staff interviews, and review of policy/procedures, the facility failed to complete a criminal background check timely before hire for 1 of 5 personnel files reviewed (Staff A). The facility reported a census of 33 residents. Findings include: 1. The personnel file for Staff A, certified nurse aide (CNA), identified a Single Contact License & Background Check (SING) form with a completion date of 8/8/16. The personnel file identified a hire date of 9/13/16. On 4/18/17 at 10:30 a.m., the Business Office Manager verified the hire date of Staff A to be 9/13/16. The Business Office Manager stated the facility was aware the criminal background checks needed to be re-run if greater than 30 days since ran before the hire date. On 4/18/17 at 10:45 a.m., the Administrator was interviewed and confirmed the facility did not re-run a background check within the 30 days prior to the actual hire date. The Administrator stated the orientation schedule for Staff A pushed back 5 days due to a need to reschedule. The Administrator acknowledged the facility was aware the background check must be completed within 30 days of hire. On 4/19/17 at 7:00 a.m., the Administrator stated she re-ran the SING check. The SING check completed on 4/18/17 at 3:46 p.m. identified Staff A had no history of a criminal record or abuse record. The facility policy titled Abuse Prevention Employee Screening Prior to Employment/New Conviction Criminal Record History, revised January 2017, included the following procedures: Employee Screening - Point 1. The facility will conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire, in the manner prescribed under 481 Iowa Administrative Code § 58.11(3).

Based on clinical record review, resident and staff interviews, and review of facility policy/procedure, the facility failed to timely report an allegation of abuse to the Department of Inspections and Appeals (DIA) and failed to separate the alleged perpetrator from the alleged victim following the allegation of abuse for 1 of 4 residents (Resident #1). The facility identified a census of 39 current residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment reference dated of 6/2/15 revealed Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident had scored 13 on the Brief Interview for Mental Status (BIMS) cognitive test which revealed his/her cognition intact. According to the MDS the resident had behavioral symptoms not directed toward others that occurred 1 to 3 days in the assessment period. The MDS identified the resident required assistance with bed mobility, transfers and toilet use. Review of the Investigation Report dated 6/29/15 revealed around 9:00 a.m. Staff K, Certified Nurse Aide (CNA) reported to the Administrator that Resident #1 stated Staff L (CNA) had (allegedly) hit him/her on the head. The Administrator would look into it. The Administrator spoke with the resident. The resident denied staff had hit him/her. No red spot or complaints of pain observed. At 3:00 p.m., follow up interview with the resident revealed no further statements. The Administrator reported she looked at documentation for the 6/28/15-6/29/15 which revealed Staff L did not work with the resident on the overnight shift and had not been assigned to that hall. Staff not scheduled to work on the 2 previous days. During an interview with Staff K, CNA on 8/25/15 at 2:30 a.m. she stated Resident #1 said Staff L had hit him/her on top of his/her head. Staff K stated the resident rubbed the top of his/her head when saying this. She reported it to the Administrator right away. Staff K stated she had never heard Resident #1 say this about other staff. During an interview with the Administrator on 7/30/15 at 2:10 PM she stated on 6/29/15 Staff K reported Resident #1 said Staff L had hit him/her on the head. She started an investigation right away and did not believe it happened. Staff L had not been assigned to that hall and did not work the 2 nights prior to the allegation. She further stated Staff L had been separated from working with Resident #1 following the call by DIA on 7/17/15; and prior to that date, she had not separated Staff L. During an interview with Staff G, CNA on 7/30/15, at 10:30 p.m., she reported Resident #1 stated he/she had been hit on the head by Staff L. Staff G stated the resident repeated Staff L had hit him/her on the head and did not give any further details. She reported this to the DON. Staff G reported this occurred prior to Staff L not being allowed to work with Resident #1 (prior to 7/17/15). Staff G stated the only bruise she ever noticed on Resident #1 had been on the upper left arm over a month ago and had been oblong shaped. An investigation dated 7/9/15 by the Director of Nursing (DON) revealed on 7/9/15 at 11:30 p.m., a certified nurse aide (CNA) reported Resident #1 stated Staff L hit him/her on the head. Upon investigation the DON documented the staff had not worked that night. The DON noted the resident had been really sleepy when asked if Staff L had hit him/her and replied no. The resident had no bumps, bruising or swelling. The DON talked with Staff L and she reported no altercations with the resident. The DON stated the resident had no unexplained injuries and bruising had been investigated. Interview with Staff L (CNA) on 7/31/15 at 1:30 p.m., she revealed sometimes Resident #1 did not want to get up out of bed. Staff L reported she had worked with Resident #1 and assisted the resident to the toilet (in the past). Staff L reported she did not work with Resident #1 since the incident occurred. Staff L stated the resident reported she had pinched him/her a few nights before the DON talked her. Staff L reported she did not recall Resident #1 being upset when she worked with him/her and would not hurt the resident or other residents. During an interview with Staff J, CNA on 8/25/15 at 11:50 a.m., she reported Resident #1 stated he/she did not like that person. When Staff J asked who, Resident #1 responded Staff L had hit him/her over the head. Staff J reported the resident had never made any other comments about other staff. Interview with Resident #1 on 8/11/15 at 10:50 a.m., he/she denied being scared of anyone. Resident #1 reported Staff L had hit him/her on the top of the head and it hurt. Resident #1 reported he/she was not afraid of Staff L and no other staff had ever hurt him/her. Resident #1 did not recall what Staff L had been doing at the time when it happened or if the Staff had been angry or not. The Department of Inspections and Appeals received a concern of bruises on Resident #1 and contacted the facility. The Concern Investigation Form dated 7/17/15, revealed the Department of Inspections and Appeals (DIA) contacted the facility to report an (alleged) abuse allegation involving Staff L and Resident #1. The form noted a head to toe assessment had been completed on the resident with no signs/symptoms of injury and no complaints of pain. The resident stated the CNA's (certified nursing assistants) are good with him/her and that he/she likes them. He/she also voiced that they had not been afraid of anybody and that he/she likes the staff. Continue the investigation and notify the Department of the past investigation. The alleged staff (Staff L) will not work with the resident until further notice. A typed document with the date of 7/17/15 identify DIA contacted the facility to ask if they were aware of an allegation of abuse between Resident #1 and Staff L. Resident #1 reported Staff L hit him/her on the head. The document included the following information: A). Interview with Resident #1 revealed Staff L had hit his/her head. The resident reported I didn ' t tell anybody she hit me, I could have sworn she (Staff L) did, and it hurt. She bumped by head with her arm and did not mean to. B) Interview with Staff L reported sometimes her arm bumps Resident #1 ' s head or her arm had bumped the resident ' s head. The facility advised Staff L to not work with Resident #1 until the investigation was completed. The care plan with a goal date of September 2015 revealed the resident may become upset/anxious and voice physical discomfort. The care plan directed staff to ensure a place quiet and give reassurance and praise for positive choices. (The resident's care plan lacked any indication of a history of behaviors, including self-harm, biting, pinching, or any other self-injurious behaviors.) Review of the Behavioral Health History and Physical dated 3/6/15 revealed the resident had [DIAGNOSES REDACTED]. The report revealed no history or self-injurious behaviors for Resident #1. A facility document called Nursing Guidelines and Procedure Manual January 2015 edition titled, What Kind of Behavior Would Be Considered Abuse identified some examples including the following: .The certified nurse aide stuck the resident on the forehead and the resident had a small bruise and cut from a ring. On 7/31/15 at 11:00 a.m., the Administrator stated she had always been directed to start an investigation immediately. If it had not been abuse, no need to turn into the Department. The Administrator stated she saw this as resident behavior, and not abuse. Review of the Policy and Procedure titled Dependent Adult Abuse dated January 2015 revealed the following: a. The staff member or employee who reasonably believes that abuse has happened shall immediately notify the person in charge or the person designated agent who shall then notify the department in 24 hour of such notification or the next business day. If the person in charge is the alleged dependent adult abuser, the staff member shall directly report the abuse to the Department of Inspections and Appeals within 24 hours. b. The charge nurse on duty must: 1. Separate the suspected perpetrator from the resident and inform them to wait in a specified area away from the resident, and maintain that separation until the abuse investigations is completed by the Department of Inspections and Appeals. c. Notify the Department of Inspections and Appeals and appropriate authorities immediately (not to exceed a 24-hour timeframe).

Based on facility policy review, the facility failed to ensure the abuse policy identified the requirement to report all alleged violations of abuse immediately (not to exceed 24 hours) to the state agency and to all other agencies as required. The policy and Procedure identified the facility to determine if abuse founded or unfounded. The facility identified a census of 39 current residents. Findings include: Review of the Mandatory Reporting policy dated January 2015, directed staff to: 1. The staff member or employee who reasonably believes that abuse has happened shall immediately notify the person in charge or the person designated agent who shall then notify the department in 24 hour of such notification or the next business day. If the person in charge is the alleged dependent adult abuser, the staff member shall directly report the abuse to the Department of Inspections and Appeals within 24 hours. 2. The charge nurse on duty must: Separate the suspected perpetrator from the resident and inform them to wait in a specified area away from the resident, and maintain that separation until the abuse investigations is completed by the Department of Inspections and Appeals. 3. The Administrator, DON and Social Services will conduct/coordinate the investigation. e. Notify DIA and appropriate authorities immediately (not to exceed 24 hours). When interviewed on 7/31/15 at 11:00 AM the Administrator stated the Abuse Policy and Procedure is in the process of being rewritten.

Based on observation, record review, and staff interview, the facility failed to collaborate with the pharmacist to assure medications in the emergency kit were not expired and ensure a system that accounted for each access of the emergency kit. Findings include: During observation on 3/18/2015 at 9:55 a.m. with Staff A, Licensed Practical Nurse (LPN), the Emergency box of medications was locked with a red plastic tie labeled . A list of contents of the emergency box titled (facilities' name) Emergency Kit included pharmacy contact information, a list of medications, quantities, and expiration dates. The expiration column under Narcotic Analgesics listed Morphine 10 milligram (mg)/ milliliter (ml) injectable 2-1 ml vials with an expiration date of 02/15, (***NEED RX), and under Miscellaneous (Misc), Atropine Sul 1%, 1 bottle with an expiration date of 02/15. After removal of the red plastic tie labeled , the medications expiration dates were confirmed by Staff A. The medications were placed back in the emergency box and secured with a numbered red plastic tie # 98 by staff A. On 3/18/15 at 11:20 a.m., the Director of Nursing (DON) provided an Emergency Drug Box Medication Use Record with two individual entries made by the DON of wasted Morphine 10 mg/ml 2 vials and Atropine 1 % solution 5 ml bottle. During an interview on 3/18/15 11:10 a.m. the Pharmacist stated the pharmacy should be contacted before administering meds from the emergency box due to possible allergies and drug interactions the resident may have. The Pharmacist also stated under no circumstances should the facility waste or destroy medications (from the emergency box). The medications should be returned to the pharmacy for proper disposal, including non- narcotic medications. A review of the Emergency Drug Box Medication Use Record revealed some inconsistency with the lock numbers removed not matching the most recent lock numbers put on, with no additional documentation regarding who removed or accessed the emergency medication kit when there was a discrepancy. 1. On 9/17/14 in the refill section showed the lock # on . The next entry on 10/29/14, showed the lock # off . 2. On 11/1/14 in the refill section showed the lock # on . The next entry in on 11/29/14 showed the lock off # 17. 3. On 11/01/14 in the refill section showed the lock # on . The next entry dated 12/3/14 showed the lock # off .. 4. On 12/24/14 the refill section showed the lock # on . The next entry dated 12/31/14, showed the lock # off . During an interview on 3/18/15 at 2:17 p.m. Staff B LPN stated when replacement medication came from the pharmacy the nurse removed the red plastic lock and replaced the medication. The nurse then applied a red number tag lock provided by the pharmacy to the box. They did not verify medications or expiration dates. During an interview on 3/18/15 at 2:17 p.m. Staff D, Registered Nurse (RN) stated she replaced medications received from the pharmacy and checked the expiration date on that medication. She did not check any other medications. The nurse replaced the red plastic tag provided by pharmacy with replacement medication to the emergency box. A review of the facility policy, November 2013 Edition, Using Medication in the Emergency Kit, revealed the protocol and Guidelines directed medications should be checked periodically for integrity, dating, etc;. The pharmacy Drug Emergency Kit Policy updated 01/21/11 identified the responsibilities of the pharmacy included the emergency kit would be maintained and serviced by the pharmacy. The pharmacy would keep record of lots and expiration dates of all medications in the kit and replace as needed.