Every finding on record at Strawberry Point Lutheran Home

Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment to reflect Preadmission Screening and Resident Review (PASRR) status for 1 of 3 residents reviewed (Resident #16). The facility reported a census of 15 residents. Findings include: The MDS dated [DATE] for Resident #16 documented the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #16's current PASRR document dated October 2023 documented a notice of a PASRR Level II Outcome. The PASRR Determination was approved with specialized services.Review of Resident #16's current Care Plan on 6/16/26 documented PASRR goals and interventions.On 6/17/26 at 11:36 AM, the MDS Coordinator revealed during an interview that Resident #16 maintained a PASRR Level II status. The MDS Coordinator stated that she coded Resident #16's MDS inaccurately, as the assessment should show his Level II status. The MDS Coordinator noted that she'd submit a modification to correct the 2/27/26 MDS.On 7/17/26 at 12:05 PM, the Director of Nursing (DON) stated during an interview that the MDS Coordinator must follow the Resident Assessment Instrument (RAI) manual and facility policies.

Based on the review of electronic health records (EHR), the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025, and staff interviews, the facility failed to complete and submit Minimum Data Set (MDS) assessments as required for 2 of 2 sampled residents (Resident #15 and Resident #3). The facility reported a census of 15 residents.Findings Include:1. Review of the facility Census List on 6/16/26 for Resident #15 revealed he was admitted to the facility on [DATE] and passed away on 3/17/26. Resident #15's Minimum Data Set (MDS) log in the Electronic Health Record (EHR) reviewed on 6/16/26 lacked a Death in Facility Tracking MDS. The review revealed the facility staff had not started or completed this tracking record. On 6/17/26 at 11:36 AM, an interview with the MDS Coordinator revealed she missed the discharge tracking record for Resident #15. She noted she should've completed a discharge MDS assessment for 3/17/26 and planned to create it immediately. She acknowledged Resident #15 required a discharge MDS within 14 days and should have been submitted within 28 days, meaning the tracking records would transmit late. She stated she followed the Resident Assessment Instrument (RAI) User's Manual and followed up with the facility if needed. On 7/17/26 at 12:05 PM, an interview with the Director of Nursing (DON) revealed she expected staff to complete and submit all MDS records on time. She stated the MDS Coordinator must follow the RAI manual and facility policies. 2. Review of the EHR for Resident #3 revealed the MDS dated [DATE] had a completed date of 5/15/26. The MDS showed an acceptance date of 6/3/26. During an interview on 6/17/26 at 11:32 AM, the Interim MDS Coordinator stated that she had been responsible for completing MDS assessments. The MDS Coordinator acknowledged awareness of the RAI Manual and understood the submission deadline to be 14 days after completion of an MDS. Regarding Resident #3's Quarterly MDS (Assessment Reference Date 05/14/2026), the MDS Coordinator confirmed that it was completed on 05/15/2026, but not submitted until 06/03/2026, missing the required deadline of 05/29/2026. During an interview on 6/17/26 at 12:03 PM, the Director of Nursing confirmed her expectation that MDS assessments be completed and submitted timely. Regarding Resident #3, the DON acknowledged the quarterly assessment was submitted late. In an email correspondence with the Administrator on 6/17/26 at 12:07 PM, the Administrator revealed the facility used the MDS RAI Manual, not any company policy, for the completion of the MDS's. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), facilities must adhere to the following regulatory timelines regarding the MDS. Completion: For non-admission OBRA and PPS assessments, the MDS Completion Date (Z0500B) must occur within 14 days of the Assessment Reference Date (ARD) (A2300). Encoding: Data must be entered into the facility's software within 7 days of the MDS Completion Date (Z0500B + 7 days) for Quarterly, Significant Correction to Prior Quarterly, Discharge, or PPS assessments. Transmission: Non-comprehensive MDS assessments must be electronically submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).

Based on record review, guardian interview, and staff interview the facility failed to ensure a resident's legally appointed guardian received timely notification regarding medication changes and equipment management issues regarding hearing aids for 1 of 3 residents reviewed (Resident #17). The facility reported a census of 15 residents. Findings include: The Minimum Data Set, dated [DATE] documented that Resident #17 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. The assessment noted Resident #17 had moderate difficulty with hearing, and used a hearing aid or other hearing appliance. Active diagnoses per the MDS included heart failure (weak heart muscle), non-Alzheimer's dementia, and chronic pain.A Progress Note titled Communication dated 6/15/26 at 11:02 AM revealed Resident #17's hearing aids were dropped off at the post office for repair and lacked notification to his legal representative. A Progress Note titled Order Note dated 6/15/26 at 12:15 PM instructed an order for a Fentanyl patch 12 mcg/hr (micrograms per hour) to change every 72 hours. This medication order lacked notification to his legal representative. On 6/16/26 at 8:14 AM Resident #17's Guardian stated during an interview that the facility didn't keep her updated on changes since Resident #17's admission to the facility. She noted she didn't know about the use of a Fentanyl patch or that the hearing aids left the facility for repairs. An interview on 6/17/26 at 12:05 PM with the Director of Nursing (DON) revealed facility staff use a secure email system to notify Resident #17's representative or will call her directly to notify of changes. She revealed she did not think his guardian was updated regarding the hearing aids, but should have been.

Based on observation, record review, staff interviews, and policy review the facility failed to ensure 1 of 3 residents at risk for elopement from the facility remained in the facility (Resident #9). The facility reported a census of 15 residents. Findings include: The Minimum Data Set (MDS) for Resident #9 dated 2/10/25 documented a Brief Interview of Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS revealed she is independent without staff assistance for dressing, bed mobility, transferring, and walking. The MDS also documented diagnoses of Wernicke's encephalopathy, cognitive communication deficit, and hypertension. Record review of the facilities undated, Final Report for Resident #9 elopement on 04/08/2025 documented the following timeline of events that occurred: a. At 2:15 PM Resident #9 was last seen by staff visiting another resident on the unit b. At 2:38 PM Staff B, [NAME] was driving by the facility and observed Resident #9 outside next to the facilities local church, Resident #9 walking down the sidewalk. Staff B immediately turned her vehicle around and stayed with Resident #9 and notified facility staff by phone. c. At 2:46 PM Resident #9 was back in the facility, the Director of Nursing (DON) completed an assessment and no injuries were found. Resident #9 was cooperative and stated that someone held the door open for her. Immediate response after resident's return on 04/08/2025: a. Head to toe assessment completed and revealed no injuries. Updated Wandering Risk Scale completed. b. Notified Resident #9 Doctor and family contact of incident. c. 15 minute checks initiated for resident safety and will remain in place until door code can be changed. d. The Administrator contacted a local security company to change door code and time it takes for alarm to sound. d. The Interdisciplinary team completed investigation and witness statements regarding response to elopement, it was determined that staff acted according to policy with no issues found. f. The interdisciplinary team reviewed elopement policy, and finds no changes necessary. A review of the policy by all staff members is initiated as a reminder of how to respond to elopements. Continuation on 04/09/2025: a. Care plan reviewed & updated with history of elopement b. Local security company completed door code change and decreased the time the alarm takes to go off from 10 seconds to 7 seconds. Record Review of Resident #9 Progress Notes on 4/21/25 revealed she had no behaviors or prior incidents of exit seeking and trying to leave the locked unit. Record Review of Resident #9 Care Plan on 4/21/25 revealed she had no behaviors or prior incidents of exit seeking and trying to leave the locked unit. During an interview with the states Climatologist (a scientist who studies the Earth's climate) on 4/21/25 at 2:59 PM informed on 4/8/25 in the city of Strawberry Point, Iowa it was 48 degrees, humidity 22%, 7 mile per hours MPH winds that made it feel like 45 degrees outside with the wind-chill, sunny and no precipitation. During an interview and observation on 4/22/25 at 3:19 PM with the Administrator revealed the facility checks the doors daily and has not had any issues with alarms not working prior or after elopement incident with Resident #9 on 4/8/25 she revealed she believes Resident #9 followed an employee out of the unit as the alarm had a 10 second delay. She revealed the door alarm never sounded around the time Resident #9 eloped from the facility, and if she had to guess she thinks maybe Resident #9 followed an employee out of the locked unit but the employee didn't notice to be able to intervene and that is why they lowered the amount of time for the door to sound to seven seconds. She revealed Resident #9 had no exit seeking behaviors leading up to this elopement and was acting her normal self. She revealed the system and policy were followed. After completion of the interview the Administrator showed the route the facility believes Resident #9 took, out the main entrance onto sidewalk and up to the parking lot. She informed Resident #9 is not a fall risk and has a very good gait. She informed Resident #9 was wearing a sweatshirt, pants and tennis shoes. After the facility assisted her back in she informed she was fine and told staff how nice of a day it was outside. Record review of the facilities Resident Elopement policy revised 2/7/25 revealed the facility followed protocol for the elopement of Resident #9 on 4/8/25. Facility staff implemented immediate interventions on 4/8/25 and completed on 4/14/25 through the following actions: a. Head to toe assessment and wandering assessment completed and revealed no injuries or changes to her baseline status. b. Doctor and family notification completed. c. Implemented 15 minute checks for resident safety and will remain in place until door code can be changed. d. Interdisciplinary team completed investigation and witness statements regarding response to elopement, it was determined that staff acted according to policy with no issues found. e. The interdisciplinary team reviewed elopement policy, and finds no changes necessary. A review of the policy by all staff members is initiated as a reminder of how to respond to elopements. f. On 4/9/25 door code was changed and time for alarm to be set off was decreased by 7 seconds. The deficient practice was identified as past non-compliance singular event as of 4/14/25, the elopement occurred prior to the survey, after the facility completed review for the current residents at risk and education was completed for all staff.

Based on clinical record review, Center for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) Assessment for 1 of 2 residents reviewed for falls with major injury (Resident #7). The facility reported a census of 15 residents. Findings include: Resident #7 MDS assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating a moderate cognitive loss. The MDS documented Resident #7 with a bilateral lower body (hips, knees, ankle, foot) functional impairment and required the use of a walker and wheelchair for mobility. Resident #7 required supervision to touch assistance for sit to stand transfers from bed/chair and partial/moderate assistance to walk 10 feet or less. The MDS listed active diagnoses of type two diabetes mellitus with neuropathy (nerve damage), anemia, arthritis, thyroid disorder, and Non-Alzheimer's Dementia. The MDS further documented Resident #7 had two falls with major injuries (bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma (a life-threatening condition where blood accumulates between the brain and its outer covering) since the prior MDS assessment completed on 10/21/24. A 4/21/25 review of Resident #7 Unwitnessed Fall Reports dated 4/02/25, 3/05/25, 2/28/25, 2/18/25, 1/1/25, 12/28/25, and 11/23/25 all documented Resident #7 with no injuries from the unwitnessed falls. A 4/21/25 review of the Electronic Healthcare Record (EHR) Progress Notes from 10/21/24 to 1/06/25 lacked documentation of any major injuries from falls occurring in the facility, hospital, or outside in the community. During an interview on 4/21/25 at 2:47 PM the Director of Nursing (DON) reported he had checked back and the resident had not had any major injuries from falls that he could find. He reported he could check further into the prior DON's documentation but could not see where any residents had had any falls with major injury. On 4/23/25 at 10:20 AM Staff A, Licensed Practical Nurse (LPN) voiced to her knowledge Resident #7 had not sustained any major injuries from any falls in the past few months. During an interview on 4/23/25 at 11:00 AM the DON reported he does not recall Resident #7 having any major injuries from any falls since the prior MDS Assessment (10/21/24). He reviewed the definition of Major Injury from the RAI manual and voiced he did not feel they were using the correct definition of major injury and the MDS was inaccurately coded. On 4/23/25 at 12:45 PM the DON reported they follow the RAI for coding the MDS. He has utilized a MDS consultant that reviews MDS assessments as well. The LTC RAI 3.0 User's Manual, Version 1.19.1, October 2024 on Page 1-4 directs the RAI process has multiple regulatory requirements. Federal regulations at 42 Code of Federal Regulations (CFR) 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status. The MDS RAI 3.0 Manual Page J-37 under Number of Falls Since Prior Assessment, Steps to Assessment directs if this is not the first assessment, the review period is from the day after the Assessment Reference Date (ARD) of the last MDS assessment to the ARD of the current assessment and to review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home.

Based on staff interviews,review of clinical records, and facility policy review, the facility failed to provide assessment and intervention in a timely manner when one of three residents reviewed had a change in condition. (Resident #1). The facility reported a census of 13 residents. Findings include: The MDS (Minimum Data Set), an assessment tool dated 12/24/2024 revealed Resident #1 had diagnoses including renal insufficiency, post traumatic stress disorder, cancer, medically complex condition, anemia, and heart failure. The resident had no cognitive impairment and required partial assistance to transfer and used a wheel chair for locomotion. The resident's Care Plan initiated 10/13/2024 indicated the resident had impaired physical mobility with an unavoidable end of life decline, and he required total staff assistance to transfer using a mechanical lift initiated 1/8/2025. It revealed the resident received St Croix Hospice Services due to terminal prognosis. It failed to address the resident's cholecystostomy tube (a drainage tube inserted into the bile duct). The resident's Physician's Orders dated 11/11/2024 directed staff to change the cholecystostomy dressing every Monday, Wednesday, and Friday, cleanse the area with soap and water, and apply a cholecystostomy dressing and Tegaderm (a clear dressing). The orders also included directions to flush the cholecystostomy tube with 10 cc (cubic centimeters) of saline on Monday, Wednesday, and Friday. The January, 2025 TAR (Treatment Administration Record) revealed staff changed the cholecystostomy dressing on 1/20/2025. On 1/22/2025 the TAR revealed staff failed to provide the treatment due to not available. The Progress Notes dated 1/22/2025 at 10:29 A.M. reported the resident transferred to the Veteran's hospital via ambulance when finding the cholecystostomy drain not in place. The physician, hospice, and family were notified. At 9:48 A.M. staff found the resident with an intact cholecystostomy dressing, but no drain. At 1:55 P.M. the hospital notified the facility the resident would be returning after being advised to follow up with a surgical consult, and no current acute concerns. The resident arrived at 5:20 P.M. with no orders and no cholecystostomy bag. The resident's January, 2025 Progress Notes failed to include documentation related to when or how the cholecystostomy tube became dislodged. On 2/3/2025 at 1:30 P.M. the resident's physician reported the resident had several health issues that were terminal including necrotic tissue. The cholecystostomy tube re-insertion required surgical intervention and it had been discussed. The removal of the tube may have contributed to his demise, however he had been declining due to Kennedy ulcers (end of life wounds due to skin failure), infection, and congestive heart failure. The resident received hospice services. On 2/3/25 at 12:54 P.M., Staff B, Administrator reported on 1/22/2025 at around 8:00 A.M., Staff C., ADON (Assistant Director of Nursing) revealed Resident #1's chole (cholecystostomy) tubing was not in place. Hospice gave him the choice and he decided to go to the hospital. Staff D, night nurse revealed at around 4:00 A.M. she noticed the line was out and assumed it was discontinued. She observed the bag attached to the bed rail and the tubing next to the resident. Staff were re-educated regarding alerting staff. Staff E, DON (Director of Nursing) educated staff regarding what to assess for anytime there is an external line and when to notify the DON. Staff failed to document in the Progress Notes and notify management when they found the resident's drainage tube had become dislodged. On 2/3/2025 at 1:10 A.M., Staff E, DON reported the resident had CHF (Congestive Heart Failure), very poor circulation, edema and swelling in his legs. At 3:00 P.M., Staff E stated the resident should have been Care Planned for the cholecystostomy tube. Staff were educated regarding assessment and intervention. On 2/3/2025 at 1:35 P.M. Staff C, ADON reported on 1/22/2025, she assisted Staff A with the resident's treatments when they observed the resident's chole tubing was not in place. The administrator and DON were notified and they began an investigation. The Progress Notes had no documentation regarding the removal of the tubing. The resident's Care Plan should have addressed the chole tubing as well. Staff received education regarding notification of the physician and administration when a resident has a change in condition. On 2/3/2025 at 10:15 A.M., Staff A, RN revealed on 1/22/2025 she found the resident's cholecystostomy tube had been removed. Staff A revealed the resident's Progress Notes failed to document when or how the tubing was removed. Staff A received no verbal report regarding the removal of the tube. The hospital did not admit the resident, they encouraged him to get a surgical consult, re-inserting the tubing required anesthesia and surgery and the resident was not a candidate. Staff A learned during the investigation that staff found the tubing in bed, near the resident during the night. The Internal Investigation dated 1/22/2025 included: at 8:38 A.M. the ADON and nurse provided cares and noted the cholecystostomy tubing and bag was not in place, and the area had been covered with a dressing. Staff D, LPN stated around 4 o'clock A.M. on 1/22/2025, she and the aide discovered the bag was hanging on the railing and the ends of the bag were cut. Staff D denied removing the device or having any knowledge as to how the device was removed. Staff D did not notify the on-call staff. The facility policy regarding notification included: The Administrator and Director of Nursing must be notified of any of the following ASAP: There is only a 2-hour window to submit a report to the state. Do not delay on notifying reportable events. Reportable Events: When abuse and/or neglect of any kind is suspected, including resident to resident. Elopement occurs. Police need to be notified within 10 minutes of resident noted missing Narcotic count is off A resident reports valuables missing Any unscheduled removal of External Devices (Catheters, Drains, Drainage bags, IVs, or other catheter devices). Please call the provider on call & hospice provider first, then call the DON/Administrator when: A resident has a fall with injury. A resident is sent to the ED (Emergency Department). Significant change in resident condition. A resident passes away. Non-Emergency: after you call the provider and contact family, please send a text to the DON/Administrator when: A resident has a fever, vomits, loose stools, or signs and symptoms of infections. Witnessed/unwitnessed falls without injury. (If unwitnessed, start neurological checks immediately, open a risk management, and put an intervention in place). The Change of Condition Policy dated 3/26/2021 included:Purpose: To ensure that appropriate care and documentation occurs when residents experience a change of condition. Procedure: 1. Assess the resident's condition: limited movement, neurological checks for injuries such as falls, pain, swelling, bruising, discoloration, fever or vital signs outside defined parameters, etc. 2. Notify the attending physician promptly. 3. Notify the family. 4. Document symptoms, assessment, treatment, notifications, etc. 5. Follow up nursing assessments and monitoring until the condition has stabilized for at least 24 hours. Assess signs and symptoms and factors related to change in condition every 4 hours, more often if symptomatic. Resident Notification Education on 1/22/2025 included: Per facility policy Administrator, DON, and On-Call provider must be notified immediately for any unscheduled removal of external devices, (catheters, drains, drainage bags, IV's or other catheter devices). This is to ensure that delay in cares are prevented and resident safety is maintained. Call the healthcare provider right away if you have any of these: for any patient with a Cholecystostomy the following warrants immediate notification: jaundice, fever, chills, redness or swelling of the incision, incision pain, dark or [NAME] colored urine, stool that is light in color, increasing belly pain, rectal bleeding, trouble breathing or shortness of breath and leg swelling.

Based on clinical record review, Long Term Care Facility Resident Assessment Instrument (RAI) review, and staff interview, the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of determining a significant change for 2 of 2 residents reviewed for significant change (Residents #4 and #15). The facility reported a census of 15 residents. Findings include: The Physician Orders for Resident #4 included an order dated 12/4/23 to admit to hospice. Resident #4's Progress Note written on 12/4/23 at 12:06 PM documented the resident was being admitted to hospice. The clinical record lacked documentation of a decline or condition change prior to this date. The Significant Change Minimum Data Set (MDS) for Resident #4 documented an Assessment Reference date (ARD) of 12/11/23. The MDS was signed off as complete on 12/25/23 (21 days after the noted need for hospice services). Resident #15's Progress Note written on 2/23/24 at 8:49 AM documented an order from the Primary Care Provider (PCP) for a hospice consult and may admit. The Significant Change MDS for Resident #15 documented an ARD of 3/7/24. The MDS was signed off as complete on 3/12/24 (18 days after the noted need for hospice services). The RAI 3.0, version 1.17.1 dated October 2019, directs the significant change MDS be completed no later than the 14th calendar day after determining a significant change in resident status has occurred. The RAI includes hospice services as a significant change. During an interview on 6/11/24 at 3:25 PM, the MDS nurse explained she works remotely for a consulting company and is only onsite approximately every 3 months. She does all record review and MDS completion remotely. She further explained she does not have any policies for completing the MDS, she follows the RAI manual guidelines. During an interview on 6/12/24 at 8:20 AM the Director of Nursing (DON) explained the facility does not have a policy for MDS completion, they follow the RAI manual guidelines.

Based on clinical record review, policy review, and staff interview, the facility failed to document the implementation of non-pharmacological interventions (any type of health care intervention which is not primarily based on medication. Some examples include toileting, exercise, diversion activity, snacks, naps, music, etcetera) prior to medication administration for 1 of 2 residents sampled for as needed anti-anxiety medication (psychoactive medications are substances that, when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or mood and emotions) (Resident #10). The facility identified a census of 15 residents. Findings include: Resident #10 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS listed diagnoses of unspecified dementia and depression, and noted the use of antidepressant medication. A Order Summary Report signed by the Provider on 3/29/24 documented an order for Lorazepam (psychoactive medication) oral tablet 0.5 milligrams (MG). Give 1 tablet by mouth every 2 hours as needed for anxiety/restlessness. Start date 10/04/23. The Care Plan revised 4/26/24 lacked direction to the staff on interventions to try prior to administration of the as needed Lorazepam medication. A 6/12/24 review of the May and June 2024 Medication Administration Records and Progress Notes revealed the Lorazepam 0.5 mg as needed medication was administered without documentation of non-pharmacological interventions being trialed at the following times: a. 5/26/24 at 0:32 AM, 8:39 AM, 5:59 PM, and 10:00 PM b. 6/09/24 at 8:10 AM c. 6/08/24 at 4:00 PM and 10:40 PM A 6/12/24 review of the May and June 2024 Behavioral Progress Notes documented the following entries: a. 5/26/24 no Behavioral Progress Note documentation. b. 6/08/24 1:42 PM Behavior Note documented Resident #10 being rude to the nurse regarding her medication. No other entries for behaviors or interventions were recorded for 6/08/24. c. 6/9/2024 10:44 Behavior Note this morning the resident would press her doorbell and when staff would go into her room the resident would be snoring. When this nurse went in and asked her what she needed, the resident was rude and demanded her medication. The nurse explained she needed to sit up in bed or get up for breakfast first as she was lying flat on her back. The resident continued to demand the medication. The nurse explained again no medication would be administered while lying flat on her back for safety reasons. Resident agreed to raise the head of her bed. The medications were administered. The nurse asked if there was anything else she needed. The resident said no, nurse left room. The resident rang her doorbell before nurse made it to nurse's station. The nurse went back in; resident demanded the nurse to pick up her TV remote off the floor. The resident's rude and demanding behaviors are worse than before she became ill with a respiratory illness. The resident's husband stated yesterday, if she's being mean, just let her be mean. The 6/09/24 entry lacked documentation of the nurse offering interventions to try to decrease the resident's anxiety. A 6/12/24 review of the May and June 2024 Task Record revealed Certified Nursing (CNA) Staff documenting initial in a box for Behavior Monitoring and Intervention each shift. The entries lacked documentation of actual non-pharmacological interventions or specific behaviors noted during the shifts. The May and June 2024 Task Records for Behavior Symptoms documented none of the above or response not required for behavior documentation. On 6/12/24 at 7:44 AM Staff C, CNA reported they document resident behaviors in Point Of Care (POC, electronic health record). They notify the nurse of any behaviors that are not resolving with interventions like snack, activity, ambulation, toileting, music, 1:1 which are some of the interventions they use. The nurses document the behaviors and interventions. On 6/12/24 at 8:12 AM Staff A, Registered Nurse (RN) reported the CNAs try interventions when behaviors are noted. They document behaviors in POC. She is not sure about target behaviors, but the unit only has 15-16 residents so the staff know the residents behaviors and interventions pretty well. She reported she documents behaviors and interventions in the Progress Notes. She verbalized as needed medications should be the last resort, so interventions should be documented by the time an as needed medication is used. It is the last measure. During an interview on 6/12/24 at 10:05 AM the Director of Nursing (DON) explained she expected the nurse to document the behavior the resident exhibited and then the interventions the nurse provided that failed prior to giving an as needed (psychoactive) medication. The nurses would document that information in the behavior progress notes. During an interview on 6/13/24 at 8:54 AM Staff D, Licensed Practical Nurse (LPN) reported if she would administer an as needed antianxiety medication, she would document the resident behavior and interventions tried in the nursing progress notes or in the behavior progress notes. Interventions would include things like offering toileting, a snack, repositioning, or a diversional activity. The Psychoactive Drugs in Nursing Facility Policy, reviewed by the facility 6/12/24, documented a purpose to ensure the safe and appropriate use of psychoactive drugs in a nursing facility. The Policy noted the Quality Assurance and Process Improvement Program should monitor outcomes of the interventions implemented. The Policy lacked direction to the nursing staff on implementation and documentation of non-pharmacological interventions with the use of as needed psychoactive medications.

Based on clinical record review, observation, document review, and staff interview, the facility failed to utilize a clean barrier under a blood glucose meter and failed to sanitize the blood glucose meter according to the facility policy/manufacturer's directions for 2 of 2 residents observed (Resident #6 and #9). The facility reported a census of 15 residents. Findings include: 1. Resident #6 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented Resident #6 utilized insulin medication for a diagnosis of diabetes mellitus. A Physician Order Summary Report signed by the Provider on 6/7/24 listed an order to check the blood sugar twice a day at alternating times, two times a day on odd days. Resident #6 Care Plan revised 4/26/24 documented a Focus Problem of a diagnosis of diabetes mellitus type two and received insulin and oral hypoglycemic medications. The Care Plan intervention directed the staff to provide blood glucose checks as (physician) ordered. During an observation on 6/11/24 at 7:33 AM Staff A entered Resident #6 room and placed the blood glucose meter directly on the bedside table without a clean barrier. An emesis basin with a tube of toothpaste and a toothbrush sat approximately five inches from where the blood glucose meter, cotton ball, alcohol prep pad and bottle of test strips had been sat directly on the bedside table. Staff A washed her hands, donned gloves and brought another pair of gloves and sat the gloves under the blood glucose meter. Staff A completed the blood sugar, then stored Resident #6 meter without cleaning the meter. Staff A failed to sanitize the blood glucose meter according to the manufacturer's recommendations. During an interview on 6/11/24 at 8:48 AM Staff A, RN, confirmed she had not cleaned Resident #6 blood glucose meter after use. She reported she thought the night shift cleaned the blood glucometer when they did the control checks. Staff A reviewed the Glucose Control Testing Log and reported she didn't see any area where it specified they were cleaning the blood glucose meters, but she thought that is when they did it. 2. Resident #9 MDS assessment dated [DATE] showed a BIMS score of 14 indicating intact cognition. The MDS documented Resident #9 with a diagnosis of diabetes mellitus type two with diabetic neuropathy. An Order Summary Report signed by the Provider on 5/03/24 documented a physician order to check the blood sugar at alternating times two times a day. The June 2024 Medication Administration Record (MAR) showed Resident #9 due for the blood sugar check on 6/12/24 in the morning (AM). During an observation on 6/12/24 at 8:01 AM Staff A checked Resident #9 MAR, opened the medication cart and retrieved supplies to check the Resident's blood sugar. Staff A entered Resident #9's room, placed the bottle of test strips, alcohol prep pads and cotton ball directly on the bedside table and placed the blood glucose meter half on top of a disposable glove and half on the bedside table. Resident #9 bedside table had a clothes pin [NAME], several bags of snacks, a cloth napkin, and a brochure laying on the bedside table. The area where Staff A laid the meter and supplies had a white colored dried half ring on the table. Staff A washed her hands, donned gloves, came back to the bedside table, cleansed the front screen on the meter with an alcohol prep pad, then placed the meter back on top of the bedside table without a clean barrier, slide the meter around on the table to put a testing strip in the meter, and continued to perform the blood sugar. At 8:08 AM Staff A placed the meter on top of the medication cart without a clean barrier. Staff A picked the meter up, cleansed the meter with an alcohol prep pad for a few seconds, then placed the meter back down in the same spot on the top of the medication cart before finally storing in the medication cart. During an interview on 6/12/24 at 8:12 AM Staff A explained she had not received any retraining since the last blood sugar she performed for the Surveyor and she had not received any training on the facility policy on how to perform a blood sugar check or how to clean the blood glucose meter. She verbalized she did not know what the facility policy required for the use of a clean barrier or the cleaning. She reported she would have to check the facility policy, but it is basic nursing that a clean barrier should be used and the meter should be cleaned after use. Staff A voiced she was not aware of the manufacturer's recommendations for cleaning the meter. During an interview on 6/12/24 at 10:14 AM the Director of Nursing (DON) voiced she expects the nurses to use a paper towel under the equipment that goes in the resident's room. After the procedure, she would dispose of the barrier, then take a PDI wipe (germicidal agent) and wipe the meter down and let the meter sit for 2 minutes before storing in the medication cart. She voiced she was not aware of the manufacturer's recommendations and reported she would have to look at the facility policy. During an interview on 6/12/24 at 1:48 PM the DON reported she was not aware of the Microdot Xtra Blood Glucose Monitoring System Operation & Quality Assurance Procedure Manual. She voiced she didn't know how old the manual was that came with the meters and she would have to update their information. The Blood Sugar Monitoring Policy reviewed 6/12/24 directed the following procedure would be used for disinfecting accu check (blood sugar) machines after each use: a. When using the accu check machine in a resident's room, place a barrier (such as a paper towel) between the machine and the surface (such as a bedside stand). b. After use, wrap the meter in a antibacterial wipe and let set for the wet time designated per the manufacturer's guidelines. The Super Sani Cloth General Guidelines for use provided by the DON on 6/12/24 documented the germicidal disposable cloth needed to remain wet on the surface for 2 minutes and allowed to air dry. The Infection Control Program Policy dated 3/24/21 directed items and equipment will be sanitized and cleaned per the manufacturer's instructions. The glucometers will be sanitized utilizing the appropriate product following their directions. The Micro Dot Xtra Operations & Quality Assurance Procedure Manual specified the following cleaning procedure: Always use personal protective equipment as specified on the Microdot(R) Bleach Wipe label. Thoroughly clean gross filth and heavy soil from surface of Microdot(R) Xtra Glucometer to be disinfected. 1. Open Microdot(R) Bleach Wipe pop-up canister. The wipes are pre-saturated with a sodium hypochlorite (bleach) hospital-use solution. 2. Remove a pre-saturated 6 x 6 wipe. 3. Thoroughly wipe the Microdot(R) Xtra Glucometer surface to be disinfected. 4. Wrap the glucometer with the Microdot(R) Bleach 5. Place the wrapped Microdot(R) Xtra Glucometer face down inside the Microdot(R) Disinfection Case. 6. Close disinfection case lid and activate 3 minute timer. 7. Allow the Microdot(R) Xtra Glucometer to remain in contact with the bleach wipe for 3 minutes. 8. Dispose of wipe in trash after use. Do not flush wipe in the toilet. 9. Dispose of the non-refillable empty canister according to state and local authorities guidelines as allowed by the Microdot(R) Bleach Wipe label.

Based on clinical record review, document review, and staff interview, the facility failed to provide the Advanced Beneficiary Notice of Non-coverage (SNF ABN) to the resident or their legal representative within 48 hours of the ending of Medicare Skilled Part A therapy services for 1 of 2 residents sampled (Resident #69). The facility reported a census of 15 residents. Findings include: The Electronic Census Record showed Resident #69 admitted to Medicare Part A Skilled services on 2/23/24 and discharged from services on 3/14/24 remaining in the nursing facility. A 3/12/2024, 12:30 Communication with the Therapy Department Late Entry Progress Note documented Physical Therapy (PT) reported the resident was not progressing and would discharge from PT, Occupational Therapy (OT), and Speech Therapy (ST) on Thursday 3/14/24. The Power of Attorney was notified via phone and a discussion took place in the resident's room at 2 PM when the legal representative was present. Resident #69 wanted to return to independent living. Therapy recommended 24/7 caregiver, assistance of one staff with a forward wheeled walker and a gait belt. The family did not feel the resident was safe to return back to independent living and wanted Resident #69 to stay in the facility. The Progress Notes further documented on 3/15/24 the resident remained in the facility and the family would be setting up a consult with hospice care. On 6/10/24 the Administrator provided a Survey Readiness Binder which contained a Beneficiary Notice Entrance Conference Worksheet which documented Resident #69 discharged from Medicare Skilled services on 3/14/24 and remained in the nursing facility private pay. The Survey Readiness Binder also contained two Detailed Explanation Notices of Non-coverage for Resident #69 for the ending of ST services on 3/13/24 and the ending of PT and OT on 3/14/24. The Survey Binder lacked documentation the resident or the legal representative had been provided the SNF ABN notice prior to the ending of Medicare Skilled services on 3/14/24. During an interview on 6/12/24 at 10:33 AM the Director of Nursing (DON) explained she is responsible for serving the beneficiary notices. She reviewed the Detailed Explanation of Non-coverage Form for Resident #69 and questioned if she served the wrong form. The DON voiced there was discussion with the family if Resident #69 would discharge home or stay in the facility, but she ended up staying in the facility. The Resident and Legal Representative did not appeal the decision to go off of Medicare services. She reported she did not have the SNF ABN form and was not familiar with the form. She voiced she had trained with the Administrator and the nurse consulting agency on serving the beneficiary notices. The SNF ABN had not been provided to the resident or the legal representative.

Based on clinical record, document review, policy review, and staff interview, the facility failed to have an Iowa Physicians Order for Scope of Treatment (IPOST) that matched the electronic health record (EHR) for 1 of 3 residents sampled (Resident #1). The facility reported a census of 14 residents. Findings include: The Admission Record showed Resident #1 admitted to the facility on [DATE]. A review on [DATE] at 01:41 p.m. of the IPOST and Advanced Directives Resuscitative Policy showed Resident #1 signed for a Do Not Resuscitate (DNR) on [DATE]. The Advanced Registered Nurse Practitioner (ARNP) signed both documents on [DATE] indicating the resident had a DNR in place. Further review of the EHR showed a Clinical Physician Orders dated [DATE] that listed code status as Cardio-Pulmonary Resuscitation (CPR) indicating the resident as a full code status. The [DATE] care plan lacked documentation of a code status. During entrance on [DATE] at approximately 10:50 a.m. the Director of Nursing (DON) reported the facility no longer has paper charts. The resident's medical records are all electronic. An interview with Staff A, Registered Nurse (RN) on [DATE] at 1:06 p.m. reported she would look at a Resident Listing Report at the nurse's station for a code status when the computers are down as Internet coverage was out at the facility. Staff A pulled a Resident Listing report dated [DATE], that listed Resident #1 as a full code. The Director of Nursing (DON) entered the nurse's station and directed Staff A that she could not use the list as it was old and not up to date. The DON reported that she would always expect the nurses to look at the computer. If the Internet was down she would expect the nurses to look at the IPOST binder. During an interview on [DATE] at 1:12 p.m. Resident #1 reported his code status as full code. An interview on [DATE] at 01:30 p.m. with the DON reported that if the EHR did not match the IPOST, she expected the nurses to follow the IPOST as it is the most accurate. An interview on [DATE] at 1:55 p.m. with the Administrative Consultant reported that they were aware the code status had been transcribed wrong in EHR and the DON was working on fixing it in the system. An interview on [DATE] at 8:57 a.m. with Staff B, Licensed Practical Nurse (LPN) reported that to find the code status of a resident, she would look at the EHR. She then reported that if the computers were down, she would look in the IPOST book at the nurse's station. An interview with the DON on [DATE] at 1:30 p.m. the DON reported that on admission, a New Admission Checklist is done. The New Admission Checklist requires two nurses to look at it and check off all the areas on the checklist including the code status/IPOST. The DON reported that she does not have Resident #'1's checklist as she does not keep them after completion. The CPR/Resuscitation Policy, dated [DATE], provided by the facility listed a purpose directing the circumstances when cardio-pulmonary resuscitation must be initiated, pursuant to federal law requirement to carry out a resident's advanced directives. The Procedure directed each resident's resuscitation status will be maintained in the clinical record as follows: DNR/CPR form will be the first form in the resident's medical chart. The Policy/Procedure failed to address where to find the code status in the EHR or IPOST binder.

Based on observation, document review and staff interview the facility failed to post staffing hour information for registered nurses (RN's), licensed practical nurses (LPN's), certified nursing assistants (CNA's) and environmental aides (EA) for each shift for 3 of 3 days from 3/20/23 - 3/22/23 sampled. The facility reported a census of 14 residents. Findings include: Observation of the Staff Posting on 3/20/23 at 11:15 p.m. revealed the Staff Posting for 6:00 a.m. to 6:00 p.m. shift had not been completed. Observation on 3/20/21 at 4:07 p.m. revealed the Staff Posting for the 6:00 a.m. - 6:00 p.m. shift remained blank. Observation on 3/21/23 at 7:40 a.m. revealed the Staff Posting for 3/20/23 documented from 6:00 a.m. - 6:00 p.m. a LPN had worked 12 hours; C.N.A.'s had worked 24 hours and the EA had worked 2 hours. The Staff Posting for 6:00 p.m. - 6:00 a.m. showed a LPN had worked 12 hours, a C.N.A. had worked 12 hours and the EA worked 2 hours. Observation on 3/21/23 at 9:54 a.m. revealed the Staff Posting for the 6:00 a.m. - 6:00 p.m. shift had not been filled out. Observation on 3/21/23 at 11:54 a.m. revealed the Staff Posting for the 6:00 a.m. - 6:00 p.m. shift observed to be blank. Observation on 3/21/23 at 3:20 p.m. revealed the Staff Posting for the 6:00 a.m. - 6:00 p.m. shift observed to be blank. Observation on 3/22/23 at 7:38 a.m. revealed the Staff Posting hours for the 6:00 p.m. - 6:00 a.m. shift, 6:00 a.m. - 6:00 p.m. shift for 3/21/23 had not been filled out. The Staff Posting hours for 6:00 a.m. - 6:00 p.m. for 3/22/23 remained blank. The Staff Posting failed to document the name of the facility, number of each type of staff, and the hours the staff worked. An interview on 3/22/23 at 10:17 a.m. with Staff B, Licensed Practical Nurse (LPN) revealed the night shift nurse is to fill out the Staff Posting. Staff B didn't think the night nurse had filled out the Staff Posting for the day. An interview with the Director of Nursing (DON) on 3/22/23 at 10:51 p.m. revealed the night nurse is expected to fill out the Staff Posting. She reported the nurses are filling out the Staff Posting wrong. She guessed that the nurses are filling it out the day after. It probably got missed. An interview with the DON on 3/22/23 at 11:55 a.m. revealed the facility does not have a policy regarding the Staff Posting. It is just done word of mouth. She reported they are now implementing a daily staff posting procedure that will be posted in the nurses station and she went back and updated the Staff Posting hours for 3/21/22 and 3/22/23.

Based on record review and staff interview, the facitity did not always provide services that met professional standards of quality. Concerns were noted for one resident ( #5) who was administered an oral medicaion solution in the form of an (IM) intermuscular injection. The facility reported a census of 14 residents. Findings include: According to documentation in the clinical record, Resident # 5 was admitted to the facility on [DATE] and had diagnoses which included dementia. anxiety disorder, hypertension and chronic atrial fibrillation. According to documentition in the clinical recored, Minimum Data Set (MDS) assessment form, Resident #5 scored 3 ( of a possible 10 ) points on the Brief Interview for Mental Status (BIMS) indicating severe impairment in cognition and decision making skills. The assessment also indicated Resident #5 was independent in bed mobility, transferring, ambulation in his room and the corridor, and eating. Resident # 5 required limited staff assistance with dressing, extensive staff assistance with toileting and total staff assistance with personal hygiene and bathing, Documentation in the nurse's notes dated 08-18-2022 at 12:00 indicated Resident # 5 became angry and agitated towards other residents and staff; getting in the face yelling, but not making any sense; beating his fists on the glass of the nurse's station door, demanding the door to be opened; unable to diffuse his behavior or redirect him; summoned the facility administrator to come to the unit; this nurse called ARNP [NAME] and requested something for his agitated behavior; ordered Lorazepam 1mg IM for agitation and anxiety x 14 days prn; IM given (R) deltoid; resident tolerated it well; he didn't complain of pain; IM given at 1050; resident currently resting in recliner in the common area. VS (vital signsa) taken According to documentaion by (staff A) on 08-18-2022 a pharmacy technician had stated staff B had called the pharmacy at appoximently 10:30 a.m. stating there wasn't any IM Ativan/Lorazepam in the e-kits, only oral Lorazepam. At approximatel 10:45 a.m. Staff D/pharmacist stated a new e-script had been recieved for Resident # 5 and the order had been filled and the nursing faciltiy had been called to let them know it was ready and could be picked up. According to documnetation in the witness statement dated 08-17-2022 (sic) at 10:40 a.m. Staff A stated she had spoke to Staff B at approximately 10:40 and Staff B stated I got tired of waiting so I opened the bottle of concentrate and drew up one milligram. He (Resident $# 5) did really well. Staff A asked Staff B to identifiy the bottle Staff B used and Staff B added that it is the oral solution , It works a little slower, but it does the trick. I've had to do this at (another facility) before, It's an oral solution, but you can use it as an IM.

Based on clinical record review and staff interview, the facility failed to resubmit a PASRR evaluation for a resident who had new mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility identified a census of 14 residents. Findings include: Review of the Level I PASRR evaluation completed for Resident #7 prior to admission to the facility showed a completion date of 7/27/16 and the resident admitted to the facility on [DATE]. When asked for a copy of the most recent PASRR Level I evaluation on 11/22/21 the facility DON (Director of Nursing) provided a copy of the 7/27/16 Level I PASRR with a negative outcome (meaning no Level II evaluation needed) and verified that is the most recent PASRR evaluation for Resident #7. Review of the negative Level I PASRR evaluation for Resident #7 revealed under the Mental Illness section question #1 marked as no with answer choices available including psychotic/delusional disorder not marked, and under the Symptoms section question #3b for mental and physical symptoms was marked none or no symptoms experienced with answer choices available including hallucinations or delusions as unmarked. The resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS (Minimum Data Set) assessment for Resident #7 dated 5/7/20, after the addition of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview 11/23/21 at 8:50 am, the DON stated the current PASRR for Resident #7 revealed multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that should have been completed last year when they were added.

Based on clinical record review, facility policy review and staff interview, the facility failed to provide a bed hold notice to 1 of 2 residents reviewed (Resident #5). The facility reported a census of 14. Findings include: Review of Resident #5's Progress Notes revealed he transferred to the hospital on 9/21/21 at 6:29 PM, admitted and returned to the facility on [DATE] at 5:23 PM. The resident's record contained no bed hold policy provided prior to hospitalization . The facility's Bed Hold/Readmission Policy, dated 6/10/16, instructed when the resident is absent from the facility, the facility shall provide written information specifying the duration of the bed hold during which the resident shall be permitted to return and resume residence in the facility. The undated Request for Bed Hold form recorded the bed hold must be completed in advance when possible, but no later than 24 hours of the absence. During an interview on 11/23/21 at 10:42 AM, the DON (Director of Nursing) stated she could not find any documentation that bed hold was discussed with the resident/family and she could not find a signed bed hold notice.

Based on clinical record review and staff interview, the facility failed to notify the Ombudsman of a resident's transfer from the facility for 1 of 2 residents reviewed (Resident #5) The facility reported a census of 14. Findings include: Review of Resident #5's Progress Notes revealed he transferred to the hospital on 9/21/21 at 6:29 PM, admitted and returned to the facility on [DATE] at 5:23 PM. Review of the resident's Progress Notes and the facility's Notice of Transfer Form to the Ombudsman did not contain a notice of transfer to the Ombudsman regarding Resident #5 on 9/21/21. During an interview on 11/23/21 at 9:24 AM the Business Office Manager stated she did not send the Ombudsman notification for the resident's hospitalization . She stated she just took over this job recently and thought it was only for discharges from the facility, not transfers to the hospital. On 11/23/21, the facility's provided an updated Notice of Transfer Form to the Ombudsman form that documented staff emailed the Ombudsman on 11/23/21 of the resident's transfer on 9/21/21.

Based on observation, staff interview and record review the facility failed to identify and provide adequate interventions to ensure that residents were safe from harm from other residents. The facility continued to provide 15 minute checks for Resident #2, yet after that implementation on 3/25/20, the Resident had 4 more incidents/altercations with other residents. The facility identified a census of 16 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) quarterly assessment dated [DATE] identified the resident with severe cognitive impairment. The MDS documented the resident as independent with ambulation, and experienced inattention and disorganized thinking. The resident's behaviors included physical and verbal directed at others. The resident experienced delusions and hallucinations. The MDS documented the resident with [DIAGNOSES REDACTED]. Review of a Care plan dated 3/2/20 showed Resident #2 had a behavior problem related to dementia. The following interventions for this concern included: - Revised on 3/9/20: assist the resident to develop more appropriate methods of coping and interacting with staff and peers and encourage the resident to express feelings appropriately. - intervene as necessary to protect the rights and safety of others. - approach/speak in a calm manner, divert attention and remove the resident from situation and take to an alternate location as needed. The resident can be very territorial and protective of what belongs to him/her. - Revised on 6/12/20: the Resident's second spouse looks similar to Resident #4 (bad marriage) and this may be a trigger for the resident. - Revised on 3/27/20: minimize potential for the resident's disruptive behaviors (yelling/screaming) by offering to talk about baseball (Cardinals), Willie Nelson, or Iowa Wrestling which diverts attention. - Revised on 3/9/20: provide a program of activities that is of interest and accommodates the residents status such as the Cardinals, Ted Williams, Iowa wrestling, Dan Gable, Willie Nelson, Johnny Cash and horses. - Revised on 7/17/20: the resident is to be monitored by the nurse and when the nurse is not available she is to assign a staff member to monitor in her absence and continue to document on 15 minute check sheets, redirect the resident when approaching others personal space (related to territorial behaviors and post traumati[DIAGNOSES REDACTED] disease). The Care Plan also revised on 4/16/20 showed the resident had a problem as an elopement risk, wandered aimlessly, significantly intrudes on privacy or activities. Interventions for this concern included: - distract the resident from wandering by offering pleasant diversions, structured activities, food, conversations, and books. The resident prefers the Cardinal baseball, Ted Williams, Iowa wrestling, Dan Gable, Willie Nelson, Johnny Cash, and horses. (Revised again on 7/17/20.) - identify patterns of wondering as appears lonely at times and intervene as appropriate. Have conversations as allowed and as able. (Revised again on 7/17/20). Resident #2 had Investigation Reports completed for having altercations with other residents that were completed on 3/6/20, 3/25/20, 4/4/20, 4/20/20, 6/11/20, 7/3/20 and 7/16/20, and altercations on 3/17/20, 4/16/20, and 4/20/20 not reported. The Incidents for Resident #2 on 3/17, 3/25, 4/4, 6/11, 7/3, and 7/16/20 involved altercations with the same resident, Resident #4. The facility's Incident/Investigation Reports with other residents were shown as followed: - 3/9/20- reported an investigation hitting and punching between 2 residents. - 3/17/20- records showed an incident witnessed, not written up, investigated, or reported. Resident #2 pushed a resident to the floor. - 3/25/20- reported an investigation with a resident on the floor in front of Resident #2's room and telling that resident to stay out. - 4/4/20-reported an investigation with a resident on the floor in front of Resident #2's room and yelling at that resident. - 4/16/20-not reported but witnessed for inappropriateness regarding Resident #2's exposed genital area. - 4/20/20- not reported for a physical encounter witnessed with Resident #2 hands to another's residents throat. - 6/11/20-reported an investigation with Resident #2 pushing, attempting to or/slapped another resident , leaving a red mark. - 7/3/20- not reported, as determined a fall by a resident in Resident #2's room, as Resident #2 stood by. - 7/16/20- reported an investigation witnessed where Resident #2 pushed another resident to the floor, causing a black eye, abrasions to the shoulder and neck. That fallen resident favored their arm while walking the next day an x-ray had been ordered. Observation on 8/3/20 at 11:00 a.m., revealed Resident #4 ambulating in the front hall just past Resident #2's room holding a blanket as it dragged around one of their feet. Resident #2 ambulated from the opposite way, heading to room [ROOM NUMBER]. Resident touched Resident #4's left shoulder with one hand as they passed and both residents kept going. A staff person from the far end of the front hall, going into a supply/bath room also observed the 2 residents in the hall and came down to adjust Resident #4's blanket, away from their foot. Observation on 8/3/20 at 10:30 a.m., revealed the Nurses Station had windows all the way around on the top half of the oblong area. The front and some of the left side windows had decorations and papers covering most of the lower window areas (approximately 1/3 covered up from bottom toward the top.) While standing inside the station there were areas where one stood, one could not observe room [ROOM NUMBER]. The front windows were difficult to see through to the front hall (where the 2 residents passed each other) and to visualize the entrance due to decorations and paper notices posted. During an interview on 7/29/20 at 3:30 p.m., Staff D, Licensed Practical Nurse (LPN), MDS Coordinator and designee Social Worker stated the Charge Nurse writes up the incident report, notifies the DON and the DON follows the report. Staff D reported the protocol for resident to resident altercations are to separate, make sure of safety for all residents, assess the residents involved and notify the DON, if unavailable, notify the Acting Administrator immediately. During an interview on 8/3/20 at 11:40 a.m., Staff G, RN, stated every 15 minute checks for Resident #2 are okay during the night but felt they are not enough during the day. Staff G remarked it is very difficult to do her job plus keep constant eye contact on the resident. Staff G remarked just this morning doing med pass she asked the housekeeper (not an CNA) to watch the resident for awhile. During an interview on 8/3/20 at 1:30 p.m., with Staff G (RN) and Staff D (LPN), Staff G stated she had just found out that she was supposed to do constant eye to eye contact with Resident #2. Staff D stated no one had really told the charge nurses they were to be on constant eye contact. Staff D stated her understanding was if the resident was in their own room, then only 15 minute checks were to be done during that time. Staff D noted they have no idea when the resident leaves the room and he/she can move quite fast at times. They felt the care plan did not exactly say eye contact and appeared vague and confusing. Both nurse's felt it was nearly impossible to keep eye to eye contact with the resident at all times. They both stated it would be a better approach to have an assigned extra person to do 1 to 1 supervision with the resident. Staff D stated there were 3 residents on the unit that require 2 staff assistance with all their cares. She stated having 2 CNA's and 1 Nurse on duty, leaves 1 staff person to monitor all the other residents and it can get busy. They also commented there have been no group huddles with staff members to help come up with other ideas for interventions. Staff D stated the facility had not tried a door alarm, or stop signs that may deter Resident #4, or tried changing one of the residents rooms to a different location on the unit. During an interview on 8/3/20 at 2:00 p.m., the Acting Administrator stated after the 3/25/20 altercation between Resident #2 and Resident #4 they placed Resident #2 on every 15 minute checks until the latest episode (7/16/20). She stated now the charge nurses are to keep an eye on Resident #2 at all times. She stated if the charge nurse has other tasks to attend to, they assign another staff person the watch the resident. She did not remember any other interventions and did not remember any staff huddles to get everyone's ideas for other interventions for Resident #2. She reported her and the DON discussed a door alarm or a stop sign but did not know if that would be appropriate. The Acting Administrator stated Resident #2 has had medication changes and also stated it is hard on the residents to change rooms. During an interview on 8/4/20 at 12:30 p.m., Staff I, Life Events and part time housekeeper, reported she usually does activities from 1 p.m. to 5 p.m. during the day and will do housekeeping in the mornings when other housekeeping staff are gone. During an interview on 8/4/20 at 1:02 p.m., Staff H, CNA, reported there were no staff huddles to see what interventions could help with Resident #2. She remarked it is difficult to do 1 to 1 supervision with Resident #2 without extra staff help to do 1 on 1 observations directly. During an interview on 8/4/20 at 3:17 p.m., Staff B, Licensed Practical Nurse (LPN), stated she felt nothing had really been done for different interventions for Resident #2's behaviors. She stated it seemed like all they did was change the resident's medications and continue the 15 minute checks. Staff B stated they are to keep an eye on him 24/7. She stated the resident's room is not in the best location and they never know when he/she leaves their room. Staff B stated the protocol for altercations/incidents is they are to be written up in an incident report, gather statements as needed, and hand over to the DON who makes the calls and follows through with the investigations. During an interview on 8/5/20 at 11:45 a.m., the Acting Administrator stated she relied on the DON and the MDS Coordinator for interventions for resident concerns. She stated after this last incident on 7/16/20 she insisted on stronger interventions and not just 15 minute checks. She found out the MDS Coordinator had been in contact with the Veteran's (VA) Hospital in Iowa City. The DON received a call back and the VA would refer the resident to the Behavioral Recovery Outreach Program (BRO) to help treat behaviors with interventions which started 7/17/20. The Acting Administrator stated she expected the DON to follow up with all incidents by implementing interventions, communicate to staff, call the families. During an interview on 8/5/20 at 1:20 a.m., the DON, after reviewing the incidents, stated they need to be better with engaging residents and look for other ideas. The DON also acknowledged not holding huddles with staff to brainstorm for ideas, especially for Resident #2. During an interview on 8/10/20 at 11:11 a.m., Staff B, LPN, stated the DON had asked her if she thought Resident #2 pushed Resident #4 on the 4/4/20 incident. She stated she had replied she thought so, and asked why else would Resident #4 be on the floor with Resident #2 yelling over the resident, as Resident #4 doesn't fall down on his/her own. The facility's Resident to Resident Prevention, Identification, Investigation, and Reporting Policy dated 7/30/17 stated the Purpose is all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Policy also defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The Policy also defined Resident to Resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and result in physical harm, pain, or mental anguish is considered resident to resident abuse. The facility will presume that instances of abuse cause physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary.

Based on resident and staff interview, and record review the facility failed to thoroughly investigate allegations of resident to resident altercations for 2 of 9 incidents reviewed involving 3 of 5 residents involved (Resident # 2, 3, and 4). The facility identified a census of 16 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident with a Brief Interview for Mental Status (BIMS) score of 3 which indicated severely impaired cognitive ability. The MDS documented the resident as independent with ambulation, and had problems with inattention and disorganized thinking. The resident's behaviors including physical aggression, verbal aggression directed at others and had delusions and hallucinations. The MDS documented the resident had [DIAGNOSES REDACTED]. The facility's Investigation Reported 4/20/20 documented a Certified Nurse's Aide (CNA) witnessed Resident #2 reach out with their hand and grab Resident #3's neck. There were no marks noted to the neck area. Resident #3 reported being ready to hit the other resident with their cane. The Director of Nursing (DON) stated she used the Iowa Health Care Association's (IHCA) guidelines and concluded this event did not need to be reported to the state. Three days later on 4/23/20, the DON added the statement to the investigation report finding the written statement from the CNA, who witnessed the incident. The DON wrote the written statement had not been the same as it had been reported to her. The DON also wrote Resident #3 had told the nurse (Staff D) Resident #2, had not touched him, and if that had happened Resident #3 would hit Resident #2 with the cane. There were no further investigation or interviews, written statements with Staff D, Staff E, and Resident #3 completed by the DON to verify this incident. During an interview on 7/30/20 at 10:25 a.m., Resident #3, who is documented with Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no impairment in cognitive skills, sat in a wheelchair holding a cane. The resident stated that back in April 2020 Resident #2 took their hand and squeezed her/his throat. The resident expressed feeling threatened with harm and asked the surveyor, wouldn't you if someone grabbed you by the throat? Resident #3 reported Staff E, Certified Nursing Aide (CNA), saw it happen and come right over and stood between them. Record Review of the Nurse's Notes dated 4/20/20 showed Staff D, Licensed Practical Nurse (LPN) documented the incident. Staff D reported Resident #3 reported Resident #2 placed their hand around Resident #3's neck and Staff E witnessed the encounter. There were no injuries or marks and Resident #3 remarked if the hand had been any tighter, he/she would hit the resident in the groin area with the cane in hand. Staff D received Staff E's written statement and also wrote in the note to 'see the witness statement'. During an interview on 8/3/20 at 7:50 a.m., Staff E stated Resident #2 had been agitated that day in April. She saw Resident #3 in front of the room, closing the door, going out for supper. Resident #2 came up and reached his/her hand to Resident #3's throat. When Staff E saw Resident #2 reaching toward Resident #3's neck she hollered out 'don't touch' the resident. Resident #3 told her of being ready to hit Resident #2 in the groin with the cane. Staff E reported writing up the statement for the DON. During an interview on 8/3/20 at 3:30 p.m., the Acting Administrator stated the incident on 4/20/20 revealed Resident #3 had stated they were ready to hit Resident #2 with a cane and this could be seen as mental anguish. She noted the facility's Resident to Resident Abuse (dated 4/13/17) involved reporting abuse included the definition as causing a resident mental anguish and this incident should have been reported to the state. She reported her and the DON use the Iowa Health Associations guidelines for reporting abuse. During a telephone interview on 8/5/20 at 1:20 p.m., the DON reported she didn't see the CNA's witness statement until later and should have investigated this incident more and reported it to the state. The DON stated she interviewed Resident # 3 who denied that Resident #2 touched him/her, but also stated they were ready to hit the other resident if needed. The DON stated she failed to write up that statement. The DON stated Resident #3 can embellish stories at times. The DON stated according to the Iowa Health Care Association's (IHCA) guidelines for reporting this event, which they refer to, the incident did not need to be reported to the state. During an interview on 8/12/20 at 8:36 a.m., the DON reviewed the IHCA's guidelines and referred to the part that gave directions for no reporting if there were no physical injury and a cognitively intact resident is able to say there was no pain or mental anguish (reasonable person standard). The DON stated the Incident between Resident #2 with #3, in which Resident #3 can be lucid at times, was not felt needed to be reported. When noting the other incidents that were not reported were between 2 residents who did not have intact cognitive skills, the DON stated she did not know why she concluded those incidents did not have to be reported. She acknowledged both residents, Resident #2 and #4 were cognitively impaired. The IHCA Flow Chart of Required Abuse Reporting in Facility involving Resident, the facility refers toward the end of answering their questions the following: - was there evidence of victim resident experiencing pain or mental anguish or physical harm (injury)? CMS (Center for Medicare/Medicaid Services) presumes that instances of abuse cause physical harm or pain or mental anguish (absent objective evidence to the contrary), but if in doubt, report. - no reporting required if no physical injury and cognitively intact resident able to say no pain or mental anguish (reasonable person standard). The facility's Resident to Resident Prevention, Identification, Investigation, and Reporting Policy dated 7/30/17 stated their Purpose included all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Policy also defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The Policy also defined Resident to Resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and result in physical harm, pain, or mental anguish is considered resident to resident abuse. The facility will presume that instances of abuse cause physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary. 2. Resident #4's MDS quarterly assessment dated [DATE] documented the resident with a BIMS score of 2 which indicated severe cognitive impairment. The MDS documented the resident with disorganized thinking and independent with ambulation. The MDS listed [DIAGNOSES REDACTED]. Record Review for the Nurse's Notes in Resident's 4's chart failed to identify any altercation on 3/17/20 with another resident. Record Review of Resident #2's chart documented the resident had continued receiving new medications. At approximately 4:50 p.m. on 3/27/20, Resident #4 became agitated and was yelling at another resident for being by Resident #2's doorway. The two residents were separated. During an interview on 7/29/20 at 1:10 p.m., Staff D, LPN, also the MDS Coordinator and designated Social Worker, reported being informed by staff of an incident which occurred on 3/17/20 between Resident #2 and Resident #4 but did not know if this had been reported to state. She reported she had not been present but allegedly Staff A, CNA, reported seeing an altercation between the residents where Resident #2 pushed Resident #4 down by room [ROOM NUMBER]. Staff A reported the protocol for resident to resident altercations is to separate, assess and add interventions as needed and to notify their supervisors. During an interview on 8/3/20 at 11 a.m., Staff A, Certified Nursing Aide, stated on 3/17/20 she witnessed Resident #2 put both hands to Resident # 4' s neck and pushed the resident fully extending their arms outward. Resident #4 hit the Nursing station wall and fell down to the floor on the buttocks. There were no injuries noted. Staff B, Licensed Practical Nurse(LPN) was inside the nursing station working on the computer and did not see the incident. The Acting Administrator had also been in the unit. The CNA stated she filled out a statement and handed it to the Nurse, Staff B. She did not know if this had been reported to the state. Staff A stated the Administrator who was also present had stated to her that didn't happen in regards to the fall. During an interview on 8/4/20 at 3:17 p.m., Staff B, LPN, stated she did not see this incident between Resident #2 and Resident #4 and doesn't believe Resident # 4 fell . Staff B did not receive a written statement from Staff A regarding what she had seen. Staff B commented after discussing the incident with the Acting Administrator, who conferred with the Director of Nursing (DON), they concluded Resident #2 only directed Resident #4 away from the doorway of the room (#15). The Acting Administrator and DON decided this did not need to be investigated, thus no incident report needed to be written nor reported to the state. Staff B did not know if it should have been a reportable incident. Durig an interview on 8/5/20 at 11:45 a.m,. the Acting Administrator reported on 3/16/20 Staff B sat inside the nursing station charting while she stood right outside the nursing station. She reported Staff A had been in another resident's room (right behind where she stood) and does not understand how Staff A could have seen Resident #2 push Resident #4, as she had been in another resident's room. She also noted she did not know if Resident #4 fell or not. She did note Staff A hustled over to where the 2 residents were in front of room [ROOM NUMBER], in the hall, and separated them. The Acting Administrator reported it should have been reported as an incident and investigated and she thought it had been, but was unable to produce the report. She stated she expected the charge nurse to write up an investigation report and the DON would follow up on it. During a telephone interview on 5/5/20 at 1:20 p.m., with the DON stated the Acting Administrator called her at home regarding the event on 3/17/20 between Resident #2 and Resident #4. The DON did not know if a push had occurred with the 2 residents, as the Acting Administrator had reported. She knew Staff A separated the 2 residents involved. The DON did not know if Staff B or the Acting Administrator talked with Staff A , regarding Staff A's account of what had happened. She noted Staff B and the Acting Administrator did not know if Resident #2 actually touched Resident #4 when Resident #4 fell . The DON commented if the resident fell an incident report should have been filed, noting she did not remember if one had been filed. During a telephone interview on 8/10/20 at 11:11 a.m., Staff B did not recall receiving a written statement from Staff A, but stated if she had she would have given it to the Acting Administrator who had been present. Staff B does not remember talking with Staff A, who witnessed the incident. Staff B reported after the Acting Administrator had conferred with the DON, they decided Resident #2 only re-directed the resident away from the room, and not to write up any incident report. Staff B reported hearing Resident #4 make a noise and saw Staff A separating the 2 residents. She also commented if Resident #4 had been on the floor, she would have written up an incident report, but did not believe she had fallen. During an interview on 8/12/20 at 8:37 a.m., the Acting Administrator stated Staff A did not write up a statement and she did not ask her to. If Staff A did witness what she said she did, then she probably should have had her write up a statement. The Acting Administrator stated she did consult with the rest of the staff and no one else had seen the altercation. The Acting Director, the DON, and Staff B just agreed there had not been an incident.

Based on staff interview and record review the facility failed to report 3 of 9 incidents reviewed involving 4 of 5 residents (Residents # 1, 2, 3, and 4). The facility identified a census of 16 residents. 1. The facility's Online Abuse or Incident Reporting List showed the following reports: - 3/9/20 for Allegation of Abuse. - 3/26/20 for Allegation of Abuse. - 4/4/20 for Allegation of Abuse. - 6/11/20 for Allegation of Abuse. -7/16/20 for Allegation of Abuse. The facility's Incident/Investigation Reports were dated as followed: - 3/9/20- reported. - 3/17/20- records showed an incident witnessed, not written up, investigated, or reported. - 3/26/20- reported. - 4/4/20-reported. - 4/16/20-not reported but witnessed for inappropriateness. - 4/20/20- not reported for a physical encounter witnessed. - 6/11/20-reported. - 7/3/20- not reported, as determined a fall in another resident's room. - 7/16/20- reported. The quarterly assessment Minimum Data Set (MDS) for Resident #1 dated 5/27/20 listed [DIAGNOSES REDACTED]. The MDS documented a BIMS score of 1 out of 15 which indicated severe impairment with cognitive skills, limited staff assistance with ambulation, had behaviors including physical aggression, verbal aggression not directed at others and experienced delusions and hallucinations. The Minimum Data Set (MDS) quarterly assessment dated [DATE] for Resident #2 identified the resident with a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated severe impairment with cognitive skills. The MDS documented the resident with [DIAGNOSES REDACTED]. The MDS documented the resident as independent with ambulation, had inattention and disorganized thinking. The resident's behaviors including physical aggression, verbal aggression directed at others and experienced delusions and hallucinations Resident #3's MDS quarterly assessment dated [DATE] documented the resident with a BIMS score of 15 out 15 which indicated no cognitive impairment skills, had delusions and verbal behavior directed at others, and independently mobile on the unit with the use of a wheelchair. The MDS listed [DIAGNOSES REDACTED]. Resident #4's MDS quarterly assessment dated [DATE] documented the resident with a BIMS score of 2 out of 15 which indicated severe cognitive impairment with disorganized thinking. Resident #4 was independent with ambulation. The MDS showed the resident had [DIAGNOSES REDACTED]. During an interview on 8/3/20 at 11 a.m., Staff A, Certified Nursing Aide (CNA), reported that on 3/17/20 she saw Resident #2 put both hands to Resident # 4' s neck and pushed the resident fully extending the arms outward. Resident #4 hit the Nursing station wall and fell down to the floor on the buttocks. There were no injuries. Staff B, Licensed Practical Nurse (LPN) was inside the nursing station working on the computer and did not see the incident. The Acting Administrator had also been in the unit. The CNA reported filling out a statement and handing it to the Nurse, Staff B. She did not know if this had been reported to the state. Staff A reported the Administrator, also present, had stated to her that didn't happen. During an interview on 8/4/20 at 3:17 p.m., Staff B stated she did not see this incident between Resident #2 and Resident #4 and doesn't believe Resident # 4 fell . Staff B stated she did not receive a written statement from Staff A regarding what she has seen. Staff B stated that after discussing the incident with the Acting Administrator, who had conferred with the Director of Nursing (DON), they concluded that Resident #2 had only directed Resident #4 away from the doorway of the room (#15). The Acting Administrator and DON decided this did not need to be investigated, thus no incident report needed to be written nor reported to the state. Staff B did not know if it should have been a reportable incident. During an interview on 8/5/20 at 11:45 a.m., the Acting Administrator stated that on 3/16/20 Staff B sat inside the nursing station charting while she stood right outside of the nursing station. She reported Staff A had been in another resident's room (right behind where she stood) and does not understand how Staff A could have seen Resident #2 push Resident #4, as she had been in another resident's room. She also noted she did not know if Resident #4 fell or not. She did note Staff A hustled over to where the 2 residents were in front of room [ROOM NUMBER], in the hall. The Acting Administrator reported it should have been reported as an incident and investigated and thought it had been, but was unable to produce the report. She stated she expected the charge nurse to write up an investigation report and the DON would follow up on it. During a telephone interview on 5/5/20 at 1:20 p.m., with the DON, she reported the Acting Administrator called her at home regarding the event on 3/17/20 between Resident #2 and Resident #4. The DON did not know if a push had occurred with the 2 residents, as she had received a report from the Acting Administrator. She knew Staff A separated the 2 residents involved. The DON did not know if Staff B or the Acting Administrator talked with Staff A , regarding Staff A's account of what had happened. She noted Staff B and The Acting Administrator did not know if Resident #2 actually touched Resident #4 when Resident #4 fell . The DON commented if the resident fell an incident report should have been filed, but stated she did not remember if one had been filed. The facility's Investigation Report dated 4/16/20 showed the nurse was called to the room by a Certified Nursing Aide (CNA) to find Resident #2 sitting next to Resident # 1's on the bed with his/her pants pulled down to the knees, exposing the groin area. Resident #1 stated I was just rubbing her/his back. There were no injuries identified. During an interview on 8/3/20 at 3:30 p.m. the Acting Administrator acknowledged this incident on 4/16/20 regarding Resident #1 and Resident #2 could be seen as exploitation and should have been reported. The Acting Administrator looked at the facility's Resident to Resident Abuse policy (dated 4/13/17) involving reporting which included exploitation and said this incident appeared as exploitation. During a telephone interview on 8/5/20 at 1:20 p.m., the DON reported she did not see this incident on 4/16/20 as exploitation, but in hindsight it would be and she should have reported this incident to the state. She reported she used the Flow Chart of Required Abuse Reporting in Facility Involving Resident from Iowa Health Care Association (IHCA) to determine if this incident should be reported. The facility's Investigation Reported 4/20/20 showed a CNA witnessed Resident #2 reach out and grabbed Resident #3's neck with their hand. There were no marks noted to the neck area. Resident #3 reported of being ready to hit the other resident with their cane. The DON's conclusion for this report, determined with the use of using Iowa Health Care Association's (IHCA) guidelines, that this event did not need to be reported to the state. During an interview on 8/3/20 at 3:30 p.m., the Acting Administrator stated the incident on 4/20/20 in which Resident #3 had stated they were ready to hit Resident #2 with a cane, could be seen as mental anguish. She noted the facility's Resident to Resident Abuse (dated 4/13/17) involved reporting abuse included the definition as causing a resident mental anguish. During an interview on 8/4/20 at 11:45 a.m., the Acting Administrator stated she expected the DON to follow up with all incidents by implementing interventions, communicating to staff, and calling the families. She stated she and the DON will typically confer about the incident and she usually makes the report to state. She stated they both can notify the state, depending on each of their availability. The Acting Administrator stated they both can complete the conclusions for the findings on the Incident Reports. During a telephone interview on 8/5/20 at 1:20 p.m., the DON reported she didn't see the CNA's witness statement until later and she should have investigated this incident more and reported it to the state. The DON stated with the use of using Iowa Health Care Association's (IHCA) guidelines this event did not need to be reported to the state. During an interview on 8/12/20 at 8:33 a.m., the DON reviewed the IHCA's guidelines and referred to the part that gave directions for no reporting if there were no physical injury and a cognitively intact resident is able to say they experience no pain or mental anguish (reasonable person standard). The DON stated the incident between Resident #2 with #3, in which Resident #3 can be lucid at times, she did not feel needed to be reported. When pointed out the other incidents not reported were between 2 residents who did not have intact cognitive skills, the DON stated she did not know why she concluded those incidents did not have to reported to state. The IHCA Flow Chart of Required Abuse Reporting in Facility involving Resident, the facility answered their questions as the following: - was there evidence of victim resident experiencing pain or mental anguish or physical harm (injury). CMS (Center for Medicare/Medicaid Services) presumes that instances of abuse cause physical harm or pain or mental anguish (absent objective evidence to the contrary), but if in doubt, report. - no reporting required if no physical injury and cognitively intact resident able to say no pain or mental anguish (reasonable person standard). The facility's Resident to Resident Prevention, Identification, Investigation, and Reporting Policy dated 7/30/17 stated their Purpose included all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Policy also defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The Policy also defined Resident to Resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and result in physical harm, pain, or mental anguish is considered resident to resident abuse. The facility will presume that instances of abuse cause physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident being unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary.

Based on observation. staff interview, and record review the facility failed to provide adequate nursing supervision to protect residents from injury by another resident for 2 out 4 residents reviewed. (Resident #2, #4). involving several altercations between Resident #2 and #4. The facility identified a census of 16 residents in the Dementia Unit. Findings include: 1. Resident #2's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident with a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS documented the resident was independent with ambulation, had inattention and disorganized thinking. The resident's behaviors included physical, verbal aggression directed at others and had delusions and hallucinations. The MDS listed [DIAGNOSES REDACTED]. Resident #2's Care plan dated 3/2/20 identified the a behavior problem related to dementia. The following interventions for this concern included: - Revised on 3/9/20: assist the resident to develop more appropriate methods of coping and interacting with staff and peers and encourage the resident to express feelings appropriately. - intervene as necessary to protect the rights and safety of others. - approach/speak in a calm manner, divert attention and remove the resident from situation and take to an alternate location as needed. The resident can be very territorial and protective of what belongs to him/her. - Revised on 6/12/20: the residents second spouse looks similar to Resident #4 (bad marriage) and this may be a trigger for the resident. - Revised on 3/27/20: minimize potential for the resident's disruptive behaviors (yelling/screaming) by offering to talk about baseball (Cardinals), Willie Nelson, or Iowa Wrestling which diverts attention. - Revised on 3/9/20: provide a program of activities that is of interest and accommodates the residents status such as the Cardinals, Ted Williams, Iowa wrestling, Dan Gable, Willie Nelson, Johnny Cash and horses. - Revised on 7/17/20: the resident is to be monitored by the nurse and when the nurse is not available she is to assign a staff member to monitor in her absence and continue to document on 15 minute check sheets, redirect the resident when approaching others personal space (related to territorial behaviors and post traumati[DIAGNOSES REDACTED] disease). The Care Plan, with a revision date of 4/16/20, identified a problem as being at risk for elopement, wandering aimlessly, significantly intrudes on privacy or activities. Interventions for this concern included: - distract the resident from wandering by offering pleasant diversions, structured activities, food, conversations, and books. The resident prefers the Cardinal baseball, Ted Williams, Iowa wrestling, Dan Gable, Willie Nelson, Johnny Cash, and horses. (And revised again on 7/17/20.) - identify patterns of wondering as appears lonely at times and intervene as appropriate. Have conversations as allowed and as able. (Revised again on 7/17/20). Resident #2 had Investigation Reports completed for having altercations with other residents that were completed on 3/6/20, 3/25/20, 4/4/20, 4/20/20, 6/11/20, 7/3/20 and 7/16/20, and altercations on 3/17/20, 4/16/20, and 4/20/20 not reported. The Incidents for Resident #2 on 3/17, 3/25, 4/4, 6/11, 7/3, and 7/16/20 involved altercations with the same resident, Resident #4. Resident #4's MDS quarterly assessment dated [DATE] documented the resident with a BIMS score of 2 which indicated severe cognitive impairment. The MDS documented disorganized thinking, independence with ambulation, gait steady at all times and no impairment with range of motion The MDS also showed the resident had [DIAGNOSES REDACTED]. The facility's Incident/Investigation Reports between the 2 residents were shown as followed: - 3/17/20- an incident witnessed, not written up, investigated, or reported had occurred between the 2 residents. Resident #2 pushed Resident #4 into the nursing station by Resident #2's room, where Resident #4 fell to the floor. There were no injuries. - 3/25/20- Resident #4 found on the floor in front of Resident # 2's room. Resident #2 yelling at Resident #4 to stay out of the room. - 4/4/20- Resident #4 found on the floor in front of Resident #2's room and yelling. - 6/11/20-Resident #2 pushing and attempting to slap Resident #4 with the fingertips, leaving a red mark. A written statement by a staff person documented Resident #2 slapped Resident #4 - 7/3/20- Resident #4 found on the floor, while Resident #2 stood to the left side. This incident had been determined as a regular fall and not an altercation between the 2 residents, as there were no witness's to observe the fall. The conclusion by the Director of Nursing (DON) determined Resident #4 appeared to have fallen to the floor, hitting the wall and the open door. Resident #4 had a red area to lower left cheek and a light scratch down left neck and a small red area on the right arm. The Report documented that Resident #2 had not appeared to be upset at that time. - 7/16/20- A staff member witnessed Resident #2 push Resident #4 to the floor. A Certified Nursing Aide (CNA) witnessed Resident #2 push Resident #4 onto the floor in front of the Nursing Station. The Staff person heard Resident #4 state Resident #2 tried to kill him/her. Resident #4 received a 3 centimeter (cm.) by 2 cm. raised area with a few scattered marks under the left eye, a 4 cm. by 3 cm. abrasion on the left shoulder and a 2 cm. by 2 cm. abrasion on the left knee. On 7/17/20 the DON noted on the report Resident #4 had a black left eye and into using the left arm. The ARNP (Advanced Registered Nurse Practitioner) called and ordered portable X-rays to be done. Observation on 8/3/20 at 11:00 a.m., revealed Resident #4 ambulating in the hall just past Resident #2's room dragging a blanket. Resident #2 ambulated from the opposite way heading to room [ROOM NUMBER]. Resident #2 touched Resident #4's left shoulder as they passed and both resident's kept going. A staff person from the far end of the front hall, going into a supply/bath room also observed the 2 residents in the hall and came down to adjust Resident #4's blanket, away from the feet. Observation on 8/3/20 at 10:30 a.m., revealed the Nurses Station had windows all the way around on the top half of the oblong area. The front and some of the left side windows had decorations and papers covering most of the lower window areas (approximately 1/3 covered up from bottom toward the top.) While standing inside the area, there were areas where one could not observe room [ROOM NUMBER]. The front windows were difficult to see through to the front hall (where the 2 residents passed each other) and entrance due to decorations and paper notices posted. During an interview on 7/29/20 at 3:30 p.m., Staff D, Licensed Practical Nurse (LPN), MDS Coordinator and Social Worker designee, stated the Charge Nurse writes up the incident report, notifies the DON and the DON follows the report. Staff D reported the protocol for resident to resident altercations are to separate, make sure of safety for all residents, assess the residents involved and notify the DON, if unavailable, notify the Acting Administrator immediately. They will investigate the incident which occurred. Staff D remarked about another incident on 3/17/20 as Staff A informed her of what altercation she had seen between Resident #2 and #4. Staff D did not know if this had been reported or not. Staff D also expressed concern regarding the incident between the same residents on 7/16/20, as she had thought Resident #4 should have been sent to the hospital. She noted the Advanced Registered Nurse Practitioner (ARNP) had wanted to send Resident #4 to the hospital. During an interview on 8/3/20 at 10:47 a.m., the resident's family member stated the facility called about incidents happening with their family member with the same resident, and stated it keeps happening. The family member stated the other resident needed to go somewhere else. The family member acknowledged the resident did not have to go to the hospital as the staff could monitor the resident at the facility. During an interview on 8/3/20 at 11:40 a.m., Staff G, RN, reported every 15 minute checks for Resident #2 are okay during the night but felt they are not enough during the day. Staff G remarked it is very difficult to do her job plus keep constant eye contact on the resident. During an interview on 8/3/20 at 1:30 P.M.,. with Staff G and Staff D,LPN, Staff G stated she had just found out that she was supposed to do constant eye to eye contact with Resident #2. Staff D stated no one had told the charge nurses they were to be on constant eye contact. Her understanding was if the resident was in their room, then only 15 minute checks were to be done during that time. Staff D noted they have no idea when the resident leaves the room and he/she can move quite fast at times. They felt the care plan did not exactly say eye contact and appeared vague and confusing. Both nurses felt it was nearly impossible to keep eye to eye contact with the resident at all times. They stated it would be a better approach to have an assigned extra person to do 1 to 1 supervision with the resident. Staff D remarked there were 3 residents in the unit requiring 2 staff assistance with all their cares. She noted having 2 CAN's and 1 Nurse on duty, leaves 1 staff person to monitor all the other residents and it can get busy. They also commented there have been no group huddles with staff members to help come up with other ideas for interventions. Staff D stated the facility has not tried a door alarm, or any stop signs, that may deter Resident #4, or try changing one of the residents rooms to a different location in the unit. During an interview on 8/3/20 at 2:00 p.m., the Acting Administrator reported after the 3/25/20 altercation between Resident #2 and Resident #4 they placed Resident #2 on every 15 minute checks until this latest episode (7/16/20) and now it is an eye on Resident #2 at all times by the charge nurse. She did not remember any other interventions and did not remember any staff huddles to get everyone's ideas for other interventions for Resident #2. She stated she and the DON discussed a door alarm or a stop sign but did not know if that would be appropriate. The Acting Administrator noted Resident #2 has had medication changes and also noted it is hard on the residents to change rooms. During an interview on 8/4/20 at 12:30 p.m., Staff I, Life Events and part time housekeeper, reported she usually does activities from 1 p.m. to 5 p.m. during the day and will do housekeeping in the mornings when other housekeeping staff are gone. During an interview on 8/4/20 at 1:02 p.m., Staff H, CNA, reported there were no staff huddles to see what interventions could help with Resident #2. She remarked it is difficult to do 1 to 1 supervision with Resident #2 without extra staff help. During an interview on 8/4/20 at 3:17 p.m., Staff B, Licensed Practical Nurse (LPN), stated feeling nothing had really been done for different interventions for Resident #2's behaviors. She stated it seemed like all they did was change the resident's medications and continue the 15 minute checks. She stated they are now to keep an eye on him 24/7. She noted the resident's room is not in the best location and they never know when he/she leaves the room. Staff B reported the protocol for altercations/incidents are to be written up in an incident report, gather statements as needed, and hand over to the DON who makes the calls and follows through with the investigations. During an interview on 8/5/20 at 11:45 a.m., the Acting-Administrator stated she relied on the DON and the MDS Coordinator for interventions for resident concerns. The Acting Administraror stated after this last incident on 7/16/20 she insisted on stronger interventions and not just 15 minute checks. She found out the MDS Coordinator had been in contact with the Veteran's (VA) Hospital in Iowa City. The DON received a call back and the VA would refer the resident to the Behavioral Recovery Outreach Program (BRO) to help treat behaviors with interventions which started 7/17/20. During an interview on 8/10/20 at 11:11 a.m., Staff B, LPN, reported the DON had asked her if she thought Resident #2 pushed Resident #4 on the 4/4/20 incident. She stated she thought so, and asked why else would Resident #4 be on the floor with Resident #2 yelling over the resident, as Resident #4 doesn't fall down on his/her own. During an interview on 8/5/20 at 1:20 a.m., the DON, after reviewing the incidents, reported they need to be better with engaging residents and look for other ideas. The DON also acknowledged not having done huddles with staff to brainstorm for ideas, especially for Resident #2. The facility's Resident to Resident Prevention, Identification, Investigation, and Reporting Policy dated 7/30/17 stated their Purpose is all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Policy also defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The Policy also defined Resident to Resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and result in physical harm, pain, or mental anguish is considered resident to resident abuse. The facility will presume that instances of abuse cause physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary.

Based on record review and staff interviews the facility did not always ensure each resident received adequate supervision to prevent accidents, which resulted in an immediate jeopardy to resident health and safety. Concerns were noted for 1 of 4 sampled Resident (#1). Resident #1 exited the facility without staff knowledge and was found outside by someone in the community and the temperature was 32 degrees Fahrenheit. The facility reported a census of 44 residents. Findings include: According to record review, Resident #1 entered the facility on 2-2-2019 and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 3 points (of 15 possible points) on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment and decision making skills. The assessment described Resident #1 required extensive staff assistance with bed mobility, transferring, ambulation, toilet use, and hygiene. Resident #1 required staff supervision with eating. Documentation in Resident #1's individual Plan of Care indicated the resident had impaired cognitive function/dementia or impaired thought process dated 2/11/19. Interventions initiated on 2-19-2019 included to have staff provide assistance to his room after meals and to redirect the resident when wandering in other resident's room. On 2-19-2019 staff identified a problem of continual wandering about the facility related to his disorientation. The Care Plan directed staff to identify reasons for wandering, keep his area free of clutter and to provide a staff environment. Review of the nurses notes dated 2-2-2019 at 7:34 p.m. staff noted Resident #1 walking around the dining room looking for a way to leave the facility. Staff directed Resident #1 down the west hall and into the dining room, but Resident #1 went down the east hall, trying to get out the door. Staff contacted his family members who were able to help calm Resident #1. Staff discussed the option of Resident #1 going to the locked memory care unit but the resident settled down and agreed to spend the night at the facility. Documentation in the nurse's notes dated 2-8-2019 indicated Resident #1 in the hallway at 3:43 a.m. partially clothed and looking for his spouse. The documentation revealed on 2/13/19 at 7:29 a.m., Resident #1 had his coat on and looking for the front door waiting for a his spouse to pick him up. Staff were able to redirect Resident #1 back to his room. A nurse's note entry dated 2-19-2019 at 11:37 a.m. indicated a care plan conference held which included the discussion of Memory Care placement in the future; however, family is not ready to move resident at this time. Documentation in the nurse's noted dated 2-20-2019 at 8:23 p.m. indicated Resident #1 wandering the hallway without his walker and staff redirected Resident #1 several times to his room. Documentation in the nurse's notes dated 3-16-2019 at 7:10 p.m. indicated an individual from the community stated she found Resident #1 out by the church (located next to the facility) while she was on a walk. The individual stated she knew Resident #1 lived at the facility by the items on his walker. Documentation in the nurses' noted dated 3-17-2019 at 1:54 p.m. indicated Resident #1 restless all day and needed redirected from wanting to leave several times. The staff noted the Resident seems very confused with his new room change which occurred on Saturday 3-16-2019, per family request. During a phone interview on 4-9-2019 at 1: 19 p.m. the State Climatologist described the weather conditions near the facility on 3-16-2019 at 7:00 p.m. as 32 degrees Fahrenheit, 80 percent humidity, north wind at 5 miles per hour resulting in a wind chill of 27 degrees Fahrenheit, over cast skies and no precipitation. According to documentation in a summary written by the facility Director of Nursing, Resident #1 unable to sleep the night of Friday, 3-15-2019 and according to Resident #1's son, he was tired. Resident #1 had a new roommate on Friday, 3-15-2019. Resident #1's son wanted Resident #1 moved to a different room, the staff moved the resident to a different room on Saturday 3-16-2019. On Saturday 3-16-2019 Resident #1's daughter took him out of the facility for a while. When they returned an unidentified staff person overheard the family member comment to Resident #1, this is the way I go home, pointing to the door. During an interview on 4-10-2019 at 1:56 p.m. the Director of Nursing clarified that the staff member pointed to the lobby in general as to how she exited the facility rather than a specific door. During the interview the Director of Nursing indicated that it's not possible to determine exactly how Resident #1 exited the building. The Director of Nursing did state that the red and green lights on the alarm pad next to the door leading to the Assisted Living (AL) unit did not always work properly. According to the Director of Nurse's written statement she tested the door leading to the Assisted Living unit when a nurse went to AL and put the code in to override the alarm, the Director of Nursing got up from her chair in the office and went to the door and could pull on the door, opening it, the door did not alarm. The Director of Nursing stated she was unaware of this happening before. The facility identified Resident #1 confused at times and impaired cognitively, wandered within the facility and at times demonstrated exit seeking behaviors. A transition to the secured unit was offered but declined by the family, however the facility failed to implement any additional interventions based on Resident #1's behaviors to ensure the safety of Resident #1. The facility abated the immediate jeopardy on 3/16/2019 by initiating 15 minute checks. On 3/17/2019 the facility added a motion alarm on resident's door and on 3/19/2019 the facility, reset all exit door alarms.

Based on record review and interviews, the facility failed to implement and protect 1 of 4 residents from environmental hazards (Resident #1). On 2/7/15 Resident #1 had a fall from his/her personal wheelchair and sustained a hairline jaw fracture and lip laceration when the wheelchair brakes gave out. Staff interviews revealed prior to this incident, the facility fixed/checked wheelchairs only when a work order came in. The facility reported a census of 50 residents. Findings include: According to the Minimum Data Set ((MDS) dated [DATE] Resident #1 had [DIAGNOSES REDACTED]. The resident had intact cognitive skills for daily decision making and scored 15 of 15 on his/her cognitive test (Brief Interview for Mental Status). The resident required extensive assistance of one staff to transfer from one surface to another. The MDS documented the resident experienced two falls with no injury since admission or the prior assessment. The Care Plan identified Resident #1 demonstrated impaired physical mobility, unsteady gait, frequent falls and required a wheel chair for self mobility. The Care Plan revealed the resident also had a [DIAGNOSES REDACTED]. On February 5, 2015, the Care Plan instructed staff to provide a walker and gait belt and two staff to transfer from surface to surface and no ambulation (walking) for Resident #1. The Care Plan also instructed staff to provide a call light, bed alarm and mat on the floor, and to keep the bed in a low position. The resident used a wheelchair without foot pedals for out of room mobility. The Fall Risk Evaluation dated 11/28/2014 revealed Resident #1 had a high risk for falls. TRIPS (Tracking Record for Improving Patient Safety) and a summary of falls provided by Staff E, LPN (Licensed Practical Nurse) established Resident #1 had a history falls: a. On 11/28/2014 at 5:30 a.m. and 10:20 p.m. during a self-transfer from the bed. The resident reported he/she got themselves up and lost their balance, falling on his/her bottom. The resident went to the emergency room and x-rays revealed no fracture. b. On 12/26/2014 at 9:05 a.m., when the resident stood from the wheelchair, he/she lost his/her balance and had been reaching for the television cord. The resident denied pain. c. On 1/21/2015 at 6:30 p.m. while getting up unassisted from the wheelchair. Staff observed the resident seated on the floor with legs straight out with no injury. The TRIPS (Tracking Record for Improving Patient Safety) and a summary of falls provided by Staff E, LPN (Licensed Practical Nurse) revealed Resident #1 fell on [DATE] at 3:25 p.m., while leaning forward in the wheelchair to get a Kleenex. The resident transferred to the emergency room with a laceration of the upper lip. The resident refused stitches and x-rays revealed a probable minimal fracture involving the anterior maxillary spinous process on the right. The emergency report dated 2/7/15 documented the head CT showed a probably minimal fracture involving the anterior maxillary spinous process on the right (jawbone area) and soft tissue air lucenices along the anterior maxilla on the right near the base of the nose. During an interview on 3/12/2014 at 10:40 a.m., DON (Director of Nursing), reported Resident #1 stood up from the wheelchair and his/her brakes gave out, and he/she fell forward. The resident went to the ER and refused stiches. The DON mentioned the resident owned his/her own wheelchair. During an interview on 2/12/15 at 12:40 p.m., Resident #1 stated yes he/she had a problem with the brakes but it had been fixed. During an interview on 3/12/2015 at 12:45 p.m., Staff E revealed staff determined the resident's wheelchair brakes failed to hold when the resident fell on [DATE]. A facility document titled Wheel Chair Process documented the following: On 12/15/14 a safety meeting discussed wheelchair repair and the issue would be revisited at the next safety meeting. On 1/19/15, the safety meeting a staff reported back on the wheelchair repair process. On 1/26/15 it was determined the wheelchairs would be under the duties of the maintenance department, and a checklist for wheelchairs was developed. The document noted the facility should insure wheelchair were properly maintained for compliance with the regulations & should be initiated. The Administrator instructed the Maintenance Department to develop a process to be compliant. On 2/4/15 the Maintenance Supervisor/Administrator continued discussion on wheelchair maintenance process. On 2/10/15 after a resident incident, ever wheelchair would be checked by the end of the week. On 2/13/15 the facility checked all wheelchairs used by residents. During an interview on 3/9/2015 at 2 p.m., the Administrator reported the facility implemented a plan of corrections, revised maintenance checklists and currently perform weekly wheelchair checks. Any wheelchair on facility property is checked weekly and when a wheelchair goes in and out of inventory. During an interview on 3/9/2014 at 2:30 p.m., Staff D, Director of Operations reported Resident #1 signed two Hold Harmless Agreements, requests independence and makes his/her own decisions. When the resident self transferred on 2/7/2014, they determined the wheelchair brakes failed to hold. Maintenance fixed the problem, and has put a corrective action in place. Now the facility routinely checks all wheelchairs. During an interview on 3/12/2015 at 1:05 p.m., Staff F, Maintenance Supervisor reported the facility added weekly wheelchair checks on Wednesdays. Prior to that they fixed problems (with wheelchairs) when work orders came in. When the nurse practitioner saw the resident on 1/13/15, he/she felt the resident needed to see an orthopedic physician related to a prior injury. On 1/21/15, he/she fell again and fractured his/her thumb. On 2/7/15 the resident had a fall from the wheelchair and sustained a hairline jaw fracture and lip laceration when they determined the wheelchair brakes gave out.