**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility policy review, resident, and staff interviews, the facility failed to ensure 1 of 9 residents reviewed (Resident #41) was free from physical abuse resulting in injury. The facility failed to put interventions in place for a resident with a known history of violent behavior (Resident #22) to protect residents. This incident constituted immediate jeopardy (IJ) to the resident's health and safety. The Iowa Department of Inspections and Appeals notified the facility of the IJ on 12/8/22 at 1:20 PM. The facility reported a census of 55 residents. Findings include: 1. The admission Minimum Data Set (MDS) dated [DATE] for Resident #22 documented an admission date of 10/3/22 from a psychiatric hospital. Resident #22 had Level II Preadmission Screening Resident Review (PASRR) in place. The MDS identified a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS included diagnoses of anxiety, depression, schizophrenia, and dementia with other behavioral disturbances. Resident #22 could independently complete most activities of daily living including ambulation. The Preadmission Screening and Resident Review (PASRR) form completed 9/20/22 by a local hospital behavioral health center revealed Resident #22 had a known behavior of physical aggression. The PASRR documented the admitting nursing facility must incorporate PASRR findings as part of the individual's plan of care. The PASRR further documented that Resident #22 went to the emergency department (ED) at a local hospital behavioral health center the day after he hit a resident at another nursing facility. This had been the third time of being seen in the ED in the previous several days because Resident #22 chose not to take his medications and had been physically forceful with others. The resident admitted to the hospital under an emergency detention order by the State District Court of the local county after a petition had been filed by the hospital alleging the resident to be seriously mentally impaired and a harm to himself and others. A copy of the court order had been provided with the PASRR assessment. Staff at the prior nursing home documented that they did not feel Resident #22 was safe to be around others due to his physical behaviors. The PASRR included that he told his doctor that he believed that someone poisoned his food, that he heard noises that other people did not hear and voices in his head. Resident #22 had a history of talking to himself, quickly changing moods, irritability, being rude, screaming, yelling, threatening, physically forceful with others, slamming doors, restlessness, demanding of others, and seeking attention from others. Resident #22's Care Plan revised 10/27/22 revealed the resident had the potential to demonstrate verbally abusive behaviors such as yelling and having loud outbursts related to dementia. Resident #22 had ineffective coping skills and a mental/emotional illness such as schizophrenia. Resident #22 could sometimes have behaviors or hallucinations where he might yell rambled words. In addition he can also yell and be verbally abusive toward staff and or residents at times. The Care Plan included the following interventions: a. Staff to intervene when he became agitated before the agitation escalated, guide away from the source of distress, and engage calmly in conversation. If Resident #22 responded aggressively, the staff should calmly walk away and approach later. The Care Plan dated 10/27/22 identified Resident #22 had a psychosocial well-being problem (actual or potential) related to the disease process of schizophrenia, dementia, intellectual disability, anxiety, and ineffective coping. The Care Plan included the following interventions dated 10/27/22: a. When conflict arises, remove the Resident to a calm safe environment and allow him to vent/share feelings. b. The Resident needs assistance, encouragement, and support to identify problems that cannot be controlled. c. Allow the Resident time to answer questions, verbalize feelings, perceptions, and fears frequently. The Care Plan lacked direction in regards to potential violent behavior towards others, incorporation of the PASRR recommendations, and how to provide safety for the staff and other residents. 2. The quarterly MDS for Resident #41 identified a BIMS score of 15, indicating intact cognition. The MDS documented included diagnoses of anxiety, depression and cancer. Resident #41 was independent with activities of daily living (ADLs). Resident #41's Care Plan revised 11/15/22 documented that Resident #41 had a psychosocial well-being problem (actual or potential) related to diagnoses of anxiety disorder and depression disorder. The Care Plan included an intervention of when conflict arises, remove to a calm, safe environment, and allow him to vent/share his feelings. During an interview 12/5/22 at 12:52 PM, Resident #41 revealed that Resident #22 came up to him recently and said he was mad at him for something. Resident #41 stated two days later Resident #22 came up to him, punched him in the left eye, and said there you go. Resident #41 stated after Resident #22 hit him, he held his face and walked away from him. Resident #41 further stated that he never did anything to Resident #22 and that he shouldn't be doing that to people. Resident #41 stated he had to have an eye procedure rescheduled due to the swelling from being punched in the eye by Resident #22 and stated the area hurt when he touched it. The Facility Incident Report dated 11/26/22 at 12:00 PM completed by Staff L, Licensed Practical Nurse (LPN), indicated that a Certified Medication Aide (CMA) called the nurses to the front nurses' station and informed them that Resident #22 hit Resident #41. The Incident Report further documented when the nurses went to Resident #22's room they observed him with a bruise and a big lump under his left eye. Resident #41 informed them that Resident #22 hit him. During an interview on 12/7/22 at 10:14 AM, Staff E, CMA, reported that on Thanksgiving Day she worked the C/D hall when she heard Resident #41 yelling. She stated that she saw Resident #22 in front of Resident #41 punching into the air in front of him screaming, I'm going to kill you! I'm going to kill you! Staff E explained that she left the medication cart to separate the two residents and directed Resident #41 to sit back down in the chair, in which he did. Staff E stated that she went back to the medication cart to complete the narcotic count. Staff E stated she then heard Resident #22 holler out again and as she turned around from the medication cart she saw Resident #22 hit Resident #41 in the eye. Staff E stated that she couldn't remember which eye was hit or which hand Resident #22 used but Resident #41's eye was black the Saturday after Thanksgiving. The facility policy titled, Abuse Prevention and Reporting, revised August 2019 revealed residents must not be subjected to abuse by anyone including other residents. The policy directed staff to identify, correct, and intervene in situations where resident to resident abuse is most likely to occur and provide protection by immediately separating the residents involved, moving the resident to another room or unit, providing 1:1 monitoring as appropriate, implementing discharge process immediately if the resident is a danger to themselves or others and initiating behavior crisis management interventions as applicable. During an interview on 12/13/22 at 9:35 AM, the Director of Nursing (DON) reported that if Resident #22 was being that aggressive toward Resident #41, she would have separated the two completely to a different room and contacted the provider in regards to the behavior including directing the use of as needed medication, contacting psychiatry and most likely starting a one on one (1:1). The DON further revealed that she expected the staff to intervene in order to prevent abuse, to give Resident #22 space, then ensure residents and staff stay away from him. The DON added Staff G, Registered Nurse (RN), remained sore after being hit by Resident #22. During an interview on 12/19/22 at 11:24 AM, the Administrator revealed it is an expectation that staff keep residents safe from abuse by intervening when needed, following policy, reporting to the Director of Nursing and/or Administrator as needed. The Abuse Prevention and Reporting Policy, dated August 2019, provided by the facility stated the facility prohibited the mistreatment, neglect, and abuse of resident, and misappropriation of resident property by anyone including but not limited to staff, family, or friends. Residents have the right to be free from verbal, sexual, and mental abuse, neglect, misappropriation of resident property, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The Policy defined Resident to Resident abuse as resident to resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and results in physical harm, pain or mental anguish. The Policy directed the staff to provide for the immediate safety of the resident upon identification of suspected abuse, neglect or mistreatment by immediately separating the resident from the alleged perpetrator, moving resident to another room, providing 1:1 monitoring as appropriate and implementing discharge processes immediately if the resident is a danger to self or to others. During an interview on 12/5/22 at 11:04 AM Resident #25 reported that Resident #22 at the end of her hallway is dangerous. He is hitting everyone. He punched a guy that lives on the A hallway. We should not have to live in danger every day. The staff lets him do whatever he wants to do because they are all afraid of him. During an interview on 12/5/22 at 11:05 AM Resident #16 reported she is tired of living in fear and shouldn't have to live in fear every day. On 12/12/22 at 3:48 PM the Administrator provided additional documentation of staff education for 1:1 supervision to all staff and updated the education on handling agitated/aggressive behaviors to ensure staff had received the required information. The Administrator or her Designees provided staff education on-site and via telephone to employees regarding the requirements of 1:1 supervision. The facility implemented the use of walkie talkies to communicate if someone needed to come takeover 1:1 supervision for Resident #22. They revised the daily wing schedules to assign the employee responsible for providing the 1:1 supervision and implemented the use of a sign in/out sheet for those staff providing the 1:1 supervision. The 1:1 supervision education specified Resident #22 to be under supervision at all times. When the Resident is in his room staff may remain outside of the room door. If the Resident is in the hallway, they must be within arms-length of the Resident. The Plan was submitted to the Surveyor via email at 3:48 PM. During an interview on 12/13/22 at 6:03 AM Staff Z, CNA, reported that she had been assigned to do one to one supervision for Resident #22. She reported she had been with him from 11:00 PM until 6:00 AM that morning. He had been in the front lounge until around midnight, then he went back to his room, and went to bed. Resident #22 slept from midnight to 5 AM, when she reported at 5 AM she got him up and brought him out to the dining room for coffee and cookies. Resident #22 observed at this time sitting at the dining room table drinking coffee and eating cookies, under 1:1 supervision. During an interview on 12/13/22 at 6:13 AM Staff X reported they were able to monitor Resident #22 with 1:1 for supervision during the night. He reported the resident had a good night sleeping from midnight to 5 AM which is his normal routine. He reported he planned to talk with the Director of Nursing (DON) and Administrator about covering the resident's mirror or taking the mirrors out of the room since the mirror seems to trigger his screaming and yelling. During an interview on 12/13/22 at 9:35 AM the Director of Nursing (DON) reported if a resident is aggressive the resident should be separated back to a different room. The physician should be contacted to give direction on what to do. She would probably put the resident on one to one supervision. When Resident #22 was at the hospital. They had done medication management on him and he didn't have behaviors and had been pleasant. He had bouts in front of the mirror but did not have physical aggression with anyone. She said there were no changes in the Care Plan after the staff observed him air punching, punching the back of the couches, and the door. She told the staff that his sister-in-law was very adamant that he has to get his medications to stay stable for his mental condition. If he didn't take his medications, they would re-approach him, and find a different staff member to try to get his medication administered. If that was unsuccessful, the staff were to try to call the sister-in-law to see if she could convince him to take his medications. The last resort is to call the DON to come give his medication. He has a delusional thought process. Some employees state they will not intervene as they do not want to get hit, but she has educated if any other residents come within the vicinity of Resident #22 they need to try to keep the other resident out of Resident #22's space. The Behavioral Management, Care Management Reference Anger and Aggression Policy dated 5/15 provided by the facility as a policy for accident/supervision documented the following approaches to be utilized: Dementia and/or related disorders: 1. Rule out potential causes of delirium or infection 2. Respond to cues of stress 3. Evaluate for pain, hunger and need to toilet 4. Reduce potential for injury 5. Plan for regular exercise 6. Be consistent Psychiatric Disorder: 1. Maintain a safe distance for caregivers and other resident/patients and visitors 2. Remove dangerous objects as able 3. Evaluate for depression and/or psychosis 4. Utilize behavior tracking records to determine time, place, possible triggers and meanings of behavior 5. Listen and validate feelings related to loss and grief 6. Acknowledge anger 7. Avoid rationalization and arguments 8. Include resident/patient and family/responsible party in planning the day and associated cares as much as possible; allow the resident/patient to have control over decisions as much as possible The Facility abated the immediate jeopardy on 12/12/22, decreasing the scope and severity to a D level deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident, family, and staff interviews, the facility failed to assess and intervene for the necessary care and services, to maintain a resident's highest practical physical well-being. The clinical record review revealed the nursing staff failed to provide a timely thorough assessment for 1 of 13 residents reviewed (Resident #5). The facility's failure to provide a timely assessment and intervention resulted in an immediate jeopardy (IJ) to the residents of the facility. The Iowa Department of Inspections and Appeals notified the facility of the IJ on 12/8/22 at 9:53 AM. The facility decreased the citation to a D level prior to exit of the survey. The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of coronary artery disease (CAD), heart disease, diabetes, and seizures. The MDS indicated that Resident #5 had an inability to walk and needed two persons to assist with transfers from their bed to their wheelchair using a sit to stand lift. The Care Plan dated 10/21/22 for Resident #5 directed staff to monitor his blood pressure, notify the physician of any abnormal readings, and monitor/document/report to the physician any symptoms of coronary artery disease (CAD) to include chest pain or shortness of breath. During an interview on 12/7/22 at 12:46 PM Resident #5 stated about two weeks before, he had trouble breathing for four days, he didn't feel well, he slurred his words and the nurse did not check on him. Resident #5 stated Staff F, Certified Nursing Assistant (CNA), took him to the front office as he couldn't breath and he wanted to call for help. Resident #5 stated Staff G, Registered Nurse (RN), took his blood pressure then left. Resident #5 stated after that Staff F told the 2 PM - 10 PM nurse, Staff I, Licensed Practical Nurse (LPN), who assessed him and called the physician. During an interview on 12/6/22 at 10:15 AM Staff F explained that she notified Staff G that Resident #5's leg was very swollen, And they blew it off. Staff F stated a week later (12/1/22) Resident #5 was having difficulty breathing with a blood pressure of 243/101 (average blood pressure is 120/80), extremely high. Staff F reported that she told Staff G who took a manual blood pressure and stated it was 143/92. Staff F stated she lied. Staff DD, Director of Physical Therapy (DPT) took Resident #5's blood pressure and reported it was over 200. Staff F stated she reported the elevated blood pressure to Staff G again who replied that the nurses were going into report. Staff F stated Staff I was the next nurse on duty, who assessed Resident #5 and sent him to the hospital. During an interview on 12/7/22 at 2 PM Staff I explained that Resident #5 stayed in the hospital for two weeks. Staff I reported that when she came to work on 12/1/22, she saw Resident #5 with Staff F in front of the Director of Nursing's office, they were checking his blood pressure. Staff I stated Staff G reported Resident #5 blood pressure as 140/unsure. Staff I said she went and assessed Resident #5's blood pressure. She got a reading of 200/105, Resident #5 complained about shortness of breath, and had diminished lung sounds. Staff I added that she offered Resident #5 to go to the emergency department (ED), If he wants to go to the hospital, that's serious, because he never wants to go. Staff I stated the Emergency Medical Staff (EMS) were in the facility for another resident but took Resident #5 first as he was more serious. During an interview on 12/7/22 at 1:19 PM Resident #5's Representative said that she visited on 11/25/22. She explained that he looked like the Hulk, as his right arm appeared swollen three times its normal size. Resident #5's Representative stated the nurse was not worried about him. Resident #5's Representative stated Resident #5 called on 12/1/22, claiming that he couldn't breath and that he was on his way to the hospital. Resident #5's Representative stated Resident #5 legs were very swollen, they removed 18 pounds of fluid off of him. Resident #5's Representative stated the hospital doctor told her to keep on at the nursing home to weigh him daily. Resident #5's Representative stated the facility had not weighed the resident yet as of the time of the interview. During an interview on 12/7/22 at 3:04 PM Staff H, LPN, stated he worked before 11/25/22 and didn't assess Resident #5, He follows cardiology and his legs are always swollen. The Physician's Order dated 9/26/22 directed to weigh Resident #5 daily. During an interview on 12/8/22 at 12:15 PM Staff F said the could not weigh Resident #5 due to the mechanical lift scale being broken. The Nurses' Notes dated 11/23/22 at 12:51 PM, the Physical Therapist (PT) notified the nurse of 2-3 pitting swelling in both of Resident #5's legs. The nurse notified the physician and requested an order for compression socks if approved by the wound clinic. The Health Status Note dated 11/23/22 at 6:58 PM indicated that Resident #5's primary care provider (PCP) called regarding the request for compression stockings. The PCP directed to let the Wound Clinic decide the course of action. The Health Status Note dated 11/25/22 at 10:55 AM documented a call placed to the Wound Clinic. The Wound Clinic reported that had no provider that day and they planned to assess him on his next appointment on 12/2/22. The nurse notified the physician office who would not give an order for an antibiotic therapy at that time. The physician's office directed to monitor his site and if necessary he could be seen in the Wound Clinic earlier in the week. The Nurses' Notes dated 12/1/22 at 3:15 PM indicated that Resident #5 had shortness of breath, a pale face, an elevated blood pressure of 200/105, a pulse of 89, respirations of 28, diminished lung sounds throughout and a negative COVID-19 test. The nurse notified the physician, who provided an order to transfer Resident #5 to the hospital. At the time of the order an ambulance was at the facility, and the nurse notified the daughter of transport to the hospital. Resident #5's clinical record lacked additional assessments prior to his admission to the hospital on [DATE]. Resident #5's Hospitalist History and Physical dated 12/1/22 at 6:33 PM indicated that he presented to the ED for high blood pressure and shortness of breath. He had a past medical history significant for CAD, heart failure with preserved ejection fraction (EF, a measurement used to determine the amount of blood that leaves your heart each time it contracts), type 2 diabetes insulin dependent, essential hypertension, and epilepsy. Resident #5 reported that he had high blood pressure that day and went to the ED. He reported having shortness of breath for at least a few days, worse with activity, but improved with rest. His shortness of breath improved after receiving Lasix (diuretic, releasing excess fluid from the body) in the ED. The ED course indicated he had no fever with a blood pressure on admission in the hypertensive urgency/emergency ranges (dangerous blood pressures), hypoxic (decreased oxygen) down to 88% that improved to 100% on 3 Liters (L). A chest x-ray revealed vascular congestion (fluid around his heart). The assessment determined a blood pressure of 186/92 and a weight of 291. The Impression indicated Resident #5's principle problem as a hypertensive emergency (high blood pressure) with active problems of acute decompensated heart failure, elevated troponin, benign hypertension, CAD, hyperkalemia (elevated potassium), type 2 diabetes, and anemia. Resident #5 denied chest pain but did have nitroglycerin in the ambulance. Resident #5's Hospital Notes dated 12/4/22 at 3:32 PM revealed he had a stroke due to being severely hypertensive (high blood pressure) on admission to hospital. The diuretic medication removed 18 pounds of fluid, with a weight of 273 pounds, and blood pressure stable at 120/56. On 12/8/22 at 10:41 AM the Director of Nursing (DON) stated she did not assess Resident #5 when he was brought up to her office. During a follow-up interview on 12/8/22 at 1:20 PM the DON stated she would expect the nurse to do treatments as ordered. The DON stated they are working on more specialized training and will have a new ADON next week. The facility removed the IJ and decreased the severity to a D level deficiency on 12/8/22 by doing the following: a. On 12/8/22 the nurses assessed the residents for signs and symptoms of a change in condition. The nurses notified the physician as necessary. b. The DON/Designee educated the licensed nurses on 12/8/22 related to completing timely assessments when a resident presents with a change of condition. Any licensed nurse who did not receive their education on 12/8/22 will complete their education prior to their next scheduled shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review and policy review, the facility failed to provide appropriate supervision in order to prevent physical abuse of 1 of 9 residents reviewed (Resident #41) resulting in injury and one staff member, Staff G, Registered Nurse (RN). The facility failed to put interventions in place for a resident with a known history of violent behavior (Resident #22) to protect residents and staff from abuse. Resident #22's admitted to the facility from a psychiatric hospital after assaulting another resident at a different facility. These incidents constituted Immediate Jeopardy to the resident's and staff's health and safety. The facility reported a census of 55 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] for Resident #22 documented an admission date of 10/3/22 from a psychiatric hospital. Resident #22 had Level II Preadmission Screening Resident Review (PASRR) in place. The MDS identified a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS included diagnoses of anxiety, depression, schizophrenia, and dementia with other behavioral disturbances. Resident #22 could independently complete most activities of daily living including ambulation. The Preadmission Screening and Resident Review (PASRR) form completed 9/20/22 by a local hospital behavioral health center revealed Resident #22 had a known behavior of physical aggression. The PASRR documented the admitting nursing facility must incorporate PASRR findings as part of the individual's plan of care. The PASRR further documented that Resident #22 went to the emergency department (ED) at a local hospital behavioral health center the day after he hit a resident at another nursing facility. This had been the third time of being seen in the ED in the previous several days because Resident #22 chose not to take his medications and had been physically forceful with others. The resident admitted to the hospital under an emergency detention order by the State District Court of the local county after a petition had been filed by the hospital alleging the resident to be seriously mentally impaired and a harm to himself and others. A copy of the court order had been provided with the PASRR assessment. Staff at the prior nursing home documented that they did not feel Resident #22 was safe to be around others due to his physical behaviors. The PASRR included that he told his doctor that he believed that someone poisoned his food, that he heard noises that other people did not hear and voices in his head. Resident #22 had a history of talking to himself, quickly changing moods, irritability, being rude, screaming, yelling, threatening, physically forceful with others, slamming doors, restlessness, demanding of others, and seeking attention from others. Resident #22's Care Plan revised 10/27/22 revealed the resident had the potential to demonstrate verbally abusive behaviors such as yelling and having loud outbursts related to dementia. Resident #22 had ineffective coping skills and a mental/emotional illness such as schizophrenia. Resident #22 could sometimes have behaviors or hallucinations where he might yell rambled words. In addition he can also yell and be verbally abusive toward staff and or residents at times. The Care Plan included the following interventions: a. Staff to intervene when he became agitated before the agitation escalated, guide away from the source of distress, and engage calmly in conversation. If Resident #22 responded aggressively, the staff should calmly walk away and approach later. The Care Plan dated 10/27/22 identified Resident #22 had a psychosocial well-being problem (actual or potential) related to the disease process of schizophrenia, dementia, intellectual disability, anxiety, and ineffective coping. The Care Plan included the following interventions dated 10/27/22: a. When conflict arises, remove the Resident to a calm safe environment and allow him to vent/share feelings. b. The Resident needs assistance, encouragement, and support to identify problems that cannot be controlled. c. Allow the Resident time to answer questions, verbalize feelings, perceptions, and fears frequently. The Care Plan lacked direction in regards to potential violent behavior towards others, incorporation of the PASRR recommendations, and how to provide safety for the staff and other residents. 2. The quarterly MDS for Resident #41 documented a BIMS of 15 out of 15 indicating intact cognition. The MDS documented the resident had diagnoses of anxiety, depression and cancer and was independent with activities of daily living. The Care Plan for Resident #41 initiated 11/13/22 documented Resident #41 had a psychosocial well-being (actual or potential) related to diagnoses of anxiety disorder and depression disorder with the intervention when conflict arises, remove to a calm, safe environment. During an interview 12/5/22 at 12:52 PM, Resident #41 revealed Resident #22 came up to him recently and said he was mad at him for something. Resident #41 stated two days later Resident #22 came up to him and punched him in the left eye and said there you go. Resident #41 stated after Resident #22 hit him he held his face and walked away from Resident #22. Resident #41 further stated that he had never done anything to Resident #22 and he shouldn't be doing that to people. Resident #41 stated he had to have an eye procedure rescheduled due to the swelling that was a result of being punched in the eye by Resident #22 and stated the area hurt when he touched it. Review of facility incident report dated 11/26/22 at 12:00 PM completed by Staff L, Licensed Practical Nurse (LPN) revealed nurses were called to the front nurse's station and informed Resident #41 had been hit by Resident #22. The incident report further documented when the nurse's went to Resident #22's room they observed him to have a bruise and a big lump under his left eye and the resident informed them he had been hit by Resident #22. During an interview 12/7/22 at 10:14 AM, Staff E, Certified Medication Aide (CMA) revealed on Thanksgiving day she was working the C/D hall when she heard Resident #41 yelling. She stated Resident #22 in front of Resident #41 punching into the air in front of him screaming, I'm going to kill you! I'm going to kill you! Staff E stated she left the medication cart to separate the two residents and directed Resident #41 to sit back down in the chair in which he did. Staff E stated she then went back to the medication cart to complete the narcotic count. Staff E stated she then heard Resident #22 holler out again and as she turned around from the medication cart she saw Resident #22 hit Resident #41 in the eye. Staff E stated she couldn't remember which eye was hit or which hand Resident #22 used but Resident #41's eye was black the Saturday after Thanksgiving. Review of facility policy titled, Abuse Prevention and Reporting, revised August 2019 revealed residents must not be subjected to abuse by anyone including other residents. The policy directed staff to identify, correct and intervene in situations where resident to resident abuse is most likely to occur and provide protection by immediately separating the residents involved, moving the resident to another room or unit, providing 1:1 monitoring as appropriate, implementing discharge process immediately if the resident is a danger to self or others and initiating behavior crisis management interventions as applicable. During an interview 12/13/22 at 9:35 AM, the Director of Nursing (DON) revealed if Resident #22 was being that aggressive toward Resident #41 she would have separated the two completely to a different room and contacted the provider in regards to the behavior including directing the use of as needed medication, contacting psychiatry and most likely starting a 1:1. The DON further revealed the expectation would be for staff to intervene in order to prevent abuse, to give Resident #22 space and ensure residents and staff stay away from him. The DON then revealed Staff G that was hit by Resident #22 was still sore. During an interview 12/19/22 at 11:24 AM, the Administrator revealed it is an expectation staff keep residents safe from abuse by intervening when needed, following policy, reporting to the Director of Nursing and/or Administrator as needed. During an interview on 12/5/22 at 11:04 AM Resident #25 reported that Resident #22 at the end of her hallway is dangerous. He is hitting everyone. He punched a guy that lives on the A hallway. We should not have to live in danger every day. The staff lets him do whatever he wants to do because they are all afraid of him. During an interview on 12/5/22 at 11:05 AM Resident #16 reported she is tired of living in fear and shouldn't have to live in fear every day. During an observation on 12/5/22 at 11:49 AM Resident #22 ambulated with a four wheeled walker through the D hallway back to his room. The staff passed room trays saying hello to Resident #22's by his first name. As Resident #22 entered his room doorway, he hit the left side of his door frame with his left hand closed into a fist. He yelled that his name was not his first name, but his middle name. He proceeded to yell if you don't know English, then don't talk to me, then repeatedly yelled his name (referring to his middle name). During an observation on 12/5/22 at 11:58 AM Resident #22 sat in the room yelling loudly damn you all to hell. I told her before that I want to be left alone! Just leave me alone! God damn it! No staff or other residents were present in the room with Resident #22. Resident #22's yelling could be clearly heard up to the double doors at the entrance of the D hallway. During an interview on 12/5/22 at 12:00 PM Staff F, Certified Nursing Assistant (CNA), said that management did not give any direction. Resident #22 punched Resident #41 last week. Resident #22 is petrifying. She can usually get him calmed down but if he goes out on a rampage they just let him go because they don't want to get in his way. It's been going on for over a month. The nurses know about it. She said lately he has been punching the walls and screaming into the mirror. Staff F reported that Resident #22 came from a locked unit. During an interview on 12/5/22 at 12:50 PM Staff K, CNA, reported that Resident #22 mostly has been in his room yelling at himself. If other residents say something to him, he may yell back at the other residents. He does raise his voice at other residents, but then he will get really quiet. Staff K reported she is not afraid of him, but she does stay back because he may try to hit. She tries to keep her distance. When Resident #22 starts to scream he is ready to go at you, so you have to be careful. During an interview on 12/5/22 at 12:56 PM Staff F reported that Resident #22 has had behaviors of screaming/yelling, hitting the walls since his admission. He will say things like, No God damn it. Don't shit in my mouth. He sounds like he has another resident inside of him. He hits the wall so hard his knuckles bleed and he has had to go get band aids. He hit another resident about a week ago. He has been in the lounge punching the back of the couch. She is not sure if other residents are afraid of him. She feels he could hit another resident. You can hear other residents yelling at him. She doesn't feel like they get any direction from management on how to intervene with the resident. During an observation on 12/5/22 at 1:02 PM Resident #22 walked behind a male resident in a wheelchair stating, I'm going to kill him. I'm going to kill him. He did not make any movements toward the male in the wheelchair in front of him, Staff F intervened. He walked using a wheeled walker behind the resident through the double doors of the D hallway, through the dining room, and into the C hallway. He did not make any physical gestures and did not make any more verbal remarks. Staff F stated it has crossed her mind that Resident #22 could hurt her, but it hasn't happened, but it has crossed her mind that he could physically hurt her. During an interview on 12/5/22 at 1:11 PM Staff O, Registered Nurse (RN), reported that Resident #22 has exhibited yelling and punching with his fist into the air, like he is hitting an imaginary person. She does believe that he could hit another resident. She has not had any reports of him hitting staff and has not heard any staff state they are afraid of him. When Resident #22 is yelling and air punching, they just stay away from him. Staff O is not sure what they have instructed the staff to do in situations like that. She has not had any residents state they are afraid of him, but they do state this is not the place for him. A handwritten statement dated 12/6/22 by Staff G documented that Resident #22 sat in the dining room at 9:45 AM demanding to be called by his middle name. He screamed that he wanted to go have a cigarette and demanded Staff G let him go right now. Resident #22 then stood up and struck Staff G in the left neck/jawline. Staff N, LPN, witnessed the incident and called 911. Resident #22 sat back down in the chair and stated, don't let them take me. An undated handwritten statement written by Staff N revealed that she sat at the nurses' desk charting, while Resident #22 sat in a chair in the dining room screaming he wanted a cigarette. The CNA's were running behind for smoke breaks. Resident #22 got up and walked over to Staff G and with a closed fist hit her on the left side of her jaw and neckline. During an interview on 12/6/22 at 9:55 AM Staff G reported that Resident #22 struck her in the jaw and neck. On 12/6/22 at 10:00 AM observed the local police department on site at the facility assessing the situation for Resident #22. During an interview on 12/6/22 at 10:04 AM Staff F stated she saw Resident #22 punched the wall yesterday. During an observation on 12/6/22 at 10:05 AM Resident #22 told the police officer that he had hit Staff G because he needed a cigarette. The Emergency Medical Service (EMS) personnel arrived and started to assess the Resident. Resident #22 cooperated with the Police and EMS personnel. During an interview on 12/6/22 at 10:05 AM Staff G stated she needed to go stand outside until Resident #22 went out, then she left the area. On 12/6/22 at 10:11 AM observed EMS personnel taking Resident #22 out of the facility to the local emergency department (ED). During an interview on 12/6/22 at 11:38 AM Staff K, CNA, said that Resident #22 wanted to be called by his middle name for the last two days. He always called her by a shortened version of her name, but right before he hit her, he used her full first name stating he wanted a cigarette then he hit her so hard it knocked her dentures to the other side of her mouth. She then reported she went behind the nurses' station behind the other staff. She had been scared and reported she is now scared of Resident #22. She hadn't always been afraid of him but she verbalized she is now afraid of Resident #22. She stated Resident #22 has hit other residents. Staff K verbalized fear that Resident #22 will come back to the facility. During an interview on 12/6/22 at approximately 2:30 PM the Administrator reported if Resident #22 returns, he will be put on one to one observation by the staff. The Health Status Note dated 12/7/22 at 3:05 PM labeled as Late Entry indicated that Resident #22 returned to the facility after an overnight observation stay at the ED. While at the ED, Resident #22 received a new order of Seroquel 12.5 milligrams (MG). During an observation on 12/8/22 at 7:02 AM Resident #22 ambulated from his room at the end of D wing, all the way through the hallway, through the dining room, through the C wing, and up to the front nurses' station with no staff present. The Administrator saw him at the front double doors and asked him how his night was. He responded that it had been all right. The Administrator walked away from Resident #22 back into her office. Resident #22 then walked back through the double doors into the C wing out of the supervision of the Administrator or other staff and back to the D hallway. No staff were present in the D hallway. An empty chair sat outside Resident #22's room. During an observation on 12/8/22 at 7:53 AM Resident #22 sat on the seat of his walker eating breakfast in his room. Staff P, CNA, observed going in and out of room D 34. Staff P went out and performed hand hygiene, then entered Resident #22's room to check on him. Staff P then exited Resident #22's room and went into room D 35. Staff L, LPN, stood at the medication cart at the front of the D hallway going in and out of rooms passing medications. Staff L never looked down the hall towards the direction of Resident #22's room. At 7:55 PM Staff P came out of room D 35 and exited out of the D hallway through the double doors to the dining room. At this time Resident #22 observed yelling from his room, God damn it, stay out. During an observation on 12/8/22 at 7:57 AM the Housekeeping Supervisor came into the D hallway walking down to the shower room to obtain supplies, then left the D hallway. Staff L continued to go into random resident rooms to pass medications leaving no staff present in the D hallway. Staff L did not look down towards Resident #22's room when she returned to the hallway. On 12/8/22 at 7:59 AM observed Staff P reenter the D hallway then enter room D 35. Resident #22 started to yell loudly random words. At 8:00 AM Staff P donned personal protective equipment (PPE) to enter room D 39. Staff P entered Room D 39. Resident #22 started to yell even louder, I get no respect, repeatedly. Staff P came out of Room D 39 removing her PPE and peaked in on Resident #22. Staff P informed the surveyor that she didn't think that Resident #22 could have a roommate. Staff P then left to go into another Resident's room. Staff L not observed in the hallway at this time. On 12/8/22 at 8:02 AM witnessed Resident #22 yelling, I get no respect. You make me so nervous. I am fucking pissed at you, you fucking bitch. Fuck you. Last time God damn nuts. On 12/8/22 at 8:04 AM watched Staff P exit the D hallway through the double doors out to the dining room with the double doors closed behind her. Staff L not observed in the hallway. At 8:05 AM Resident #22 continued to ramp up screaming and yelling. At 8:05 AM Staff L came back to the hallway. Resident #22 observed walking in the room, no supervision outside of the doorway. At 8:06 AM Staff L left the hallway to enter room D 31 leaving no supervision in the hallway for Resident #22. Resident #22 continued to scream and yell from his room. At 8:09 AM Resident #22 observed sitting in front of the mirror in his room yelling into the mirror. On 12/8/22 at 8:10 AM observed Staff L return to the hallway to the medication cart to prepare medication. At 8:11 AM the Housekeeping Supervisor entered the D hallway going to the shower room to obtain supplies as Staff L went into another resident's room to pass medications. At 8:12 AM Staff P came back to the D hallway and walked to the shower room, then exited the D hallway. At 8:13 AM witnessed Staff F, CNA, entered the D hallway. During an interview on 12/8/22 at 8:14 AM Staff F stated they are to provide Resident #22 with one to one supervision. She stated she did not know who had been assigned to provide one to one supervision to Resident #22 from 6:00 AM to 8:00 AM On 12/8/22 at 8:15 AM observed Staff A, nurse aide (NA), enter the hallway carrying her purse and coat which she sat down on the chair outside of Resident #22's room. She stated she had to sit with Resident #22 to make sure that he didn't have any physical contact with anyone. During an interview on 12/8/22 at 11:26 AM Staff X, LPN, reported that Resident #22 assaulted a 100-pound lady at another nursing facility, really badly. They couldn't get him off of her. They had put the female resident in the same hallway as him and he assaulted her again. That facility sent him to the hospital and then he was admitted to Cedar Falls Health Care Center. Staff X reported being pretty upset when Resident #22 admitted to the facility. They were not given much history on Resident #22 with his admission. Staff X stated to be honest, they gave us zero guidance. He read the paperwork and he tried to give the staff guidance. He told the staff to keep an eye on him and if he got worked up to not push him, not escalate the situation, and to come get him if they needed him. Typically, they do not have issues until 5 AM then Resident #22 will get up and start hearing voices. In an email from the Administrator on 12/19/22 at 11:24 AM, the Administrator responded the expectation is that the staff keep residents safe from abuse by intervening when needed, following policy, reporting to the charge nurse, DON, and/or Administrator as needed. The Facility abated the Immediate Jeopardy on 12/12/22, decreasing the citation to a D level by ensuring the staff received education and provide a plan for one to one supervision for Resident #22. On 12/8/22 the Iowa Department of Inspection and Appeals determined an immediate jeopardy for the facility failing to provide supervision to prevent potential abuse for all other residents and staff. A Plan of Correction for removal of immediate jeopardy submitted by the facility on 12/8/22 detailed the following information: 1. Resident #22 Care Plan has been reviewed and updated by the DON/Designee on 12/8/22 with interventions regarding his history of physically aggressive behavior to ensure protection of residents and staff from physical abuse. 2. An audit was completed by the DON/Designee on 12/8/22 to identify residents with known violent behaviors to ensure their Care Plan has interventions regarding aggressive behavior to ensure protection of residents and staff from physical abuse. 3. The Regional Director of Clinical Services educated the Social Service Designee and Director of Nursing on 12/8/22 related to the requirements of implementing a plan of care that includes interventions for residents with aggressive behavior. 4. DON/Designee will complete audits of 24-hour reports including progress notes daily for 4 weeks then 5 times weekly for 8 weeks to ensure residents that present with aggressive behaviors continue to have Care Plan interventions implemented to address the aggressive behaviors. Results of these audits will be presented to the QAPI meeting monthly for 3 months for review and recommendations as needed. The DON is responsible for monitoring and following up as needed. An undated Staff Roster with the Administrator's initials handwritten by each employee's name titled Staff Education on how to handle agitated/aggressive behaviors was submitted to the Iowa Department of Inspection and Appeals on 12/8/22 at 9:56 PM. The document included Guidance for increased supervision during periods of aggression. a. Talk in a calm voice b. Make slow transitions or movements c. Do not engage in arguments d. Allow resident to have false allusions - do not tell them they do not exist e. Do not leave the resident unattended f. Provide a barrier between the upset resident and other residents (ex. Placing yourself between the upset resident and another resident that may be passing by. g. Try to redirect the resident to a quiet area with less people h. If warranted, use a personal device to call the facility for assistance (reminder you are not to leave the resident unattended). The Administrator notified the State Bureau Chief on 12/8/22 at 9:08 PM that Resident #22 went out to the emergency department per his request as he felt an increase in agitation. Resident #22 had a psychiatric appointment set up for the next week and the Administrator communicated that he would be one-on-one till further medical assistance is provided and he feels balanced out or the facility finds other placement. All staff were educated on how to handle behaviors of aggression on 12/8/22. During an interview on 12/12/22 at 10:12 AM Staff CC, Housekeeping/Laundry, reported that she did not get the behavioral training from the previous week. She thought they didn't have her correct phone number so they weren't able to get in touch with her, but she assumed she would get the training that day at some point. During an interview on 12/12/22 at 10:18 AM Staff R, CNA, reported that she did not receive any behavioral training from the previous week by the facility. During an interview on 12/12/22 at approximately 11:00 PM the Administrator reported she had educated all the employees on the Staff Roster or she had texted out the education on handling agitated/aggressive behaviors to the employees. She had not followed up with the employee to see if they actually received the education or understood the education that she sent out. The Nurse consultant stated to the Administrator that it is not enough to text the education out. She needs to provide follow-up to ensure the education was received and the staff understood the information. The Administrator reported she would provide further follow-up. During an interview on 12/12/22 at 12:30 PM Staff T, CNA, reported they worked 10 PM to 6 AM the past weekend Friday (12/9/22) and Saturday (12/10/22). She reported that she did not do 1:1 supervision for Resident #22 during those shifts, as the schedule indicated she worked as a regular CNA/Certified Medication Aide (CMA). She had been assigned to the D wing but technically they work everywhere in the facility. Friday night Resident #22 roamed around the first hour out to the front lounge, then to the dining room for about an hour. She reported they had four staff Friday night and only 2 sides on Saturday night. During an interview on 12/12/22 at 2:08 PM Staff U, CNA, reported they had not been able to do one to one supervision for Resident #22 on Friday (12/9/22) and Saturday (12/10/22) night. They checked on Resident #22 every 15 - 20 minutes. Staff T, CNA, went back to check the D wing. She stayed up front and watched the A and B hallways. The nurse did their regular job. They have residents that require two staff for their cares so they (Staff U and Staff T) worked together to complete rounds. Staff W, RN, watched the call lights to make sure that no one got up out of bed. Resident #22 sat up in the front lounge area for a few hours, then he got up, walked back to his room, and went to bed around midnight. Staff U explained that they did the best they could. On 12/12/22 at 2:14 PM Staff W reported they had someone call in that Sunday night at 9:10 PM. She explained that she reached out to several staffing agencies trying to get that staff replaced. She talked to the DON who gave her a list of staff to call. She talked to numerous people and could not get anyone to come in. She stated Resident #22 had been in the front lobby. They gave him food and fluids. Then he wanted to go back to the bathroom. They took him to the bathroom and they stayed with him until he went to sleep. They alternated checking on him but could not stay at his bedside 24/7. She reported she did not have a checklist to sign off, but they checked on him frequently. She reported that when the aides did rounds, she would go back, and check on him but she also had a mountain of orders to get through so she did sit at the desk to do orders. He slept the rest of the night. It wasn't easy but they worked as a team to watch him. On 12/12/22 at 3:48 PM the Administrator provided additional documentation of staff education for 1:1 supervision to all staff and updated the education on handling agitated/aggressive behaviors to ensure staff had received the required information. The Administrator or her Designees provided staff education on-site and via telephone to employees regarding the requirements of 1:1 supervision. The facility implemented the use of walkie talkies to communicate if someone needed to come takeover 1:1 supervision for Resident #22. They revised the daily wing schedules to assign the employee responsible for providing the 1:1 supervision and implemented the use of a sign in/out sheet for those staff providing the 1:1 supervision. The 1:1 supervision education specified Resident #22 to be under supervision at all times. When the Resident is in his room staff may remain outside of the room door. If the Resident is in the hallway, they must be within arms-length of the Resident. The Plan was submitted to the Surveyor via email at 3:48 PM. During an interview on 12/13/22 at 6:03 AM Staff Z, CNA, reported that she had been assigned to do one to one supervision for Resident #22. She reported she had been with him from 11:00 PM until 6:00 AM that morning. He had been in the front lounge until around midnight, then he went back to his room, and went to bed. Resident #22 slept from midnight to 5 AM, when she reported at 5 AM she got him up and brought him out to the dining room for coffee and cookies. Resident #22 observed at this time sitting at the dining room table drinking coffee and eating cookies, under 1:1 supervision. During an interview on 12/13/22 at 6:13 AM Staff X reported they were able to monitor Resident #22 with 1:1 for supervision during the night. He reported the resident had a good night sleeping from midnight to 5 AM which is his normal routine. He reported he planned to talk with the Director of Nursing (DON) and Administrator about covering the resident's mirror or taking the mirrors out of the room since the mirror seems to trigger his screaming and yelling. During an interview on 12/13/22 at 9:35 AM the Director of Nursing (DON) reported if a resident is aggressive the resident should be separated back to a different room. The physician should be contacted to give direction on what to do. She would probably put the resident on one to one supervision. When Resident #22 was at the hospital. They had done medication management on him and he didn't have behaviors and had been pleasant. He had bouts in front of the mirror but did not have physical aggression with anyone. She said there were no changes in the Care Plan after the staff observed him air punching, punching the back of the couches, and the door. She told the staff that his sister-in-law was very adamant that he has to get his medications to stay stable for his mental condition. If he didn't take his medications, they would re-approach him, and find a different staff member to try to get his medication administered. If that was unsuccessful, the staff were to try to call the sister-in-law to see if she could convince him to take his medications. The last resort is to call the DON to come give his medication. He has a delusional thought process. Some employees state they will not intervene as they do not want to get hit, but she has educated if any other residents come within the vicinity of Resident #22 they need to try to keep the other resident out of Resident #22's space. The Behavioral Management, Care Management Reference Anger and Aggression Policy dated 5/15 provided by the facility as a policy for accident/supervision documented the following approaches to be utilized: Dementia and/or related disorders: 1. Rule out potential causes of delirium or infection 2. Respond to cues of stress 3. Evaluate for pain, hunger and need to toilet 4. Reduce potential for injury 5. Plan for regular exercise 6. Be consistent Psychiatric Disorder: 1. Maintain a safe distance for caregivers and other resident/patients and visitors 2. Remove dangerous objects as able 3. Evaluate for depression and/or psychosis 4. Utilize behavior tracking records to determine time, place, possible triggers and meanings of behavior 5. Listen and validate feelings related to loss and grief 6. Acknowledge anger 7. Avoid rationalization and arguments 8. Include resident/patient and family/responsible party in planning the day and associated cares as much as possible; al[TRUNCATED]