**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based record review and staff interview, the facility failed to ensure residents were allowed to choose schedules, clothing, or bathing preferences for 2 of 4 residents reviewed (Resident #1 and #4). The facility reported a census of 34 residents. Findings include: 1.) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment.The resident required substantial to maximal assistance with a shower/bath. The resident's diagnoses included anxiety and depression. The Care Plan identified the resident had an activity of daily living self care performance deficit. The interventions included she required one staff assistance for completion of bathing. The Progress Notes dated 4/26/25 at 9:10 a.m. documented Resident #1 accused the bath-aide Staff A Certified Nursing Assistant (CNA) of being rough and rushing her during shower and making her wait on her jewelry, commenting she didn't have time to pamper her right then. An undated note titled Staff B Certified Medication Aide (CMA)'s Statement documented the resident said Staff A refused to use the jets (in the whirlpool) and would not pamper her the same as everyone else. A note titled Resident #1's Statement with the Administrator and Director of Nursing (DON) included the resident said when Staff A put her in the bath she didn't turn the bubbles on and she said she didn't have time for them. A note titled Staff A's Statement included the resident said something about bubbles. Staff A told resident #1 she couldn't [NAME] around, she had other resident's baths to do. On 5/19/25 at 1 p.m. Resident #1 stated Staff A was mean. She said Staff A wanted to do her bath last, but they told her it had to be done before breakfast. She took her to the bath and only filled it up to her knees and would not run the jets. Staff A said she didn't have time for that. On 5/20/25 at 12:24 p.m. Staff A stated that morning they kept bringing people to her for a bath, and pressing her to get them done. She was told she was not doing them fast enough. So she didn't turn on the jets so the baths wouldn't take so long. 2) According to the MDS assessment dated [DATE], Resident #4 scored 15 on the BIMS indicating no cognitive impairment. The resident required substantial to maximal assistance with upper/lower body dressing, and was dependent for transfer to bed. The resident's diagnoses included heart failure and morbid obesity. The Comprehensive MDS assessment dated [DATE] documented it was somewhat important for Resident #4 to choose what he wanted to wear and choose his own bedtime. The Care Plan dated 4/1/22 identified the resident had altered respiratory status related to obstructive sleep apnea and used a Continuous Positive Airway Pressure (CPAP) machine at night. The Care Plan dated 2/20/24 identified the resident had a psychosocial wellbeing problem or potential related to illness/disease process and decline in health, but mentally aware. Interventions included allowing him time to answer questions and to verbalize feelings, perceptions, and fears, and encouraging participation from resident who depends on others to make own decisions. Explain all procedures, all changes, rules, and options. The Care Plan revised 4/1/22 identified the resident had an ADL self care performance deficit related to limited physical mobility. Interventions included total mechanical lift with assist x 2 for all transfers. A Disciplinary Action Report dated 9/16/24 documented on the weekends of 9/2/24 and 9/11/24 the specific work rule identified resident rights. Staff A made the resident go to bed at 8 p.m. and wear a gown after he asked not to. Staff A put the resident's CPAP on wrong and wouldn't listen to the resident. A note Written by Staff B Certified Nursing Assistant (CMA) and attached, included the resident reported to her that Staff A made him go to bed at 8 p.m. Staff A told him he had to wear a hospital gown because he was passing a lot of gas and they couldn't have that and that was why he had to be put in bed. She also put his CPAP on wrong and he tried telling her. No, he didn't want to go to bed and he didn't wear a gown. But she wouldn't listen. The report was signed by the Director of Nursing (DON) and Staff A. On 5/20/25 at 12:24 p.m. Staff A stated she did not recall the write up. On 5/22/25 at 11:45 p.m. the DON stated Staff A signed the write up with no rebuttal. The facility undated Resident's [NAME] of Rights included self-determination. The resident had the right to and the facility must promote and facilitate resident self- determination through support of resident choice, including but not limited to: The resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the physician, and the resident's representative immediately of a resident's allegation of rough treatment for 1 resident (Resident #1). The facility reported a census of 34 residents. Findings's include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required substantial to maximal assistance with a shower/bath. The resident's diagnoses included anxiety and depression. The Progress Notes dated 4/26/25 at 9:10 a.m. documented Resident #1 accused the bath-aide (Staff A Certified Nursing Assistant (CNA) of being rough and rushing her during shower (her breast got pinched with a gait belt, and jammed toothbrush in her mouth). The resident also complained of pain in her breast radiating to the back of her shoulder, feeling weak, and unable to walk. The resident assisted to her room via wheelchair. Vital Signs and Blood Sugar checked and within normal limits. No evidence of injury noted to left breast at this time. Would continue to monitor. The Director of Nursing (DON) notified of the incident. An Incident Report dated 4/26/25 documented the resident stated Staff A was rough with her during her bath on Saturday. She pinched her breast while she had her in her shower chair with the shower chair belt, jammed her toothbrush into her mouth and wouldn't turn the jets on. The Physician notified on 4/28/25 at 11:53 a.m. the Administrator notified on 4/28/25 at 7:56 a.m. and the family notified on 4/28/25 at 12 p.m. A fax dated 4/28/25 notified the physician of Resident #1's allegation. On 5/21/25 at 4:20 p.m. the DON confirmed the physician and resident representative were notified 4/28/25. They should have been notified the day the resident reported it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) of an allegation of potential abuse within the required time frame for 1 resident reviewed (Resident #1). The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident required substantial to maximal assistance with a shower/bath. The resident's diagnoses included anxiety and depression. The Progress Notes dated 4/26/25 at 09:10 a.m. documented Resident #1 accused the bath-aide of being rough and rushing her during shower (she pinched her breast with the gait belt, and jammed the toothbrush in her mouth). On 5/20/25 at 9:30 a.m. Staff B Certified Nursing Assistant (CMA) stated Resident #1 told her that Staff A Certified Nursing Assistant (CNA) was rough in the bath. Her boob got pinched when she applied the bath chair safety belt. Staff A refused to turn the jets on. She also jammed the toothbrush in her mouth. On 5/19/25 at 3:20 p.m. the (DON) said Staff A was taken off of baths and moved to north hall away from Resident #1 on Saturday, worked Sunday, and was suspended on Monday. On 5/22/25 at 11:45 a.m. the Administrator stated they reported to the state on 4/28/25, and confirmed they had not reported the incident to the state agency (DIAL) timely. The facility undated Abuse Prevention, Identification, Investigation and Reporting Policy documented all allegations of resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported to the Iowa Department of Inspections and Appeals, not later than two (2) hours after the allegation was made, if the events that caused the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that caused the allegation involved neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation of resident property, but do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure appropriate transfer techniques to prevent injury for 1 of 3 resident's reviewed (Resident #6). The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #6 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment.The resident required partial to moderate assistance with sitting to standing. The resident's diagnoses included cancer, anemia, atrial fibrillation, and heart failure. The Care Plan dated 7/24/24 identified the resident had an activity of daily living self care performance deficit related to weakness and cancer. The interventions included the resident had chronic pain at varied levels, and having 2 staff present with cares and mobility, may help with gentle moving and tasks to alleviate pain. The Progress Notes dated 10/7/24 at 11:06 a.m. documented Resident #6 had skin tears to his right forearm The surrounding skin was warm and dry, and blood noted from each skin tear. The areas measured: a. 4 cm by 1cm, b. 2.5 cm by 1 cm, c. 2 cm by 1 cm. Op-site (clear dressing) applied to each area. Education provided to staff on not grabbing the resident's arms because he had fragile skin. A Disciplinary Action Report dated 10/7/24 documented Staff A Certified Nursing Assistant (CNA) violated a specific work rule by grabbing Resident #6's wrist instead of the gaitbelt, resulting in skin tears to his right forearm. Staff A signed the report. On 5/22/25 at 11:55 a.m. the Director of Nursing (DON) stated Staff A signed the disciplinary action with no rebuttal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to immediately separate an alleged abuser from all potential victims. The facility reported a census of 34 residents. Finding's include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included anxiety and depression. The Progress Notes dated 4/26/25 at 09:10 a.m. documented Resident #1 accused the bath-aide of being rough and rushing her during shower (she pinched her breast with the gait belt, and jammed the toothbrush in her mouth). On 5/20/25 at 9:30 a.m. Staff B Certified Nursing Assistant (CMA) stated Resident #1 told her that Staff A Certified Nursing Assistant (CNA) was rough in the bath. Her boob got pinched when she applied the bath chair safety belt. Staff A refused to turn the jets on. She also jammed the toothbrush in her mouth. Staff B went to the charge nurse, who was from a temp agency. Together they called the Director of Nursing (DON). They made Staff A work away from the resident. On 5/19/25 at 3:20 p.m. the DON said Staff A was taken off of baths and moved to north hall away from Resident #1 on Saturday, worked Sunday, and was suspended on Monday. The facility undated Abuse Prevention, Identification, Investigation and Reporting Policy documented upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility should immediately implement measures to prevent further potential abuse of residents from occurring while the investigation was in process. If this involved an allegation of abuse by an employee, this would be accomplished by separating the employee accused of abuse from all residents.

Based on clinical record review, staff interviews and policy review, the facility facility failed to protect a resident from verbal and physical abuse by a staff member for 1 of 12 residents reviewed for abuse (Resident #24). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #24 dated 12/10/24 identified a Brief Interview for Mental Status (BIMS) score of 03, indicating severely impaired cognition. The MDS identified Resident #24 was dependent on staff for bed mobility, toileting and transfers. The MDS documented Resident #24 had physical and verbal behavioral symptoms directed toward others 1 to 3 days per week. The MDS included diagnoses of hypertension (high blood pressure), pneumonia, diabetes mellitus, Alzheimer's disease, cerebrovascular accident with hemiplegia (stroke affecting one side), non-Alzheimer's dementia, anxiety, depression and adjustment disorder with mixed disturbance of emotions and conduct. The Care Plan with a revised date of 12/4/24 documented Resident #24 had behavior problems related to anxiety and revealed Resident #24 may yell or strike out at staff who provide care. The Care Plan directed the following interventions: -Staff to approach and explain the care that was going to be provided. Staff to give Resident #24 choices as needed. If Resident #24 irritated or agitated, staff to attempt to learn why. Staff to address Resident #24 personal needs such as pain, hunger and temperature. Staff to offer diversional activities and topics such as travel, fishing, working as a mechanic and farmer. Staff to use firm kindness and not to argue with Resident #24. -If reasonable, staff to discuss Resident #24 behavior and explain why the behavior was not appropriate and unacceptable. - Staff to intervene as necessary to protect the rights and safety of others. Staff to approach and speak in a calm manner and divert attention. Staff to remove Resident #24 from the situation and take to alternate locations as needed. On 1/16/25 at 1:50 PM, Staff A, CNA (Certified Nursing Assistant) reported last week either on Thursday or Friday around 7 AM, Staff B, RN (Registered Nurse) had gone to Resident #24's room to check his blood sugar. Resident #24 attempted to bite Staff B and Staff A helped stop him by grabbing his hand and when she did, he pulled his head away from Staff B. Staff B stated, If you bite me I will knock all the teeth out of your mouth and raised her hand to strike him. Staff A responded Hey and Staff B put her hand down. On 1/16/25 at 2:10 PM, Staff B, RN reported when she got angry she might say she wanted to hit something but had never said anything to a patient. Staff B stated she thought she should take up boxing to help her get rid of some frustrations. Staff B said she would never say she wanted to hit something in a patient's room, she stated she had said it at the desk. Staff B said she had been a nurse for 32 years and would never want to hit a patient. An Incident Report titled Alleged Neglect dated 1/16/25 at 5:18 PM documented a state official reported to nursing that a nursing staff yelled and raised a hand at Resident #24. The immediate action was the staff member was suspended. A hand written statement completed by Staff C, CMA (certified medication aide) dated 1/16/25 documented he was down South and heard Staff B, RN say to Resident #24 if you hit me, I ' m going to smack you back. Staff C documented the incident happened in front of the nurses station where Resident #24 was parked before the staff brought him down for meals. A handwritten statement completed by Staff A, CNA dated 1/20/25 documented she was in Resident #24's room and Staff B, RN came into the room. Staff B grabbed Resident #24's finger and he went to put his mouth on Staff B's hand. Staff B raised her hand. Staff A documented she told Resident #24 to hold still and let Staff B get his blood. Staff B put down her hand and said if you bit me I will knock every tooth out of your mouth. Staff A documented later on Staff B was at the nurses station telling everyone there what she said to Resident #24 that morning, I will knock every tooth out of your mouth. On 1/21/25 at 10:30 AM, Staff C, CMA reported the statement written on 1/16/25 was about a previous incident that had happened. Staff C reported he had heard Staff B say to Resident #24, if you hit me, I'm going to smack you back. He reported it happened when Staff B was trying to obtain Resident #24's blood sugar in front of the nurses station where Resident #24 sat before going down for meals. Staff C reported he did not say anything to anyone about what he had heard. He reported he did not think Staff B would actually hit someone. Staff C reported he did not think any other staff members were around or heard it. He said the aides were down the hallways. He reported Staff B claimed that she liked to joke around. Staff C stated he did not remember the exact date the incident happened but thought it was either on a weekend or a Friday as that was when he worked as a medication aide with Staff B. He reported Staff B does get frustrated at times. He said one time when the aides had reported a resident had fallen and Staff B was needed in the resident room, she said, God Damn and then slammed the medications down on the medication cart. Staff C also reported he had seen Staff B smack her fist down on the table when she got frustrated. He said Staff B does not like to work by herself and gets upset when there was not a second nurse. On 1/21/25 at 12:45 PM, Staff A, CNA reported she had gone back, looked at the schedule and determined the incident occurred on Monday,1/6/25 as she was giving baths that day and Resident #24 was scheduled for the bath. She stated she took the bath chair into the room with her and was going to get him up. She stated Staff B, RN came into the room to get Resident #24 blood sugar. She stated Staff B leaned over Resident #24, grabbed his hand and he tried to bite her. Staff A reported Staff B told Resident #24, Don't you dare bite me, I am going to knock every tooth out of your mouth. She stated Staff B raised her right hand in the air like she was going to slap him but she did not. She stated Staff B did not explain what she was going to do prior to trying to get his blood sugar. Staff A reported she was able to get Resident #24 to calm down and he did let Staff B do the blood sugar. She stated Staff D, CNA heard noises coming from outside the room and she came in. Staff A reported she told Staff D what had happened. Staff A reported Staff B was at the nurses station later on repeating what she had said to Resident #24. On 1/21/25 at 2:30 PM, Staff D, CNA reported on 1/6/25 she had heard some noise coming from Resident #24's room and she went into the room to see if they needed any help. She stated Resident #24 was having his normal behaviors which was hitting and yelling. She stated Staff A, CNA and Staff B, RN were in the room and were either trying to get Resident #24's blood sugar or give medications. Staff D stated she was not sure which one but she knew something with nursing was taking place as Staff B was in the room. She stated she left the room and later returned to help Staff A transfer Resident #24 into the shower chair. Staff D stated later around lunch time Staff A had told her that the way Staff B was talking to Resident #24 made her uncomfortable. Staff D said she told Staff A that if it made her uncomfortable that she needed to report it. Staff D reported Staff A did not tell her what it was that Staff B had said that made her uncomfortable. Staff D reported Staff B was not nice to the staff. She stated Staff B would talk about staff behind their backs. The untitled, undated, unsigned investigation summary provided by the facility on 1/21/25 documented on 1/16/25 a state surveyor entered the building regarding a complaint against Staff B, RN towards Resident #24. The summary revealed Staff B was suspended pending investigation on 1/16/25 when the Director of Nursing (DON) was informed of the allegation. On 1/22/25 at 7:20 AM, the Administrator reported she learned of the abuse allegations on 1/16/25. She stated she was out of the building and got a text that the nurse was being walked out and suspended. She stated the DON started the investigation on 1/16/25. On 1/22/25 at 7:52 AM, the Administrator said she would expect staff to make sure the resident was safe and not in danger, report the allegations of abuse to the nurse or supervisor immediately, follow up/make sure the allegations were taken care of and if not tell someone else or report to the state themselves. A facility policy titled ( facility name) Abuse Prevention, Reporting, Investigation Policy and Procedure revised April 2017 documented the residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees to take action to protect and prevent abuse and neglect from occurring within the facility by the following: a. Not using verbal, mental, sexual and physical abuse, corporal punishment, or involuntary seclusion. b. Not employing individuals who have been found guilty of abusing, mistreating individuals by a court of law and have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, and/or mistreatment of residents or misappropriation of their property. c. Reporting any knowledge of actions by a court of law against an employee for service as a Nurse Aide, or other nursing facility staff to the State Nurse Aide Registry of Licensing Authorities. d. Ensuring that all alleged violations involving mistreatment, neglect, or abuse including, injuries, injuries of unknown source, and misappropriation of resident property are reported to officials in accordance with Federal and State laws and also to the Administrator, DON, and the Resident Services Director. e. Providing evidence that all alleged violations are thoroughly investigated and thereby preventing further potential abuse while an investigation is in process. f. Reporting results immediately to the State Survey Agency g. Taking corrective action in cases where alleged abuse is verified.

Based on staff interview, personnel record review, facility investigation review, and policy review the facility failed to notify DIAL (Department of Inspection, Appeals and Licensing) of an alleged verbal and physical abuse for Resident #24 that occurred on 1/6/25 at 7:00 AM in a timely manner. The CNA (Certified Nursing Assistant) reported she told the DON (Director of Nursing) of the allegations of abuse later that afternoon on 1/6/25. The DON denied being told or hearing of the allegation of abuse. The facility investigation for the alleged abuse was initiated on 1/16/25 after DIAL entered the facility and notified the DON of the allegations. The facility reported the incident to DIAL on 1/16/25 at 3:34 PM. The facility reported a census of 39 residents. Findings include: On 1/16/25 at 1:50 PM, Staff A, CNA reported last week either on Thursday or Friday around 7 AM, Staff B, RN (Registered Nurse) had gone to Resident #24's room to check his blood sugar. Resident #24 attempted to bite Staff B and Staff A helped stop him by grabbing his hand and when she did, he pulled his head away from Staff B. Staff B stated, If you bite me I will knock all the teeth out of your mouth and raised her hand to strike him. Staff A responded Hey and Staff B put her hand down. Staff A reported Staff D, CNA had come into Resident #24's room right after the incident because she had heard raised voices. Staff A reported she had told Staff D what had happened and Staff D told her that it was inappropriate and to tell the DON. Staff A reported it was a really busy day so she told the DON around 3 PM and the DON said she would deal with it. When asked if the DON had done anything, Staff A reported she never went back to follow up. Staff A reported she had worked the following weekend and Monday and Staff B had also worked the weekend. Staff A reported she had also told Staff E, another CNA about the incident. On 1/16/25 at 2:10 PM, Staff B, RN reported when she got angry she might say she wanted to hit something but had never said anything to a patient. Staff B stated she thought she should take up boxing to help her get rid of some frustrations. Staff B said she would never say she wanted to hit something in a patient ' s room, she stated she had said it at the desk. Staff B said she had been a nurse for 32 years and would never want to hit a patient. Review of the document titled Intake revealed the facility filed allegation of abuse with DIAL for Resident #24 on 1/16/25 at 3:34 PM. An Incident Report titled Alleged Neglect dated 1/16/25 at 5:18 PM documented a state official reported to nursing that a nursing staff yelled and raised a hand at Resident #24. The immediate action was that a staff member was suspended. A hand written statement completed by Staff C, CMA (Certified Medication Aide) dated 1/16/25 documented he was down South and heard Staff B, RN say to Resident #24 if you hit me, I ' m going to smack you back. Staff C documented the incident happened in front of the nurses station where Resident #24 was parked before the staff brought him down for meals. The untitled and unsigned facility investigation summary provided by the facility on 1/21/25 documented on 1/16/25 a state surveyor entered the building regarding a complaint against Staff B, RN towards Resident #24. It was reported Staff B was reported to have an allegation of abuse and it was reported to the DON and nothing was done. The summary documented the incident had not been reported to the Administrator at any time. The summary revealed Staff B was suspended pending investigation on 1/16/25 when the DON was informed of the allegation and an incident report was filed with DIAL. A facility form titled Disciplinary Action Report dated 1/20/25 for Staff A, CNA documented the violation occurred on 1/6/25 as Staff A did not report alleged abuse immediately so it could be reported to DIAL. Staff A, CNA stated she watched Staff B raise her hand and yell at the resident. Staff A did not turn into supervisor immediately, which is policy, so the incident can be reported within 2 hours. The form was signed by the DON and Staff A on 1/20/25. On 1/21/25 at 10:30 AM, Staff C, CMA reported the statement written on 1/16/25 was about a previous incident that had happened. Staff C reported he had heard Staff B say to Resident #24, if you hit me, I'm going to smack you back. He reported it happened when Staff B was trying to obtain Resident #24's blood sugar in front of the nurses station where Resident #24 sat before going down for meals. Staff C reported he did not say anything to anyone about what he had heard. He reported he did not think Staff B would actually hit someone. Staff C reported he did not think any other staff members were around or heard it. He said the aides were down the hallways. He reported Staff B claimed that she liked to joke around. Staff C stated he did not remember the exact date the incident happened but thought it was either on a weekend or a Friday as that was when he worked as a medication aide with Staff B. He reported Staff B does get frustrated at times. He said one time when the aides had reported a resident had fallen and Staff B was needed in the resident room, she said, God Damn and then slammed the medications down on the medication cart. Staff C also reported he had seen Staff B smack her fist down on the table when she got frustrated. He said Staff B does not like to work by herself and gets upset when there is not a second nurse. On 1/21/25 at 11:31 AM, Staff E, CNA reported she had heard from Staff A, CNA that Staff A and Staff B, RN were getting Resident #24 up and Staff B said to Resident #24, I will knock out all of your damn teeth out of your mouth, if you try to bite me again. She said Staff A reported Staff B raised her right fist in the air. Staff A reported she thought it had happened on a Thursday and she heard about it the following day when she was working on 1/10/25. Staff E reported Staff A told her that she had reported the incident to the DON. Staff E reported Staff B had been mean before. When asked what she meant by mean, Staff E stated Staff B was not directly mean to the residents but would talk about them at the nurses station. On 1/21/25 at 12:45 PM, Staff A, CNA reported she had gone back, looked at the schedule and determined the incident occurred on Monday,1/6/25 as she was giving baths that day and Resident #24 was scheduled for the bath. She stated she took the bath chair into the room with her and was going to get him up. She stated Staff B, RN came into the room to get Resident #24's blood sugar. She stated Staff B leaned over Resident #24, grabbed his hand and he tried to bite her. Staff A reported Staff B told Resident #24, Don't you dare bite me, I am going to knock every tooth out of your mouth. She stated Staff B raised her right hand in the air like she was going to slap him but she did not. She stated Staff B did not explain what she was going to do prior to trying to get his blood sugar. Staff A reported she was able to get Resident #24 to calm down and he did let Staff B do the blood sugar. She stated Staff D, CNA heard noises coming from outside the room and she came in. Staff A reported she told Staff D what had happened. Staff A reported Staff B was at the nurses station later on repeating what she had said to Resident #24. Staff A reported she could not recall who else was sitting at the nurses station. She stated later that week, she thought on Friday,1/10/25, Staff E, CNA asked her about the incident so she told Staff E what had happened. Staff A reported she had told the DON about the incident later that day on Monday 1/6. She stated the DON was busy and she was not sure the DON totally understood what she was talking about. She stated the DON told her that she would look into it. On 1/21/25 at 2:30 PM, Staff D, CNA reported on 1/6/25 she had heard some noise coming from Resident #24's room and she went into the room to see if they needed any help. She stated Resident #24 was having his normal behaviors which was hitting and yelling. She stated Staff A, CNA and Staff B, RN were in the room and were either trying to get Resident #24's blood sugar or give medications. Staff D stated she was not sure which one but she knew something with nursing was taking place as Staff B was in the room. She stated she left the room and later returned to help Staff A transfer Resident #24 into the shower chair. Staff D stated later around lunch time Staff A had told her that the way Staff B was talking to Resident #24 made her uncomfortable. Staff D said she told Staff A that if it made her uncomfortable that she needed to report it. Staff D reported Staff A did not tell her what it was that Staff B had said that made her uncomfortable. On 1/21/25 at 3:20 PM, The DON reported she found out about the allegations of abuse the day DIAL entered the facility for a complaint on 1/16/25. She reported that was why the date of the incident was uncertain. She stated initially she was told that the incident occurred the week before on a Thursday or Friday. She said during the facility investigation and staff interviews she identified the incident occurred on 1/6/25. She reported during the investigation she learned Staff A was in Resident #24's room getting him up for a bath. Staff B, RN came in the room and took his finger to do blood sugar, he struck out and she raised her hand. She stated the investigation was unclear on what Staff B had said in the room. She reported the location of the incident was also unclear. She stated at first it occurred at the nurses station, then in the Resident #24's room in the wheelchair and then in the room in the bed. She stated Staff B did not admit to anything. She said Staff B reported she has been in nursing for 32 years and had never raised a hand to a patient. When asked if Staff A had reported allegations of abuse to her, the DON stated no. She stated Staff A did not come to her office and if Staff A said anything in passing she did not hear it. The DON stated if something had been reported to her, she would have done something immediately and started an investigation. She stated the normal process was to separate/suspend, report to DIAL, start an internal investigation, and notify family/physician of the allegations. On 1/22/25 at 7:20 AM, the Administrator reported she learned of the abuse allegations on 1/16/25. She stated she was out of the building and got a text that the nurse was being walked out and suspended. She stated the DON started the investigation on 1/16/25. On 1/22/25 at 7:52 AM, the Administrator said she would expect staff to make sure the resident was safe and not in danger, report the allegations of abuse to the nurse or supervisor immediately, follow up/make sure the allegations were taken care of and if not tell someone else or report to the state themselves. Review of the facility's internal investigation lacked documentation that the police were notified of the allegations of abuse. On 1/22/25 at 4:30 PM, the Administrator reported the facility did not notify the policy of the allegations of abuse. A facility policy title (facility name) Abuse Prevention, Reporting, Investigation Policy and Procedure revised April 2017 documented the residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees to take action to protect and prevent abuse and neglect from occurring within the facility by the following: a. Not using verbal, mental, sexual and physical abuse, corporal punishment, or involuntary seclusion. b. Not employing individuals who have been found guilty of abusing, mistreating individuals by a court of law and have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, and/or mistreatment of residents or misappropriation of their property. c. Reporting any knowledge of actions by a court of law against an employee for service as a Nurse Aide, or other nursing facility staff to the State Nurse Aide Registry of Licensing Authorities. d. Ensuring that all alleged violations involving mistreatment, neglect, or abuse including, injuries, injuries of unknown source, and misappropriation of resident property are reported to officials in accordance with Federal and State laws and also to the administrator, DON, and the Resident Services Director. e. Providing evidence that all alleged violations are thoroughly investigated and thereby preventing further potential abuse while an investigation is in process. f. Reporting results immediately to the State Survey Agency g. Taking corrective action in cases where alleged abuse is verified. The policy further documented in cases where there was suspected or known sexual/abuse or in incidents where there is serious physical injury or incidents of theft, law enforcement should be notified first and then other sources notified. In all cases, evidence should not be handled until law enforcement has arrived.

Based on staff interviews, facility investigation review, time card detail, and policy review the facility failed to separate a staff member from dependent residents accused of alleged physical and verbal abuse that occurred on 1/6/25 at 7:00 AM for Resident #24. The CNA (Certified Nursing Assistant) reported she told the DON (Director of Nursing) of the allegations of abuse later that afternoon on 1/6/25 and the DON denied being told or hearing of the allegation of abuse. The staff member worked full shifts on 1/6/25, 1/7/25, 1/9/25, 1/11/25, 1/12/25, 1/15/25 and a partial shift on 1/16/25. The facility investigation for the alleged abuse was initiated on 1/16/25 after DIAL (Department of Inspections, Appeals and Licensing) entered the facility and informed the DON of the alleged abuse. Two staff members interviews reflected inappropriate behavior with the nurse and Resident #24. The facility reported a census of 39 residents. Findings include: On 1/16/25 at 1:50 PM, Staff A, CNA reported last week either on Thursday or Friday around 7 AM, Staff B, RN (Registered Nurse) had gone to Resident #24's room to check his blood sugar. Resident #24 attempted to bite Staff B and Staff A helped stop him by grabbing his hand and when she did, he pulled his head away from Staff B. Staff B stated, If you bite me I will knock all the teeth out of your mouth and raised her hand to strike him. Staff A responded Hey and Staff B put her hand down. Staff A reported Staff D, CNA had come into Resident #24's room right after the incident because she had heard raised voices. Staff A reported she had told Staff D what had happened and Staff D told her that it was inappropriate and to tell the DON. Staff A reported it was a really busy day so she told the DON around 3 PM and the DON said she would deal with it. When asked if the DON had done anything, Staff A reported she never went back to follow up. Staff A reported she had worked the following weekend and Monday and Staff B had also worked the weekend. Staff A reported she had also told Staff E, CNA about the incident. On 1/16/25 at 2:10 PM, Staff B, RN reported when she got angry she might say she wanted to hit something but had never said anything to a patient. Staff B stated she thought she should take up boxing to help her get rid of some frustrations. Staff B said she would never say she wanted to hit something in a patient's room, she stated she had said it at the desk. Staff B said she had been a nurse for 32 years and would never want to hit a patient. Review of the document titled Intake revealed the facility filed allegation of abuse with DIAL for Resident #24 on 1/16/25 at 3:34 PM. An Incident Report titled Alleged Neglect dated 1/16/25 at 5:18 PM documented a state official reported to nursing that a nursing staff yelled and raised a hand at Resident #24. The immediate action was that a staff member was suspended. Review of Staff B Time Card Report dated 12/29/25 to 1/11/25 revealed Staff B worked full 12 hours shifts on 1/6/25, 1/7/25, 1/9/25 and 1/11/25. Review of Staff B Time Card Reported dated 1/12/25 to 1/15/25 revealed Staff B worked full 12 hours shifts on 1/12/25 and 1/15/25. On 1/16/25 Staff B worked a partial shift and left the facility at 2:58 PM. A hand written statement completed by Staff C, CMA (Certified Medication Aide) dated 1/16/25 documented he was down South and heard Staff B, RN say to Resident #24 if you hit me, I ' m going to smack you back. Staff C documented the incident happened in front of the nurses station where Resident #24 was parked before the staff brought him down for meals. The untitled and unsigned facility investigation summary provided by the facility on 1/21/25 documented on 1/16/25 a state surveyor entered the building regarding a complaint against Staff B towards Resident #24. It was reported Staff B was reported to have an allegation of abuse and it was reported to the DON and nothing was done. The summary documented the incident had not been reported to the Administrator at any time. The summary revealed Staff B was suspended pending investigation on 1/16/25 when the DON was informed of the allegation and an incident report was filed with DIAL. On 1/21/25 at 10:30 AM, Staff C, CMA reported the statement written on 1/16/25 was about a previous incident that had happened. Staff C reported he had heard Staff B say to Resident #24, if you hit me, I'm going to smack you back. He reported it happened when Staff B was trying to obtain Resident #24's blood sugar in front of the nurses station where Resident #24 sat before going down for meals. Staff C reported he did not say anything to anyone about what he had heard. He reported he did not think Staff B would actually hit someone. Staff C reported he did not think any other staff members were around or heard it. He said the aides were down the hallways. He reported Staff B claimed that she liked to joke around. Staff C stated he did not remember the exact date the incident happened but thought it was either on a weekend or a Friday as that was when he worked as a medication aide with Staff B. He reported Staff B does get frustrated at times. He said one time when the aides had reported a resident had fallen and Staff B was needed in the resident room, she said, God Damn and then slammed the medications down on the medication cart. Staff C also reported he had seen Staff B smack her fist down on the table when she got frustrated. He said Staff B does not like to work by herself and gets upset when there is not a second nurse. On 1/21/25 at 11:31 AM, Staff E, CNA reported she had heard from Staff A, CNA that Staff A and Staff B, RN were getting Resident #24 up and Staff B said to Resident #24, I will knock out all of your damn teeth out of your mouth, if you try to bite me again. She said Staff A reported Staff B raised her right fist in the air. Staff A reported she thought it had happened on a Thursday and she heard about it the following day when she was working on 1/10/25. She reported Staff A told her that she had reported the incident to the DON. Staff E reported Staff B had been mean before. When asked what she meant by mean, Staff E stated Staff B was not directly mean to the residents but would talk about them at the nurses station. On 1/21/25 at 12:45 PM, Staff A, CNA reported she had gone back, looked at the schedule and determined the incident occurred on Monday,1/6/25 as she was giving baths that day and Resident #24 was scheduled for the bath. She stated she took the bath chair into the room with her and was going to get him up. She stated Staff B, RN came into the room to get Resident #24 blood sugar. She stated Staff B leaned over Resident #24, grabbed his hand and he tried to bite her. Staff A reported Staff B told Resident #24, Don't you dare bite me, I am going to knock every tooth out of your mouth. She stated Staff B raised her right hand in the air like she was going to slap him but she did not. She stated Staff B did not explain what she was going to do prior to trying to get his blood sugar. Staff A reported she was able to get Resident #24 to calm down and he did let Staff B do the blood sugar. She stated Staff D, CNA heard noises coming from outside the room and she came in. Staff A reported she told Staff D what had happened. Staff A reported Staff B was at the nurses station later on repeating what she had said to Resident #24. Staff A reported she could not recall who else was sitting at the nurses station. She stated later that week, she thought on Friday,1/10/25, Staff E, CNA asked her about the incident so she told her what had happened. Staff A reported she had told the DON about the incident later that day on Monday 1/6/25. She stated the DON was busy and she was not sure the DON totally understood what she was talking about. She stated the DON told her that she would look into it. On 1/21/25 at 2:30 PM, Staff D, CNA reported on 1/6/25 she had heard some noise coming from Resident #24's room and she went into the room to see if they needed any help. She stated Resident #24 was having his normal behaviors which was hitting and yelling. She stated Staff A, CNA and Staff B, RN were in the room and were either trying to get Resident #24's blood sugar or give medications. Staff D stated she was not sure which one but she knew something with nursing was taking place as Staff B was in the room. She stated she left the room and later returned to help Staff A transfer Resident #24 into the shower chair. Staff D stated later around lunch time Staff A had told her that the way Staff B was talking to Resident #24 made her uncomfortable. Staff D said she told Staff A that if it made her uncomfortable that she needed to report it. Staff D reported Staff A did not tell her what it was that Staff B had said that made her uncomfortable. On 1/21/25 at 3:20 PM, The DON reported she found out about the allegations of abuse the day DIAL entered the facility for a complaint on 1/16/25. She reported that was why the date of the incident was uncertain. She stated initially she was told that the incident occurred the week before on a Thursday or Friday. She said during the facility investigation and staff interviews she identified the incident occurred on 1/6/25. She reported during the investigation she learned Staff A was in Resident #24's room getting him up for a bath. Staff B, RN came in the room and took his finger to do blood sugar, he struck out and she raised her hand. She stated the investigation was unclear on what Staff B had said in the room. She reported the location of the incident was also unclear. She stated at first it occurred at the nurses station, then in the Resident #24's room in the wheelchair and then in the room in the bed. She stated Staff B did not admit to anything. She said Staff B reported she has been in nursing for 32 years and had never raised a hand to a patient. When asked if Staff A had reported allegations of abuse to her, the DON stated no. She stated Staff A did not come to her office and if Staff A said anything in passing she did not hear it. The DON stated if something had been reported to her, she would have done something immediately and started an investigation. She stated the normal process was to separate/suspend, report to DIAL, start an internal investigation, and notify family/physician of the allegations. On 1/22/25 at 7:20 AM, the Administrator reported she learned of the abuse allegations on 1/16/25. She stated she was out of the building and got a text that the nurse was being walked out and suspended. She stated the DON started the investigation on 1/16/25. On 1/22/25 at 7:52 AM, the Administrator said she would expect staff to make sure the resident was safe and not in danger, report the allegations of abuse to the nurse or supervisor immediately, follow up/make sure the allegations were taken care of and if not tell someone else or report to the state themselves. A facility policy titled (facility name) Abuse Prevention, Reporting, Investigation Policy and Procedure revised April 2017 documented the residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees to take action to protect and prevent abuse and neglect from occurring within the facility by the following: a. Not using verbal, mental, sexual and physical abuse, corporal punishment, or involuntary seclusion. b. Not employing individuals who have been found guilty of abusing, mistreating individuals by a court of law and have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, and/or mistreatment of residents or misappropriation of their property. c. Reporting any knowledge of actions by a court of law against an employee for service as a Nurse Aide, or other nursing facility staff to the State Nurse Aide Registry of Licensing Authorities. d. Ensuring that all alleged violations involving mistreatment, neglect, or abuse including, injuries, injuries of unknown source, and misappropriation of resident property are reported to officials in accordance with Federal and State laws and also to the administrator, DON, and the Resident Services Director. e. Providing evidence that all alleged violations are thoroughly investigated and thereby preventing further potential abuse while an investigation is in process. f. Reporting results immediately to the State Survey Agency g. Taking corrective action in cases where alleged abuse is verified. The policy further documented the alleged abuser will be immediately suspended from work pending the completion and results of the investigation, depending on the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed ensure residents on antibiotics were re-evaluated for excessive duration, for 2 of 3 residents reviewed (Resident #7 and #8). The facility reported a census of 39 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #7 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including cardiorespiratory conditions and anxiety. The Care Plan revised 5/7/24 identified Resident #7 on routine antibiotic therapy for preventative measures secondary to a history of chronic urinary tract infections (UTI's). Interventions included administering medication as ordered, and taking Cephalexin daily at bedtime for prevention. Antibiotics were non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, and vaginitis. Observe the resident for possible side effects to antibiotic therapy. The Medication Administration Record (MAR) for January 2025 showed Resident #7 on Cephalexin 500 mg 1 capsule by mouth at bedtime for prevention related to UTI, with a start date of 4/23/22. The resident's clinical record lacked documentation the physician had re-evaluated the antibiotic for continued use. On 1/22/25 at 8:02 a.m. Resident #7 stated she had 3 bladder surgeries and went through a very difficult time. She had UTI's and drank a lot of cranberry juice. She had not had a UTI in awhile. She said she could not say what medications she took. She did not know if she took an antibiotic. On 1/23/25 at 8:48 a.m. the Pharmacy Consultant stated some people go on prophylactic antibiotics long term and some for the rest of their lives. He said the prophylactic antibiotic dose was usually a lower dose of 250 mg of Cephalexin. He would look into the residents dose of 500 mg. He had not been looking at the long term antibiotics with his med reviews. On 1/23/25 at 2 p.m. the Infection Preventionist (IP), stated she started in December of 24. She looked at Resident #7's record and the Cephalexin had not been reviewed in the last year. The undated facility Antibiotic Stewardship for Nursing Homes information documented up to 70% of nursing home residents received one or more systemic antibiotics every year. Studies showed that 40-75% of antibiotics used in nursing homes may be unnecessary or inappropriate. Risks of impairment from antibiotic overuse were high for older adults residing in nursing homes. Potential risks included infections, adverse drug reactions and colonization or infection with antibiotic-resistant organisms. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of anxiety, schizophrenia, seizure disorder, and heart failure. The MDS showed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. Review of the Care Plan with a revision date of 2/22/24 revealed Resident #6 on antibiotic therapy prophylactically related to history of frequent urinary tract infections and to monitor/document for side effects and effectiveness. Review of the Physician Orders revealed Resident #6 started on the prophylactic antibiotic on 10/19/23. Review of the facility Progress Notes revealed Resident #6 was to have a urology appointment on 5/5/2024. The Director of Nursing acknowledged and verified that Resident #6 did not go to this appointment and she wasn't sure why.

Based on observations, clinical record review and policy review the facility failed to give medications according to manufacturer's instructions for 1 out of 6 residents observed during medication pass (Resident #8). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #8 dated 1/13/25 identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS identified Resident #8 was independent with bed mobility, transfers and walking. The MDS included diagnoses of cerebral palsy, non-alzheimer's dementia, seizures and moderate intellectual disabilities. The January 2025 Medication Administration Record (MAR) directed staff to administer Fosamax (used to treat or prevent osteoporosis) 70 MG (milligrams) one tablet by mouth one time a week in the AM on Thursday related to specified disorders of bone density and structure. The order lacked specific directions on how the medication should be administered. On 1/23/25 at 7:58 AM, observed Resident #8 sitting at the dining room table and she had finished eating her breakfast. Staff F, CMA (Certified Medication Aide) prepared Resident #8 morning medications which included the Fosamax. The CMA administered all the medications at the dining room table with a glass of water. Staff F verified Resident #8 had finished eating breakfast when the Fosamax was given along with the other medications. Staff F reported the January MAR directed the Fosamax to be given during AM medication pass. The CMA reported sometimes Resident #8 will take her medications in her room before breakfast and other times take them in the dining room during or after breakfast. During observation with the morning medication pass on 1/23/25 with Resident #8 and review of January 2025 MAR revealed the following medications were given at the same time as the Fosamax: -Levothyroxine Sodium (treat hypothyroidism) 50 MCG (Micrograms). The Levothryroxine was scheduled on the January 2025 MAR as Early and according to manufacturer's guidelines was also to be given on an empty stomach. -Calcium Carbonate (antacids) 2 tablets in the morning for an upset stomach. -Ferrous Sulfate (Iron supplement) 325 MG one tablet in the morning. -Fluoxetine HCL (Antidepressant) 30 MG in the morning. -Vitamin D3 (supplement) 2000 IU (international units) in the morning. -Lamotrigine 25 MG 2 tablets in the morning for seizures. - Myrbetriq Extended Release 50 MG in the morning for overactive bladder. -Omeprazole Delayed Release 20 MG in the morning every other day for vomiting. -Phenytoin Sodium Extended 100 MG in the morning for seizures. -Multivitamin with minerals (supplement) 1 tablet in the morning. The Fosamax medication manufacturer's instructions instructed patients to swallow the medication whole with 6 to 8 ounces plain water at least 30 minutes before the first food, drink or medication of the day and not to lie down for at least 30 minutes after taking the medication and until after food. The manufacturer's instructions documented calcium supplement, antacids, vitamins or other oral medications can interfere with the absorption of the Fosamax. On 1/23/25 at 8:30 AM, the DON (Director of Nursing) reported she would expect the Fosamax medication to be given 1/2 hour before eating or taking any other medications and to sit up right 1/2 hour after taking the medication. An undated facility policy titled Medication Disbursement Policy documented the purpose of the policy was to establish guidelines to promote the health and safety of persons served by ensuring the safe assistance and administration of medication and treatments or other necessary procedures. The policy further documented that staff administering medication must know or be able to locate medication information on the intended purpose, side effects, dosage and special instructions. The policy directed staff to compare the medication sheet with the label of each medication for the following: right person, right medication, right time, right date, right route, right dose, and right expiration date.

Based on personnel record review, staff interviews and policy review the facility failed to provide appropriate screening prior to employment for 2 of 5 employees reviewed for background checks. The facility did not receive approval for the employee to work after the criminal background check revealed the employees had a past criminal history. The facility reported a census of 39 residents. Findings include: 1. The personnel file for Staff E, (Certified Nursing Assistant) documented a start date of 7/29/24. The Single Contact License and Background Check (SING) dated 7/15/24 indicated a criminal history record was found and required further research. The Iowa Criminal History results revealed Staff E had been charged with operating while intoxicated, 1st offense. The personnel file for Staff E lacked documentation that a record check evaluation was conducted and an approval to work was obtained through the Iowa Department of Human Services. Review of current nursing schedules revealed Staff E was an active CNA at the facility. 2. The personnel file for the active DON (Director of Nursing) documented a start date of 5/13/24. The Single Contact License and Background Check (SING) dated 5/3/24 indicated a criminal history record was found and required further research. The Iowa Criminal History results revealed the DON had been charged with operating while intoxicated, 1st offense. The personnel file for the DON lacked documentation that a record check evaluation was conducted and an approval to work was obtained through the Iowa Department of Human Services. During the survey, the DON was actively working. On 1/23/25 at 12:20 PM, the Administrator reported the facility did not have any documentation indicating the employees had been approved to work. She stated since it has been more than 30 days since the background checks had been completed the facility was not able to obtain any additional information from the Iowa Department of Human Services. The Business Office Manager (BOM) was present and reported after the facility received the criminal background check history, the facility did not do anything further. The Administrator acknowledged the facility abuse policy did not address screening of new employees or completing background checks. The Administrator reported she did not have any other policies or procedures that address completing background checks. A facility policy title (facility name) Abuse Prevention, Reporting, Investigation Policy and Procedure revised April 2017 documented the residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees to take action to protect and prevent abuse and neglect from occurring within the facility by not employing individuals who have been found guilty of abusing, mistreating individuals by a court of law and have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, and/or mistreatment of residents or misappropriation of their property. The policy failed to include direction on screening of new employees and when/how to conduct background checks on new employees.

Based on personnel time card records and staff interview, the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data. The facility reported a census of 39 residents. Findings include: The facility Payroll Based Journal (PBJ) Staffing Data Report for fiscal year quarter 4 2024 (July 1 - September 30) showed an area of concern triggered. The facility failed to have licensed nursing coverage 24 hours a day on 7/5, 7/6, 7/7, 8/2, 8/10, 8/11, 8/15, 8/24, 8/25, 9/7, 9/8, and 9/22/24. The facility provided time card information for facility staff working the days above, and agency staffing invoices documenting agency staff working the same day above, showing the facility had a nurse on 24 hours per day. On 1/22/25 at 5:02 p.m. the Administrator provided documentation they had 24 hour staffing on the days that were lacking on the PBJ report. She understood this needed to be reported accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure resident ' s current code status was available for 1 out of 15 residents reviewed (Resident #42). The facility reported a census of 41 residents. Findings include: Resident #42 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. Resident #42 ' s MDS ' s documented diagnoses of atrial fibrillation (irregular heart beat), hypertension (high blood pressure), renal disease, pneumonia, thyroid disorder, anxiety and depression. The clinical record review revealed Resident #42 was admitted to the facility on [DATE]. Review of a form titled Iowa Physician Orders Scope of Treatment (IPOST) revealed Resident #42 ' s legal representative chose Resident #42 to be DNR status (Do Not Attempt to Resuscitate) with comfort measure only. The IPOST documented comfort measures included the use of medications by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. No transfer to hospital for life-sustaining treatment. Transfer if comfort needs cannot be met in the current location. The IPOST was signed by the physician on [DATE] and by Resident 42 ' s legal representative on [DATE]. Review of Physician Orders and the Care Profile on the top of the page/screen in the clinical record lacked documentation of the DNR order or comfort measure. On [DATE] 11:30 AM, the Director of Nursing (DON) reported each resident should have their IPOST scanned in the medical record. She stated the code status should be listed at the top of the page in the medical record and also in the Physician Orders. On [DATE] at 2:05 PM, Staff B, Licensed Practical Nurse (LPN) stated if a resident was to code she would look for the resident code status at the top of the screen in the medical record. She stated if the code status was not listed there she would look for the IPOST scanned in the medical record. On [DATE] at 9:38 PM, Staff C, LPN reported if a resident was to code he would first go to the computer and look at the top of the screen for the code status. He stated if the code status was not listed there then he would look for a doctor note for more information or in the Physician Orders. He stated if he could not locate the code status he would call the Director of Nursing (DON) right away. On [DATE] at 7:45 AM, Staff D, CMA stated if a resident was to code, the first place she would look for the code status was at the top of the page in the medical record. She stated if it was not listed there she would go to the nurse. On [DATE] at 8:00 AM, the DON reported her expectation was for each resident ' s code status to be listed on the top of the screen in the medical records. She acknowledged and verified Resident #42 ' s code status was not put in the Physician Orders and was not at the top of the screen in the medical record. The DON stated the facility screwed up and she would fix it right away. She stated it was her responsibility to make sure the code status was listed. She stated that she expected the code status to be put into the physician orders on admission and to double check the order when the order/IPOST comes back signed by the physician. An undated facility policy titled Facility CPR (Cardiopulmonary Resuscitation) Policy documented each resident ' s resuscitation status will be maintained in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to notify the physician regarding a significant weight loss in 1 out of 1 residents reviewed for nutritional needs (Resident #17). The facility reported a census of 41 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 documented diagnosis of Alzheimer's disease, renal insufficiency, and diabetes mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. The MDS indicated that Resident #17 was coded for weight loss and not on physician prescribed weight loss regimen. Review of Care Plan with a revised date of 1/9/24 revealed Resident #17 had potential for nutritional problems related to a therapeutic diet, variable intake by mouth and cognitive deficits. Review of Resident #17 ' s clinical record reviewed the following information: On 11/21/2023, the resident weighed 153.6 pounds. On 12/26/2023, the resident weighed 145.4 pounds which is a -5.34 % Loss in 30 days. Review of Resident #17 ' s clinical chart lacked documentation of the physician being notified regarding significant weight loss. Review of facility provided policy titled Weight Change/Monitoring with a revised date 10/16/08 revealed the following: Residents ' weights will be monitored weekly by the Consultant Dietitian. All significant or severe weight changes will be reported to the physician. A significant weight change sheet is filled out. The Consultant Dietitian will evaluate all weight changes on a weekly and quarterly basis. The weight will be recorded in the dietary weight record and documented over time for evaluation Interview at 2/14/24 at 11:20 a.m., with the Dietician revealed that when the weights are looked at, the Dietician then sends an email or report to the facility with recommendations and the facility is responsible to report weight loss to the physician. Interview at 2/14/24 at 4:00 p.m. with the Director of Nursing (DON) revealed the physician should have been notified of the significant weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews the facility failed to develop a care plan to address risk factors and interventions for 1 out of 15 residents (Residents #42) reviewed for comprehensive care plans.The facility reported a census of 41 residents. Findings include: Resident #42 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. Resident #42 ' s MDS ' s documented diagnoses of atrial fibrillation (irregular heart beat), hypertension (high blood pressure), renal disease, pneumonia, thyroid disorder, anxiety and depression. The MDS documented Resident #42 received anticoagulant (blood thinner) medication for 7 days during the lookback period. A Physician Order dated 1/23/24 directed staff to administer Warfarin Sodium (Coumadin) (anticoagulant) 1.5 mg (milligrams) by mouth in the evening every Monday and Friday and 3 mg in the evening on Tuesday, Wednesday, Thursday, Saturday and Sunday for blood clots related to essential hypertension. Review of Resident #42 ' s Care Plan with target date of 2/5/24 revealed the anticoagulant medication, potential side effects and what to monitor for while taking the high risk medication was not addressed on the comprehensive care plan. On 2/14/24 at 9:30 AM, Staff E, MDS Coordinator acknowledged and verified the anticoagulant was not addressed on the plan of care. She stated she does not routinely address the anticoagulant medications on the care plan. She stated she would do an audit and address it right away. On 2/14/24 at 3:06 PM, the Administrator reported the facility does not have a care plan policy. She stated they follow CMS and state guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review the facility failed to provide appropriate catheter care for 1 of 1 residents reviewed (Resident #1). The facility reported a census of 41 residents. Findings include: Resident #1 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #1 required partial/moderate assistance with bed mobility and substantial/maximal assistance with chair/bed to chair transfers. The MDS identified Resident #1 was dependent on staff with transfer to the toilet. The MDS indicated that Resident #1 has an indwelling catheter. Resident #1 ' s MDS included diagnoses of heart failure, hypertension, neurogenic bladder, diabetes mellitus, and schizophrenia. The Care Plan with revised date of 8/15/23 identified Resident #1 had an indwelling catheter due to atonic bladder (muscle in bladder loses it ability to contract, making emptying the bladder difficult) and flaccid neurogenic bladder (lack bladder control due to nerve damage). On 2/12/24 at 1:26 PM observed Resident #1 sitting in the recliner in her room with the catheter bag inside a dignity bag lying on the floor next to her recliner. On 2/13/24 at 12:45 PM observed Resident #1 sitting in the recliner in her room with the catheter bag inside a dignity bag hanging on the side of the garbage can. The garbage can was tipped to the side, leaning up against the recliner and the catheter bag inside the dignity bag was sitting on the floor. The catheter bag was full of urine and caused the garbage can to tip. On 2/13/24 at 1:15 PM Staff A, Certified Nursing Assistant (CNA) emptied Resident #1' s catheter bag and then hung the catheter bag inside a dignity bag on the garbage can that had garbage in it. Staff A reported she normally hangs the catheter bag on the garbage can unless Resident #1 was in bed or in the recliner. On 2/14/24 at 10:01 AM, the Administrator reported the facility does not have an indwelling catheter policy. She stated they follow the CDC guidelines. On 2/14/24 3:39 PM, the Director of Nursing (DON) reported she would expect the catheter bag not to be hung on a garbage can and not to be touching the floor. The DON stated she was looking at some other options for hanging the catheter bag when in the recliner.

Based on observations, clinical record review, and staff interviews, the facility failed to assure a medication error rate of less than 5%. During observation the facility had 2 errors out of 28 opportunities for error resulting in an error rate of 7.14% (Resident #14). The facility reported a census of 41 residents. Findings include: A Physician order dated 10/6/2019 for Resident #14 directed staff to administer Cholecalciferol (vitamin d3) 5000 units one tablet by mouth in the morning for supplement. A Physician order dated 3/3/2022 for Resident #14 directed staff to administer Calcium 500 mg (milligrams) with Vitamin D 200 units one tablet by mouth one time a day for supplement. On 2/14/23 at 7:13 AM observed Staff B, Licensed Practical Nurse (LPN) administer the following medications to Resident #14 during morning medication pass: A. Calcium 600 mg with Vitamin D3 400 international units (IU) one tablet B. Vitamin B-12 500 mcg (microgram) one tab by mouth On 2/14/24 at 12:00 PM, Staff B LPN acknowledged and verified she did not give the correct medications during morning medication pass. On 2/14/24 at 12:45 PM Staff B, LPN reported she had told the Director of Nursing (DON) about the two medications errors. She stated she had received disciplinary actions for the medication errors. On 2/14/24 at 12:50 PM, the DON reported she had completed disciplinary action with Staff B. The DON stated she showed Staff B where the correct stock medications were located in the medication cart. She stated she was going to do a medication administration audit with Staff B. The DON reported she informed Resident #14 about the medication errors as she is her own responsible party. An undated facility policy titled Medication Administration Policy documented the purpose of the policy was to establish guidelines to promote the health and safety of persons served by ensuring the safe assistance and administration of medication and treatments or other necessary procedures. The policy directed staff to compare the medication sheet with the label of each medication for the following: a. Right person b. Right medication c. Right date d. Right time e. Right route f. Right dose g. Expiration date The policy further directed staff to compare the label with the medication sheet for a second time and a third time before administering the medication to the person.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure resident's were free of significant medication errors for 1 of 8 residents reviewed (Resident #6). The facility reported a census of 41 residents. Finding's include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #6 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including diabetes, non-Alzheimer's dementia, a seizure disorder, and anxiety disorder. The Care Plan identified the resident used psychotropic medications (meds) of antipsychotic and antianxiety medication secondary to diagnosis of Schizophrenia and Anxiety disorder. The care plan identified the resident at risk of altered mood state and adverse side effects to psychoactive medication use. The resident sometimes displayed dissatisfaction with other residents behavior or protocol's within the facility. The interventions included administering medications as ordered,and monitoring/documenting for side effects and effectiveness. The resident had a seizure disorder related to epilepsy. The interventions included giving seizure medication as ordered by the doctor. The resident took phenytoin three times a day and topiramate. The Progress Notes dated 12/13/23 at 11:00 a.m. documented a late entry. The nurse accidentally gave the wrong medication to the resident. The resident rested in bed at that time. The resident denied pain or any discomfort at that time. No cough or shortness of breath (SOB) noted at that time. The resident denied signs/symptoms (S/S) of lethargy, dizziness, sweating, or chills at that time. Vital signs obtained. Monitoring the resident's vital (Apical pulse) sign every 30 minutes x1 hour, every 1 hour x1, and every 2 hour x2. Called the emergency room (ER) nurse to explain the situation, and the ER Nurse advised to send a fax to the physician to review. The medications accidentally given: a. Cyclobenzeprine 10 mg (muscle relaxant) b. Digoxin tab 125 Mcg (antiarrhythmic and blood pressure support) c. Gabapentin 300 mg (anticonvulsant and nerve pain) d. Gabapentin 600 mg e. Lamictal 25 mg (anticonvulsant) f. Mirtazapine 15 mg (antidepressant) g. Trazadone 100 mg (antidepressant) The December Medication Administration Record (MAR) documented the resident received her scheduled medications at bedtime (HS) on 12/13/23 including: a. Atorvastatin 20 mg (can treat high cholesterol and triglyceride levels), b. Gabapentin 600 mg, c. Keflex 250 mg (antibiotic), d. Metoprolol 100 mg (high blood pressure, chest pain and heart failure), e. Phenytoin 100 mg (anticonvulsant), f. ASA 81 mg. The clinical record lacked any documentation the physician was consulted about the Resident #6's medications, if any should be given. On 2/12/24 at 3:09 p.m. Resident #6 stated she was given another residents meds one night. She said they kept coming in and taking her blood pressure. When she asked the nurse why, he said because she had a stress test recently. He lied. The next day someone else told her she received another resident's medications. She asked that the med aide or other nurse give her meds after that. On 2/13/24 at 9:38 p.m. Staff C Licensed Practical Nurse (LPN) reported he recalled the medication error that occurred with Resident #6 in December. Staff C stated he was passing medications and he got a cup of medications ready for a another resident. He stated he usually put the resident's name on the cup and he failed to do that. He got Resident #6's medications ready after the other residents and did not mark the medication cup with the resident's name. He stated he made a mistake and gave the other resident's medication to Resident #6. He stated the medication error happened around 7 p.m. He stated he caught the error right away. He stated that Resident #6 did not receive her own medications and she did not receive duplicates/doubles. He stated he called the DON right away regarding the medication error and she instructed him to call the ER. He stated he did Resident #6's vitals and sent a Progress Note to the ER doctor. He was told to assess the resident every hour for the whole night. He stated the DON met with him for 15-30 minutes providing education and training on medication administration. He stated he signed a letter that he understood the risk and consequences. He reported that Resident #6 was aware that she received the other resident's medication. He stated he told her he made a mistake and apologized. He reported that Resident #6 was very mad. He stated his relationship with Resident #6 was improving and he had been providing emotional support. He stated he started at the facility as a LPN in September, his first job as a nurse. On 2/15/24 at 8:10 a.m. the DON stated Staff C did not give the resident her HS meds. After it happened, he called her and she instructed him to make the list of meds she received and call the physician about how he should proceed. At 8:40 a.m. the DON said Staff C did not document on the MAR the meds were omitted that evening. She would need to do some more education. The undated facility Medication Administration Policy identified the purpose to establish guidelines to promote the health and safety of persons served by ensuring the safe assistance and administration of medication and treatments or other necessary procedures. The policy directed staff to compare the medication sheet with the label of each medication for the following: a. Right person b. Right medication c. Right date d. Right time e. Right route f. Right dose g. Expiration date The policy further directed immediately prior to the administration of any medication or treatment, staff would identify the person and explain what would be done. A Disciplinary Action Report dated 12/14/23 documented Staff C received a first written counseling related to the med error incident. The recommendations to prevent reoccurrence included going over the 5 rights of med pass and never pull up meds until ready to dispense.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility document review, and staff interviews, the facility failed to conduct regular inspections of side rails as part of a regular maintenance program for 1 out of 15 residents (Resident #21). The facility reported a census of 41 residents. Findings include: Resident #21 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 07, indicating moderately impaired cognition. The MDS indicated Resident #21 required substantial/maximal assistance with bed mobility and was dependent with assistance of 2 persons with transfers. Resident #21 ' s MDS ' s documented diagnoses of hypertension (high blood pressure), non-Alzheimer ' s dementia, depression, osteoarthritis, and chronic pain syndrome. The MDS documented Resident #21 had bed rails used less than daily on the bed. On 2/12/24 at 3:31 PM observed Resident #21 lying in bed. Resident #21's bed had upper bilateral metal side rails, quarter length in size. A Physician Order dated 3/4/2020 documented Resident #21 had bilateral side rails for assist and support when in bed. Review of an untitled form dated January 2023 to December 2023 documented inspection of the bed rails for Resident #21 revealed assessments had not been completed for the months of October 2023, November 2023, and December 2023. The facility was unable to provide bed rail assessments for January or February 2024. On 2/13/24 at 1:31 PM, the Administrator reported due to an error on the maintenance side, bed assessments had not been completed. On 2/13/24 at 2:00 PM, the Director of Nursing (DON) reported Resident #21's bed had not been audited by Maintenance since September 2023. She stated it made her sick to her stomach that the audits were not completed. She stated that she expected Maintenance to conduct audits quarterly. A facility policy titled Bed Safety revised 6/12/2019 documented the policy statement was to provide a safe sleeping environment for the residents. The policy directed maintenance staff to inspect all beds and related equipment as part of the regular bed safety program to identify risks and problems including potential entrapment risks. The policy further directed the maintenance department to provide a copy of inspection to the Administrator and to report results to the Quality Assurance Committee for appropriate actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to provide professional standards of care for 1 of 14 residents reviewed for following doctor's orders, (Resident #140). Resident #140 was admitted with specific insulin orders and the facility failed to transcribe the orders correctly. The facility reported a census of 35 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #140 was independent with mobility transfers, walking and eating. A Brief Interview for Mental Status (BIMS) assessment completed on 1/5/23 at 3:05 PM showed the resident had a BIMS score of 12 (moderate cognitive deficits). The Care plan dated 1/5/23 included diagnosis of type 1 diabetes, heart disease, abnormal levels of other serum enzymes, and schizophrenia. The resident required close monitoring for signs and symptoms of hypoglycemia and hyperglycemia and staff were directed to administer diabetic medications as ordered. On 1/25/23 at 10:36 AM, Resident #140 was in her room working with the Physical Therapist (PT) and doing some upper body exercises. She was well groomed and responded appropriately to questions. She acknowledged that her blood glucose levels were difficult to manage but she said that she did not often notice the signs and symptoms of hyperglycemia or hypoglycemia. According to the Center for Disease Control (CDC), the target range for blood glucose (BG) levels before meals is 80 to 130 milligrams per deciliter (mg/dL). Two hours after the start of a meal: less than 180 mg/dL. Retrieved on 1/25/23 from Manage Blood Sugar | Diabetes | CDC A review of the clinical record revealed an admission order for Resident #140 from the hospital dated 1/5/23 at 10:38 AM that included an order for Insulin Aspart Solution (NovoLOG) 100 unit/mL (milliliter) 6 units, 4 times a day along with a sliding scale dose according to the BG reading. The facility orders showed an order entry dated 1/5/23 at 10:56 AM for Insulin Aspart Solution 100 unit/mL with a sliding scale dose based on the BG level 4 times a day. The entry lacked the scheduled 6 units of insulin to be given with the sliding scale dose. According to a Nursing Note dated 1/5/23 at 12:55 PM, Resident #140 was admitted to the facility at that time. The vitals tab in the electronic chart showed the first documentation of a blood glucose check was at 5:52 PM that evening with a level of 515 mg/dL. According to the vitals tab in the electronic chart the resident had the following BG levels: a. 1/5/23 at 5:52 PM; 515 mg/dL b. 1/5/23 at 7:20 PM; 543 mg/dL c. 1/5/23 at 8:42 PM; 338 mg/dL d. 1/5/23 at 11:15 PM; 34 mg/dL. A follow up nursing note indicated that the facility protocol for hypoglycemia was implemented at that time. A signed Nursing Communication dated 1/6/23 at 12:43 AM showed that the nursing staff had been in contact with the emergency room doctor for follow up orders as the BG levels fluctuated. A Nursing Note dated 1/10/23 at 2:48 PM indicated that the resident's blood sugars continued to be erratic. On 1/16/23 at 3:45 PM the doctor gave a new order to add 8 units of insulin 3 times a day before meals along with the sliding scale dose. Since the new orders were implemented on 1/16/23, the resident continued to have fluctuating BG levels. The vitals tab shows 6 days from 1/16/23 through 1/23/23 where the BG was above 400. On 1/25/23 at 9:19 AM, the Director of Nursing (DON) acknowledged the insulin order had been entered incorrectly for Resident #140 upon admission. She said the previous DON had entered orders herself and did not have a second nurse check to verify, and she was in the process of changing that practice. The DON said that the facility knew Resident #140 had been a brittle diabetic at the time of admission but she was found to be asymptomatic with highs and lows. On 1/25/23 at 12:26 PM Staff E, Certified Nursing Assistant (CNA) said that he worked with the resident many times since her admission. When she was first admitted she required one person assistance but had gotten much stronger and was currently walking on her own. He remembered that the first day she was admitted she was very confused and had gone into another resident's room and was laying on the floor but that hadn't happened since. On 1/25/23 at 11:03 AM the doctor for Resident #140 said that one of the challenges with the effort to stabilize the blood glucose levels had been changes in providers. He was not aware that the resident had an order for 6 units along with the sliding scale upon admission from the hospital. He said that would have made a difference in the management of her glucose levels in the first week. He said that he made some changes to include a scheduled insulin with the sliding scale. A facility policy last reviewed on 9/24/16 titled: Hypoglycemia, stated that when the blood glucose level was below 70, staff were to give the resident something to eat or drink with 15 grams of fast acting carbohydrates. On 1/26/23 at 9:27AM the DON said that she was not aware of a policy on admission order entries and having double checks, but she was going to change the practice and implement a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interview, the facility failed to provide the supervision and/or assistance needed by residents to prevent accident or injury for1 out of 5 residents reviewed (Resident #8). The facility reported a census of 35 residents. Resident #8's Minimum Data Set (MDS) assessment dated [DATE], current at the time of the latest fall, documented a Brief Interview for Mental Status Score (BIMS) of 15, indicating the resident was cognitively intact. Resident #8 was independent in all Activities of Daily Living (ADLs) except for ambulation outside of their room which required supervision, encouragement or cueing. A walker was required for ambulation. The MDS section Health Conditions indicated Resident #8 had diagnoses of schizophrenia, orthostatic hypotension, non-Alzheimer's dementia, seizure disorder, anxiety disorder, dizziness and giddiness. Resident #8's Care Plan dated 6/14/16 documented Resident #8 was a high risk for falls related to history of falls. Most recent fall documented was on 1/4/23. On 7/26/22 it was documented the care plan was reviewed and remains appropriate. The interventions were as listed: On 8/6/20 the care plan documented that gripper strips were to be applied in the showers. On 4/28/21 the care plan documented that gripper strips would be applied next to bed to prevent slipping. On 10/27/22 the care plan documented to remind resident to walk with two wheeled walker in hallways and use 1 assist with gait belt. Clinical record review of Progress Notes show documentation of Resident #8 falls on 1/4/23, 8/22/22, 7/8/22, 5/26/22, and 4/17/22. In an observation on 1/24/23 at 3:25 PM, no gripper strips were observed in Resident #8's room or the north and south shower rooms. In an interview with Resident #8 on 1/24/23 at 3:29 PM, she stated that she removed the gripper strips by her bed a couple of months ago because they were peeling up and she was tripping over them. Throughout the survey process, Resident #8 was observed to be ambulating alone in the hallways with her walker without assist or gait belt. In an interview with the MDS Coordinator on 1/26/23 at 9:25 AM, she stated that the expectation for documenting ambulation assistance would be under ADLs and not fall interventions. She stated she would update the care plan to reflect this. She stated she would look into the gripper strip issue as she was not sure if the decision had been made to remove them or not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews the facility failed to have ready and reasonable access to personal funds upon request for 1 of 1 residents reviewed (Resident #4). The facility reported a census of 35. Findings Included: The Minimum Data Set (MDS) dated [DATE], documented Resident #4 ' s Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderate cognitive impairment. The MDS coded the resident possessed the ability to make herself understood and understood others. In interview on 1/23/23 at 12:09 PM, Resident #4 revealed residents do not have access to personal funds after business hours or on the weekends. In an interview on 1/24/23 at 10:34 AM, Staff I, Certified Medication Aide (CMA), reported residents could withdraw money from their trust funds when the Business Office is open. In an interview on 1/24/23 at 10:27 AM, the Business Office Manager (BOM), reported that residents could withdraw money from their trust funds during business hours. The BOM added that she asked residents if they need money prior to any known absences. The BOM reported residents did not have access to funds after business hours or on the weekends. In an interview on 1/22/23 at 3:01 PM, the Director of Nursing (DON), acknowledged that residents have a right to their funds upon the request. The DON planned to have money available at the nurses station so that residents could withdraw money after business hours and on the weekends. The DON reported the facility lacked policies related to the availability of trust funds to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interviews and policy review the facility failed to provide the residents with a comfortable homelike environment to 2 of 14 residents reviewed (Resident #5 and Resident #8). The facility reported a census of 35 residents. Findings include 1. The Minimum Data Set (MDS) for Resident #5 dated 12/28/22 documented a Brief Interview of Mental Status (BIMS) as 15 indicating no cognitive impairment. The MDS documented diagnosis of multiple sclerosis and renal insufficiency . The MDS documented admission to the facility on [DATE]. In an interview on 1/23/23 at 11:41 AM, Resident #5, stated the facility had a problem with plumbing. Resident #5 stated that the showers never get hot or stay hot. 2. The Minimum Data Set (MDS) for Resident #8 dated 11/09/22 documented a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented diagnosis of anemia, diabetes mellitus, hyponatremia, and non-alzheimer's dementia. The MDS documented admission to the facility on [DATE]. In an interview on 1/26/23 at 8:13 AM, Resident #8, stated that she used to take showers in the North hall shower room. Resident #8 stated she hasn't been able to use the north shower for over 2 months now because the water in the north shower room has been too cold to use. Resident #8 stated she showers twice a week on Tuesday and Friday. Resident #8 stated the showers in the south shower room are not warm enough either but not as cold as the north shower room was. On 1/24/23 continuous observation from 9:04 AM through 9:19 AM. The temperatures were checked by Staff G in the North wing bathroom shower after water ran from 9:08 AM till 9:11 AM with a temperature of 95.0. Temp checked next in the Haven (Alzheimer's unit) wing tub after water ran from 9:13 AM till 9:15 AM with a temperature of 97.0 noted. Temp checked at 9:18 AM with a thermometer that is part of the tub on the South wing noted to be 99.0. Staff H was giving a bath to a resident at that time. In an interview on 1/24/23 at 9:04 AM, Staff G, stated the acceptable range for water temperature for water in the shower rooms is 95.0 to 110.0. Staff G stated that there are 3 shower rooms in the facility. One shower room is located on the north wing, one shower room is located on the south wing, and one shower room is located on the Haven (Alzheimer's unit) wing. Staff G stated to reach optimal temperature water should run through the faucet for 1-2 minutes. Staff G stated the tub in the north bathroom works but is not used. Staff G stated staff only use the south shower room for baths and showers. Staff G stated that staff use the south shower because it is new. Staff G reported that temperatures are checked every Monday with the thermometer that was currently used. Staff G stated that rooms are checked and shower rooms are checked. Staff G stated that water was not always checked in the same faucets. In an interview on 1/24/23 at 10:45 AM, Staff H, stated she was the only one doing showers 1/24/23. Staff H stated the shower temp was 99.0 degrees during shower at 9:18 AM during a shower being given to residents. Staff H stated the tub and shower is not used in the Haven (Alzheimer's unit) wing. Staff H stated that the shower has been too cold to use on the haven wing and the tub is not used. Staff H stated residents from the Haven unit are brought to the South shower room for their showers. Staff H stated the south shower room is the only shower room that is utilized at the facility. Staff H stated the North shower runs too cold and the tub does not work and hasn't worked the entire time she has worked at the facility. Staff H stated she has worked at this facility for 2 and a half years. In an interview on 1/24/24 at 12:38 PM, Staff G, stated if the temperature is noted to be too hot or too cold it would be fixed by turning up or down the mixing valve. Staff G stated that temperatures would be rechecked after turning up or down the mixing valve but do not chart the rechecked temperatures anywhere. Review of document titled Water Temperature Log on 01/24/23 at 11:10 AM temperatures under 105 degrees were noted in north shower room on 7/8/22, 8/1/22, 8/15/22, 9/27/22, 10/12/22, 10/28/22, 12/2/22, 12/9/22, 12/28/22, and 1/23/23. Temperatures under 105 degrees in the south shower room on 9/7/22, 9/27/22, and 12/2/22. Temperatures under 105 degrees on the west wing were documented on 12/2/22, 12/9/22, and 1/23/23. Documentation of Temperature checks being completed uncharted for 7 weeks last year. Review of document on 1/24/23 at 11:00 AM titled Surveyor Guidance for Identified Excessively Hot Tap Water Temperatures That May Cause Scald Burns in Health Care Facilities dated January 2002 reflect temperature of 105-115 for nursing homes. In an interview on 01/24/23 at 11:00 am, Staff B, stated Surveyor Guidance for Identified Excessively Hot Tap Water Temperatures That May Cause Scald Burns in Health Care Facilities is the document the facility follows for compliance. Staff B stated there is a copy in files in the Staff B office and maintenance department also has a copy to follow. In an interview on 1/26/23 at 9:35 am, Staff C, stated the expectation for temperatures of shower water in the facility is 105-115. Staff C stated if there was an issue with the temperature of the water at the facility the facilities maintenance department would address it first. Staff C stated if the maintenance staff could not fix the problem outside plumber would be contacted.

Based on document review and staff interviews the facility failed to provide residents sufficient nursing staff with the appropriate competencies and skill sets by not having a registered nurse 8 consecutive hours a day. The facility reported a census of 34 residents. Findings include Document review of staff schedule on 1/24/23 at 1:21 PM noted registered nurse coverage for 12/11/22. The only registered nurse coverage for 12/11/22 was Staff A. Document review of Staff Disciplinary Report on 1/25/23 at 11:16 AM stated on 12/11/22 Staff A failed to stay for the entire required 8-hour shift. The Disciplinary Report stated Staff A worked 2-3 hours on 12/11/22. Document review of Daily Staff Posting on 1/25/23 at 12:10 PM the day position notes a need for 8 hour registered nurse coverage. Interview on 1/25/23 at 10:14 AM, with Staff C, revealed on 12/11/22 Staff A was at the facility from 9:30 am till 11:30 am. During interview on 1/25/23 at 11:09 AM, Staff B, stated the facility's expectation is that a registered nurse would be present in the building at least 8 hours every day. If a registered nurse is not assigned duty for that day staff are expected to call Staff B and Staff B would come in for coverage. Staff B stated she is currently doing the scheduling and staff B ensures a registered nurse will be present at least 8 hours every day. During interview on 1/25/23 at 11:35 AM, with a member of the facilities board who was the reporter of the incident on disciplinary report. Member stated that on 12/14/22 a day shift nurse, who's name Member did not recall, reported Staff A was not working 8 hours daily or 40 hours weekly. Member stated the day shift nurse was upset because Staff A was not here the required time even if Staff A was salary. During interview on 1/25/23 at 12:10 PM, Staff B, stated the facility has no policy on staffing. Staff B stated the facility goes by the needs noted on the daily staff posting document.