Oakland Manor

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

titled Abuse Prevention with a last reviewed date 10/21/2022 documented the facility is committed to protecting the residents from abuse by anyone including other residents. Alleged violations involving abuse are to be reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, are reported immediately but not later than 24 hours after the allegation is made, to the administrator of the facility and to other officials (including State Survey Agency and local law enforcement as required).

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oakland Manor

737 North Highway Oakland, IA 51560

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on record review, staff interviews and facility policy review the facility failed to update 2 of 3 resident's care plans (Resident #1 and Resident #2) after they were involved in a resident to resident altercation. The facility reported a census of 40 residents.Findings include:1) According to the quarterly Minimum Data Set (MDS) with a reference date of 9/11/2025 documented a Brief Interview of Mental Status (BIMS) score of 10. A BIMS score of 10 suggested mild cognitive impairment. The MDS documented

the following diagnoses: dementia, neurogenic bladder, schizophrenia, and post-traumatic stress disorder (PTSD).A Progress Note documented on 9/27/2025 at 1:27 PM: between 11:00 AM and 11:30 AM Resident #1 began to become more agitated while sitting at the smoking doors, yelling out at staff stating let me out of this f***ing place, I want to go back to council bluffs. This nurse and a Certified Nursing Assistant CNA) came up to resident, said CNA attempted to push resident in his wheelchair but he grabbed

the CNA's hand, ripping off her finger nail. Resident began to laugh, yelling out and continued to talk to himself. By this time resident had pushed himself to the nurses station and began yelling at another resident (Resident #2), the situation escalated, both residents began yelling and cursing at each other in-between dining area and nurse's station. Resident #1 than stood up out of his wheelchair and Resident #2 stood up out of his wheelchair as well. Resident #1 than stepped forward, striking Resident #2 in the face using a closed fist. This nurse and CNA were able to separate these residents prior to any further physical altercations occurring.Review of Resident #1's care plan with a revision date of 10/3/2025 revealed

it lacked information about the resident to resident altercation that took place on 9/27/2025.2) According to

the quarterly MDS with a reference date of 9/8/2025, documented Resident #2 had a BIMS score of 6. A BIMS score of 6 suggested mild cognitive impairment. The MDS documented the following diagnoses for Resident #2: renal failure and metabolic encephalopathy.A Progress Note documented on 9/27/2025 at 3:01 PM: Resident #2 was hit in the face prior to noon meal by Resident #2 who was being aggressive.

Resident #1 started yelling at Resident #2 which aggravated him, that led to both of these residents yelling at one another. It ended in Resident #1 hitting Resident #2 in the face. The situation was de-escalated by

this nurse and CNA. This situation occurred at nurse's station. This resident was not injured, no new skin concerns observed related to altercation. Resident denied pain and discomfort.On 10/15/2025 at 11:18 AM

the MDS Coordinator stated all departments are responsible for updating their portion of the resident care plans. When asked who would have been responsible for updating Resident #1 and Resident #2's care plans after the altercation on 9/27/2025, she stated the nurse in charge that day or whomever was doing

the reportable incident report. The MDS Coordinator was not in the building the weekend this incident too place but thought the care plan had been updated.On 10/15/2025 at 11:54 AM the Administrator acknowledged Resident #1 and Resident #2's care plans should have been updated to reflect the altercation that took place on 9/27/2025. She added the MDS Coordinator completes the Care Plans. Their care plans should include interventions to keep the residents safe, any medications that were adjusted and interventions to prevent this from happening again.The facility provided a document titled Comprehensive Person-Centered Care Plan with a last reviewed date of 10/23/2019, indicated each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care.

Event ID:

Facility ID:

If continuation sheet