Oakland Manor

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Manager approached her and let her know Resident #1 was getting in Resident #3's face. Staff A asked her if she separated them and the Dietary Manager denied doing so. Staff A went over and Resident #1 was not happy but no doing anything. Staff A asked Resident #1 hey let's go this way and they both walked away from Resident #3's table. When she returned to speak with Resident #3 to see what happened, he stated she hit him on the chest and grabbed his shirt. He denied injuries.On 11/5/2025 at 9:48 AM the Dietary Manager stated she had given Resident #3 his coffee and silverware then made her way to the TV room. She came back and saw Resident #1 at Resident #3's table with a coffee lid in her hand. Resident #3 had his coffee cup in one hand and his silverware in his other hand. Resident #1 was also gripping his silverware. Resident #1 stated this is mine, cursed at Resident #3, she was being forceful. The Dietary Manager noticed Staff A was in the TV room and got her to assist with the situation. She later learned that Resident #1 hit Resident #3 after she dropped of his silverware and coffee. When asked if she separated

the residents she denied doing so because she had a coffee pot in her hand and did not want to sit it down so Resident #1 could grab it. She stated she put the coffee pot in the kitchen then got Staff A. The Dietary Manager stated Resident #1 and Resident #3 were at Resident #3's dining room table that was next to the kitchen where she placed the coffee pot. She would have walked past that table to get Staff A. She added

she could have attempted to separate them but Resident #1 can be aggressive.On 11/5/2025 at 10:00 AM Certified Nursing Assistant (CNA) stated if she came across the incident between Resident #1 and Resident #3 she would go and redirect Resident #1 away from the situation. She would offer Resident #1 to sit with her which usually will calm her down.On 11/5/2025 at 10:28 AM Staff B CNA stated if she witnessed what happened between Resident #1 and Resident #3, she would have tried to separate the two, asked Resident #1 to come with her and notify the nurse.On 11/5/2025 at 11:10 AM the MDS Coordinator indicated she has been locked out the drive that provides policies, procedures and guidelines they utilize.

She was unable to look for specific policies, procedures, guidelines related to resident-to-resident altercations.On 11/5/2025 at 11:50 AM the Administrator stated when there is a verbal altercation witnessed staff are to alert management or the charge nurse and ask them for help. When asked if staff should separate the residents involved, she stated well yes immediately. They should separate to help deescalate the situation.The facility provided a document, found in their email, titled Abuse Prevention, with

a revision date of 10/21/2025. The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individuals.

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If continuation sheet

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

11/05/2025

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

silverware. Resident #3 stated well she came up to my table and thought my silverware was her's; she said that. He told her they were his and then she hit him right in the middle of the chest. Then you came over.

Residents separated from each other.The facility was asked to provide their investigative file for the resident-to-resident altercation on 10/17/2025 involving Resident #1 and Resident #2. The facility provided

the following information: a summary of their investigation, Resident #1's face sheet, medication changes prior to and after the altercation, psychological services progress notes, progress notes, care plan, and clinical treatment plan reviews (plan of care); Resident #2's facesheet and care plan. The investigative file lacked staff interviews/statements and resident statement/interviews.The facility was asked to provide their investigative file for the resident-to-resident altercation on 10/18/2025 involving Resident #1 and Resident #3. The facility provided the following information: a summary of their investigation, Resident #3's face sheet and care plan. The investigative file lacked staff interviews/statements and resident statement/interviews.On 11/4/2025 t 1:49 PM Resident #2 stated Resident #1 tried to push him while he was in his wheelchair while

they were outside smoking. He asked her to stop but she wouldn't, then she started to hit him for no reason.

Staff got her away from him and has not happened since then.On 11/4/2025 at 1:56 PM Resident #3 stated Resident #1 hit him on the chest and put his hands on the center of his chest. He denied any injuries and indicated this was the first time anything like this has happened. After she hit him, staff came to remove Resident #1 from his table and kept her away. He denied further issues with Resident #1.On 11/5/2025 at 11:10 AM the MDS Coordinator was asked if the facility had additional information on the resident-to-resident altercations on 10/17/2025 and 10/18/2025. She stated she would send a text message to the Administrator to ask her. The Administrator informed her everything that was provided upon entrance is everything she has for the two resident-to-resident altercations. She denied having interviews specifically for the two altercations.On 11/5/2025 at 11:50 AM the Administrator acknowledged she completed the investigations for the two resident-to-resident altercations. Only statements she received were from the charge nurses on those days. The Administrator stated she did not get other staff interviews or resident interviews and that was her failure. When asked how an investigation is to be completed, she stated she would basically get what happened from the charge nurse and since Resident #1 was not interviewable she could not interview her. With Resident #2 and Resident #3 they both would be able to say if they are injured and if the incidents affected them in anyway. The Administrator stated Resident #1 was not physically violent; she was not like punching anyone. She added she would usually ask other staff and residents what happened. This would different because if she was violent and caused injury but she does not have the strength to do that. She indicated Resident #1 is not violent, just has behaviors with her dementia and is not seen as a violent person to cause bodily injury.

Event ID:

Facility ID:

If continuation sheet

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

11/05/2025

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

had taken place, she would have walked up to Resident #1 to redirect her away from the situation. She would offer to sit down with her as that usually calms her down when she is around other people.On 11/5/2025 at 10:28 AM Staff B CNA stated she was not present in the dining room when Resident #1 hit Resident #3; she was assisting other residents. When she arrived to the dining room, Staff A told her what had happened. They had Resident #1 sit with Staff C at the table of residents that required assistance with their meals. Staff B went on to deliver supper trays to residents that ate in their rooms. Staff B did not think Resident #1 was on one-to-one supervision at that time but if she was staff assigned would need to keep

an eye on the resident at all times. When asked what she would have done if she had witnessed the incident between Resident #1 and Resident #3, she stated she would have gone up to Resident #1 and asked her to come with her. Staff B would then alert the nurse of what happened.On 11/5/2025 at 11:50 AM

the Administrator stated after the incident on 10/17/2025 with Resident #1 and Resident #2, Resident #1 was placed on one-to-one supervision for 48 hours. This was put in place by herself and the previous Director of Nursing (DON). She stated on 10/18/2025 Resident #1 wandered to Resident #3's dining room table and she accused him of taking her silverware but he did not. Resident #1 struck Resident #3 but he did not respond. The Administrator stated she was told there were staff in the dining room at that time but not next to Resident #1. She was unsure why they were not within a foot of Resident #1 but since it was meal time, there were staff in the dining room. She stated if a resident is on one-to-one supervision staff should be within a couple feet of her. If they were unable to maintain one-to-one supervision they should have initiated every 15 minute checks but she was never informed staff were having issues providing one-to-one supervision.

Event ID:

Facility ID:

If continuation sheet