Four Oaks Family & Children’s Services

Deficiency cited, recertification survey : N 207 483.374(b) FACILITY REPORTING

Based on record review and interview, the facility failed to report serious occurrences to the State Medicaid agency, Iowa Medicaid Enterprise (IME), and the State-designated Protection and Advocacy system, Disability Rights of Iowa (DRI). This affected 2 of 2 children reviewed (Child 1 and Child 2). Findings follow: 1.Record review on 8/12/2026 revealed Child 1's incident report, dated 11/25/2025, indicated Child 1 hit her elbow on the door latch to her bedroom. The facility took Child 1 to the Emergency Room where aa medical professional applied three sutures to close the wound. No documentation could be provided showing IME had been notified. Additional record review revealed the Quality Compliance Manager emailed DRI of the incident on 12/15/2025. 2. Record review on 8/12/2026 revealed Child 2's incident report, dated 1/19/2026, indicated Child 2 superficially cut both her arm and neck. The facility transferred Child 2 to St Luke's Hospital for psychiatric evaluation. No documentation could be provided showing IME had been notified. Additional record review revealed the Quality Compliance Manager emailed DRI of the incident on 1/23/2026. Record review on 8/13/2026 revealed the facility's Incident Reporting and Management policy, revised 4/11/2024, indicated the Quality Specialist would fax/email reports of serious occurrences to the appropriate recipients by the end of the day following the incident. When interviewed on 8/13/2026 at 12:20 p.m., the Quality and Compliance ...

Deficiency cited, recertification survey : N 143 483.358(d) ORDERS FOR USE OF RESTRAINT OR SECLUSION

Based on record review and interview, the facility failed to ensure a verbal order for an emergency safety intervention (ESI) was obtained timely. This affected 1 of 3 sample children (Child 1). Findings include: Record review on 8/11/2025 revealed Child 1's Behavior Management Report (BMR) dated 6/8/2026, indicated staff restrained Child 1 from 1:23 p.m. to 1:25 p.m. Further review failed to reveal an authorization signature and indicated staff members had not notified health services of the restraint until 6:10 p.m. Record review on 8/11/2026 revealed the Four Oaks 2026 Behavior Management Policy, revised 5/1/2026, indicated the use of physical restraint should be authorized by a qualified staff member who possessed appropriate credentials, knowledge, and expertise, and in accordance with federal or state requirements, and documented on the BMR. When interviewed on 8/11/2026 at 2:25 p.m., Nurse A confirmed staff members failed to seek authorization for the restraint documented in Child 1's BMR until 6:10 p.m.

Deficiency cited, recertification survey : N 145 483.358(f) ORDERS FOR USE OF RESTRAINT OR SECLUSION

Based on record review and interview, the facility failed to ensure a post-restraint assessment was conducted within 1 hour of the initiation of the ESI. This affected 1 of 6 sample children (Child 1). Findings include: Record review on 8/11/2025 revealed Child 1's Behavior Management Report (BMR) dated 6/8/2026 indicated staff restrained Child 1 from 1:23 p.m. to 1:25 p.m. Further review failed to reveal an authorization signature and indicated staff members had not notified health services of the restraint until 6:10 p.m. Record review on 8/11/2026 revealed the Four Oaks 2026 Behavior Management Policy, revised 5/1/2026, indicated the licensed authorizer conducted the physical assessment within 1 hour post-restraint. When interviewed on 8/11/2026 at 2:25 p.m., Nurse A confirmed staff members failed to seek authorization when they restrained Child 1 until 6:10 p.m., and the post-restraint assessment was not conducted until 6:15 p.m.

Deficiency cited, recertification survey : N 222 483.376(f) EDUCATION AND TRAINING

Based on record review and interviews, the facility failed to ensure staff members demonstrated competency in restraint on a semiannual basis. This affected 2 of 17 staff members (Staff F and Staff G) involved in emergency safety interventions (ESI) reviewed. Findings follow: 1. Record review on 8/10/2026 revealed Child 2's Behavior Management Report (BMR) dated 7/14/2026 documented Staff F participated in the seclusion of Child 2 from 10:47 a.m. to 11:07 a.m. Record Review on 8/11/2026 revealed Four Oaks RELIAS staff training transcripts indicated the facility certified Staff F in the Mandt System (crisis intervention training) on 7/9/2025. Documentation of a skills refresher at the required six-month interval could not be provided. 2. Record review on 8/10/2026 revealed Child 3's Behavior Management Report (BMR) dated 7/14/2026 documented Staff G participated in the seclusion of Child 3 from 1:21 a.m. to 1:32 a.m. Record Review on 8/11/2026 revealed Four Oaks RELIAS staff training transcripts indicated the facility certified Staff G in the Mandt System on 1/26/2025. Documentation of a skills refresher at the required six-month interval could not be provided. Record review on 8/11/2026 revealed the facility's Behavior Management Policy, updated 5/1/2026, indicated the facility provided staff members initial Mandt training within the first 60 days of employment, and annual recertification of the Behavior Management program Training. Additionally, staff demonstrated physical ...

Deficiency cited, complaint survey : A 170 41.10 Active Treatment

Based on record review and interview, the facility failed to provide support as directed by an individual plan of care. This affected 1 of 1 children's (Child 1) files reviewed in Complaints #130016-C and #132020-C. Findings follow: 1. Record review on 5/4/26 revealed the Child 1's Behavior Management Report #14642, dated 4/12/2026 at 4:20 p.m., indicated Child 1 attempted to strangle himself with a computer cord. Record review on 5/4/2026 revealed Child 1's individual plan of care, updated on 4/6/2026, documented Child 1's history of self-abusive behavior. Child 1's plan directed staff to place Child 1 on a Level of Protection (LOP) when Child 1 displayed self-abusive behavior or suicidal comments and actions. The facility's Level of Protection, dated 2/5/2026, documented any program staff or team member could start a LOP when a child demonstrated signs of self-harm or suicide. The policy directed facility staff used a screening tool to determine the level of risk of self-harm. Only a licensed clinician had the authority to end a LOP. Additional record review failed to indicate staff initiated a LOP. When interviewed on 5/6/2026 Child 1's therapist confirmed staff should have implemented a Level of Protection when Child 1 wrapped computer cords around his neck. 2.Record review on 5/7/2025, revealed Child 1's Level of Protection/Columbia-Suicide Severity Rating Scale form, dated from 3/17/2026 to 3/30/2026 indicated staff provided Child 1 heightened level of supervision ...

Deficiency cited, complaint survey : N 149 483.358(h) ORDERS FOR USE OF RESTRAINT OR SECLUSION

Based on record review and interview, the facility failed to document restraints before the end of the shift. This affected 1 of 1 children (Child 1) in Complaints #130016-C and #132020-C. Findings include: Record review on 5/4/2026 revealed the following: Child 1's Behavior Management Report #14635, dated 4/12/2026, documented Child 1 attempted to intervene in a restraint involving another child in the unit. Staff A placed hands on Child 1 and directed Child 1 to the seclusion room at 12:08 p.m. Child 1's Behavior Management Report #14642, dated 4/12/2026, documented Child 1 attempted to strangle himself using a computer cord. Staff A escorted Child 1 to the seclusion room at 4:20 p.m. Child 1's Behavior Management Report #15017, dated 4/27/2026, documented Child 1 attempted to hit Staff A. Staff A placed Child 1 into the seclusion room at 9:10 p.m. Record review on 5/5/2026 revealed facility surveillance video dated 4/12/2026 at 12:08 p.m., showed Staff A physically redirected another child. Child 1 chased after Staff A. Both disappeared off camera. When they moved back into camera view, Staff A stood behind Child 1. Staff A grasped Child 1's right wrist with his right hand and wrapped his left hand over Child 1's forearm just inside the elbow. Staff A secured Child 1's forearm against Child 1's waist as he was escorted to the seclusion room. The facility surveillance video dated 4/12/2026 at 4:20 p.m., showed Child 1 placed a computer cord around his neck in Pod 2. Staff ...

Deficiency cited, complaint survey : N 189 483.370(b) POST INTERVENTION DEBRIEFINGS

Based on record review and interview, the facility failed to include supervisory and administrative personal in a debriefing session. This occurred in 1 of 3 interventions reviewed for Child 1 in Complaints #130016-C and #132020-C. Findings include: Record review on 5/4/2026 revealed Child 1's Behavior Management Report #15017 dated 4/27/2026, documented Staff A placed Child 1 in seclusion from 9:10 p.m. to 9:20 p.m. The staff debriefing took place at 10:00 p.m. The staff debriefing included all 3 staff members involved in the emergency safety intervention. Additional record review failed to reveal a supervisor or administrator participated in the debriefing. Record review revealed the facility's Behavior Management Policy, dated 11/20/2025, indicated supervisory personnel participated in the debriefing. When interviewed on 5/7/2026 at 10:50 a.m., the Quality Compliance Manager and the Vice President of Residential Services confirmed a supervisor or administrator should have been included on Behavior Management Report #15017.

Deficiency cited, complaint survey : N 214 483.376(a) EDUCATION AND TRAINING

Based on record review and interviews, the facility failed to ensure staff recognized when a restraint occurred prior to a seclusion. This affected 3 of 3 staff (Staff A, Staff B and Staff C) in Complaints #132016-C and #132020-C. Findings include: Record review on 5/5/2026 revealed facility surveillance video dated 4/12/2026 at 12:08 p.m., showed Staff A physically redirected another child. Child 1 chased after Staff A. Both disappeared off camera, when they moved back into camera view, Staff A stood behind Child 1. Staff A grasped Child 1's right wrist with his right hand and wrapped his left hand over Child 1's forearm just inside the elbow. Staff A secured Child 1's forearm against Child 1's waist as he was escorted to the seclusion room. The facility surveillance video dated 4/12/2026 at 4:20 p.m., showed Child 1 placed a computer cord around his neck in Pod 2. Staff A watched Child 1 through the doorway. Child 1 attempted to grab additional computer cords, Staff A placed his right arm under Child 1's arm and his left arm high across Child 1's chest and abruptly pulled Child 1 off balance. This maneuver caused Child 1 to fall to the floor, where Staff A removed the computer cord from Child 1's neck. Staff A grabbed Child 1's right wrist, pulled him to his feet, grasped Child 1's left wrist with his left hand, and wrapped his right hand over Child 1's forearm just inside the elbow to keep Child 1's forearm secured against his waist as he escorted him to seclusion. The ...

Deficiency cited, incident survey : N 149 483.358(h) ORDERS FOR USE OF RESTRAINT OR SECLUSION

Based on interview and record review, the facility failed to document a restraint before the end of the shift in which it occurred. This affected 1 of 1 children (Child 1) in Complaint #131792-C. Findings include: Record review on 3/31/2026 revealed Child 1's Behavior Management Report, dated 2/17/2026, documented Staff A escorted Child 1 from the unit to seclusion using a MANDT 2.0-approved escort technique at 7:41 p.m. after Child 1 pushed past staff in an effort to physically go after a peer. Record review on 4/1/2026 revealed surveillance video from 2/17/2026, showed Staff A initially placed Child 1 into a MANDT-approved escort. Staff A lifted Child 1's feet briefly from the floor en route to the seclusion room, which restricted Child 1's movement. Continued record review revealed the facility's Behavior Management Policy dated 11/20/2025, indicated the use of physical restraint would be documented and placed in the individual's record. Continued record review revealed Staff A had not completed a corresponding Behavior Management Report documenting a restraint. When interviewed on 4/9/2026 at 11:25 am, the Quality Compliance Manager and the Vice President of Residential Services confirmed Staff A should have documented a brief restraint on a Behavior Management Report.

Deficiency cited, complaint survey : A 170 41.10 Active Treatment

Based on observation, interview, and record review, the facility failed to provide supports identified in the individual plan of care. This affected 1 of 3 children (Child 1) in investigation #130758-C and #131054-C. Findings include: Observations on 12/22/2025 at 3:15 p.m. revealed Child 1 sat at a table completing school work without a staff member within three arm's length proximity. All staff members in the unit were gathered at the staff desk approximately 15 feet from Child 1. At 4:10 p.m., Child 1 walked to the kitchen unaccompanied by a staff member. Record Review on 12/22/25 revealed Child 1's incident forms, dated from 10/7/25 to 12/22/25, documented 39 actual or attempted elopements. The following reports documented facility failure to provide 1:1 supervision as directed: a. On 10/24/2025 at 5:00 p.m., a staff member took Child 1 and another child to the adjacent administrative building. Child 1 eloped and returned to the unit on 10/25/25 at 1:00 a.m. b. On 10/29/2025 at 5:00 a.m., Child 1 eloped. A single staff was assigned the overnight shift and was not able to provide Child 1 1:1 supervision. Child 1 returned to the unit at approximately 3:00 p.m. c. On 11/2/2025 at 9:00 a.m., Child 1 eloped when a staff member entered the restroom. The police returned Child 1 to the unit at approximately 1:00 p.m. d. On 11/4/2025 at 4:50 p.m., Child 1 eloped. It was documented 1 staff member was alone in the Cambridge Unit and was dealing with another peer's behavior issues. ...

Deficiency cited, complaint survey : N 188 483.370(a) POST INTERVENTION DEBRIEFINGS

Based on record review and interview, the facility failed to conduct face-to-face post intervention briefings within 24 hours after an emergency safety intervention. This affected 1 of 3 children (Child 2) in Complaint #131028-C. Findings include: Record review on 12/18/2025 revealed Child 2's Behavior Management Report, dated 10/17/2025, documented Staff A restrained Child 2 in a standing 1-arm Mandt restraint from 9:00 pm to 9:10 pm. after Child 2 struck them in the face with a closed fist. No post-emergency safety intervention debriefing with Child 2 was documented. Continued record review revealed the facility's Behavior Management Policy dated 3/28/2024, indicated debriefings would occur. When interviewed on 12/29/2025 at 3:15 pm, the Compliance Manager confirmed these findings.

Deficiency cited, complaint survey : N 189 483.370(b) POST INTERVENTION DEBRIEFINGS

Based on record review and interview, the facility failed to have an appropriate supervisory and administrative staff along with all staff involved in the emergency safety intervention included in a debriefing session. This affected 1 of 3 children (Child 2) in Complaint #131028-C. Findings include: Record review on 12/18/2025 revealed Child 2's Behavior Management Report, dated 10/17/2025, documented Staff A restrained Child 2 in a standing 1-arm Mandt restraint from 9:00 pm to 9:10 pm. after Child 2 struck them in the face with a closed fist. The report indicated a staff debriefing was conducted; however, neither the date nor the time was documented. The debriefing did not include a supervisor or administrator. Additionally, there is no documentation available to confirm staff members were excused from attending the debriefing. Continued record review revealed the facility's Behavior Management Policy dated 3/28/2024, indicated debriefings would occur. When interviewed on 12/29/2025 at 3:15 pm the Compliance Manager confirmed these findings.

Deficiency cited, recertification survey : A 170 41.10 Active Treatment

Based on interview and record review the facility failed to implement the individual plan of care within days of admission for 1 of 3 children (Child 1). Findings includes: Record review on 10/14/2025 revealed Child 1's individual plan of care indicated the facility admitted Child 1 on 7/18/2025. The facility implemented Child 1's plan of care on 8/5/2025, 18 days past the date of admission. When interviewed on 10/14/2025 at 12:25 pm the Care Manager confirmed these findings.

Deficiency cited, recertification survey : A 215 41.11(3)a, b Individual Plan of Care

Based on interview and record review the facility failed to update the individual plan of care within 30 days for 1 of 3 children (Child 1). Findings include: Record review on 10/14/2025 revealed Child 1's indivdual plan of care indicated the facility completed the 2nd update of Child 1's plan of care on 10/12/2025, 38 days after the previous update on 9/4/2025. When interviewed on 10/14/2025 at 12:25 pm the Care Manager confirmed these findings.

Deficiency cited, recertification survey : A 215 41.11(3)a, b Individual Plan of Care

Based on record review and interview, the facility failed to recommend changes to client plans when they eloped. This affected 6 of 9 children reviewed (Child 1, Child 2, Child 3, Child 4, Child 5, and Child 7). Findings follow: Record review conducted between 10/30/2025 and 11/13/2025 documented 81 elopements in September and October 2025. Examples included but were not limited to the following: 1.Child 1's file contained 14 documented incidents of elopement. Child 1's plan of care contained no recommended changes to reduce this behavior. 2.Child 2's file contained 9 documented incidents of elopement. Child 2's plan of care contained no recommended changes to reduce this behavior. 3. Child 3's file contained 14 documented incidents of elopement. Child 3's plan of care contained no recommended changes to reduce this behavior. 4. Child 4's file contained 15 documented incidents of elopement. Child 4's plan of care contained no recommended changes to reduce this behavior. 5. Child 5's file contained 6 documented incidents of elopement. Child 5's plan of care contained no recommended changes to reduce this behavior. 6. Child 7's file contained 5 documented incidents of elopement. Child 7's plan of care contained no recommended changes to reduce this behavior. Additional record review revealed the facility's Run Protocol dated 6/1/2025, indicated the youth's potential for runaway would be assessed at admission, during team and progress management meetings and as frequently as ...

Deficiency cited, complaint survey : N 126 483.356 (a)(1) PROTECTION OF RESIDENTS

This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to keep Child 1 safe from restraint being used as a means of coercion, discipline, convenience, or retaliation. This affected 1 of 1 children (Child 1) in investigation #130869-C. Findings include: Document review on 12/2/2025 of an Iowa Department of Health and Human Services Child Abuse Assessment Summary completed in 11/19/2025, revealed Staff A placed Child 1 in a restraint of 10/20/2025. When interviewed on 12/2/2025 at 9:55 am the Compliance Manager confirmed these findings stating video evidence revealed Staff A had not used Four Oaks approved restraint techniques (Mandt System). Staff A had used unapproved restraint techniques and was no longer employed by the facility. She further explained the facility was not aware of the incidnet at the time it occurred. Video review on 12/3/2025 revealed on 10/20/2025 Staff A engaged in brief non-Mandt restraint of Child 1 at 1:20:30 pm. Child 1 sat on the floor and attempted to stick an item in an electrical outlet located to the immediate right of the unit seclusion room. Staff A grasped Child 1's left hand until Child 1 dropped the item. After dropping the item, Child 1 struck Staff A on the left shin. Staff A reacted to this and restrained Child 1 on the floor for approximately 6 seconds. Child 1 was not in a prone position, but was positioned on their left side as Staff A reached over their body to grasp both wrists. This ...

Deficiency cited, recertification survey : A 170 41.10 Active Treatment

Based on interview and record review the facility failed to implement the individual plan of care within 14 days of admission for 1 of 3 children (Child 1). Findings include: Record review on 8/19/2025 revealed Child 1's individual plan of care indicated the facility admitted Child 1 on 2/20/2025. The facility implemented Child 1's plan of care on 3/9/2025, 17 days past the date of admission. When interviewed on 8/20/2025 at 2:40 pm the Compliance Manager confirmed these findings.

Deficiency cited, recertification survey : N 178 483.366 NOTIFICATION OF PARENT(S) OR LEGAL GUARDIAN

Based on interviews and record review the facility failed to ensure parents or guardians were notified as soon as possible following the initiation of each emergency safety intervention (ESI). This affected in 3 of 5 sample children (Child 1, Child 2 and Child 3). Findings follow: Interview with the Quality Department Manager and Program Director along with the review of the Behavior Management reports and staff training records on 6/10/2025 and 6/11/2025 revealed the following: 1. Child 1 was restrained on 6/8/2025 from 7:44 am to 8:05 am. Review of the Behavior Management report indicated the child's parent/guardian was contacted via email on 6/10/2025 at 3:11 pm. 2. Child 2 was restrained on 4/11/2025 from 5:40 pm to 5:49 pm. Review of the Behavior Management report indicated the child's parent/guardian was contacted, via a weekly summary, on 4/14/2025 at 2:28 pm. 3. Child 3 was restrained on 1/20/2025 from 10:51 am to 10:57 am. Review of the Behavior Management report indicated the child's parent/guardian was contacted via a staffing meeting on 2/3/2025 at 12:00 pm. Additional record review revealed the facility's Behavioral Management Policy, dated 3/28/24, directed the facility provided appropriate notifications regarding ESI within 24 hours of the intervention. When interviewed on 6/11/2025 at 9:58 am, the Quality Department Manager confirmed these findings.

Deficiency cited, recertification survey : N 221 483.376(e) EDUCATION AND TRAINING

Based on interview and record review the facility failed to ensure facility staff were certified in the safe use of restraint techniques under Therapeutic Crisis Intervention (TCI) or MANDT Systems (MANDT) prior to participating in emergency safety interventions. This affected 1 of 18 staff reviewed (Staff A). Finding follows: Interview with the Quality Department Manager and Program Director along with the review of the Behavior Management reports and staff training records on 6/10/2025 and 6/11/2025 revealed the following: Record review on 6/10/2025 revealed Child 4's restraint documentation dated 4/7/2025, indicated Staff A participated in the physical restraint. Staff A's training records documented she was last certified in TCI on 6/12/2017. Staff A completed MANDT certification training on 4/8/2025. Training records failed to reveal documentation of current certification in TCI or MANDT when she participated in Child 4's restraint on 4/7/2025. The facility's Behavior Management policy dated 3/28/2024 directed staff participated in behavior management program training within 60 days of hire and annual recertification. The facility policy further directed staff completed bi-annual competency practice and testing. When interviewed on 6/11/2025 at 1:20 pm, the Quality Department Manager confirmed these findings.

Deficiency cited, recertification survey : N 222 483.376(f) EDUCATION AND TRAINING

Based on interview and record review the facility failed to ensure staff demonstrated competencies in the safe use of restraint techniques under Therapeutic Crisis Intervention (TCI) or MANDT Systems (MANDT) on a semiannual basis for 2 of 18 staff (Staff B, Staff C) and failed to ensure staff demonstrated competencies in the use of cardiopulmonary resuscitation (CPR) on an annual basis for 2 of 18 staff reviewed who participated in emergency safety interventions (Staff D, Staff E). Findings include: Interview with the Quality Department Manager and Program Director along with the review of the Behavior Management reports and staff training records on 6/10/2025 and 6/11/2025 revealed the following: 1. Child 5's physical restraint documentation dated 5/4/2025, indicated Staff B participated in the physical restraint. Staff B's training records documented she completed TCI certification training on 8/26/2024. Additional TCI training documents could not be provided. Semiannual TCI competency training could not be located. 2. Child 5's physical restraint documentation dated 2/4/2025, indicated Staff C participated in the physical restraint. Staff C's training records indicated she completed TCI certification training on 6/12/2024. No further TCI training documents could be provided. Semiannual TCI competency training could not be located. The facility's Behavior Management policy dated 3/28/2024 directed staff participated in behavior management program training within 60 days of ...

Deficiency cited, complaint survey : N 140 483.358(a) ORDERS FOR USE OF RESTRAINT OR SECLUSION

Based on interviews and record review the facility failed to secure an order for restraint and/or seclusion by a physician or other license practitioner permitted by the State and the facility to use emergency safety interventions for 3 of 5 interventions reviewed (Child A). Findings include: Record review on 6/2/2025 revealed the following: 1.Behavior management report #6502 revealed Child A's seclusion documentation, dated 4/7/2025 from 3:41 pm to 3:51 pm documented the Certified Medical Assistant (CMA) provided a verbal order for seclusion. Approval from an authorized licensed professional could not be located. 2.Behavior management report #6768 revealed Child A's restraint documentation, dated 4/15/2025 from 3:20 pm to 3:21 pm documented the Certified Medical Assistant (CMA) provided a verbal order for seclusion. Approval from an authorized licensed professional could not be located. 3.Behavior management report #6756 revealed Child A's seclusion documentation, dated 4/15/2025 from 3:21 pm to 3:41 pm documented the Certified Medical Assistant (CMA) provided a verbal order for seclusion. Approval from an authorized licensed professional could not be located. When interviewed on 6/2/2025 at 1:25 pm the Quality Compliance Manager explained facility practice allowed the CMA to provide the verbal order and then a Registered Nurse (RN) co-signed and approved the written order within 24 hours. The Quality Compliance Manager acknowledged no documentation of the RN co-signature ...

Deficiency cited, complaint survey : N 145 483.358(f) ORDERS FOR USE OF RESTRAINT OR SECLUSION

Based on interviews and record review the facility failed to have a physician or other licensed practitioner assess the physical and psychological wellbeing of the resident within 1 hour of the initiation of the emergency safety interventions for 3 of 5 reviewed (Child A). Findings include: Record review on 6/3/2025 revealed the following: 1.Behavior management report #6502 revealed Child A's seclusion documentation, dated 4/7/2025 from 3:41 pm to 3:51 pm indicated the on-duty Certified Medical Assistant (CMA) completed the assessment at 4:00 pm. A physical and psychological assessment by a licensed practitioner permitted by the state could not be located. 2.Behavior management report #6768 revealed Child A's restraint documentation, dated 4/15/2025 from 3:20 pm to 3:21 pm indicated that the on-duty Certified Medical Assistant (CMA) completed the assessment on 4/15/2025 at 3:50 pm. A physical and psychological assessment by a licensed practitioner permitted by the state could not be located. 3.Behavior management report #6756 revealed Child A's seclusion documentation, dated 4/15/2025 from 3:21 pm to 3:41 pm indicated that the Certified Medical Assistant (CMA) that the on-duty Certified Medical Assistant (CMA) completed the assessment on 4/15/2025 at 3:50 pm. A physical and psychological assessment by a licensed practitioner permitted by the state could not be located. Additional record review revealed the facility's Behavioral Management Policy, dated 9/2022, directed this ...

Deficiency cited, complaint survey : N 189 483.370(b) POST INTERVENTION DEBRIEFINGS

Based on interviews and record review the facility failed to have an appropriate supervisory and administrative staff along with all staff involved in the safety intervention included in a debriefing session for 1 of 5 interventions reviewed (Child A). Findings include: Record review on 6/2/2025 revealed the following: Record review of behavior management report #6756 revealed Child A's seclusion documentation, dated 4/15/2025 from 3:21 pm to 3:41 pm, noted a Staff debriefing took place at 4:30 pm. One of the three staff involved in the safety intervention completed the debriefing. The debriefing failed to include a supervisor or administrator. Documentation of staff being excused from the debriefing could not be produced. On 6/2/2025 at 2:20 pm the Quality Compliance Manager confirmed these findings.

Deficiency cited, complaint survey : N 202 483.372(c) MEDICAL TREATMENT FOR INJURIES

Based on interviews and record review the facility failed to provide documentation that the staff involved in a safety intervention that resulted in an injury to a resident or staff, met with a supervisory staff to evaluate the circumstances that caused the injury for 1 of 5 interventions reviewed (Child A). Findings include: Record review on 6/3/2025 of behavior management reports #6768 and #6756 revealed Child A was placed in a restraint on 4/15/2025 from 3:20 pm to 3:21 pm, directly following, the child was placed in seclusion from 3:21 pm to 3:51 pm. Seclusion intervention documentation noted a minor rug burn to the child's left check was sustained while trying to aggressively bite staff. Staff debriefing section listed as "client injury:circumstances and evaluation" had "none" listed in the comments. Discussion of the safety intervention and evaluation of the circumstances of the injury between the involved staff and supervisory personnel could not be located. When interviewed on 6/3/2025 at 1:42 pm the Quality Compliance Manager (QCM) confirmed Child A was injured during the restraint. QCM explained facility nursing staff took photos of Child A's injury. The QCM acknowledged a discussion between involved staff and supervisory staff should have occurred.

Deficiency cited, complaint survey : N 222 483.376(f) EDUCATION AND TRAINING

Based on interviews and record review the facility failed to ensure that staff demonstrated competencies in the safe use of restraint (MANDT Systems) on a semiannual basis for 1 of 6 staff (Staff 1) and the use of cardiopulmonary resuscitation (CPR) on an annual basis for 1 of 6 staff (Staff 2) reviewed who participated in emergency safety interventions. Findings include: Record review on 6/3/202 revealed the following; 1.Staff 1's training records indicated Staff 1 completed initial MANDT certification on 8/8/2024. Review of behavior management reports specify Staff 1 participated in an emergency safety intervention of Child B on 3/21/2025. Staff 1 should have received competency training in February 2025. No documentation of semiannual MANDT competency training could be located. 2.Staff 2's training records indicated Staff 2 completed CPR certification on 11/2/2023. Review of behavior management reports specify Staff 2 participated in an emergency safety intervention of Child B on 4/5/2025. At the time of the 4/5/2025 intervention 15 months had passed since his CPR certification. No documentation of annual competency could be located. 3.Staff 2's training records indicated Staff 2 CPR certification on 11/2/2023. Review of behavior management reports specify Staff 2 participated in an emergency safety intervention of Child A on 4/7/2025. At the time of the 4/7/2025 intervention 15 months had passed since his CPR certification. No documentation of annual competency could be ...

Deficiency cited, recertification survey : A 170 41.10 Active Treatment

Based on interview and record review the facility failed to develop the individual plan of care for 1 of 3 residents (Child 1) within 14 days of admission. Findings include: 1. Review of one child's case file (Child A) revealed an admission date of 7/11/2024. The individual plan of care was not completed until 7/31/2024. The development of the plan was completed at 20 days rather than within the specified 14 days of admission. 2. On 11/18/2024 at 3:10 pm the Utilization Manager confirmed these findings.

Deficiency cited, recertification survey : A 170 41.10 Active Treatment

Based on interview and record review the facility failed to develop the individual plan of care for 1 of 3 residents (Child 1) within 14 days of admission. Findings include: 1. Review of one child's case file (Child A) revealed an admission date of 7/11/2024. The individual plan of care was not completed until 7/31/2024. The development of the plan was completed at 20 days rather than within the specified 14 days of admission. 2. On 11/18/2024 at 3:10 pm the Utilization Manager confirmed these findings.

Deficiency cited, recertification survey : A 170 41.10 Active Treatment

Based on interview and record review the facility failed to implement the individual plan of care within 14 days of admission for 2 of 3 children (Child 1, Child 2). Findings include: 1.Review of Child 1's resident case file revealed an admission date of 2/16/2024. The initial individual plan of care was dated 3/4/2024 which is 17 days past the date of admission. 2.Review of Child 2's resident case file revealed an admission date of 5/28/2024. The initial individual plan of care was dated 6/14/2024 which is 18 days past the date of admission. When interviewed on 9/14/24 at 22:45 p.m. the Senior Compliance Manager confirmed care plans were not implemented within 14 days of admission.

Deficiency cited, recertification survey : N 137 483.356(d) PROTECTION OF RESIDENTS

Based on interview and record review the facility failed to ensure the policy on restraint and seclusion included the phone number and mailing address for the State Protection and Advocacy organization. Findings include: Review of the facility's Behavior Management Policy and Procedures revealed the phone number and mailing address for Disability Rights Iowa (the the state's Protection and Advocacy organization) was not included in the policy. On 4/30/2024 at 3:48 pm, the Utilization Manager confirmed these findings.

Deficiency cited, recertification survey : N 156 483.358(j) ORDERS FOR USE OF RESTRAINT OR SECLUSION

Based on interview and record review the facility failed to ensure the licensed practitioner signed the restraint or seclusion order possible regarding 6 of 9 Behavior Management Restraint Reports reviewed involving Child #1, Child #2, Child #3, Child #4. Findings include: 1. Review of the Behavior Management Reports on 4/30/2024 and 5/1/2024 revealed: a. Child #1 was restrained on 3/1/2024 from 6:50 am to 6:57am. The order to restrain was secured however the licensed practitioner failed to sign the order. b. Child #2 was restrained on 9/2/2023 from 2:49 pm to 2:53 pm and on 12/16/2023 from 11:24 am to 11:29 am. Both orders to restrain were secured however the licensed practitioner failed to sign either order. c. Child #3 was restrained on 2/7/2024 from 6:45 pm to 6:50 pm. The order to restrain was secured however the licensed practitioner failed to sign the order. d. Child #4 was restrained on 2/11/2024 from 8:56 pm to 9:07 pm and on 2/15/2024 from 8:09 am to 8:25 am. Both orders to restrain were secured however the licensed practitioner failed to sign either order. 2. On 5/1/2024 at 11:50 am, the Program Director confirmed these findings.

Deficiency cited, recertification survey : N 202 483.372(c) MEDICAL TREATMENT FOR INJURIES

Based on interview and record review the facility failed to ensure staff met with supervisory staff to evaluate the circumstances that caused injury regarding 2 of 2 Behavior Management Restraints reviewed where injuries occured. Findings include: 1. Review of the Behavior Management Reports on 4/30/2024 and 5/1/2024 revealed: a. Child #4 was restrained on 2/11/2024 from 8:56 pm to 9:07 pm. During the restraint the child was unharmed but staff sustained an injury to their wrist accordng to a comment on the report. The restraint report had a Staff Injury; Circumstances and Evaluation section with only N/A listed. No discussion, evaluation or plan to prevent further injuries between staff and supervisory staff was documented. b. Child #4 was restrained on 2/15/2024 from 8:09 am to 8:25 am. During the restraint on 2/15/2024 the child was unharmed but documentation in the report revealed the child attacked the staff biting their arm and clawing at their hand drawing blood. The restraint report had a Staff Injury; Circumstances and Evaluation section with only N/A listed. No discussion, evaluation or plan to prevent further injuries between staff and supervisory staff was documented. 2. On 5/1/2024 at 12:15 pm, the Program Director confirmed these findings.