Every finding on record at Iowa Veterans Home

Based on observation, interview, clinical record review, and facility policy review, the facility failed to ensure safe wheelchair transportation for 2 of 3 residents reviewed (Resident #12 and Resident #13). The facility staff failed to put on foot pedals when pushing residents in their wheelchair. The facility reported a census of 353 residents.Findings include: 1. Review of the Minimum Data Set (MDS) assessment, dated 6/24/25, identified Resident #12 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated severe cognitive impairment. The list of diagnoses included non-Alzheimer's dementia, cancer, and diabetes mellitus. The MDS indicated Resident #12 depended on staff for all transfers, they couldn't walk and used a wheelchair for mobility. The Care Plan Focus initiated 9/10/24, reflected Resident #12 needed help with their day-to-day tasks, as he could fall, he needed assistance with maintaining his strength and ambulation. He required a secured environment for his safety. The Interventions included:a. Locomotion off the unit: one staff assist with a manual wheelchair.b. Locomotion on the unit: Resident #12 could propel himself at times, otherwise staff to assist.c. Wheelchair used for mobility. During an observation on 9/8/25 at 11:31 AM, Resident #12 sat at a dining room table in a high back, tilting wheelchair, positioned upright/sitting. A staff member approached him, backed him away from the table, turned the wheelchair around, and began to transport him out of the dining room without foot pedals attached to the wheelchair. Approximately 2 feet from the table, staff pushed Resident #12 in wheelchair over a threshold that transitioned from vinyl flooring to carpeted flooring, Resident #12 abruptly put both feet down on the floor which stopped forward motion of the wheelchair. Following this, the staff member left to retrieve foot pedals, applied them to the wheelchair, and continued transporting Resident #12. 2. Review of the MDS assessment, dated 8/12/25, revealed Resident #13 had a BIMS score of 7 out of 15, which indicated severe cognitive impairment. The list of diagnoses included non-Alzheimer's dementia, hemiparesis/hemiplegia (one-sided weakness or loss of sensation), and traumatic brain injury. The MDS indicated Resident #13 required partial to moderate staff assistance for all transfers, they couldn't walk and used a wheelchair for mobility.The Care Plan Focus, initiated 10/16/23, indicated Resident #13 needed assistance with their daily routine. The Interventions included:a. Locomotion off the unit: one staff assist with a manual wheelchair.b. Locomotion on the unit: independent mobility with a manual wheelchair.During an observation on 9/9/25 at 11:22 AM, Resident #13 sat in a wheelchair at the long edge of the dining room table, with foot pedals attached to the wheelchair, but not in use, folded away on the sides of the wheelchair. Resident #13 attempted to self-propel their wheelchair towards the head of table. Staff B, Registered Nurse (RN), approached and pushed Resident #13's wheelchair from the long side of table around to the short side of table without placing feet on the foot pedals. Resident #13's feet skimmed over the top of the floor during transport. During an interview on 9/9/25 at 3:00 PM, Staff B, Registered Nurse (RN), stated staff must put foot pedals on a wheelchair before they transport a resident for safety and to prevent injury. During an interview on 9/9/25 at 3:45 PM, the Nursing Services Director revealed they expected the staff to apply foot pedals to wheelchairs prior to transporting residents, to keep their feet off the floor. The facility provided an undated document titled, Standards of Care instructed under the section Safety Strategies for the facility to have wheelchair pedals used with all transport.

Based on clinical record review, staff interview and facility policy review, the facility failed to provide a documented rationale on why a resident's as needed (PRN) psychotropic medication needed continued longer than 14 days for 1 of 5 residents reviewed (Resident #87). In addition, the facility failed to perform a periodic re-evaluation of the medication regimen to determine the continued need for the medication. Findings include: Resident #87's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS included diagnoses of non-Alzheimer's dementia, Parkinson's disease, depression, bipolar disorder (mood imbalance) and impulse disorder (the failure to resist a temptation, urge, or an impulse. The MDS documented Resident #87 received antipsychotic, antianxiety, and antidepressant medications during the 7 days of the assessment reference period. The Care Plan initiated 7/19/24 indicated Resident #87 had a risk for adverse effects due to the use of psychotropic medications to aid with the treatment of his bipolar disorder and depression. The Interventions directed gradual dose reduction (GDR) review completed by the pharmacy/physician per the facility's protocol. The Clinical Physician Orders reviewed on 4/30/24 listed the following lorazepam 2 milligrams (mg)/milliliters (ml) orders: a. Give 0.25 ml by mouth every 4 hours as needed for anxiety or agitation. End date listed as infinite. i. Start date 1/3/24, Discontinued on 1/27/24. ii. Start date 1/26/24, Discontinued 4/16/24. b. Start date 4/16/24: Give 0.5 ml by mouth every 4 hours as needed for anxiety/restlessness. End date listed as infinite. The Health Status Note dated 1/3/24 at 9:26 pm documented the facility staff received a telephone order for lorazepam, 0.25 mls every 4 hours as needed for anxiety/agitation. The note lacked a duration for the order. On 4/30/24 at 4:23 pm, Staff A, Registered Nurse(RN) Nurse Clinician, explained when Resident #87 started the lorazepam order, he received hospice services. She stated Resident #87 received hospice services since November 2023. On 4/30/24 at 4:38 pm, Staff B, RN Nursing Service Director, stated she spoke to the Pharmacy Director, who told her the original medication order should be for 14 days. However, due to Resident #87 receiving hospice services, any renewals after that are for an indefinite time period. On 5/1/24 at 11:30 am, Staff B stated when the pharmacy receives a PRN order for a psychotropic medication without an end date, the pharmacy calls the prescribing provider to verify if the medication is to have an end date prior to processing the order. The facility couldn't provide documentation for Resident #87 from the prescribing provider with a documented rationale for the extension of the prescription beyond 14 days. In addition, the facility couldn't provide documentation why Resident #87 required the continued use of lorazepam or an evaluation for continued use after the initial prescription. The facility policy Antipsychotic and Psychoactive Drug Protocol, revised 1/31/23, directed the following: a. Give psychotropic medication only when necessary to treat a specific diagnosed and documented condition; b. Understanding the timeframe for PRN psychotropic medications which are NOT antipsychotics to 14 days, unless the prescriber deemed a longer timeframe is appropriate.

Based on clinical record review, observation, resident interview, family interview, staff interview, and facility to ensure each resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility failed to treat each resident with respect and dignity and care for each residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Resident #5 was moved to another unit within the facility away from friends and was instructed he could not leave the new unit without staff supervision. The facility also banned the resident from going to casinos or shopping trips. The resident could not manage his own money and if there were any infractions the resident would be discharged . The resident was fearful of being discharged . After the move to the new unit, Resident #5 was sleeping more and required an antidepressant to help with nicotine withdrawal and depression. The resident was tearful and expressed sadness of not being able to see his friends. Concerns were also identified for Residents #1, #7, #8, #9, #4, #12 as the facility restricted/and removed the rights of the residents to smoke as they have done since admission to the facility. Resident #14 was reprimanded after speaking his thoughts when visitors were in the building. The facility reported a census of 428. Findings include: 1. The annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 identified an original admitted [DATE]. The MDS recorded a Brief Interview for Mental Status (BIMS) score of 15 without signs/symptoms of [MEDICAL CONDITION]. A score of 15 indicated intact cognition. The MDS recorded the resident displayed no behaviors during the 7 day look-back period. The MDS revealed the resident independent with transfer and locomotion on/off the unit. The MDS documented [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] continued to identify a BIMS score of 15 without signs/symptoms of [MEDICAL CONDITION] and no display of behaviors. The resident remained coded as independent for transfers and locomotion on the unit but documented as totally dependent upon 1 person for locomotion off the unit. The care Directives dated 1/13/20 informed staff the resident independent with transfers and locomotion on the unit with a manual wheelchair. Under locomotion off unit, the directives informed staff the resident to be assist of 1 person with manual wheelchair and his boundaries to be the unit. The staff directed to escort the resident for all off unit activities/appointment and were not to leave the resident unattended. The care plan problem area updated 9/27/19 identified the resident enjoyed having a job to earn additional spending money so he could go to the casino and shopping. The care plan directed staff to encourage ongoing involvement in the incentive therapy program. The care plan problem area updated 9/30/19 identified the resident preferred self-directed leisure time and would like to participate in facility sponsored activities of his choice. Activities such as unit meetings, special meals both on and off campus, shopping trips, and casino trips, combined with those activities that he independently planned in between; such as going to the casino on the shuttle and outings with family and be smoke free on those outings. The care plan directed staff to invite the resident to activities which coincided with his activity interests such as: casino trips, fishing, sporting events, meal outings, shopping trips, and tours. The goal evaluation dated 12/31/19 documented the resident goal processing. The resident satisfied with the activities he attended on and off the unit, adjusting to living on a new unit, and cooperative with the restrictions of smoking. The resident said he enjoyed going out for special meals and outing with the facility. The resident tended to spend most of his time in his room but did come out occasionally to participate in unit activities such as pet visits and going out to eat. The care plan problem area created 10/25/19 identified the resident had an addiction to nicotine and wanted to be smoke free. The measurable goal created 10/25/19 and updated 12/27/19 documented the resident would be smoke free and adhere to his smoking cessation plan in the next 90 days with next review date in 78 days on 3/31/20. On 10/25/19 the care plan directed staff to: provide the resident with smoking cessation agents to help his cravings; encourage the resident to attend the smoking cessation group or individual psychotherapy; provide with an escort when leaving grounds for activities/appointments to help monitor purchases; and provide the resident with a total funds restriction to help limit his access to money. The care plan intervention created 10/25/19 and discontinued 12/27/19 documented the resident transferred to a different building to help deter him from smoking or being around the smoke room. The goal evaluation dated 12/27/19 documented the resident had not smoked since transfer to KU5 (Ulery building unit 5) and [MEDICATION NAME] (antidepressant medication) started on 11/8/19 with the resident reporting it helped him with cravings. The Smoking Assessment signed 12/26/18 documented the following: Question (Q) 1 - resident smoked Q2 - resident alert Q3 - resident physically capable of holding a cigarette, matches/lighter, and lighting and extinguishing own cigarette without assistance. Q4 - resident able to extinguish a lit cigarette ash/cigarette which had fallen on his/her person and/or on others Q5 - resident able to call for help if lit cigarette ash/cigarette fell on his/her person or on others Q6 - resident able to move without assistance to designated smoking area Q7 - resident had a past history of poor judgment regarding safety of himself or others Q8 - check box left blank to indicate the resident did not have medical contraindications to smoking Q9 - resident instructed in facility policy regarding safety of himself or others [MEDICATION NAME] - resident signed the Resident Smoking Agreement and Smoker Release of Responsibility Form Q13 - Smoking Status based on Q1 thru [MEDICATION NAME] = Unsupervised smoker. Comments - Resident without smoking incident on facility campus. Smoking incident occurred on 4/6/18 when resident smoked in a public bathroom without injury while on a REC (Recreational) trip for breakfast at a restaurant off facility property. The resident received education from REC staff and set up to no longer have smoking materials for trips but received materials when he returned to facility campus. The resident compliant since last facility incident on 8/30/18 where the resident had a strong odor of smoking, however, no evidence of inappropriate smoking found. The Smoking Assessment signed 2/28/19 documented identical information for questions Q1 thru Q13 as 12/26/18 assessment and the resident remained an Unsupervised smoker. The Comments section recorded security found evidence of smoking at the IT (Incentive Therapy) laundry location; ashes found, broken lit cigarette in trash can, and smell of smoke. Others in room not smokers and denied smoking. The resident denied at first but then said he did break his cigarette in half and threw it away. The resident didn't admit to not smoking, he just stated he didn't understand but would except his punishment anyway. Smoking assessment completed, resident appropriate with restrictions placed until 4/30/19. The Smoking Assessment signed 4/1/19 documented identical information for questions Q1 thru Q13 as 2/28/19 assessment and the resident remained an Unsupervised smoker. The Comments section recorded the resident continued on restriction until 4/13/19 due to resident purchasing cigarettes in the smoke room prior to REC trip. The current restriction of 2 cigarettes given to the resident at a time and the resident to check lighter back into staff upon returning to the floor. The resident's smoking practice remained appropriate upon assessment and reassessment to occur after 4/13/19. On 6/19/19 at 10:15 p.m. the Progress Notes documented the resident instructed on updated designated smoking areas and that oxygen equipment must be stored in appropriate area. The resident verbalized understanding that smoking outside of designated smoking areas would result in immediate removal of smoking privileges until reassess by the care team. The Smoking Assessment signed 6/20/19 documented identical information for questions Q1 thru Q13 as 4/1/19 assessment and the resident remained an Unsupervised smoker. The Comments section recorded the resident assessed, safe smoking practices at that time, and resident aware of new smoking restrictions. The Smoking Assessment signed 6/26/19 (however referred to actual date of 6/25/19) documented identical information for questions Q1 thru [MEDICATION NAME] as 6/20/19 assessment but the resident changed on Q12 to a Supervised smoker. The Comments section recorded the resident assessed, safe smoking practices at that time, and resident aware of new smoking restrictions and consequences of unsafe smoking practices. The incident report categorized as type behavior dated 6/26/19 at 3:05 p.m. documented the resident seen smoking outside of Dack building main entrance according to a phone call received by Staff J, Registered Nurse (RN), from the switchboard operator. Per the operator, 2 phone calls received about Resident #5 smoking inappropriately. Resident #5 on a recreation trip and notified his cigarettes needed removed and he must return to his unit immediately for a follow-up to be done. Staff J documented she completed a smoking assessment, reviewed safety expectations with the resident, and all smoking materials would be removed with smoking restrictions put in place. To prevent re-occurrence, the resident would be on smoking restriction of 1 cigarette at a time with maximum of 6 cigarettes a day, smoking materials to be locked up, resident to obtain smoking material from staff and staff to get materials from the resident when he returned to unit, and recreation would check with resident prior to him leaving on trips that he did not have smoking materials. The plan to be put in place for 6 months. On 6/26/19 at 3:26 p.m. the Progress Note documented a call received regarding the resident being seen by 2 witnesses smoking by [NAME][NAME]prior to REC (Recreation) trip. Call placed to switchboard to verify individuals that reported the incident. Call placed to staff who were on the trip with the resident, incident reported, cigarettes taken from resident's possession on the trip, and smoking materials to be given to licensed staff upon return of the resident. The IRCC (Interdisciplinary Resident Care Conference) team discussed and made plan of action to entail resident receiving a total of 6 cigarettes in a day's time, 1 at a time, lighter to be returned upon return of resident to unit, and restrictions to be put in place for 6 months. On 6/27/19 at 6:38 a.m. the Progress Note documented by Staff O, RN, recorded the smoking changes and incident on hold at that time due to needing to discuss specifics with witnesses; care plan on hold at that time until clarification received. At 1:18 p.m., Staff O documented calls made that morning to witnesses, a driver and security, of resident smoking in un-designated area on 6/27/19 (date likely documented in error as should have been 6/26/19), as well as spoke with Nursing Supervisor and Switchboard Operator whom made calls. All individuals shared the resident smoked and had reports of resident smoking at Chapel entrance. Resident seen at about 12:30 p.m. on 6/27/19 per facility driver. The resident questioned and voiced it was not him and he did not smoke outside of the designated area. The resident able to voice the appropriate places to smoke and the safety expectations for resident smoking; reviewed and signed. The Administrator of Nursing contacted for guidance and confirmation on witnessed activity of inappropriate smoking practice outside of the chapel doors at 12:32 p.m. on 6/27/19, which was not a designated area. Cigarette butt found on the ground underneath the bench outside of the chapel doors. The resident again questioned on activity that occurred with accusations of inappropriate smoking; resident again denied. Encouraged resident he was seen smoking in un-designated area and consequences would be all smoking materials removed from his possession (placed in treatment room), as well as educated resident on new smoking restrictions placed on afternoon of 6/27/19. Staff shadowed the resident down to outdoor designated smoking area and observed he could smoke safel. Staff and administration updated on smoking restrictions, as well as directives updated. Restriction would be in place for the next 6 months (12/27/19). Continue to monitor resident for adherence to smoking expectations contract, his smoking restrictions, and guidelines put in place to assist resident with better smoking practices. The Smoking Assessment signed 6/27/19 documented identical information for questions Q1 thru Q12 as 6/26/19 assessment and the resident remained a Supervised smoker. The Comments section recorded the resident assessed following violation of smoking expectations as he smoked in a non-designated smoking area. Restrictions put into place for 6 months. The resident signed and acknowledged the new smoking expectations. The resident assessed and practiced safe smoking in designated area. The resident aware of the new smoking restrictions and consequences of unsafe smoking practices. The smoking policy form #475-2082, dated as revised 6/19, titled Safety Expectations for Resident Smoking, signed by Resident #5 on 6/27/19 included the following: a. Smoking is not permitted by residents in any facility building, entrance, hallway, restroom, public area, or where oxygen is used or stored, except for the smoking rooms located as follows: Dack main floor, Malloy main floor, Heinz Hall first floor north lounge. All other units have been designated as completely non-smoking. b. Smoking is not permitted within 15 feet of any entryway to any building or within 30 feet of any air intake of any building, with the exception of[NAME]nd Ulery, where there is no smoking outside of the buildings. Smoking is not permitted on the dining patio on the south side of the canteen. c. Any unsafe smoking incidents or violation of safety rules will be reported and evaluated by the unit team and/or the Safety Officer. Incidents or safety violations are subject to action steps that may lead to restrictions in the ability to keep cigarettes and lighters/matches with you up to and/or including discharge to a different facility. As of 6/27/19, the facility smoking policy did not require residents to store smoking materials with the facility. On 6/27/19 at 4:00 p.m., Staff M, Social Worker (SW), documented in the Progress Note he met with Resident #5 with Staff O to discuss the resident's smoking incident the day before where he was observed smoking outside the facility chapel doors while waiting to load the facility bus to go on a recreation fishing trip. In the meeting, Staff M asked the resident if he was aware of the changes in the smoking areas/policy and designated areas to smoke. Resident #5 able to verbalize the changes and identified the areas where smoking allowed. When asked about the incident from the day before, the resident denied smoking in that area. Staff M discussed the reasons for the changes in smoking policy due to the facility's most recent VA survey and to ensure resident safety. Resident #5 continued to deny smoking in the area. Smoking expectations reviewed with the resident and he was informed that they would continue to look into the incident. Following the initial meeting, Staff M and Staff O went to the area outside the facility chapel and able to find a discarded cigarette butt under the bench which matched the brand the resident smoked. It was also noted there were video surveillance camera in the area. Staff M and Staff O met with the Administrator of Nursing to discuss. The video surveillance footage reviewed and able to verify the resident smoked outside of the facility chapel area at approximately 12:32 p.m. the day before (12/26/19). They then met again with the resident to discuss the incident and able to show him a picture of him smoking. They informed Resident #5 that due to smoking in a non-smoking area and continued smoking violations over the past year, he would now be placed on a cigarette restriction of 1 cigarette at a time with a total of 6 cigarettes per day for the next 6 months. They also informed him that all smoking materials would be kept at the nurses station and he would return all smoking materials when he came back to the unit from smoking. Current smoking areas reviewed with the resident and he verbalized the areas back to Staff M and Staff O. Cigarettes and lighter in his possession removed from his room and taken to the unit nurses station. On 7/1/19 at 1:19 p.m. Staff M documented in the Progress Note the resident voiced he felt things going pretty well overall but he remained upset about the new smoking rules at the facility. Staff M noted the resident emotional and tearful when discussing the new regulations/rules. The resident stated since his recent smoking incident he felt like he had been labeled an outlaw and explained he felt staff watched him more because of his smoking. Staff M noted the resident had been compliant with his smoking restriction and generally kept to himself and did spend time off unit. The resident reported his mood as rotten related to the recent smoking changes, he did feel kind of depressed, and the mood assessment completed that day showed a score of 5 which was up from a zero in the previous quarter (zero indicated no signs/symptoms of depression). The resident endorsed a loss of interest/pleasure in doing things, felt down/depressed, trouble staying asleep due to right hip pain, felt tired, and felt bad about himself. Most of the mood triggers due to the smoking issue and change in facility smoking policy. Under Support Networks, Staff M documented the resident generally kept to himself but did socialize with staff on the unit and other residents in the facility smoking lounge. Under Restrictions the note included the resident restricted for 6 months due to repeated issues with smoking and would end on 1/1/20. On 7/1/19 at 9:40 p.m. the Progress Note documented the resident upset when he went to get cigarettes and told he had already had 6 cigarettes. The resident said he didn't believe he smoked 6 cigarettes but told they could only go by the sign out sheet and nothing could be done until 6:00 a.m. the next morning. The entry recorded the resident groaned under his breath and left the unit to go downstairs. On 7/3/19 at 4:19 p.m. the Progress Notes documented a unit staff person thought they seen Resident #5 in his room with 2 packs of cigarettes and reported to Staff M. Staff M met with the resident in his room to discuss the report and noted the resident went on a casino trip that day. The resident denied buying cigarettes at the casino and Staff M asked if he could search the resident's room/locked drawer. Resident #5 consented with no cigarettes found. Staff M further asked if he could look in the resident's bag on the back of his wheelchair then the resident admitted he had bought 2 packs of cigarettes from another resident in the smoke lounge and denied purchasing at the casino. Staff M reminded the resident he remained on a cigarette restriction of 1 cigarette at a time and that ALL smoking materials must be kept at the nurses station. The resident's name placed on the 2 packs removed from his room and placed in the treatment room with a note placed on the 24 hour report to remind staff to search resident's wheelchair bag for cigarettes upon return from smoking lounge. The incident report categorized as type behavior dated 7/7/19 at 10:00 a.m. documented staff found cigarettes and lighter in resident's wheelchair, a full pack of his brand of cigarettes in his possession, and he stated he received them from a resident in the smoke room who owed him a pack. Noted that on 7/6/19 the resident only requested 2 of his 6 cigarettes from staff for the day. Nursing Supervisor contacted and discussed intervention as resident on a restriction already. The NS (Nursing Supervisor) advised no smoking until the IRCC team could meet and discuss the situation, the resident informed, and nicotine product offered but declined. On 7/7/19 at 2:01 p.m. the Progress Note documented Resident #5 seen leaving the unit at 11:20 a.m., staff addressed him, and he stated he was going to lunch. The NS called to unit to report security intervened on resident attempting to enter the smoke room as the attendant aware of the resident's restrictions to smoking. Security counseled the resident and staff reminded him of no smoking restriction. The Smoking Assessment signed 7/7/19 documented identical information for questions Q1 thru Q6 and Q8 thru Q12 as 6/27/19 assessment but Q7 left blank to indicate the resident did not have a past history of poor judgement; the resident remained a Supervised smoker. The Comments section recorded the resident assessed following violation of smoking restrictions as found with smoking materials in his possession in his room in wheelchair. Current smoking restrictions listed only 6 cigarettes in a day, 1 at a time, as well as no smoking materials in resident's possession. Applied new restrictions of no smoking at that time to resident until the IRCC team could discuss and make new decision regarding resident's smoking. The resident aware of new smoking restrictions. As of 7/7/19, the facility smoking policy stated incidents would first be evaluated before action steps taken. However, staff restricted the resident from smoking prior to evaluation. On 7/8/19 at 3:46 p.m. the Progress Note documented the new intervention for the smoking incident on 7/7/19 the resident would obtain 1 cigarette/lighter at a time from the smoke room monitor as requested and to return lighter to smoke room monitor upon exiting the room. At 4:50 p.m. the notes recorded the resident received directive he was not to bum or purchase smoking materials from other residents. On 7/9/19 at 12:58 p.m. the Progress Note documented the attendant at the smoking room stated they observed the resident selling a full pack of cigarettes to other resident in smoke room. Resident on restriction of 1 cigarette at a time and seen smoking 1 after another in smoke room by staff that supervised the area. At 4:23 p.m., Staff M spoke to the resident in his room about being observed selling a pack of cigarettes and the resident denied as he only got 1 cigarette at a time. Staff M requested to search the resident's room and no cigarettes found. Staff M again reminded the resident of his current restriction and expectation that he comply. At 8:22 p.m. the notes documented security asked to look at the video footage from the camera in the Malloy smoke room between 12:00 p.m. and 12:30 p.m. to see if they could see the resident with a pack of cigarettes and any interaction with another resident selling the pack of cigarettes. Security stated at 12:15 p.m. he seen the resident get a cigarette and lighter from the smoking monitor, entered smoke room, and lit cigarette. Shortly after arriving in smoke room the resident spoke to another resident, pulled something out of his pocket, at first security could not identify object for sure, then resident turned the object and security identified it as a gold colored pack of cigarettes. Security then said he watched the exchange of money, resident giving peer the pack of cigarettes. The primary nurse and nursing supervisor again spoke with the resident and confronted him about this new information. Resident continued to deny he ever had a pack of cigarettes and did not sell anyone cigarettes. Told resident he was on video tape and he just shrugged and continued to deny. They discussed they were glad he smoked in the appropriate places safely but told the whole reason why restricted to 1 cigarette at a time with cigarettes kept with smoke monitor was to ensure he went to the correct area to smoke. Explained to the resident if he carried cigarettes on him, it was way more likely he could light up somewhere he shouldn't. They then firmly told the resident if he had another smoking incident of smoking somewhere he shouldn't it would be very hard to justify him being allowed to smoke anymore. They reinforced this saying he may have to move to another building where there was no smoking. They told the resident they didn't want to have to do that but he needed to comply with the smoking rules. On 8/15/19 Resident #5 signed another new smoking policy, form #475-2082, dated as revised 8/19 (1st version), titled Safety Expectations for Nursing Resident Smoking. The new smoking policy included no information related to a 3 strike system. The major change on the smoking policy included smoking no longer permitted anywhere outside of the buildings or on facility grounds. The incident report categorized as type Equipment/Environmental dated 8/26/19 at 6:30 p.m. documented Resident #5 observed by the smoke room monitor allowing ashes to drop on his clothing and brushing them onto the floor as well as purposefully ashing on the floor rather than using the ash tray. Licensed staff notified and directed not to give Resident #5 any more cigarettes that night. The resident stated they took his cup away from him so he ashed into ashtray most of the time if he could get to one but sometimes he couldn't get to the ash tray because of the wheelchairs and walkers blocking them. The report documented the resident was issued a strike for the incident and also monitored 3 times to ensure safety with ashing and told to wear a smoke guard at all times when smoking. The Smoking Assessment signed 8/27/19 documented identical information for questions Q1 thru Q6 and Q8 thru Q12 as 7/7/19 assessment but Q7 now checked to indicate the resident did have a past history of poor judgement; the resident remained a Supervised smoker. The Comments section recorded the resident assessed following violation of safe smoking when found not disposing of ashes appropriately having ashes on himself. A smoking guard added to the resident for safety and 1st strike applied to the resident. Resident aware of new smoking restrictions and educated on strike system as well as monitored smoking x3 cigarettes appropriately. New safety expectation signed by the resident. On 8/27/19 at 2:22 p.m. Resident #5 again signed the smoking policy, form #475-2082, dated as revised 8/19 (1st version), titled Safety Expectations for Nursing Resident Smoking. The form contained no documentation in relation to a 3 strike system. On 8/27/19 at 4:39 p.m. the Progress Note documented the staff met with the resident in his room to further discuss his current smoking restriction and to discuss the strike system in relation to smoking. The resident informed of the expectations when smoking in the smoking lounge and he would be receiving his first strike for his smoking incident the night before. Discussion of the implications of future incidents in regards to the strike system were discussed and a copy given to the resident. On 9/3/19, Resident #5 signed the smoking policy form #475-2082, dated as revised 8/19 (2nd version), and titled Safety Expectations for Nursing Resident Smoking. The major change in this revision the facility moved to only 3 smoke times for the day. The incident report categorized as type behavior dated 9/5/19 at 2:20 p.m. documented the resident observed to throw his cigarette into ashtray without extinguishing it first as the smoke room was closing. Upon observation of the ashtray, staff noted the previous 2 cigarettes had not been extinguished either. The action to prevent re-occurrence documented as the resident no longer had smoking privileges and staff to monitor the resident's room twice a day to ensure he had no smoking materials on him. On 9/8/19 at 3:42 p.m. the Progress Note documented by Staff O recorded staff brought her the resident's coat after staff removed from resident to give him a shower and happened to find 3/4 of a pack of cigarettes and a Meskwaki match book. Supervisor notified of violation and resident upset not understanding why smoking taken away. Reviewed with the resident the violation and he said he had nothing more to say. When asked if he had any other materials in his room he denied any other materials present. Smoking replacement product offered and he declined. Smoking guide updated in the smoke rooms and NDS (Nursing Services Director) aware; would continue to monitor for further attempts to smoke and redirect resident as needed. On 9/13/19 at 3:08 p.m., the Progress Note documented Security notified the unit at 1:30 p.m. they smelled cigarette smoke in the bathroom on the main floor with ashes noted in the toilet and Resident #5 in the bathroom; he denied smoking. Staff F and Staff J located the resident outside and spoke with him; he denied smoking but consented to a search. Staff F and Staff J found 1 pack of cigarettes and 1 lighter on him. Staff searched the resident's room where they found 3 packs of cigarettes in a Meskwaki bag; the resident went to the casino on 9/12/19. The resident continued to deny smoking until found on him and told in violation of smoking policy where he lost his smoking privileges the previous weekend. The resident aware cigarettes found in his room and he declined a nicotine replacement. The care plan updated to search the resident's room twice a day with cares. On 9/14/19 at 3:59 p.m. the Progress Note documented it was explained to the resident that due to his cigarette purchase on a prior outing, he would not be able to go on outing to Wal-Mart. On 9/26/19 at 8:42 a.m. the Progress Notes documented the resident's room searched while he finished up in the shower and the RTW found a red lighter in the pocket of the residents tan [NAME]et he wore daily. No cigarettes or other smoking material found, lighter removed. The incident report categorized as type Equipment/Environmental Smoking dated 10/1/19 at 1:23 p.m. documented the resident observed in the courtyard outside of Malloy LRC (Malloy Leisure Resource Center) with an UNLIT cigarette. When asked what he was doing the resident tossed the cigarette away. The staff retrieved resident from the area and brought him back to the unit to discuss the incident. The resident's room searched with 1 pack of cigarettes found in the resident's coat pocket and 2 more packs found in a bag hanging behind the wheelchair with 1 lighter and empty book of matches. The resident denied having any further smoking materials. A final warning letter issued to the resident if further incidents occurred he would be discharged from the facility. The resident agreeable to start on the nicotine patch. Staff would continue to complete room searches as previously. The resident voiced understanding of his final warning. A letter dated 10/2/19 on facility letter head documented the following: The purpose of this letter is to inform you of your final notice pursuant to Iowa Administrative Code section 801-10.43 (35D) which states: The Commandant or designee shall administer and enforce all rules adopted by the commission, including rules of discipline and, subject to these rules, may immediately suspend the membership of and discharge any member from the facility for infraction of the rules when the commandant or designee determines that the health, safety, or welfare of the members of the facility is in immediate danger and other reasonable alternative have been exhausted. The administrative rules allow the facility to place your residency in probation status following a second offense

Based on clinical record review, observation, resident interview, family interview, and staff interview, the facility failed to ensure a comprehensive care plan developed to address a resident no longer allowed to smoke (Resident #1) and a resident who used smokeless tobacco (Resident #14); out of 13 residents reviewed for comprehensive care plans. The facility reported a census of 428 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 identified an original admitted [DATE]. The MDS recorded the resident with unclear speech, rarely made self-understood, but had the ability to understand others with clear comprehension. The MDS recorded the resident's memory for short and long term memory without signs/symptoms of [MEDICAL CONDITION]. The MDS revealed the resident independent without assistance for locomotion on/off the unit and the presence of functional limitation in range of motion on only 1 side of both upper and lower extremities. The MDS documented [DIAGNOSES REDACTED]. The care plan problem area updated 10/29/19 identified difficulty speaking and expressing himself due to effects of stroke in 2012. The care plan problem area updated 1/30/19 identified the resident enjoyed smoking even though it was not recommended with his health history and his family supportive of his wish to smoke. The interventions included to assess his smoking abilities when being monitored in the smoke room to monitor his ability to continue to smoke safely. On 2/27/19, the care plan updated to include the resident signed the Smoking Safety Expectations form annually. On 4/29/19 the care plan Goal Evaluations documented the resident did not have any unsafe smoking incidents during the quarter, he smoked in the Malloy smoke room or outside when the weather nice, and he demonstrated safe smoking techniques during the observed quarterly smoking assessment. On 7/28/19 the Goal Evaluation again documented the resident smoke safely in a supervised setting in Malloy building smoke room, no unsafe smoking incidents during the quarter, and family voiced upset over the new smoking changes after provided a misinterpreted statement that the facility going smoke free on 10/1/19. The family member felt smoking the only thing the resident had left to enjoy, the SW (Social Worker) gave appropriate information about the new smoking rules of supervised smoking indoors only. The Smoking Assessment signed 10/29/19 documented the resident remained an Unsupervised smoker. The Comments section recorded the resident smoked in the Malloy smoke room, no incidents of unsafe smoking during the quarter, and no concerns noted when observed on 10/28/19. The resident monitored 3 times daily in Malloy smoking room per facility smoking policy. Review of the clinical record revealed as of 11/1/19, Resident #1 demonstrated no unsafe smoking violations and remained an unsupervised smoker per the smoking assessments. On 11/26/19 at 10:09 a.m., the Progress Note documented while staff assisted Resident #1 on the toilet, they noticed a burn hole in the resident's sweat pants. Staff found 1 by 1.5 cm (centimeter) burn to the resident's anterior right thigh. The family member made aware the resident's smoking privileges had been removed due to injury to self and resident aware of inability to continue to smoke. Observation on 1/2/20 at 1:06 p.m. revealed the interior smoking room in the Malloy building located on the 1st floor unlocked. Several residents present in the room actively smoking with 3 staff members present to assist and monitor the area; Staff A, RN, Staff B, RN, and Staff C, RTW (Residential Treatment Worker, equivalent to a CNA (Certified Nurse Aide)). Staff C stood at a cart with drawers and a book on the top; the drawers contained each individual resident's smoking materials in separate baggies. The book contained the following information: Resident #1, lived on M4S (Malloy 4th floor South) - 11/26/19 no longer allowed to smoke. On 1/8/20 at 4:03 p.m. an interview conducted with Resident #1's family member. The family member voiced they were not at all happy with the changes to the smoking policies. The family member reported smoking had been acceptable for 7 years then the facility pulled the rug out from under the resident. The family member stated letting Resident #1 smoke the only exercise he got as he couldn't go outside anymore. The family member said the resident used to go down every hour and half, have cigarette, then back to his room, but now just sat in his room. The family member reported they seen a change in the resident as he was much more morose since the facility took his cigarettes and they talked with him on how much he slowed down in the last couple months. The family member stated the resident lost interest and part of that due to not smoking. The family member stated the facility informed them there was absolutely no chance of re-assessment as he was in a 1 and done offense. The family member voiced they felt so sad the facility took away smoking from someone in his condition who had such limited quality with nothing to look forward to. On 1/9/20 at 11:20 a.m. observation revealed Resident #1 in his room with door closed, watching TV. Resident #1 sat in a wheelchair and able to answer some questions with yes/no endings. Resident #1 attempted to answer a few open ended questions, but mumbles unable to be understood. Did acknowledge that his family member okay to speak for him on the resident rights and smoking issues. Resident #1 responded yes he felt he would want to keep smoking if allowed, yes he burned himself, yes he had been wearing a smoke guard at the time, yes he had burned himself before, yes he lost his privileges as a result. The care plan contained no other documentation to indicate the resident no longer allowed to smoke. 2. The MDS assessment dated [DATE] for Resident #14 identified the resident with clear speech and ability to make self-understood as well as understood others with clear comprehension. The MDS recorded a BIMS score of 15 without signs/symptoms of [MEDICAL CONDITION]. The MDS coded the presence of delusions but no other behaviors. The MDS revealed the resident independent with transfers and locomotion on/off the unit. The MDS documented [DIAGNOSES REDACTED]. The care Directives dated 1/13/20 documented under General Condition the resident no longer using tobacco as of 1/7/20 and if seen chewing tobacco, staff to notify Licensed Staff to ensure the resident not using while on a nicotine patch. Under Negative Behaviors, the Directives recorded the resident could be accusatory and made false accusations at times. On 12/2/19 at 3:19 p.m. the Progress Note documented the resident started chewing again on that day after quitting 5 months prior. On 12/15/19 at 11:13 a.m., Staff J, RN, documented a late entry for 12/14/19 without a reference time in the Progress Notes. Staff J wrote Resident #14 down by the smoke room the day before (12/14/19) to hand Staff J his smokeless tobacco as Staff J monitored the smoke room. Staff J questioned Resident #14 why he gave her the tobacco and Resident #14 stated he was told by Staff K, Certified Medication Aide (CMA), he needed to have it in the cart by the smoke room and only use in smoke room. Staff J documented she told Resident #14 she would not debate the issue as Resident #14's tone loud and comments negative. Resident #14 then entered the smoke room with his tobacco and he did not usually go to the smoke room. Staff J recorded on Sunday, 12/15/19 without a time reference, Resident #14 came to her that morning and informed her the smoke monitor wanted some clarification on his smokeless tobacco. Staff J informed Resident #14 he did not need to use the tobacco down in the smoke room, he should just use in his room. When questioned who told him that, Resident #14 responded a woman who was not the usual staff. Resident #14 stated he was just upset and he didn't have any more smokeless tobacco but it was in the cart. Staff J informed Resident #14 he would have to wait until 1:00 p.m. for her to retrieve his chew from the cart downstairs. On 12/15/19 at 11:17 a.m., Staff K wrote a late entry for 12/14/19 without a time of reference in the Progress Notes. Staff K recorded Staff L, RTW, seen the resident put dip of chew in his mouth and told him she didn't think he could chew there, just the smoke room. Resident #14 started yelling, oh yes he could chew wherever he wanted to. Staff K asked Resident #14 to please take his meds which he did without problem then wheeled out of common area yelling, he could do whatever he wanted to. Staff K recorded Staff L then called the supervisor and asked about the policy for chew and when she got off the phone reported the supervisor said he could chew anywhere. On 12/16/19 at 10:46 a.m. the Progress Note recorded an RN Directive Update under General Precautions, new Directive on smokeless tobacco (chewing), verification resident may chew anywhere on/off facility grounds. On 12/16/19 at 4:16 p.m., the Progress Note documented by Staff M, Social Worker, recorded a letter provided to Resident #14 from facility administration notifying him the current smoking protocol would continue beyond 1/1/20; provided letter as the resident continued to use chewing tobacco. On 1/3/20 at 8:06 a.m., a late entry Progress Note created for 12/31/19 at 4:20 p.m. The entry recorded the facility psychiatrist responded to the resident's request for more [MEDICATION NAME] ([MEDICAL CONDITION] medication used to treat influenza type A and also [MEDICAL CONDITION] type symptoms) to help decrease tremors and the psychiatrist responded with no change at that time due to potential side effects of [MEDICAL CONDITION] but recommended the resident stop tobacco use as it could affect the drug levels of his medication. Resident #14 updated on 1/3/20 at 7:45 a.m. and the resident reported he would stop chewing after his 5 cans were gone. Resident #14 did not agree chewing tobacco could impact his drug metabolism and the nurse discussed that all nicotine products could do that. The note documented the resident in wheelchair at that time with mild hand tremors, no head tremors. On 1/7/20 at 3:18 p.m. the Progress Note documented the resident requested nicotine patch as he was trying to quit chewing tobacco as all 5 cans of chew gone and he would not be buying anymore. In an interview on 1/15/20 at 2:43 p.m. Staff K recalled working the weekend of 12/14/19 and 12/15/19. Staff K reported while she prepared medication, Staff L seen Resident #14 grab a chew can and Staff L said she didn't think he could chew anywhere. Staff K stated Staff L then called the supervisor who said the resident could chew anywhere. Staff K reported Resident #14 upset. Staff K stated she tried to diffuse the situation and Resident #14 took his meds and left. Staff K said the only thing she heard other than that was Resident #14 went downstairs and told someone he could only chew in the smoke room and that was not correct but he had already left. Staff K clarified it was after the resident went downstairs that Staff L called the supervisor who called back right away to clarify he could chew wherever he wanted. Staff K commented Resident #14 did not come back the rest of her shift for her to pull him aside and explain the policy. In an interview on 1/16/20 at 8:40 a.m. Staff J reported very familiar with Resident #14. Staff J responded Resident #14 chewed off and on for the approximately 2 years while he lived at the facility. In response to what the smoking policy said on chewing tobacco, Staff J stated from what she understood, as long as the smokeless tobacco locked up in a resident's room then allowed to keep it themselves. Staff J recalled an incident occurred with Resident #14 revolving around whether or not he could hold his chewing tobacco on is person but stated she was not up on the unit/floor at the time as she was monitoring the smoke room. Staff J reported Resident #14 went down to the smoke room and said to her he had to use his chewing tobacco in the smoke room. Staff J stated she was puzzled and did not know until she was up on the unit about the incident. Staff J reported someone who normally worked the other end of the unit, Staff L, told the resident to go downstairs to chew. Staff asked who told him that. The comprehensive care plan failed to address the resident's use of smokeless/chewing tobacco, the possibility interactions with medications with the use of chewing tobacco, or inform staff where the resident allowed to chew.

Based on observation, clinical record review and staff interview, the facility failed to follow infection control precautions for one resident observed during two separate observations. (Resident #8) The facility census was 437 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #8 had [DIAGNOSES REDACTED]. During observation on 2/26/19 at 9:06 a.m., the resident laid in bed. Staff E, Licensed Practical Nurse, LPN dropped a lancet on the floor. Staff E picked up the lancet wearing gloves. Wearing the same gloves Staff E administered the residents oral medications from a plastic medication cup then touched the residents bed control and light switch with the same gloves. During the observation Staff E placed a glucometer on the residents bedside table with no barrier. The bedside table had numerous personal items on it. After completing the residents blood sugar check Staff E placed the glucometer directly on the top of the medication cart. Staff E then placed the glucometer into a case and stated it had belonged to the resident. Staff E placed the case into the cart and failed to sanitize the top of the medication cart. Immediately after the observation Staff E verified they had used the lancet dropped on the floor and worn the same gloves after picking it up and should not have. Staff E also verified they did not place a barrier on the bedside table so should not have placed the glucometer on the top of the cart. During observation on 2/26/19 at 10:28 a.m., Staff A, Certified Nurse Aide, CNA and Staff B, CNA completed supra pubic catheter cares for the resident as the resident laid in bed. Staff B prepared supplies on bedside a table. A hair brush fell on to floor and Staff B picked it up and placed it on gloves on the bedside table. Staff B failed to wash their hands after picking up the brush and donned a pair of gloves from the table. Staff B cleansed around the residents suprapubic catheter. Staff B changed gloves, using a pair that was on the bedside table under the brush that had been on the floor. Staff B placed a new drain sponge around suprapubic catheter wearing same gloves. Upon completion Staff B verified the brush had been on the floor. During interview on 2/27/19 at 2:15 p.m., the Director of Nursing stated staff would be expected to discard or sanitize an item if it fell on the floor.

Based on clinical record review and staff interview, the facility failed to complete a Level II Pre-Admission Screening and Resident Review (PASRR) to ensure residents with a mental disorder and a change in condition received services appropriate for their needs for one of five residents reviewed (Resident #185). The facility census was 437 residents. Findings Include: 1. Clinical record review revealed Resident #185 was admitted to the facility on [DATE] and had a negative Level I PASRR completed 9/8/17. Further record review identified the resident to have major [MEDICAL CONDITION] entered as a [DIAGNOSES REDACTED]. Review of Admission Minimum Data Assessment (MDS) Tool dated 9/13/18 shown the resident in Section A 1500 not to be considered by the state level II PASRR process to have a serious mental illness. [DIAGNOSES REDACTED]. Medications taken shown to be an antidepressant 7 days of the assessment and no psychological therapy marked as provided. Review of the Quarterly MDS dated [DATE] shown the same information as the admission MDS with no changes noted. During interview on 2/27/19 at 1:06 p.m., the Admissions Supervisor reported not being sure if the major [MEDICAL CONDITION] was already recognized for the resident. The admission Supervisor stated the resident came from another facility and shown a Quarterly MDS dated [DATE] on file for the resident that came in an application packet for admission to the facility. Review of the [DIAGNOSES REDACTED]. Further review of Resident #185's admission file shown a History and Physical (H & P) completed on 9/12/18 by one of the facility doctors. In the past medical history section of the H & P identifies the resident to have major [MEDICAL CONDITION] and at the time of the assessment on sertaline 50 mg 1 tablet daily. The Admissions Supervisor reported not aware of the process the Admission Coordinator has to alert him to re-submit a PASSR if there is a change in the mental condition of a resident. During an interview on 2/27/19 at 2:36 p.m., the Director of Nursing (DON) stated the expectation is that a PASRR be submitted for review on a resident when a change in mental health is identified to see if a Level II PASSR is created and if any services are recommended for the resident in regards to the change.

Based on clinical record review, facility policy review and staff interviews, the facility failed to provide a written notice to the resident or the resident representative in regards to information explaining the Bed Hold Policy when a resident transferred to the hospital for two of five residents reviewed (Resident #273 and #417). The facility census was 437 residents. Findings include: 1. Progress Notes dated 11/21/18 at 3:25 p.m., documented Resident #237 was being transferred to the local hospital emergency room (ER) for a vascular consult. Progress Notes dated 11/21/18 at 9:32 p.m., documented the resident transferred to another hospital. Progress Notes lacked documentation to indicate written information was given regarding the bed hold policy to the resident or the resident representative to explain the duration of the bed hold policy, if the resident permitted to return and resume residence in the nursing facility, nor the reserve bed payment policy. Review of the chart revealed no Bed Hold Notice form filed on the chart for the days Resident #237 out of the facility in the hospital. Review of the Bed Hold Policy effective 1/18/19 identified the purpose of the policy to be to define the procedures governing room retention for hospitalized residents and/or those on leave, while allowing reasonable access to residents who are on the waiting list. The procedure explains the following: a. Upon admission to the facility, each resident/resident representative will receive and review the facility Bed Hold Policy. b. Upon transfer out of the facility the resident/resident representative will again be issued the Bed Hold Policy and then confirm whether they wish to have their bed held in their absence. c. This information will be relayed in writing or verbally within the first 24 hours of the resident transfer from the facility. During interview on 2/27/19 at 9:31 a.m., Staff D, Social Worker reported the Bed Hold Policy was gone over at admission. Staff D stated a new clause had been added (A Check-Box) to the Notification Guidelines Form that asks if the resident/resident representative wants a copy of the bed hold policy with every leave or transfer to the hospital. The form is reviewed and renewed annually. During interview on 2/27/19 at 9:48 a.m., Staff D looked in Resident #237's chart and noted the last Notification Guidelines Form was from 9/23/16 and had not been updated with the new form revised as of 10/18 with the clause in it regarding the Bed Hold Policy and if wanting a copy of it mailed with leave or transfer to hospital. During interview on 2/27/19 at 2:15 p.m., the Director of Nursing (DON) stated the expectation in regards to the Bed Hold Policy to be that the Nurses make sure the Notification Guideline Form is up to date for all residents annually. In Resident #237's case since the Notification Guideline Form not updated in regards to the Bed Hold Policy, then that matter should have been discussed with the resident representative when the resident went to the hospital. 2. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #417 had [DIAGNOSES REDACTED]. A progress noted dated 12/24/18 at 11:49 a.m., documented the resident would be transferred to the local hospital emergency roiagnom on [DATE] and admitted to have a port set and [MEDICAL TREATMENT] set up. A progress note dated 12/26/18 at 2:40 p.m., documented the tentative plan had been for the resident to be discharged from the hospital the following Friday and return to the facility. Record review revealed no bed hold completed. During interview on 2/27/19 at 2:15 p.m., the Director of Nursing, DON stated they had been unable to find a bed hold after the resident had been hospitalized . The DON stated the resident had been sent out for a procedure and admitted to the hospital and the facility failed to complete a bed hold. The DON showed the surveyor the form Notification Guidelines dated 2/2/18, which documented the family wanted to have a copy of bed hold policy with leave or transfer to hospital. The DON stated the facility should have done one for the 12/26/18 hospitalization .

Based on clinical record review and staff interview, the facility failed to follow physician orders [REDACTED]. (Resident #15, #23, #14, #19 & #21) The facility census was 441 residents. Findings include: 1. The Minimum (MDS) data set [DATE], documented Resident #15 has [DIAGNOSES REDACTED]. Physician order [REDACTED]. Review of the October Medication Record dated 2017, revealed no weight on 10/24/17. Review of the September Medication Record dated 2017, revealed no weight on 9/28/17 Review of the September Medication Record dated 2017, documented on 9/5/17 the resident weighed 307 pounds and on 9/12/17, the resident weighed of 320 pounds. Record review failed to revealed the physician was notified as directed. During interview on 11/7/17 at 2:40 p.m., Staff B, Registered Nurse confirmed the record lacked documentation of the weights being completed and the physician being notified of the weight gain. Clinical record review revealed no BMP completed for the month of October 2017. 2. A Progress note dated 9/28/17, documented Resident #23 had [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The Medication Record dated September 2017, lacked the resident blood pressure and pulse being completed on 9/19/17. During interview on 11/8/17 at 2:25 p.m., Staff C, nurse supervisor, confirmed the Medication Record lacked the blood pressure and pulse being completed on 9/11/17. 3. The Resident [DIAGNOSES REDACTED].#14 had [DIAGNOSES REDACTED]. The physician order [REDACTED]. The Medication Record dated October 2017, lacked the residents daily weight being completed on 10/1/17. During interview on 11/9/17 at 8:35 a.m., Staff A confirmed the daily weight was not completed on 10/17/17. 4. Progress Notes dated 10/5/17, documented Resident #19 had [DIAGNOSES REDACTED]. A Physician order [REDACTED].½ tablet by mouth daily The Medication Record included [MEDICATION NAME] 200 mg take ½ tablet by mouth daily, to take blood pressure and pulse weekly, and to change track ties weekly. The Medication Record lacked documentation for blood pressure and pulse on 8/16/17 and 8/23/17 and for changing track ties 9/6/17 and 9/27/17. 5. Progress Notes dated 11/3/17, documented Resident #21 had a [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The Medication Record included [MEDICATION NAME] 5 mg by mouth at bedtime daily and to take blood pressure and pulse weekly. The Medication Record lacked documentation for blood pressure and pulse on 8/24/17, 10/5/17 and 10/26/17. During interview on 11/8/17 at 2:45 p.m., Staff D, Registered Nurse acknowledged the blood pressure and pulse was not completed.

Based on observation, clinical record review and staff interview, the facility failed to ensure one of 16 residents reviewed received exercises as planned and failed to utilized a hand split as directed. (Resident #13). The facility census was 441 residents. Findings include: 1. The Account information form with an original admitted [DATE], and a readmitted [DATE], documented Resident #13 with [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE], documented the resident required limited assistance to extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, ambulation, dressing, hygiene, and toilet use. The Plan of Care with an onset date of 11/15/16, documented a problem of impaired mobility and right sided weakness with approaches and interventions that include to complete all activities of daily living and task as indicated. The Standard of Care undated, documented that active range of motion accomplished through residents participation in am/pm cares. Plan of action/variance: Resident scheduled to attend open gym and a weekly neuro exercise group. Right [MEDICAL CONDITION]. Right wrist moderately contracted. Still able to grab onto bar to aid in transfers. Resident to wear a right hand splint. Resident attendance at open gym is poor. Uses manual wheelchair for primary mode of locomotion on and off the unit. Non-ambulatory. Observation on 11/7/17 at 7:30 a.m., Staff E, resident treatment worker, RTW and Staff F, RTW performed morning cares on the resident. Observation revealed no splint on the resident right wrist. Staff completed morning cares without offering active or passive range of motion. Observation on 11/7/17 at 8:10 a.m., revealed the resident in the wheelchair with the right wrist contracture. During interview on 11/7/17 at 8:30 a.m., Staff E, stated to their knowledge a right wrist splint has never been used on the residents right wrist. During interview on 11/7/17 at 8:30 a.m., Staff F, stated to their knowledge a right wrist splint was never used on the residents right wrist. During interview on 11/8/17 at 11:25 a.m., Staff A, nursing supervisor stated staff are to perform active or passive range of motion during morning cares and follow the standards of care for the facility.

Based on clinical record review, physician and staff interviews, the facility failed to ensure Resident #1 was free from abuse by Resident #2. Resident #2 argued with Resident #1 about a chair at Bingo. With a fisted hand, Resident #2 hit Resident #1 and Resident #1 fell on to the floor. Resident #1 had a [MEDICAL CONDITION] as a result of the altercation and fall. The sample consisted of 3 residents and the facility reported a census of 438 residents. Findings include: 1. Resident #2 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 4/4/17. The MDS had a BIMS (Brief Interview for Mental Status) of 11. A score of 11 represented a moderate cognitive impairment. The MDS identified there resident had no physical, verbal behaviors during the assessment period and generally rejected care every 1-3 days. The MDS functional status indicated the resident as independent with bed mobility, transfers, walking in room and corridor, eating and using the toilet. The resident required limited assistance with dressing and personal hygiene. The MDS identified the following [DIAGNOSES REDACTED]. A history and physical examination [REDACTED]. The examination indicated the resident was appropriately placed on a secured unit due to requiring nursing assistance, neurocognitive disorder with aggressive behaviors and risk for elopement. The resident was closely followed by psychiatry who made several changes over the past month. The record revealed the resident's last resident to resident physical incident occurred on 12/18/16. The Care Plan dated 1/2/17, indicated the goal had not been met. The resident was involved in several verbal altercations and 1 physical altercation in which both resident and peers sustained minor injuries. The approaches included and directed staff to use health/psychiatry as needed, ongoing evaluation of behavior and potential side effects from current psychoactive medications. The approaches included to see the certified nurse aide, CNA touch directives for detailed approaches including safety strategies, target behaviors with interventions and directives for locomotion off the unit. A Progress Note dated 4/15/17 at 2:16 p.m., indicated the resident had tooth pain and received [MEDICATION NAME] (antibiotic) for an abscessed tooth. The document titled Resident Incident Report dated 4/16/17 at 9:20 a.m., documented Resident #2 pushed Resident #1 to the ground due to an argument over a chair at Bingo. Resident #1 fell to the floor hard and possibly sustained a [MEDICAL CONDITION]. Resident #2 had a verbal altercation with another resident because that peer had 2 Bingo cards. On 5/16/17 at 2:46 p.m., the Recreational Therapist was interviewed and stated at the time of the incident, the Recreational Aide got a chair out for Resident #1. Resident #1 walked independently with a walker. Each resident had a side of the chair and tugged back and forth. The therapist stated she heard all this and turned around and used the microphone and told both residents to stop. Resident #2 had fists up in front of his/her own face and was ready to fight. Resident #2 hit Resident #1 on the right side of face. This caused Resident #1 to fall onto the floor. The therapist stated this happened before in August 2016 in a restaurant. On 5/16/17 at 3:19 p.m., Staff C (Recreational Aide) was interviewed and stated there were 2 staff members present. Staff C stated she pulled up a chair for Resident #1. Resident #2 arrived and pulled the chair out that the aide had reserved for Resident #1. Resident #1 arrived and said he/she was going to sit there. Staff C stated Resident #2 began cursing and putting his/her fists up and moving his/her feet like they were going to fight. Staff C stated she moved back and Resident #2 threw a fist at Resident #1. Resident #1 fell down backwards. Resident #2 sat in the chair Staff C stated she thought Resident #2 wanted to sit in the chair because she was young and Resident #2 had [MEDICAL CONDITION]. On 5/16/17 at 3:50 p.m., Staff D (Certified Medical Assistant) was interviewed and stated she did not witness the actual altercation. Staff D stated she entered and saw Resident #1 on the floor. Resident #2 walked over and asked if Resident #1 was going to be okay. Staff D stated she told Resident #2 to go sit down and Resident #2 said Well if you're not going to answer me, you can (expletive) off and the resident walked away. On 5/16/17 at 2:40 p.m., Staff B (Registered Nurse Clinician) was interviewed and stated she arrived and saw Resident #1 on the floor complaining of extreme pain in the right hip. Staff B stated Resident #2 had an altercation at a restaurant last year. Staff B stated the physician increased his/her medications and now required 1 on 1 and does not go off the CCDI (Chronic Confusion Dementing Illness) unit to play Bingo. Resident #2 remained in a private room and does not leave the unit. On 5/16/17 at 3:30 p.m., Staff F (Activity Specialist) was interviewed and stated staff are present and cautious taking Resident #2 off the unit right now. Staff F stated Resident #2 needed 1 on 1 for 5 days after the incident. Staff F described Resident #2 as: will take off, impulsive, self centered and did not have remorse after the incident. On 5/17/17 at 1:32 p.m., Resident #2's physician was interviewed and described Resident #2 as hypersexual and irritable. The physician stated the resident improved at first. The physician said he saw the resident again today and increased medication ([MEDICATION NAME]-for [MEDICAL CONDITIONS] [MEDICAL CONDITION]) again for physical aggression. The physician considered Resident #2 as unusual since he/she was high functioning with poor memory and questioned if the resident was possibly [MEDICAL CONDITION] (mental illness). The physician stated when he attempted to discontinue the medication, the resident would get more irritable with the staff and it was not the norm to have irritability with other residents since the resident's usually hypersexual. The physician identified the aggression with peers as new. On 5/18/17 at 10:22 p.m., Staff A (Licensed Practical Nurse) was interviewed and stated she saw Resident #1 and Resident #2 arguing and pulling the chair back and forth. Staff A stated she headed to intervene but by the time she got to them, Resident #1 was on the floor. Staff A stated she was 2-3 steps away and it happened so fast. 2. Resident #1 had a MDS assessment with a reference date of 2/14/17. The MDS identified Resident #1 had [DIAGNOSES REDACTED]. The MDS revealed Resident #1 had a BIMS score of 11 which identified as moderately cognitively impaired. The MDS identified the resident as independent with ambulation. A Progress Note dated 4/16/17 at 10:01 a.m., indicated an incident occurred at 9:15 a.m. The recreation aide got Resident #1 a chair as he came to the table to attend the activity before Resident #2. Resident #2 came on the opposite side of Resident #1 and moved Resident #1's chair. The note indicated a verbal altercation occurred and Resident #2 let go of the chair and put up fists ready to hit. Resident #2 then swung with his/her left hand and struck Resident #1 on the right cheek. Resident #2 knocked Resident #1 over, resulting in a fall. The recreational aide stood at the opposite side of the table and witnessed the verbal exchange and could not get to the other side of the table to use body as a physical barrier before Resident #2 hit Resident #1. A Progress Notes dated 4/16/17 at 10:27 a.m., indicated the ambulance transported the resident to the hospital emergency room . A Progress Notes dated 4/16/17 at 12:26 p.m., indicated the facility received a telephone call from the emergency room nurse. The resident had a fractured right hip and was admitted for surgery to repair the hip. The Resident Incident Report dated 4/16/17 at 9:20 a.m., indicated Resident #2 punched Resident #1. Resident #1 landed on his/her right hip. Resident #1 transferred to to the hospital emergency room . A Progress Notes dated 4/24/17 at 9:56 a.m., indicated the resident returned to the facility from the hospital. The resident currently had left lower lobe pneumonia (lung infection). A progress note at 2:05 a.m., indicated the resident had an incision approximately 15 cm (centimeters) in length with 22 staples in place. The resident received Tylenol as needed for discomfort.

Based on clinical record review and staff interview, the facility failed to follow physician orders [REDACTED]. (Resident #4 & #2). The facility census was 440 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #4 dated 8/4/16, documented [DIAGNOSES REDACTED]. The MDS documented the resident required limited assistance of one for dressing and toilet use. A dietary progress note dated 8/5/16 at 10:35 a.m., documented the resident had a significant weight loss noted at one month and most likely related to fluid retention with fluctuations in daily weight noted throughout the quarter as well with use of diuretics. The physician order [REDACTED].>The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A physician order [REDACTED]. A mini nebulizer treatment flow sheet/respiratory assessment form for the month of August 2016, revealed no respiratory assessment with oxygen saturation on the following days: - the 7th after the treatment at 8:00 p.m. - the 8th before and after the treatment at 12:00 p.m. -the 10th before and after the treatment at 8:00 p.m. -the 12th after the treatment at 12:00 p.m. and after the treatment at 8:00 p.m. - the 13th after the treatment at 8:00 p.m. - the 17th before and after the treatment at 12:00 p.m. - the 24th before and after the treatment at 12:00 p.m. -the 25th after the treatment at 4:00 p.m. - the 26th after the treatment at 4:00 p.m. - the 27th after the treatment at 8:00 p.m A progress note dated 9/1/16 at 12:11 p.m., documented the residents lung sounds were diminished with faint expiratory wheezes noted, with a recent weight gain and shortness of breath. The MAR for the month of September 2016, included the order for daily weights. The MAR indicated [REDACTED]. A physician progress notes [REDACTED]. The note documented the resident had an increase in weight and lower extremity [MEDICAL CONDITION] as well as increased need for oxygen. [MEDICAL CONDITION], likely element of cor pulmonale (enlargement of right side of heart due to lung disease). The Ulery North Nurse Supervisor stated during interview on 9/28/16 at 7:00 a.m., the facility had been working on a problem with documentation and staff were to complete an incident report if they noticed missing documentation from a previous shift. On 9/29/16 at 7:30 a.m., the facility provided the surveyor with a physician order [REDACTED]. 2. The MDS assessment dated [DATE], for Resident #2 documented [DIAGNOSES REDACTED]. A physician order [REDACTED]. Review of the residents record revealed the residents HgbA1C was drawn on 8/20/16 and 2/19/16, with no HgbA1C drawn between those two dates. During interview on 9/28/16 at 7:51 a.m., the fourth floor unit manager (Registered Nurse) confirmed no further laboratory draws were completed or in the residents chart.

Based on record review and staff interviews, the facility failed to provide adequate supervision to protect against hazards from self and failed to transfer the resident with a gait belt by direction of the facility Standards of Care policy (Resident #1). The sample consisted of 4 residents and the facility reported a census of 456 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment dated [DATE]. The MDS indicated the resident had severe impairment of cognitive skills for daily decision making, transferred independently and did not ambulate. The MDS dated [DATE] revealed Resident #1 had modified independence in cognitive skills for daily decision making, had short term memory impairment and required total dependence of two staff to transfer and did not ambulate. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had behavior problems that fluctuated with inattention, disorganized thing, altered level of consciousness and decreased level of psychomotor activity (moving slowly, staying in one position, staring into space). The MDS indicated the resident required 2 plus staff persons to transfer, the resident, provide bed mobility, dressing and toilet use. On 10/14/2015 and last updated 4/8/2016, the Plan of Care revealed Resident #1 had pain related to degenerative joint disease, reflux, [DIAGNOSES REDACTED] with right [PROCEDURE], rib pain and shoulder pain. The Plan of Care indicated the resident fell on [DATE] and reported right hip pain and back pain since that fall with negative x-ray results. Since that fall, the resident chose not to ambulate, but instead use the wheel chair. On 3/25/2016 the resident sustained [REDACTED]. On 7/2/2015 and updated on 4/8/2016, the Plan of Care identified Resident #1 had chronic confusion with behavioral disturbances related to cognitive/perception impairment. The resident had two falls the past quarter: On 2/3/2016 the resident fell when attempting to pull pants up after using the toilet. No injury was sustained. The Care Plan updated to include: assist of 1 to transfer, pull alarm added to wheel chair. On 3/24/2016, staff eased resident to the floor because the resident became weak during a transfer from wheel chair to bed. The resident sustained [REDACTED]. On March 25 (2016) the resident sustained [REDACTED]. Mode of transfer changed to Lyko mechanical lift. Resident became dependent with two staff for bed mobility, toilet use and bathing. Resident condition had declined prior to clavicle fracture. Resident's mood remained stable and through quarter. The family remained actively involved and was at bedside when resident passed away on 4/4/2016. Resident #1's Directives, Activities of Daily Living information that staff posted in the resident's room included: Printed on 3/25/2016 - transfer with assist of 2, wheel chair for activities. Printed on 4/1/2016 - transfer with Lyko Viking lift with medium green sling for all transfers. The Progress Notes included: 3/24/2016 at 3:18 a.m. revealed Resident #1 had right shoulder pain. Tylenol, a warm blanket and Theragesic cream administered without much relief. 3/24/2016 at 1:45 p.m. - Resident #1 complained of right shoulder and back pain. Scheduled meds given to help with pain, rested in bed 30 minutes and then yelled to get up. Two staff assisted and Theragesic cream applied. On 3/24/2016 at 2:47 p.m. - Resident #1 reported increased pain in right shoulder and entire right side down to legs, denied radiating pain or chest pain. The physician ordered Morphine oral concentrate 5 mg sublingual as needed for pain. On 3/24/2016 at 11:12 p.m. - Post Fall Documentation related to fall at 4:35 p.m. Resident attempted to transfer from wheel chair to bed with staff, I just can't do it. Staff eased resident to the floor with no noted injuries. Resident changed to two person assist with transfers. Two falls in the last 30 days; both during resident transferring. 3/25/2016 at 10:16 a.m. - Staff reported while transferring resident this morning with two person assist, they heard a pop sound from the right shoulder area. Resident immediately assisted to sit down in wheel chair and noted to have swelling and slight discoloration to inner clavicle area. The nurse practitioner ordered an x-ray that identified a fracture of the right clavicle. Roxinol given for pain. The resident transferred to the emergency department via ambulance for an evaluation. At 1:14 p.m. the emergency room provider informed the facility that Resident #1 had a complete slightly displaced fracture at the junction of the proximal and mid third right clavicle. At 11:46 p.m. staff documented the resident complained of pain all over, received pain medication, had slight swelling and bruising at the right clavicle area and wore a sling. The PRN Administration/Effectiveness Record indicated the resident received Roxinol .25 milliliter at the following times for right shoulder pain: On 3/24/16 at 4:40 p.m. On 3/25/16 at 8:45 a.m., 9:45 a. On 3/26/16 at 2:30 a.m., 10:30 a.m., 1:20 p.m., 3:10 p.m. On 3/27/16 at 9:55 a.m. On 3/30/16 at 4:30 p.m., 7:40 p.m. and 8:45 p.m. On 3/31/16 at 9:05 a.m., 1:15 p.m., 5:00 p.m. and 7:30 p.m. The resident also received as needed Tylenol for comfort and fever. On 4/4/2016 at 7:18 a.m. the Progress Note indicated the resident passed away during the night shift with family present. The Resident Incident Report dated 3/25/2016 at 8:00 a.m. indicated Resident #1 sustained a right clavicle fracture, sent to ER (emergency room ) for evaluation, given Roxinol for pain prior to leaving. Action to prevent re-occurrence: Staff education to use gait belt with transfers, awaiting return from ER. The Resident Incident Report dated 3/24/2016 at 4:35 p.m. indicated Resident #1 had an adverse event without harm. Staff helped the resident transfer from wheel chair to bed at resident's request due to right shoulder pain, and mid transfer, the resident stated he/she just couldn't do it and started going down. Staff helped the resident lower to the floor. Action to prevent re-occurrence: Care Plan changed to 2 (staff) persons with transfers. The facility Standards of Care signed by Staff A, CNA (Certified Nurse's Aide) on 2/20/2016; indicated Staff A reviewed the policies that included the use of a gait belt with any hands on transfer and ambulation. On 1/20/2016, Staff B, CNA signed the Standards of Care form that reviewed facility policies including gait belt use. During an interview on 4/20/2016 at 11:25 a.m., Staff A, CNA revealed he/she worked at the facility for [AGE] years. Staff A went to Resident #1's room to assist with a transfer. The resident's room had no gait belt. Staff A reported the resident was anxious to get out of bed and wanted to go to the bathroom. Staff A and Staff B lifted the resident up. Staff A assisted the resident on the right side, placed one arm under the resident's arm and one arm around the resident's back. When they stood the resident up, they heard a pop. The resident had been the assist of one to transfer, but had been changed the night before to assist of two. All staff received re-education related to gait belt use. During an interview on 4/20/2016 at 11:25 a.m., Staff B revealed he/she worked at the facility for [AGE] years. Staff B responded to the resident's bed alarm at approximately 8:00 a.m. Resident #1 attempted to sit up from bed and wanted to go to the bathroom. Staff B asked Staff C, LPN (Licensed Practical Nurse) who walked past the resident's room, to please get Staff A to assist. The resident's room normally had a gait belt present, but not at that time. Staff A and Staff B had no gait belt on them. Now, spare gait belts are kept on medicine carts. Staff B knew the facility required staff use a gait belt any time they touch a resident during a transfer unless the Care Plan indicates otherwise. Normally, they would have used a gait belt. Staff A and Staff B stood the resident and pivot transferred to the wheel chair, and they heard a pop in the shoulder area. The resident said that's going to hurt for a long time. After this incident they reviewed the gait belt policy and the added intervention that gait belts are also kept on the medicine cart. Staff B stated Resident #1 had been declining prior to the incident, had behaviors, and refused to eat at times. The resident made attempts to self-transfer. The night before, staff lowered the resident to the floor during a transfer. The day before this incident, the resident hit a CNA while in the dining room and said you broke my arm. During an interview on 4/21/2016 at 3:00 p.m., Staff C, LPN (licensed practical nurse) stated he/she walked past Resident #1's room, Staff B asked her/him to get Staff A. Staff C never looked into Resident #1's room. Staff never asked Staff C for a gait belt. During an interview on 4/20/2016 at 2:00 p.m., Staff D, RN (Registered Nurse) stated she was called to Resident #1's room. Staff A and Staff B had transferred the resident and they reported they had heard a pop. The resident's clavicle area appeared raised and the resident complained of pain. Staff D stated she notified the Nurse Practitioner and the resident had an x-ray that identified a fracture. The resident went to the emergency room for an evaluation and returned later that day with a sling. Staff D learned that Staff A and Staff B transferred the resident without a gait belt. Staff A and Staff B never gave Staff D a reason as to why they failed to use a gait belt. Later, when staff transferred the resident from the wheel chair to bed they used a gait belt. They had to get one, as the resident failed to have one in the room. Each resident that requires transfer assistance is to have a gait belt in the room or in the bag at the rear of the wheel chair. Extra gait belts are kept in the medication cart or in the supply closet. Resident #1 had an alarm and received end of life care for a couple of weeks prior to the incident. The resident had impulsive behaviors, would not listen and did what he/she wanted. During an interview on 4/20/2016 at 12:45 p.m., Staff E, CNA, CMA (Certified Medication Aide) reported working the day Resident #1 sustained the injury, though not present in the room at the time it occurred. Gait belts are to be kept in resident rooms. Resident #1 had a sensor alarm, would frequently yell help or would try to get up without assistance. The resident was impatient and would not wait for staff. Staff E indicated staff received gait belt education after the incident. During an interview on 4/21/2016 at 2:00 p.m., Staff E, RN reported Staff A came and reported they transferred Resident #1 and they heard a pop. Staff E and Staff D went to assess the resident and observed the area that was not in correct alignment. Staff E and Staff D felt the resident had a fracture, placed ice on the area and sent the resident for an x-ray. Resident #1 complained of pain. Staff A and Staff B indicated they failed to use a gait belt during the transfer from the bed to wheel chair, but did not say why. Gait belts are to be used for all assisted transfers. During an interview on 4/21/2016 at 3:30 p.m., Staff F, RN, Supervisor, reported he/she investigated the incident and interviewed Staff A and Staff B. One staff responded to the Resident #1's alarm and summoned help. The second staff came to the resident's room to assist. The room had no gait belt and the resident wanted to go to the bathroom and was climbing out of bed. Staff A and Staff B said they each took a side, transferred the resident and heard a pop. The resident's shoulder had an immediate discoloration. Staff A and Staff B understood the gait belt standard of care, however they felt the resident's need was immediate

Based on observation, record review, facility policy review, and staff interview, the facility failed to follow the policy for 1 of 4 residents reviewed who sustained injuries of unknown origin (Resident #11). The facility reported a current census of 533 residents. Findings include: An Incident Report dated 2/19/16 at 10:28 p.m. revealed Staff A, certified nursing assistant (CNA), responded to Resident #4's call light and request to remove the bed pan. Resident #4 became aggressive as Staff A began to provide pericare. Staff A documented he/she informed Resident #4 we have to get you cleaned up, and proceeded to turn Resident #4 onto his/her back. Resident #4 then grabbed/hit Staff A. Staff A indicated he/she pushed Resident #4's hand down and directed the resident to stop hitting so cares could be completed. A Progress Note dated 2/19/16 at 10:34 p.m. revealed Staff B, registered nurse (RN), assessed a U shaped skin tear on top of Resident #4's right hand which measured 1.5 cm x 1 cm. The skin tear was surrounded by purple, bruised skin. On 3/16/16 at 2:03 p.m., Staff A confirmed he/she completed the 2/19/16 Incident Report after Resident #4 hit him/her during pericare. Staff A demonstrated placement of his/her hand, with the palm of his hand open, then placed upon his/her forearm. Staff A stated he/she only used the palm of the hand rather than fingertips grasping the resident's forearm so you don't bruise or hurt the resident. Staff A demonstrated placement of his/her hand with fingertips touching the forearm to demonstrate how a bruise could occur. Staff A stated Resident #4 got mad. The resident asked what he/she was trying to do, and then stated, you think you're so tough. Staff A proceeded to roll Resident #4 onto his/her right side which positioned the resident's right arm under his/her body. Staff A indicated the resident was unable to move his/her right arm. Staff A demonstrated how he/she held Resident #4's left forearm with the palm of the right hand, and indicated pericare was completed with his/her left hand. Staff A felt Resident #4 could move his/her left arm from side to side, but was unable to move his/her arm upwards to hit the CNA as he/she continued to provide pericare. Staff A stated he/she pressed the resident's forearm down so the resident would not hit him/her. Staff A indicated initially Resident #4 resisted the restriction of his/her arm movement, but Staff A kept the resident's arm down during pericare. Staff A stated no other staff assisted with cares or observed the incident. When pericare was completed, Staff A exited Resident #4's room and requested Staff C, CNA, provide transfer assistance because he was frustrated and did not want to return to Resident #4's room. Staff C identified the skin tear upon entry to Resident #4's room, and reported the skin tear to the nurse. On 3/16/16 at 3:55 p.m. Staff C, certified medication assistant (CMA), stated she entered Resident #4's room and noted the skin tear on Resident #4's hand after Staff A provided cares at the end of their shift. Staff C stated upon entry into the resident's room, Resident #4 was worked up Staff C stated Staff A reported Resident #4 struck at him so he grabbed the resident's hand. Staff C did not observe the skin tear earlier in the shift. On 3/16/16 at 1:25 p.m. Staff E, RN and Nurse Supervisor, expressed concern regarding documentation noted in Staff A's 2/19/16 Incident Report. Staff E stated Staff A received verbal counseling and education that the documentation could be misunderstood and wanted to ensure Staff A was aware he could not hold a resident down. During an interview on 3/17/16, the Director of Nursing (DON) stated after the concern regarding the 2/19/16 Incident Report was identified by the surveyor, the facility reviewed the information, made corrective action and initiated an investigation. The DON indicated she was not aware of how Staff A held Resident #4 during cares. Upon scrutiny of information provided by Staff A during interview, the DON stated we would consider that potential abuse and immediately initiate an investigation had they been aware of the incident. The DON stated Staff A would have been suspended or terminated and separated from residents pending investigation. The facility Abuse policy, effective date 1/15/16, directed all employees are mandatory reporters and required to report abuse allegations immediately to a Supervisor or Administrator of the Day. The Supervisor will begin the investigation process immediately. The policy directed the Supervisor will remove the alleged perpetrator from direct care of the alleged victim.

Based on record review, staff and resident interviews and observations, the facility failed to provide adequate supervision to ensure against hazards from self for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 478 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment, with a reference date of 8/27/14, which identified [DIAGNOSES REDACTED]. The MDS reflected the resident had a cognitive score of 6. A score of 6 represented a severe cognitive impairment. Resident #1 required limited assistance of 1 person for bed mobility and limited assistance of 1 person for transfers and toilet use. Review of the Aide Directives Sheet dated 8/22/14, reflected the directive directed the staff to assist Resident #1 with 1 person for bed mobility, transfers with their walker and required toileting every 2 hours and as needed. The safety measures in place included: a blue mat beside the bed when in bed, a Zone 1 bed alarm and ask the resident if she/he needed to use the toilet on each rounds. Review of a Fall assessment dated [DATE], reflected Resident #1 had a fall score of 15 which identified the resident at a high fall risk potential. Review of the Progress Notes dated 10/19/14 at 5:37 p.m. and noted late entry for 10:00 a.m. identified the time of fall as 10:00. The note reflected that Staff A transferred Resident #1 to the bathroom per wheelchair, removed the wheelchair from the bathroom and then left the resident briefly unattended on the toilet. The staff found the resident on the floor in the door of the bathroom and crying out with right hip pain. Review of a Resident Incident Report # dated 10/19/14 at 10:00 a.m. revealed a staff member walking down the hall and heard Resident #1 yelling for help. They found the resident laying on the floor next to the resident ' s bathroom. The resident was given Tramadol (analgesic) 50 milligrams by mouth and an ice pack was applied to the right hip. The report reflected the staff transferred Resident #1 to a local hospital for an evaluation. Resident #1 sustained a fractured right hip and had a surgical repair scheduled. The incident report reflected the facility provided education with the staff regarding safety strategies for residents who have alarms prescribed in order to prevent a re-occurrence. Review of a local hospital x-ray report dated 10/19/14 reflected the resident complained of right hip pain and sustained a right lesser trochanter hip fracture. During an interview with Staff A on 11/10/14 at 2:00 p.m. Staff A stated they transferred Resident #1 to the toilet, left the resident sitting alone on the toilet and left the resident's room to offer another resident assistance. Staff A stated they were confused regarding the Standards of Care. Staff A stated she thought they could leave the resident alone on the toilet as they only had a bed alarm and not a chair alarm. Staff B (registered nurse) was interviewed on 11/5/14 at 2:10 p.m. Staff B stated Resident #1 was not to be left unattended while sitting on the toilet and she/he had a bed alarm (to alert staff when rising away from the bed). On 11/5/14 at 11:00 a.m., Staff C (resident treatment worker) was interviewed and stated any resident with an alarm cannot be left unattended when on the toilet or on the edge of the bed. On 11/5/14 at 4:50 p.m., Staff E (resident treatment worker) was interviewed and confirmed when a resident required an alarm, and then the resident could not be left unattended when sitting on the toilet. On 11/5/14 at 4:55 p.m., Staff F (resident treatment worker) was interviewed and stated a resident needing an alarm, should not be left unattended in the bathroom unless it would be specifically care planned for this (direction).

Based on observation and staff interview, the facility failed to serve and store food and kitchen equipment under sanitary conditions. The facility census was 476 residents. Findings include: 1. Observation during the initial dietary tour on 8/25/14 at 9:50 a.m. with Staff A, Assistant Food Service Director revealed the following: a. The Hobart 2 door refrigerated salad roll-in had a large partially empty sheet pan of watermelon jello and a partially full sheet pan of raspberry jello, both made on 8/24/14 with no covers on either pan. Large sheet pans of 7-Up marshmallow jello, lemon jello and peach cream jello with expiration dates of 8/29/14 and no covers on the pan. Staff A commented staff should have covered the pans. b. The Traulsen thickened juices refrigerator had 2 glasses of red honey thickened drink, 1 glass of orange honey thickened drink, 1 glass of honey thickened punch and 1 glass of honey thickened nectar with expiration dates of 8/23/14. Staff A commented staff should have discarded the expired drinks. The pan storage area contained eight large cook roaster pans had pitted and rusted areas on the inner surface and greasy residue on one of the pans. Four small roaster pans had pitted and rusted areas on the inner surface. Forty-one stacked pizza pans had scattered areas of greasy coating and white residue present. Staff A reported it might be a lime remover substance. A large inverted shallow 2 inch pan liner had a greasy residue. Twenty-one 4 inch half pans were stacked wet with soiled surfaces on 6 of the pans. Staff A reported staff were to ensure pans were dry before stacking and storing. One 2 inch half pan had a soiled surface. Twelve 4 inch stacked steam table pans were wet with a white residue on one pan. Four 2 inch stacked steam table pans were wet with residue on two of the pans. One cereal pan was stored wet with residue on the surface. Eleven 1/3 inch steam table pans and two 6 inch deep pans were stacked wet. Six large pans had pitted inner surfaces. Eleven metal measuring cups of various sizes had pitted areas on the interior surfaces. One large fry pan had pitted inner surfaces and one sauce pan had dried food on the inner surface and four sauce pans had pitted inner surfaces. On 8/25/14 at 11:45 a.m., Staff B, cook reported the pizza pans were used approximately once a month. 2. Observation of the Canteen on 8/25/14 at 11:20 a.m., with the Canteen Manager revealed the Hobart 2 door refrigerator had 2 rusty shelves in the bottom of the refrigerator. One of the shelves had a heavy later of rust and a hand held can opener had rusted areas on the blade. 3. Observation of the refrigerator/freezer in the kitchenette on Dack 4th floor on 8/25/14 at 12:29 p.m., revealed 9 inch by 13 inch cake pan in the refrigerator with partially gone chocolate dessert with no date or label. Two covered dishes of ice cream in the freezer had resident names with no dates. 4. Observation of the refrigerator in the kitchenette on Dack 3rd floor on 8/25/14 at 12:38 p.m., revealed a partially full 15 ounce jar of Great Valu Guacamole Dip with a resident's name and no date of opening. 5. Observation of the refrigerator in the kitchenette on Loftus 2nd floor on 8/25/14 at 12:50 p.m., revealed a styrofoam take out container of potato salad, chicken and baked beans with a resident name and no date. During the tour, Staff F, Dietitian, verified the container lacked a date and reported the resident's food was brought in on 8/22/14 and needed to be consumed that day (8/25/14). 6. Observation during the environmental tour on 8/27/14 at 7:33 a.m., revealed the Dack 1st floor activity storage room refrigerator next to the dining room had two containers of unopened commercial potato salad . In a plastic bag on the shelf above the potato salad was a prepackaged container labeled DMF Bart Co. Canadian Nightcrawlers and a partially gone blender bottle of a brown liquid had no name or date. A sign posted on the refrigerator read; "All items must have a dated label". 11. During observation in the Ulery 6 unit on 8/26/14 at 11:30 a.m., Staff P, activities plated food in the kitchen area. Staff P wore gloves and touched a large knife handle, the outside of an ice cream bucket which held shredded lettuce, a spatula handle and the handle of a large scoop on the steam table. Staff P used the same gloved hand to pick up tomato slices and bread and plated the items for a resident. Staff P changed their gloves, touched the handle of a utensil on the steam table and the outside of the lettuce bucket with their gloved hands. Staff P then touched a tomato, bread and reached the gloved hand into the lettuce bucket and grasped lettuce and placed the items on the bread and plated the items for a resident. During the observation, Staff P repeatedly touched utensils, the outside of the lettuce bucket and refrigerator handle then touched food items and plated them for residents. During interview on 8/28/14 at 10:40 a.m., the Administrator of Nursing stated activities staff were trained on proper food service techniques.

Based on observation, dietary menu review, facility policy review and staff interview, the facility failed to ensure 32 residents on a pureed diet received food in the amount planned during observation of one meal service. The facility census was 476 residents. Findings include: 1. The Therapeutic Spreadsheet dated 8/27/14, noted the Pureed Serving included a Number #10 scoop (1/3 cup serving) of pureed country fried steak. Observation on 8/27/14 at 9:25 a.m., showed Staff Q, Cook placing 40-1/3 cups (using the #10 scoop) of ground country fried steak into a large Robot (blender) to puree. Staff Q added a large quantity of beef broth and 1/4 cup of thickener and continued to blend. After the mixture was blended, Staff Q took a #10 scoop and counted out 40 servings and placed the fried steak mixture directly into the steam pan. Staff Q did not measure the full mixture of pureed meat to calculate a full serving size for each resident. The leftover pureed meat in the Robot measured slightly over 2 1/2 servings (of #10 scoop). Staff Q placed the Robot, with the leftover pureed meat into the dishwasher machine. Staff Q stated of always preparing pureed meat by always using the scoop size that was designated on the spreadsheet menu for the pureed diets. The facility's Simplified Diet Manual dated 2012, listed a method for determining the portion sizes of consistency altered foods that included the following: a. Measure out desired number of servings into container for pureeing. Puree the food. Add any necessary thickener or liquid to obtain desired consistency. b. Measure the volume of the food after it has been pureed. c. Divide the total volume of the food by the original number of portions. This is the new portion size.

Based on observation and staff interview, the facility failed to provide a safe environment for residents. The facility census was 476 residents. Findings include: 1. During the environmental tour on 8/26/14 from 1:02 p.m. to 3:22 p.m., the Loftus parts room (L021) had two tanks of Qwik Freeze Portable Pipe Freezing Equipment labeled "Caution: CO gas" that were not secured to keep from tipping. The Security Officer reported that the tanks should be secured. On 8/26/14 at 3:05 p.m., Staff I, storekeeper reported one tank was full and the other approximately 1/2 full. Staff I commented they did not know why the tanks were there.

Based on observation and staff interview, the facility failed to provide a clean, comfortable and homelike resident environment. The facility census was 476 residents. Findings include: 1. Observation during the environmental tour on 8/26/14 at 1:00 p.m., revealed the floor tiles in the beauty shop had numerous discolored tiles around and between three shampoo chairs. Large rubber mats on the floor by the shampoo chairs had large areas of discoloration. The contract housekeeping service schedule indicated the beauty shop floor was stripped and refinished annually and the floor was polished on a monthly basis. 2. Observation during the environmental tour on 8/27/14 at 7:33 a.m., revealed the ceramic shop sink countertop had three chipped areas with the largest measuring approximately 1 inch by 1/4 inch. Eighteen cabinets under the countertops in the resident work area with chipped or missing areas of veneer with scattered splinters and roughened areas. Two shelves in the left lower cabinet had a large amount of residue. The two door spray cabinet had large areas of rust and missing paint on the door edges. Staff K, Activity Assistant stated housekeeping staff did not clean the cabinets and ceramic shop staff had a hard time keeping up with cleaning the cabinets.

Based on observation, record review and staff, family, and resident interviews the facility failed to provide adequate supervision to ensure against hazards from self and failed to revise the Care Plan to meet the resident ' s safety needs for 1 of 6 residents reviewed (Resident #3). Findings include: 1. The Minimum Data Set (MDS) assessment with reference date of 6/6/13, documented Resident #3 had [DIAGNOSES REDACTED]. The MDS indicated the resident scored 10 out of 15 for a brief interview for mental status. A score of 10 identified the resident as moderately impaired for decision making skills. The MDS revealed the resident required no assistance for bed mobility, walking, transfers and toilet use. The MDS documented the resident had no functional limitations to the upper or lower extremities. The Care Plan identified a problem on 11/20/12 with the resident as a high risk for falls related to impaired muscular-skeletal osteoporosis, pain, use of high risk medications, history of falls resulting in injury, difficulty walking at times with edema, and fluid imbalance. The Care Plan directed staff to use a bed alarm set on zone 1 when the resident is in bed for the night. The Care Plan lacked specific details as to the actual time the alarm is to be activated or deactivated. The Care Plan directed staff to encourage the resident to wear non-skid footwear with transfers, keep pathways clutter free, keep call light in reach when in room, keep frequently used items in reach, and directed staff to keep the bed in a low locked position. An assessment Fall Risk with a reference date of 12/10/12 documented a total score of 15 for the resident. The Assessment Fall Risk revealed a total score of 10 or greater indicates a resident should be considered high risk for potential falls, and a prevention protocol should be initiated immediately and documented on the care plan. The Assessment Fall Risk comments documented an annual assessment which included; the resident had three falls this past quarter to include dates 9/11/2, 9/22/12, and 10/10/12. The fall on 9/11/12 indicated the resident had been found on the floor at the entrance of the room with walker next to the bed, the resident reported scooting to the door after an attempt to stand and feet slipped, with no injury reported. The fall on 9/22/12 indicated the resident fell in the bathroom, the resident reported to have slipped which resulted in right knee pain. The fall on 10/10/12 documented the resident did not have on non-skid footwear and slipped next to the bed, was incontinent of urine, and sustained a skin tear to the left elbow and pain to the left foot. The resident had five falls this year 5/30/12, 7/11/12, 9/11/12, 9/22/12, and 10/10/12. A Resident Incident report dated 1/15/13 at 10:25 p.m. documented the writer went to answer the resident ' s bathroom light and found the resident sitting on the floor. The writer (of the report) asked the resident what happened and the resident reported falling when getting off of the toilet. The Incident reported documented the resident had a red right elbow. The incident report lacked documentation of whether the bed alarm had sounded. The Post Fall Documentation dated 1/15/13 at 10:28 p.m. documented the resident received education to ask for assistance with ambulation if feeling weak or tired and to use the walker when ambulating, and updates to care plan not needed. An Assessment Fall Risk dated 1/15/13 documented a total score of 11. The Assessment Fall Risk comments reflected the resident had been found sitting on the bathroom floor, and the resident reported standing from the toilet and falling. The resident ' s range of motion was identified as within normal limits, and the resident did not use the walker, or have eyeglasses or hearing aids. The Resident Incident Report dated 5/05/13 at 1:49 p.m. indicated the resident ' s call light was activated and was found on the floor in front of the toilet. The resident reported she/he had just lost balance. The Incident Report documented the resident sustained [REDACTED]. The Post Fall Documentation dated 5/05/13 at 4:05 p.m. revealed the resident received reinforced education for the resident to call for transfer assistance. The discussion of a pull away alarm to alert staff occurred, but the resident declined this option. The Post Fall Documentation lacked any other intervention put in place other than the repeat of resident education as per the previous fall. The Resident Incident Report dated 6/09/13 at 5:15 p.m. documented the description of the event as an unwitnessed fall in the resident ' s room, the resident was found by staff sitting next to the bed, the resident reported falling in the bathroom when ambulating from the toilet to the sink due to loss of balance and fell on the buttocks. The resident did wear non-skid socks, no obstacles where in place. The resident reported pain in the right fourth and fifth toes; however no injuries were evident upon exam. The action to prevent re-occurrence revealed fall prevention strategies are in place and appropriate for the resident. Staff continued to encourage the resident to use the wheeled walker as well as non-skid footwear when up. Resident also had a bed alarm in place when in bed. The report lacked documentation that the bed alarm had sounded. The Post Fall Documentation dated 6/09/13 at 5:45 a.m. documented education had been provided to the resident to call for assistance when needing assistance or feeling unsteady, and to also use the wheeled walker when ambulating. The Post Fall Documentation indicated fall prevention strategies reviewed and no changes are warranted at the present time. The Resident Incident Report dated 7/03/13 at 8:00 a.m. documented the resident had fallen on the floor next to the outside wall with head towards shower and feet just outside the door of the bathroom. The resident reported to the writer " I broke my hip and it is worst then the last time. " Staff reported hearing a resident yelling that they had fallen. When staff arrived, the resident ' s head was under the wheelchair, no light was on in the bathroom and the walker was over by the sink. The resident reported heading to the bathroom but had a feeling of going down a long hallway and got tired and fell . The resident had on non-skid slipper socks. Writer noted deep purple bruising starting to the left outer thigh. The resident denied hitting head with the fall. Three staff assisted the resident to the bed with a full lift. The resident had been incontinent. The treatment required indicated an x-ray of the left hip and pelvic area had been completed, then the resident had been transferred to the hospital after the x-ray was positive for a fracture. The Incident Report lacked documentation if the bed alarm had been sounding. The History and Physical dated 7/03/13 documented that the residents x-ray showed a left hip fracture. The Shift to Shift Rounds dated 6/8/13 and 7/3/13 documented the ongoing and off going staff checked that all the residents were present and all safety strategies were in place. Observation on 7/17/13 at 9:20 a.m. revealed the resident in bed with a bed alarm set on zone 2. The alarm controls were not covered. The alarm cover was on a table in the resident ' s room. During an interview on 7/17/13 at 9:20 a.m. Staff D, Registered Nurse, reported that the alarm cover should have been on the bed (to disguise the bed alarm controls), then Staff D covered the alarms with the plastic cover device. During an interview on 7/16/13 at 11:45 Staff D, Registered Nurse (R.N.) reported the following interventions for the resident: floor strips added on 9/11/12, zone 1 bed alarm and one-half side rails added on 10/17/13, then since 1/30/13 post fall interventions have been education provided to the resident, then after the 7/03/13 fall zone 2 bed alarm, floor mats, and a cover over the alarm controls were put in place. During an interview on 7/17/13 at 9:20 a.m. the resident answered orientation questions correctly as to the time of day, what the resident had for breakfast, names of offspring, and the residents ' date of birth. The resident reported that he/she could not remember much about the fall, it just hurt. The resident reported he/she did not know he/she had a bed alarm. During an interview on 7/17/13 at 10:55 a.m. Staff A, Certified Nurses Aide (C.N.A) could not recall if the alarm was sounding when she found the resident on the floor on 6/09/13 at 5:45 a.m. Staff A reported accountability checks (shift to shift rounds) are completed with the ongoing and off going C.N.A ' s, which include verification that all the safety precautions for each resident are in place and location the of each resident is established. The resident will ask for help if he/she needs it, the resident is pretty much independent. During an interview on 7/17/13 at 9:30 a.m. Staff C, R.N. reported that she worked on 6/08/13 from 10:00 p.m. to 6/09/13 at 6:30 a.m. Staff C reported that Staff A, C.N.A informed her that the resident had fallen. Staff C could not remember is the alarm was sounding when she entered the room to assess the resident at 5:45 a.m. on 6/09/13. Staff C reported the resident stated getting up at 3:30 a.m. Staff C reported the resident doesn ' t usually get up that early. Staff C reported the resident had been fully dressed for the day. During an interview on 7/17/13 at 10:10 a.m. Staff G, R.N. reported that the accountability checks started on 1/28/13. During an interview on 7/17/13 at 9:45 a.m., Staff D, R.N. accountability checks are performed with the staff starting the shift and staff leaving the shift (C.N.A staff), at which time safety precautions are checked. During an interview on 7/17/13 at 3:30 p.m. Staff B, C.N.A reported she works day shift routinely. Staff B reported that the resident is usually up before 6:15 a.m. Staff B reported accountability checks are done with both ongoing and offgoing C.N.A staff, which include safety precautions like alarms, floor mats. During an interview on 7/17/13 at 4:10 p.m., Staff H, C.N.A reported she usually worked second shift. Staff H, reported the resident would typically go to bed at about 9:00 p.m., and that ' s when the bed alarm is turned on. Staff H reported she did know if the resident ever shut off the bed alarm. Staff H reported the resident would ask for help occasionally to put on gown at night, and ask for help for foot soaks at night. During an interview on 7/17/13 at 4:15 p.m. Staff I, C.N.A reported she usually worked second shift. Staff I reported the resident would put on the call light if needing help, but the resident was usually independent. Staff I reported she was never aware that the resident shut off the bed alarm. Staff I reported the bed alarm would be put on when the resident went to bed, at about 9:00 p.m. During an interview on 7/16/13 at 11:25 a.m. Staff F, C.N.A reported that the resident was in a locked bed at 6:25 a.m. on 7/03/13 with the bed alarm on zone one, and the call light was in reach. Staff F, C.N.A reported that the resident was not out to the dining room by 8:00 a.m. on 7/03/13. Staff F reported she stopped to go to the bathroom before checking on the resident, and while in the bathroom she heard a resident yell for help. Staff F reported she finished in the bathroom, and then asked Staff E, R.N. to check on the resident. Staff F went to check on the resident also and that is when she found the resident on the floor in the bathroom with the residents feet towards the entrance to the bathroom. Staff F reported no alarm was sounding when entering the room. Staff F reported the resident is to have the bed alarm on at night per the residents care plan. Staff F reported the resident was usually up in the morning when accountability checks are done. Staff F reported that she did witness the resident shut off the bed alarm once and passed it onto the nurse on duty, but not sure which nurse that was. During an interview on 7/17/13 at 9:50 a.m. Staff F, C.N.A reported that during the accountability checks on 7/03/13 at 6:25 a.m. the resident was in bed asleep, the bed alarm was on, the bed was in the locked and low position, and the a call light was in reach of the resident. During an interview on 7/16/13 at 11:00 a.m. Staff E, Registered Nurse, stated Staff E reported prior to the resident ' s last fall, the resident was independent with transfers, but did call staff for help if needed assistance to propel wheelchair when the resident was tired. Staff E reported the resident was very hard of hearing, but could use a marker board for communication. Staff E reported Staff F informed her the resident had fallen on 7/03/13 at about 8:00 a.m. Staff F demonstrated to the surveyor where and how the resident was found on the floor of the resident ' s bathroom. Staff F reported the resident wore non-skid slipper socks, a walker was close to the sink, a wheelchair was in front of the toilet, and the resident was lying along the left side of the bathroom wall when entering the bathroom, with the feet pointed towards the entrance of the bathroom. Staff E reported no alarm sounding. Staff E stated the resident ' s feet are so deformed that the resident could not wear shoes, due to the resident ' s feet almost being heel to heal when walking with toes pointed outward. Staff E stated the resident informed her she/he had broken a hip and it was worse than the last time. Staff E reported the resident had a history of [REDACTED]. Staff E reported the resident ' s family was notified, as well as the physician, and then an x-ray was completed which confirmed a fracture. The resident was then transported to the hospital for surgical repair. Staff E reported the resident was not known to walk without the walker. Staff E identified the resident to be independent with walking in the resident ' s room and would use the wheelchair in the hallway. The resident would use continuous oxygen per a nasal cannula due to shortness of breath. On 7/16/13 at 9:18 a.m. Staff D, Registered Nurse was interviewed and stated the resident will not be able to bear weight for a month. The resident does already receive an as needed narcotic medication for chronic deformed foot pain. Staff D reported the alarm did not sound related to the 7/3/13 8:00 a.m. fall, but the resident is usually awake in the morning anytime between 5:30 a.m. and 7:00 a.m. Staff D stated the staff had reported to her that they saw the resident shut off the alarm about four months ago, but it did not get passed on in report. On 7/16/13 at 1:06 p.m. the resident ' s family member was interviewed and stated the resident had been weaker since January of this year, and showed a steady slow decline. The family member stated staff had asked him/her if the resident could shut off the bed alarm, and the resident ' s family member did not know if the resident could shut off the alarm. The resident ' s family member stated the facility staff reported the alarm did not sound when they entered the room on 7/03/13. The resident ' s family reported the resident had trouble lifting his/her feet prior to the fall.

Based on personnel record review, facility policy review and staff interview, the facility failed to ensure staff completed mandatory dependent abuse training within six months of employment for one of sixteen employees reviewed. The facility census was 501 residents. (Staff D) Finding include: 1. Personnel record review documented the facility hired Staff D, Resident Aide on 8/27/12. The personnel file lacked evidence of mandatory reporter training for dependant adult abuse. During interview on 6/6/13 at 8:20 a.m., the Nursing Administrator stated Staff D had the training but there were no records to verify it. The Nursing Administrator stated the facility had Staff D complete the training on 6/5/13, and provided the surveyor the record of training for that time. Facility policy entitled Recognizing, Responding to and Preventing Resident Abuse, Employee Education, dated 9/16/11, documented all employees would attend a mandatory two hour session upon their employment at the Iowa Veterans Home and every five years thereafter.

Based on clinical record review and staff interviews, the facility failed to ensure staff provided adequate supervision and assistive devices to ensure against hazards to self and the health service supervisor failed to supervise the implementation of the planned interventions to prevent falls which resulted in the resident fracturing the left hip (Resident #1). The sample consisted of 5 residents. The facility identified a census of 525 residents. Findings include: 1. A Progress Note dated 1/1/11 thru 12/31/12, documented Resident #1 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 4 of 15 and required extensive assistance of 2 staff with bed mobility, transfers, ambulation in his/her room and corridor and as dependent on staff with dressing and personal hygiene. A Plan of Care dated 2/2/12, documented the resident had the following fall safety strategies in place: a. Bed locked and in the lowest position. b. Call light in reach. c. Hip pads at all times. d. Room well lit and clutter free. e. Hard soled, properly fitting footwear when up. f. Bed alarm at all times. g. Gripper socks at his/her hour of sleep. h. Top side rails at all times. i. Assistance with toileting when up at night. (due to a history of urinating on the floor) j. Wheelchair for all off unit activities, except to and from the bus. k. Chair alarm when up. l. Blue mat on the south side of the bed. m. Strongly encourage the resident to lie down to stretch out in between meals. n. Do not leave unattended while on the toilet and/or commode at bedside. A History Assessment form dated 7/27/12 at 7:47 a.m., documented Resident Treatment Worker (RTW) had alerted the writer the resident's roommate had put on his/her call light to alert staff the resident was on the floor on his/her side of the room. The resident was found lying on his/her left side with blood under his/her head. The resident complained of left hip pain around the pelvic area and left elbow pain. The form documented a Registered Nurse Assessment revealed a three centimeter (cm) by 4 cm red abraded area over the resident's left knee with some swelling noted. The resident complained of left hip pain in the pelvic/groin area with an extension of the leg. The resident also complained of left elbow pain with a 21 cm by 2 cm purple bruise noted distal to the left elbow, a 3 cm skin tear on his/her left elbow, an abraded area over the Resident's left temple, a 1.2 cm skin tear to the back of his/her left ear and a 1.2 cm skin tear to the neck/head area directly behind the Resident's left ear. The Action to Prevent Re-Occurrence portion of the report documented the resident's bed alarm was not on and the resident had no gripper socks or hip pads on as directed by the care plan. A Radiology Report dated 7/27/12, documented the resident sustained [REDACTED]. During an interview on 8/16/12 at 10:15 a.m., Staff B, Laundry worker, confirmed he/she had been supplying the linen closet on Dack 3 when he/she heard a resident say " help " as he/she heard a trash can fall. Staff B responded to the request for help and found the resident positioned on his/her back on the floor in his/her room by the room divider wall. Staff B stated the resident had only been wearing a disposable undergarment and the bed alarm was not sounding. Staff B consoled the resident and immediately requested assistance from an unknown nurse. During an interview on 8/16/12 at 9:05 a.m., Staff D, RTW confirmed during rounds at midnight the resident had on hipsters. Staff D stated unsure if he/she had assisted the resident at 2:00 a.m. for rounds but knew that Staff J, RTW had assisted the resident at 4:00 a.m. Staff D stated the next thing he/she knew, Staff B came to him/her and stated the resident as on the floor. Staff D ran to the resident's room and the resident was found lying on his/her left side on the floor by the divider wall without the bed alarm sounding. The resident wore only a Depend (disposable brief) undergarment, with no clothes or hipsters. Staff D yelled for the nurses who immediately came to the resident's room and assisted. Staff D confirmed he/she was aware the resident required hipsters and a bed alarm since moving to Dack 3 several months earlier and the information was documented on the Resident's Care Plan. A facility interview document, completed on 7/31/12 at 6:30 a.m., with Staff J, (RTW), confirmed he/she performed rounds for the resident on 1st, 2nd and 3rd rounds and the resident required a bed alarm and hipsters. Staff J confirmed the bed alarm was on but the resident did not wear the hipsters. On 8/15/12 at 12:40 p.m., Staff H, RTW, was interviewed and confirmed on 7/27/12 at approximately 5:15 a.m., she assisted the resident with morning cares. When Staff H pulled back the resident's covers, the resident began to kick. At that point Staff H asked Staff I, (RTW) who had been assisting the resident's roommate, to come and assist with cares. Staff H stated when the resident was kicking at her, the bed alarm did not sound and the resident had no hipsters or socks on his/her feet. Upon completion of the morning cares, Staff H confirmed she left the resident in bed with a shirt and Depend undergarments, but no hipsters and no bed alarm prior to exiting the room. A facility interview document completed on 7/27/12 with Staff I, RTW, confirmed he/she assisted the resident with morning cares on 7/27/12, but had not put on hipsters or gripper socks and/or turned on the resident's bed alarm prior to exiting the room. During an interview on 8/15/12 at 11:10 a.m., Staff K, Registered Nurse, confirmed the resident was on the floor on the roommates side by the divider wall. The resident had been wearing a hospital gown with white socks and no hipsters and the bed alarm was not sounding. During an interview on 8/16/12 at 11:10 a.m., Staff L, Nurse Clinician, confirmed the resident was found on the floor on the roommate ' s side by the divider wall. The resident was wearing a hospital gown with white socks, a brief and no hipsters and the bed alarm was not sounding. A facility interview completed on 7/28/12 at 10:25 a.m., Staff M, RTW, confirmed the resident was required to wear hipsters and have his/her bed alarm on when in bed. A facility interview document, completed on 7/28/12 at 10:32 a.m., indicated Staff N, (RTW) confirmed the resident was required to wear hipsters and have his/her bed alarm on when in bed.

Based on clinical record review, staff interviews and review of manufacturer ' s guidelines, the facility failed to ensure adequate staff knowledge and use of a resident safety device for Resident #1 and the facility director of nursing failed to supervise the implementation of the planned interventions so alarms sounded and alerted staff the resident was attempting to self transfer without staff assistance for one of eight residents reviewed with a history of falls. The facility reported a census was 517 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]., anxiety and osteoporosis. The MDS assessment documented the resident required total assistance of two staff persons for bed mobility and extensive assistance of two staff persons for transfers. A fall summary dated [DATE], indicated the resident had attempted to self transfer from the bed unassisted and or would sit at edge of bed with an attempt to transfer so a bed alarm was placed to prevent the resident from falling. The Plan of Care dated [DATE], included a problem of palliative care related to distressing symptoms, debilitating conditions, potential for an unpeaceful death as exhibited by pain, poor nutritional intake, need for assistance with activity of daily living (ADL) and family desire for palliative care. The problem included a goal to have pain/distressing symptoms well controlled and comfort care needs met. The interventions included for falls were: a. Resident not to sit at edge of bed unattended. b. If fall occurs, obtain vital signs and notify nurse. c. Resident may sit on toilet unattended with Medlift brakes on. d. Keep room free from clutter. e. Maintain adequate lighting in room. f. Place non-skid slipper socks before transfers. g. Keep call light in reach at all times. h. Keep bed in lowest position with bed brakes on at all times. i. Strip bed alarm when resident in bed. Respond immediately if activated to prevent falls. A fall summary dated [DATE], indicated the resident as at high risk for falls. The summary documented the resident had been a Medlift (electric lift) transfer with two staff at all times due to poor weight bearing. The summary indicated the resident no longer ambulated and had not attempted to transfer self out of the bed unassisted, or sit at the edge of the bed during that quarter. The summary indicated the resident had a history of [REDACTED]. An incident report dated [DATE] at 8:50 p.m., indicated the resident was found on the floor lying on left side and halfway under the bed. The form indicated the resident had bruising of the left shoulder, left elbow, right foot 2nd toe, and a large bruise to the right lower leg just below the knee. The resident complained of pain to left leg with movement. The form indicated the bed strip alarm was not sounding at the time of the fall but had sounded earlier when staff got the resident up. An action to prevent re-occurrence was a new strip alarm put on the bed that worked properly and a blue mat on the floor by the bed. The form indicated fall precautions were in place and the bed alarm did not alarm. The form included no documentation that staff had checked the alarm function at the time the resident was laid in bed. A nursing progress report dated [DATE] at 9:41 p.m., documented the resident was found on the floor on his/her left side and partially under the bed. A progress note dated [DATE] at 10:04 p.m., documented the resident was seen by the Advanced Registered Nurse Practitioner (ARNP) who determined the resident did not have any abnormal findings. A nursing progress note dated [DATE] at 1:32 p.m., documented the resident was in too much pain with movement of extremities so the resident was kept in bed for comfort. A physician progress notes [REDACTED]. The note documented the ARNP at the time felt the resident did not have an acute fracture, but earlier that day the RN stated the leg may have been more outwardly rotated and the resident complained of pain in the leg with range of motion. The ARNP documented there was still no clear indication of a fracture. A physician progress notes [REDACTED]. The note documented the resident had an acute fracture on the right proximal tibia and fibula, and the distal left femur (displaced). The note documented the resident was not a good candidate for major surgery due to lung and heart condition. A nursing progress note dated [DATE] at 11:25 a.m., documented the resident stated he/she hurt everywhere and stated "oh God, don't touch me". A nursing progress note dated [DATE] at 2:13 p.m., documented the resident had an orthopedic appointment and was issued bilateral immobilizers to the lower extremities. A final summary for the resident dated [DATE], documented the resident expired on [DATE] at 11:20 a.m., with [DIAGNOSES REDACTED]. On [DATE] at 10:30 a.m., Staff G, Regulatory Compliance Officer reported the resident expired and stated the cause of death was due to fractures sustained when the resident had fallen out of bed. During interview on [DATE] at 11:05 a.m., Staff F, Nurse Supervisor-2 showed the surveyor the sensor strip alarm that was on the residents bed. At that time, Staff F stated Malloy nursing staff were unaware the alarm had a switch for a volume setting under the battery cover. The switch under the cover revealed it to be in the low volume setting. Staff F stated the switch was on the low setting when the resident had fallen out of bed. Staff F stated that to check the alarm system for proper function staff should listen for a single beep from the alarm when a resident was laid down. Staff F stated staff who had laid the resident in bed the day of the incident were not able to recall if the alarm sounded upon laying the resident on it. Staff F showed the surveyor a small red light on the front of the alarm box and stated the light was an indicator when on to alert staff of a low battery on the alarm. Staff F pointed out two larger red lights on the top of the alarm box and stated when the alarm sounded the red lights flashed. Staff F pointed out a push button on either side of the alarm and stated the alarm would be silenced by pushing the buttons simultaneously. On [DATE] at 3:15 p.m., Staff F stated if staff did not hear a beep upon laying a resident down, they should tell the charge nurse. Staff F stated he/she felt one of the problems with the alarm could have been the alarm box would be placed behind the headboard of the bed and it could have prevented staff from hearing the alarm when the resident was laid down, or that the television or other extraneous noise could have interfered with their ability to hear the beep indication the alarm was working. A manufacturers user manual for the alarm system used on the resident, included a directive to test each pad before each use and remove it from service at any sign of damage or at the end of the stated life of the pad (as labeled on it), whichever comes first. The manual included a directive to replace the battery immediately when the red low battery light on the control unit went on. The control unit would not function properly with a low battery. A review of the manufacturers guidelines revealed the alarm used on the resident had three volume settings, high, low and nurse call (for call light system activation). A review of the facility investigation revealed an interview with Staff C, Resident Treatment Worker, RTW on [DATE] at 10:15 p.m. Staff C reported laying the resident down after supper that evening. Staff C did not remember if the alarm beeped when the resident was put in bed. Staff C reported the alarm was not been beeping when he/she found the resident. During interview on [DATE] at 2:00 p.m., Staff C, RTW stated Staff D and Staff E had gotten the resident up and stated the resident ' s alarm had gone off. Staff D stated he/she laid the resident down and did not recall the alarm beeping then. Staff D stated he/she did not know how to check an alarm for a low battery. The facility investigation included an interview with Staff D, RTW on [DATE] at 10:34 p.m. Staff D reported he/she assisted the resident to get out of bed at 3:00 p.m. or 3:40 p.m. on that evening and the resident ' s alarm had sounded for about 3 seconds, and the alarm shut off as he/she reached to turn it off. Staff D reported the resident was hallucinating for a couple of days. On [DATE] at 3:04 p.m., Staff D was interviewed and stated the resident was seeing people in light for two to three days prior to the incident. Staff D stated a couple of the girls found the resident on the floor and yelling at his/her roommate. Staff D stated he/she did not remember caring for the resident that day, and did not remember getting the resident up. Staff D stated he/she did not know how to check if an alarm battery was low on strip alarms, but did know that you had to push the two side buttons to see if it worked. Staff D stated that if the alarm did not beep when you laid a resident down you should tell the charge nurse. The facility investigation included an interview with Staff E, RTW on [DATE] at 10:27 p.m. Staff E reported he/she and Staff D had gotten the resident up before supper and the bed alarm went off. Staff D stated he/she assisted the resident back to bed after supper but did not remember doing anything with the alarm, and did not remember if it beeped or not but assumed it had not because he/she would have remembered it beeping by the noise. Staff D reported the resident ' s bed alarm was not sounding upon entering the residents room after the resident had fallen. During interview on [DATE] at 1:54 p.m., Staff E, RTW stated he/she had helped Staff C put the resident to bed on the day of the incident. Staff E stated he/she did not know the resident had an alarm and Staff C and Staff D had gotten the resident up, and he/she watched. Staff E stated the resident was seeing people and remembered that from report. Staff E stated it was his/her first day and he/she did not know if he/she should have helped lay the resident down. Staff E stated the resident had two half rails up but did not remember the position of the bed or how high it was. Staff E stated he/she did not remember hearing an alarm sound at all when the resident was put in bed. Staff E stated he/she had not known anything about the alarms on the day the resident had fallen. The facility investigation included an interview with Staff B, RN on [DATE] at 11:08 p.m. Staff B reported he/she responded to the incident and found the resident on the floor and under the bed, but did not know how he/she got there. Staff B stated the resident ' s side rail was up and the alarm was not sounding. Staff B described several bruises including one to the residents right lower leg under the knee that looked like the resident bumped it really good. Staff B stated the resident complained of a lot of pain whenever the leg was moved. Staff B reported one of the staff was orienting another and when they put the resident back in bed, they stated they did not remember hearing the alarm go off when they put the resident on it, so it had not sounded when the resident was on the floor. Staff B stated it came back to the fact that the alarm was beeping when they got the resident out of bed, and it did not seem to be beeping when they put the resident back in the bed. During interview on [DATE] at 12:38 p.m., Staff B, RN stated the resident was hallucinating prior to the day he/she fell and talking about helping a guy. Staff B stated all he/she knew was the RTWs got the resident up and he/she did not eat well for supper, and the RTWs laid the resident down with a strip alarm on the bed. Staff B stated he/she was not notified of any problems with the alarm until after the resident fell . Staff B stated an RTW came out of the resident ' s room later and stated the resident was on the floor. Staff B stated the resident was on the floor on his/her left side, under the bed. Staff B stated the bed was in the lowest position and the resident was under the edge of it. Staff B stated the resident had only the top side rails up. Staff B stated his/her understanding was one of the RTWs stated he/she did not hear the alarm beep when the resident was laid on it. Staff B stated in the past the resident had attempted to get up without help but did not know when. During interview on [DATE] at 8:49 a.m., Staff A, RTW reported being one of the staff who responded when the resident fell . Staff A stated the resident was lying on the floor with their head toward the wall. Staff A stated he/she picked up the alarm that was attached to the head board and noticed no lights flashing and the alarm was not sounding. Staff A stated all alarm batteries were changed monthly and he/she would not think they would go low. Staff A stated when you lay someone down and the alarm does not beep that tells you it is not working. Staff A stated one should then check the cords and if it looked okay you should notify the charge nurse the alarm was not working. On [DATE] at 10:00 a.m., Staff G provided the surveyor a list of residents with alarms. The list included ten residents with bed alarms and seven residents with chair alarms. On [DATE] at 10:52 a.m., Staff G stated the facility currently had two residents which used the strip alarms. On [DATE] at 10:07 a.m., Staff F stated after the incident all staff were educated on how to check a battery and check for proper functioning of the strip alarms. Staff F at that time stated it was difficult making sure that all staff were educated on things when necessary if they did not attend meetings, and sometimes the facility relied on the staff peers to relay information. On [DATE] at 11:34 a.m., Staff F stated the facility had no policy to direct staff about what to do if an alarm did not work properly. Staff F stated staff do not document specific information to indicate that alarms are checked for proper functioning each shift, but did document on an accountability form that indicated for each shift they knew where the resident was at, that fall precautions were in place and alarms were on and functioning when the resident was laid down. Staff provided the surveyor with a copy of the form that revealed no staff initials to indicate accountability for the ,[DATE] shift on [DATE]. A monthly alarm check and battery change form for [DATE], revealed staff changed the resident's alarm battery on [DATE].

Based on observation, clinical record review and staff interview, the facility failed to prevent the development of avoidable heel pressure sores and then did not always provide the needed interventions to promote healing once identified for 1 of 2 residents reviewed with skin issues (Resident #1). The facility census was 507 residents. On 5/10/2012, Resident #1 fell which resulted in a fractured right femur (thigh bone). The resident returned to the facility on [DATE] and without pressure ulcers present. The Progress Notes dated 5/24/2012 reflected pressure ulcers were identified on the right heel. The treatment consisted of a Podus boot to the right foot (when resident allows), float heels and weekly assessments. Observation revealed staff did not always apply the Podus boot and the resident had been observed wearing shoes. The care plan had not identified a potential problem with pressure ulcers and interventions to prevent the development of the avoidable heel pressure ulcers. Findings include: 1. Resident #1 had an MDS (Minimum Data Set) assessment with a reference date of 4/12/2012. The MDS identified the resident had cognition impairments, did not ambulate in room or corridor during the evaluation and required one person assistance to transfer. The MDS identified the resident at risk for pressure ulcers and had a pressure ulcer. The treatments included a pressure reducing device for the chair and bed. A history and physical report dated 5/20/2012 at 1:33 p.m. identified Resident #1 with dementia, chronic pain due to a right [MEDICAL CONDITION] and removal of hardware due [MEDICAL CONDITIONS] in 2005. The current care plan identified a problem with chronic pain due to a (old) [MEDICAL CONDITION]. The care plan did not address a potential for pressure ulcers and interventions for staff to follow. The Progress Notes dated 5/10/12 at 11:32 p.m., documented the resident's alarm was sounding and the resident was found standing up turning into bed when staff went to assist the resident missed the bed and fell on right side onto floor. The resident ' s right leg was bent underneath the left foot. The resident was yelling out in pain. The physician was notified and the resident was transferred to the hospital. The Progress Notes dated 5/11/12 at 12:34 a.m., documented the resident sustained [REDACTED]. The Progress Notes, Head To Toe assessment dated [DATE] at 2:04 p.m., documented the resident returned to the facility and the resident alert to name only and aphasic (impairment of language ability). The muscle skeletal assessment documented orders were received for weight bearing transfers only to the right lower extremity. The resident was a poor 2 person transfer and staff would try a Sabina lift. The right knee incision was well approximated with 5 staples intact. The right lateral knee was well approximated with 6 staples. The right groin incision was well approximated with 8 staples intact. All of the incisions were without signs or symptoms of infection. Extensive bruising was noted to the knee, groin and hip. The resident's skin was pink, hot and dry. The Braden scale (prediction for pressure ulcers) scored a 15 (12 and under represented high risk), heels, back and buttocks assessed with [REDACTED]. The Progress Notes dated 5/16/12 at 3:38 p.m., documented a new RN Directive- Sabina lift for all transfers, no ambulation and encourage resident to toilet every two hours ,offer urinal if refuses to toilet. Check and change attends (brief) every 2 hours, if resident refuses to be toileted or allow staff to check attends need to reproach 10-15 minutes later. If resident still refuses report to RN (Registered Nurse). Monitor for any skin breakdown redness, open areas bleeding, etc, and report immediately. Notify if right groin dressing is wet or off. The care plan did not direct staff to float heels or reposition every 2 hours. The Progress Notes dated 5/17/12, 1:45 p.m., documented the resident returned yesterday post [MEDICAL CONDITION]. Reviewed the Care Plan with primary nurse and Ulery 1-3 team members and it was determined the resident will not require a significant change at this time. The two areas that changed on his/her care plan are bed mobility and transfers. Staffs are to reposition the resident every 2 hours if allows and transferred with a Sabina lift. The Progress Notes dated 5/24/12 at 5:15 a.m., documented at approximately 12:00 a.m.; staff reported the resident had a purple area on the right lateral heel. The purple area observed at the time was dry and intact. Foot positioned so that there was no pressure to the heel. The area measured 2.25 centimeters (cm) by 3.0 cm wide. The discolored area was irregular in shape and there was a dry crusty callous area approximately one centimeter in diameter at one edge of the area. Adjacent to the purple area on the back of the heel there was an area of light redness approximately one centimeter in diameter. Heel protectors were applied and staffs were directed to avoid pressure to the heel at all times. The Progress Notes dated 5/24/12 at 10:59 a.m., documented a wound assessment. The resident ' s right lateral heel appeared to be a pressure ulcer measuring 1.5 cm by 0.8 cm. The Wound care committee notified and will defer staging until assessed by wound committee. No drainage, odor or pain noted. The area was purple in color and boggy with light palpation. The area is intact with no surrounding [DIAGNOSES REDACTED] (redness) noted. The treatment included application of Podus boot to the right foot at all times as resident will allow, float heels off the bed and set up weekly Registered Nurse measurements. The Progress Notes dated 5/24/12, at 11:05 a.m., documented RN Directive Update. Reposition the resident every 2 hours as resident allows. Reposition to back and left side only at this time. Use pillows to help aid with positioning. Podus boot to right foot at all times as resident allows. Assist with dressing, ted hose on in a.m. and off at bedtime. Left heel assessed with [REDACTED]. The Progress Note dated 5/25/12 at 4:09 p.m., documented pressure area to right outer heel area measured 1.5 cm by 8 cm. Area not open, soft to touch dark purplish in color. Pressure area unstageable at this time. Continue with plan of care in place. The Progress Notes dated 5/26/12, at 8:43 a.m., documented the resident with facial grimacing and saying "ouch" with transfers and movement of the right foot and leg. No change in the right foot, the pressure area was purple and boggy. The Progress Notes dated 5/27/12 at 8:49 p.m., documented the resident yelling out at the beginning of shift wanting up in wheelchair. Right heel still purple, no bogginess noted with light palpation. Podus boot applied at bedtime. The Progress Notes dated 5/28/12, at 9:42 p.m., documented no change in right heel, purple with decreased bogginess noted with light palpation. Podus boot applied at bedtime. Review of the current Plan of Care provided on 6/1/12, revealed no documentation of the right heel pressure sore. Review of the nurse Directives dated 5/31/12, day, evening and night shift directed staff to reposition the resident every 2 hours as the resident allows, reposition to back and side only at this time. May use pillows to help aid with positioning. The physician's order [REDACTED].? scoop mixed with milk with meals (to promote healing). On 5/24/12, at 10:15 a.m., observation revealed the resident in bed sleeping on his/her back with bilateral heels resting on the mattress. Observation revealed the resident's Podus boots on the dresser across the room. On 5/31/12, at 2:50 p.m., observation revealed Staff A and B transporting the resident to the dining table. Observation revealed the resident with black shoes on. At the time, Staff C stated the resident's Podus boot was to be on the right foot at all times. Observation revealed staff removed the right shoe and placed the Podus boot on the resident ' s right foot. On 6/5/12, at 9:45 a.m., observation revealed the resident sitting at the dining table with black shoes on both feet.

Based on observation, clinical record review and interviews, the facility failed to plan for and direct nursing services to ensure Resident #3 received adequate supervision against hazards. Resident #3 fell and sustained bilateral nasal fractures during a wheelchair escort transfer when he/she put his/her feet down. At the time of the fall, the wheelchair pedals were not being used and the resident escort employee transferring the resident had no training. The facility and or director of nursing had not provided training to ensure residents' needs were met. The facility failed to ensure staff utilized planned interventions for Resident #1. The facility census of 500 residents. Findings include: 1. The Minimum Data Set (MDS) assessment documented Resident #3 had [DIAGNOSES REDACTED]. The MDS assessment revealed the resident moved about the unit but required limited assistance of 1 staff for locomotion off the unit. The MDS assessment documented the resident required extensive assistance of 1 staff for dressing and limited assistance of 1 staff for toilet use and personal hygiene. A directive for the resident dated 9/30/11, documented the resident ambulated independently in the room and hall and could not leave the unit without an escort. The Care Plan dated 8/19/11, indicated the resident could attend off unit therapeutic activities with an escort provided by volunteer services. An Incident Report dated 9/29/11 at 10:28 a.m., documented the resident sustained [REDACTED]. The Escort said they were coming down the ramp on the north side toward Dack and the resident put their feet down and was going to stand up then the resident fell face forward onto the floor (cement). The resident was found laying on the floor on their right side with blood present on their face and hands. The resident was alert and oriented. Pedals were on the wheelchair were up. Laceration center of forehead and blood coming from both nostrils of nose. Blood on hands from resident touching face. Redness on right knee. Resident able to move all extremities without pain or difficulty. Resident assisted to standing and into wheelchair and taken to medical clinic. The resident was evaluated by facility physician and transported to emergency room for further evaluation and treatment. Nurse notes dated 9/29/11 at 11:07 a.m., documented the physician examined the resident and noted a deep laceration on the residents forehead with nose bleeding from fall. Need two layers of suture which cannot be provided at the facility. The resident also needs a CT scan of the head. The resident was accepted to be transferred to the emergency room at the hospital. Nurse notes dated 9/29/11 at 11:26 a.m., documented nurse called stat to Sheeler basement at north end of ramp by respiratory. The resident was being brought back to the unit in a wheelchair by an employee escort from the beauty shop and the escort reported the resident put their feet down and was going to stand up then fell forward face first to the floor. The wheelchair pedals were both up on the wheelchair. The resident was taken to the medical clinic after examination. An emergency room report dated 9/29/11, documented the resident as transferred from a facility after apparently trying to get up out of a wheelchair and fell forward hitting their face on the floor. Examination revealed a somewhat Y-shaped laceration on the mid forehead. The wound was cleansed and re-approximated on the 3 legs of wound as it is Y-shaped, but right at the middle where they converge, there was not the ability to get a good repair. A total of one subcutaneous suture was used and then 14 sutures for skin edge approximation were utilized. CT of the facial bones show what appears to be acute bilateral nasal fractures, slightly worse on the right. There is the appearance of a blowout fracture but the age was undetermined on the inferior orbital rim on the right. There was an obvious soft tissue laceration over the forehead. Nurse notes dated 9/29/11 at 3:39 p.m., documented the resident returned from the emergency room . The resident sustained [REDACTED]. The orbital fracture had an undetermined age of fracture but may see effect to eye muscles that residents eyes would not move together. The resident had 14 stitches placed to the forehead laceration along with steri strips. The resident tolerated the procedure well and denied pain/discomfort. During interview on 10/11/11 at 1:40 p.m., Staff A (Chief Financial Officer)revealed the Commandant had ordered all resident escort positions to be replaced with staff members. During interview on 10/11/11 at 1:30 p.m., Staff B (Vocational Rehabilitation Specialist) stated they try to match up residents for jobs. Staff B does nothing without unit approval. Staff B stated department supervisors train resident employees not he/she. Staff B stated they have taken all resident transport positions away and had to reassign people. During interview on 10/12/11 at 11:00 a.m., Staff C stated the facility stopped the Resident Employee Escort program. After reviewing the incident they found Resident Employees did not have training on how to escort properly using a wheelchair. Staff B stated they were currently re-evaluating the process of how to assign resident positions. During interview on 10/11/1 at 12:00 p.m., the Resident Escort involved in the incident stated they were at the beauty shop to return a resident to Dack and took the resident through the tunnel when the resident put their feet down and jumped out of the wheelchair and fell forward. The Resident Escort stated they had never had any training regarding transporting residents and had been doing the job for three months. 2. The MDS assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS indicated the resident required limited assistance for bed mobility and extensive assistance of 2 staff with transfers, dressing, toilet use and personal hygiene. The MDS documented the resident as not steady, only able to stabilize with human assistance when moving from a seated to standing position, when moving on and off the toilet and for surface to surface transfers. The MDS documented the resident had range of motion impairment on both sides of their upper extremities and no impairment of lower extremities. The MDS documented the resident utilized a wheelchair for mobility. The Care Plan dated 7/28/11, revealed the resident at high risk for falls. Interventions included: a. Keep the bed in low position b. Encourage slow transitions for lying to sitting to standing. c. Keep call light within reach. d. Keep the room free from clutter. e. Provide the resident with non-slip footwear during transfers. f. Encourage use of hearing aides. g. Toilet frequently h. Place frequently used items within reach. i. Educate on how to prevent or decrease risk for fall. A Directive dated 9/26/11, documented the resident required the assistance of two staff with bed mobility. The resident utilized a Liko lift (manual lift device) for all transfers with two staff. The resident had a manual wheelchair and needed escort for all activities and appointments off the unit. Nurses notes dated 9/25/11 at 2:48 p.m., documented the resident was heard yelling that they had slipped off the bed. The resident was lying on the floor with their head turned to the left. The resident stated they were sitting on the edge of the bed and continued to slid off and could not hold themselves enough to stay on the bed. The resident had shoes on and the lift sling around their middle. The resident reports they hit their head and their head hurts. Denies pain in other places. Injury description- hematoma to left forehead (above left eye), bruise and swelling to left eye, abrasion to left elbow and very small abrasion to left knee and right knee. Nurse notes dated 9/25/11 at 6:25 p.m., documented the resident as in a very good mood and denies pain at the time. Residents eye swelled shut with bruising around the eye. Ice pack continued and resident alert and oriented. During interview on 10/12/11 at 8:15 a.m., Staff G, certified nurse aide, CNA stated on the day of the incident (9/25/11) they had completed the residents cares and noted the resident had just returned to the facility from the hospital on Thursday, 9/22/11. Staff G had the sling wrapped around the resident, sat the resident up on the side of the bed to adjust the sling. Staff G put the call light on and no one answered, so Staff G left the resident sitting at the side of the bed to go get help. Left the room and walked out in the hall and saw staff down the hall. Got staff to help with the resident and when they got back into the room the resident was on the floor. Staff G stated the type of sling used with the resident required the resident to be sat at the side of the bed to apply. Staff G stated one person could do the residents cares as the resident rolled from side to side, but admits they had helped staff in the past with the residents cares. During interview on 10/11/11 at 1:00 p.m., Staff D indicated Staff G should have known how to take care of the resident because Staff C had worked at the facility for a long time. During interview on 10/12/11 at 9:48 a.m., Staff E stated Staff G should have known how to care for the resident. Staff E stated Staff G should have known the resident needed help with balance as they have a strap over their chest while in the wheelchair. During interview on 10/12/11 at 9:30 a.m., Staff F stated the aides no longer receive a paper Directive and are required to look up how to care for the resident on the computer. Staff F reviewed the Directive for the resident and confirmed the Directive did not indicate the resident should not be left sitting at the side of the bed alone, nor did it reflect the Velcro strap the resident utilized in the wheelchair to prevent falling out of the wheelchair. Observation on 10/12/11 at 10:15 a.m., revealed the resident's wheelchair in the restroom, the wheelchair had a 4 inch wide Velcro strap on the wheelchair. The resident stated he/she used the Velcro strap on the wheelchair to prevent him/her from falling out of the wheelchair.

Based on clinical record review, policy review and staff and resident interviews, the facility failed to provide adequate supervision to ensure against hazards from self, others, or elements in the environment and failed to plan for and direct the nursing care and services in order that each of the resident ' s needs are met (Resident #1). The facility identified a census of 539 residents and the review sample consisted of 7 residents. On 9/8/2010, Resident #1 eloped from a secured locked unit, unsupervised and traveled approximately 4 blocks to a community setting and attempted to catch a ride to the down town area. A community member notified the facility and informed the switchboard of the resident ' s location and activity. A staff person had last seen the resident at approximately 9:45 a.m. while preparing to transport residents to a movie activity held in the Malloy building and did not verify if the resident should be alone and unsupervised. Many residents were left with a volunteer while the activity specialist obtained additional residents for the activity. The volunteer was interviewed and stated he/she did not know the residents. Although it could not be determined which door the resident eloped from, the Administrator of Nursing thought the resident left from the Malloy building where the movie was presented. The resident was picked up by a security personnel at 10:15 a.m. Findings include: 1. The Minimum Data Set (MDS) assessment with a reference date of 7/22/10 indicated Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident with indicators of delirium periodic thinking/awareness (not of recent onset), periods of altered perception or awareness of surroundings and periods of restlessness. The MDS indicated the resident as independent with transfer and locomotion on the unit and required supervision of one staff member for locomotion off the unit. The Elopement Risk assessment dated [DATE] identified a score of 8 and a total score of 8 or more represented risk for elopement. The assessment reflected the resident had attempted elopement within the past 6 months. The care plan with a goal date of 10/28/10, documented the resident resided in Sheeler 3 E, a secured dementia unit and required close supervision and a name tag with a green dot for all off unit/off grounds recreational activities. The care plan directed staff of the following: a. Utility workers could take the resident off the unit every Tuesday at 2:00 p.m. b. The resident could go to Malloy cafeteria prn (as needed), c. Staff may take off daily, if feasible; d. Resident must have 1:1 and unit radio whenever going off unit with only Iowa Veterans Home staff to escort resident off unit. e. Will provide close supervision and a nametag with a green dot for all off unit/off grounds recreational activities (start date 1/22/2010). The Iowa Veterans Home Resident incident report # dated 9/8/10 at 11:27 a.m. documented Resident #1 eloped from the recreation activity held in Malloy Lower Level Recreational Center (MLRC). Resident #1 was found between 8th and 9th Street and Summit trying to hitchhike. A community person saw the resident and notified the Iowa Veterans Home. The progress note dated 9/8/10 at 11:33 a.m., indicated Staff F, Registered Nurse (RN) was informed by the facility switch operator that a resident had eloped and was located between 8th and 9th street sitting on someone ' s door steps and was trying to hitch hike. A person in the community saw the resident and notified Iowa Veterans Home. The facility security personnel went to get the resident. The resident stated, he/she was headed uptown to do some business. The security officer was able to get the resident into the car. Upon the return to the Iowa Veteran ' s Home, the resident sat on a bench in front of the Sheeler Building and smoked a cigarette which was obtained from another resident. After much encouragement by the unit staff, the resident did agree to return to the secured unit. Thirty minute checks were placed in effect and staff were made aware no further off unit activities or appointments for the resident. The Weather Bureau in Johnston was notified and identified the temperature on 9/9/2010 to be 54 degrees at 9 AM, 60 degrees at 10 AM and 64 degrees at 11 AM. During an interview on 9/14/10 at 11:30 a.m., Resident #1 stated he/she did not remember leaving from the facility and denied any injuries. The resident's care plan was updated on 9/8/10 which directed the staff to follow: a. No off unit activities or appointments at this time; b. 30 minutes checks to monitor whereabouts c. Provide a name tag with a green dot; d. Escort with very close supervision so that he/she doesn't elope (very important). The Progress Note dated 9/8/10 at 1:29 p.m. indicated Staff F documented the care plan had changed to reflect no further off unit activities or appointments at this time due to the high risk for elopement and 30 minutes checks to monitor resident's whereabouts. Staff A (Activity specialist) was interviewed on 9/13/10 at 12:35 p.m. and stated on the date of the elopement (9/8/2010), the activity was changed to watch a movie due to the cold weather. Staff A continued to state she/he called 3E/3W to inform the unit of the change in activity. At 9:15 a.m., Staff A stated he/she met with volunteers and took residents to the unit starting on S3E. Staff A explained when she/he arrived on the unit, no residents had been ready, so proceeded to ask residents in the day room and in the sun room if they would like to go watch a video. Six residents wished to see a movie so each resident received a name tag. Each name tag had an affixed green dot (for off ground/off unit). Another staff person wrote the names of the residents on the black board upon arrival to the movie room while Staff A returned to S3W to obtain additional residents. Staff A returned with 6 additional residents. The 6 additional residents had wore the required name tags (with a green dot adhered). Staff A was paged at 9:45 a.m. Staff F had informed Staff A that Resident #1 was found off of the grounds of the facility. After the paged telephone call, Staff A stated she then checked with the volunteers to see it Resident #1 had made it to the movie room. The volunteer stated he/she had left the room so had left another volunteer, Staff E, with the residents. Staff A spoke with Staff B (Activity Specialist). Staff B stated she/he had seen the resident in the hallway and the resident stated had been received the program to be off of the unit. Staff A documented on 9/8/10 that he/she, Staff B and the Director of Rehabilitation Services discussed a plan to keep resident ' s safe: a. At no time should there not be a staff in the room. b. Only certain volunteers (same core group) will be assigned by Volunteer Services Director to the activities. c. Immediate participation will begin when residents arrive at the activity. d. Will always be aware when the resident is to be with staff only during recreations and researching through chart. With the changes in his/her responsibilities (case load), extended illness of team partner and ever changing health and mental status of the five units he/she heavily relied on the unit team members to remind him/her of changes to resident's diets, mobility or behavior since June 2010. Staff A stated on the day of the elopement, Resident #1 was dressed in a short sleeve golf shirt and long pants with his/her name tag in place with name, unit and a green dot to alert others he/she is wandering/elopement risk. Staff B was interviewed on 9/13/10 at 2:00 p.m., and stated on 9/8/10, the 5 dementia units had a scheduled activity in the Malloy RC area. Each of the 3 staff for these units went to their prospective units to obtain residents. Staff B stated she went to 2 E and had 8 residents who wanted to attend the activity; 2 in wheel chairs and 5 walking. Staff B stated as she/he was turning the corner by the Avery, Resident #1 came around the corner. Staff B stated the unit had been providing a behavior treatment program for ambulatory residents in the 3 E unit so she/he thought Resident #1 was going to breakfast in the dining room. Staff B stated she spoke to the resident and asked if she/he was now off on own and Resident #1 informed Staff B the unit had provided a program to be off the unit. Staff C was interviewed on 9/14/10 at 11:45 A.M. and stated on 9/8/2010, the unit had the usual staffing pattern with regular staff on S3E. The residents were still in bed that morning at the time of the activity as residents had been allowed to sleep in as part of the culture change initiated recently which allowed residents to wake on their own. Staff E (Volunteer) was interviewed on 9/14/2010 at 1:35 P.M. and stated he/she came to S3E to help bring residents to the Malloy building to watch a movie on 9/8/10. Staff E stated he/she was alone, at one time with 10 residents and was told to wait in the room until more residents were brought to the room. Staff E further stated the volunteers do not pay attention to the telephone calls to the recreation department and identified self as an escort for the residents in all buildings. Staff E stated he did not know all of the residents. Staff D (Security personnel) was interviewed on 9/14/10 at 10 AM. Staff D stated the switchboard called and said a report was received that one of the residents was located at 9th and summit trying to hitch a ride. Staff D immediately left to bring the resident back to the facility. Staff D did not locate the resident at the designated area but found the resident sitting on the terrace steps in front of a house approximately ? block away at 10:15 a.m. Staff D took the resident to the switchboard to find the location of where the resident lived. Two staff persons arrived to escort the resident to the unit but the resident refused but then agreed to return. Staff D The Director of Rehabilitation Services was interviewed on 9/15/10 at 12:55 P.M. The Director stated last week on 9/8/10 there was an activity in the Malloy LRC for the dementia units where a movie was shown. The staff and volunteers began to bring the residents from S3E to the Malloy LRC (MLRC-Malloy lower level Recreational Center) Resident #1 was attended by a volunteer and the resident left the MLRC unattended. Staff B came upon the resident near the MLRC in front of the aviary and asked him/her where he/she was going. The resident stated could leave because of the program treatment. Staff B stated she/he continued with the residents from unit S2 E to the MLRC and the other staff and residents arrived for this activity between 9:25 AM and 9:35 AM. The Director of Rehabilitation Services stated he/she believed the elopement occurred because Staff A did not follow the plan of care when Staff A arrived and allowed Resident #1 to be attended by a volunteer. The Director continued to state the staff did not follow the practice to always have a staff person in the room with a resident with dementia. Staff B recognized this resident in the hallway, a resident from a locked unit. Staff B did not assure the resident was safe to be left alone even though the resident stated had a behavior treatment program to be off of the unit. Because the nursing staffs were making changes to provide a more homelike environment with culture change, residents were not ready to attend the movie activity which caused staff to be hurried and did not follow the normal process for an activity. Now nursing will provide a staff person on all activities for Sheeler 3 and 2 E if 5 or more residents are attending. The unit will not have green dot elopement risk residents off unit activities until a policy is reviewed with the staff. The Director continued to state the plans should be in place for residents to attend off unit activities within 3 weeks. The Director of Volunteer Services was interviewed 9/15/10 at 10:35 AM and stated it was her understanding this incident occurred because a volunteer was left in charge of 10 residents from a locked units without adequate information about the residents involved. The usual practice would require 2 staff members to be responsible for monitoring the resident in the MLRC and not a volunteer. The Volunteer Director stated the facility policy #10 indicated the volunteers are used to supplement but not replace the services of a paid employee On 9/14/10 the Administrator of Nursing provided a written statement which confirmed Resident #1 had eloped from an off unit activity. The nursing staffs on Sheeler #E were 3 RTWs and 1 additional staff that floated between Sheeler 3 W and 3 E. In addition there were 2 registered nurses. The recreation staffs assigned to the activity were 3 Activities Specialist (recreation therapists) along with 5 volunteers for approximately 20 residents. The plan was for a recreation therapist to supervise the resident during the activity. Recreation stated they had enough recreation staff and volunteers to supervise the activity. Resident #1 also had his/her name tag with green dot identifying them as an elopement risk in place before leaving the unit. The plan was not followed as recreation therapists left the activity to gather additional residents for the activity and delegated supervision to a volunteer. Resident #1 had informed the volunteer before leaving that he/she was able to leave the unit because of the behavior program and later repeated this to a recreation therapist when seen by her. (This is the language that Iowa Vets Home utilized when working with someone who may be able to manage increased independence.) Neither person questioned this. The resident had eloped previously, approximately 8/09. There were no recent changes noted for the resident and he/she frequently remarks about wanting to leave the facility. Resident #1 had no changes in routine and off unit activities are not scheduled each day but did attend off unit activities with recreation on occasion. This resident had gone outside the facility before but only when supervised by staff. On this particular incident, she stated the resident exited the southwest door of the MLRC but it was unknown which building door he/she exited. Before Resident #1 exited the MLRC they were seated with the other residents who were attending the activity. All exits from the MLRC are visible to staff at all times. The facility had completed the following to prevent further occurrence: 1) A list of residents attending off unit recreation activities will be developed. 2) Upon arrival at the activity all residents on the list will be accounted for. 3) Upon return to the Nursing unit after the activity, all residents will be accounted for. 4). Lists will be signed off and retained. 5). Any resident leaving an activity will be accompanied if identified as a wandering risk. 6) Staff person will remain with residents at all times at the activity location (not volunteers). 7). Unit staff will assist with off unit activities where 5 or more residents from the Sheeler 3/2 E are in attendance. The Iowa Veterans Home is located on a campus of building within the city limits of Marshalltown. The facility is not near a heavily traveled street or highway. The streets surrounding the facility are moderately traveled. The Nursing Administrator's final statement was the facility failed to supervise Resident #1 and this resident was allowed to leave the activity unescorted. Review of the Iowa Veterans Home Policy 235 titled Recognizing and Responding to Resident At Risk For Elopement dated 2/2010, indicated the purpose of the policy was to provide for resident assessment and care planning that assured the safety and well-being of identified residents who display or have potential elopement behavior. The policy continued to indicate The Iowa Veterans Home would be responsible for the safety, supervision of and well-being of all residents Note: At the time of the investigation, the violation was coded at "J", Immediate and Serious Jeopardy Level . By 9/9/2010 the facility had implemented measures that adequately addressed the jeopardy situation and the violation was lowered to a "D" . The faciltiy provided 30 minute checks of the resident and the activities department implemented safety measures. The activities department began inservices and policy/procedures to: not leave a resident alone with a volunteer, upon arrival to an activity, all residents on the list would be accounted for, upon return to the unit after an activity all residents would be accounted for, all residents would be on a list of residents attending off unit recreation activitiesand the lists would be singed off and retained. Any resident leaving an activity would be accompanied if identified as a wandering risk. The unit staff will assist with off unit activities when 5 or more residents from the Sheeler-3/2 E are in attendance. The facility continues to need to: ? Continue to inservice all employees regarding the policy/procedures for maintaining safety and supervision of residents during activities and when off of the unit. ? Continue to ensure the volunteers are not replaced by staff workers. ? Staff from the Sheeler-3/2 will continue to assist with off unit activities when 5 or more residents attend an activity.