Every finding on record at Prairie View Home

Based on observation, interview and review of the Quality Assurance Plan, the facility failed to establish written policies for resident care regarding the Comfort Care/End of Life program, or fall prevention/safe transfer techniques. The facility reported a census of 36 residents. Findings include: 1) A review of the Resident Matrix found that the facility had 8 residents on the End of Life/Comfort Care/Palliative program. According to a Comfort Cares document, dated 10/3/22 at 11:25 AM, Resident #23 and the family, requested comfort cares related to emphysema and Chronic Obstructive Pulmonary Disease (COPD). The request included no hospitalization , labs, or weights, and orders for as needed (PRN) comfort medications; Morphine sulfate concentrate 20 milligrams per milliliters (mg/ml) give 0.5 ml every hour PRN. The indications for the medication use included; shortness of breath, comfort, end of life and restlessness. On 8/8/24 at 8:08 AM, Resident #23 was sitting the hallway reading a book. She did not remember the fall in the bathroom in February and she said that she mostly has pain in her feet and she has medication for that, it seems to help. She said that she can do most things for herself, very independent in her room and around the facility. The resident did not know what the Comfort Cares program was that she is on. A review of the Inter Disciplinary Team Meetings for Resident #23 revealed that the Comfort Care program was not addressed in the meetings. On 8/7/24 at 12:33 PM, the Director of Nursing (DON) said that they would keep morphine on hand as long as it didn't expire because of the cost to the resident, and the complications of getting new orders if a resident had a change in condition. She said that the residents were kept on the medications indefinitely as long as they were on the Comfort Cares program. She said that the resident had significant pain and the use of morphine at that time was appropriate. On 8/8/24 at 8:34 AM, the Administrator said the facility did not have a policy or guidelines for the Comfort Cares Program. 2) On 8/5/24 at 2:32 PM, Staff C, Certified Nurse Aid (CNA), said that she was transferring Resident #6 from the shower to the wheel chair when the resident's legs gave out and she was lowered to the floor. Staff C said that she did not apply a gait belt around the resident before transferring her. In an observation on 8/6/24 at 8:24 AM, Resident #21 was wheeled into the whirlpool room by Staff B, CNA. The resident used her walker to lift herself up out of the wheel chair. She kept her head down and took small steps. Staff B did not apply a gait belt around the resident and grabbed onto the back of the resident's waistband to assist her into the whirlpool chair. On 8/7/24 at 12:40 PM, The Director of Nursing (DON) and the Administrator said that they did not have a policy on gait belt use, fall prevention, or safe transferring techniques, but they educated the staff on these techniques in the annual staff meetings. According to the Quality Assessment and Assurance (QAA) Policy, the QAA committee would ensure that the best possible care and services were maintained for the residents. The team would evaluate the level of services by a systematic collection of data for the day to day care and would compare this evaluation with the results of previous evaluations. After this comparison would determine whether quality of care had been maintained or improved. In a facility document titled: Quality Assurance Components indicated that fall protocols, policies and procedures would be in place.

Based on observation, interview and record review the facility failed to provide safe transfer techniques for 2 of 2 residents reviewed. Staff failed to use a gait belt when transferring Resident #6 from the whirlpool chair to the wheel chair. The resident became weak and fell to the floor. In an observation, Resident #21 was transferred from the wheel chair to the whirlpool chair without the use of a gait belt. The facility reported a census of 36 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive deficits). The resident required substantial assistance with sit to stand, toilet transfers, and tub transfers. Her diagnoses included renal insufficiency and Alzheimer's Disease. The Care Plan updated on 6/17/24, showed Resident #6 had limitations in range of motion, and had the potential for injury related to osteoarthritis. Staff were to assist with transfers and walking, and to use the gait belt. A Nursing Note dated 6/7/24 at 9:00 AM, showed that Staff E, Registered Nurse (RN) was called to the whirlpool room after Resident #6 had fallen. The resident was on the floor and complained of right hip and thigh pain and she was unable to straighten her leg. She rated her pain an 8 out of 10. The resident had received scheduled pain medication at breakfast so the nurse was unable to give any additional pain medication. A Nursing Note dated 6/7/24 at 9:40 AM, showed that she left the facility by ambulance at 10:00 AM, and at 11:01 AM the hospital was sending her back to the facility. She had not sustained a fracture. Upon return the facility received orders for Physical Therapy and Occupational Therapy (PT/OT) and transfer with 2 staff. On 8/5/24 at 2:32 PM, Staff C, Certified Nurse Aid (CNA), said she was transferring Resident #6 from the shower to the wheel chair when the resident's legs gave out and she was lowered to the floor. Staff C said that she did not apply a gait belt around the resident before transferring. On 8/7/24 at 8:20 AM, Staff E, Registered Nurse (RN), said that the CNA called her into the shower room after the resident went down. She remembered the resident did not have a gait belt on. She called for an ambulance and the resident was in a lot of pain. On 8/7/24 at 12:40 PM the Administrator and the Director of Nursing (DON) acknowledged that Staff C knew better than to transfer the resident without the use of a gait belt, and the she had been disciplined. They said that the staff are educated on safe transferring on a regular basis. 2) According to the MDS dated [DATE], Resident #21 had a BIMS of 11 (moderate cognitive deficit). She required set up assistance with toileting hygiene and dressing and substantial assistance with bathing, and transferring in and out of tub/shower. Her diagnoses included heart failure, renal insufficiency, overactive bladder and shortness of breath. The Care Plan updated on 4/22/24, showed she had limited range of motion and had the potential for injury related to weakness, congestive heart failure, shortness of breath and osteoarthritis. The resident was to ambulate toward meals with the assist of one with wheel chair to follow. A Fall Risk Evaluation for Resident #21, dated 6/5/24 at 1:38 PM, showed a score of 13 (total score if greater than 10, indicated high fall risk). Nursing Notes included the following: On 7/31/24 at 8:20 AM, resident started on Mucinex for cough/congestion and reported feeling dizzy, lightheaded and was seeing things that were not there. The medication was discontinued. On 8/1/24 at 12:16 PM the resident experienced more fatigue. On 8/2/24 at 11:02 AM, she had Shortness of Breath (SOB), fatigued and did not want to do therapy. On 8/4/24 at 4:42 PM, she was improving, still experiencing SOB upon exertion. In an observation on 8/6/24 at 8:24 AM Resident #21 was wheeled into the whirlpool room by Staff B, CNA. The resident used her walker to lift herself up out of the wheel chair. She kept her head down and took small steps. Staff B did not apply a gait belt around the resident and grabbed onto the back of the resident's waistband to assist her into the whirlpool chair. On 8/8/24 at 8:08 AM, Resident #21 said that she was able to get herself to the bathroom and in and out of bed on her own. She said that there were times that she didn't feel safe on her feet and she will ask for help and that makes her feel safer, because she did not want to fall. She said that she does need help getting in and out of the whirlpool chair. On 8/7/24 at 12:40 PM, the DON said Resident #21 was independent and able to walk freely around in the facility so she did not feel that a gait belt was necessary. She said that the resident was able to ambulate down the hallways unassisted, and they did not have a policy on gait belt use, safe transferring techniques or on fall prevention. On 8/8/24 at 8:18 AM, Staff C and Staff F, CNA, said that they used a gait belt with every transfer. When asked about assisting residents that were considered independent, they were unsure and said it depends on their current status and if the resident had change in condition or was feeling weaker than normal. They were not aware of a policy on gait belt use. In a facility document titled: Quality Assurance Components indicated that fall protocols, policies and procedures would be in place.

Based on observation, interview and record review the facility failed to ensure that residents were free from unnecessary medication for 1 of 6 reviewed. Resident #23 had an as needed (PRN) order for morphine dated October of 2022. The indications for use included; shortness of breath, comfort, end of life and restlessness. On 2/20/24, staff used the medication when Resident #23 had neck pain. The facility reported a census of 36 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #23 had a Brief Interview for Mental Status (BIMS) of 10 (moderate cognitive ability). She was independent with sit to standing, toilet transfer and required set up assistance with toileting hygiene and upper body dressing. The resident received scheduled pain medication and had diagnoses that included anxiety disorder, depression, non-Alzheimer's Dementia and heart failure. The Care Plan updated 3/14/24, showed Resident #23 had the potential for alteration in sleep pattern related to pain, staff were instructed to use the scheduled medications and to update the physician if the medications were not working. The resident had numerous health concerns, pain, and negative complaints about neck pain. She had increased depression and was started on an antidepressant. The resident had alterations in comfort related to polyneuropathy, had a pain management program and was on comfort cares. According to a Comfort Cares document, dated 10/3/22 at 11:25 AM, Resident #23 and the family, requested comfort cares related to emphysema and Chronic Obstructive Pulmonary Disease (COPD). The request included no hospitalization , labs, or weights, and orders for as needed (PRN) comfort medications; Morphine sulfate concentrate 20 milligrams per milliliters (mg/ml) give 0.5 ml every hour PRN. The indications for the medication use included; shortness of breath, comfort, end of life and restlessness. The clinical chart lacked a reference to the ongoing PRN morphine in the Monthly Medication Review (MMR) pharmacist reports. On 8/6/24 at 6:18 AM, Staff D, Registered Nurse (RN) reviewed the facility narcotic logs. A Controlled Medication Utilization Record showed that Resident #23 had an active order for morphine sulfate 20mg/ml and the medication had been delivered to the facility on [DATE]. It was used on three separate dates: 3/25/23, 12/18/23 and 2/20/24. On 8/7/24 at 6:11 AM, Staff A, Licensed Practical Nurse (LPN) said that she worked on 2/20/24 when the resident was complaining of neck pain. She said Resident #23 was totally independent with her cares, and she had been working with Physical Therapy (PT) which caused her to have some increased pain. She had orders for bio freeze and scheduled Tylenol, but she also had an order for morphine that would use occasionally but she would have used a PRN Tylenol before giving the morphine. A review of the Medication Administration Record (MAR) showed that Resident #23 had an order for Tylenol 325 milligrams (mg) give 2 tablet every 6 hours as needed (PRN) for pain. The Tylenol was not used in the month of February. On 8/7/24 at 12:33 PM, the Director of Nursing (DON) said that they would keep morphine on hand as long as it didn't expire because of the cost to the resident, and the complications of getting new orders if a resident had a change in condition. She said that the residents were kept on the medications indefinitely as long as they were on the Comfort Cares program. She said that the resident had significant pain and the use of morphine at that time was appropriate. On 8/8/24 at 8:08 AM, Resident #23 was sitting the hallway reading a book. She said that she mostly had pain in her feet and she had medication for that, and it seemed to help. The resident did not know what the Comfort Cares program was and if it was a service that she was getting. According to the facility undated policy titled: Monthly Drug Regimen Review Policy, the pharmacist would report any irregularities to the attending physician and the report would be acted upon. Irregularities included but not limited to any drug that met the criteria for an unnecessary drug. An unnecessary drug was defined as any drug when used in excessive dose, for an excessive duration, without adequate monitoring, without adequate indications for its use, in the presence of adverse consequences which indicate the dose should be reduced or discontinued or combination of the above.

Based on observations, staff interviews, and a professional dietician interview the facility failed to ensure food was prepared under sanitary conditions and failed to prevent cross contamination of food. The facility identified a census of 44 residents. Findings included: The facility's Week 1 menu identified the following items as part of the planned menu for the lunch meal on 11/15/23 for pureed diets: Roast beef Mashed potatoes Gravy Roasted Carrots Strawberry Shortcake Biscuit Bread and margarine Milk Observation on 11/15/23 from 11:15 AM to 12:09 PM, revealed Staff A, Cook, removed a tray of dish cups from the cupboard, placed the tray on the counter, then slid the tray to the back of the counter. Staff A used the same counter area to place and look through meal tickets. During meal service, Staff A used the same counter area to place scissors each time she cut food. Staff A also failed to prevent cross contamination of food by using the same pair of scissors to cut the shrimp tails from breaded shrimp, cut roast beef into bite size pieces and cut biscuits in half. After each action Staff A placed the scissors on the unsanitized counter area. In an interview on 11/23/23 at 12:12 PM, Staff A reported she realized during meal service the scissors were not placed on a sanitary surface. Staff A also reported that she should have used separate scissors for each food to prevent cross contamination. In an interview on 11/23/23 at 12:28 PM, the Dietary Manager (DM), reported she expected staff to use a sanitary area for food utensils during food service. The DM also reported she expected staff to use different scissors or cutting utensils on each food to prevent cross contamination of food. In an interview on 11/23/23 at 12:48 PM, the Dietitian reported she expected staff to use different scissors or cutting utensils on each food to prevent cross contamination of food. On 11/123/23 at 1:08 PM, the Administrator reported the facility lacked a policy regarding kitchen sanitation.

Based on review of the planned menu, observation, and staff interviews the facility failed to serve the proper amount of pureed foods to residents that required a pureed diet. The facility identified a census of 44 residents. Findings included: The facility's Week 1 menu identified the following items as part of the planned menu for the lunch meal on 11/15/23 for pureed diets: Roast beef Mashed potatoes Gravy Roasted Carrots Strawberry Shortcake Biscuit Bread and margarine Milk Observation on 11/15/23 at 10:36 PM, revealed Staff A, Cook, pureed 7 servings of roast beef, roasted carrots and biscuits. Staff A reported she planned to serve the roast beef and biscuits with a #8 size scoop. Observation on 11/15/23 from 11:15 AM to 12:09 PM, revealed Staff A filled the entire #8 scoop when serving roast beef and biscuits to the first 5 of 7 residents on the pureed diet. The last 2 residents on the pureed diet only received partial #8 scoops of roast beef and biscuits. Observation on 11/15/23 at 12:11 PM showed the pureed roast beef and biscuit pans empty of food. In an interview on 11/23/23 at 12:12 PM, Staff A reported the last two residents received partial portions of roast beef and biscuits because the pureed food ran out. Staff A stated, I should have made more. In an interview on 11/23/23 at 12:28 PM, the Dietary Manager (DM), reported if there isn ' t enough pureed food she expected staff to make additional servings. The DM stated, I prefer they make an extra serving to start with. In an interview on 11/23/23 at 12:48 PM, the Dietitian reported that she expected all residents on a pureed diet to receive a full portion of food. The Dietation added, especially a full serving of protein. On 11/123/23 at 1:08 PM, the Administrator reported the facility lacked a policy regarding portion sizes.

Based on record review and resident and staff interview, the facility failed to send a copy of a Notice to Transfer to a representative of the Office of the State Long Term Care Ombudsman for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 68. Findings include: According to the Minimum Data Set with assessment reference date 5/16/19 Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had [DIAGNOSES REDACTED]. During an interview on 6/3/19 at 11:05 a.m., the resident reported hospitalization in the last year. The Health Status Note dated 6/21/18 at 6:07 p.m. showed confirmation the resident was admitted to the hospital for the diagnosis, [MEDICAL CONDITION]. During an interview on 6/5/19 at 8:11 a.m., the Administrator stated she was unable to find a notice to the Ombudsman.

Based on record review and staff interview the facility failed to provide a written summary of the baseline care plan to the resident or the resident representative for 1 of 8 residents reviewed (Resident #61). The facility reported a census of 68. The findings include: According to the Minimum Data Set (MDS) with assessment reference date 4/29/19, Resident #61 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS showed an entry date to the facility of 4/23/19. The resident had [DIAGNOSES REDACTED]. The chart lacked documentation the facility reviewed the baseline care plan with the resident or the resident's representative. During an interview on 6/4/19 at 1:35 p.m., the Social Worker reported she gave the baseline care plan to the husband but must have missed documenting it.

Based on record review and staff interview the facility failed to assure appropriate rationale of gradual dose reduction attempts made for 1 of 5 residents reviewed (Resident #6). The facility reported a census of 68 residents. Findings include: The Minimum Data Set (MDS) with assessment reference date 5/16/19 indicated Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS reported antidepressants were taken 7 of 7 days in the look-back period. The resident had [DIAGNOSES REDACTED]. Per the chart review, the resident had started an order on 6/1/18 for [MEDICATION NAME] 100 milligrams (MG) two tablets by mouth one time a day for the [DIAGNOSES REDACTED]. The pharmacy Gradual Dose Reduction review for [MEDICATION NAME] ([MEDICATION NAME]),on 12/4/18 showed the Physician stated no to trying to decrease the [MEDICATION NAME] from 200 mg every day to 150 mg every day. The form lacked rationale regarding the denial of the gradual dose reduction. During an interview on 6/5/19 at 8:50 a.m., the Director of Nursing, Registered Nurse, reported no further documented attempts with a rationale as to why the resident should not have a decrease in dosage.

Based on observation, record review, family interview the facility failed to always document the family notified of medication changes including new orders for 1 of 4 resident records reviewed. (Resident #3) The facility identified a census of 67 current residents. Findings include: 1. According to the MDS dated [DATE] Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs score of 5 which indicated the resident had severe cognitive impairment. According to the MDS the resident required extensive assistance with bed mobility, transfers, dressing, eating and toilet use. The care plan with a Target date of 10/25/18 directed staff to provide medications/treatments as per physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. On 7/24/18 the order clarified for [MEDICATION NAME] 50 mg daily in the AM and up to 3 times a day as needed for pain. Nurses Notes dated 7/19/18 at 11:08 AM documented, Family request [MEDICATION NAME] be given one time a day in the AM. Review of the Progress Notes dated 7/19/18 at 3:49 PM revealed new orders to decrease [MEDICATION NAME] order from 2 times a day to every day in the AM per family and physician orders. Pharmacy had been notified. Daughter left a message. On 7/24/18 at 3:15 PM revealed an order clarification received for [MEDICATION NAME] 50 mg daily in the AM and up to 3 times a day as needed for pain. Pharmacy and daughter aware of orders. During an interview on 10/30/18 at 10:50 AM Resident #3's daughter reported the last she knew on (MONTH) 24, (YEAR) her mother was off [MEDICATION NAME] totally and the facility had not notified her of any new [MEDICATION NAME] orders.

Based on observation, a hand washing procedure, sheet, and staff interview, the facility failed to practice routine hand washing in order to prevent the spread of infection during medication pass and a blood sugar check. The facility reported a census of 67 residents. Findings included: An undated Hand Washing Procedure dated signed and dated on 11/24/14 by Staff B, Registered Nurse (RN), directed staff that hand washing was the most important procedure to prevent and control infections. Observation of medication administration and a blood sugar check on 12/19/16 revealed the following: a. On 12/19/16 at 4:00 p.m., Staff B removed [MEDICATION NAME] (used to treat high blood pressure and heart failure) 50 milligrams (mg) from the medication cart and administered the medication to Resident #17 and failed to wash or sanitize her hands and continued with the next resident's medication administration. b. Staff B administered [MEDICATION NAME] (used to treat nerve pain) 600 mg. and [MEDICATION NAME]-[MEDICATION NAME] 25 mg/100mg. (used to treat Parkinson's disease), 2 tablets, to Resident #16 at 4:05 p.m., failed to wash or sanitize her hands, and continued with the next resident's medication administration. c. Staff B administered [MEDICATION NAME] 5 mg. (used to treat nausea, vomiting, and esophageal reflux) and [MEDICATION NAME] (used to treat gastric reflux and stomach ulcers) 1 gram to Resident #18 at 4:08 p.m., failed to wash or sanitize her hands, and continued with the next resident's medication administration. d. Staff B administered [MEDICATION NAME] 5 mg. to Resident #13 at 4:11 p.m., failed to wash or sanitize her hands, and performed a blood sugar check and administered Insulin to the next resident. e. Staff B donned gloves, used a lancet, and obtained blood to check a blood sugar from Resident #19's right second finger at 4:17 p.m. Staff B changed her gloves, drew up [MEDICATION NAME] (a type of insulin) 12 units, administered the insulin subcutaneously to the resident's left abdomen, and removed her gloves. Staff B returned to the medication cart and wrapped the blood sugar device with a Super Sani Cloth to sanitize the device. Staff B stated she was finished for now and had not yet washed or sanitized her hands. During an interview 12/21/16 at 4:00 p.m., the Administrator stated she expected staff to wash or sanitize their hands between each resident during medication administration and cares.

Based on record review and staff interview, the facility failed to obtain criminal background and abuse checks prior to hire for 1 of 6 employee records reviewed (Staff A). The facility reported a census of 67 residents. Findings include: 1. An Application for Employment dated 03/14/16, identified Staff A applied for a maintenance position at the facility and was available for employment on 3/15/16. A list of employees hired from 2/6/16 to 12/5/16 revealed the facility hired Staff A on 3/14/16. A Single Contact License and Background Check (SING) showed Staff A's criminal and abuse registries background checks completed on 3/15/16. The undated facility Employee Screening Prior To Employment policy/procedure documented the facility needed to perform Iowa criminal background and dependent child/adult abuse registry checks prior to employment. On 12/20/16 at 2:20 p.m. the Human Resources Director was interviewed and stated Staff A had orientation on 3/14/16 and began working in maintenance on 3/15/16. At 2:45 p.m., the Human Resources Director presented Staff A's 3/14/16 time sheet that revealed Staff A worked 7.37 hours on 3/14/16.

Based on observation and staff interview the facility failed to ensure an environment free of potential accident hazards in regards to an unattended whirlpool (WP) bathtub half full of water with a chemical, from cognitively impaired residents. The facility reported a census of 70 residents. Observation on 2/16/15 at 3:35 PM revealed an open door to a SPA room (bath room) that contained a whirl pool (WP) bathtub, in the Southeast hallway of the facility. Closer observation revealed a full body Penner WP bathtub, half full of water with the jets running in the tub and a foamy substance in the water. Observation revealed no staff attended to the Spa room. Ongoing observation revealed Staff A, Certified Nurse Aid (CNA) identified the bath aide who worked with resident's in the Southeast hallway as Staff C, CNA and stated Staff C left for the day. According to a Time Care Report form, Staff C clocked out and left the facility for the day at 2:50 PM on 2/16/15, approximately 45 minutes prior to the observation of the unattended WP tub. During interview on 2/16/15 at 3:50 PM Staff B, CNA entered the Spa room in the Southeast hall, turned off and emptied the WP tub. Staff B stated she regularly gave baths in a Spa room located in a different area of the facility. Staff B stated at the end of baths on any given day, a disinfectant cleaner is added to the WP tub water and the Spa room is left unattended while the WP tub runs, with the jets on, for at least 20 minutes. Staff B confirmed that practice is the same in the Spa room for the Southeast hall as well. Staff B confirmed the Spa room doors lacked a lock on the door. Staff B confirmed the use of a disinfectant cleaner in the tub of water in the southeast hall and identified the chemical as Penner Patient Care WP disinfectant cleaner. During interview on 2/16/15 at 3:55 PM Staff A stated she worked the Southeast hall often. Staff A reported the Spa room as being left unattended at the end of baths every day while the WP tub ran with water and disinfectant, for approximately 20 minutes. Staff A identified the tub room door as closed during that time, but not locked. During interview on 2/16/15 at 3:58 PM the facility Director of Nursing (DON) stated Staff C should not have left the WP tub unattended with water and disinfectant in the tub. During interview on 2/16/15 at 4:15 P.M., the DON identified 2 independently mobile, cognitively impaired residents resided in the southeast hall of the facility. During telephone interview on 2/18/15 at 12:20 PM Staff C stated she should not have left the WP tub with water and disinfectant, unattended in the Spa room. Review of a Material Data Safety Sheet (MSDS) for Penner Whirlpool Disinfectant Cleaner included instructions to keep out of reach of children and can be harmful if swallowed.

Based on clinical record review and staff interview, the facility failed to document the necessary care and assessment of a resident receiving [MEDICAL TREATMENT] through a left arm graft /shunt (Cortex Graft) - a section of artificial material which is attached to an artery and vein. Concerns were identified with (Resident #11). The facility reported a census of 70 residents. Findings included: According to a Minimum Data Set (MDS) with an assessment reference date of 1/1/15, Resident #11's had [DIAGNOSES REDACTED]. The MDS revealed the resident currently received [MEDICAL TREATMENT] services and identified the resident's admission to the facility as 10/27/14. Review of an admission nursing assessment, dated 10/27/14, revealed staff assessed the resident with a left upper arm shunt. Review of a facsimile to the facility from the resident's [MEDICAL TREATMENT] center, titled "Nursing Home /[MEDICAL TREATMENT] Center In-Service" form, included the following in regards to the resident's left arm graft/shunt: a. A pulse or buzz feeling is present in the graft that is caused by the blood rushing through the connected vessels. It is important to check the graft daily for the presence of a pulse or buzz. Absence of a pulse or buss may indicate the graft is clotted which may make it unusable for [MEDICAL TREATMENT]. If a lack of a pulse or buzz is noted, notify the [MEDICAL TREATMENT] unit at once. Review of a Medication Administration Record [REDACTED]. Further review of medication administration records revealed the months of November, 2014 and December 2014, staff continued to document an assessment of the resident's pulse in his/her left arm, monitored a BP daily and instructed staff to not take a BP in the resident's left arm. Review of medication administration records between January 1, 2015 and February 18, 2015 revealed no entries and/or assessment of the resident left arm pulse. The resident's assessment of his/her BP changed to weekly and no instructions for staff to avoid a BP reading in the resident's left arm. Review of a care plan with initial varying goal dates of 2/8/15 - 2/12/15, lacked any mention of the resident receiving [MEDICAL TREATMENT] services, thus no direction for assessment of possible complications from [MEDICAL TREATMENT], checking the resident's pulse in his/her left arm daily or avoidance of a BP reading in the resident's left arm. Further record review between the dates of 1/1/15 and 2/18/15 lacked any documented assessment of a pulse in the resident's left arm. During interview on 2/18/15 at 1:15 P.M., Staff E, MDS/Licensed Practical Nurse, confirmed the resident's care plan lacked mention of the resident's [MEDICAL TREATMENT] services and/or care needed in regards to his/her shunt, bleeding or avoiding a BP reading in his/her left arm. Staff E stated she believed staff documented the resident's fistula assessment on a weekly skin assessment form. Review of Resident #11's weekly skin assessment forms from admit through 2/18/15, lacked weekly assessment of the resident's graft site. During interview on 2/18/15 at 1:45 P.M., Staff E stated staff documented a daily assessment of the resident's pulse in his/her left arm daily on the medication administration record. As noted above, between the dates of 1/1/15 and 2/1815, staff documented no assessment of the resident's pulse in his/her left arm.

Based on record review and interview, the facility failed to notify a resident's Physician in regards to a change in physical status following a fall for 1 of 13 active resident's reviewed (Resident #7). The facility reported a census of 70 residents. Findings included According to Medication Review Report form date February 3, 2015, Resident #7 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an assessment reference date of 12/11/14, identified the resident with severely impaired mental status. The MDS revealed the resident sometimes made his/herself understood and sometimes understood others. The MDS identified the resident's balance during transitions and walking as not steady but able to stabalize without staff when moving from seated to standing position, when turning around and facing the opposite direction while walking, moving on and off the toilet and with surface -to-surface transfers (transfer between bed and chair or wheelchair), no impairments in range of motion in the resident's upper and lower extremities. The MDS revealed the resident required no use of an ambulation device. Review of Resident #7's Progress Notes revealed the following: On 2/16/15 at 2:20 PM nursing staff documented the resident's knees buckled during ambulation, fell and landed toward his/her right hip. (Note- no time documented as to the time the fall occurred). Staff documented no apparent injuries noted such as shortening or rotation of a leg. Staff assisted the resident to his/her feet, the resident became clammy for a few minutes and refused to walk. Staff documented the resident sat on a bed for a few minutes, staff stood the resident again, the resident refused to walk, transferred the resident to a wheelchair and transferred the resident to a recliner. Review of the Fall Scene Investigation Report form dated 2/16/15, revealed the fall occurred at 7:55 AM. On 2/16/15 at 2:53 PM nursing staff documented 2 staff attempted to take the resident to a dining room for lunch, the resident seemed to be in pain, became clammy and slightly nauseous. Staff documented the resident was taken back to a recliner and made a decision to contact a Medical Provider about an X-ray. At 12:40 PM (4 and 1/2 hours after the fall) call placed to resident's physician and an order received for a mobile x-ray to come into the facility. Review of a imaging services form (X-ray report), dated 2/16/15, revealed the resident sustained [REDACTED]. During telephone interview on 2/17/15 at 12:23 PM Staff D, Registered Nurse (RN), confirmed being on duty at the time of Resident #7's fall on 2/16/15 at 7:55 AM Staff D stated delay in notifying a Medical Provider in regards to the resident's fall "probably a little longer than it should have been". Staff D stated Staff E, MDS/ Licensed Practical Nurse (LPN) informed Staff D she needed to notify a Medical Provider within 1 hour of a resident's fall. Staff D stated if she thought the resident had a fracture, she would have notified a Medical Provider. During interview on 2/18/15 at 10:50 A.M., Staff F, LPN stated if a resident fell and could not or would not stand after the fall, the resident's Medical Provider needed to be notified right away. During interview on 2/18/15/ at 11:05 A.M., Staff G, RN stated if a resident with a [DIAGNOSES REDACTED].

Based on review of facility menus, observation and interview the facility failed to serve food as planned for 2 residents on a pureed diet. The facility reported a census of 61 residents. Findings included: Review of a noon meal therapeutic menu for 9/11/12 revealed the diet plan for a resident on a pureed diet included: 2/3 cup Calico Bean Casserole- pureed 4 ounces- carrots pureed 1 slice bread with butter (1 each) pureed Observation of the Calico Bean Casserole puree on 9/11/2 at 10:35 a.m., revealed Staff C (Cook) confirmed 2 residents on a pureed diet and would prepare 1 extra puree serving. Staff C (Cook)placed 3 - 2/3 cup scoops Calico Bean Casserole into a Robot Coupe blender, added 2 bread slices with butter, (rather than 3 bread slices), added 1 cup of milk and pureed the mixture till pudding like. Staff C (Cook) measured the total volume of the pureed mixture and placed the mixture in a steam oven. During the same observation, Staff C (Cook) stated she did not need to puree the carrots as the facility purchased the pureed vegetables already pre-formed, pureed and frozen in single servings packages. Observation of the noon meal service on 9/11/12 at 11:20 a.m., revealed Staff C (Cook) serving the noon meal. Ongoing observation revealed, Staff C(Cook) served 2 residents on pureed diets, the same Calico Bean Casserole puree as described above that lacked 1 slice of bread. Ongoing observation revealed, 2 plastic packages of pureed carrots on the cooks steam table. Staff C(Cook) confirmed the size of the pureed carrot packages weighed 3 ounces rather than 4 ounces. Observation of a facility walk in freezer contained a cardboard box with pre-formed, pureed frozen carrots, peas, corn and green beans. Closer observation of the box revealed the weight of each package as 3 ounces. During telephone interview on 9/11/12 at 2:10 p.m., the facility Dietitian confirmed Staff C (Cook) needed to place 3 bread slices in the Calico Bean Casserole when pureed, for equal amounts served. The Dietitian confirmed dietary staff need to serve 4 ounce servings of vegetables as planned on the menu rather than 3 ounces. The Dietitian stated she had not been aware the preformed packages weighed 3 ounces rather than 4 ounces.

Based on record review and staff interview, the facility failed to provide physician visits every 60 days for 2 out of 13 current residents reviewed. (Resident # 5) The facility reported a census of 61. Findings include: 1. Record review of the Minimum Dated (MDS), dated [DATE], for Resident # 5 revealed [DIAGNOSES REDACTED]. The MDS documented the resident had a Brief Interview for Mental Status score of 13 which signified the resident had an intact cognition. Record review of the Iowa Department of Human Services, dated 6/6/12, revealed the resident changed from private pay to Medicaid on 4/1/12. Record review of the physician progress notes [REDACTED]. The record did not reveal a more recent visit to the resident within a 60 day period. Staff interview with Staff A Licensed Practical Nurse on 9/12/12 at 10:30 a.m. revealed she knew when the physician was due for his monthly rounds. She said the physician came in August, but did not make his rounds because of an emergency. She said he would be coming back to the facility at the end of the month. 2. A facility Admission Record, dated June 9, 2011, documented Resident #10 with an admitted [DATE] and funding source Medicaid. physician's orders [REDACTED]. Nurse's Notes documented a physician saw the resident July 7, 2011, October 21, 2011, October 26, 2011, December 7, 2011, and February 10, 2012. Record review revealed physician progress notes [REDACTED]. During interview September 13, 2012 at 10:15 a.m. Staff D verified the resident had not been seen by the attending physician since June 26, 2012 but would see if another physician had seen the resident. During interview September 13, 2012 at 1:45 p.m. Staff D verified the resident not seen by any physician from July 7, 2011 until October 21, 2011.

Based on record review and staff interview, the facility failed to notify the physician of the non compliance of 1 of 4 residents reviewed (Resident #2). Resident #2 suffered a [MEDICAL CONDITION] 05/17/12 with surgical repair. The resident returned to the facility and was to follow post hip precautions, including an abductor pillow in bed for 6 weeks. The facility failed to assure the pillow was placed at bedtime, failed to document the resident removed the pillow him/herself, and failed to notify the physician of the non compliance. The facility reported a census of 73. Findings include: According to the Minimum Data Set (MDS) assessment, dated 05/28/12, Resident #2 scored 6 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. Resident #2 required extensive assistance with bed mobility, transfers, ambulation, dressing, toilet use and personal hygiene. The MDS documented Resident #2 demonstrated unsteadiness moving from a seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. Resident #2 normally used a walker. The Resident Care Plan, dated 05/31/12, identified Resident #2 with an alteration in self ability to perform activities of daily living (ADL's) related to dementia, and a recent [MEDICAL CONDITION] with increased ADL and mobility assistance required. The approaches included: a. Required extensive assistance with bed mobility, transfers, ambulation and locomotion. A Nursing Home Transfer Orders sheet from the hospital, dated 05/21/12, documented Resident #2's primary [DIAGNOSES REDACTED]. An Occupational Therapy (OT) Initial Assessment, dated 05/22/12, documented Resident #2 was involved in an episode involving another resident resulting in him/her falling and breaking his/her left hip on 05/17/12. Resident #2 had surgery and returned to the facility on [DATE]. Resident #2 had to follow posterior hip precautions involving not crossing legs, or bending forward. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. A History and Physical, dated 06/10/12, documented Resident #2 resided in the facility's Alzheimer's unit and had an alarm, but apparently some time had discontinued his/her own alarm and staff found him/her in a chair complaining of left hip pain. Staff did not know of a fall. Resident #2 had dementia but stated she did not fall that he/she knew of. They were uncertain whether maybe he/she had fallen in the night and gotten him/herself back up. Resident #2 had a dislocated left hip and sent for care of the orthopedist for further evaluation where the hip was replaced under fluoroscopy and conscious sedation and then admitted to the hospital for observation. During an interview on 07/05/12 at 3:03 p.m. Staff D CNA stated she worked 06/09/12 on the evening shift. Staff D stated Resident #2 wanted to walk, so they walked with him/her. Staff D stated Resident #2 did not have any complaints of pain and nothing unusual happened. Staff D stated she did not put the abductor pillow between Resident #2's legs that night. She said at first Resident #2 used it after he/she fractured his/her hip, but they had quit before then. During an interview on 07/05/12 at 3:09 p.m. Staff E CNA stated she worked the evening of 06/09/12. She said Resident #2 walked in the hallway with staff, and back and forth to the bathroom. Resident #2 walked okay and did not complain of pain. Staff E stated nothing unusual occurred. Staff E didn't know if Resident #2 had the abductor pillow placed at bedtime, she didn't think she put him/her to bed. Staff E wasn't sure if Resident #2 still used it at that time. During an interview on 07/06/12 at 8:27 a.m. Staff F CNA stated she worked the night shift 06/09/12 to 06/10/12. She said they checked residents every 2 hours. Staff F stated she didn't know if Resident #2 used the abductor pillow that night. She said if the evening shift didn't place it, she would not have placed it. She said it was very possible they were no longer using it at that point, because Resident #2 notoriously took it off and threw it on the floor. Resident #2 said he/she didn't like it. Staff F thought Resident #2 may have had a pillow under his/her feet. During an interview on 07/03/12 at 1:57 p.m. Staff A Certified Nursing Assistant (CNA) stated she came to work at 6:00 a.m. 06/10/12. She glanced in the resident's rooms and Resident #2 was in bed on his/her left side. She didn't know if he/she had the abductor pillow, he/she was covered up. Later when she went to get Resident #2 up, the door was closed. When she entered the room, Resident #2 sat in the recliner. The alarm did not sound. Resident #2's walker sat between the bed and the recliner. Resident #2 complained his/her leg hurt, so Staff A got the nurse. Staff A stated Resident #2 wanted a shot to knock him/her out and didn't want to eat. They did not move Resident #1 from the recliner. Staff A stated the night shift did not report any problems regarding Resident #2. During an interview on 07/05/12 at 11:41 a.m. Staff B Registered Nurse (RN) stated she passed medications in the main dining room and the CNA called and said Resident #2 complained of pain. She went and assessed Resident #2 and gave him/her routine pain medication. The CNA told Staff B Resident #2 had untied his/her alarm and she found him/her sitting in the recliner. The CNA also told her Resident #2's door had been closed when it had been open. Resident #2 sat in the recliner when Staff B got to his/her room, and he/she had the alarm on then. Staff B questioned Resident #2 about what happened and he/she could not tell her. Resident #2 had no other signs of injury. Staff B gave Resident #2 a pain pill and went back and reassessed the pain. Staff B asked Resident #2 to move his/her left leg and he/she wouldn't move it. Staff B received orders to send Resident #2 to the hospital and notified his/her family. Staff B stated she did not do an incident report because Resident #2 did not fall and they didn't know it wasn't related to Resident #2's [MEDICAL CONDITION]. After checking her documentation Staff B stated she called the hospital later and found out Resident #2 had a dislocated hip. Staff B stated she knew a lady who crossed her leg over mid line 2 times and dislocated her hip twice. Staff B didn't know if Resident #2 used the abductor pillow at night. During an interview on 07/05/12 at 2:47 p.m. Staff C CNA stated she thought Resident #2 used a foam pillow between his/her legs when he/she first came back after fracturing his/her hip. She didn't know if he/she continued using it prior to dislocating his/her hip. Staff C stated Resident #2 didn't keep it in place anyway, he/she took it out. During an interview on 07/05/12 the DON stated she didn't know if they used the abductor pillow up until the time he/she dislocated his/her hip, but they documented they did. During an interview on 07/05/12 at 10:59 a.m. the Physical Therapist stated hip precautions were in place to prevent hip dislocation. She stated post hips should not bend over or internally rotate the hip. She stated the abductor pillow would prevent crossing the affected leg over the mid line. A Physician's note, dated 06/13/12, documented Resident #2 suffered hip dislocation of a cemented [MEDICAL CONDITION] hemiarthroplasty while at the facility. they did not know exactly how it occurred but it took a fair amount of force to dislocate, or at least it takes assumption of a compromising position outside a safe window of flexion, adduction and internal rotation to dislocate a cemented [MEDICAL CONDITION] hemi. They were able to reduce it successfully in the emergency room . They admitted Resident #2 to the hospital to be fit with a hip abduction orthosis. During an interview on 07/06/12 at 11:55 a.m. the Orthopedic Surgeon stated he considered Resident #2's dislocated hip a major injury. Resident #2 had to be taken to the hospital, sedated, and the dislocation reduced. Resident #2 was hospitalized and fit for a custom orthotic device. The surgeon stated hip dislocation after hip repair could happen, but it was not common, and it was very unusual for this type of repair to dislocate. He said it would take some force or effort, such as a fall to dislocate it. He said it was possible when she got up on her own that morning that she could have contorted (twisted or strained) the leg in a way to dislocate it, but it would not occur just from walking. He said the abductor pillow was a standard order for 6 weeks after surgery. He said it was important in keeping the leg aligned. If he had known Resident #2 non compliant with the abductor pillow he could have tried a knee immobilizer, it would prevent some of the same compromising positions she needed to avoid. The Nurse's Notes, dated 06/14/12, documented Resident #2 returned to the facility. Resident #2 had an abductor brace that went around his/her torso and extended down the left leg to the mid thigh. Resident #2 needed to wear the brace at all times and remove only for bathing and monitoring skin.

Based on record review and staff interview, the facility failed to investigate an injury of unknown origin and report the injury requiring treatment and hospitalization to the Department of Inspections and Appeals for 1 resident (Resident #2). The facility reported a census of 73. Findings include: According to the Minimum Data Set (MDS) assessment, dated 05/28/12, Resident #2 scored 6 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. Resident #2 required extensive assistance with bed mobility, transfers, ambulation, dressing, toilet use and personal hygiene. The MDS documented Resident #2 demonstrated unsteadiness moving from a seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. Resident #2 normally used a walker. The Nurse's Notes, dated 06/10/12 at 8:15 a.m., documented Resident #2 complained of pain of the left hip to the Certified Nursing Assistant (CNA). Resident #2 received scheduled pain medication. At 9:15 a.m. staff reassessed the pain and Resident #2 stated he/she still had left hip pain, and would not move his/her left leg. Staff notified the hospital for orders to transfer by ambulance for evaluation. At 9:30 a.m. staff received the order to transfer to the hospital for evaluation of the left hip. At 9:55 a.m. emergency medical services transferred Resident #2 to the hospital. At 12:15 p.m. staff contacted the hospital for an update. Resident #2 would transfer to another hospital for left hip dislocation. At 3:40 p.m. staff received a phone call from the hospital and were advised they would be keeping Resident #2 overnight for evaluation. A History and Physical, dated 06/10/12, documented Resident #2 resided in the facility's Alzheimer's unit and had an alarm, but apparently some time had discontinued his/her own alarm and staff found him/her in a chair complaining of left hip pain. Staff did not know of a fall. Resident #2 had dementia but stated she did not fall that he/she knew of. They were uncertain whether maybe Resident #2 had fallen in the night and gotten him/herself back up. Resident #2 had a dislocated left hip and sent for care of the orthopedist for further evaluation where they, under fluoroscopy and conscious sedation, replaced it. Resident #2 would be admitted for observation. A Physician's note, dated 06/13/12, documented Resident #2 suffered hip dislocation of a cemented [MEDICAL CONDITION] hemiarthroplasty while at the facility. They did not know exactly how it occurred but it took a fair amount of force to dislocate, or at least it took assumption of a compromising position outside a safe window of flexion, adduction and internal rotation to dislocate a cemented [MEDICAL CONDITION] hemi. They were able to reduce it successfully in the emergency room . They admitted Resident #2 to the hospital to be fit with a hip abduction orthosis. The Nurse's Notes, dated 06/14/12, documented Resident #2 returned to the facility. Resident #2 had an abductor brace that went around his/her torso and extended down the left leg to the mid thigh. Resident #2 needed to wear the brace at all times and remove only for bathing and monitoring skin. During an interview on 07/03/12 at 12:45 p.m. the Director of Nursing (DON) stated they investigated all injuries of unknown origin and there would be an incident report. Regarding Resident #2's dislocated hip, she stated Resident #2 complained of pain and had some medication. She stated she did not talk to staff to find out if anything unusual happened. During an interview on 07/05/12 at 11:59 p.m. the DON stated she did not investigate Resident #2's dislocated hip because it wasn't an injury, it could happen after a [MEDICAL CONDITION]. The DON acknowledged Resident #2's clinical record lacked documentation about what happened prior to the hip dislocation and had no incident report. According to the facility policy, Investigation of Injuries of Unknown Origin must be investigated immediately to rule out abuse. The investigation must determine a causal factor and facilitate implementation of interventions. The facility policy, Mandatory Reporting, documented it was the responsibility of the employees, facility consultants, attending physicians, family members, visitors etc.. to promptly report any incident of neglect or resident abuse, including injuries of unknown source... to facility management.

Based on observation, record review, and staff interview, the facility failed to provide adequate supervision to prevent elopement for 1 of 4 residents reviewed (Resident #1). Resident #1 was found outside the facility 6/16/12 at 2:45 p.m. by a CNA and was returned to the facility. No one knew how he left the facility or when and no alarms sounded. The facility also failed to provide adequate supervision and assistive devises to prevent accidents for 1 of 4 residents reviewed (Resident #2). Resident #2 suffered a hip fracture 05/17/12 with surgical repair. Resident #2 had a personal alarm with a blue clip which the resident untied on the night shift 06/09/12-06/10/12. Staff retied the string. The morning of 06/10/12 the resident again untied the string of the alarm, got up unattended and staff found him/her in the recliner complaining of pain. The resident transferred to the hospital for treatment of [REDACTED]. Findings include: 1. According to the Minimum Data Set (MDS) assessment, dated 06/10/12, Resident #1 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Resident #1 required supervision with ambulation in the corridor and normally used a walker. The Resident Care Plan, dated 06/14/12, identified Resident #1 with impaired thought processes related to Parkinsonism with confusion and forgetfulness at times. The approaches included: a. Calm resident if signs and symptoms of distress develop during cares or any decision making process. b. Potential for elopement: In secure dementia unit, door alarms, census checks. The Behavior Sheet, dated 06/09/12, documented Resident #1 cried, paced the hall, and pushed on the door to leave. An Occupational Therapy Initial Assessment, dated 06/12/12, documented Resident #1 previously lived with family, but they were unable to meet his/her needs any longer at home, resulting in the need for placement. Resident #1 had shown some behaviors since admission and on that date tried to find a way to get out of the facility. The Behavior Sheet, dated 06/13/12 at 5:30 p.m., documented Resident #1 had increased agitation, restlessness, paced, talked in angry tones, and tried to leave. A Medication Assessment and Follow-Up Charting Form, dated 06/14/12, documented staff noted Resident #1 with increased behaviors, attempts to get out of the facility, verbal aggression, pacing, and became easily annoyed with staff. The Physician increased Ativan to 1 milligram (mg) 3 times a day and 2 mg at bedtime. The Behavior Sheet, dated 06/16/12 at 3:30 p.m., documented Resident #1 dismantled a window in room 999, climbed out the window and tried to leave. A CNA brought the resident back in the facility. Resident #1 was short tempered with staff and placement. During an interview on 07/03/12 at 11:08 a.m. Staff G Certified Nursing Assistant (CNA) stated she didn't think there was anything out of the ordinary the day Resident #1 eloped. She said Resident #1 didn't try to get out of the facility every day, but he/she did at times. She said they were watching Resident #1 closer and walking with him everywhere because of unsteadiness on his/her feet. They didn't actually help Resident #1, but made sure they supervised him/her. Resident #1 tried to get out the doors. Staff G stated she left the same time as Staff H CNA. She said when they went through the door they waited until the door locked. She said it didn't lock right away after it shut, and she didn't know how long it took to lock. Staff G didn't think there were many visitors that day, she thought 2. She didn't think there were any visitors when she left. During an interview on 07/05/12 at 10:42 a.m. Staff H CNA stated she worked day shift the day Resident #1 eloped. She said they had a few visitors in the morning, but there were no visitors when she left at 2:30 p.m. She said Resident #1 kept going door to door and walked unsteadily She said the nurse told them to do 1 to 1 with him/her and they did. She said when Resident #1 saw someone come in or go out the door he/she would walk that way and they would walk with him/her. When the afternoon shift came on they reported Resident #1 going to the doors trying to get out and told them to watch him/her like a hawk. They thanked them for the heads up. Staff H stated 1 person had to watch Resident #1 and the other had to watch the rest of the residents. She said she and Staff G waited to hear the door lock when leaving the unit that day. She said it took a few seconds, but she didn't know how long. She said a lot of people used the south door right by the unit. Staff H stated (after work) she talked to someone, then got her things to change clothes. She left the building about 3:00 p.m., or a little after. She did not hear any door alarms while changing clothes. When she left, she saw Resident #1 in the ditch and assisted him/her back into the building. She did not know how he/she got out. During an interview on 07/05/12 at 2:47 p.m. Staff C CNA stated she worked the afternoon Resident #1 eloped. She said she and Staff E CNA assisted another resident up from the dining room, to the bathroom, and back to the dining room. She said she looked for Resident #1 afterward, and then staff brought him/her back in. She never heard the door to the unit open or close and no alarms went off. Staff C stated some visitors were present but she didn't know who. Staff C stated they were keeping an eye on Resident #1. He/she went in/out of other resident's rooms messing with the windows. Resident #1 told staff he knew how to bust windows. Staff C stated all the windows were closed after the elopement. She said day shift reported Resident #1 going to the doors and told them to watch him/her close, which they did. She didn't know how Resident #1 got out. During an interview on 07/05/12 at 3:09 p.m. Staff E CNA stated she worked the shift Resident #1 eloped. She said there were some visitors around, but not a lot. She said visitors came and went as they pleased, and frequent visitors knew the code to the keypad. Staff E did not see Resident #1 leave. She said she last saw Resident #1 at the desk while getting things ready in the kitchen. She said they did take another resident to the bathroom, but thought Resident #1 still there after that. She did not hear any alarms go off. She said it was a matter of 2 to 3 minutes from the time she last saw Resident #1 and staff brought him back to the unit (from outside). During an interview on 07/05/12 at 3:36 p.m., Staff I Licensed Practical Nurse (LPN) stated the day Resident #1 eloped he went to doors wanting to go home. This was not unusual for him/her. Staff I stated Resident #1 redirected fairly easily. Staff I stated she instructed the day shift to watch what Resident #1 did. She said at times Resident #1 became verbal, but not physical. When Staff I passed medications in the unit Resident #1 seemed calm and had coffee. Staff I stated no alarms went off around the time of the elopement. Around 2:50 p.m. Staff I saw Staff H and Resident #1 coming up the hall, and she asked Staff H what went on, and went back to the unit to see what happened. She said no one knew how he got out. Staff I investigated and found Resident #1's walker in the far room, and the screen was out of the window. It appeared the window was open, but she didn't realize there was a second glass. She asked Resident #1 how he/she got out, and he/she said out the window. When they investigated further, they could not get the window open. The alarms were checked and functioning immediately after the elopement. Staff I did not give the afternoon staff any direction when they came in, they received report from the day shift. During an observation on 07/03/12 at 10:51 a.m. the surveyor entered the Unit with staff, and noted pictures of the residents on the wall to the right. The west exit door had an alarm with no key pad to bypass it. The exit door to the courtyard had an alarm with no keypad to bypass it. Staff entered a code in the east exit door keypad to exit the unit (into a hall). Notes were posted on both sides of the unit door not to hold the the door open for residents. An exit door located to the right after exiting the unit lead outside. The door did have a keypad with no number posted. An exit door to the next right had an alarm with no keypad to bypass it. During an interview on 07/05/12 at 7:20 a.m. Staff K MDS Coordinator stated the code to get in the unit was the same as the code to the other doors to get out. She stated the code to get out of the unit differed and only staff knew that code. At 8:05 a.m. Staff K stated there was a lag from the time they entered the code to the door until it locked. She said it lagged seconds, long enough to get a wheelchair or cart through the door. She stated the staff had keys to silence the alarm, and they had to go to the door to do this. The surveyor walked through the door with Staff K and waited to hear the door lock, but didn't hear it. After 30 seconds Staff K attempted to open the door. It would not open and the alarm sounded. Staff A responded to the alarm, checked who attempted the door and silenced the alarm.

Based on record review, staff and physician interviews, the facility failed to consult with the resident's physician or family when there was a significant change in the resident's mental status for one of four residents reviewed. Resident #1 had aggressive, threatening, agitated and destructive behavior on 5/12/12. The facility did not notify the resident's physician or family of the incidents. Subsequently on 5/18/12, the resident pushed a staff which caused the staff to bump Resident #2. Resident #2 fell and fractured a hip as a result of Resident #1's behavior. Facility census was sixty-five (65) residents. Findings include: Nurses notes identified on 5/8/12 at 11 a.m., Resident #1 admitted to the facility from the hospital. A hospital discharge summary, dated 5/8/12, stated the resident admitted to the mental health unit of the hospital following aggressive behavior of trying to hit an emergency medical technician and strangle the resident's spouse. The resident's family divulged the resident had increased behaviors of aggressiveness and anger over the past month. A physician's report of examination for Iowa District Court, dated 5/2/12, assessed the resident as not a danger to self or others at this time. It stated the resident is still aggressive at times but responded well to medications. Nursing home placement was recommended. Following the examination for Court, the resident admitted to the facility per court order on 5/8/12. Nurses notes, dated 5/12/12 at 11 a.m. and documented by Staff P (registered nurse), identified the resident ripped shoes apart by tearing up laces and ripping the tongue out of the shoe. Staff gave the resident gripper socks to wear. At 11:45 a.m. , the resident refused lunch and continued to pace in the hall carrying silverware. At 12:30 p.m. the resident approached another resident from behind and put a fork to the other resident's neck and applied slight pressure while muttering to the other resident. At 12:45 p.m., the resident again paced the hall with a stormy look on his/her face. The resident tried to grab mail from the nurse and called the nurse a name. At 1 p.m. the resident threw a rocker over in room. When the nurse passed medications, the resident tried to grab the medication cup from the nurse. Staff attempted to give the resident [MEDICATION NAME] (antianxiety) by mouth but the resident refused it. The resident dropped 2 spoons and a fork and the nurse picked them up. As the nurse did this, the resident started coming at the nurse with another fork but did not attack. The maintenance man assisted staff in administering an intramuscular (IM) injection to calm the resident down. At 1:50 p.m., after the medication, the resident appeared less agitated. The record lacked evidence the facility notified the physician or the resident's family of the incident. On 6/6/12 at 10:10 a.m. the Director of Nursing stated the incident was treated as a behavior so there was no notification. On 6/6/12 at 12:12 p.m., the resident's physician stated the facility needed to find the resident a new physician because he does not make visits to the facility and he does not feel comfortable ordering things for a resident he would not see but if staff would have notified him of the incident, he would have recommended the resident be seen by the psychiatrist for the behaviors. On 6/11/12 at 10:26 a.m., Staff P stated the resident refused the oral medication because he/she was upset that staff attempted to take the forks away from the resident. Staff P stated she did not think the resident posed a danger to others. Staff just needed to get to know the resident. Staff P stated the other resident's neck did not contain marks from Resident #1 placing a fork to it. Nurses notes dated 5/17/12 at 9:30 p.m. identified Resident #1 walking in the hall towards the East door when he/she suddenly charged and became angry shoving a nurse aide as she entered a resident room. The staff accidentally bumped the resident in the room (Resident #2) after the resident shoved her causing Resident #2 to fall and sustain injury. Following the fall, at 10:50 p.m. nurses notes identified Resident #2 transported to the emergency room for evaluation. A physician consultation form from Spencer Hospital, dated 5/18/12, identified Resident #2 with a left valgus impacted femoral neck fracture. The fracture required surgical repair.