Every finding on record at English Valley Nursing Care Center

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to prevent falls causing major injuries for 3 out of 5 residents reviewed with falls and a history of major injury (Residents #16, #21 and #36). The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #36 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 7 out of 15 and had the following diagnoses: Chronic Systolic Congestive Heart Failure, Debility, Cardiorespiratory Conditions and Alzheimer's. The MDS documented Resident #36 required extensive staff assistance with bed mobility, transfers, locomotion on the unit, toileting and personal hygiene, and totally dependent on staff for bathing. Review of the Care Plan dated 3/8/22 identified the resident with the problem that she required assist with her cares due to arthritis and had falls when she was at home and directed staff to: a. Transfer the resident with a Hoyer with assist of two staff using the blue sling and place lambs wool between legs where sling wraps around. b. Transfer per stand lift. c. She prefers showers, enjoys baths, but transfers with the lift chair scare her. A review of the Nurse's Notes documented the following: On 9/28/23 7:10 AM, Staff walked by her door and saw Resident #36 sitting on the floor with her back against the mattress. Denied hitting head. Stated she slid off side of the bed. Assisted back to bed with assist of 3 staff members using the stand lift. Did not voice any discomfort. Able to bear weight per usual. Resident screened for signs/symptoms of COVID. Resident denies shortness of breath/dyspnea/cough/sore throat or other concerning symptoms. Respiratory rate regular and unlabored. A review of the Incident Report dated 9/30/23 at 8:20 AM, documented the following: a. Resident #36 had a witnessed fall in the hallway. Staff A, Certified Nursing Assistant (CNA) was pushing the resident in wheeled shower chair to Resident #36's room. Upon coming to the threshold in hallway, Staff A stood in front of the chair to pull over threshold. Staff A reported Resident #36 started to lean over which caused the chair to tip. Staff A attempted to keep the chair upright and had to lower Resident #36 to the floor between her legs. The resident sitting on her bottom when the nurse got to her. Resident #36 was not sent to hospital. b. Intervention: No transporting resident in wheeled shower chair. c. Addendum: Sent to emergency room (ER) at 6:15 PM and diagnosed with bilateral femur fractures and pneumonia. A review of a statement written by Staff A, CNA dated 10/1/23, revealed she gave Resident #36 her shower on Saturday, September 30, 2023, while washing her legs she told me they hurt and looked swollen. After she completed the shower, she notified the Director of Nursing (DON) to look at Resident #36's legs. The DON applied an ace wrap to Resident #36's legs after she assessed her and left with instructions to elevate her legs when in the recliner. Resident #36 was upset about her hair washed, so Staff A thought to move her with the shower chair to her room. She moved Resident #36 to the first doorway and got in front of her to move the chair over the bump. Then Resident #36 leaned forward and the chair moved out from under her. Staff A attempted to keep her from falling, however her foot (Staff A) slipped and Resident #36 landed on the floor. Three staff members assisted getting the resident up and transported her to her room to her recliner. A review of the Nurse's Progress Notes revealed at 9/30/23 at 8:30 AM, Resident #36 sat on the floor in doorway threshold with shower chair behind her and Staff A standing next to her. Staff A reported she transported Resident #36 back to the room in the shower chair when Resident #36 leaned forward which caused the shower chair to tip. Staff A attempted to stop the fall and lowered Resident #36 to the floor. Assessed for injuries, none noted. Resident #36 could not describe what happened. Assisted by staff and gait belt on to chair and taken to her room. No new injuries noted. Stand lift used to transfer her into the recliner and her feet were noted to be puffy. Feet elevated. Intervention for this incident is that resident is not to be transported per shower chair. On 9/30/23 AT 6:05 PM the Nurse Practitioner (NP) called in orders to send to the ER of choice for evaluation and treatment post fall. A review of the Nurse's Progress Notes revealed the following: a. On 9/30/23 at 6:15 PM, Resident #36's daughter wanted her sent to the hospital. Ambulance called and report called to the ER. b. On 9/30/23 10:03 PM, Received telephone call from the hospital who reported Resident #36 was admitted to acute care with diagnoses of pneumonia and bilateral femur fractures. Treating with antibiotics and no surgical intervention at this time. A review of the History and Physical by the Emergency Department (ED) physician dated 9/30/23 at 8:06 PM, documented the following: A review of the x-rays of both knees performed at the hospital revealed a fractures of the distal femoral shaft (thighbone) to the left and right femurs. On 9/30/23, the Care Plan updated to include the new intervention that Resident #36 will not be transported out of shower or bathroom in shower chair or bath chair. A review of the Nurse's Notes at the facility had documented on 10/2/23 at 5:10 PM, call received from the hospital. Resident #36 passed away today at 4:40 PM. In an interview on 10/17/23 at 9:25 AM, Staff A, CNA reported Resident #36 did not have a history of falls until 9/28/23 and 9/30/23 and to be transferred with assist of 2 using the stand lift. On 9/30/23, after she showered Resident #36 and tried to transport her in the hall in the shower chair, Resident #36 leaned forward and the shower chair went out from underneath her. She did not transfer her to a wheelchair as Resident #36 was already upset about having her hair washed and thought one less transfer would not be as upsetting. Resident #36 was sent to the hospital later that night. In an interview on 10/17/23 at 10:00 AM, Staff B, Licensed Practical Nurse (LPN) reported Resident #36 did have a history of behaviors and was to be transferred with a stand lift with 2 people. Staff B also reported staff occasionally have used the shower chairs to transport residents, however, she felt it was not a safe practice. Staff B also reported the threshold between the fire doors is made out of wide metal and staff have caught different things on that threshold, such as the med cart. If Staff A had used a wheelchair, the fall could have been prevented. In an interview on 10/17/23 at 2:39 PM, Staff C, Registered Nurse (RN) reported she could not recall if Resident #36 had a history of falls, however, she did recall that Resident #36 would try to get up on her own. Fall interventions implemented included: keeping her room close to the Nurse's Station, transfer with stand lift and if they had problems, could use the Hoyer lift. Staff C also reported the fall could have been prevented if a wheelchair was used to transport the resident rather than using the shower chair. In an interview on 10/17/23 at 12:29 PM, the DON reported Resident #36 was already upset about having her hair washed and Staff A thought that one less transfer from shower chair to the wheelchair would be less upsetting to her. The fall could have been avoided if she had transported Resident #36 in a wheelchair rather than the shower chair. After that incident, she told all staff they would no longer use shower chairs to transport residents out of the shower room. She eliminated the use of that particular shower chair and purchased a larger shower chair. In an interview on 10/18/23 at 8:39 AM, Staff D, CNA reported the aides used the shower chair to transport only one or two residents from the shower room to their rooms. She did not work the day Resident #36 fell , however, reported the fall could have been avoided if Resident #36 was transported in a wheelchair instead of the shower chair. In an interview on 10/18/23 at 8:49 AM, Staff E, CNA reported the bump in between the fire doors could be hard to push shower chairs and the fall with Resident #36 could have been avoided if she was transported in a wheelchair rather than a shower chair. In an interview on 10/18/23 at 9:10 AM, Staff F, CNA/Certified Medication Aide (CMA) reported Resident #36 did not have a history of falls before her first fall on 9/28/23 and she was not here when Resident #36 fell on [DATE]. Fall precautions in place were use of a low bed and transfer with a stand lift with assist of 2. The fall on 9/30/23 could have been avoided if the resident had been transported in a wheelchair instead of a shower chair. A review of the facility policy titled: Falls and Fall Risk, Managing dated as last reviewed 6/10/22 documented the following under Resident-Centered Approaching to Managing Falls and Fall Risk: a. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. b. If a systemic evaluation of a resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). c. Examples of initial approaches might include exercise and balance training a rearrangement of room furniture, improving footwear, changing the lighting, etc. d. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated within increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. e. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. f. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. g. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g.,hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. h. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. 35434 2. The MDS Assessment Tool, dated 8/7/23, listed diagnoses for Resident #21 which included non-Alzheimer's dementia, Huntington's (a disease which causes nerve cells in parts of the brain to gradually break down and die) disease, and [NAME]-[NAME] Syndrome(a disorder where two or more neck vertebrae [types of bones] were fused together from birth). The MDS documented the resident required limited assistance of 1 staff for bed mobility, transfers, walking, dressing, eating, and personal hygiene, and extensive assistance of 1 staff for toilet use and bathing. The MDS identified the resident had 1 fall with a non-major injury during the review period and listed the resident's BIMS score as 15 out of 15, indicating intact cognition. A 2/16/23 Incident/Accident Report stated staff found the resident on the floor in front of her chair and she had her seat alarm pushed to the side of her chair. A 3/14/23 Incident/Accident Report stated the resident was found on her back on the floor. She sustained a 3 centimeter (cm) x 2 cm pink abrasion to the back of the neck to the right side. A 3/15/23 Care Plan entry stated the resident had a chair alarm on at all times when not in bed. A 4/19/23 Incident/Accident Report stated the resident leaned forward from her chair, went to her knees, and then bumped her head on the floor. An 8/9/23 Incident/Accident Note stated staff heard a thud from the Nursing Station and found the resident on the floor of the bathroom doorway with her pants down. The resident had a small bloody nose, a bump on her head, and small superficial (shallow) scrapes to her knuckles of the left hand. The resident stated she took herself to the bathroom prior to activities. Her call light was activated and her chair alarm was not on. A CNA took her back to her room at 9:30 a.m., after her bath and forgot to turn it back on. The resident reported nausea and lightheadedness 30 minutes after her fall and had an emesis (referring to vomit). The resident transferred to the Emergency Department (ED) at 12:10 p.m. An 8/9/23 Nurse's Notes stated the facility received a call from the ED nurse and the resident would transfer to a different hospital. An 8/9/23 Major Injury Determination Form stated the provider stated after reviewing the circumstances, injury, and prognosis of the patient, she believed the injury sustained was a major injury. An 8/10/23 ED report stated the resident had a closed non-displaced fracture (a fracture in which the bone cracked but retained proper alignment) of the first cervical vertebra (a bone of the neck). The report stated she would transfer to another hospital. An 8/10/23 Nurse's Note stated the resident returned from the hospital and was at baseline with ambulation(walking). A statement documented by Staff G, CNA, dated 8/10/23, stated she assisted the resident with a bath and walked her back to her room. The resident sat in her chair and Staff F handed her, her tablet, call light, and blanket and left the room at approximately 9:30 a.m. On 10/17/23 at 2:08 p.m., Staff G stated on the day of the resident's fracture, she assisted the resident with a bath and back to her recliner. Staff G stated she forgot to turn the resident's chair alarm back on after her bath. On 10/18/23 at 10:45 a.m., the DON stated she sat at the Nursing Station and she heard Resident #21's call light alert. She stated she heard another staff member say she would answer the call light. She stated it was not long after this that they found her in the doorway of the bathroom with her pants pulled down. She stated she thought this was less than 3 minutes after the call light alerted and stated the chair alarm was not on. The DON stated this was an oversight and the CNA forgot to turn it back on after assisting her. The DON stated alarms should function correctly. 3. The MDS Assessment Tool, dated 12/19/22, listed diagnoses for Resident #16 which included non-Alzheimer's dementia, anxiety disorder, and adjustment disorder. The MDS identified the resident was independent with transfers, and the resident's BIMS score as 11 out of 15, indicating moderately impaired cognition. A 1/2/23 Incident Accident Report stated the resident was found on the floor of the bathroom and sustained a small bump on the back of the head. On 1/3/23 at 7:17 a.m., Nurse's Notes stated staff heard the resident yelling and found her lying on the floor on the right side. The nurse noted 2 different bumps on the head after the fall. On 1/3/23 at 6:15 p.m., an Incident/Accident Report stated the resident sat in the wheelchair in the hallway and arched her back and slid off the wheelchair to her bottom. The resident had no injuries or complaints of pain. On 1/3/23 Care Plan entries stated the resident would have a Physical Therapy and Occupational Therapy Evaluation to treat following a recent fall and stated the facility would provide a smaller and shorter wheelchair to prevent her from sliding out. On 1/4/23 at 6:05 a.m., Nurse's Notes stated the resident was very confused and would bear no weight with transfers. The facility would transfer the resident to the hospital due to her change in mentation. An 1/4/23 ED Provider Note stated the resident presented to the ED following 3 falls in the last 24 hours. The note stated the resident had a femoral neck fracture (a type of hip fracture). A Major Injury Determination Form, dated 1/4/23 form stated the provider believed the injury sustained was a major injury. The form stated the resident was independent in the facility with a walker prior to the fall. A 1/4/23 Nurse's Note stated the resident returned from the hospital and required the assistance of staff to transfer into the wheelchair. A 1/6/23 Care Plan entry stated a remote sounding floor alarm was placed in her room and directed staff to utilize it when left unattended. The MDS assessment tool, dated 1/11/23, stated the resident required extensive assistant of 2 staff for transfers. On 3/6/23 at 6:25 a.m., Nurse's Notes documented staff entered room and the resident was on the floor. The note stated the resident's left leg was shorter and rotated inward. The resident had a floor alarm in place but it was not sounding. The facility transferred the resident to the ED. On 3/6/23 at 9:13 a.m., Nurse's Note stated the hospital called and the resident did not have a fracture or break. On 10/16/23 at 1:56 p.m., the resident walked down the hall with 1 staff member and a gait belt.

Based on observation, record review, and interview, the facility failed to maintain minimum safe water temperatures in resident rooms and the shower room. The facility reported a census of 40 residents. Findings: During a tour of the facility on 02/22/21 at 3:19 p.m., the survey team requested the Maintenance Supervisor to obtain and provide water temperatures and he provided the following(all temperatures in degrees Fahrenheit): room [ROOM NUMBER] 126.1 room [ROOM NUMBER] 126.5 room [ROOM NUMBER] 126.8 room [ROOM NUMBER] 126.3 room [ROOM NUMBER] 124.7 room [ROOM NUMBER] 125.6 During the tour, the Maintenance Supervisor stated he was newer in the position and the water was way worse when he first arrived. When asked to clarify, he stated the water was hotter when he first arrived. He stated he hadn't had a chance to readjust the water heater. He stated he obtained water temperatures every day and stated he would readjust the water heater and inform the survey team upon completion. The surveyor then asked the Maintenance Supervisor for a copy of the daily water temperature checks and he then stated he did not check the temperatures every day but completed them weekly. During an observation on 02/22/21 at approximately 4:00 p.m., the survey team obtained a temperature of 123.8 in the shower room. During an interview on 02/22/21 at 5:13 p.m., the Maintenance Supervisor stated he readjusted the water temperature to 105 degrees and also drained the water tanks. The survey team requested the Maintenance Supervisor obtain and provide water temperatures to the team. The following was provided: room [ROOM NUMBER] 100.2 room [ROOM NUMBER] 100.4 room [ROOM NUMBER] 101.4 room [ROOM NUMBER] 101.8 room [ROOM NUMBER] 102.5 room [ROOM NUMBER] 101.4 Shower room [ROOM NUMBER].2 Review of water temperature logs during the period of 12/11/20-2/20/21, revealed the facility checked water temperatures 5 times on the following dates: 12/11/20, 01/09/21, 01/22/21, 02/07/21, and 02/20/21. The dates were difficult to read on the document and it appeared the year was first written as 2020 but then was written over as 2021. The document included the following temperatures: 12/11/20 room [ROOM NUMBER]=123 12/11/20 room [ROOM NUMBER]=123 12/11/20 room [ROOM NUMBER]=123 01/9/21 Whirlpool=113 01/9/21 room [ROOM NUMBER]=123 01/9/21 room [ROOM NUMBER]=124 01/22/21 room [ROOM NUMBER]=123 01/22/21 room [ROOM NUMBER]=123 02/07/21 room [ROOM NUMBER]=122 02/07/21 room [ROOM NUMBER]= 123 02/20/21 room [ROOM NUMBER]=123 02/20/21 room [ROOM NUMBER] = 123 On the document, most of the numeral 2's were crossed through with a 1, for example 123 also looked like it could have been 113. During an interview on 03/02/21 at 12:05 p.m., the Administrator stated they set the water temperatures to a range of 100-115 degrees Fahrenheit. During an interview on 03/02/21 at 1:12 p.m., the Administrator stated the facility did not have a policy related to hot water temperatures. --

Based on observation, record review, and staff interviews, the facility failed to prime (remove air bubbles from the needle) the needle tip of an insulin pen before injecting insulin in 1 of 1 residents observed receiving insulin (Resident #19) and failed to recognize a non-crushable medication when giving pills to 1 of 3 residents receiving crushed pills (Resident #35). The facility reported a census of 40 residents. Findings include: 1. The Medication Administration Record [REDACTED]. During an observation of insulin administration on 02/24/21 at 8:00 a.m., Staff A, Licensed Practical Nurse(LPN), disinfected the top of the insulin pen with an alcohol wipe. Staff A then turned the dial on the pen to 2 units and pushed the end of the pen without a needle screwed onto the pen to prime. On 02/24/21 at 8:10 a.m. Staff A stated she normally primes the pen with the needle tip in place. The facility procedure titled Insulin Administration dated 02/05/18 directed to disinfect the top of the pen with an alcohol wipe, screw on needle to insulin pen, turn dial to 2 units and push end of pen to prime needle. On 03/01/21 at 3:55 p.m. the Director of Nursing(DON) reported the expectation for staff to clean the top of the insulin pen with alcohol, put the needle on, scroll to two units, and prime the needle prior to selecting the dose and administering the insulin. 2. The Medication Administration Record [REDACTED]. During an observation of the medication pass on 02/25/21 at 7:40 a.m., Staff A crushed an [MEDICATION NAME] coated aspirin and gave it to Resident #35 in applesauce. During interview on 02/25/21 at 8:02 a.m. Staff A stated the pharmacist makes recommendations on crushing medications. Staff A stated the pharmacist had not caught the [MEDICATION NAME]-coated aspirin order after speech therapy made the recommendation to crush Resident #35's medications. During interview on 03/01/21 at 3:55 p.m., the Director of Nursing (DON) stated the expectation is that an [MEDICATION NAME] coated aspirin is not crushed. The pharmacist reviewed medications monthly and made recommendations but had not noted Resident #35 received crushed medications with an order for [REDACTED]. -

Based on observation, clinical record review, policy review, and staff interview, the facility failed to report an injury of unknown origin(an arm fracture) to the State Agency for 1 of 1 residents reviewed with an injury of unknown origin(Resident #22). The facility reported a census of 40 residents. Findings: 1. The MDS(Minimum Data Set) assessment tool, dated 01/11/21, listed [DIAGNOSES REDACTED]. The MDS documented resident completely depended on 1 staff for dressing, eating, and personal hygiene, and completely depended on 2 staff for bed mobility, transfers, and bathing. The MDS also documented the resident's cognition was severely impaired. An observation on 02/25/21 at 8:59 a.m. revealed Staff C CNA(Certified Nursing Assistant) and Staff E CNA transferred the resident with a mechanical lift from the chair to the bed. An undated, untitled statement, written by Staff C stated on 02/06/21 the resident's arm was flaccid and her arm was usually very restrictive. The note stated she informed Staff D Registered Nurse (RN) of this and Staff D assessed the resident and later stated the arm was at baseline. The note stated by Monday (02/08/21), the resident's arm was bruised. An undated, untitled statement, written by Staff D, stated on 02/06/21, a CNA reported to her the resident's arm appeared much more relaxed than normal. The note showed Staff D assessed the resident and she was at baseline. A 02/08/21 12:57 p.m. a nursing note stated staff over the weekend noted that the resident's right arm was more flaccid and that today the resident had a light purple bruise on the 5th right finger 4 cm(centimeters) x 2 cm and a dark purple bruise on the inside of the right elbow 3 cm x 9 cm. A Nursing Note done 02/09/21 10:25 p.m. documented the resident's right arm was more swollen and the resident had increased grimacing with touch. The note stated staff administered [MEDICATION NAME](a narcotic pain reliever) and ice and obtained an order for [REDACTED].>A Nursing note dated 02/10/21 4:23 a.m. documented resident's arm remained swollen and she continued to have facial grimacing and moaning. A Radiology report done 02/10/21 documented the resident had a displaced fracture(a break in the bone resulting in the bone being out of alignment) of the distal humerus(arm bone) which appeared to be subacute( in between acute-of sudden onset and chronic-long-term). A Care Plan entry, dated 02/10/21, documented the resident relied on staff to provide all cares. The facility policy Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 12/22/16, included injuries of unknown source as abuse. The policy deemed an injury of unknown source as occurring when both of the following conditions were met: -The source of the injury was not observed by any person or the source of the injury could not be explained by the resident and -The injury was suspicious because of the extent of the injury or the location of the injury. On 03/01/21 at 1:16 p.m., Staff D stated Staff C reported to her the resident's arm was more flaccid. Staff D stated she assessed the resident and observed nothing abnormal and there was no bruising. She was not sure when she next returned to work but when she did return, the resident then had bruising on her arm. On 03/01/21 at 1:40 p.m., Staff C stated on 02/6/21, when she first cared for the resident early in the morning, the resident's arm was really flaccid. She stated she informed Staff D and Staff D told her later the resident's arm was ok at that time. Staff C stated when she came to work on 02/08/21, the residents' arm was bruised. On 03/02/21 at 8:28 a.m., the DON(Director of Nursing) stated she heard on 02/08/21 that the resident's arm was more flaccid. She stated by Tuesday (2/9/21) the arm was more bruised and the resident had an x-ray. After the results of the x-ray, the DON spoke to all staff who had contact with the resident from 02/05/21-02/07/21. She stated the facility was unable to determine what happened. She stated because the injury was not deemed a major injury and it did not cause a change in the resident's condition, it was her understanding the facility did not need to report it. On 03/02/21 at 10:00 a.m., the Provisional Administrator stated she was aware of the resident's fracture and stated she inquired with nursing as to whether or not it was reportable. She stated she left it up to the Nursing Department to determine if the injury required reporting. --

Based on record review and interview, the facility failed to ensure the completion of a criminal background checks for 1 of 4 newly hired employees(Staff B). The facility reported a census of 40 residents. Findings: Record review of facility New Hire list, Staff B had a hire date of 06/25/20. Review of a Single Contact License and Background Check(SING), dated 06/22/20, stated further research required and directed staff to await the DCI's(Division of Criminal Investigation) final response. Review of DCI Iowa Record Check Request Form S, dated 06/24/20, showed Criminal History record report and Iowa Criminal History report listing a conviction for Staff B. Review of personnel file for Staff B did not contain a DHS(Department of Human Services) Record Check Evaluation with permission to work documentation. Review of facility policy Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 12/22/16, stated the facility would conduct an Iowa criminal record check on all prospective employees. During an interview on 03/02/21 at 11:24 a.m., the Administrator stated the former Administrator completed Staff B's record check and stated she could not find an evaluation or permission to work from DHS in Staff B's file. During an interview on 03/02/21 at 12:01 p.m., the Administrator stated the facility would suspend Staff B pending the completion of a new SING check and Record Check Evaluation.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to provide timely assistance for 2 of 9 residents requiring toileting assistance (Resident #46 and #37), and failed to provide thorough perineal cares for 1 of 6 residents observed. (Resident #46). The facility census was 43 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #46 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident was frequently incontinent of bowel and bladder. During observation on 4/9/18 at 12:17 p.m., the resident sat in a wheelchair at a dining room table. At 1:12 p.m., Staff C, Certified Nurse Aide, CNA and Staff D, CNA assisted the resident to transfer from the wheelchair to the resident's recliner in his/her room. Staff did not ask if the the resident needed to use the toilet and did not check the resident's incontinent brief to determine if it needed changed. During observation on 4/9/18 at 2:18 p.m., the resident sat in his/her recliner. During observation on 4/9/18 at 4:03 p.m., the resident sat in his/her recliner and the front and pelvic region of the resident's pants appeared wet. A strong smell of urine was present in the hallway near the resident's room. During observation on 4/9/18 at 4:18 p.m., Staff E, CNA and Staff F, CNA entered the resident's room and stated they would change the resident. A strong smell of urine was present in the resident's room. When they assisted the resident to stand and walk to the toilet, the back portion of the resident's pants was saturated from the lower back to the knees. Once the resident sat on the toilet, Staff E removed the resident's brief and pants. The brief was completely saturated with urine. While the resident sat, Staff E cleansed the resident's frontal perineal area from front to back with wipes including the inguinal folds. After assisting the resident to stand, Staff E cleansed the resident's rectal area in a front to back direction. Staff E did not cleanse all skin areas which would have been in contact with the resident's wet pants and/or brief including the back of the legs down to the knees, the inner thighs down to the knees, the right and left outer buttocks and the right and left hips. During interview after cares on 4/9/18 at 4:18 p.m., Staff E and Staff F stated they began work at 2:00 p.m. and this was the first time this shift they had assisted the resident. They stated Staff G was the only other CNA on shift at that moment. During interview following cares on 4/9/18 at 4:18 p.m., Staff G, CNA stated she had not assisted the resident during the shift. An undated care plan entry stated the resident required assistance with toileting. The care plan did not include a toileting schedule. The facility Perineal Care policy, revised 12/27/17, directed staff to include the buttocks and upper thighs when completing perineal cares. During interview on 4/11/18 at 2:34 p.m., the Director of Nursing stated in general residents should be taken to the bathroom or changed about every 2 hours. She stated Resident's #46 should be taken to the bathroom or checked and changed after lunch and stated the resident did not always know when he/she was incontinent. She stated the resident was usually incontinent of urine and stated staff should be sure to cleanse the entire area during perineal cares. 2. The MDS assessment dated [DATE], indicated Resident #37 had [DIAGNOSES REDACTED]. Care plan dated 2/8/18, directed staff to check and change for incontinence. If Bowel Movement is anticipated try sitting on the commode. During observation on 4/10/18 at 6:55 a.m., the resident was sitting in a recliner geri chair at a table in the assisted dining room. Staff moved the resident to the lounge area after breakfast. At 10:03 a.m., or three hours and eight minutes later, Staff A, CNA took the resident to a room at and provide a check and change. Observation revealed the resident was incontinent of a large bowel movement which had gone up the front of the incontinent brief and leaked onto her shirt and pants. The facility Toileting Schedule-Prompted Voiding policy, revised 12/27/17, stated staff should follow the care plan with regards to the resident's toileting schedule. The policy stated staff should assist residents with toileting upon rising, either before or after meals, and at bedtime and stated residents who were not responsive to a toileting schedule should be carefully checked at 2 hour intervals and changed promptly when wet.

Based on clinical record review, staff and resident interviews the facility failed to provide 2 baths a week for 5 of 11 residents reviewed (Resident #2, 3, 4, 5, 7). 1. Resident #2's MDS assessment dated [DATE] showed the resident with moderate memory loss, independent in the room, and required physical help from staff with parts of the bathing process. The MDS showed the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION]. The Care Plan with a revision date of 1/19/17 identified a need for total assist with most cares with an intervention that included a request to give a tub bath and not a shower. The current bath schedule (according to the DON), undated, showed the resident scheduled for a whirlpool bath every Tuesday and Friday, twice a week. Record review of the computer generated 'legend report' for documentation of baths completed revealed the following dates for baths not completed due to lack of staff initials: 11/18/16, 12/9/16, 12/27/16, 12/30/16, 1/6/17, 1/13/17, 1/24/17, and 1/31/17. The legend report also failed to document a refusal by the resident on those dates. 2. Resident #3's MDS assessment dated [DATE] showed no memory loss and required total dependence on staff assistance with bathing. The MDS showed the resident had [DIAGNOSES REDACTED]. The MDS dated [DATE] (following hospitalization ) showed the resident had moderate memory loss. The Care Plan revised on 1/5/17 identified a need for assistance with personal cares with an intervention to have a bath on day shift. The current bath schedule, undated, showed the resident scheduled for a bath every Tuesday and Friday. Record review of the computer generated 'legend report' for documentation of baths completed revealed the following dates for bath not completed due to lack of staff initials: 11/5/16, 11/15/16, and 12/9/16. The legend report also failed to document a refusal by the resident on those dates. An interview on 1/31/16 at 3:25 p.m. the DON reported an expectation for staff to document in the computer if the resident refused a bath/shower. Staff A, Business Office Person, reported the computer system has the option to initial for a refusal from a resident. 3. Resident #4's MDS assessment dated [DATE] identified the resident with a severe memory loss. The resident required total dependence for staff assistance with bathing. The MDS showed the resident had [DIAGNOSES REDACTED]. The Care Plan revised on 1/19/17 identified a need for total assistance with most cares with an intervention to have only a tub bath ( not a shower). The current bath schedule, undated, showed the resident scheduled for a bath every Tuesday and Saturday. Record review of the computer generated 'legend report' for documentation of baths completed revealed the following dates for bath not completed due to lack of staff initials: 11/1/16, 11/8/16, 11/15/16, 11/19/16, 11/29/16, 12/17/16, and 1/3/17. The legend report also failed to document a refusal by the resident on those dates. 4. According to the Significant Change Minimum Data Set (MDS) Assessment Tool dated 11/28/16, Resident #5 had [DIAGNOSES REDACTED]. Resident #5 also identified to be moderately impaired with cognitive skills for daily decision making. The MDS documented the resident required extensive to total assistance with 2 staff for transfers, bed mobility, also with dressing, toilet use, personal hygiene and bathing. The Nursing Care Plan identified the resident to need total assist with cares due to [MEDICAL CONDITION]'s Disease. Nursing staff instructed that 2-3 people may need to assist the resident with cares, transfers, and during baths as the resident may get angry. Review of Resident #5's bathing records for the following months showed the resident did not receive baths on Monday and Friday as scheduled: a. November 2016 no bath the week of 11/6-11/12. b. November 2016 only one bath the weeks of 11/13-11/19 and 11/20-11/26. c. The week of November 27 to December 3 no bath documented. d. December 2016 no bath the week of 12/4-12/10. e. December 2016 only one bath the weeks of 12/11-12/17, 12/18-12/24 and 12/25-12/31. f. January 2017 only one bath the week of 1/15-1/21. g. January 2017 no bath the week of 1/22-1/28. 5. According to the Quarterly Minimum Data Set (MDS) Assessment Tool dated 11/14/16, Resident #7 had [DIAGNOSES REDACTED]. Resident #7 also identified to be cognitively intact. The MDS documented the resident to be independent for transfers, bed mobility and ambulation but did need extensive assist of 1 staff for dressing and bathing. The Nursing Care Plan identified the resident needing more assist from staff, but not liking to accept it. Nursing Staff directed to give the resident early reminders when it is bath day so the resident can be ready for the bath in the afternoon. Review of Resident #7's bathing records for the following months showed the resident did not receive baths on Wednesday and Sunday as scheduled: a. November 2016 no baths documented for the week of 11/6-11/12. b. December 2016 no baths documented for the week of 12/18-12/24. c. December 2016 only one bath documented for 12-25-12-31. d. January 2017 only one bath documented for the weeks of 1/1-1/7 and 1/8-1/14. e. January 2017 no baths documented for the week of 1/15-1/21. During an interview on 2/1/17 at 9:05 a.m., Resident #7 stated generally got baths on Wednesday and Sundays and today was a bath day for him/her. The resident reported get baths most of the time, but the Certified Nurse Aides (CNA's) do miss once in awhile. During an interview on 2/1/17 at 8:10 a.m., the Administrator reported the CNA's should be documenting in a program on the computer when a resident receives a bath. The Administrator did acknowledge there to be a lack of documentation of baths being done per the CNA's. The Administrator was not aware of another area where the CNA's may document baths. During an interview on 2/1/17 at 8:20 a.m., the Administrator returned to report the CNA's tell the Nurse if a resident refuses to have a bath or shower, but not sure if documented. The Administrator stated knew the baths were getting done, or some of the residents family members would be letting the facility know, but the gap is there in the documentation and can't be proven if done or not. During an interview on 2/2/17 at 8:30 a.m., Staff B, CNA reported after giving a resident a bath it is documented in a program in the computer. If a resident refuses the bath/shower, CNA's need to report this to the Nurse, but unsure where the Nurse documents the refusal or not. The CNA's go to the Communication Book at the Nurse's Station and there in the front of the book is the bath schedule for residents the CNA's go by.

Based on record review and staff interviews the facility failed to follow the Physician's orders and failed to administer the correct dosage of medication for 2 of 11 residents (Residents #1 and #8). The facility identified a census of 45 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had no memory loss and required extensive staff assistance with cares. The MDS showed the resident had [DIAGNOSES REDACTED]. The Medication Review Record dated 1/1/17 and 11/28/16 directed staff to draw blood for BMP ( Basic Metabolic Panel- shows the sodium level, and other levels related to kidney/metabolic functions) every Tuesday. A Laboratory Report dated 8/23/16 showed the Nurse Reactionary wrote a new order to draw the resident's BMP every other month. Laboratory Reports showed blood drawn for the BMP completed on 9/13/16, 10/28/16, and 11/22/16. The record did not contain laboratory/blood work results for January 2017. An interview on 2/1/17 at 9:20 a.m. the Director of Nursing (DON), Registered Nurse (RN), reported sending a facsimile (fax) on 1/25/17 to the Nurse Practitioner, requesting blood work for certain residents for this year. The DON reported not being aware of a change in the blood work orders for Resident #1. 2. Resident #8's MDS assessment dated [DATE] showed the resident with severe memory loss. The MDS showed the resident had [DIAGNOSES REDACTED]. The Medication Review Report dated 12/12/16 and 12/29/16 directed staff to administer Calcium plus D (Vitamin D)-Tablet 500/200 milligrams (mg.)/units orally every day for supplement. The Medication Administration Report (MAR) dated January 2017 showed documentation of the medication Calcium plus D-Tablet 500/200 milligrams (mg.)/units orally every day for supplement. Observation on 1/31/17 at 8:00 a.m. the MDS Coordinator, passed medications to Resident #8. The MDS Coordinator picked up the resident's bottle of Calcium with D-600/800 milligrams with the resident's initials on it and said out loud, as she poured one tablet into the medication cup, Calcium with D- 600/800 mg. The resident took the cup of medication given by the nurse and swallowed them. An interview on 2/1/17 at 9:00 a.m., with the DON and MDS Nurse, the MDS Nurse reported knowing the dosage given was not what the order stated, but thought staff had fixed that. The MDS Nurse reported the bottle had been from the resident's home. Both Nurse's were aware of the dosage difference, and thought the pharmacy stated they did not have the 500/200 dosage. Both Nurse's were unaware the dose problem had not been corrected. The DON replied she would look into this.

Based on observation, review of State Fire Marshal website information and staff interview, the facility failed to ensure electrical equipment was properly utilized in one resident room. The facility census was 47 residents. Findings include: On the Department website in the February 2004 Insight, the State Fire Marshal's Office documented clarification on use of surge protectors. The posted information documented the electrical surge protector shall be of metal or steel construction and approved by Underwriters Laboratories or another recognized laboratory. The paper documented items that could be used with an electrical surge protector and items prohibited from use with a surge protector that included clocks, lamps, personal grooming and care devices, battery chargers, and motor driven appliances. 1. Observation on 2/9/16 at 12:50 p.m., revealed a lamp, suction machine and feeding pump plugged into a black surge protector with the cord draped over the residents curtain rod above the window in room 331. During interview on 2/9/16 at 12:50 p.m. Resident #3 reported the feeding pump, suction machine and nebulizer treatment machine were plugged into the surge protector in their room most of the time. Observation on 2/10/16 at 6:56 a.m., revealed a Kangaroo Joey feeding pump in operation and a suction machine plugged into a black surge protector, with the cord hanging over the curtain rod above the residents window in room 331. :

Based on observation, interview, and document review, the facility failed to ensure an infection control program that monitored and took actions to prevent the spread of infections. This failure had the potential to affect all 50 residents of the facility. Findings include: 1. Review of the facility's infection control data with Staff J, LPN on 12/18/13 at 3:15 p.m., revealed no documented evidence regarding employees with potentially communicable diseases or infections. Interview on 12/18/13 at 3:35 p.m. with Staff J, LPN, who is the Infection Control Coordinator, and the facility Director of Nursing confirmed the facility did not track staff infections as part of it's infection control program. 2. On 12/17/13 at 10:10 a.m., Staff B, CNA and Staff C, CNA transferred Resident #7 to the commode in Resident #7's room. The incontinent brief removed revealed a smearing of bowel movement. Staff C, CNA wiped the resident's rectum of BM 5 times with gloved hands then, without changing gloves or sanitizing hands, pulled up the resident's incontinency brief and trousers. 3. On 12/17/13 at 9:35 a.m. Staff A, RN completed wound care treatments for Resident #7's hands. After cleansing the wounds on the resident's left and right hands, Staff A, RN sat the wound cleanser bottle on the resident's bed sheet without a barrier. After completing the treatment, without cleaning the outside of the wound cleanser bottle, Staff A, RN placed the bottle in the resident's wound care treatment tray that contained treatment supplies and ointment. 4. On 12/18/13 at 1:50 p.m. Staff B, CNA emptied Resident #8's leg bag of urine in the resident's bathroom, carried the urine graduate to the dirty utility room covered in a plastic bag. While in the dirty utility room, Staff B, CNA rinsed the graduate with the water wand, without covering the graduate with the plastic bag, Staff B, CNA returned the soiled graduated to the resident's room and placed the graduate into a plastic bag in the resident's bathroom. 5. The Minimum Data Set (MDS) Resident assessment dated [DATE] documented Resident #1 had [DIAGNOSES REDACTED]. Observation on 12/19/13 at 9:15 a.m. revealed Staff D, Registered Nurse (RN) use scissors to cut [MEDICATION NAME] (dressing material used to cover the residents open wound). Staff D did not clean the scissors before the dressing change. After the dressing change, without cleaning, the scissors went back into a box in the medication cart. During an interview on 12/19/13 at 4:15 p.m., the Director of Nursing reported staff is supposed to clean the scissors with a disinfectant wipe after completing a dressing change. 6. According to the MDS dated [DATE], Resident #3 had been incontinent of bowel and bladder and required total assistance of 1 staff member for personal hygiene and dressing, and total assistance of 2 staff members for transfers, and toilet use. The MDS also documented the resident had [DIAGNOSES REDACTED]. Observation on 12/17/13 at 4:10 p.m. revealed Staff F, CNA cleaning the resident of a moderate amount of bowel movement. Without changing gloves or sanitizing hands, Staff F pulled up the resident ' s incontinent brief and pants, touched the resident ' s chair, bathroom door and handle, then took the commode bucket to the dirty utility room, and returned with the same pair of gloves on. During initial resident tour on 12/16/13 at 10:30 a.m., the Director of Nursing reported the resident had a recent urinary tract infection. During an interview on 12/19/13 at 3:00 p.m., the Director of Nursing reported Staff F should have changed gloves and washed hands after cleaning the resident.

Based on observation, interview, and document review, the facility failed to cover and date supplement supplies stored in the freezer. The facility reported a census of 50 residents. Findings include: Observation on 12/16/13 at 8:30 a.m., revealed a Victory Freezer with about twenty 8-ounce uncovered, undated glasses of ice cream on the top shelf. During an interview on 12/16/13, the Dietary Supervisor reported the glasses in the freezer contained product used for supplements. During an interview on 12/19/13 at 4:00 p.m., the Administrator reported they follow the food code for food storage. According to the 1989 Food Code all food items should be covered and dated.

Based on group interview, and staff interview the facility failed to provide residents with mail delivery on Saturdays. The facility reported a census of 50 residents. Findings include: During Group interview on 12/16/13 at 2:00 p.m., 5 of 5 residents reported they did not receive mail on Saturdays. The residents reported that the activity staff member is off on Saturday. During an interview on 12/19/13 at 12:05 p.m., the facility social worker reported usually a housekeeper or laundry staff person gets the mail from the post office on Saturday. The social worker reported the assisted living facility, next door, gets mail delivered to them, but the nursing home staff has to go down to the box at the post office to get their mail.

Based on observation and document review, the facility failed to provide cares in accordance with 1 resident's Care Plan. (Resident #2) Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had [DIAGNOSES REDACTED]. The MDS documented the resident had moderately impaired cognitive skills for daily decision-making, required total assist of one staff member for personal hygiene, dressing, and required extensive assistance of two staff members for toileting. The MDS also documented the resident had physical and verbal behavioral symptoms directed toward others. The resident's Care Plan identified confusion as focus care area initiated on 5/9/13, and directed staff to explain what they are going to do in simple terms so the resident can better understand. The Care Plan documented the resident's confusion would result in behaviors, at times, that may be disruptive and could place the resident and others at risk for injury. The Care Plan directed staff to make sure the resident is safe then leave the resident alone and re-approach the resident a few minutes later if the resident is being combative. Observation on 12/16/13 at 3:20 p.m. revealed Staff E, Certified Nurse's Aide (CNA) assisting Resident #2 with incontinence care. Staff E sprayed Periwash directly on the resident's groin, the resident became very agitated yelled and hit the staff member. The staff continued to provide peri care. The Director of Nursing stepped in and attempted to calm the resident, and asked the resident about pain. The resident reported hurting all over. However, staff did not stop to allow the resident time to calm, the nurse to get the resident's pain medication, and reproach later as directed in the resident's Care Plan. The Staff put the resident in a Hoyer lift for transfer from the bed to the wheelchair. The resident yelled "No" loudly, hit, and pushed the Hoyer lift bar in front of the resident.

Based on record review, observation, and facility policy the facility failed to provide complete incontinence care in accordance with facility policy for 2 of 4 residents observed. (Resident #'s 2 and 7). The facility reported a census of 50 residents. Findings include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented the resident had [DIAGNOSES REDACTED]. The MDS also documented the resident had moderately impaired cognitive skills for daily decision making, as well as, physical and verbal behavioral symptoms directed toward others. The resident required total assistance of 1 staff member for personal hygiene and dressing, and required extensive assistance of 2 staff members for toileting. The resident Care Plan initiated 7/30/13, identified the resident had an open sore to the coccyx, and was incontinent of bowel and bladder. The Care Plan directed staff to check the resident for incontinence and change the incontinent pad to reduce the resident ' s restlessness and skin irritation. The Care Plan also directed staff to monitor the resident ' s skin during cares and apply appropriate treatment. Observation on 12/16/13 at 3:20 p.m., revealed Staff E, Certified Nurse's Aide (CNA) assisting Resident #2 with incontinence care. Staff E sprayed Periwash directly on the resident's groin, the resident became very agitated yelled and hit the staff member. The staff continued to provide peri care using a pre-moistened wipe in a circular motion, without turning to a clean side with each wipe, to clean the rectal area. The Perineal Care (Incontinent Care) Policy, revised 7/24/06, directed staff to wash the rectal area with warm water, and wash from the perineal area to the rectum. During an interview on 12/19/13 at 9:30 a.m., Staff C, CNA reported peri spray should be sprayed on a cloth then used to clean the resident, but may spray it on the resident if incontinent of bowel movement, but would tell the resident first. During an interview on 12/19/13 at 2:30 p.m., the Director of Nursing reported that staff is not supposed to spray the Periwash directly on the resident. Instead, staff should spray the Periwash onto an incontinent wipe or washcloth then used to clean the resident. 2. Resident #7's MDS dated [DATE], documented the resident had [DIAGNOSES REDACTED]. The MDS documented the resident was frequently incontinent of bowel and bladder, totally dependent on 2 staff for toilet use and dependent on staff for personal hygiene and bathing. On 12/17/13 at 10:10 a.m., Staff B, CNA and Staff C, CNA transferred the resident to the commode in Resident #7's room with use of a mechanical lift. Removal of the incontinent brief revealed a smearing of bowel movement and a strong odor of urine. With no results, Resident #7 stood with the aide of the mechanical lift. The resident had BM on the rectum and Staff C, CNA wiped the resident's rectum 5 times, pulled up an incontinency brief and then pulled up the resident's trousers. Staff C failed to clean the resident's left or right groin areas or perineum of urine. Interview on 12/17/13 at 10:30 a.m. with Staff B, CNA for verification of the resident's incontinency status, revealed the resident was incontinent of urine.

Based on record review, observation, and interview the facility failed to provide 3 of 50 residents with the proper amount of meat for one of one meal observations. (Resident #5, 15, and 16) The facility reported a census of fifty residents. Findings include: According to the Diet Type Report dated 12/16/13 Residents #5, 15, and 16 had orders for regular diets. According to the Week 3 Tuesday Menu for 12/17/13 the regular diet contained a noon meal with one piece of swiss steak. Observation on 12/17/13 at 12:10 p.m. revealed the room trays for Residents #5, 15, and 16 did not contain a whole 4-ounce serving of general meat. Observation on 12/17/13 at 12:30 p.m. revealed no general meat left, 2 servings of ground meat left, and 6-ounces of pureed meat left. During an interview on 12/17/13 at 9:25 a.m. Staff K, Cook reported that each swiss steak is a 4-ounce piece. During an interview on 12/17/13 at 12:40 p.m. Staff K reported that staff are fed before the residents, and that can make it difficult sometimes to make sure the residents get enough, on second shift the staff eat after the residents. During an interview on 12/19/13 at 10:00 a.m. the Dietary Supervisor reported the residents with room trays on 12/17/13 were Residents #5, 15, and 16.

Based on observation, clinical record review and staff interview, the facility failed to utilize infection control practices to prevent the transmission of organisms for one of three residents observed during personal cares. (Resident #3). The facility census was 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance for toilet use, personal hygiene, bed mobility and dressing. Observation on 11/14/12 at 7:13 a.m., revealed Staff B, Certified Nurse Aide, CNA cleansed the resident's rectal area of loose stool. Without washing their hands or changing gloves Staff B applied [MEDICATION NAME] cream to the resident's groin and genitalia. Observation revealed the resident had an open area on the genitalia. During interview on 11/15/12 at 12:01 p.m., Staff B reported upon completion of incontinence care they should have washed their hands.

Based on observation, clinical record review and staff interview, the facility failed to complete an ongoing assessment for one of seven residents reviewed with a skin issue. (Resident #3). The facility census was 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance for toilet use, personal hygiene, bed mobility and dressing. Observation on 11/14/12 at 7:13 a.m., during incontinence cares revealed the resident had rash to the groin area and a small open area on the genitalia. The Resident Data Collection form dated 10/25/12, lacked skin irregularities of the resident's groin area or genitalia. The Skin Condition Report record initiated 10/25/12, lacked documentation of skin irregularities to the resident's groin area or genitalia. The Skin Condition Report dated 11/14/12, documented an open area to the resident's genitalia but lacked documentation of any reddened area. Nurse notes dated 10/25/12 11:30 a.m., revealed the resident had a yeast infection of the groin and topical anti-fungal medication applied. Nurse Notes reviewed from 10/25/12 to 11/15/12, lacked documentation of any further assessment or description of the groin area. During interview on 11/15/12 at 11:27 a.m., Staff D, Registered Nurse reported he/she did not document follow up on resident's anti-fungal treatment to the groin area.