Every finding on record at Evans Senior Living Community

Based on clinical record review, observation, manufacturer's directions for use, and staff interview, the facility failed to discard a vial of insulin after 28 days per the manufacturer's directions for use and drew up insulin for administration for 1 of 2 residents sampled (Resident #27). The facility identified a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive loss. The MDS documented Resident #27 received insulin injections for a diagnosis of diabetes mellitus. The Order Listing Report signed by the Provider on 6/06/23 showed the following order for insulin aspart solution (a short-acting, manmade version of human insulin): Insulin aspart solution 100 units/milliliter inject as per sliding scale: if 70 - 149 = 6 units. Notify the provider if blood sugar is below 70. 150 - 200 = 7 units 201 - 250 = 8 units 251 - 300 = 9 units 301 - 500 = 10 units. Notify the provider if the blood sugar is greater than 300, subcutaneously before meals related to type 2 diabetes mellitus with ketoacidosis (a serious complication of diabetes where the body cannot produce enough insulin) without coma (state of prolonged loss of consciousness). If the blood sugar is below 90, administer the insulin after meals. Start date 3/07/23. During an observation on 6/13/23 at 11:50 a.m. Staff A Registered Nurse (RN) performed a blood sugar with a result of 226 milligrams/deciliter. On 6/13/23 at 11:52 a.m. Resident #27 reported she didn't know why her blood sugar would be that high. She had eaten eggs, toast, and orange juice for breakfast. She had not asked for more orange juice at breakfast. During an observation on 6/13/23 at 11:53 a.m. Staff A returned to the medication cart and checked Resident #27's physician orders for sliding scale insulin. Staff A opened the medication cart and removed a plastic bag containing Resident #27 box of insulin aspart vial. At 11:54 a.m. Staff A reported the vial of insulin had been opened on 5/12/23 and pointed to the plastic bag that had opened 5/12/23 written on the outside of the bag. Staff A drew up 8 units of insulin aspart per the physician order, locked the medication cart and verbally confirmed she was ready to administer the sliding scale insulin to Resident #27. The Surveyor stopped Staff A from administering the insulin to Resident #27. On 6/13/23 at 11:56 a.m. Staff A reviewed the open date for the insulin vial and then pulled the insulin aspart box from the medication cart. She reviewed the side panel of the box that directed to discard the insulin after 28 days. Staff A opened the electronic calendar on her laptop screen and counted the number of days from 5/12/23. She reported the 28th day would have been 6/10/23 and the insulin should not be given. On 6/13/23 at 11:56 a.m. the Regional Nurse Consultant who observed the insulin preparation reported the insulin should not be administered. On 6/13/23 a review of the pharmacy label on the plastic bag that contained the box of insulin directed to discard the vial at 28 days. A Review of the June 2023 Medication Administration Record (MAR) on 6/14/23 revealed the insulin aspart had been administered on the following dates after 6/08/23 (day 28): a. 6/09/23 at 7:30 a.m. 9 units b. 6/09/23 at 11:30 a.m. 1 unit c. 6/09/23 at 5:30 p.m. 1 unit d. 6/10/23 at 7:30 a.m. 6 units e. 6/10/23 at 11:30 a.m. 7 units f. 6/10/23 at 5:30 p.m. 7 units g. 6/11/23 at 7:30 a.m. 9 units. h. 6/11/23 at 11:30 a.m. 9 units. i. 6/11/23 at 5:30 p.m. 8 units. j. 6/12/23 at 7:30 a.m. 6 units k. 6/12/23 at 11:30 a.m. 9 units l. 6/12/23 at 5:30 p.m. 10 units m. 6/13/23 at 7:30 a.m. 6 units During an interview on 6/14/23 at 1:45 p.m. the Director of Nursing reported she expected the nurses to follow the manufacturer's directions for use. The Medication Administration Policy, revised 4/01/23, provided by the facility, directed the nurse/oral medication technician to check labels (on the medication) with the medication administration record. The Policy lacked direction to follow manufacturer's directions for medication use. The Insulin Aspart box side panel directed to discard the product after 28 days. The Manufacturer's Patient Information insert instructed to throw away all Novolog (Insulin Aspart) after 28 days, even if the vial still had insulin left in it.

Based on observation, dietary menu review and staff interview, the facility failed to follow the planned menu for four residents on a pureed diet. (Resident #3, #4, #17 & #24) The facility census was 34 residents. Findings include: 1. The planned menu for the week of 2/24/20, signed by the Dietician on 10/11/19, documented on Wednesday 2/26/20, for the noon meal residents on a pureed diet would receive Slurry Cheddar Cornbread as a part of the meal. During observation of the noon meal on 2/26/20 at 12:10 p.m., Staff A served four pureed meals to Resident #3, Resident #4, Resident #17 & Resident #24. The residents did not receive the Slurry Cheddar Cornbread as planned. Observation revealed residents on a General diet, Mechanical Soft diet and House Diabetic diet were all served the Cheddar Cornbread as planned. At the conclusion of the meal service observation revealed residents on a Pureed diet were not served a suitable substitute for the Slurry cheddar cornbread. During interview on 2/26/20 at 12:28 p.m., the Dietary Manager verified residents on a Pureed diet did not been receive the Slurry Cheddar Cornbread with their meal and should have and no suitable substitute was prepared for the four residents on a Pureed diet.

Based on record review, and staff interview, the facility failed to ensure that the dietary supervisor had the required qualification, which could adversely affect the facility's 38 residents. Findings include: On 2/4/19 at 10:43 AM the Food Service Supervisor (FSS) said she worked at the facility for [AGE] years, as a dietary aide and then transitioned as the FSS in (MONTH) (YEAR), approximately 7 months now. The FSS acknowledged that she does not have the required certification for the position. An undated facility document for the dietary department, defined the qualifications and responsibilities of the FSS that included completion of the Certified Dietary Manager Certification Program within 1 year of hire if not certified prior to hire date. The document enumerated the responsibilities of the FSS that included supervising all dietary staff as well as food preparation for the residents to meet their individual dietary needs, complies with all resident care plans, organizes, directs and supervises the performance of all dietary functions and personnel.

Based on clinical record review and staff interview, the facility failed to ensure that information regarding Advanced Directives (AD) was readily available for staff to be able to carry out measures according to resident's choice of whether or not to provide Cardiopulmonary Resuscitation (CPR), and the facility failed to review and update code status information for 1 of 12 residents reviewed (Resident #11). The facility reported a census of 38 residents. Findings include: According to the Minimum Data Set ((MDS) dated [DATE], Resident #11 had an admission date of [DATE]. The MDS listed [DIAGNOSES REDACTED]. Record review revealed the resident's clinical records did not show information about Advanced Directives. On [DATE] at 8:32 AM, the Assistant Director of Nursing (ADON) stated that information about AD is placed in front of residents' charts. The ADON also stated that is the only place where staff would check to know about residents' code status. The ADON further stated that the charts are kept in the locked room by the nurses' station and the nurses are the ones responsible in checking to see the code status of residents. When asked about the process in a situation where certified nurse aides (CNA) would be the ones to find an unresponsive resident, the ADON replied that the CNA would have to call for the nurse, who would then go to check the charts. On [DATE] at 8:48 AM, when unable to find AD information in the resident's chart, the ADON assisted in attempting to look for the AD information but then verified that there is none in the resident's chart. On [DATE] at 9:37 AM, the ADON provided the resident's CPR form containing the code status information dated [DATE], that indicated the resident does not want to be resuscitated. The ADON said that she found the form in the resident's thinned records, adding that she does not know how the form ended there. The ADON reiterated expectation that the form should have been in the resident's chart. The ADON also verified that the date on the form was prior to the resident's admission to facility, and ADON stated they review residents' code status during annual conferences, significant change in health condition, or when they are readmitted to the facility. The ADON acknowledged that review dates were not indicated in the records and the ADON did not provide any evidence that the resident's code status has been reviewed. The facility document titled, Cardiopulmonary Resuscitation Policy, revised on ,[DATE], directed staff to maintain each resident's resuscitation status in the clinical record, directly under the front cover of the resident's chart. The policy did not provide guidelines on when and how resuscitation status of a resident is reviewed and updated.

Based on clinical record review and staff interview, the facility failed to provide notice to the resident and/or representative of the facility's bed hold policy prior to or upon transfer to the hospital for 1 of 2 residents reviewed (Resident #25 ). The facility reported a census of 38 residents. Findings include: 1. Review of Resident #25 medical record revealed no documentation of notification to the resident or resident's family regarding the bed hold policy when the resident transferred to the hospital on [DATE]. Review of the Census List revealed Resident #25 as on unpaid leave to the hospital on [DATE]. Review of the facility bed hold policy revealed the following procedure: 2. Before a resident is transferred to a hospital or the resident goes on a therapeutic leave, the facility will provide the bed hold notice form to the resident or resident's representative. a. The bed hold notice will be printed on the facility's letterhead thus identifying the facility and providing contact information. b. A facility representative will note the resident or representative's decision to hold the bed as either as administrative note or a clinical progress note in point click care. The note will include the person making the decision, the decision to hold or not hold the bed, and the time frame for holding the bed. An interview with the Director of Nursing on 2/6/19 at 2:10 PM acknowledged the absence of documentation related to bed hold policy in the resident chart at the time of the transfer. Expectation would be for staff to document either a conversation or signature of bed hold policy.

Based on observation, record review and staff interview the facility failed to ensure submission for an updated Level I screening related to a new [DIAGNOSES REDACTED].# 32). The facility reported a census of 38 residents. Findings include: Resident #32's admission Minimum Data Set ((MDS) dated [DATE], did not identify [MEDICAL CONDITION], or any mental disability. Resident # 32's preadmission screening resident review (PASRR) dated 5/13/16, indicated a negative level I screen outcome, and included instructions that there was no need to complete another level I screening unless Resident # 32 was known or suspected to have a major mental illness or intellectual disability or any significant change in treatment needs. The resident's annual MDS dated [DATE], documented [DIAGNOSES REDACTED]. The MDS also indicated that Resident # 32 received anti-anxiety, and anti-depressant medications. However, there was lack of evidence to show completion of PASRR level I to include the resident's newly identified [MEDICAL CONDITION] diagnosis. On 2/5/19 at 8:30 AM, the Assistant Director of Nursing (ADON) verified that there was no record to show a new screening, despite Resident # 32's change in mental diagnosis. The ADON stated that the facility was not aware that another screening was needed for a change in mental health condition.

Based on observation, record review, resident and staff interview and facility policy review, the facility failed to ensure proper supervision to prevent elopement for 1 of 38 residents reviewed (Resident #30) and the facility also failed to supervise a hot pack after application resulting in a Stage I burn for 1 of 1 residents reviewed with use of a hot pack (Resident #3). The facility reported a census of 38 residents. Findings include: 1. Resident #30's admission record indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's baseline care plan dated 7/20/18, indicated placement of wander guard related to the resident's cognitive impairment and history of walking away from church. The resident's admission Minimum Data Set ((MDS) dated [DATE] and quarterly MDS dated [DATE], failed to identify the resident used a wander guard. Both MDS assessments indicated the resident needed supervision for locomotion off unit. The resident's quarterly Minimum Data Set ((MDS) dated [DATE], identified the resident with mild cognitive impairment with a brief interview for mental status (BIMS) score of 10 (moderately impaired cognition). The MDS described the resident as independent with activities of daily living (ADL) except that she needed supervision or oversight for locomotion off unit. The resident's care plan, initiated on 10/2/18 identified a problem with wandering with no rationale purpose. The care plan goal for Resident #30, to wander safely within specified boundaries. Interventions included redirection of of resident from the exit doors. The care plan revised on 1/29/19 included placement of a wander guard to the resident's left ankle. On 2/5/19 at 9:24 AM the facility reported a facility elopement incident that involved Resident #30. The Confidential Incident Report form, dated 1/29/19, indicated that on the same date, Resident #30 exited the care center to the assisted living (AL) apartments. The report showed the resident told staff that someone had pressed the door code and she followed them out to the AL. The report further noted the AL staff met the resident on the first floor and then brought her back to the facility. The report noted the resident's condition as alert, confused and independent with mobility. On 2/6/19 at 8:12 AM the Director of Nursing (DON) acknowledged the resident exited the care center without staff supervision on 1/29/19. The DON stated that the interventions implemented after the incident included wander guard placement and changing of the door code. On 2/6/19 at 9:43 AM the Assistant Director of Nursing (ADON) stated that the resident had been at risk for wandering and elopement since admission and used a wander guard then. The ADON said that wander guard was taken off on 12/3/18, based on Interdisciplinary team (IDT) decision that the resident no longer needed it because she did not make any attempts to exit from the care center. In addition, the ADON said the resident had questioned about wearing the wander guard and stated she felt embarrassed about it. The progress notes documented the following exit-seeking behaviors the resident manifested: a. On 8/3/18, commented about not wanting to be at the care center b. On 8/8/18, made a comment about running away from the care center c. On 8/12/18, made 3 attempts to exit the care center prior to 8:30 AM d. On 8/23/18, attempted to exit the care center with a tenant form AL e. On 9/9/18, made an attempt to exit care center with another resident f. On 10/12/18, wandered throughout the care center during the morning shift g. On 10/18/18, d. On 8/23/18, attempted to exit the care center with a tenant form AL h. On 10/21/18, made a comment about wanting to discharge to home. i. On 12/3/18, wander guard was removed when Resident # 30 questioned the need to wear wander guard bracelet and that there were no documents/reports of recent exit seeking behavior and adjusted well to being in facility j. On 1/29/18, exited facility with a visitor to AL and without staff supervision The facility provided a wandering monitoring tool from 8/21/18 through 9/30/18, that showed Resident #30 had no wandering and exit-seeking behaviors manifested. The documentation is inconsistent with the progress notes above which revealed the resident had manifested the behaviors multiple times. On 2/7/19 at 9:28 AM, Resident #30 got upset when interviewed about the incident on 1/29/19. the resident stated that she found the door open so she walked through, but does not remember how she got back to the care center. On 2/7/18 at 10:30 AM, Staff G Certified Nurse Aide (CNA) stated that the resident continues to wander at times, and staff were made aware of the need to redirect when the resident gets close to the exit doors. 2. A Minimum Data Set ((MDS) dated [DATE] documented [DIAGNOSES REDACTED]. A Brief Interview of Mental Status documented a score of 15 which indicated intact cognition. The care plan with an initiated date of 11/14/18 revealed resident at risk for skin breakdown related to incontinence and decreased mobility. Report any sign of skin breakdown (sore, tender, red or broken areas). Revision date of 2/6/19 instructed staff to monitor burn on back and provide treatment as ordered, reporting any signs and symptoms of infection to provider. The care plan with an initiated date of 1/10/19 revealed resident has complaints of pain related to chronic back pain. Warm compress to be applied by nurse for comfort, as needed. Progress notes dated 1/9/19 documented Staff D, Certified Medication Aide (CMA) applied hot pack at 7:53 PM Staff D placed it on the resident's back and asked if it was okay and the resident said. yes. At 8:05 PM the resident pushed her call light button and Staff F, Certified Nurse Aide answered the call light. The resident said it was too hot. At that time, Staff F took the hot pack to the Charge Nurse, Staff E, Registered Nurse. Progress notes dated 1/9/19 at 9:57 PM revealed the resident commented when pack was first applied it felt good and was not too hot, but after a short time it became too warm and that's when she pushed her call light button for help. Staff E assessed the resident; taking her vital signs and measuring the area. The outer area was bright red, warm to touch and measured 13 cm x 11 cm. and was blanchable. No blistering noted at the time. The raised inner area measured 3.0 cm x 0.8 cm. Resident allowed Staff E, RN to apply a cold compress. An Incident Report dated 1/9/19 at 8:05 PM was completed by Staff D, CMA and Staff E, RN. Vital signs within normal limits. Measurements taken and noted. Family and Doctor notified. The resident was seen by provider the next day at the facility 1/10/19 at 9:30 AM. A MD/Nursing Communications dated 1/9/19 at 9:02 PM documented Doctor order to discontinue hot pack at bedtime and continue to monitor. A Major Injury Determination Form was completed by provider on 1/10/19 at 9:30 AM in the facility. Provider documented burn 13 cm x 11 cm to right upper back and 3 cm x 0.8 cm area within the burn swollen. Good potential for healing with no further sequela. After reviewing the circumstances, injury and prognosis of the patient, the doctor believed the injury sustained NOT a major injury and , to the best of his knowledge, barring any complications, believed the patient would return to his/her previous functional status. A Clinical Nursing Home Note dated 1/10/19 by provider documented patient is a [AGE] year old female who is being seen for an acute visit. She had an order for [REDACTED]. This was wrapped in a plastic bag, wrapped in a hand towel, then wrapped in a doubled bath towel and placed on top of Resident #3's skin. The hot pack had been placed on her back about 10 minutes or less . The staff noticed reddened area on her right mid back area. The patient stated it did not hurt and it never has. It is along her bra line and she states her bra is not irritating it. Assessment: First degree burn, superficial. Plan: Continue to monitor the area for bleeding, discharge signs or symptoms of infection. This is not a major injury. (MONTH) continue with war pack to affected area at bedtime. Will be followed up on rounds or via fax if needed. Progress Note of 1/11/19 at 12:55 PM documented serous drainage noted on non adherent pad. Wound bed pink and open since blister had popped. No signs or symptoms of infection noted. Resident denied discomfort to area. Progress Note dated 1/11/19 at 3:56 PM clarification received from provider to apply warm pack to back at bedtime, avoid are of skin concern until healed. Progress Note dated 1/11/19 at 11:16 PM received fax from provider with the following order to warm pack to low back at bedtime. Progress Note dated 1/12/19 at 9:26 PM noted 72 hour follow up: blister is pink to lower back, no drainage noted, denies pain at this time. Vital signs taken. Progress Note dated 1/14/19 at 8:37 PM noted weekly skin sheets: raised area to right mid upper back with burn decreased to 1 cm x 0.8 cm, standing order for [MEDICATION NAME] applied until healed. No complaints of pain to the sight. Right mid upper back decreased 1.5 cm x 1.2 cm blanches. No complaints of pain to sight. Progress Note dated 1/28/19 at 9:27 PM noted weekly skin sheets: red area to right mid back is 1.8 cm x 1.2 cm slightly bigger. Still blanches and no complaints of pain to site. Raised area with in reddened area decreased to 0.5 cm x 0.4 cm there is a small dark red scab in place. Progress Note dated 2/4/19 at 9:10 PM skin update: right mid upper back with in burn is white in center with light redness around it. No drainage noted. Measures 0.4 cm x 0.5 cm. Skin assessments of both outer and inner areas are documented as such: 1/9/19 outer 13 cm x 11 cm, red and blanches. Inner 3.0 cm x 0.8 cm raised area firm. 1/14/19 outer 1.5 cm x 1.2 cm red and blanches. Inner 1.0 cm x 0.8 cm, area not raised. 1/21/19 outer 1.5 cm x 2.5 cm red and blanches. Inner 1.0 cm x 0.5 cm 1/28/19 outer 1.5 cm x 1.2 cm red and blanches. Inner 0.8 cm x 0.4 cm red scab 2/4/19 outer 1.0 cm x 1.5 cm red and blanches. Inner 0.4 cm x 0.5 cm with white center Physician order [REDACTED]. Wash cloth to be warmed up with tap water in sink only, Avoid area of skin concern until healed. Treatment Administration Report for (MONTH) 2019 revealed order for hot pack at bedtime for lower back pain with a start date of 11/1/18. [MEDICATION NAME] Ointment 500 unit/gram apply to right mid upper back topically every evening shift for raised area until healed. Start date of 1/11/19. When interviewed on 2/6/19 at 9:40 AM the resident reported she remembered the night it happened and said it was fine when they first applied it on her back. After a few minutes it got hotter and that's when she pushed her call light. She is very soft spoken an speech is garbled at times and she is hard to understand. She went on to say that it is getting better (per her daughter) and it does not hurt. An interview on 2/6/19 at 9:54 AM with the Corporate Registered Nurse stated this policy regarding the application of warm compresses has been in place since the 90's. This was in place 1/9/19 when the incident occurred with Resident #3. Corporate nurse would not consider Staff D, Certified Med Aid as a licensed personnel to apply warm compresses. On 2/6/19 at 10:07 AM the Assistant Director of Nursing (ADON) stated there are no other residents in the facility with hot pack orders and Resident 3's order was discontinued. An interview on 2/6/19 at 10:24 AM with Staff A, Certified Nurses Aid (employed at the facility 2 years) reported she was trained to get a washcloth and run hot tap water, then put it in two (2) trash bags and wrap it in a pillowcase. She reported she has never used a microwave and hasn't done a hot pack for over 2 months. An interview on 2/6/19 at 10:34 AM with Staff B, Certified Nurse Aide (employed at the facility for 6 months) reported when she needs a hot pack she takes 1 or 2 washcloths and runs them under warm tap water from the faucet. She then places them in a plastic bag and wraps a hand towel around it and applies it to the area. She then checks the resident every 15 to 30 minutes to see if it is working or if it needs to be reheated. Staff B stated she has never used a microwave or witnessed anyone using a microwave. She has never had to do a hot pack since starting here in (MONTH) (YEAR). On 2/6/19 at 10:37 AM Staff C, RCT (employed at the facility for 2 and 1/2 years) reported she has only done a couple of hot packs. She takes one (1) small washcloth runs it under hot tap water, wrings it out and puts it in two (2) double bags then a hand towel outside the bags and then applies it to the area. Both times, the residents were independent and when she return to check on them, they had already taken them off. She reported she has never seen a co worker use the microwave to do this. When interviewed on 2/6/19 at 11:15 AM Staff D, CMA (employed at the facility for over [AGE] years) reported she normally works another hall. She was aware of the doctor's order to apply hot pack at 8 PM to the resident's back. This was the first time she had done this for Resident #3. She reported she took a hand towel and wet it, then placed it in the microwave in the employee break room for 30 to 45 seconds. She tested it on both her arms and it was okay temperature wise. She then placed it in a bag, wrapping it in another hand towel and then a bath towel folded in half. The resident was sitting in her recliner and she placed the hot pack on the resident's right upper side and gave the resident her call light. Staff F, CNA answered the resident's call light when it was getting to hot. Staff F went to get Staff E, RN to assess the resident. Staff D reported she did not see the area at that time. Staff D continued that she works part time at the local hospital and we use microwaves there to heat up hot packs. This is the only time I have used a microwave here at the facility and I feel terrible about it. When interviewed on 2/6/19 at 11:20 AM Staff E, RN (employed at the facility 18 months) reported Staff F, CNA brought her the hot pack and said the resident said it was too hot. She went to assess the resident and found the area warm to the touch and bright red. The resident allowed her to apply a cold washcloth and she took the resident's vital signs. All being within normal limits. She then measured the area and can't remember specifics. She called the resident's daughter and notified the Doctor by fax. She also called the DON and Administrator who both came in at that time. She assisted the resident for bed and received a fax back from provider stating to monitor and provider would be in tomorrow to assess. During an interview on 2/6/19 at 11:37 AM with Staff F, CNA (employed at the facility 3 years) reported the resident used her call light and asked for the hot pack to be removed. The hot pack felt okay to touch to her. She took the hot pack to the charge nurse on duty and the nurse went to assess the resident. She stated she has never used a microwave and she doesn't think CNA's are allowed to apply hot packs. During an interview on 2/6/19 at 12:50 PM the DON stated she was contacted the evening of the incident and came in to provide support to the resident, staff and resident daughter. The Administrator also came in the night of the incident. The DON reported the Administrator is on vacation out of the country at this time. Observation of Resident #3's treatment on 2/6/19 at 3:12 PM completed by Staff E, RN, Resident #3 rolled to her right side Staff E washed the area with soap/water and patted dry. [MEDICATION NAME] ointment applied with Q tip and left open to air. Area measured 2.2 cm x 2.4 cm (outer). Inner area measures 0.4 cm x 0.4 cm, superficial area pink and healing well. On 1/9/19 immediate education was provided to all staff present at the time of the incident and signatures were obtained. The following day, remaining staff were educated. An undated facility procedure instructed staff to : Licensed personnel only (ie: nurses, therapists) are to apply warm compresses. Utilize tap water only when performing warm compress treatment.

Based on record review, observation, and staff interviews the facility failed to provide complete incontinence care for 1 of 4 residents observed for incontinence care (Resident #7). The facility census was 49 residents. Findings include: Review of the MDS (Minimum Data Assessment) for Resident #7 dated 6/28/16 documented the resident required extensive assistance of 1 to 2 staff for ADL's (Activities of Daily Living) including bed mobility, transfers, ambulation, eating, personal hygiene, and toilet use. The MDS also shows the resident is frequently incontinent of bowel and bladder. During observation of incontinence care for Resident #7 on 9/19/16 at 1:45 p.m. after the resident had been incontinent of bowel and bladder, Staff A used washcloths with soap and water to cleanse the residents buttocks area wiping several times without cleansing deep between the buttocks cheeks leaving stool visible to the surveyor, Staff A then applied petroleum jelly on Resident #7's buttocks as a skin protective barrier and leaving visible stool on the glove used to apply the petroleum jelly. Staff A removed the glove and took a clean incontinence brief into their hand, the surveyor asked Staff A if they intended to put the incontinence brief on at this time, Staff A responded yes, the surveyor pointed to the discarded glove and asked Staff A what was on the glove, Staff A stated they did not see the stool on the glove until that time and would complete cleansing the buttocks of Resident #7. During an interview 9/19/16 at 2:30 p.m. the facility DON (Director of Nursing) who also observed the incontinence care for Resident #7 verified that Staff A had not completely cleansed the buttocks area and they wanted to direct Staff A to complete cleansing the residents buttocks area before applying the incontinence brief but is aware they are only to observe and not assist.

Based on observation and staff interview, the facility failed to properly date and label containers of food intended for resident consumption. The facility reported a census of 46 residents. Findings include: 1. During the initial dietary tour on 10/12/15 at 10:45 a.m., observation revealed the following: a. Three packages of 12 count hot dog buns not labeled with an expiration or opened date. b. A package of hamburger buns not labeled with an expiration or opened date. c. Two loaves of raisin bread not labeled with an expiration or opened date. d. A butter container with what appeared to be applesauce inside that had a note from a resident's family with no date or label on container. e. A stainless steel small container that appeared to contain butter with no date or label on container. During an interview during the same tour, the dietary manager stated these food items should be dated and labeled. ¿@ ¿@ ¿@ ¿@ ¿@ ¿@

Based on record review and interviews with staff and a nurse practitioner, the facility failed to provide adequate supervision to ensure against hazards from self (Resident #1). The resident was left unattended in a wheelchair without supervision and without the planned Velcro seat belt alarm and personal body alarm. The resident was found on the floor and identified to have a fractured tibia and fibula (bones of lower leg). The facility identified a census of 51 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 10/6/14 which identified the resident had [DIAGNOSES REDACTED]. The assessment reflected the resident had severely impaired cognitive skills, sometimes made self-understood, rarely/never understood others, with short and long term memory deficits, non-ambulatory and required extensive assistance from staff with transfers. A Care Plan, initiated on 4/4/13 reflected the resident used physical restraints, Velcro alarmed seat belt in the wheel chair related to a history of falls, intellectual impairment and the need for a Hoyer lift (mechanical lift). The interventions directed staff to: a. The seat belt will remain on when at meals for safety and prevention along with aiding in upright positioning. b. The resident wears a helmet that provides protection to head when in the wheel chair. c. A personal body alarm (PBA) and alarmed Velcro seat belt to alert staff of attempts at independent transfers, need for assistance and safety in the wheel chair. In evolution chair. Velcro strap under wheel chair seat. Motion sensor when in bed and in the doorway when out of room. According to a care form posted on the wall in the resident's room, he/she required the following: a. Resident is non-ambulatory. b. A PBA (personal body alarm), seat belt alarm with Velcro and a motion detector on the door (are used). c. A low bed with a mat (are used). d. Helmet on resident when up. e. Stay in front of the resident when the seat belt is off. f. Keep in the lounge area when up or in the dining room for meals and/or activities. A Medication Review Report form signed by a Nurse Practitioner 10/30/14, directed the staff the resident required a Velcro seat belt restraint every shift for safety effective 3/13/13. A Fall Risk assessment form dated 10/1/14 at 1:11 a.m. identified the resident at risk for falls. According to a Progress Notes form dated 8/16/14 at 9 p.m., staff had been called to the lounge and found the resident lying on back on the floor with the seat belt alarm sounding. The resident had no injury. According to an Incident Report form dated 10/21/14 at 5 p.m., the resident had been found lying on his/her back under the sink in his/her room with a bruise noted over his/her left eye, a slight abrasion and wincing with ankle flexing. The form reflected the resident utilized a seat belt restraint. According to an emergency room Note dated 10/22/14 identified the resident had been seen on 10/21/14 and an x-ray identified a right distal tibia and fibula (lower leg bones) fracture. The resident wore a CAM boot (provides immobilization and protection) on the right foot. On 10/22/14 the resident returned to the emergency room due to increased swelling and bruising in the left lower extremity ankle. The resident withdrew when touched, as if painful. An assessment identified the resident had a left foot and ankle contusion and sprain, secondary to the fall on 10/21/14. On 11/12/14 at 1:40 p.m., Staff A, Certified Nursing Assistant (CNA) was interviewed and stated her and another new CNA, in training, had transferred the resident to a wheel chair to get ready for supper. Staff A stated she then left the resident in the room and failed to apply the PBA and/or the Velcro alarmed seat belt restraint. Staff A stated she had been aware he required both devices. On 11/12/14 at 2:25 p.m., Staff B, CNA/CMA (Certified Medication Aide) was interviewed and stated she had left another resident's room and heard Resident #1 say " Help me " . Another CNA entered his/her room and the staff member returned to her medication cart. The staff member then heard the CNA request assistance in the resident's room over the Walkie Talkie system. The staff member entered the resident's room and found the resident lying on the floor with no alarms sounding. The staff member confirmed the resident utilized a Velcro alarmed seat belt restraint, a PBA alarm, a door alarm and the staff had been directed not to leave the resident unattended in his/her room. On 11/19/14 at 4:30 p.m., a Nurse Practitioner (involved in the resident's care) was interviewed and confirmed the fall may have been prevented had the staff placed all of the interventions according to the Care Plan. (i.e., PBA, seatbelt Velcro alarm and positioned in a supervised area).

Based on observation, clinical record review, staff interviews and hospital staff interview, the facility failed to assess pain and then provide appropriate interventions for 1 of 4 residents reviewed (Resident #1). Resident #4 fell and the nurse failed to fully acknowledge the resident ' s pain. The nurse had the staff transfer the resident from the floor and into a wheelchair. The Administrator transported the resident to the hospital (few blocks away) via the facility van. An x-ray identified Resident #1 had a [MEDICAL CONDITION]. The facility identified a census of 50 residents. Findings include: Resident #1 had a quarterly MDS (Minimum Data Set assessment with a reference date of 3/24/14. The MDS identified the resident with a BIMS (Brief Interview of Mental Status) score of 6 out of 15. A score of 6 identified the resident had a severe cognitive impairment. The MDS reflected the resident required supervision with ambulation in his/her room and could be independent with ambulation while in the corridor. Review of the resident ' s Care Plan, identified on 4/4/13, the resident had been identified at risk for falls related to a need for an assistive device. The interventions included the following: a. Follow the facility ' s fall protocol. b. Ensure the resident had been wearing appropriate footwear when ambulating or mobilizing the wheel chair. According to a Fall Risk form dated 5/17/14, the resident had been receiving anti-depressant and anti-hypertensive/cardiovascular medications, utilized an ambulation device and as visually impaired. A Progress Notes form dated 5/17/14 at 10:45 p.m., revealed Staff A, Registered Nurse (RN) documented the following: This nurse had been called to the resident's room. The resident was found lying on his/her left side on the floor next to a walker and bed side table. The resident ' s shoes had been on, room floor clean and dry. The resident ' s blood pressure registered 128/72, pulse 52, respirations 28 and temperature 97.6 degrees Fahrenheit. The resident was sent to the emergency room . A Incident Report form dated 5/17/14 at 4 p.m., identified Staff A documented the following information: This nurse had been called to the resident ' s room. The resident was found lying on his/he left side on the floor next to the walker and bed side table. The resident wore shoes and the room floor clean and dry. The resident stated "I don't know what happened. I was just walking from my dresser to my bed. I did not hit my head." An assessment had been completed. The resident complained of sharp pain in the left hip rated at a 10 on a 0 to 10 scale. (10 having been the highest). The resident had been assisted with a gait belt and 3 staff assisted the resident to the wheel chair and sent to the hospital via the Evans van. An emergency room (ER) Summary form dated 5/17/14 at 4:40 p.m., documented the following: The patient dropped off at the ER waiting room with hip pain. Left leg shortened and externally rotated. Moaning and crying out in pain. The family was notified. According to a hip x-ray Preliminary Report form dated 5/17/14 at 5:41 p.m., the impression included the following: a. An acute impacted transcervical or basicervical left femoral neck fracture. b. [DIAGNOSES REDACTED]. c. Osteopenia. d. [MEDICAL CONDITION] lumbar spine with curvature. c. Prior internal fixation of the right hip. A local hospital transfer summary and consent reflected the physician ordered the resident be transferred from a local hospital to another hospital for orthopedic care. The Iowa EMS report reflected the resident was transported and received [MEDICATION NAME] 2 milligrams intravenously for pain. On 6/3/14 at 2:40 p.m., Staff C, Certified Nursing Assistant (CNA) was interviewed and stated she had been giving report to another staff member prior to break when she heard a fall/crash and the resident yelled and screamed in pain. The staff member responded immediately, entered the resident's room and observed the resident's shelf tipped into the window and a bedside stand tipped into the shelf, the bathroom door shut and the resident lying on his/her left side in front of the bathroom door. The staff member stated she had not moved the resident but rather called Staff A, Registered Nurse (RN) who responded within a couple of minutes. Staff A then checked the resident out a little bit feeling around his/her bottom and hip area and performed some ROM exercises. Staff A then rolled the resident onto his/her back and sat him/her up enough and placed a pillow under his/her head. When the resident had been repositioned, he/she complained of pain and would yell ouch and his/her hands shook. The staff member denied having observed any leg deformity because she would have not known what to look for. The staff member stated Staff A kept moving the resident's leg while he/she had been clearly in pain and could not understand why he kept moving the extremity. At that point Staff A instructed the staff to assist the resident off of the floor so 2 staff members supported the resident's upper torso and 2 staff members supported the resident's lower extremities and transferred the resident to the wheel chair while the resident complained of pain but to no specific area. Once the resident had been positioned in the wheelchair, Staff A propelled the resident to the nurse's station and she went to break. When the staff member returned to the floor, the resident had been transferred to the hospital. The staff member stated although she followed the directive of Staff A, everything she had been taught had been to not move the resident. On 6/3/14 at 2:06 p.m., Staff B, CNA was interviewed and stated she entered the resident's room and observed him/her positioned on the floor and more on his/her back than left side. The resident expressed it hurts, it hurts, oh my goodness it hurts. The staff member denied having repositioned the resident at that point. The nurse (Staff A) entered the room and asked the resident specific questions. Staff A asked where it hurt and took vitals. The staff member stated she could see the left leg had been shorter than the right. Then someone directed the staff to get a gait belt and then directed staff to keep him/her as still as possible as the resident had been transferred per 4 staff assistance (which could not be further defined) to the wheelchair with no complaints of pain. The staff member then left the resident's room. On 6/4/14 at 9:25 a.m., Staff A, RN stated he had been called to the resident's room and found him/her on the floor by the bathroom door, between a dresser and a bedside stand positioned on his/her left side/back area with an appearance of distress. The staff member repositioned the resident on his/her back with a pillow under the head with his/her knees bent and assessed the resident. When he asked the resident where the pain had been the resident had not been real descriptive. The staff member then performed range of motion (ROM) to the resident's right leg. The ROM did not seem to bother the resident much compared to the left leg which the resident had not tolerated at all. The staff member denied any leg deformity. At that point, the resident had been requesting the staff just leave him/her on the floor to die. The staff member stated he felt so bad for the resident that he wanted him/her off the floor so the staff applied a gait belt. While Staff B supported the resident's legs, he and Staff C supported the resident's upper torso and transferred him/her to the wheel chair. The staff member stated the resident had no further pain at that time and seemed to calm down. The staff member then propelled the resident to the nurse's station, called the resident ' s family member, informed him/her he felt the resident had a [MEDICAL CONDITION] and received a directive to send him/her to the hospital. The staff member asked the family member if he/she wanted an ambulance transfer and the family member said he/she would leave it up to the staff member just to get the resident to the hospital and he/she would arrive in approximately 30 minutes. The staff member called the facility ' s Administrator who transported the resident to the hospital emergency room . The staff member stated he should have left the resident positioned on the floor until the ambulance arrived however; he had not liked the situation with the resident requesting to die. On 6/3/14 at 3:45 p.m., the Administrator confirmed he had received a telephone call from Staff A stating the resident had fallen and needed to go to the hospital for an x-ray, however with no urgency. When he arrived at the facility, the resident had been positioned in a wheelchair by the nurse's station while the resident stated he/she felt good at that point. The Administrator and an unknown CNA assisted the resident into the facility ' s van via the wheelchair and a ramp device and he transported him/her to the hospital emergency room with no indications of pain. Upon arrival, the Administrator wheeled the resident into the emergency room and the hospital staff assumed the resident's care and treatment. The Administrator confirmed he would have expected the staff to leave the resident positioned on the floor following a fall with a suspected fracture. On 6/4/14 at 10:40 a.m., a hospital nurse was interviewed and stated the resident had been brought to the hospital emergency room by the Administrator of the nursing facility via a wheelchair and the facility ' s van. After the Administrator signed the resident's hospital paperwork, he left the resident unattended in the waiting room for approximately 5 minutes. At which time she heard the resident crying, yelling out in pain and wishing to die because the pain had been so bad. The hospital staff brought the resident back to a room via the wheel chair and noted his/her left leg had been 3-4 inches shorter than the right leg and rotated out. The nurse stated she knew the hip had been fractured before the x-ray. During an interview on 6/3/14 at 3:40 p.m., the Director of Nursing (DON) stated she would have expected the nurse to maintain the resident as positioned on the floor until the arrival of the ambulance crew. The ambulance crew would have made the decision to transfer the resident based on their assessment. On 6/3/14 at 1:40 p.m., the DON was interviewed and stated the facility did not have a fall policy and procedure. The DON stated she expected the nursing staff to utilize their own assessment skills which included following the nursing standard of practice when it came to a fall with a suspected fracture. On 6/6/13 at 11:25 a.m. the physician confirmed he would have expected the facility staff to maintain the resident ' s position on the floor and await arrival for paramedics. The movement could cause harm and permanent damage to the hip area regarding to nerve, muscle and bone involvement. The physician stated it did not matter if the hospital was 2 blocks or 2 miles away and the resident should have transported by the ambulance and not by the Administrator of the facility.

Based on observation, Department website review and staff interview, the facility failed to utilize a metal electric surge protector for the appropriate electronic devices. The facility census was 49 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 items that could be used with a metal electric 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 8/2/12 at 1:25 p.m., revealed a metal surge protector present in the beauty shop area. Observation revealed three electric clippers plugged into the surge protector. During interview on 8/2/12 at 1:26 p.m., Staff B, Maintenance Director indicated the surge protector would be removed and a new four plug outlet would be installed immediately.

Based on observation and staff interview, the facility failed to ensure kitchen equipment was stored in a sanitary manner in order to prevent food borne illness. The facility census was 50 residents. Findings include: 1. Observation on 7/31/12 at 9:20 a.m., with the Food Service Supervisor revealed the following kitchen equipment as on the dried pan rack, indicating it was ready for use: a. Two steel mixing bowls contained areas of white dried debris, mainly on the bottom of the bowel that could be scratched off with a finger. b. Two steel half-steam pans contained multiple drops of water and one with water that ran in the pan. c. One steel quarter steam pan contained multiple drops of water. 2. Observation on 7/31/12 at 9:25 a.m., revealed a number 8 steel scoop that contained three moderate sized yellow areas of debris in a kitchen drawer. 3. Observation on 8/2/12 at 1:50 p.m., with the Dietary Supervisor revealed the following on the dried pan rack: a. Three-half steam pans contained multiple drops of water inside and outside. b. One-quarter steam pan contained multiple drops of water inside the pan. The Dietary Supervisor stated the pans are expected to be clean and dried once placed on the dry rack.

Based on personnel record and staff interview, the facility failed to operate and provide services in compliance with all applicable State regulations. According to Iowa Code 135C.33(2)a, a person who has a criminal record cannot be employed in a health care facility unless the DHS (Department of Human Services) has evaluated the crime report and concluded that the crime report does not merit prohibition from employment. The facility failed to obtain the required DHS evaluation prior to employment for one (1) of five (5) staff reviewed (Staff C). The facility census was 51 residents. Findings include: The personnel file for Staff C (Registered Nurse) documented a hire date of 8/10/10, with current employment in the facility. The criminal background check completed 8/4/10, identified a possible positive criminal history which required further research. This required the facility to await the Department of Criminal Investigations (DCI) final response for criminal history clearance. The facility received information from DCI dated 8/9/10, which documented Staff C had a positive criminal history, with the record attached. The personnel file for Staff C lacked evidence the facility obtained approval from DHS for the individual to work in the licensed health care facility. During interview on 7/15/10 at 9:20 a.m., Staff B (Office manager) stated Staff C was initially hired on a part-time basis and currently worked full-time in the facility. Staff B stated the facility did not think an approval needed to be obtained for the type of crime on the criminal history when Staff C was hired. Staff B stated on 7/6/11 during a consultant audit, the facility discovered an approval had been needed for all criminal hits. Staff B stated a new background check was completed on 7/6/11, and the DCI response with criminal record had remained the same. Staff B stated a request for approval to work was sent to DHS on 7/6/11, and the facility had not received a response from DHS yet. A review of a facility policy titled Dependent Adult Abuse (no date), documented the facility would conduct a criminal record check on a prospective employees, but did not include obtaining an approval to work from DHS for those with a criminal history.

Based on personnel record review, facility policy review and staff interview, the facility failed to ensure staff completed mandatory dependent adult abuse training with in six months of employment for one of five employees hired . The facility census was 51 residents. (Staff A) Finding include: 1. Personnel file record review documented the facility hired Staff A (Cook) on 10/27/10. The personnel file lacked evidence of mandatory reporter training for dependant adult abuse within six months of his/her hire. A certificate in the file documented Staff A had received the training on 6/24/11, nearly eight months after hire. A facility policy titled Dependant Adult Abuse (no date), documented each employee would be required to complete two hours of training related to the identification and reporting of dependent adult abuse within six months of initial employment, with two hours of additional training required every five years. During interview on 7/13/11 at 1:30 p.m., Staff B (Office Manager) stated Staff A did not have the training within the first six months of employment because he/she had been on vacation when the facility training for dependent adult abuse took place. During interview on 7/15/11 at 9:15 a.m., Staff B verified Staff A had worked 118 hours on an as needed basis after the six month period allowed after hire before having the training.