Every finding on record at MercyOne Dyersville Senior Care

Based on observation, staff interview, and policy review the facility failed to wear appropriate Personal Protective Equipment (PPE) when handling soiled laundry. The facility reported a census of 33 residents. Findings include: In an observation on 11/04/24 at 11:18 AM the Environmental Services (EVS) Coordinator donned a pair of gloves and failed to put on a gown before she took soiled clothes out of the bin and placed them into the washer. The soiled clothes came into contact with her scrubs. Chemicals were placed in the tub and the washer was started. She then removed and discarded her gloves. In an interview on 11/04/24 at 11:08 AM the EVS Coordinator explained soiled laundry comes in from Senior Care in clear linen bags. They do personal items and all the curtains/room dividers here at the facility. Clothing gets sorted into the washing machines directly. She noted she wears only gloves when sorting, unless she has to rinse feces out. Then she wears a gown. In an interview on 11/06/24 at 10:24 AM the EVS Coordinator explained whenever they hire a new person she does three days of laundry training. She instructs staff to wear only gloves to grab soiled linens. She acknowledged she was not aware of the guidelines for PPE when handling dirty laundry, and noted the laundry policy was not thorough. The facility policy titled Laundry, undated failed to specify the appropriate PPE to be worn when sorting soiled laundry.

Based on observation, policy review, and staff interview the facility failed to serve and distribute meals under sanitary conditions. The facility reported a census of 30 residents. Findings include: During an observation on 1/7/24 at 10:21 AM the 2 garbage cans at the end of the prep table were uncovered and approximately 1/2 full. There was baked chicken on the prep table. During an observation on 1/7/24 at 12:11 PM Staff C served 13 cups to 11 residents handling the cups with her palm over the open beverage and fingers on the drinking rim surface. During an observation on 1/8/24 at 4:49 PM the 2 garbage cans at the end of the prep table remained uncovered and approximately 1/3 full. There was bacon, lettuce, tomatoes, toast, and a bin of assembled BLT sandwiches on the table. Sandwiches were being assembled during the observation. During an observation of the evening meal on 1/8/24 from 5:15 PM to 5:52 PM Staff D, cook, wheeled the steam table to the dining room. She donned gloves. She then plugged in the steam table, removed all the lids from the steam table pans, lifted the plate tray on the steam table and snapped it into place and placed all the serving utensils in the pans on the steam table. Several BLTs were removed from the steam table pan with Staff D's right hand lifting the edge of the sandwich and then using tongs grab the sandwich with left hand and placed on the plates. Several sandwiches were cut with the knife in Staff D's left hand and her right hand on top of the sandwich. The ground chicken was served from the steam table using a soup spoon. The chicken was scooped up using the spoon in the left hand and using the right hand to hold the meat on the spoon to the plate. During the entirety of the meal service the left glove was changed twice. The right glove was not changed. Facility policy titled Resident Meal Service with an effective date of 8/23 directed staff to handle food with gloves or appropriate utensils. The policy lacked direction on when to change gloves. During an interview on 1/9/24 at 12:12 PM the Dietary Manager explained she would expect staff to hold cups below the drinking surface and she would not expect food to be handled with dirty gloves. She explained she would expect food to be served with serving utensils and not a soup spoon. She further explained she would expect the garbage cans to be covered.

Based on policy review and staff interview the facility failed to have an Infection Preventionist that worked at the facility at least part time. The identified Infection Preventionist worked at a location in a different city. The facility reported a census of 30 residents. Findings include: The undated MercyOne [NAME] Medical Center policy titled Infection Prevention Surveillance Program DB documents the Infection Preventionist services are provided at 96 hours per pay period as identified needs and functions of the hospital. During an interview on 1/9/24 at 2:15 PM Staff B, RN identified herself as the Infection Preventionist. She explained her office was in [NAME] and the facility was treated as a unit of [NAME] even thought the location was in a different city. She further explained she is onsite at the facility quarterly. She is not in the facility weekly and does not work at this location.

Based on clinical record review, Center for Medicare and Medicaid Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, and staff interview the facility failed to submit a MDS assessment within 14 days of the MDS completion date for 1 of 1 residents sampled for submission (Resident #28). The facility identified a census of 30 residents. Findings include: Resident #28's Minimum Data Set (MDS) assessment dated [DATE] showed a completion date of 11/06/23. An Electronic File Batch Report dated 1/09/23 provided by the MDS Coordinator documented Resident #28's quarterly 10/30/23 MDS as accepted into the data base on 1/09/24 at 9:53 AM. An Internet Quality Improvement and Evaluation System (iQIES) (an internet-based system that includes survey and certification functions) Report, MDS 3.0 Nursing Home (NH) Final Validation Report dated 11/13/23 9:30 AM documented 18 MDS records accepted to the data base with 2 rejected records. Resident #28's 10/30/23 quarterly MDS record was not included in the 20 records processed. An iQIES Report MDS 3.0 NH Final Validation Report dated 11/13/23 at 9:51 AM documented two records submitted into the data base. Resident #25's 10/30/23 quarterly MDS record was not included in the 2 records processed. An iQIES MDS 3.0 NH Validation Report dated 11/15/23 at 2:37 PM documented four records accepted into the data base and report on 11/28/23 at 6:02 AM documented 1 record accepted into the data base. Resident #25's 10/30/23 quarterly MDS was not included in the records. On 1/09/23 at 9:36 AM the MDS Coordinator reported she had not submitted Resident #28's MDS assessment until 1/09/24. She reported they had issues with submitting the assessments back in October 2023 for about three weeks, so the MDS was missed. The normal process is to completed the MDS, then lock and submit the MDS within a week of the MDS being completed. She reported she follows the RAI manual. During an interview on 1/09/23 at 1:44 PM the Director of Senior Care reported she expected the MDS Coordinator to follow the RAI manual and submit the MDS timely. The CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's manual revised on October 2023 instructs MDS assessments must be submitted within 14 days of the MDS Completion Date.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) Assessment with diagnosis and medication classification for 3 of 3 residents sampled (Resident #5, #21 and #29). The facility identified a census of 30 residents. Finding include: 1. Resident #5's Urology Consultation Note dated 5/31/23 documented long-term use of an indwelling catheter (a catheter which is inserted into the bladder, via the urethra and remains in place to drain urine from the bladder) due to incomplete bladder emptying, likely secondary to neurogenic bladder. A Physician Order Sheet dated 10/23/23 documented a physician order for a 16 French, 5 cubic centimeter (cc) balloon, change monthly. The order had been on file since 6/16/23. The MDS assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 9 indicating moderate cognitive loss. The MDS documented the use of an indwelling catheter and total dependence upon staff for toileting. The MDS lacked a documented diagnosis for the use of the catheter. The December 2023 Medication Administration Record (MAR) documented Resident #5's indwelling urinary catheter had been changed on 12/20/23 per the physician order. On 1/09/24 at 9:46 AM the MDS Coordinator confirmed Resident #5 was utilizing an indwelling catheter and a diagnosis for the catheter had not been documented on the MDS. The MDS Coordinator reported she utilized the RAI (Resident Assessment Instrument Manual) for coding the MDS. The CMS LTC Facility RAI 3.0 User's Manual Version 1.18.11, Chapter 1, page 1-4 documents the RAI process has multiple regulatory requirements. Federal regulations at 42 Code of Federal Regulations 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status. Chapter 3, Page I-1 documents to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. 2. Resident #21's Physician Order Sheet dated 10/09/23 documented a diagnosis of atrial fibrillation and the following physician orders: a. Continue Warfarin 4 milligrams (mg), give one tablet by mouth on Mondays and Fridays. b. Warfarin 5 mg, give one tablet by mouth on all other days. A Review of the October 2023 MAR revealed no use of antiplatelet medication. Resident #21's MDS assessment dated [DATE] showed a BIMS score of 6 indicating severe cognitive loss. The MDS documented a diagnosis of atrial fibrillation and use of anti-platelet medication. On 1/09/24 at 9:47 AM the MDS Coordinator verbalized if the resident is on an aspirin, she codes the use of an antiplatelet medication. She didn't know why she did not code the use of an anticoagulant medication correctly. She must have missed it. During an interview on 1/09/24 at 1:44 PM the Director of Senior Services reported she expected the MDS Coordinator to utilize the RAI manual to accurately code the MDS. The CMS LTC Facility RAI 3.0 User's Manual Version 1.18.11 October 2023, Chapter 3, page N-7 instructs to code all high-risk drug class medications according to their pharmacological classification which includes N0415E1 Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin). 42134 3. The MDS dated [DATE] documented Resident #29 received an antipsychotic medication and had an indication for use of the medication. The MDS also documented the resident had not received an antianxiety medication. Review of the Physician Order Sheet and the MAR reveal the resident was not receiving an antipsychotic medication. The MDS did not have antianxiety medication or indication of use documented. Review of the Physician Order Sheet and MAR revealed Resident #29 was receiving an antianxiety medication and had an indication for its use.

Based on clinical record review, document review, and staff interview, the facility failed to stop the use of unnecessary medication as ordered by the physician for 1 of 5 residents reviewed (Resident #21). The facility reported a census of 30 residents. Findings include: Resident #21's Face Sheet documented admission to the facility on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive loss. The MDS documented the use of an antibiotic with no active diagnosis of infection on the MDS. A Physician Order Sheet dated 7/13/22 documented admission to the facility with listed diagnoses which did not include any history of chronic urinary tract infections (UTI's). Review of the Physician Order Sheet and the discharge orders dated 7/13/22 revealed no physician orders for Cephalexin antibiotic for prophylactic use. A review of the Pharmacy Consultation notes from January 2023 to November 2023 documented Resident #21 taking the Cephalexin medication with no recommendations regarding the antibiotic length of use. Physician Order Sheets signed by the provider on 6/17/23, 8/25/23 and 10/23/23 documented an order for Cephalexin 500 milligrams (mg), give one capsule by mouth daily. A Nurses Note dated 11/17/23 documented Resident #21 returned from a cardiology appointment with orders for the following: a. Furosemide 20 mg on Mondays, Wednesdays and Fridays to see if improves difficulty breathing, if not may discontinue; b. Lab work in two weeks; c. Weights at least twice weekly, call with weights in 1-2 weeks; d. Continue TED hose as previous; e. Check BP three times a week; f. Follow-up with cardiology in six month. An After Visit Summary Note from Cardiology dated 11/17/23 documented antibiotic use and resistance: if antibiotics are used too often, they may not work on infections or illnesses. Your health care team is here to provide you with the best care. Medicines will only be given when needed. To learn more, visit the Centers for Disease Control and Prevention (CDC) website: www.cdc.gov/getsmart. The After Visit Summary Note listed the current medications to continue for Resident #21 as of 11/17/23. The list of medications did not include a physician order for Cephalexin 500 mg one tablet daily. The After Visit Summary identified a current allergy to the antibiotic Azithromycin. The November 2023 Medication Administration Record (MAR) documented the nursing staff administered Cephalexin 500 mg 1 capsule by mouth daily at hour of sleep from 11/01/23 - 11/30/23. The December 2023 MAR showed Cephalexin 500 mg 1 capsule by mouth daily administered daily at hour of sleep from 12/01/23 - 12/31/23. On 1/07/24 at 2:37 PM Staff A Registered Nurse (RN) reported Resident #21 is on the Cephalexin for frequent urinary tract infection (UTI's). The family had been concerned about her frequent UTI's and wanted her on the medication. They were looking at taking her off of the antibiotic, but the family and the physician talked and decided to continue the medication a while back. She reported there was probably no documentation of it in the chart. Resident #21 had taken the antibiotic prior to her admission to the facility and the family wanted it to continue. A Review of the Nurses Notes on 1/09/23 revealed no documentation of any order clarification regarding the Cephalexin antibiotic after 11/17/23. On 1/09/24 at 11:18 AM Staff A reported it is the responsibility of the charge nurse to review the paperwork that is returned with residents after physician appointments. The paperwork is usually reviewed by the day shift nurses, but sometimes when residents go out to the university, they come back late. She reported she signs the paperwork as noted with her name and date after she checks the paperwork. She confirmed Resident #21 After Visit Summary from the physician appointment on 11/17/23 had not been noted by the nurse and verified the Cephalexin had not been ordered. Staff A reviewed the nurses notes and physician orders in the chart and stated there had been no follow-up with the physician to clarify the Cephalexin antibiotic medication. A review of the physician orders on 1/09/24 at 11:30 AM revealed no physician orders written for antibiotic treatment for UTI from July 2023 to present. Resident #21 did have antibiotic treatment ordered 7/24/23 for pneumonia. During an interview on 1/09/24 at 1:44 PM the Director of Senior Care verbalized she expected the nurses to follow the physician orders and clarify the physician orders when needed. The Drug Regimen Review Policy directed drug regimen review consists of a review and analysis of prescribed medication therapy, medication use review, including nursing documentation of medication ordering and administration. The Policy did not address time limits on the use of antibiotics. The Physician's Orders Accepting, Transcribing and Noting Policy directed to ensure accuracy of transcription and followed as written, all orders will be checked and noted by a nurse; verification will be designated by bracket, date, time and signature. The Antimicrobial Stewardship Program Policy included to reduce the expenditures for antibiotics.

Based on clinical record review, staff interview and facility document review the facility failed to notify a physician after a resident reported suicidal thoughts for 1 out of 1 resident reviewed (Resident # 25). The facility reported a census of 34 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE], listed the Brief Interview for Mental Status (BIMS) score of 5 (sever cognitive impairment). The MDS read Resident # 25 is independent with ambulation and transfers. The Psych Note dated 8/11/22, listed diagnoses of depressive disorder and generalized anxiety. The Note directed they can call with any concern for a sooner appointment. The Care Plan dated 3/16/2020, directed staff to assess and screen for social isolation, depression, and concerns, will notify family and physician of mental health status. The Care Plan continued to reflect will see psychiatrist as needed. Nurses Notes dated 10/19/22, reflected Resident # 25 reported she just wants to die, said she wants to get a gun and kill herself. The Nurse notified the son and the Deacon. The nurse failed to notify the Physician. The Nurses Notes for Resident # 25 failed to reflect further follow up regarding her suicidal comments. On 11/15/22 at 1:53 PM, Social Services (S.S.), reported she failed to know Resident # 25 verbalized the wish to kill herself. She stated the facility has an Advance Registered Nurse Practitioner (ARNP ) who comes in and addresses the mental health needs of the residents. She stated she is not sure if Resident # 25 is on her list. The S.S. staff revealed she expected the nursing staff to communicate suicidal talk to the the S.S. staff. On 11/17/22 at 9:55 AM, the Registered Nurse (RN) Director, reported the facility failed to have a policy for family notification. The RN Orientation Pathway, undated, reflected in the phase 2, use of the SBAR (situation, background, assessment and recommendation) with the physician.

Based on clinical record review, staff interview and facility policy review the facility failed to address resident's high risk medications for 1 out of 5 residents reviewed (Resident # 31). The facility reported a census of 34 resident. Findings included: The Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses of atrial fibrillation (afib) and dementia. The Medication Administration Record (MAR) dated 11/22, directed Warfarin (coumadin) (blood thinning medication) 5 milligram (mg) and cephalexin (antibiotic) 500 mg. The Doctor's Order dated 8/2/22, documented the cephalexin 500 mg as a prophylactic medication. The order continued to read Warfarin 5 mg for afib. The Care Plan for Resident # 31 dated 7/26/22, failed to identify Resident # 31's use of a blood thinning medication and failed to address Resident # 31's long term use of an antibiotic medication. On 11/17/22 at 8:05 AM, the MDS/Care Plan Coordinator reported she expected blood thinning medications and antibiotic medication addressed on the Care Plan. She said, she failed to have a guide to follow for developing the Care Plan she used the trigger for the Care Area Assessment (CAA). On 11/17/22 at 8:53 AM, the Registered Nurse (RN) Director, reported she expected the blood thinning medication addressed on the Care Plan, but not the antibiotic medication, because it is on the MAR with the diagnoses. The facility provided a policy titled Patient-Resident Care Plans undated, it directed at point # 1. The admitting nurse shall initiate interim care plan of the resident based on the initial assessment of the resident and physician ' s orders. The Care Plan will be developed by the multidisciplinary team, with the participation of the physician, resident, family, or legal representative within 7 days after completion of the comprehensive assessment (MDS).

Based on clinical record review and staff interview, the facility failed to ensure the comprehensive care plan included all services required to ensure the residents medical and nursing needs was met for two of six residents reviewed. (Resident #21 & #32) The facility census was 38 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 had [DIAGNOSES REDACTED]. A physician order [REDACTED]. The Care plan with a revision date of 1/22/19, failed to address the [DIAGNOSES REDACTED]. During interview on 5/21/19 at 2:18 p.m., the Director of Long Term Care stated they should have a care plan for signs and symptoms of hypo/[MEDICAL CONDITION] (high or low blood sugar) and to monitor for side effects of insulin. 2. The MDS assessment dated [DATE], documented Resident #32 had [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The Medications Record dated 5/1/19 to 5/31/19 documented the resident received [MEDICATION NAME] on a daily bases for the dates. The residents Care Plan lacked documentation the resident was on an anticoagulant and lacked interventions. During interview on 5/21/19 at 1:32 p.m. , the Care Plan Coordinator reported she should have covered the anticoagulant on the Care Plan.

Based on observation, facility policy review, staff and resident interviews, the facility failed to ensure six of six residents received the required information regarding their right to file a grievance. The facility census was 38 residents. Findings include: 1. Observation on 5/19/19 at 11:30 a.m., revealed staff posting, survey results book, the contact information for the Ombudsman, State Agency and Resident Rights in a public area. Observation failed to reveal the Grievance Policy and the Grievance Official contact information. During Resident Council on 5/20/19 at 10:15 a.m., six of six residents reported not knowing the Grievance Officers name or the procedure to file a grievance. During interview on 5/21/19 at 10:25 a.m., Staff A, Registered Nurse, RN, reported they were aware of a Grievance Policy or a Grievance Officer for the long-term care facility. During interview on 5/21/19 at 10:59 a.m., the Director of long-term care, RN, reported there was a Compliance Officer at a sister facility outside of town where grievances are reported. The Director reported grievances are brought up during care plan conferences from residents to the staff in attendance. The resident's are able to report any concern to staff and an electronic grievance (VOICE) can be filed. The Director noted there was no postings for the Grievance Policy or identification of a Grievance Officer in the building and would look into it. On 5/21/19 at 12:25 p.m., the Director provided a policy titled Response to Patient or Family Complaints that failed to identify a Grievance Officer and contact information.

Based on clinical record review and staff interview, the facility failed to notify the state ombudsman office when two of two residents reviewed was transferred out of the facility for medical concerns. The facility census was 38 residents. (Residents #24 & #37) Findings include: 1. Nurse Notes dated 4/4/18 at 2:00 p.m., documented Resident #24 had increased weakness throughout the shift, was pale and had complaints of nausea. The family requested the resident be evaluated by a physician. Nurse Notes dated 4/8/18 at 4:30 p.m., documented the resident was readmitted to the facility. 2. Nurse Notes dated 4/28/19 at 3:30 a.m., documented Resident #37 was admitted to the hospital for right side facial swelling and fever. Nurse Notes dated 5/2/19 at 2:30 p.m., documented the resident returned from a hospitalization for right sided facial swelling abscess, [MEDICAL CONDITION]. During interview on 5/21/19 at 10:45 a.m., Staff B, Social Services reported only reporting one discharge to the state ombudsman office when a resident left the facility to go to an assisted living facility, otherwise she did not report any other transfers or discharges in the last year.

Based on clinical record review, facility policy review and staff interview, the facility failed to document bedhold was offered for two of two residents reviewed for transfers to the hospital. The facility census was 38 residents. (Residents #24 & #37) Findings include: 1. Nurse Notes dated 4/4/18 at 2:00 p.m., documented Resident #24 had increased weakness throughout the shift, was pale and had complaints of nausea. The family requested the resident be evaluated by a physician. Nurse Notes dated 4/8/18 at 4:30 p.m., documented the resident was readmitted to the facility. The residents clinical record lacked documentation a bed hold notice was given to the resident and/or responsible party upon transfer. 2. Nurse Notes dated 4/28/19 at 3:30 a.m., documented Resident #37 was admitted to the hospital for right side facial swelling and fever. Nurse Notes dated 5/2/19 at 2:30 p.m., documented the resident returned from a hospitalization for right sided facial swelling abscess, [MEDICAL CONDITION]. The residents clinical record lacked documentation a bed hold notice was given to the resident and/or responsible party. During interview on 5/21/19 at 12:54 p.m., Staff B, Social Services reported they are looking for the bed hold documentation for the two residents in question. Staff B reported the nurses would typically document the bed hold policy was given to the family/responsible in the nurses notes. The facility Bed Hold Policy (undated) documented when a resident has a temporary absence from the facility for medical treatment or therapeutic leave, the facility will: Ask the resident and family if they wish to have the bed held. Document the response on the attached form Bed Hold Information and Notice and complete the form. Retain a copy of the Notice for the Medical Record. Requests for extension of the time of the bed hold may be directed to the Patient Care Coordinator, Director of Patient Care Services. Resident are notified in writing of the rates for holding a bed at least annually be the administration.

Based on clinical record review, physician, family and staff interview, the facility failed to notify the physician immediately of an accident that resulted in injury requiring physician intervention for one of two residents reviewed. (Resident #87) The facility census was 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], indicated #87 had [DIAGNOSES REDACTED]. Progress notes dated 2/5/18 at 5:00 a.m., documented the resident was found sitting on floor between bed and bathroom at 4:00 a.m., when coming into room to be given set up medication. Progress notes dated 2/5/18 at 5:30 a.m., Staff H, registered nurse, RN called family after the Hospice RN assessed the resident. Family chose to let the resident sleep and call the Doctor's office when open to request an X-ray. Progress notes dated 2/5/18 at 8:00 a.m., by Staff F, Licensed Practical Nurse, LPN revealed an order for [REDACTED]. emergency room report dated 2/5/18, documented diagnostic studies: X-ray evaluation of left hip shows an intertrochanteric fracture of left hip. Clinical Impression: Left [MEDICAL CONDITION]. During interview on 2/6/18 at 4:45 p.m., Staff H, RN, stated they contacted Hospice, but did not contact the physician. During interview on 2/6/18 at 5:00 p.m., the family member stated the facility notified them of the fall and they told the nurse as long as the resident was comfortable they could wait for the physician. During interview on 2/7/18 at 8:50 a.m., Staff F, LPN stated she did not contact the physician at the time of fall. The Physician was contacted at 8:00 a.m., during normal office hours. During interview on 2/7/18 at 11:59 a.m., the physician office stated medical doctor said if the resident was in constant pain the whole time after the fall, the facility should have contacted the physician.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure safe administration of medication for one resident (Resident # 35) observed during a nebulizer treatment and failed to ensure implementation of physicians order regarding Gradual Dose Reduction (GDR) of [MEDICATION NAME] for one resident (Resident #12). The facility census was 37 residents. Findings include: 1. On 1/31/18 at 11:56 a.m., Resident #35 was observed sitting in a wheelchair, as Staff A Registered Nurse, RN informed the resident about the nebulizer treatment. The nebulizer was observed lying on top of the resident's bedside table with clear liquid already in the medication cup of the nebulizer. After assessing the resident , Staff A put the nebulizer via face mask to the residents face and turned it on. When asked what the medication was and who prepared it, Staff A replied that it was prepared by Staff B, Licensed Practical Nurse, LPN but she was the one giving it because she had to do an assessment first. At 12:00 p.m., Staff B acknowledged she prepared the medication and left it in the room to be administered by Staff A. Staff B reported that the medication was [MEDICATION NAME]. Staff B further reported that LPNs can prepare medications to be given by the RN because of the assessment part required for the treatment. On 2/1/18 at 12:08 p.m., Staff E, LPN reported the RN does the nebulizer treatments. When asked if she already prepared nebulizer medication to be administered by the RN, Staff E replied she would let the one who gives the medication to be the one to prepare it. A physician order [REDACTED]. The facility policy titled, Oak Crest Manor Medication Administration, with latest revision date of 7/17, provided, Medication shall NEVER be left for the resident to take later. On 2/7/18 at 1:30 p.m., Staff F, LPN stated she would not prepare a nebulizer medication for the RN to give. 2. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #12 had [DIAGNOSES REDACTED]. Pharmacist's documentation dated 10/20/17, indicated the resident was on 45 mg (milligram) [MEDICATION NAME] taken at HS (hours of sleep at night), [MEDICATION NAME] 60 mg daily, and [MEDICATION NAME] 2 mg HS. In addition, there was pharmacy recommendation for a trial GDR of [MEDICATION NAME] to 30 mg HS. The physician responded with an order to implement the pharmacist's recommendation as requested. The Medication Administration Record [REDACTED]. On 2/7/18 at 2:34 p.m., the Director of Nursing (DON) verified the physician order [REDACTED].>

Based on observation, clinical record review and staff interview, the facility failed to provide proper technique with wound care to prevent the spread of infection for one of two residents observed. The facility census was 37 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE], indicated Resident # 86 had [DIAGNOSES REDACTED]. During observation on 2/6/18 at 10:09 a.m., Staff A, Registered Nurse, RN provide wound care to the residents right heel pressure ulcer. Upon entering the room with supplies, Staff A washed hands and donned gloves, removed the soiled dressing from the residents right heel with scissors from the overbed table. After removing the dressing Staff A did not remove their gloves or wash hands. Staff A wearing the contaminated gloves, cleansed the wound to the right heel with soap and water and removed gloves and but failed to wash hands. Staff A applied [MEDICATION NAME] to the residents right heel and wrapped the right lower extremity with a kling dressing with bare hands. Staff A positioned the residents lower extremity and cleaned up the supplies. After disposing of the supplies, Staff A placed the contaminated scissors in a basin in the residents closet with clean wound dressing supplies. Physician order [REDACTED]. During interview on 2/7/18 at 2:30 p.m., the Director of Nursing stated staff should change gloves and wash hands when going from soiled to clean and the scissors should be cleaned before storing.

Based on observation and staff interview the facility failed to identify open dates for multiple bags of open food held in the freezer. The facility identified a census of 35 residents. Findings include; 1. During initial tour of the kitchen on 11/21/16 at 9:00 a.m. with Staff A, Production Coordinator, revealed the following opened foods in the walk-in freezer, without any labeled dates to reveal when the bags of food were opened: - 80 ounces (oz.) of mango dates, 1/3 full. - 40 oz. of onion petals, 3/4 full. - 40 oz. of mixed vegetables, 3/4 full. - 5 pounds of cherries, 1/3 full. - 64 oz. of corn, 3/4 full. - large bag of carrots and red peppers, 1/3 full. - small bag of orzo (grain), 1/3 full. - 64 oz of broccoli, 1/3 full. When lifting the bag up, the tie tag fell off, revealed the open bag not sealed tightly. - 64 oz. of peas. 3/4 full. - 64 oz. beans, 3/4 full. - 64 oz. cauliflower, 4/3 full. - large bag of boneless chicken breasts 3/4 full, no identification label present. - medium bag of little smokies, 3/4 full. - large bag of pulled pork, 3/4 full. When lifting the bag up, the tie tag fell off, revealed the open bag not sealed tightly. - medium bag of egg noodles, 1/3 full. - large bag of sausage patties, 2/3 full. - large bad of hot dogs, 1/2 full. - 3 hamburger patties, unlabeled, in a plastic bag, with some white frost crystals present. The Production Coordinator replied they never date open bags of food that go into the freezer, unless they were cooked. The facility's Food Labeling and Dating Policy dated 12/15 related to all refrigerated food. The Policy did not include frozen food.

Based on record review, staff interview and policy review, the facility failed to ensure 1 of 5 staff members reviewed completed mandatory reporter abuse training within 6 months of date of hire (Staff A). The facility reported a census of 35 residents. Findings include: 1. Review of the human resources record on 12/21/15 for Staff A, Housekeeper, revealed a hire date of 4/12/16 and documentation of the completion of the two-hour mandatory reporter abuse training completed on 10/24/16, 13 days past due. During an interview on 11/22/16 at 8:00 a.m., the Human Resources (HR) Assistant reported that she was now aware that Staff A had not completed the required training within 6 months of hire. The HR Assistant reported all staff are instructed upon hire for the timely manner to have the Online Mandatory Reporter for Dependent Adult Abuse Training completed. She noted it is up to the new staff person to complete the task. The HR Assistant noted Staff A received alerts per the email system of the HealthStream computer training system of the training which needed to be completed. The Email system also notifies the Director of the Department for that staff person regarding that staff member's status of mandatory training. The HR Assistant pointed out a new policy this past year, 7/16, to address this issue, as they noted there were some errors with the education being completed. She also pointed out the new directive which stated if the mandatory education went past due, the new person would not be allowed to work. When the Time Schedule for Staff A came available, she agreed Staff A did work 2 days without completion of the mandatory training. The HR Assistant also reported it is up to the Director of each Department to make sure the Mandatory Abuse Training is completed. During an interview on 11/22/16 at 8:35 a.m. Staff G, Environmental Services, stated she is in charge of environmental services at this location. Staff G noted the Director of Environmental Services is at another location. Staff G noted Staff A did work those 2 days without having the Mandatory Abuse Training completed. Staff G reported she probably received a notice, but had been unclear if Staff A had completed it and/or unaware the training was so close to due time. Staff G remarked of not knowing if she was responsible to assure the staff complete the Mandatory Abuse Training, or if the Director of the Environmental Services (at the other location) was responsible. During an interview on 11/23/16 at 7:35 a.m., Staff D, housekeeping, reported overlooking the date for the mandatory training to be completed. Staff D replied of not being good with computers and did not check her emails for the alerts. Staff G informed her the mandatory training not completed after she had worked 2 days. During an interview on 11/23/16 at 8:40 a.m. Staff G wanted to clarify the statements made on 11/22/16. Staff G reported the facility's old rule included mandatory abuse training to be completed with hire. The facility's new rule is the new staff person has 6 months to complete the training. Therefore Staff G noted thinking Staff D had completed the training upon hire. She noted she forgot the new rule, and it was her fault the training had not been completed. Review of the Facility's Freedom from Abuse or Neglect: Child, Dependent Adult, Domestic, or Staff Abuse Policy last reviewed on 11/16, directed staff that all mandatory reporters must complete Child Abuse/Dependent Adult Abuse training. The training must be approved by the Iowa Abuse Education Review Panel and completed within 6 months of initial employment and every 5 years thereafter. New employees are considered delinquent for training 6 months and 1 day after date of hire. Other employees are considered delinquent for training 5 years and 1 day after previous training. Violators will be disciplined according to Human Resources Policy I.C.05. Review of the Facility's Policy for Mandatory Education revised on 7/1/16 stated the purpose to provide guidelines and ensure mandatory education is completed within the required time frames. The Procedures included the following - When hired, colleagues are required to complete their mandatory education during their orientation period. Mandatory education will be available through the HealthStream/HeartCode e-learning systems. - Directors will receive Healthstream report of upcoming due dates, past due dates and completion dates from the Education Specialist. Directors will schedule a time for colleague to complete education prior to due date. - If mandatory education is past due, a colleague will not be allowed to perform regular work duties until completed. Failure to comply with mandatory education may result in disciplinary action.

Based on observation, record review and staff interview, the facility failed to properly maintain and administer injectable medications for 1 of 2 residents reviewed who received daily insulin injections (Resident #4). The facility reported a census of 35 residents. Findings include: During the review of the facility medication room on [DATE] at 9:37 a.m. to 9:55 a.m. with Staff I, Registered Nurse, it was noted the medication refrigerator contained boxes with vials of opened and unopened insulin. Review of the box containing an opened [MEDICATION NAME] for Resident #4 revealed handwritten notations that the vial opened on [DATE] and to expire on [DATE]. Also noted were 2 more vials of [MEDICATION NAME] in the refrigerator for Resident #4, unopened. Review Resident #4's physician's orders [REDACTED]. Review of the Resident's [DATE] Medication Administration Record [REDACTED]. The insulin noted signed off as given for November including ,[DATE], ,[DATE] and ,[DATE], the 3 days after the insulin expired. Review of the Diabetic Record for Resident #4 shown that the morning blood sugars taken as ordered before breakfast on [DATE] and again on [DATE] to be 85. On [DATE] the nurse waited to give the resident his/her insulin until after breakfast and documented no signs and symptoms of [DIAGNOSES REDACTED] noted. Review of information emailed from the facility's pharmacist on [DATE] entitled Administration: Subcutaneous under the Storage/Stability paragraph addresses how [MEDICATION NAME] should be stored. Nursing instructions included once punctured (in use), store vials refrigerated or at room temperature less then 30 degrees Celsius or 86 degrees Fahrenheit and use within 28 days. During an interview on [DATE] at 10:06 a.m., Staff I stated the insulin should not have been administered 3 more days after the insulin expiration date. Staff I noted to give the expired vial of insulin to another nurse for disposal.

Based on observation, record review and staff interview the facility failed to follow proper infection control procedures when preparing a subcutaneous insulin injection for 1 of 2 administration opportunities observed for 1 resident (Resident #4). The facility reported a census of 35 residents. Findings include: 1. During the Medication Administration Observation on 11/21/16 at 11:45 a.m. to 12:00 p.m., noted Staff J, Registered Nurse (RN) passing medications. At 11:50 a.m., Staff J prepared to give Resident #4 the scheduled [MEDICATION NAME]of 8 Units subcutaneously (under the skin). Staff J observed to remove the multi-dose vial of [MEDICATION NAME]from the medication refrigerator and set on the counter. Staff J gathered supplies needed to administer the injection which included an insulin syringe . Staff J removed the cap off the needle and placed the cap on a paper towel barrier. Staff J then picked up the insulin vial and tipped the vial up and took the uncapped syringe and punctured the rubber top of the vial without cleansing the top first and drew up the prescribed 8 Units of [MEDICATION NAME] insulin. Staff J took the drawn up insulin to the resident and administered the insulin as prescribed. Review of Resident #4's physician's orders [REDACTED]. Review of the Resident's November 2016 Medication Administration Record (MAR) revealed an entry for the [MEDICATION NAME]inject 6 Units subcutaneous at breakfast and 8 Units noon and supper. Review of the Lippincott Procedures - Subcutaneous Injection revised 8/12/16 that the facility follows as reported by the Patient Care Coordinator, instructed the nursing staff on proper techniques when using single-dose or multi dose vials of medicine. The procedure directed the nurse to disinfect the vial's rubber [MEDICATION NAME] with an antiseptic pad using friction, and then allow it to dry. During an interview on 11/22/16 at 11:31 a.m., Staff J admitted he/she missed a step yesterday 11/21/16 when preparing Resident #4's insulin before lunch. Staff J reported forgot to cleanse the top of the vial with alcohol before drawing up the insulin. During the Infection Control Interview on 11/22/16 at 1:30 p.m., the facility Infection Preventionist Performance Improvement staff stated that it is an expected proper protocol to cleanse off the top of a multi-dose vial such as insulin, even if for the same resident. The vial should be cleansed each time before the nurse sticks the needle into the top of the vial to draw up the medicine.

Based on personnel record review, facility policy review and staff interview, the facility failed to ensure two of five staff completed mandatory reporter abuse training within 6 months of date of hire. (Staff A & B) The facility census was 37 residents. Findings include: 1. Personnel record review documented Staff A, Certified Nurse Aide, CNA was hired date on 4/20/15, the personnel record failed to document the completion of the two-hour mandatory reporter abuse training. 2. Personnel record review documented Staff B, CNA was hired on 2/23/15, the personnel record failed to document the completion of the two-hour mandatory reporter abuse training until 11/24/15 or nine months after hire. During interview on 12/21/15 at 1:07 p.m., Human Resources staff reported they were aware Staff A had not completed the required training within 6 months of hiring and reported she and the Director of the facility had talked to Staff A about being late completing the training. Human Resources staff concurred after reviewing records that Staff B was overdue by three months with completing the required training. Review of the Freedom from Abuse or Neglect: Child, Dependent Adult, Domestic, or Staff Abuse Policy last reviewed on 7/15 directed all mandatory reporters must complete Child Abuse/Dependent Adult Abuse training. The training must be approved by the Iowa Abuse Education Review Panel and completed within 6 months of initial employment and every 5 years thereafter.

Based on clinical record review and staff interviews, the facility failed to ensure one of four residents reviewed were appropriately supervised in order to prevent accidents. The facility census was 39 residents. (Resident #1) Findings include: 1. The medical record documented Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had both long term and short term memory problems and was moderately impaired in his/her decision making skills. The individual care plan dated 4/15/13, indicated the resident required staff assistance with all activities of daily living. The plan of care identified the resident at high risk for falling with approaches that included transfer with walker, gaitbelt and one staff assisting, TABS (alarm) to bed, recliner and wheelchair and remind the resident to use the call light A physical therapy note dated 2/1/13, documented a wheel chair was used for transporting the resident only and staff were currently walking the resident to the dining room and sitting the resident in a regular chair with good tolerance. Recommend supervision with being in regular chair and tab alert for safety. Nurse notes dated 2/1/13 at 9:30 a.m., indicated staff responded to the resident's alarm sounding and found him/her on the floor. Staff assessed the resident and found no injuries but did reinforce to call for assistance and to wait for staff assistance. Nurse notes dated 5/27/13 at 6:30 p.m., indicated the resident was found on the floor by other family in the dining room after dinner. The resident was lying on his/her side. The resident tried ambulating by self without walker. A Fall Event form dated 6/4/13 for a fall that occurred on 5/27/13 at 6:30 p.m., documented nurse was called over to dining room by family member of another resident and reported a resident fell while trying to walk. The resident was found on the floor on his/her right side. The form asked what to do to prevent event from happening again? With the following response- ensure the resident is not left in the dining room unattended and should be taken back to room quickly after meal time. An X-ray obtained on 5/28/12, revealed the resident had a fracture of his/her left femoral neck. During interview on 6/17/13 at 10:54 a.m., Staff A, patient care coordinator stated staff assisted the resident in ambulating from his/her room to the dining room at meal time and assisted the resident to sit in a regular dining room chair. Staff A stated the facility used TAB/clip alarms for the resident in his/her wheelchair, recliner and bed, but did not use any alarm on the dining room chair. During interview on 6/17/13 at 1:44 p.m., Staff B, registered nurse stated she was at the nurse's station on 5/27/13 when the resident fell , but did not see the resident stand and attempt to ambulate without assistance. Staff B confirmed the resident did not have an alarm on the dining room chair, but added if there had been an alarm that sounded when the resident stood, she would have been able to respond and possibly prevent the fall.