Every finding on record at Advanced Health Care of Henderson

Based on observation, interview, document review, and record review, the facility failed to ensure a fall prevention was in place for 1 of 22 sampled residents (Resident 62) who was identified as being at risk for falls. This failure resulted in the resident not receiving necessary safety interventions required to reduce the risk of avoidable accidents.Findings include:Based on observation, interview, document review, and record review, the facility failed to ensure a fall prevention was in place for 1 of 22 sampled residents (Resident 62) who was identified as being at risk for falls. This failure resulted in the resident not receiving necessary safety interventions required to reduce the risk of avoidable accidents.Findings include:Resident 62 (R62) was admitted on [DATE] with diagnoses including sepsis, unspecified organism, other specified diseases of liver, pneumonia, chronic obstructive pulmonary disease with (acute) lower respiratory infection, fall, weakness, liver injury with transaminitis, and atrial fibrillation status post cardioversion. On 06/09/2026 at 8:30 AM, R62 indicated falling out of bed the previous night on 06/08/2026. No fall mats were observed beside the resident's bed. R62's significant other verbalized R62 was unable to get out of bed independently.A physician order dated 05/29/ 2026, documented several safety measures for R62 to include the bed must be kept in the lowest position while in bed, fall mats must be placed on the floor when in bed, and non skid socks must be always worn. The order indicated the interventions were intended to reduce the resident's risk of falls and enhance overall safety.The care plan dated 05/29/2026, document R62 and the caregiver would demonstrate measures to increase safety and prevent falls throughout the resident's stay. The target date for this short term goal was 08/29/2026.The Care Plan approach documented the facility would identify factors increasing the patient's risk for repetitive falls and implement appropriate interventions. R62's bed would be kept in the lowest position whenever they were in bed. The call light and frequently used items would be placed within easy reach, and R62 oriented to the call light system and encouraged to use it before attempting to ambulate. Staff would respond promptly to call lights.R62 would be oriented to the room, bathroom, and overall environment, and furniture remained in consistent positions to avoid confusion or hazards. Staff would check on R62 every one to two hours. When appropriate, R62 would be placed in a room near the nurse's station or a high traffic area to enhance monitoring. Physical and occupational therapy services would be involved to support mobility and safety needs.A fall mat would be used when R62 was in bed with responsible partly consent, the bed would be positioned against the wall to further reduce fall risk.An observation detail list report indicated R62 was at risk for falls due to impaired mobility. The R62's care plan included a goal the resident would remain free from serious injury related to falls, provided appropriate interventions were implemented and maintained.A nursing progress note dated 06/09/2026 documented at 8:37 AM, R62 was alert and oriented two to three times with intermittent confusion and forgetfulness at baseline. In the morning, R62 reported falling out of bed shortly before staff arrived, landing on left side and striking left shoulder and left hip. The progress note documented R62 was able to get up from the floor and return to bed independently before notifying staff. The progress note documented R62's required moderate assistance with transfers and mobility. An assessment showed no visible injuries. A skin assessment revealed no deformity to the left shoulder, left hip, or surrounding areas. R62 denied pain and remained at baseline mental and physical status. R62 would continue to be monitored for any delayed signs of injury or changes in pain, mobility, or overall condition. The progress note indicated fall precautions would remain in place, and staff would continue close observation.A progress note dated 06/09/2026 at 12:20 PM, documented the Occupational Therapist arrived to initiate therapy; however, prior to treatment, R62 reported they had experienced a fall from bed during the previous night, landing on their right shoulder and right hip, resulting in pain in both areas. An assessment was completed, and no visible redness, bruising, swelling, deformity, skin discoloration, or other acute signs of injury were noted in the reported areas. The R62 continued to verbalize pain, though no objective findings were observed. Due to the reported fall and ongoing complaints of pain, the MD was notified of the patient's report and assessment findings. The MD ordered X rays of the shoulder and hip to rule out an acute injury.A progress note documented X ray results showed a fracture of the right clavicle and right pubis. The MD ordered R62 to use a right arm sling for the right upper extremity and to remain non weight bearing on the right side, with weight bearing as tolerated for the right lower extremity.A treatment administration history dated 06/09/2026, documented between 6:00 AM and 6:00 PM, the fall mats were in place when R62 was in bed. Based on direct observation at 8:30 AM, the fall mat was not positioned on the floor as required. This discrepancy showed the documentation did not accurately reflect the residents' actual safety measures at the time of the observation.On 06/11/2026, at 10:05 AM, a Certified Nursing Assistant (CNA) indicated when a resident was identified as a fall risk, a sign was placed on the resident's door. The resident should have a fall mat on the floor, the bed should be kept in the lowest position, and the must be checked frequently, especially when walking down in the hallway. The CNA acknowledged they had not noticed the fall mat on the floor in R62's room. On 06/11/ 2026, at 10:10 AM, a Registered Nurse (RN), indicated when a resident was identified as a fall risk, a fall risk assessment must be completed, and the resident's record should be reviewed to determine which prevention measures are to be put in place. The RN confirmed that the resident should have a fall mat, the bed should be kept in the lowest position, and the call light must be within reach. Staff would educate the residents about the use of the call light, and the residents should be checked at least every two hours.On 06/11/2026 at 10:15 AM, the Director of Nursing (DON) indicated when a resident was a fall risk, there was a fall assessment upon admission, a fall scale determining what prevention needed to be put in place, sure as a fall mat, lowered bed, non-skid socks. The DON indicated the fall mat should always be on the fall when a resident was in bed. On 06/11/2026 at 10:30 AM, a family member of R62 indicated they had seen the fall mat placed behind the television (TV), rather than on the floor, during their visits with R62. The family acknowledged 06/10/2026 was the first time they had seen the fall mat on the floor.On 06/11/2026 at 10: 45PM, a Physical Therapist (PT) indicated R62 had limited mobility and needed help to get out of bed. The PT indicated R62 mentioned they fell out of bed the previous night and got back into the bed and did not complete therapy on 06/09/206. The PT indicated reporting the fall to the DON. The PT acknowledged not noticing there was a fall mat on the floor in room R62.The facility's policy titled fall prevention (undated) safety interventions may include but are not limited to fall mats, bed in low position and touch pad call light.

Based on observation, interview, and document review the facility failed to ensure sanitary conditions were maintained related to the storage of chemicals in a manner to prevent contamination of food, food preparation areas, equipment and utensils. The deficient practice had the potential for food contamination for all residents of the facility who receive meals prepared and served by the facility. Findings include: On 06/09/2026 at 10:30 AM, during tour of kitchen various chemicals were observed on top of metal cabinet inside the kitchen bathroom. The chemicals including cleaning products, disinfectants, and spray grease or lubricant were noted on top of the cabinet. On 06/09/2026 at 4:18 PM, the Dietary Manager indicated the cabinet in the bathroom had been in place for nine years. The Dietary Manager verbalized a delivery was made late last week and there was no more room in the cabinet, and a staff member must have placed the additional chemicals on top of the cabinet and should have been placed inside or in the housekeeping storage room in another area of the facility. The facility policy titled Food Storage (undated) documented chemicals must be clearly labeled, kept in original containers when possible, and stored in designated area away from food.

Based on record review, the facility failed to ensure the Water Management Plan included all relevant actions to prevent, identify, and address the growth and spread of Legionella and other waterborne illnesses.Findings include:A review of the facility's Water Management Plan, titled Risk Management Plan for Legionella Control (undated), revealed the plan included a hazard identification and risk assessment which listed possible general events which could compromise water safety and result in circumstances that would be beneficial for the growth of microbes that cause waterborne diseases. The assessment did not include measures to prevent the growth of waterborne pathogens and how to monitor the pathogens. A review of the documentation indicated the only measure being monitored was water temperature.Documentation indicated the facility had conducted monthly water temperature monitoring at various points in the facility utilizing the Water Management Observation Log. The Log provided a way to document the water temperatures and locations where the water temperatures were taken from. The bottom of the form lists the following bullet points:- Cleaning and disinfection of shower heads (annually)- Flushing of infrequently used outlets (weekly)- Visual checks of identified high risk areasThe water management plan did not include the process or procedure for the disinfection of shower heads, flushing of infrequently used outlets, and did not identify the person responsible for the tasks.

Based on record review, interviews, and document review, the facility failed to ensure a resident was protected from over sedation for one unsampled resident. The deficient practice led to resident being over sedated, requiring hospitalization . Findings include: Resident 25 (R25) R25 was admitted on [DATE] with diagnoses including chronic pain and body mass index 19.9 or less. A progress note dated 04/19/2024, documented R25 was sent to hospital after possible overdose, exhibiting signs and symptoms of altered mental status and did not respond after two (2) doses of naloxone (Narcan, drug to reverse effects of opioid medication) were given. A physician order dated 04/09/2024 documented to give Clonazepam 1 mg with special instruction of do not give in combination with opiate, may take at least two hours in between benzodiazepine and opiate administration, avoid over sedation. The medication administration record indicated the following medications were given in the morning on 04/19/2024: - Citalopram 40 mg at 6:00 AM (anti-depressant) - Morphine 15 mg at 6:03 AM (opioid pain medication) - Lidoderm patch 5% at 7:00 AM (topical analgesic patch for pain) - Clonazepam 1 mg at 7:30 AM (benzodiazepine for anxiety) On 07/18/2024 in the afternoon, a Registered Nurse (RN) indicated nurses would use clinical judgment to determine if a resident was over sedated based on the residents' normal level of orientation. The RN explained if a significant amount of sedating medications were given in a short period of time, it might be difficult to determine actual sedation level at time of dosing. On 07/23/2024 in the afternoon, a Licensed Practical Nurse did not recall the specific situation, however verbalized being one of the nurses who gave the medication to R25 and explained a day shift and night shift nurse had given some of the medications in the morning. The LPN verbalized when a resident was receiving both opioid and benzodiazepine there was a standing order to separate the medications by at least two hours to prevent over sedation. On 07/18/2024 at 3:26 PM, the Clinical Nurse Manager indicated a resident on multiple sedation inducing drugs would generally have specific parameters of when the medication could be administered specifically if medications were benzodiazepines and opioid type medications. The Clinical Nurse Manager explained there should have been at least a two-hour window of time between the Clonazepam and Morphine to accurately determine if resident was over sedated. On 07/19/2024 at 10:27 AM, the Medical Director indicated being familiar with the resident and situation involving resident hospitalization . The Medical Director verbalized the number of medications administered in the morning of 04/19/2024, likely contributed to over sedating the resident and confirmed the order was not followed appropriately to ensure at least two hours between dosage of opiates and the benzodiazepine medications. The Medical Director reported the over sedation of R25 would not necessarily occur immediately based on several factors, and could present later in day when medication reached peak level in the body. The facility policy titled Pain Management documented patients would have appropriate pain control measures to optimize comfort and wellbeing. Pain levels would be controlled at acceptable levels to maximize recovery and facilitate participation in daily treatments and activities of daily living. Patient expressing or demonstrating pain would be provided with pain relief options including: - rest - positioning - relaxation techniques - diversion techniques - heat/cold application - routine and/or as needed medications - adjunctive medications

Based on observation, interview and document review, the facility failed to ensure food stored inside the walk-in freezer were labeled with a date and time, a label was changed to reflect the appropriate date and time, a container of expired seasoning was discarded, a condiment squeeze bottle was labeled and a dietary aide did not touch and adjust their glasses several times during tray line for the lunch meal service. The deficient practices could have led to contamination of kitchen surfaces and food borne illness. Findings include: On [DATE] in the morning, a brief kitchen tour revealed the following: -A condiment squeeze bottle containing a yellow substance stored on the counter was not labeled. The cook identified the substance as liquid butter. Walk-in Freezer #1 - Cottage Cheese 5 lb. container expired [DATE] - Raw fish stored in container with label used by date [DATE] - Gallon bag containing a corn meal type substance was not labeled. Walk-in Freezer #2 -Pan wrapped with aluminum foil contained approximately ,d+[DATE] slices of cheesecake was not labeled. Seasoning Storage Shelf - Pappy's seasoning used by date Nov. 2023 On [DATE] at 8:11 AM, a cook indicated the process for organizing the seasonings was to clean the shelf and relabel the items every week. On [DATE] in the afternoon during the tray line for the lunch meal service, a dietary aide adjusted their glasses several times. On [DATE] in the afternoon, the Nutritional Services Director explained the process of the labeling of the seasoning. The Nutritional Services Director was made aware of the Pappy's seasoning was expired. The Nutritional Services Director removed the container from the shelf and showed it to the cook. The Nutritional Services Director indicated the seasoning should have been thrown away. The Nutritional Services Director disclosed had observed the dietary aide adjusting their glasses and wiping their forehead during tray line. The Nutritional Services Director indicated the staff would be in serviced. The facility policy entitled food storage dated 2021, documented all foods should be covered, labeled, and dated. All foods will be checked to assure foods will be consumed by their safe use by dates or discarded. The facility policy entitled Hand Washing dated 2021, documented to wash hands after engaging in other activities that contaminate hands.

Based on observation, interview, record review, and document review, the facility failed to ensure a physician order for self-administration was obtained and an assessment was completed before allowing the resident to self-administer the medications. This deficient practice could potentially lead to serious medication errors, adverse drug reactions, or other health complications for the resident. Findings include: Resident 23 (R23) R23 was admitted on [DATE], with diagnoses including pleural effusion, muscle weakness and hypertension. The Brief Interview of Mental Status dated 06/29/2023, documented a score of 14/15, which means R23's cognitive status was intact. On 07/19/2023 at 9:22 AM, R23 was in the bathroom. There were three pills placed in the medication cup by R23's bedside. When R23 went back to the bed, R23 explained the medications were potassium, iron, and Lasix (diuretics). R23 indicated more medications were taken earlier and unassisted; the medications were self-administered per resident's request. R23 indicated a desire to self-administer the medications. R23's medical records lacked documented evidence a physician order and self-administration assessment were in place for all medications except for Mucinex (cough medication). On 07/19/2023 at 9:3AM, Registered Nurse 1 (R1) confirmed the medications were left at the bedside per R23's request. RN1 indicated R23 was alert and oriented. On 07/21/2023 at 12:32 PM, Registered Nurse 2 (RN2) indicated the RN who left the medications at bedside was a new RN, but might have forgotten not to leave the medications at bedside. RN2 indicated self-administration of medication required an order and assessment before allowing the resident to self-administer the medications. On 07/21/2023 at 1:34 PM, the Assistant Director of Nursing (ADON) indicated R23 was alert and oriented, but regardless, there should have been a self-administration assessment and an order to ensure the resident's safety. The ADON indicated the resident should meet the criteria, be able to distinguish between colors, various shapes, correctly tell time, read the medication labels, and be psychologically competent to handle and administer their own drug regimen. The ADON confirmed there was no order or assessment in place for R23's self-administration of all the medications except for Mucinex. A facility policy titled Administration of Medication dated 09/28/2023, documented stay with the resident until all medication had been ingested. A facility policy titled Self-Medication Administration (undated), documented the residents may self-administer medications if it was determined were capable of doing so in a safe and consistent manner. As part of the overall evaluation, staff would assess each resident's mental and physical abilities to determine whether were capable. The resident requesting to self-administer medications would be assessed as mentioned above. The Self-Administration Assessment form would be maintained in the medical record.

Based on observation, interview, record review, and document review, the facility failed to ensure the fall mats were appropriately placed as ordered for a fall risk resident who had repeated falls, for 1 of 14 sampled residents (Resident 138). This deficient practice could potentially lead to serious injuries or further complications for the fall-risk resident, including fractures, head injuries, or other physical harm. Findings include: Resident 138 (R138) R138 was admitted on [DATE], with diagnoses including Parkinson's disease, repeated falls, and rhabdomyolysis (breakdown of muscle tissue). The Brief Interview of Mental Status dated 07/10/2023, documented a score of 7/10, which means R138's cognitive status was severely impaired. A physician order dated 07/20/2023, documented fall precautions: bed in the lowest position, fall mat to be used while in bed, and frequent checks every 2-4 hours. A Care Plan dated 07/07/2023, documented R138 was at risk for falls related to impaired mobility, and an intervention included a fall mat when the resident was is bed. and to check the resident every 2 to 4 hours. The Observation Detail List Report dated 07/07/2023, documented R138 was disoriented and had a history of one to two falls for the past three months. R138 was at risk for falls due to impaired mobility. R138's gait, balance, and ambulation documented a balance problem while standing or walking and decreased muscular coordination or jerking movements. Changes in gait patterns, required the use of assistive devices and was non-ambulatory. The Physical Therapy Treatment Encounter Note dated 07/20/2023 documented R138's precautions, including fall risk and a history of Parkinson's disease. During the session, R138 required extensive assistance due to a rigid posture and difficulty in sequencing during transfers. The main barrier impacting the session was cognitive impairment due to Parkinson's disease. On 07/19/2023 at 9:36 AM, R38 lay in bed and mumbled words. The fall mat on the left side of R138 was in place, but the other fall mat was placed away from the bed, leaning on the wall in the corner adjacent to the television (TV) stand. R138's family was at the bedside and indicated R138 had Parkinson's disease, was at high risk for falling, fell at home, and was injured, which is why R138 was admitted to the hospital. The spouse indicated the fall mat was placed away upon family's arrival to R138's room. On 07/19/2023 at 4:05 PM, R138 lay in bed with eyes closed. R138 was alone in the room. R138's fall mat was placed away from the bed, leaning on the wall in the corner adjacent to the TV stand. On 07/20/2023 at 8:05 AM, R138 lay in bed, awake, and confused, and involuntary movements were noted. R138 was alone in the room. R138's fall mat was placed away from the bed, and was leaning on the side of the TV stand. On 07/20/2023 at 9:43 AM, R138 lay in bed, confused, restless, and unattended. There was one fall mat in place on R138's left side. A Certified Nursing assistant (CNA) indicated R138 was confused, and a fall mat was required because R138 was a fall risk and tried to get out of bed. The CNA and a Registered Nurse (RN) confirmed the other fall mat was not appropriately placed when R138 was in bed and unattended. Both indicated there should have been bilateral floor mats in place to decrease the impact of a fall in case the resident fell . An RN indicated the fall mat could be removed during bedside care or transfer using the wheelchair, but it should be in place when R138 was in bed and unattended. On 07/20/2023 at 9:55 AM, an RN verified R138 was a fall risk. The care plan falls interventions included the placement of the bilateral fall mats at bedside when R138 was in bed and unattended. On 07/21/2023 at 10:19 AM, the Physical Therapist (PT) indicated R138's goal was to increase functional activity tolerance, promote independence to minimize falls, and enhance safety awareness. Currently, R138 required maximum assistance with mobility and transfers. The PT indicated R138 had undergone evaluations and was receiving both Physical Therapy and Occupational Therapy services. On 07/21/2023 at 10:27 AM, the Occupational Therapist (OT) reported that R138 could not walk without assistance and experienced involuntary movement episodes due to Parkinson's disease. The PT further mentioned that R138 required substantial verbal cueing due to confusion. The OT expressed concern that R138's involuntary movements could increase the risk of falls and could also affect the proper placement of the fall mat, potentially resulting in inadequate cushioning or protection upon impact. A facility policy titled Fall Prevention revised 10/28/2022, documented to ensure optimal resident safety while promoting resident independence and maximizing psychosocial well-being. Safety interventions would be implemented and monitored with appropriate documentation as indicated. The assigned Licensed Nurse would be responsible for ensuring safety checks were completed and documented in notes for verification.

Based on observation, interview, record review, and document review, the facility failed to ensure: the indwelling (Foley) catheter order size was followed or clarified for two of 14 sampled residents (Residents 25 and 95), the urinary output was adequately monitored for a resident with a urinary indwelling catheter for one of 14 sampled residents (Resident 95); and the attending physician was notified regarding bladder scanner results above 400 milliliters for a resident with an indwelling catheter for one of 14 sampled residents (Resident 95). These deficient practices could potentially lead to complications, such as urinary tract infections, urinary retention, catheter-associated issues, urethral damage, leakage, and bladder kidney damage, and compromise the residents' overall health and well-being. Findings include: A facility policy titled Indwelling Urinary Catheter Site Care revised 12/19/2022, documented residents with indwelling urinary catheters would receive routine catheter care during daily care and as needed. Resident # 25 (R25) R25 was admitted on [DATE], with diagnoses including urinary retention and knee joint replacement. The Brief Interview of Mental Status dated 07/03/2023, documented a score of 12/15, which means R25's cognitive status was intact. A physician order dated 06/18/2023, documented an indwelling catheter size 16 French, 10 cc balloon for urinary retention. A physician order dated 07/08/2023, documented an indwelling catheter size 14 French, 5 cc balloon for urinary retention. A Care Plan dated 06/18/2023, documented impaired urinary elimination related to urinary retention with a Foley catheter. The Observation Detail List Repot dated 06/18/2023, documented R25 was incontinent with an indwelling (Foley) catheter. The Bowel and Bladder observation dated 06/18/2023, documented R25 was alert and oriented times four and had a 16 French Foley catheter in place. An evaluation of R25's Foley utilization was justified and would be assessed daily. On 07/19/2023 at 12:10 PM, R25 was in the wheelchair, and the Foley catheter was in place, anchored, and draining yellow urine. R25 indicated having urinary retention at night on 7/17/2023, and bladder pain. R25 indicated the staff reinserted the Foley catheter at almost midnight on the same day, and in the morning, the urine output was 1400 milliliters. On 07/20/2023 at 9:24 AM, R25 lay in bed. The Foley was anchored to R25's left thigh and kinked at this time. The Foley bag had 400 milliliters (ml) of yellow urine with no sediments noted. R25 indicated the bladder training had started at 7:30 AM for 3 days before removal. R25 indicated the staff attempted to discontinue before, bladder training was done, but after it was removed, R25 experienced urinary retention after 24 hours, so the Foley had been reinserted. A Certified Nursing Assistant confirmed the Foley currently in place was 14 French. On 07/20/23 at 11:30 AM, the Charge Registered Nurse (CRN) indicated the Foley catheter order should have been verified for the correct order size and match with what was inserted. If there were two orders, the physician should have been notified to clarify the Foley orders to prevent confusion and discontinue the other one. The CRN indicated the assigned nurse was responsible for ensuring the correct Foley size was carried out as ordered. On 07/20/2023 at 11:35 AM, the Director of Nursing (DON) indicated R25's Foley catheter had attempted to be removed and reinserted three times. The DON indicated there were three different orders, and one order was discontinued, but the standing order did not match what R25 had in place. The DON indicated the correct size must be verified to avoid confusion among staff and to prevent resident urethral damage if a bigger size had been used or a smaller size could result in leakage because Foley catheters had different sizes. The DON indicated the order should have been promptly clarified. 29141 Resident #95 (R95) R95 was admitted on [DATE], with diagnoses including dementia, urinary retention, anemia, urinary tract infection. A physician's order dated 07/12/2023, documented an order for indwelling catheter size of 16 French (16 French were equivalent to 5.3 millimeters of diameter) and balloon 10 cubic centimeter (CC) for urinary retention. A physician order dated 07/12/2023, documented indwelling catheter may be changed French 16, balloon 10 cc for malfunction. On 07/21/2023, a Registered Nurse (RN) confirmed R95 had an indwelling catheter size 18 French (6.0 millimeter). The RN verbalized physician orders for indwelling catheter replacement should be followed, including the size of the indwelling catheter. The vitals report revealed R95's urine output was not monitored on 07/12/2023 night shift, and on 07/13/2023 in the morning shift. The Medication Administration Record (MAR) documented the indwelling catheter was replaced because it was not in place and the bladder scan documented a urinary retention of 692 ml. The MAR did not document the size of the catheter inserted. A Physician's order dated 07/12/2023, revealed a bladder scan may be performed if there was no urine output within eight hours and/or the resident complained of bladder discomfort. The order indicated straight catheterization may be used if the bladder scan resulted in equal or more that 400 milliliters (ml) and the attending physician notified. On 07/21/2023 at 9:30 AM, the Clinical Manager explained Certified Nursing Assistances (CNAs) emptied drainage bags every shift or more often and would document amount in the medical record. The CNAs should notify the licensed nurses about abnormal findings in the urine such as hematuria (bloody urine), cloudy urine or no output. The Clinical Manager indicated if a resident with indwelling catheter did not have urine output, or had retention confirmed by scan, it was considered a change in condition, the attending physician should be notified, and pertinent documentation should have been recorded in medical record. The Clinical Manager verbalized nurses could use clinical judgment to choose the size of the indwelling catheter. The Clinical Manager acknowledged the attending physician should have been notified about the urinary retention and the change of the indwelling catheter size. 07/21/23 4:41 PM, a CNA explained urine output was measured when emptying the indwelling catheter drainage bag and documented in the medical record. The CNA indicated licensed nurses should be notified if there was no urine output. The Medical record lacked documented evidence of change in condition documentation related to urinary retention detected on 07/13/2023. There was no evidence a new physician order for an indwelling catheter size 18 French was obtained. A Care Plan dated 07/12/2023, documented impaired urinary elimination related to the presence of an indwelling catheter. The care plan lacked documented evidence of approaches to monitor urinary output for indwelling catheter malfunctioning.

Based on observation, interview, record review and document review, the facility failed to ensure an empty Oxygen (O2) humidifier bottle was changed as ordered / scheduled and appropriately documented in the Medication Administration Record (MAR) for 1 of 14 sampled residents (Resident 136). This deficient practice had the potential to lead to serious health consequences and compromising the resident's respiratory support and overall well-being. Findings include: R136 (R136) R136 was admitted on [DATE], with diagnoses including long term use of anticoagulants and multiple myeloma A Physician order dated 07/04/2023, documented to change Oxygen tubing and humidifier bottle each week on Friday AM shift. Initial and date tubing and bottle when replaced. A Care Plan dated 07/04/2023, documented R136 was at risk of ineffective breathing pattern related to episode of shortness of breath while lying. The Medication Administration Record dated 07/14/2023, documented the humidifier bottle was changed. The humidifier bottle itself was dated 07/11/2023. On 07/19/2023 at 9:49 AM, R136 was verbally responsive but exhibited confusion. O2 was being administered at 2 liters per minute (LPM) through a nasal cannula connected to the O2 source on the wall. The humidifier bottle contained approximately 125 milliliters (ml) of water, and it was dated 07/11/2023, the O2 tubing was unlabeled. On 07/20/2023 at 12:34 PM, R136 was lying in bed with eyes closed. O2 was flowing at 2LPM through nasal cannula, the humidifier bottle was dated 07/11/2023 and was almost empty. On 07/21/2023 at 08:23 AM, R136 was lying in bed with eyes closed but easily arousable. O2 was flowing at 2LPM, but the humidifier bottle was empty. The water bottle was dated 07/11/2023. The Medication Administration Record dated 07/14/2022, documented the humidifier was changed as scheduled on 07/14/2023. On 07/21/2023 at 12:20 PM, a Registered Nurse (RN) confirmed the O2 humidifier bottle was empty and dated 07/11/2023. The RN explained the humidifier bottle was supposed to be changed, but the empty bottle was already taken out, and unaware of who had changed it. The RN indicated the assigned nurse was responsible for changing the humidifier bottle. On 07/21/2023 at 12:31 PM, a Charge RN (CRN) confirmed the humidifier bottle was empty and dated 07/11/2023. The CRN replaced it with a new humidifier bottle, dating it for the current day. The CRN indicated the night nurses were responsible for ensuring the humidifier bottle was not empty and were changed as scheduled. On 07/21/2023 at 12:45 PM, the Director of Nursing (DON) indicated the O2 humidifier should have been changed weekly on Fridays, irrespective of the remaining water content in the bottle, and the used bottle should be discarded. The DON indicated the staff were expected to document accurately if the O2 humidifier was not changed, it should not be documented as being changed. The DON verbalized the potential risks of not changing the empty O2 humidifier, which could lead to skin dryness in the nose and potentially cause bleeding. A facility policy titled Oxygen Administration dated 10/28/2023, documented appropriate safety precautions were utilized to provide safe administration. Equipment was maintained per the manufacturer's recommendations. Verify the physician orders or facility protocol for Oxygen administration.

Based on record review, interview, and document review, the facility failed to ensure a pain assessment was performed and documented for the administration of pain medication prescribed as needed for 1 of 14 sampled residents (Resident #2). The deficient practice had the potential to lead to adverse physical and psychological resident outcomes affecting the recovery and interfering with the activities of daily living. Finding include: Resident #2 (R2) R2 was admitted on [DATE], with diagnoses including recurrent intermittent falls in the past 2-years, history of bilateral knee surgery, lumbar spinal stenosis, chronic back pains, and history of lumbar spine surgery. On 07/19/2023 in the morning, R2 verbalized having pain often in the knees and low back and occasionally medications were not effective. R2's medical record documented the following orders for pain management: Hydrocodone-acetaminophen 10-325 milligrams (mg) 1 tablet orally every four hours as needed for pain scale four to ten (4-10) ordered on 06/30/2023, discontinued on 07/14/2023, and re-ordered on 07/16/2023. Lidocaine adhesive patch 5 %; topical for right heel pain to be applied to the affected area in the morning and remove at night. The medication was ordered on 07/04/2023. Acetaminophen 325 mg tablet, administer 650 mg orally for pain level one to three, headache, or body temperature greater than 100.4 Fahrenheit every four hours as needed. The medication administration record (MAR) for July 2023, revealed Hydrocodone-acetaminophen was administered 46 times from 07/01/2023 through 07/21/2023. The pain level assessment was documented only four times on 07/09/2023 at 7:32 AM, 07/09/2023 at 3:08 PM, 07/10/2023 at 4:37 AM, and 07/18/2023 at 7:20 AM. On 07/20/2023 at 2:00 PM, a Registered Nurse (RN) explained pain medications ordered as needed should be administered following pain scale parameters. The RN indicated pain level assessment should have been documented in the MAR. On 07/21/2023 at 4:00 PM, the Nurse Clinical Manager (NCM) explained pain medication should be administered following the prescribed parameters to prevent the administration of unnecessary medications. The NCM acknowledged that by assessing the pain intensity nurses could determine which medication was indicated to manage the pain if the resident had two or more pain medications ordered as needed, that follow pain scale parameters for the administration. The care plan dated 06/15/2023, documented approaches for pain management including monitoring the resident for pain using the 1 to 10 pain scale and administer pain medication as ordered. The facility policy titled Pain Management indicated pain would be assessed using a standard pain scale of zero (0) to ten (10). The policy documented pain medication ordered as needed would be administered following the pain assessment including location, onset, duration, and intensity. The policy indicated pain medication administered as needed should be documented in the EMAR (electronic MAR) including the reason for the administration and the location and the intensity of the pain as per the 0-10 pain scale.

Based on interview, record review and document review, the facility failed to ensure a patient with cognitive impairment did not sign an arbitration agreement for 1 of 14 sampled residents (Resident #95). The deficient practice had the potential to deny the residents and/or surrogates their right to resolve their disputes in a court of law. Findings include: Resident #95 (R95) R95 was admitted on [DATE], with diagnoses including dementia, urinary retention, anemia, urinary tract infection. Arbitration agreement document dated 07/12/2023, revealed R95 signed the document. On 07/20/2023, R95's representative explained the resident was not capable to perform decision-making tasks due to the impaired cognition and the arbitration agreement document should have been discussed and signed by the representative. On 07/20/2023 at 4:00 PM, the Director of Nursing (DON) explained documents were given by admission staff to sign at the date of admission. The DON acknowledged R95 had impaired cognition and the arbitration agreement should have been discussed with the power of attorney (POA). Care plan dated 07/12/2023, revealed R95 was at risk for abuse, neglect, and exploitation related to dementia, episodes of confusion, and impaired physical mobility. The approaches included education to be provided to the resident and family regarding residents' rights. The facility policy titled Arbitration Agreement Translation dated 05/08/2023, documented the facility would ensure the patient and their representatives understood the arbitration agreement.

Based on interview, record review and document review, the facility failed to ensure an allegation of abuse was reported for one sampled resident (Resident #3) and one unsampled resident (Resident #7). Findings include: Resident #7 (R7) R7 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Compliment/Concern Report dated 08/09/2021, documented R7 reported a staff member aggressively removed their underwear and started to touch R7's genitals. The staff member told the resident it would make them feel better. The staff member continued to do it for several minutes. R7 conveyed being upset and the incident had made them feel insecure. The resident of concern's medical record lacked documented evidence of the reported incident. An Education Documentation dated 08/10/2021, documented a Certified Nursing Assistant (CNA) was taking too long cleaning the resident and it made the resident uncomfortable. On 07/20/2022 at 1:56 PM, the Director of Nursing (DON) defined abuse as neglect, verbal, physical, financial, and sexual. The DON explained the facility's process was to investigate an allegation of abuse within 72 hours to determine whether the allegation was considered as abuse or not. If it was not an abuse, the facility would not report it to the State agency. The DON recalled investigating the reported incident on 08/09/2021. The DON explained the CNA assigned to R7 was a new graduate and provided incontinent care as they were taught in school, gentle. The facility concluded the allegation was not an abuse and therefore it was not reported to the State agency. Resident #3 (R3) was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A Case Manager (CM) Progress Note dated 03/11/2022 revealed the CM being called to the resident's room by an occupational therapist due to the way family member was speaking to the resident. The CM documented hearing family member even prior to entering the resident's room. The CM then stood outside the resident's door and asked family member to lower their voice and calm down while speaking to the resident. The CM asked the facility administrator to speak with family member who also asked family member to calm down while speaking to the resident. On 07/20/2022 at 8:45 AM, the CM indicated they witnessed family member yelling at the resident telling the resident they needed to get up and start walking. On 07/20/2022 at approximately 1:40 PM, the CM clarified the resident's family member was both yelling and finger pointing at the resident. The CM indicated yelling was considered abuse against the resident. The yelling was heard in the hallway by other residents' family members. The CM mentioned the family member was told to leave the facility by the administrator. On 07/20/2022 at approximately 2:25 PM, the Director of Nursing (DON) indicated verbal abuse was anything that could be considered demeaning towards the resident. The DON confirmed yelling was considered a form of verbal abuse. The DON indicated if a resident was being yelled at by either family or staff, it would be considered verbal abuse. The DON confirmed the witnessed incident of family member yelling and pointing at the resident was not reported to the state agency. The facility's policy titled, Abuse Policy and Procedure (undated) version: A0717 was reviewed. The policy indicated verbal abuse was defined as any use of oral, written, or gestured language that included disparaging and derogatory terms to patients or their families, or within hearing distance, to describe patients, regardless of their age, ability to comprehend or disability. The policy noted covered individuals shall report to the state agency.

Based on interview, record review and document review, the facility failed to ensure a resident who was incontinent of bladder received appropriate services for one unsampled resident (Resident #8). Findings include: Resident #8 (R8) R8 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Admission assessment dated [DATE], documented R8 was incontinent of bowel and bladder. R8 required extensive assist with one-person physical assist with toileting. The Bowel and Bladder Observation dated 06/29/2021, documented R8 was categorized under Level III. Residents under this category would have been checked for incontinence every two hours and peri-care given after each incontinent episode. A Compliment/Concern Report (undated) documented on 07/09/2021, R8's family member had complained R8 was wearing the same incontinent briefs from the night before when they came in the facility at 8:00 AM the next day. The incontinent briefs and pads were completely soaked with urine. A statement from a Certified Nursing Assistant (CNA) dated 07/09/2021, documented the CNA last checked R8 at 3:00 AM. A Nursing Progress Note dated 07/09/2021, documented R8's family member complained R8 had been wearing the same incontinent brief from 7:00 PM the night before which meant R8 had not been changed for 13 hours. On 07/20/2022 at 1:38 PM, a Clinical Nurse Manager confirmed investigating the complaint from R8's family member on 07/09/2021. The investigation showed R8's incontinent briefs was soaked with urine. The CNA assigned to R8 the night before last checked R8 at 3:00 AM. The staff member was educated on incontinent care and ensuring to check on the residents. The Clinical Nurse Manager conveyed it was important for the staff members to ensure the residents were kept dry to prevent infection and skin breakdown. Complaint #NV 899

Based on observation, interview, and document review, the facility failed to ensure a garbage dumpster was not overfilled, uncovered, and free from spreading litter. Findings include: On 03/01/2022 at 9:00 AM, a garbage dumpster in the east end parking lot was overfilled with garbage bags and other materials. Garbage bags were observed around the dumpster. A Dietary Aide was present and confirmed the observation. On 02/18/2022 at 9:15 AM, the facility Administrator acknowledged the lid of the dumpster should have been closed to prevent insects and rodent infestation. The facility policy titled Garbage and Refuse dated 02/23/2021 documented, garbage containers should be maintained in a sanitary manner. The policy indicated the facility should have sufficient containers to hold all garbage and refuse, and the garbage storage areas should be kept clean and sanitary.

Based on observation, interview, record review and document review, the facility failed to develop and implement a comprehensive care plan for oxygen administration for 1 of 15 sampled residents (Resident #132). Findings include: Resident #132 (R132) R132 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 03/01/22 at 1:37 PM, R132 was lying in bed receiving oxygen at 2 liters per minute via nasal cannula. The cannula was connected to an oxygen outlet on the wall. The oxygen was being administered without the use of a humidifier. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated to change the oxygen tubing and the humidifier each week on Friday. Interim care plan dated 02/20/2022, indicated to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The medical record lacked documented evidence a comprehensive resident-centered care plan for oxygen administration with specific interventions was initiated and implemented. Minimum data set (MDS), five-day assessment dated [DATE], did not document R132 was receiving oxygen before the admission and in the first five days post-admission. On 03/02/22 at 1:15 PM, a Clinical Nurse Manager (CNM) confirmed that a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The CNM explained residents were placed on oxygen at admission following a standing physician order. The CNM acknowledged a comprehensive care plan for oxygen administration was not developed. The facility policy titled Comprehensive Care Plan 05/17/2021, documented the facility would develop a resident-centered care plan that should reflect the facility protocols, the manner of evaluation, and goals of care.

Based on observation, interview, record review and document review, the facility failed to follow the facility policy for a resident's intravenous access (IV) dressing for 1 of 15 sampled residents (Resident #85). Findings include: Resident #85 (R85) R85 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/01/2022 at 11:17 AM, R85 was awake and alert in bed, with a right upper arm intravenous (IV) access. The resident's IV dressing was undated, and the bottom part of the dressing was beginning to peel off. The resident explained the IV access was inserted in the hospital for antibiotic therapy related to a urinary tract infection. The resident indicated the IV dressing had not been changed since the resident's admission on 02/22/2022. The Hospital Discharge Summary dated 02/22/2022, revealed a midline (a peripherally inserted intravenous central line) was placed in R85's right upper arm due to the resident being a hard stick and the need for IV antibiotics. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/01/2022 at 3:20 PM, a Registered Nurse (RN) observed and described R85's midline dressing as undated, intact on the upper part, but lower part was starting to peel. The RN explained the resident's antibiotic therapy was resumed and completed at the facility, but the attending physician had wanted the IV line maintained in the event of need. The RN indicated the facility's policy was to change all IV dressings on Wednesday evenings and dressings should be signed and dated. On 03/01/2022 at 3:51 PM, the Clinical Nurse Manager recalled changing the resident's midline dressing on 02/23/2022 and acknowledged failing to sign and date the resident's midline dressing. The Clinical Nurse Manager explained the resident who was on pain medications, may have been confused and was not able to recall the task performed on 02/23/2022. On 03/02/2022 at 11:19 AM, another RN indicated IV dressing changes were done every Wednesday for midline and peripherally inserted central catheters (PICC) lines. The resident had completed an IV antibiotic course on 02/24/2022 but the physician ordered to maintain the line in case it was needed. The RN explained all IV accesses were to be maintained in accordance with facility policy which included site assessment, flushing, and dressing changes, until the physician ordered the line to be discontinued. On 03/03/2022 at 3:00 PM, the Director of Nursing (DON) indicated the facility utilized the Lippincott Manual as the professional standard for clinical practice. The DON indicated IV dressing changes were changed every Wednesday and more often when soiled or loose. The DON verbalized IV dressings needed to be signed and dated to communicate to other staff the task had been carried out. The DON verbalized failing to maintain IV accesses appropriately could lead to complications such as infection. The Lippincott Manual of Nursing Practice policy statement (undated), revealed licensed nurses employed by the facility will perform all areas of clinical practice in accordance with the most current edition of Lippincott Manual of Nursing Practice which was last updated on 02/23/2021. The Lippincott Manual updated on 02/23/2021, revealed catheter dressing changes must be labeled with date the dressing was changed.

Based on observation, interview, record review and document review, the facility failed to follow physician's order for Oxygen administration for 1 of 15 sampled residents (Resident #132). Findings include: Resident #132 (R132) R132 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 03/01/22 at 9:30 AM, R132 was lying in bed receiving oxygen at 2 liters per minute via nasal cannula. The cannula was connected to an oxygen outlet on the wall. The oxygen was being administered without the use of a humidifier. 03/01/22 at 1:37 PM, R132 was lying in bed receiving oxygen at 2 liters per minute via nasal cannula. The resident indicated oxygen was placed continuously since admission. A physician order dated 02/20/2022, documented oxygen per nasal cannula as needed to maintain oxygen saturation greater than 90%. The order indicated to change the oxygen tubing and the humidifier each week on Friday. The vital signs log documented R132's oxygen saturation was monitored at least three times daily. The vital signs revealed the oxygen saturation was consistently over 90 % while the resident was receiving oxygen at 2 liters per minute. The vital signs log lacked documented evidence the oxygen saturation was obtained at room air to determine the need of oxygen. A physical therapy note dated 02/24/2022, documented R132's oxygen saturation greater than 90 % on room air during therapy. A physical therapy note dated 02/25/2022, documented R132's oxygen saturation was 96 % on room air. On 03/02/22 at 1:15 PM, a Registered Nurse (RN) confirmed that a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN explained residents were placed on oxygen at admission following a standing physician order and the acknowledged oxygen was administered continuously to R132 due to periods of desaturation. The RN could not provide documented evidence of R132's oxygen desaturation. The facility policy titled Oxygen Administration dated 02/23/2021, documented the staff should review the physician's orders or protocols for oxygen administration. The policy indicated a humidifier bottle would be placed as ordered.

Based on observation, interview, record review and document review, the facility failed to ensure a staff member donned appropriate personal protective equipment (PPE) while providing care to a resident on transmission-based precautions for 1 of 15 sampled residents (Resident #85). Findings include: Resident #85 (R85) R85 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/01/2022 at 11:17 AM, a yellow signage outside R85's room documented, Quarantine Precautions: mask, eye protection, gloves and gown required when entering room. On 03/01/2022 at 11:20 AM, R85 was awake and alert in bed. The resident indicated being informed by staff was on quarantine precautions due to new admission status. The resident reported staff members were not consistent with PPE use and stated, some wear them, some don't. On 03/01/2022 at 3:00 PM, a Certified Nursing Assistant (CNA) was observed inside R85's room with no gown, gloves or eye protection while pushing a vital signs machine towards the door. The CNA who was wearing a face mask acknowledged not donning eye protection, gown and gloves when R85's vital signs were obtained. The CNA indicated the PPE caddie outside R85's room was empty and needed to be re-stocked, but the CNA had arrived late for work. The CNA read the yellow signage on R85's room door, the CNA verbalized the signage was clear on PPE requirements and there was no excuse for not wearing appropriate PPE. On 03/01/2022 at 3:15 PM, a Registered Nurse (RN) explained unvaccinated residents were placed on quarantine precautions for 14 days and staff members were required to wear a face mask, eye protection, gown and gloves when entering transmission-based precaution (TBP) rooms. The RN indicated the CNA should have replenished the PPE caddie with supplies from the stock room or retrieved PPE from other PPE caddies in the same hallway. The RN verbalized signages on the resident room doors were updated constantly and the CNAs failure to not wear required PPE inside R85's room was inexcusable. On 03/01/2022 at 3:30 PM, the Infection Preventionist (IP) explained residents who were not vaccinated against COVID-19 were placed on TBP for 14 days as a safety measure for staff, other residents, and visitors. Signages were affixed on resident room doors to communicate each resident's TBP status and PPE requirements. The IP verbalized there was no excuse for the CNAs failure to don appropriate PPE in R85's room since infection control training was constantly provided to staff and the facility had sufficient PPE supply. On 03/03/2022 at 2:45 PM, the Director of Nursing (DON) indicated the CNA who was relatively new to the facility was provided infection control training upon hire and was provided a tour of the facility which included PPE storage areas. The DON indicated the yellow signage outside R85's door should have been sufficient to instruct the CNA on PPE requirements and the CNAs failure to don proper PPE was unacceptable. The facility policy titled Droplet/Contact precaution (undated), revealed staff must don a face mask or N95 respirator, eye protection, gown, and gloves before entering the room.

Based on interview, record review and document review, the facility failed to ensure an allegation of abuse was reported to the state agency in accordance with the facility's Abuse Policy and Procedure. Findings include: Resident #1 (R1) R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. R1 was discharged from the facility on 12/17/2020. Following the discharge, family members notified the facility with concerns of employee abuse. On 02/11/2021 at 2:30 PM, the DON submitted a facility reported incident to the state agency regarding an investigation into an alleged employee to resident abuse. The incident was investigated upon receipt of information on 12/18/2020. The investigation revealed the allegation of abuse was unsubstantiated. The DON acknowledged the incident was not reported to the state agency in accordance with the facility's Abuse policy. On 02/11/2021 at 3:30 PM, the Administrator reviewed the facility's Abuse policy and confirmed the incident which was reported by the family member to the facility on [DATE], was an allegation of abuse. The administrator indicated although the information was received a day after the resident of concern was discharged , the facility should have reported the incident to the state agency and failed to do so. The facility policy titled Abuse Policy and Procedure (undated), documented allegations of abuse were to be investigated no later than five working days from the incident and reported immediately to the state agency.

Based on interview, record review and document review, the facility failed to ensure 1) physician's order was followed for a bladder scan, 2) a telephone order for indwelling catheter care and management was transcribed and carried out and 3) the facility procedure for indwelling catheter insertion was followed for one of eight sampled residents (Resident #1). Findings include: R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. 1. Bladder Scan A Physician Order dated 12/11/2020, documented to perform bladder scan if no urine output within eight hours and/or complaints of bladder discomfort. May straight catheterize if results equal or more than 400 cubic centimeters (cc). On 03/24/2021 at 3:44 PM, the Director of Nursing (DON) explained the facility had a standard order for all residents who had [MEDICAL CONDITION] (defined by the facility as no urinary output within eight hours). A bladder scan would be performed, and catheterization could be done depending on results and physician order. A Nursing Progress Note dated 12/16/2020, revealed the resident had been unable to void (urinate) all morning. On 03/25/2021 at 2:10 PM, the DON indicated the resident's last recorded urination was on 12/16/2020 at 5:44 AM. On 12/16/2020 at 2:12 PM (greater than eight hours without urinating), the DON performed an indwelling catheter insertion. The medical record lacked documented evidence a bladder scan was performed when the resident failed to urinate within eight hours or longer. On 03/25/2021 at 2:15 PM, the DON confirmed there was no documentation a bladder scan was performed on the resident, before an indwelling catheter was inserted on 12/16/2020. The DON assumed a bladder scan had been performed when the nurse requested assistance from the DON to insert the resident's indwelling catheter. The DON recalled being informed the indication was for [MEDICAL CONDITION] and expected the nurse to document the bladder scan results if the procedure was done. The facility policy titled Indwelling Catheter Insertion dated 05/01/2020, documented the need for the catheter should be assessed per facility policy. 2. Indwelling Catheter Order A nursing progress note dated 12/16/2020, revealed the resident had not voided (urinated). The DON inserted a Foley catheter to expel urine. The medical record lacked documented evidence there was a physician order for [REDACTED]. On 03/24/2021 at 3:44 PM, the DON explained when a telephone or written physician's order was received for an indwelling catheter insertion, the nurse who received the order must immediately transcribe the order into the resident's Medication Administration Record [REDACTED]. An order set for all residents who had an indwelling catheter should also be entered and must include the following: - routine catheter care every shift - empty bag every shift or when needed. - may change indwelling catheter as needed related to malfunction - change Foley monthly - ensure privacy bag On 03/34/2021 at 4:13PM, the DON confirmed there was no documented evidence of a physician order for [REDACTED]. The DON confirmed the telephone order was not, but should have been transcribed into the electronic health record to ensure licensed nurses document the catheter care which would include draining the urinary bag, recording drainage amount and description and identifying complications such as signs and symptoms of infection. The DON indicated the nurse who received the telephone order was no longer employed by the facility and could not be interviewed. 3. Indwelling Catheter Procedure and Urine Laboratory Testing The facility policy titled Indwelling Urinary Catheter Insertion dated 05/01/2020, documented the licensed nurse who performed the procedure should document the type and size of catheter and balloon, amount of fluid inserted in the balloon, how the patient tolerated the procedure and amount of urine and its characteristics. On 03/24/2021 at 3:44 PM, the DON confirmed documentation must immediately follow the procedure of an indwelling catheter insertion, but it was not done when the resident of concern's indwelling catheter was inserted on 12/16/2020. The DON performed the indwelling catheter insertion on the resident of concern on 12/16/2021 using a French (commonly used to measure the size of a catheter in diameter) 16. The resident of concern's urine was described as amber-colored, containing sediment and was malodorous. The DON explained the facility's practice was to obtain an order for [REDACTED]. The DON recalled it was a busy time for the facility and there were no excuses for the oversight. The DON verbalized a bladder scan should have been performed and documented, physician's telephone orders for urinalysis, urine culture and sensitivity and indwelling catheter insertion and care should have been transcribed and carried out and the facility's documentation requirements with regards to indwelling catheter insertion should have been followed. On 03/25/2021 in the afternoon, the attending Physician explained had given an order for [REDACTED].