Every finding on record at August Healthcare at Iliff

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide a clean and homelike environment for 2 of 36 residents in the survey sample, Residents #14,& 27. 1. For Resident #14 (R14), the facility staff failed to provide a clean and homelike environment. On the most recent minimum data set (MDS), an annual assessment with an assessment reference date (ARD) of 7/7/2026, the resident scored 6 on the brief interview for mental status (BIMS) assessment, indicating they were severely cognitively impaired for making daily decisions. On 7/28/26 at 7:27 AM during the environmental tour, an observation was made of R14's room. Upon entering the room, a strong urine odor was detected. When R14's closet door was opened the odor became significantly stronger and was concentrated within the closet. On 7/28/26 at 7:30 AM, an interview was conducted with the Director of Housekeeping who stated, housekeepers clean the residents' rooms every day and R14's clothing is laundered twice weekly. He further stated, we constantly check, we could wash her clothes today and tomorrow it would be full of clothes to wash. Additional observations were made on 7/30/2026 at 10:30 AM and 1:18 PM. The findings remained the same. On 7/30/2026 at 4:47 PM, the Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. 2. For Resident # 27 (R # 27), the facility staff failed to ensure a clean homelike environment. R # 27's most recent MDS (minimum data set) and quarterly assessment with an ARD (assessment reference date) of 05/24/2026, coded R # 27 as scoring a 14 out of 15 on the brief interview for mental status (BIMS), indicating the resident is oriented to person, place and time and has unimpaired immediate recall. On 07/29/2026 at 10:01 AM, R # 27 was interviewed regarding her stay at the facility, and she stated They have mice here. I have seen them come out of the closet at night. Observation of the closet revealed clothing hanging up, boxes on the floor, clothing items between the boxes on the floor and small black debris that appeared to be mouse droppings on the floor throughout the closet. Review of the facility's policy titled Pest Control states .Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated. All staff must report pest issues while maintaining a clean environment. The survey team requested the facility's pest control logs on 07/28/2026 and 07/29/2026 and pest control service reports were provided. Review of the facility's pest control service report dated 07/28/2026 reported finding two mice on a sticky pad trap that was placed in the employee break room, including a photograph of the findings. On 07/30/2026 at 4:45 PM, the [NAME] President of Nursing, [NAME] President of Operations, Director of Nursing, and Administrator were made aware of the above concerns. No additional information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to treat a pressure sore for one Resident (Resident #2) of the four (4) residents in the survey sample. The findings included;For Resident #2, the staff failed to provide a baseline treatment for what would reveal itself to be an unstageable sacral pressure sore from 12-30-24 through 1-3-25 (5 days). Resident #2 was originally admitted on [DATE]. The Resident was discharged to the hospital on 1-14-25 and did not return. Diagnoses for Resident #2 included but were not limited to; Post infectious acute Viral encephalitis and encephalomyelitis, acute cerebral edema, intracranial space occupying lesion, persistent vegetative state, ventilator dependence, and an unstageable coccyx (later called sacrum by staff) pressure sore. Resident #2's admission Minimum Data Set (an assessment protocol) documented the Resident as completely dependent on 1-2 staff members for all Activities of Daily Living care. The Resident was incontinent of bowel and bladder and was vegetative, with no response to verbal or physical stimuli. A review of Resident #2's clinical record was conducted during the survey. The review revealed no physician treatment orders for the pressure area from admission on [DATE] until 1-3-25. The 3 new orders were instituted on 1-4-25 by staff. They were for the following;Juven dietary supplement for wound healing 2 times per day.Weekly skin checks.Cleanse open area on the sacrum with wound cleanser, pat and dry, and apply hydrofera and cover with dry dressing.On 1-14-25 the dressing order was changed to Cleanse open area on the sacrum with wound cleanser, pat and dry, and apply Medi-honey and cover with dry dressing. The treatment was applied only on that day as the Resident was discharged to the hospital on that same day.On 12-30-24 the first Admitting daily skin assessment documented existing pressure ulcer, sacrum only. A note was included which documented During physician assessment, the referred healed stage 2 on the sacrum per doctor is actually a mild skin maceration, and a birth mark is noted on his left side. The macerated area measured 5 cm long [centimeters] by 6 CM wide with no depth. On 1-1-25 the second Admitting daily skin assessment documented Skin maceration coccyx area measured 5 cm long [centimeters] by 6 CM wide with no depth. On 1-2-25 the third Admitting daily skin assessment documented admitted with Skin maceration sacrum with no measurement given. On 1-9-25 a Weekly Skin Review was documented by staff. The document review revealed open area on sacrum, hydrofera in progress, no discomfort noted, Resident seen by doctor [name] on 1-8-25 during rounds The document went on to describe low air loss mattress, pressure ulcer unstageable, unchanged, moderate necrosis and slough tissue present, 5 cm long by 8 cm wide, no tunneling, no sign of infection, no change in treatment.On 4-6-26 a staff interview was conducted with the Pediatric Director RN B [Registered Nurse B]. RN B stated that she did remember the Resident as he was such a sad case. She went on to say when Resident#2 was admitted , the physician thought the pressure sore was acquired while hospitalized and was just beginning to break down and open on admission to the nursing facility. That's why the maceration was only in one spot and not covering the entire buttocks and genitalia of Resident #2.On 4-6-26 the Director of Nursing [DON] was interviewed and remembered the Resident. He stated that everyone knew that the wound was a DTI [deep tissue injury] and that it happened in the hospital. He was then asked if that was known, why did staff not obtain treatment orders or institute a care plan for the Resident upon admission. His response was I don't know.The care plan was reviewed and revealed that on 1-3-25, after orders for treatment were obtained from the physician, a baseline care plan with interventions was derived 5 days after admission.Treatment and Medication Administration records (TAR's/MAR's) as well as physician orders were reviewed and revealed that no treatment orders for the pressure ulcer were obtained from 12-30-24 until 1-3-25 and were not begun until 1-4-25.Facility policies were reviewed and it was revealed that weekly skin assessments were to be performed, and treatments obtained as needed. Wound evaluation documents were available in the clinical record, however, no treatments were ordered and implemented for 5 days for a known admitted pressure ulcer. The facility Administrator, and DON (Director of Nursing) were informed of the findings during an end-of-day de-briefing on 4-7-26, at approximately 4:30 p.m. The facility stated they had no further information to present at the time of exit.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop a baseline care plan within 48 hours of admission to address skin impairment for one resident (Resident #2) in a survey sample of four residents. The findings included;For Resident #2, the staff failed to develop a baseline care plan within 48 hours of admission to identify and address a skin impairment that was present upon admission. Resident #2 was originally admitted on [DATE]. Diagnoses for Resident #2 included but were not limited to; Post infectious Viral encephalitis and encephalomyelitis, acute cerebral edema, intracranial space occupying lesion, persistent vegetative state, ventilator dependence, and an unstageable coccyx (later called sacrum by staff) pressure sore. Resident #2's admission Minimum Data Set (an assessment protocol) documented the Resident as completely dependent on 1-2 staff members for all Activities of Daily Living care. The Resident was incontinent of bowel and bladder and was vegetative, with no response to verbal or physical stimuli. A review of Resident #2's closed clinical record was conducted during the survey. Resident #2 discharged to the hospital on 1-24-26 and did not return to the facility. On 12-30-24 the first Admitting daily skin assessment documented existing pressure ulcer, sacrum only. A note was included which documented During physician assessment, the referred healed stage 2 on the sacrum per doctor is actually a mild skin maceration, and a birth mark is noted on his left side. The macerated area measured 5 cm long [centimeters] by 6 CM wide with no depth. On 1-1-25 the second Admitting daily skin assessment documented Skin maceration coccyx area measured 5 cm long [centimeters] by 6 CM wide with no depth. On 1-2-25 the third Admitting daily skin assessment documented admitted with Skin maceration sacrum with no measurement given. The review revealed no physician treatment orders for the pressure area from admission on [DATE] until 1-3-25. On 1-14-25 the dressing order was changed to Cleanse open area on the sacrum with wound cleanser, pat and dry, and apply Medi-honey and cover with dry dressing. The treatment was applied only on that day as the Resident was discharged to the hospital on that same day.On 1-9-25 a Weekly Skin Review was documented by staff. The document review revealed open area on sacrum, hydrofera in progress, no discomfort noted, Resident seen by doctor [name] on 1-8-25 during rounds The document went on to describe low air loss mattress, pressure ulcer unstageable, unchanged, moderate necrosis and slough tissue present, 5 cm long by 8 cm wide, no tunneling, no sign of infection, no change in treatment.On 4-6-26 a staff interview was conducted with the Pediatric Director RN B [Registered Nurse B]. RN B stated that she did remember the Resident as he was such a sad case. She went on to say when Resident#2 was admitted , the physician thought the pressure sore was acquired while hospitalized and was just beginning to break down and open on admission to the nursing facility. That's why the maceration was only in one spot and not covering the entire buttocks and genitalia of Resident #2.On 4-6-26 the Director of Nursing [DON] was interviewed and remembered the Resident. He stated that everyone knew that the wound was a DTI [deep tissue injury] and that it happened in the hospital. He was then asked if that was known, why did staff not obtain treatment orders or institute a care plan for the Resident upon admission. His response was I don't know.The comprehensive care plan was reviewed and revealed that on 1-3-25, after orders for treatment were obtained from the physician 5 days after admission.The facility Administrator, and DON (Director of Nursing) were informed of the findings during an end-of-day de-briefing on 4-7-26, at approximately 4:30 p.m. The facility stated they had no further information to present at the time of exit.

Based on staff interviews, clinical record reviews and facility documentation review, the facility staff failed to ensure the professional standards of quality regarding medication administration for one resident (Resident # 2) in survey sample of 6 residents.Findings included:Resident # 2 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's Disease, Atrial Fibrillation/Flutter, Chronic Heart Failure, Type 2 Diabetes and Hypertension. Resident # 2 was discharged from the facility on 4/20/2025.The most recent Minimum Data Set (MDS) Assessment was an admission assessment with an Assessment Reference Date (ARD) of 3/21/2025. The MDS coded Resident # 2 with a BIMS (Brief Interview for Mental Status) Score of 13 out of 15 indicating no cognitive impairment. The assessment also coded Resident # 2 as requiring assistance of one to two staff persons with ADLs (activities of daily living.)Review of the closed electronic clinical record was conducted on 2/3/2026 - 2/5/2026. Review of the March 2025 and April 2025 Medication Administration Records revealed documentation that medications were not administered as ordered by the physician.On 2/4/2026 at 12:50 p.m., nurses were observed passing medications. Interviews were conducted with Licensed Practical Nurse # 2 and Licensed Practical Nurse # 4 who both stated it was important for nurses to administer medications and follow physicians orders. Rivastigmine Patch 24 Hour 9.5 MG/24HR Apply 1 patch transdermally at bedtime for dementia and remove per schedule not being removed as ordered. The documentation on the Medication Administration Records revealed orders start date 3/15/2025 and D/C (discontinue) date 3/27/2025 -to remove the patch at 7:59 p.m. and apply the patch at 8:00 p.m. Further review of the March MAR revealed a slot for removing the patch at 1318 (1:18 p.m.), Remove 1959 (7:59 p.m.) and Apply 2000 (8:00 p.m.). The instructions for removal of the patch were not clear. There were two removal times listed. On the April 2025 MAR, the times of removal of the patch were 1433 (2:33 p.m.) and Remove 1959 (7:59 p.m.) and Apply 2000 (8:00 p.m.) There was no documentation of the sites were the patches were applied. On 2/5/2026 at 9:40 a.m., the Director of Nursing stated it was important to document the sites so the staff would know where the patches had been applied. The Director of Nursing stated the professional guidance was provided by [NAME].According to Lippincott Nursing Procedures, Eighth Edition, Chapter 2, Standards of Care, Ethical and Legal Issues, on page 17 read, Common Departures from the Standards of Nursing Care. Claims most frequently made against professional nurses include failure to make appropriate assessments, follow physician orders, follow appropriate nursing measures, communicate information about the patient, follow facility policy and procedures, document appropriate information in the medical record . Guidance from the National Institutes of Health in the article The nurses medication day stated that Nurses serve as a barrier, protecting residents from potential hazards. Calls were also common to request 'missing meds' (medications) followed by waits until they were delivered. Waiting reflected system failures ncbi.nlm.nih.gov accessed 2/6/2026.According to healthline.com, transdermal patches must be used properly to work well. It is important to rotate the sites (locations) where patches are applied. This is important because placing a patch in the same location as the old one may irritate the skin. healthliine.com-accessed online 2/9/2026 During the end of day debriefing on 2/5/2026 the Administrator, [NAME] President of Operations and Director of Nursing were informed of the findings. No further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure medications were available for administration for 1 Resident (Residents # 2 ) in a survey of 6 residents. Findings included:Resident # 2 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's Disease, Atrial Fibrillation/Flutter, Chronic Heart Failure, Type 2 Diabetes and Hypertension. Resident # 2 was discharged from the facility on 4/20/2025.The most recent Minimum Data Set (MDS) Assessment was an admission assessment with an Assessment Reference Date (ARD) of 3/21/2025. The MDS coded Resident # 2 with a BIMS (Brief Interview for Mental Status) Score of 13 out of 15 indicating no cognitive impairment. The assessment also coded Resident # 2 as requiring assistance of one to two staff persons with ADLs (activities of daily living.)Review of the closed electronic clinical record was conducted on 2/3/2026 - 2/5/2026.Review of the Nurses Notes revealed documentation of several medications not being available for administration on 3/15/2025, 3/16/2025 and 3/17/2025. Medications listed as not available on 3/15/2025 and 3/16/2025 were still listed as not being available on 3/17/2025. Examples of those medications included but were not limited to:Rivastigmine Patch 24 Hour 9.5 MG/24HR Apply 1 patch transdermally at bedtime for dementia and remove per schedule was documented as unavailable on 3/15/2025 at 8 p.m., 3/16/2025 at 8 p.m. and 3/17/2025 at 8 p.m.Amantadine HCl ER Oral Capsule Extended Release 24 Hour 137 MG Give 2 capsule by mouth at bedtime for Parkinsons waiting for pharmacy to deliver 3/16/2025 at 9 p.m. and 3/17/2025 at 9 p.m.3/15/2025 23:21 DDAVP Rhinal Tube Nasal Solution 1 spray in both nostrils at bedtime for for frequent urination give nightly not available3/15/2025 23:09 Clobetasol Propionate External Foam 0.05 % Apply to irritated area of scalp topically at bedtime for itchy scalp not available3/15/2025 23:22 Amiodarone HCl Tablet 200 MG Give 2 tablet by mouth two times a day for abnormal heart rhythm After four days, then only 1 table daily not available3/16/2025 09:17 Amiodarone HCl Tablet 200 MG Give 2 tablet by mouth two times a day for abnormal heart rhythm for 4 Days After four days, then only 1 table daily Awaiting delivery. 3/16/2025 22:21 Amiodarone HCl Tablet 200 MG Give 2 tablet by mouth two times a day for abnormal heart rhythm for 4 Days After four days, then only 1 table daily Awaiting pharmacy delivery. 3/16/2025 21:20 Amantadine HCl ER Oral Capsule Extended Release 24 Hour 137 MG Give 2 capsule by mouth at bedtime for Parkinsons Awaiting pharmacy delivery. 3/16/2025 20:20 Rivastigmine Patch 24 Hour 9.5 MG/24HR Apply 1 patch transdermally at bedtime for dementia and remove per schedule Awaiting pharmacy delivery. 3/16/2025 20:19 Clobetasol Propionate External Foam 0.05 % Apply to irritated area of scalp topically at bedtime for itchy scalp Awaiting pharmacy delivery.3/16/2025 20:19 DDAVP Rhinal Tube Nasal Solution 1 spray in both nostrils at bedtime for for frequent urination give nightly Awaiting pharmacy delivery. 3/16/2025 19:17 Rivastigmine Patch 24 Hour 9.5 MG/24HR Apply 1 patch transdermally at bedtime for dementia and remove per schedule Awaiting pharmacy delivery. 3/17/2025 07:53 Ergocalciferol Capsule 50000 UNIT Give 1 capsule by mouth one time a day every Mon for vitamin supplement Take with a meal Awaiting pharmacy delivery3/17/2025 22:01 Rytary Oral Capsule Extended Release 61.25-245 MG Give 1 capsule by mouth five times a day for Parkinsons Place capsule on back of his tongue. Monitor swallowing closely. May pocket medication. waiting for pharmacy to deliver3/17/2025 21:48 Amantadine HCl ER Oral Capsule Extended Release 24 Hour 137 MG Give 2 capsule by mouth at bedtime for Parkinsons waiting for pharmacy to deliver3/17/2025 21:42 Clobetasol Propionate External Foam 0.05 % Apply to irritated area of scalp topically at bedtime for itchy scalp waiting for pharmacy to deliver3/17/2025 21:41 Rivastigmine Patch 24 Hour 9.5 MG/24HR Apply 1 patch transdermally at bedtime for dementia and remove per schedule not applicableOn 2/4/2026 at 11:10 a.m., an interview was conducted with Licensed Practical Nurse # 3 who stated medications should be available for administration. He also stated nurses should try to obtain the medications by the next day after admission.The Director of Nursing stated that the expectation was that medications would be available for administration as ordered by the physician. He stated that the Pharmacy had two scheduled deliveries daily. He further stated that medications for new admissions would not be available on the day of admission but should be available for administration by the next day. The Director of Nursing provided a Pharmacy delivery manifest which stated the medication Rivastigmine Patch 24 Hour 9.5 MG/24HR was delivered to the facility on 3/17/2025 at 4:51 p.m. The medication Administration Record and Nurses Progress Notes stated the medication was not available. The Director of Nursing stated the nurse documented incorrectly on that date because the medication had been delivered to the facility and was available. Review of the Pixus contents revealed none of the medications were available in the inventory.Review of Physicians Orders revealed valid orders for the medications not available for administration.During the end of day debriefing on 2/6/2026, the Administrator, [NAME] President of Operations and Director of Nursing were informed of the findings. They stated medications should be available for administration.No further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain a clean and safe environment for all of the Resident room floors and common hallway located on the entrance hall of the facility. The findings included: On 8-15-23 at 11:00 a.m., Initial tour of the facility was conducted. Beginning at room [ROOM NUMBER], surveyors found crusted food debris, what appeared to be cracker or cookie crumbs, a pink gelatinous substance, tan droplets, and wet patches lining the entire hallway of Resident's rooms with no wet floor signs deployed. The hallway floor was sticky under foot, and in the individual resident rooms the floors were slick and slippery with a greasy substance which caused the surveyor to slip twice. House keeping carts were noted in the hallway with staff attending them, however, staff were in conversation with each other at the carts, and not engaged in employing the equipment for the purpose of cleaning. Bathrooms were observed to be dirty. Toilets were not flushed after use, and urine and toilet paper were observed in them. The hallway had an odor of urine. An interview was conducted with a staff member rendering care in room [ROOM NUMBER] (CNA A) Certified Nursing Assistant Restorative Aide. She stated that the halls get that way, and toilets need be clean. She stated I don't know when asked what was slippery on the room floors, and was observed to slip herself when exiting room [ROOM NUMBER]. On 8-15-23 at 12:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that the hallway would be cleaned immediately, and his expectation was that staff should clean the bathrooms if they were dirty. On 8-15-23 at 3:00 p.m., the DON and Regional [NAME] President of Operations were notified at the end of day debriefing of the concerns regarding the unsafe and unclean front hall. They stated that cleaning was completed on the front hall at that time and they had no further information to provide.

Based on observation, resident and staff interview, facility documentation review, clinical record review, the facility staff failed to provide fresh drinking water for two residents (Resident #3, and #4) in a survey sample of 4 residents. For Resident #3, and #4, there was no fresh drinking water in the room from 11:00 a.m., until 3:00 p.m. The findings included: On 8-15-23 during initial tour of the facility, the Resident #3's room was observed, and an attempt to interview the Resident was conducted. The Resident had garbled speech but did shake his head to signify yes and no to questioning. The Resident was not able to ask for water. There was no fresh drinking water in the room for the Resident, and when asked if he was thirsty he signified yes by nodding his head. The room and Resident were observed again at 12:00 p.m., 1:00 p.m., 2:00 p.m., and 3:00 p.m., no fresh drinking water was in the room at any of those times. The Resident's clinical record was reviewed and indicated a swallowing evaluation was conducted by Speech Therapy on 7-25-23, and denoted that the Resident would be ordered a regular diet with mechanical soft items, and that he was able to tolerate thin liquids. The Resident's admission Minimum Data Set (MDS) assessment documented that the Resident required extensive assistance with eating, but did take part in the process. The Resident's care plan denoted that he was at risk for dehydration, and required feeding assistance, however offered no interventions for the dehydration risk other than Diet as ordered. 2. On 8-15-23 during initial tour of the facility, the Resident #4's room was observed, and an attempt to interview the Resident was conducted. The Resident had clear speech and answered yes to questioning. There was no fresh drinking water in the room for the Resident, and the Resident was sitting in her wheel chair eating veggie straws snacks from a snack size bag. She was asked if she was thirsty and replied yes. CNA A (Certified Nursing Assistant) was in the room and introduced herself as an Restorative Aide. The surveyor asked her why there was no water in Resident #3, and Resident #4's room at that time and she responded, They can ask if they want. CNA A then went out into the hallway to the ice cooler on a rolling cart and returned with a 120 milliliter clear plastic cup approximately half full with water in it. The Resident took the water and drank it all. CNA A left the room and did not return. The Resident's clinical record was reviewed and indicated a diet order entered 8-7-23 and denoted that the Resident would be ordered a regular diet with mechanical soft items, and that she was able to tolerate thin liquids. The Resident's most recent Minimum Data Set (MDS) assessment documented that the Resident could feed herself, and that was observed on initial tour. The Resident's care plan denoted that she was at risk for dehydration, constipation, urinary tract infections, encourage adequate fluid intake under the urinary tract infection care plan, and to ask yes no questions due to dementia. The Resident would have to be cued to do things as she would not ask for things. The Resident would not ask for water. The care plan offered no other interventions for fluids in the dehydration risk care plan other than Diet as ordered. The room and Resident were observed again at 12:00 p.m., 1:00 p.m., 2:00 p.m., and 3:00 p.m., no fresh drinking water was in the room at any of those times. On 8-15-23 at the end of day debrief, the [NAME] president of Operations, and the Director of Nursing (DON) were notified of the above findings. The DON stated his expectations were that, Water pitchers are to be filled every shift. No further information was provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure that a Resident who received a indwelling (Foley) catheter after admission, was assessed for removal of the catheter as soon as possible for 1 Resident (#'s 21) in a survey sample of 35 Residents. This is harm. The findings included: 1. For Resident #21, the facility staff failed reassess the need of an indwelling (Foley) catheter after Resident #21 had one episode of urinary retention. The resident experienced Urinary Tract Infections (UTIs) that required antibiotics. This is harm. On 3/21/23 at 9:25 AM Resident #21 was observed in her bed with eyes closed resting, the Resident had a Foley with a dignity bag cover in place. On 3/22/23 a review of the clinical record revealed the following: 12/28/2022 -4:46 PM-Nursing Progress Note Text: Charge nurse observed patient not voiding throughout this shift. Assessment done. Denied pain, abdomen soft, non-distended. I/O done, collected 550 cc clear urine. MD notified. Gave an order to insert 16F Foley catheter. RP [name redacted] called no answer, message left with a call back number. Pt now lying comfortable in bed, call light within reach. Will continue to monitor. 12/29/22 - 9:00 AM - MD/NP/PA -Progress Note - #Urinary retention: 12/28 resident with urinary retention and Foley inserted. She denies any urinary burning, difficulty urinating, bladder pressure, fever. Stated never had a UTI [Urinary Tract Infection] in the past. Foley draining clear yellow urine. - send urine for U/A & C&S [Urinalysis and Culture and Sensitivity], verbal orders given to nurse. -voiding trial next week. Review of the clinical records showed the voiding trial was not done. Review of the clinical records revealed that Resident #21 developed urinary tract infections after receiving a Foley catheter at the facility. Excerpts from physician notes are as follows: 1/5/23 10:25 AM - MD/NP/PA progress note -#UTI- pending culture, UA positive. will start Macrobid while awaiting culture results. order staff to exchange for new foley cath. Will cont. to monitor. 1/9/23 11:20 AM - MD/NP/PA -Progress Note - #UTI- will cont. Macrobid Will cont. to monitor. no changes to current poc. [plan of care] 1/11/23 10:32 AM - MD/NP/PA -Progress Note - #Urinary retention: 12/28 resident with urinary retention and Foley inserted. No dysuria [painful or difficult urination]. Getting treated for UTI #UTI: Cuter grew >100,000 E-coli. Getting treated with antibiotics till 1/12. Tolerating Macrobid well. C/W current dose. 1/18/23 8:29 AM - MD/NP/PA -Progress Note #UTI- resolved. Will cont. to monitor. 1/25/23 8:56 AM - MD/NP/PA -Progress Note - #WBC elevated- asked for labs and urine to be checked on Monday-pending. 2/6/23 9:58 AM - MD/NP/PA -Progress Note - #UTI- Macrobid was started. cont. as prescribed will trend labs. Patient seen and examined. On 3/9/23 at 10:45 AM, a physician note read that Resident #21 was to have a second voiding trial. It read in part, Foley catheter with mild hematuria [blood in urine]. - Do voiding trial and insert new foley if no output in 8 hrs. However, the second voiding trial ordered on 3/9/23 was never carried out. On 3/22/23 at 12:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) C who was asked what the process is for a verbal or telephone order for a voiding trial, LPN C stated that the nurse taking the order would put the order into the system and notify the family. When asked how a voiding trial is done, she stated that on the day of the voiding trial the Foley would be removed and then the nurses would wait 4-6 hours and see if the resident urinates or has a wet brief. If the Resident does not urinate on their own the MD would be notified for further orders. LPN C was asked the purpose of a voiding trial, LPN C stated the purpose of a voiding trial is to see if the Resident can empty their bladder naturally on their own. When asked what the risk is for having an indwelling Foley catheter LPN C stated that there is a risk of bacteria entering the urinary tract and causing and infection. On 3/23/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, staff interview, and record review, the facility failed to ensure tube feeding bags were properly labeled for two of five residents (Resident (R)161 and R15) sampled for tube feeding. Findings include: 1. Review of R161's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R161 was admitted with diagnoses that included tracheostomy and gastrostomy care. Review of R161's Order Summary, located under the Orders tab of the EMR, revealed a physician's order for a tube feeding. During an observation on 03/21/23 at 12:09 PM, the label on the tube feeding bag for R161 was reviewed. The label did not indicate the time the bag was hung, the rate of flow, or the initials of the person who hung the tube feeding bag. Only the first name of the resident and the date were indicated. During an observation on 03/22/23 at 2:37 PM, the label on the tube feeding bag for R161 still lacked the time, rate of flow, and initials of the person who hung the tube feeding. During an interview on 03/22/23 at 3:00 PM, Licensed Practical Nurse (LPN D) stated that tube feeding bag labels were pre-printed from the computer daily with the requisite information. LPN D reviewed the label for R161 and confirmed the label only indicated the resident's first name and the date. LPN D stated the bag of tube feeding was hung by a night shift employee and confirmed that the label lacked the time, rate of flow, amount, and initials of the person who hung the bag. LPN D stated she could not tell who hung the bag or when it was hung based on the information documented on the label. Review of the facility's undated policy titled Enteral Nutrition Policy revealed, . The feeding bag should be dated and initialed by the nursing hanging the feeding . 2. Review of R15's Admission Record, located under the Profile tab of the EMR, revealed R15 was admitted to the facility with diagnoses that included quadriplegia, spastic quadriplegic cerebral palsy, dysphagia, and gastrostomy care. Observation on 03/22/23 at 1:42 PM revealed LPN C initiating a tube feeding for R15. The bag of tube feeding was labeled with R15's last name, current date, time, rate of infusion, and type of tube feeding. LPN C's initials were not documented on the label. LPN C initiated the tube feeding and was asked to review the label on the tube feeding bag. LPN C confirmed he had not added his initials to the tube feeding label. During an interview with the Director of Nursing (DON) on 03/22/2023 at 2:38 PM, the DON stated it was his expectation that tube feeding bags should be labeled with the name, date, time, and initials of the nurse initiating the feeding. Review of the facility's undated policy titled Enteral Nutrition Policy revealed, . The feeding bag should be dated and initialed by the nursing hanging the feeding .

Based on interview, clinical record review and facility documentation the facility staff failed to ensure that as needed (PRN) orders for psychotropic drugs are limited to 14 days for 1 Resident (#'s 13) in a survey sample of 35 Residents. The findings included: 1. For Resident #13 the facility staff failed to ensure that proper evaluation and documentation by physician was obtained for a PRN Ativan order that lasted 6 weeks (4/25/22-6/4/22). On 3/22/23, during clinical record review, it was discovered that Resident #13 had orders for a routine dose of Ativan 0.5 mg twice a day and a PRN order that read: Ativan Tablet 0.5 MG (Lorazepam) - Give 1 tablet by mouth every 4 hours as needed for Anxiety -Start Date 04/25/2022 5:00 PM D/C Date 06/06/2022 9:37 AM A review of the pharmacy recommendations revealed that on 5/20/22 the pharmacy sent a form to the physician that read: Dr [name redacted] -Recommend discontinuing PRN use of Ativan for this resident [#13 name redacted] or REORDER for a specific number of days, per the federal guideline: S483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in S483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. NOTE: HOSPICE RESIDENTS ARE NOT EXCLUDED PER REGULATION A review of the clinical record revealed that the physician did not address this notice from the pharmacy until 6/6/22, when he wrote HOSPICE continue for 14 days on the form and sent to the pharmacy. On 3/22/23 at approximately 3:00 PM, an interview was conducted with the Director of Nursing (DON) who was asked about the administration of PRN anti-anxiety drugs. The DON stated that he knew they should be limited to 14 days unless otherwise documented in the chart. By the end of survey date, the DON was unable to locate appropriate documentation to support the physician ordering PRN Ativan for a period of more than 14 days. On 3/23/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, and record review, the facility failed to maintain residents' dignity when they failed to ensure one (Resident (R) 14) of 35 sampled residents did not have a thick growth of chin hair and one (R160) of 35 sampled residents' urinary bag was covered. Findings include: 1. An observation on 03/21/23 at 1:00 PM, revealed R14 had a thick growth of hair on her chin. Another observation on 03/22/23 at 1:05 PM, revealed R14 still had a thick growth of facial hair. Review of R14's Admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R14 was admitted with diagnoses that included but not limited to: dementia, hemiplegia, and hemiparesis affecting the right side. Review of R14's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/23, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating R14 had severely impaired cognition. The MDS recorded R14 required extensive assistance with dressing and toileting. During an interview on 03/22/23 at 1:07 PM, Certified Nursing Assistant (CNA) C stated R14 was shaved once a week and whenever staff noticed the facial hair was growing. CNA C stated, We don't usually wait until it (facial hair) is thick before we shave it. CNA C stated R14 was shaved on Wednesdays and Saturdays when she received her showers. CNA C was shown the growth on R14's face and confirmed R14 had not been shaved in more than a week. Review of the facility's policy titled, Your Rights and Protections As a Nursing Home Resident, dated 01/30/22, revealed, . As a nursing home resident . You have the right to be treated with dignity and respect . 2. An observation on 03/21/23 at 09:48 AM, revealed R160 had an uncovered urinary catheter bag hanging on the left side of the bag that was visible from the hallway. Observations on 03/21/23 at 4:11 PM, and 03/22/23 at 11:17 AM revealed R160's urinary catheter bag was not covered. Review of R160's Physician Orders, located under the Orders tab of the EMR, revealed an order, dated 03/07/23, for a urinary catheter. During an interview on 03/22/23 at 2:04 PM, CNA C stated she had observed earlier that R160 needed a dignity cover on the urinary catheter bag, but she was not able to find one in the supply room. CNA C stated she was unaware of how long R160's urinary catheter bag was uncovered and that it had skipped her mind to cover it during her shift. CNA C stated she was unaware of who or when the urinary catheter bag was covered. CNA C stated she had received training on the subject and was aware urinary catheter bags needed to be covered. During an interview on 03/22/2023 at 1:46 PM, the Director of Nursing (DON) stated it was his expectation that a dignity cover be placed on every urinary catheter bag to preserve the resident's dignity.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 1 Resident (#32) in a survey sample of 35 Residents. The findings included: For Resident #32, the facility staff failed accommodate 1) an electrical outlet or a power strip available on the right side and 2) family pictures where the Resident could view them. On 3/21/23 at approximately 10:00 AM, Resident #32 was observed sitting upright in her bed watching TV. Resident #32 stated that due to physical limitations of her condition she needed to have the electrical outlet or a power strip available on the right side so that she could charge her phone. Resident #32 also stated that the facility put her family pictures up where there were already hooks in the wall; however it was not located where she could view them. When asked if she had asked the facility for assistance with these issues, she stated that she had told them a few weeks ago but had heard nothing about it. On the morning of 3/22/23 an interview was conducted with Employee D who stated that he was aware of the issue with the outlet and her needing it on the right side due to her physical condition. Employee D stated that he was trying to get approval for a power strip or an additional outlet to be installed. On 3/23/23 Resident #32 stated that she was being moved to the other side of the room because the outlet would be on the right side so she would be able to access it. On 3/23/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation interview, clinical record review and facility documentation the facility staff failed to provided services that meet professional standards care for 1 Resident (#21) in a survey sample of 35 Residents. The findings included: For Resident #21 the facility staff failed to follow physician orders after a Foley catheter was ordered for 1 week and a voiding trial was to be started the following week. On 3/21/23 at 9:25 AM Resident #21 was observed in her bed with eyes closed resting, the Resident had a Foley catheter with a dignity bag cover in place. On 3/22/23, a review of the clinical record revealed the following: 12/29/22 - 9:00 AM - MD/NP/PA -Progress Note - #Urinary retention: 12/28 resident with urinary retention and Foley inserted. She denies any urinary burning, difficulty urinating, bladder pressure, fever. Stated never had a UTI in the past. Foley draining clear yellow urine. - send urine for U/A & C&S, verbal orders given to nurse. -voiding trial next week. 3/9/23 10:45 AM - MD/NP/PA -Progress Note - # Urinary retention: Foley catheter with mild hematuria. - Do voiding trial and insert new foley if no output in 8 hrs. A review of the clinical record revealed that no voiding trial was started for the order on 12/29/22 or 3/9/23 and the Resident continued to have the Foley catheter. On 3/22/23 at 12:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) C who was asked what the process is for a verbal or telephone order for a voiding trial, LPN C stated that the nurse taking the order would put the order into the system and notify the family. When asked how a voiding trial is done, she stated that on the day of the voiding trial the Foley would be removed and then the nurses would wait 4-6 hours and see if the resident urinates or has a wet brief. If the Resident does not urinate on their own the MD would be notified for further orders. LPN C was asked the purpose of a voiding trial, LPN C stated the purpose of a voiding trial is to see if the Resident can empty their bladder naturally on their own. When asked what the risk is for having an indwelling Foley catheter LPN C stated that there is a risk of bacteria entering the urinary tract and causing and infection. On 3/22/23 at 11:45 AM an interview was conducted with the Director of Nursing (DON.) The DON was asked how physician orders get put into the system. The DON stated that then nurses enter the orders into the system the physicians do not enter them directly. When asked about the expectations of nurses following physician orders, he stated that it is the expectation of the nurse to enter orders correctly into the system and to follow the physician orders. When asked what the protocol is when an order is missed, he stated that the physician and Resident Representative be notified. When asked to provide voiding trial documentation for the voiding trial ordered on 12/29/22 and 3/9/23 he was unable to provide it by end of survey. According to Lippincott Manual of Nursing Practice, Eleventh Edition, 2019, page 15, Standards of Practice, Box 2-1 entitled, Common Legal Claims for Departure from Standards of Care, read in part, Failure to perform a nursing treatment or procedure properly and Failure to implement a physician's, advanced practice nurse's, or physician assistant's order properly or in a timely fashion. On 3/23/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure that the Residents have an environment free from accident hazards to prevent avoidable accidents for 1 Resident (#20) in a survey sample of 35 Residents. The findings included: For Resident #20 the facility staff failed to identify potential hazard and implement interventions to reduce hazard and monitoring for proper functioning and effectiveness the wander guard bracelet. On 3/21/23 Resident #20 was observed sitting in his wheelchair in his room reading his bible. Attempts to converse with the Resident were unsuccessful in as resident does not speak English and has a diagnosis of dementia. A review of the clinical record revealed an order for checking the placement and function of wander guard every night. Excerpts from the care plan are as follows: INTERVENTIONS Check function of safety device as ordered by physician Reorient/validate and redirect as needed the resident needs activities that minimize the potential to wander while providing diversion and distraction Date Initiated: 03/17/2022. 3/22/23 at 1:30 PM, an interview was conducted with LPN C who was asked about the wander guard and how it worked. He then demonstrated by wheeling Resident #20 to the door and watching as the alarms set off and door locked. He stated that the Resident would not be able to leave as the door would lock and staff would be aware that someone was trying to leave if they heard that alarm. On 3/22/23 at 2:33 PM, an interview with RN B was conducted and she stated that the night shift checks for the functioning of wander guards. On 3/22/23 at 2:39 PM, an interview was conducted with LPN B who stated that night shift checks the wander guard to see if they are working. She said that day shift is not responsible for checking the functioning of the wander guard. When asked if she knows how to check the wander guard, she said she brings the Resident near the door and if the alarm sounds it's working. On 3/22/23 at 2:51 PM, an interview was held with the DON who was asked about checking wander guard bracelets and he stated they should be checked nightly for functioning. When asked who was responsible for doing this, he stated the night shift nurses. When asked how this was done, he stated that old system we had a wand that we pass over the bracelet, and it would light up green or red. [NAME] meant the battery was good and the bracelet was functional and red meant we needed a new bracelet. When asked how you can determine functionality with the new bracelets, and he stated they can bring the Residents to the door. The DON was asked if he was aware of the physician order that stated wander guard bracelets are to be checked nightly for function. He stated that he was aware of the order. When asked if night shift is waking people up to take them to the door to check the bracelet, and he stated they were not. When asked if there have been any elopements since the new system was in place and he stated that there had not been. On 3/22/23 at 3:30 PM, Employee D brought up the log where maintenance checks the alarms at the doors. When asked how he checks the alarms he stated he takes one of the wander guard bracelets to each exit door to see if it will lock and alarm. When asked how the bracelets are checked that are on the Residents, he stated he did not know because it was a nursing responsibility. He stated he was only responsible for checking and logging the door response to a functional bracelet. When asked if a bracelet is not functioning what would happen, he stated that the Resident would be able to leave the building because the door would not lock, and it would not sound an alarm. Employee D showed this surveyor the wand that was used to check the old wander guard bracelets when asked if this works to check the new bracelets, he stated that it does not. When asked when the new system and new bracelets started, he stated that it was started in June of 2022. On 3/23/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide respiratory care, consistent with professional standards of practice, for 1 Resident (#104) in a survey sample of 35 Residents. The findings included: For Resident #104 the facility staff failed to label and date and properly store the tubing for her nebulizer. A review of Resident #104's orders revealed the following: 3/14/23 6:00 PM - Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML via nebulizer three times a day x 7 days. On 3/21/23 at approximately 10:00 AM, an observation was made of a nebulizer machine on the bedside table. the tubing and mouthpiece were still connected to the machine and it was laying in the open no date on the tubing and it was not in a bag or covered in any way. At that time an interview was conducted with Resident #104 who stated the staff always leave the nebulizer there on the bedside table, when asked if they clean it after each use, she stated that she has never seen them take it apart. On the afternoon of 3/22/23 at 9:30 AM, another observation was made of the nebulizer with tubing and mouthpiece intact on the bedside table tubing and mouthpiece again not dated or in a bag. On 3/22/23 at approximately 2:00 PM an interview was conducted with LPN C who stated that night shift was supposed to change and date tubing for Nebulizer and oxygen tubing weekly. She stated if the Resident got an order for Nebulizer treatments, then the nurse that receives the order should date the tubing when she opens it and uses it. Then after giving the treatment, she should rinse the mouthpiece and medication chamber and place it in a bag. The tubing and set up should not be left on the table open without any cover. When LPN C asked what the risks are for leaving the nebulizer connected and, on the table, she stated that means it was not disconnected and cleaned and leaving it in the open is a risk germ getting into the mouthpiece or tubing. On 3/23/23 at approximately 2:45 PM, an interview was conducted with RN B who stated that the nebulizer and oxygen tubing are to be dated and stored in a bag at the bedside and that the aero chamber and the mouthpiece are to be rinsed out after each use. Excerpts from the website Medlineplus.gov about standard care of the nebulizer are as follows: (https://medlineplus.gov/ency/patientinstructions/000006.htm) After each use: You will need to clean your nebulizer to prevent bacteria from growing in it, since bacteria can cause a lung infection. It takes some time to clean your nebulizer and keep it working properly. Be sure to unplug the machine before cleaning it. Wash the medicine cup and mouthpiece with warm running water. Let them air dry on clean paper towels. Later, hook up the nebulizer and run air through the machine for 20 seconds to make sure all the parts are dry. Take apart and store the machine in a covered area until the next use. On 3/23/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to promptly inform the responsible party of the speech therapy treatment plan and initiation of speech therapy treatment for one Resident (Resident #1) out of a sample size of 6 Residents. The findings included: On 11/30/2021 at approximately 10:00 A.M., the facility staff provided a copy of Resident #1's speech therapy notes as requested. A review of the documents revealed that Resident #1 received speech therapy services from 10/08/2021 through 10/26/2021. There was no evidence in the documentation that the responsible party was notified that speech therapy services were initiated and ongoing. On 11/30/2021, Resident #1's closed clinical record was reviewed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was not a Speech Therapy Clarification order around the time speech therapy was initiated on 10/08/2021. The progress notes on 10/08/2021 were reviewed. There was no evidence in the progress notes that the responsible party was notified of speech therapy services. Excerpts of a social services discharge summary note dated 11/04/2021 at 3:20 P.M. documented, This dept [department] along with ADON [assistant director of nursing], therapy director met with RP [responsible party] [name] and RP [name] on the week of the 10/18/21 to discussed [sic] resident's care and overall decline .Therapy dept [department] also reported that resident was being followed by speech therapy for aspiration precaution and RP [name] stated that a swallow study was previously done and that they are aware of his risks for aspiration and declining cognition but stated that they would like for speech therapy to be stopped as there was no need for it. On 11/30/2021 at approximately 1:45 P.M., an interview with Employee E, the speech therapist, was conducted. When asked if she notifies the responsible party if speech therapy services are being initiated, the speech therapist indicated that she does not notify families when she evaluates Residents for speech therapy services or initiates a treatment plan. When asked who notifies the family when therapy is being provided, the speech therapist indicated she did not know. When asked if she notified nursing that speech therapy services are being initiated, the speech therapist stated that nursing would know because there's an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked why speech therapy was initiated, the speech therapist stated it was due to Resident #1's declining cognition. On 11/30/2021 at approximately 1:50 P.M., an interview with Licensed Practical Nurse C (LPN C) was conducted. When asked who notifies the responsible party when speech therapy is initiated, LPN C stated that the therapist will notify the family. In summary, Resident #1 received speech therapy services from 10/08/2021 through 10/26/2021. A review of the clinical record and an interview with the speech therapist revealed that Resident #1's responsible party was not notified of the evaluation or initiation of speech therapy services on 10/08/2021 until the week of 10/18/2021 (10 days after services began). On 12/01/2021 by the end of survey, the administrator and DON were notified of findings and they stated they had no further documentation or information to submit.

Based on staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to maintain an accurate clinical record for one Resident (Resident #1) in a sample size of 6 Residents. Specifically, there was conflicting information about Resident #1's code status in the clinical record. The findings included: On 11/29/2021 and 11/30/2021, Resident #1's electronic closed clinical record was reviewed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were active orders for Full Code and DNR from 09/30/2021 through 10/08/2021. An excerpt of a provider note dated 09/27/2021 at 9:50 A.M. documented, [Resident #1] wants to be DNR. A document entitled, Durable Do Not Resuscitate Order dated 09/27/2021 was signed by the physician and Resident #1's responsible party. On 11/29/2021, Resident #1's electronic care plan was reviewed. There was a focus with an initiation date of 09/21/2021 (and no end date) entitled, Resident's Advance Directive is full code. There was not a focus on the electronic care plan addressing the DNR status. On 11/30/2021 at approximately 1:55 P.M., the administrator was notified of findings that the electronic care plan was not revised when the code status changed. The administrator stated that the electronic care plans are locked and updated quarterly. The administrator also stated that she was not clinical and the MDS Coordinator revised the care plans. On 12/01/2021 at 9:55 A.M., an interview with the Minimum Data Set (MDS) coordinator was conducted. The MDS Coordinator verified that she updates the electronic care plans. When asked about the expectation to revise the care plan if there is a change in code status, the MDS Coordinator stated that she would expect the care plan would be revised the same day the code status changed. The MDS Coordinator also stated that the social worker updates the care plan pertaining to code status. On 12/01/2021 at 10:10 A.M., an interview with the social worker was conducted. The social worker confirmed it was her responsibility to update the care plan with changes in code status. When asked about the code status for Resident #1, the social worker stated that Resident #1 had a full code status when he was first admitted but the responsible party indicated Resident #1 wanted to be a DNR. The social worker then stated once the DNR was signed, she updated the code status in the electronic health record (to be visible on the banner) and the care plan was updated on paper in the hard chart but not in the electronic health record. The social worker stated normally she gives a paper copy (of the care plan) to the MDS Coordinator and the MDS Coordinator puts it into the electronic health record. On 12/01/2021, the administrator provided a copy of Resident #1's care plan revision dated 09/30/2021 entitled, Resident/Patient has a DNR order in place effective 09/30/2021. The administrator also provided a signature sheet of a document dated 09/30/2021 entitled, Care Plan Review. The document was signed by Resident #1's daughters, the social worker, the wound nurse, and the assistant director of nursing. At approximately 2:00 P.M., the administrator stated after that care plan review, a paper copy of the revised care plan was placed in the hard chart. The administrator then provided a copy of their policy entitled, Care Plan Revisions Upon Status Change. In Section 2(f), it was documented, Care plans will be modified as needed by the MDS Coordinator or other designated staff member. If addendums are required and time has lapsed for electronic submission, addendums may be added to the patient's hard clinical record. In summary, there were two conflicting active orders for full code and DNR from 09/30/2021 through 10/08/2021. Also, there was a focus on the electronic care plan for full code from 09/21/2021 through to the day of discharge and a paper copy care plan in the hard chart for DNR from 09/30/2021 through to the day of discharge.

Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to obtain lab test on 10/14/2021 as ordered by the physician for one Resident (Resident #1) in a sample size of 6 Residents. The findings included: On 11/29/2021 and 11/30/2021, Resident #1's closed clinical record was reviewed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/30/2021, the administrator provided a copy of all of Resident #1's lab reports as requested. There was not a lab report with a collection date of (Thursday) October 14. There were lab reports with collection dates of 10/08/2021 and 10/18/2021. On 11/30/2021, the administrator was notified of findings and acknowledged a lab was missing for 10/14/2021. The administrator then submitted a letter signed by the Medical Director and dated 11/30/2021. Excerpts of the letter included the following: On 10/14/2021, resident [Resident #1's name] was scheduled for CBC, BMP to be drawn. Unfortunately, the lab was missed . and I decided the lab could wait to be drawn on the next scheduled lab day which was Monday, October 18, 2021.

Based on observations, interviews, and review of the facility policy, the facility failed to ensure garbage was properly disposed of and contained in closed dumpsters. Bagged garbage was left out and not immediately placed in a container. Unsanitary conditions and/or uncontained trash increases the likelihood of pest infestations and had the potential to affect all 81 residents residing in the facility at the time of the survey. Findings include: A review of the facility's policy titled, Dispose of Garbage and Refuse, dated 10/2019, stated, It is the center policy all garbage and refuse will be collected and disposed in a safe and efficient manner. In addition, the policy stated, The Dining Services Director will ensure proper practice for handling garbage and refuse including: Garbage and refuse is removed from the kitchen area routinely during the day and at the end of the workday. The policy further stated, The Dietary Services Director will be responsible for appropriate recycling practices are in place as outlined by local authorities. On 03/15/21 at 9:55 AM, observations were conducted outside the kitchen entrance of the facility, following an initial tour of the kitchen area. Twelve bags of garbage were observed sitting on the ground, approximately five feet from the kitchen entrance. On 03/15/21 at 12:12 PM, additional observations of the area outside the kitchen entrance and an interview with the Certified Dietary Manager (CDM) were conducted. The CDM was observed placing the 12 bags of garbage in the facility's garbage dumpster. The CDM stated the 12 bags outside the kitchen contained aluminum cans that were intended for recycling. However, the CDM further stated the bags had not been retrieved at the scheduled time and were left on the ground outside the kitchen entrance. The CDM acknowledged the garbage bags were not supposed to be left on the ground outside the kitchen entrance. On 03/15/21 at 12:15 PM, an interview was conducted with the Administrator. The Administrator stated she expected garbage to be placed in the facility's dumpsters and acknowledged the garbage bags should not have been stored on the ground outside the kitchen entrance.

Based on observations, interviews, and review of facility policies, the facility failed to store food under sanitary conditions. Specifically, one of two nourishment refrigerators located at the nursing stations in the facility was not clean and contained unlabeled and undated foods. This failure had the potential to affect 51 out of 81 residents in the facility who might consume food stored in the refrigerator on the North Unit. Findings include: Review of the facility's policy titled, Nursing Services Space, dated 08/15/20, stated, If a refrigerator is provided in a nursing station, it will meet the following standards: a. Be located in a clean area not subject to contamination by human waste; and e. If foods are retained in the refrigerator, they will be covered and clearly identified as the contents and date initially covered. On 03/15/21 at 10:30 AM, observations were conducted at the nursing station on the North Unit of the facility. Observation of the nourishment refrigerator revealed unlabeled and open food and drink containers in the refrigerator. Two plastic containers of leftover foods were unlabeled and undated. The unlabeled and undated food containers contained steamed broccoli and fruit salad. In addition, an opened, 23 ounce aluminum can of Arizona Grape Aid Fruit Juice Cocktail was observed on the bottom shelf of the refrigerator. Further observations of the refrigerator revealed food and drink stains on the shelves and the bottom of the inside of the refrigerator. On 03/15/21 at 10:40 AM, an interview was conducted with Registered Nurse (RN)7. RN7 stated food and drink located in the refrigerators at the nursing stations should be labeled and dated. On 03/15/21 at 10:45 AM, an interview was conducted with the Director of Nursing (DON). The DON confirmed the nourishment refrigerators were for resident use only and stated the unlabeled foods and drink in the refrigerator appeared to belong to staff. In addition, the DON acknowledged the refrigerator was dirty and needed to be cleaned. However, the DON stated no one had been assigned to clean the refrigerator because he was not aware it was dirty. During the interview, the DON confirmed any foods in the refrigerators at the nursing stations should be labeled with the contents, covered, and dated. On 03/17/21 at 12:10 PM, an interview was conducted with the Administrator. The Administrator stated the DON made her aware of the improper food storage in the refrigerator located at the nursing station. The Administrator stated she expected nursing staff to properly store foods in the refrigerator and follow the policies for proper food storage.

Based on observation, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide [MEDICATION NAME] medication as ordered for 1 resident (Resident #4) in a sample size of 4 residents. For Resident #4, the facility staff failed to provide the medication, [MEDICATION NAME], for [MEDICATION NAME] pump refill resulting in hospitalization for [MEDICATION NAME] withdrawal on 09/02/2019. This is harm at Past Non-compliance. The findings included: Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #4's most recent Minimum Data Set with an Assessment Reference Date of 10/19/2020 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. On 11/17/2020, in the course of a complaint investigation, the clinical record was reviewed. A nursing progress note dated 08/19/2019 at 2:56 P.M. documented, Pt. (patient) stable on room air. In no distress. AM care done by CNA (certified nursing assistant). In bed with HOB (head of bed) elevated. Tolerated GTF (gastrostomy tube feeding), meds (medications) and water flushes well. [MEDICATION NAME] pump refill RX (prescription) order confirmed and faxed to pharmacy. Will continue to monitor. An excerpt of a physician's progress note dated 08/19/2019 at 8:46 A.M. under the header, Plan documented, f/u (follow-up) with (physician name, neurologist) for pump refill 8/21 (August 21) - had to reschedule due to delay in receiving med from pharmacy. SW (social worker) coordinating with neurology office to move appointment to 8/26. No plans to change dose. A physician's orders [REDACTED]. An excerpt of a physician's progress note dated 08/26/2019 at 8:01 P.M. under the header Assessment documented, [MEDICATION NAME] pump refill due - unable to get med from pharmacy despite MULTIPLE phone calls from RN (registered nurse) and MD (medical doctor) starting back on 8/21. An excerpt under the header Plan documented, start (sic) if med still not here by Thursday (08/29/2019), plan to start [MEDICATION NAME] 20mg qid (20 milligrams four times a day) and monitor closely for signs of withdrawal. (name of facility staff point of contact for ordering pump) discussing with (physician name, neurologist) and his nurse daily. if develops withdrawal symptoms, send to ED (emergency department). A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The entry entitled, [MEDICATION NAME] (10 MG) Tablet ([MEDICATION NAME]) Give 20 mg via [DEVICE] every 6 hours for [MEDICAL CONDITION] was signed off as administered from 08/30/2019 at 12:00 P.M. through 09/02/2019 at 12:00 P.M. A physician's progress note dated 09/02/2019 at 11:04 A.M. under the header CC (chief complaint)/Acute Problems documented, Fever, [MEDICAL CONDITION] altered mental status. Under the header HPI (history of present illness), it was documented, [MEDICATION NAME] pump was due to be refilled on 8/21 but there has been difficulty getting medication from pharmacy. Team has been in close contact with (physician's name, neurologist) and patient was started on [MEDICATION NAME] 20 mg q 6 (every 6) hours enterally. Patient was started on [MEDICATION NAME] last week for [DEVICE] site [MEDICAL CONDITION]. He subsequently developed very strong smelling urine- due to clinical concern for UTI (urinary tract infection), antibiotics changed to [MEDICATION NAME] yesterday. UA (urinalysis) and culture results are pending. The patient developed low grade fever to 100.6 last night. Staff reports he is grimacing today and making unusual movements. Under the header ROS (review of systems), it was documented, [MEDICATION NAME] pump is not yet alarming. An excerpt under the header Assessment documented, Concern for [MEDICATION NAME] withdrawal given fever, [MEDICAL CONDITION] altered mental status. An excerpt under the header, Plan, it was documented, Continue enteral [MEDICATION NAME] 20 mg q 6 hours. Will send to ED for close monitoring given signs/symptoms of [MEDICATION NAME] withdrawal. Pediatric Neurology will help get pump refilled. On 11/17/2020, a copy of the Discharge Summary from the hospitalization was requested and the facility staff provided a hospital document dated 09/09/2019 entitled, AVS (After Visit Summary) - Discharge Instructions. Under the header entitled, Reason for your Hospital Admission, it was documented, (Resident #4's name) was admitted due to [MEDICATION NAME] withdrawal, presumed UTI, and an abdominal ileus. His pump cartridge was refilled and his abdominal ileus resolved with bowel rest and he was able to tolerate his home feeds prior to discharge. An excerpt of a facility physician's note dated 09/09/2019 at 11:08 A.M. under the header, Assessment documented, Patient has now recovered from [MEDICATION NAME] withdrawal and is back to baseline. On 11/17/2020 at approximately 3:30 P.M., an interview with Employee H, the Director of the Pediatric Unit, was conducted. When asked about the process for refilling (Resident #4)'s [MEDICATION NAME] pump, Employee H explained that the medication is ordered from the pharmacy, received, and then sent with (Resident #4) to the MD office for the pump to be refilled. When asked about the events preceding Resident #4's hospitalization for [MEDICATION NAME] withdrawal in September 2019, Employee H stated that the facility was turned over to a new company in August 2019, which included new pharmacy services. Employee H stated there was a learning curve for the new pharmacy. Employee H stated the pharmacy was not familiar with [MEDICATION NAME] and the dose specifics. Employee H stated that the appointment for the pump refill needed to be rescheduled because the medication wasn't received from pharmacy. On 11/08/2020 at approximately 4:10 P.M., Resident #4 was observed in his room sitting up in his wheelchair. Resident #4 was neatly dressed, awake, and focused on the television. A copy of the facility policy (on ordering/receiving medications from the pharmacy) was requested and the facility staff provided a policy entitled Miscellaneous Special Situations. Under the header Policy, it was documented, Medication is used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. The situation may be due to the pharmacy being temporary out of stock of a particular product, a drug recall, manufacture shortage of an ingredient, or the situation may be permanent because the drug is no longer being made. The facility must make every effort to ensure that medications are available to meet the needs of each resident. On 11/18/2020 at approximately 3:00 P.M., the administrator and Director of Nursing were notified of findings and stated they had no further information or documentation to offer. The facility submitted the following Plan of Correction: 1. Corrective Action Resident (initials) was hospitalized , and his pump was filled by his neurologist in the hospital. 2. Other Potential Residents No other residents were affected by this deficient practice. 3. New Measures/System Change The Pediatric Assistant Directors of Nursing (ADON) and the Pediatric Medical Director stressed to the pharmacy the importance of having the [MEDICATION NAME] in-house prior to the day of the scheduled refill appointment. The pediatric ADON will contact the pharmacist in charge at a minimum of two weeks prior to the scheduled neurology appointment to ensure the [MEDICATION NAME] is delivered to the facility prior to the appointment. The facility director of nursing will verify the receipt of the [MEDICATION NAME] in the facility one week prior to the scheduled neurology appointment. 4. Monitoring The facility pediatric assistant director of nursing will ensure that the [MEDICATION NAME] is received in the facility prior to patient's appointment. 5. Compliance Date The projected completion date will be December 31, 2019 which will have been two successful refills and monitoring will be ongoing. No other issues were discovered on survey. Past Non-compliance

Based on observation, staff interview, facility documentation review, clinical record review and in the course of a complaint investigation the facility failed to safely transfer one resident (Resident #19) of 23 residents in the survey sample, causing injury resulting in harm. The facility identified, corrected/implemented and inserviced staff concerning the incident, which prevented no further incidents to occur. The deficiency was cited at a Past Non-compliance at a harm level, thus no further plan of correction is needed. 1. Resident #19 sustained lacerations to both legs during a transfer from wheelchair to bed resulting in an emergency room visit and sutures to her left leg. The findings included: 1. Resident #19 was originally admitted to the facility on [DATE] and readmitted after a hospitalization on [DATE] with the [DIAGNOSES REDACTED]. Resident was discharged from the facility on 4/20/15, therefore a closed record review was conducted. The most recent Minimum Data Set (MDS) was a Significant Change assessment with an Assessment Reference Date (ARD) of 3/25/15. The MDS coded Resident #19 with intact cognition; required extensive assistance from 2 staff members for bed mobility and transfers; did not walk in room or corridor; was dependent on staff for locomotion on and off the unit; required extensive assistance of staff for dressing, toilet use, personal hygiene and bathing. The MDS coded Resident #19 with lower extremity weakness on both sides and not steady, only able to stabilize with staff assistance during surface-to-surface transfer (transfer between bed and chair or wheelchair). On 4/28/16 Resident #19's clinical record was reviewed. The review revealed the following Progress Notes which read: 3/9/2015 at 09:33 (9:33 a.m.) Interdisciplinary Note written by the Social Worker included: .continues with skilled care, she is alert and oriented. In PT resident .transfers with sliding board with min-mod assist, non ambulatory . A sliding board is described by www.myshepherdconnection.org as a piece of equipment that can be used if a person is not able to use their legs to complete a transfer between surfaces or if a standing transfer is not safe to perform. The board is used to make a solid bridge between two surfaces that a person can slide across to transfer between them. 3/12/15 at 20:51 (8:51 p.m.) Evaluation completed.at 8.00pm 2 cna (certified nursing assistant) assist resident to bed observe resident bleeding from both legs during pivot transfer, writer went to room to assess observe resident bilateral lower extremity with large amount of fresh bright red blood on floor, resident sustain a skin tear to right lower leg and laceration to left lower leg during transfer from wheel chair to bed, dry dressing with pressure applied. pt (patient) was admitted on [DATE] with laceration to left lower leg, has a + 4 edema to bilateral lower extremities and a +3 to bilateral arms .patient has a very fragile skin, edema and is on bumex 1mg (a diuretic/fluid pill) and coumadin 4mg (an anticoagulant/blood thinner) .MD (Dr. Name) notified order to transfer resident via 911 to (Name of Hospital) for further evaluation . 3/13/15 07:41 (7:41 a.m.) Resident arrived at 11.50pm on a stretcher accompanied by 2 personal and daughter. dressing in place on both legs . 3/13/15 14:59 (2:59 p.m.) Skin/Wound Note .This morning assessed resident's lacerations on bil lower extremities. Dr (Name) and daughter were in the room. Laceration on L leg lateral (close to knee): 6x 10 x 0.8 cm (centimeters) with 11 stitches Laceration on R lower leg 8 x 8.5 x x 0.6 cm. Increased edema to bil LE's (bilateral lower extremities) (legs/feet) Also noted on L heel DTI (deep tissue injury) (bloody blister not open) 0.5 x 0.6 cm .She did not have this bloody blister before . Review of Resident #19's care plan included, but not limited to, the following: Focus The resident has an ADL (activities of daily living) self care performance deficit due to recent hospitalization and prolonged medical treatment for [REDACTED]. She remains non ambulatory at this time. Date Initiated: 02/23/2015. Goal She will improve current level of function in ADL's and begin working with parallel bars durig (sic) this review. Date Initiated: 02/23/2015 .Revision on: 03/03/2015. Interventions .TRANSFER: She requires extensive assist of 1-2 staff using sliding board. Date Initiated: 02/23/2015 .Revision on: 03/03/2015. On 4/28/16 at 11:00 a.m. a review of the Physical Therapy (PT) notes was conducted. The PT notes contained the following: Physical Therapy Plan Of Care initiated 2/5/15 included an Initial Assessment Functional Deficits .Weight bearing Status, Left LE .Current Level-50% weight bearing . Transfers, Bed/Chair .minimal assistance (1-25%) . Functional Deficit Other Due to increased difficulty with static standing d/t (due to) pain, mode of transfer is sliding board. NSG (nursing) made aware. 02/27/2015 PT Therapist Progress note Current Level of Function included: .The patient is able to safely transfer from bed < > wheelchair requiring contact guard assist (contact with patient due to unsteadiness) with sliding board. 03/16/2015 PT-Therapist Progress & Updated Plan of Care included: Current Level of Function Minimal assistance The patient is able to safely transfer from bed < > wheelchair requiring minimal assistance (1-25% assist) .squat pivot transfer. On 4/28/16 at 11:50 a.m. an interview was conducted with the Rehab Department Manager (Other-B) and Physical Therapist (Other-C). Other-C was identified as the primary PT who worked with Resident #19. The PT assessments and goals were reviewed. When asked what the transfer status was for Resident #19, Other-C read the initial assessment mode of transfer is sliding board. NSG made aware. When asked how the nursing staff were taught what the appropriate transfer method was, Other-C stated we Would generally pull the CNA off the floor and teach them on the unit. She stated we Would expect nursing to use the sliding board until cleared to transfer another way. The PT squat pivot transfer from 3/6/15 was discussed. Other-C stated As far as I remember I did not train nursing staff to pivot transfer (Resident #19). The Resident was very motivated and she tried really hard. Other-C stated To the best of my knowledge, nursing should have been using the sliding board for transfers. The interview concluded at 12:10 p.m. An investigation report, regarding the leg lacerations was provided by the Administrator (Employee-C) and Director of Nursing (Employee-A) was reviewed on 4/28/16. The investigation report which was typed by Employee-A included: CNA-C (Name) was the primary C.N.A and he called CNA-B (Name) for help, the wheel chair was moved close to the bed and had no foot rest. Both C.N.A's had gait belts during the transfer of the resident. Resident stated hands were swollen and really could not help with the transfer. During pivot and transfer, C.N.A's noticed resident's right leg was bleeding. CNA-C (Name) called for help and the charge nurse came into room. (Name) who was the charge nurse called (Name) the supervisor to the room. Prior to (Name) entering the room, the left leg was noticed to be bleeding also. Both (Name), CNA-B, CNA-C & (Name) agreed that the cut was new, the blood was fresh and that injury occurred during the transfer as the laceration and skin tear on assessment were indications of new onset and origin. Both CNA-C and CNA-B did not see any contact happen because they were focused on the upper body, they are however were confident that the injury was as a result of the pivot transfer . On 4/28/16 at 12:30 p.m. when asked what would be documented in regard to training nursing staff, Physical Therapist, Other-C stated, she Would document in progress note if staff are trained in change of transfer status and If training wasn't documented then it wasn't done. She (Resident #19) wasn't cleared to stand pivot (with nursing staff). Other-C stated she Would've documented if we removed the sliding board from the room. A telephone interview was conducted with CNA-B with the Director of Nursing present. In summary, CNA-B stated she remembered the day Resident #19 acquired the wounds on her legs. CNA-B stated she knew Resident #19 was a 2 person transfer but did not recall if a sliding board was in the room. She stated when the resident came back from the hospital (after the injuries) rehab taught staff to use the sliding board. CNA-B stated when they stood her up she began bleeding on one leg then the other but did not remember her leg hitting the wheelchair. When asked how the CNA's know how to transfer a resident (transfer status) CNA-B stated at the time there was a card (Kardex) on the back of the closet door (with the information) but now the information is in the computer. An attempt was made to contact the primary CNA (CNA-C); a voice message was left to call the facility with no return call received. On 4/28/16 at approximately 1:25 p.m. when asked if the kardex was found, the Director of Nursing stated There is no kardex in the record. The Administrator and Director of Nursing were informed of the harm level deficient practice due to the transfer. Administration was questioned why the CNA's would determine to use a stand pivot instead of a slide board. The Administrator asked where it was documented to use the slide board beside the rehab notes; the surveyor stated it was on the care plan and in an interdisciplinary note. At 2:30 p.m., the Administrator stated (Name of Employee-A) and I investigated the incident fully. The MDS coordinator put the sliding board in the care plan. The Director of Nursing then stated I Believe the MDS put in sliding board in error. There were no concerns regarding transfers identified during the survey. The faciltiy provided the following information after the survey: Resident #19 sustained lacerations to her bilateral lower legs on March 12, 2015 during a two person transfer. Following this incident it was determined that no other residents had been injured while being transferred, however others may possibly in the future. The Director of Nursing and the RN nursing supervisors re-educated the nursing staff on transferring resident with fragile skin on March 13, 2015. The Director of Nursing and Director of Rehab worked together to develop a new tool and policy to alert all staff to the rehab department ' s individualized plans for resident transfers, ambulation, weight bearing status, diet, liquids, NPO status, and/or special instruction. This newly developed tool and policy was presented and adopted by the facility during the April 24, 2015 Quality Improvement Committee Meeting. The Director of Nursing educated the nursing staff on this new tool during his monthly meeting held on May 12, 2015. The Director of Nursing continued reviewing all resident unusual occurrences and found none were related to improper resident transfers. The facility maintains that it was back in compliance by June 1, 2015. This is a Past-Non Compliance Deficiency Complaint Deficiency.