Every finding on record at Miners Colfax Medical Center

Based on record review and interview, the facility failed to ensure care plan revisions occurred for 2 (R #4 and R #5) of 6 (R #1, R #2, R #4, R #5, R #6, and R #11) residents reviewed when staff failed to update care plans to include the use of anticoagulant medications. This deficient practice is likely to result in the residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of the facility's Person-Centered Comprehensive Care Plan policy, revised on 11/04/25, revealed the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment. R #4B. Record review of R #4's quarterly MDS assessment, dated 04/23/26, revealed the following:1. R #4 was admitted to the facility on [DATE].2. R #4 was taking anticoagulant (blood thinner) medications.3. R #4 had a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 11 (moderately impaired). C. Record review of R #4's physician orders, dated 02/02/26, revealed an order for Eliquis (anticoagulant) 2.5 milligrams (MG), to be taken twice a day.D. Record review of R #4's monthly Medication Administration Record (MAR; a tool used to document the administration of medications), dated 08/2026, revealed R #4 was administered Eliquis as ordered.E. Record review of R #4's Care Plan Report, not dated, revealed no interventions regarding R #4's use of an anticoagulant medication.F On 08/03/26 at 1:28 pm, during an interview, R #4 stated he takes an anticoagulant medication. G. On 08/07/26 at 9:37 am, during an interview, the Director of Nursing (DON) stated anticoagulants are a high-risk medication and should be included in the care plans. She stated R #4's care plan did not meet her expectations because it should have included the use of anticoagulants and it did not. She stated the nurse on shift who received the order should update the care plan when a new order is implemented. All nurses are trained by the DON on how to create and update care plans as part of the facility's documentation training. R #5H. Record review of R #5's significant change MDS assessment, dated 04/27/26, revealed the following:1. R #5 was admitted to the facility on [DATE].2. R #5 was taking anticoagulant (blood thinner) medications.3. R #5 had a BIMS of 12 (moderately impaired). I. Record review of R #5's physician orders, dated 04/14/26, revealed an order for apixaban (anticoagulant) 5 MG, to be taken twice a day. J. Record review of R #5's monthly MAR, dated 08/2026, revealed R #5 was administered apixaban as ordered. K. Record review of R #5's Care Plan Report, not dated, revealed no interventions regarding R #5's use of an anticoagulant medication. L. On 08/03/26 at 9:57am, during an interview, R #5 stated he takes an anticoagulant medication. M. On 08/07/26 at 9:37 am, during an interview, the DON stated anticoagulants are a high-risk medication and should be included in the care plans. She stated R #5's care plan did not meet her expectations because it should have included the use of anticoagulants, but it did not. She stated the nurse on shift who received the order should update the care plan when a new order was implemented. She stated all nurses were trained by the DON on how to create and update care plans as part of the facility's documentation training.

Based on record review and interview, the facility failed to ensure that 5 (R #6, 8, 10, 17, and 22) of 5 5 (R #6, 8, 10, 17, and 22) residents medication regimen was reviewed by a licensed pharmacist. That the licensed pharmacist documented any recommendations or changes to each resident's medication regimen and that the physician reviewed these recommendations and submitted a written response to accept or reject these recommendations. These deficient practices could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions and adverse side effects. The findings are: R #6 A. Record review of R #6 face sheet dated 05/14/25 revealed he was admitted to the facility on [DATE] with multiple diagnoses. B. Record review of R #6's physician orders revealed multiple medication orders started on various dates. C. Record review of R #6's medical record including his electronic medical record (EMR) and his paper medical record (PMR) from 06/01/24 to 05/15/25 failed to find any written communication between the facility pharmacist and R #6's medical provider that indicated that R #6's medications had been reviewed by the pharmacist, that the pharmacist had submitted any recommendations regarding R #6's medication regimine or that the medical provided had reviewed and responded to any pharmacist recommendations. R #8 D. Record review of R #8 face sheet dated 05/14/25 revealed he was admitted to the facility on [DATE] with multiple diagnoses. E. Record review of R #8's physician orders revealed multiple medication orders started on various dates. F. Record review of R #8's medical record including his electronic medical record (EMR) and his paper medical record (PMR) from 08/01/24 to 05/15/25 failed to find any written communication between the facility pharmacist and R #8's medical provider that indicated that R #8's medications had been reviewed by the pharmacist, that the pharmacist had submitted any recommendations regarding R #8's medication regimine or that the medical provided had reviewed and responded to any pharmacist recommendations. R #10 G. Record review of R #10 face sheet dated 05/14/25 revealed he was admitted to the facility on [DATE] with multiple diagnoses. H. Record review of R #10's physician orders revealed multiple medication orders started on various dates. I. Record review of R #10's medical record including his electronic medical record (EMR) and his paper medical record (PMR) from 02/01/25 to 05/15/25 failed to find any written communication between the facility pharmacist and R #10's medical provider that indicated that R #10's medications had been reviewed by the pharmacist, that the pharmacist had submitted any recommendations regarding R #10's medication regimine or that the medical provided had reviewed and responded to any pharmacist recommendations. R #17 J. Record review of R #17 face sheet dated 05/14/25 revealed he was admitted to the facility on [DATE] with multiple diagnoses. K. Record review of R #17's physician orders revealed multiple medication orders started on various dates. L. Record review of R #17's medical record including his electronic medical record (EMR) and his paper medical record (PMR) from 05/01/24 to 05/15/25 failed to find any written communication between the facility pharmacist and R #17's medical provider that indicated that R #17's medications had been reviewed by the pharmacist, that the pharmacist had submitted any recommendations regarding R #17's medication regimine or that the medical provided had reviewed and responded to any pharmacist recommendations. R #22 M. Record review of R #22 face sheet dated 05/14/25 revealed he was admitted to the facility on [DATE] with multiple diagnoses. N. Record review of R #22's physician orders revealed multiple medication orders started on various dates. O. Record review of R #22's medical record including his electronic medical record (EMR) and his paper medical record (PMR) from 09/01/24 to 05/15/25 failed to find any written communication between the facility pharmacist and R #22's medical provider that indicated that R #22's medications had been reviewed by the pharmacist, that the pharmacist had submitted any recommendations regarding R #22's medication regimine or that the medical provided had reviewed and responded to any pharmacist recommendations. P. On 05/14/25 at 11:25 am during interview with Director of Nursing (DON), she stated that the facility conducts a monthly meeting in which the contracted pharmacist and the medical director attends. She stated that during this meeting, resident medications are discussed. She stated there was no documentation of this discussion that was contained in any resident's EMR or PMR. Q. On 05/14/25 at 11:25 am during interview with the Administrator (ADM), he stated that the facility does not have a formal review of resident medications. He acknowledged that there was no documentation of resident medications being reviewed by the pharmacist, that the pharmacist was not providing written medication recommendations to the medical provider and that there was no pharmacy recommendations for the medical provider to respond to. ADM stated that he was aware that this was a necessary process and that he was working to begin the process in the upcoming month.

Based on observation and staff interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Proper labeling and dating of food items in the kitchen freezer. 2. Inadequate food storage practices including leaving box of white rice open to air. 3. Employees wore appropriate hair restraints. These deficient practices are likely to affect all 23 residents listed on the census provided by the Administrator on 05/12/25 and may lead to foodborne illnesses in residents if proper food storage and safe food handling practices are not adhered. A. On 5/12/2025 at 2:00 PM, during an observation of the kitchen revealed one twenty-five-pound box of white rice was left open to air and stored on a shelf in the dry storage area. B. On 05/12/2025 at 2:07 PM during an interview, the Dietary Manager (DM) confirmed that the box of rice was left open and stated it should have been sealed for proper storage. C. On 05/13/2025 at 4:43 PM during an observation of the kitchen revealed two five-pound bags of frozen blueberries stored in freezer #1 without labels and dates D. On 05/13/2025 at 4:45 PM during an interview, Dietary [NAME] (DC) #1 confirmed the blueberries were not labeled and dated and acknowledged that the blueberries should have been. E. On 05/15/2025 at 11:35 AM during an observation of the kitchen revealed that Dietary Aide (DA) #1 was not wearing a beard guard. F. On 05/15/2025 at 11:38 AM during an interview, the DM confirmed that DA #1 was not wearing a beard guard and stated that he should have been.

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 2 (R #'s 1 and 18) of 2 (R #'s 1 and 18) residents reviewed when staff failed to: 1. Update R #1's plan of care to include skin irritation (itchiness) that required topical skin medication/lotion. 2. Update R #18's plan of care to include Albuterol (medication used to prevent and treat wheezing and difficulty breathing) use via a nebulizer (oral medical device used for producing a fine spray of liquid), and storage of nebulizer. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's physician orders dated 03/06/25 revealed R #1 was prescribed [NAME] External Lotion 0.5-0.5 % (percent), apply to legs topically as needed for itching. C. Record review of R #1's nursing progress notes revealed the following: 1. 03/06/25 at 11:14 am: R #1 stated that he is itchy at night when he goes to bed. R #1 was educated and encouraged to use the [NAME] External Lotion that is available to him. 2. 05/14/25 at 9:41 am: R #1 complained of itches on his legs and sometimes other parts of his body. D. Record review of R #1's care plan reviewed on 05/15/25, revealed the care plan did not contain any documentation for [NAME] External Lotion use or R #1's chronic itchiness. E. On 05/13/25 at 10:38 am during an interview with R #1, he stated that his arms and legs are always itchy, and the nurses were providing medication for that. F. On 05/14/25 at 5:51 pm during an interview with Certified Nursing Assistant (CNA) #2, she confirmed R #1 had experienced chronic skin irritation and R #1 will require medication to treat the itchiness. G. On 05/15/25 at 12:18 pm during an interview with the Assistant Director of Nursing (ADON), she confirmed R #1's chronic skin irritation and topical medication treatment should be care planned and was not. R #18: H. Record review of R #18's face sheet revealed R #18 was admitted into the facility on [DATE]. I. Record review of R #18's Medication Administration Record (MAR) dated 04/01/25 through 04/30/25 revealed R #18 was administered Albuterol Sulfate Inhalation Nebulization 2.5 mg per 3 ml (milliliter), every four hours as needed for wheezing shortness of breath, 16 times throughout the timeframe. J. Record review of R #18's MAR dated 05/01/25 through 05/14/25 revealed R #18 still had active orders for Albuterol Sulfate Inhalation Nebulization (medication was only on hold for 05/03/25 through 05/08/25). K. Record review of R #18's care plan reviewed on 05/13/25, revealed R #18's Albuterol use with a nebulizer including nebulizer storage was not care planned. L. On 05/13/25 at 10:30 am during an observation and interview, R #18's nebulizer hung on an oxygen concentrator above his bed, and not in a bag for storage. R #18 confirmed he still uses his nebulizer sometimes when he needs it. M. On 05/14/25 at 3:34 pm during an interview with Registered Nurse (RN) #1, she stated that R #18 requires treatment for wheezing most mornings. RN #1 also stated that R #18's nebulizer should be stored in a bag when not in use. RN #1 confirmed R #18's nebulizer was stored above his bed and not in a bag, and R #18's Albuterol with nebulizer use should be care planned, but was not. N. On 05/15/25 at 12:23 pm during an interview with the ADON, she stated that R #18 does not like to store his Albuterol nebulizer in a storage bag when not in use. The ADON confirmed R #18's Albuterol use with a nebulizer and R #18's preference to not store the nebulizer in a bag when not in use, were not care planned and should have been.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #13) of 1 (R #13) resident reviewed for anticoagulant (blood thinner) medication use. This deficient practice could result in a failure to provide adequate care and treatment of the resident's needs. The findings are: A. Record review of R #13's face sheet revealed R #13 was admitted into the facility on [DATE]. B. Record review of R #13's physician's orders revealed the following: 1. 01/26/24: Aspirin (analgesic medication used to relieve pain) 81 mg (milligram) oral tablet one time a day. 2. 01/26/24: Clopidogrel (antiplatelet used to prevent platelets or blood cells from clumping together to form a clot) 75 mg one time a day. - R #13 was not prescribed an anticoagulant medication. C. Record review of R #13's latest MDS Section O- Special Treatments, Procedures, and Programs dated 03/06/25 revealed R #13 was administered an anticoagulant medication within the past 14 days. D. On 05/15/25 at 12:09 pm during an interview with the Assistant Director of Nursing/ MDS Coordinator (ADON/MDSC), she stated that she thought R #13 was taking an anticoagulant medication and that's why his MDS was documented that way. The ADON/MDSC confirmed R #13 was not and did not take an anticoagulant medication, making R #13's MDS was inaccurate, and it should not have been.

Based on observation, record review, and interview, the facility failed to provide a quality care that meets professional standards for 2 (R #3 and R #41) of 2 (R #3 and R #41) residents when the facility failed to: - Obtain physician orders prior to providing oxygen (O2) and having O2 equipment readily available in a resident's room. - Obtain physician orders for over the counter medicaiton (OTC; medications sold to individuals without a prescription) and for the resident to self-administer medication. If the facility is not obtaining physician orders for medications and treatments, then the physician and staff may be unaware of the potential for medication interactions, overdosing, or side effects. The findings are: R #3 A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's physician orders reviewed on 05/13/25, revealed no physician order for O2 use. C. Record review of R #3's care plan reviewed on 05/13/25, revealed O2 use was not care planned. D. On 05/13/25 at 2:42 pm during an observation and interview with R #3, O2 tubing with a saline humidifier (device that moistens oxygen delivered through a humidifier) was present above R #3's bed. R #3 stated that he will use the O2 if he needs it. E. On 05/14/25 at 3:54 pm during an interview with Registered Nurse (RN) #1, she stated that R #3 did not use O2. RN #1 confirmed the O2 tubing and humidifier present in R #3's room should not have been there without a physician's order. F. On 05/14/25 at 5:56 pm during an interview with Certified Nursing Assistant (CNA) #3, she stated that R #3 will sometimes wear O2 if he wants to, and the CNAs will always offer O2 to R #3. G. On 05/15/25 at 12:24 pm during an interview with the Assistant Director of Nursing (ADON), she stated that R #3 does not use O2 and the O2 tubing and humidifier that was in R #3's room should not have been in there without physician orders. R #41 H. On 05/12/25 at 3:52 PM, during an observation, the cabinet located R #41's room contained the following: - Bacitracin zinc ointment (OTC antibiotic), - Bigeloil topical pain gel (OTC pain relief gel), - Lidocaine ointment (OTC anesthetic.) I. Record review of R #41's physician orders, dated May 2025, revealed the following: - The resident did not have orders for bacitracin zinc ointment, Bigeloil topical pain gel, or lidocaine ointment. - The resident did not have an order to self-administer medication. J. Record review of R #41's care plan reviewed on 05/23/25, revealed the care plan did not contain information regarding the resident self-administering OTC medication. K. On 05/12/25 at 4:57 PM, during an interview, the Assistant Director of Nursing (ADON) stated the resident's family brought in R #41's OTC medications. She stated all medications require a physician order, to include OTC medications.

Based on observation, interviews, and record review, the facility failed to ensure medications, including over the counter medications (OTC; medications sold to individuals without a prescription), were not accessible to all residents located on the [NAME] Hall. This deficient practice could result in impairment or decline in a resident's mental or physical condition if a resident came in contact with the medications. The findings are: A. On 05/12/25 at 3:52 PM, during an observation, the cabinet located R #41's room contained the following: - Bacitracin zinc ointment (OTC antibiotic), - Bigeloil topical pain gel (OTC pain relief gel), - Lidocaine ointment (OTC anesthetic.) B. Record review of R #41's physician orders dated May 2025, revealed the following: - The resident did not have orders for bacitracin zinc ointment, Bigeloil topical pain gel, or lidocaine ointment. - The resident did not have an order to self-administer medication. C. On 05/12/25 at 4:51 PM, during an interview, Certified Nurse Aide (CNA) #1 stated staff should label and keep the bacitracin zinc ointment, Bigeloil topical pain gel, and lidocaine ointment in the medication cart. D. On 05/12/25 at 4:57 PM, during an interview, the Assistant Director of Nursing (ADON) stated the resident's family brought in R #41's OTC medications. She stated staff should keep all medications in the medication cart.

Based on interview and record review, the facility failed to ensure staff communicated and collaborated with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 2 (R #6 and #12) of 2 (R #6 and #12) residents reviewed for dialysis. If the facility is unaware of the status, condition, or complications that arise during dialysis treatment then residents are likely not to receive the appropriate monitoring and care they need. The findings are: R #6: A. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE]. B. Record review of R #6's physician orders, dated 06/29/22, revealed an order to increase dialysis chair time/treatment duration to 3 hours and 15 minutes starting on 07/01/22. C. Record review of R #6's care plan, dated 04/24/24, revealed the following: - Focus: The resident was very weak after dialysis treatments, and it took away most of the resident's energy for the day. - Interventions/Tasks: The resident needed someone to propel their wheelchair down to dialysis on dialysis days, Monday, Wednesday, and Friday. D. Record review of R #6's dialysis communication record (communication form used to communicate between the facility and the dialysis center about the patients status), dated 03/01/24 through 03/31/24, revealed eleven of the thirteen forms did not contain information regarding the resident's post dialysis status, the date, and the signature of the facility nurse. E. Record review of R #6's dialysis communication record, dated 04/01/24 through 04/25/24, revealed eight of the ten forms did not contain information regarding the resident's post dialysis status, the date, and the signature of the facility nurse. F. On 04/24/24 at 11:54 am during an interview with Registered Nurse (RN) #1, she stated she was not aware she needed to complete the post dialysis section of form or document vitals in the electronic health record (EHR) post dialysis. G. On 04/24/24 at 11:58 am during an interview with RN #2, she stated none of the staff completed the post dialysis sections on communication forms. RN #2 stated she did not complete the post dialysis section on residents' dialysis communication forms when the residents returned from dialysis. H. On 04/24/24 at 5:46 pm during an interview the Assistant Director of Nursing (ADON), she stated the expectation was for staff to complete dialysis communication forms. The ADON stated nursing staff should be aware of residents' conditions when residents return from dialysis. R #12: I. Record review of R #12's face sheet revealed R #12 was admitted into the facility on [DATE]. J. Record review of R #12's physician orders, dated 10/07/21, revealed an order for hemodialysis (a machine that filters wastes, salts, and fluid from the blood when the kidneys cannot do it) every Monday, Wednesday, and Friday. K. Record review of R #12's care plan, dated 04/25/24, revealed the following: - Focus: The resident's kidneys did not function properly. Since May of 2019, the resident went to dialysis three times a week. - Interventions/Tasks: The resident needed someone to propel their wheelchair down to dialysis on dialysis days, Monday, Wednesday, and Friday. L. Record review of R #6's dialysis communication record dated 03/01/24 through 03/31/24, revealed ten of the thirteen forms did not contain information regarding the resident's post dialysis status, the date, and the signature of the facility nurse. M. Record review of R #6's dialysis communication record, dated 04/01/24 through 04/25/24, revealed ten of the twelve forms did not contain information regarding the resident's post dialysis status, the date, and the signature of the facility nurse. N. On 04/25/24 at 10:15 am during an interview with the Director of Nursing (DON), she confirmed R #6's and R #12's dialysis communication forms were not completed and should have been.

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (R #7) of 2 (R #7 and #12) residents reviewed for comprehensive care plans when staff did not develop a care plan for oxygen (O2) use. Failure to develop and implement a resident-centered care plan may result in staff not understanding and implementing the needs and treatments of residents, possibly resulting in decline in abilities. The findings are: A. Record review of R #7's face sheet revealed R #7 was admitted into the facility on [DATE]. B. Record review of R #7's physician orders, dated 10/22/23, revealed an order for O2 at 2 liters per minute (lpm) via nasal cannula (tubing that provides O2 through the nose). Keep O2 saturations at 90 percent (%), as needed (PRN). C. Record review of R #7's care plan, dated 04/24/24, revealed the record did not contain documentation regarding R #7's O2 use. D. On 04/23/24 at 9:50 am during an observation, R #7 did not wear O2, but R #7's O2 tubing was connected to the O2 wall mount in her room. E. On 04/24/24 at 11:38 am during an interview with Certified Nursing Assistant (CNA) #1, she stated R #7 used O2 as needed. F. On 04/24/24 at 5:17 pm during an interview with the Assistant Director of Nursing (ADON), she confirmed R #7 had orders for as needed O2 use. She stated staff did not care plan R #7's oxygen use, but they should have.

Based on record review and interview, the facility failed to meet professional standards for maintaining resident records for 1 (R # 6) of 1 (R #6 ) residents when staff failed to ensure R #6's code status readily viewable in the resident's Electronic Health Record (EHR). This deficient practice is likely to result in residents end-of-life medical care choices not being honored. The findings are: A. Record review of R #6's EHR revealed R #6 was admitted to facility on 07/09/09, but the record did not contain the resident's code status on the EHR on the banner. [The facility's practice was to note the resident code status on the top page that opened first when accessing the resident's EHR. This is called the banner]. B. On 4/25/24 at 9:47 am, during an interview with Director of Nursing (DON), she stated all residents should have an advanced directives in their chart. The DON confirmed R #6's code status was not on the resident's EHR banner, and it should be on the banner. C. On 4/25/24 at 9:58 am, during an interview with the Social Services (SS), she stated she completed all advanced directives upon admission, and there should be one in all the residents' charts. The SS stated she completed R #6's advanced directive. She confirmed R #6's code status was not on the resident's EHR banner, and it should be on the banner.

Based on observation, record review, and interview, the facility failed to meet professional standards of care for 1 (R #4) of 1 (R #4) residents by not obtaining physician's orders for the use of a therapeutic cup. This deficient practice is likely to result in residents receiving assistive devices that are not needed or ordered by the physician. The findings are: A. On 04/24/24 at 5:02 pm during observation of the dinner meal in the dining room, R #4 drank coffee out of a sippy cup (a drinking cup designed to prevent or reduce spills). B. Record review of R #4's physicians orders revealed the record did not contain an order for the use of a sippy cup. C. Record review of R#4's care plan revealed the care plan did not address the use off a sippy cup. D. On 04/24/24 at 5:50 pm, during a interview with CNA #1, she confirmed R#4 drank out of a sippy cup at all meals. E. On 04/24/24 at 5:50 pm, during a interview with Nurse #2, she stated R #4 drank from a sippy cup, but he did not have an order for it. She stated there should be an order for the use of a sippy cup. F. On 04/25/24 at 10:00 am during an interview with the Director of Nursing, she confirmed R #4 did not have an order for the sippy cup, but he should.

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 1 (R #6) of 1 (R #6) residents reviewed when staff failed to update the care plan to reflect new dietary behaviors. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE]. B. On 04/24/24 at 11:53 am during an interview with Registered Nurse (RN) #1, she stated R #6 would chew his food and spit it in the trash. C. On 04/24/24 at 5:02 pm during a dinner observation, R #6 ate dinner in the dining room with a trash can next to him. R #6 threw food in the trash. D. On 04/24/24 at 5:05 pm during an interview with Certified Nursing Assistant (CNA) #1, she confirmed R #6 threw food in the trash for awhile, and he also did that if he ate in his room. CNA #1 stated everyone knew R #6 threw food in the trash at each meal. E. Record review of R #6's care plan, dated 04/24/24, revealed the following: - Focus: When the resident ate and drank they coughed and had phlegm. - Interventions/Tasks: The resident's diet was changed to mechanical soft texture per Speech-language pathologist (SLP) recommendations. - Staff did not document food or meal behaviors in R #6's care plan. F. On 04/24/24 at 5:41 pm during an interview with the Assistant Director of Nursing (ADON), she stated staff should have updated R #6's care plan to include his meal behavior. The ADON confirmed R #6's meal behavior was not care planned.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions by not ensuring food items were stored off of the floor. This deficient practice is likely to affect all 26 residents. If the facility fails to adhere to safe food handling practices, in which residents are likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 03/03/23 at 8:46 am during an kitchen follow up observation, the following was observed: 1. 1- 30 pound (lb) box of Sysco Margarine was stored on the bare floor by the refrigerator with other boxes stacked on top. 2. 1- 30 lb Sysco Reliance Potato Fry Crinkle Cut box was stored on the bare floor by the refrigerator with other boxes stacked on top. 4. 1- 10 lb Hormel Natural Choice Fully Cooked Pork Sausage Links box was stored on the bare floor by the refrigerator with other boxes stacked on top. B. On 03/03/23 at 8:47 am during an interview with the Assistant Dietary Manager (ADIM), he stated, Normally, we try to get it [food shipment] from the delivery driver. ADIM confirmed findings and stated food boxes should not be left on the floor.

Based on interview and record review, the facility failed to meet professional standards for 1 (R #16) of 1 (R #16) by not weighing in accordance with the physician's orders. This deficient practice is likely to have residents experience un-noticed weight loss. The findings are: A. Record review of physicians order dated 10/07/21 revealed to obtain weekly weights. B. Record review of R #16 Vital and Weight Sheet, revealed no weekly weight was recorded for the week 02/24/22. C. On 03/02/23 at 4:43 PM during an interview with Licensed Practical Nurse (LPN) #1, she stated that the facility had not conducted R #16's weekly weight as ordered by Physician for the week of 02/24/23. She further stated that R #16 is a Dialysis patient and should be weighed weekly.

Based on observation, record review, and interview, the facility failed to ensure that the Matrix (a form used to identify pertinent care categories (relevant) for residents) was accurate by reflecting R #19 was on Transmission Based Precautions (TBP) status. (the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission) This deficient practice is likely to result in residents not receiving the appropriate care and treatment they need. The findings are: A. Record review of R #19's face sheet revealed R #19 was admitted into the facility on [DATE] and resided in Room (RM) #106-1. B. Record review of the Matrix provided by the Administrator dated 03/01/23 for the facility revealed that R #19 was on transmission-based precautions. C. On 03/02/23 at 10:37 am during an observation, R #19's room was observed not be on TBP. D. On 03/02/23 at 4:23 pm during an interview with Certified Nursing Assistant (CNA) #2, When asked if R #19 was on Transmission Based Precautions, she stated. No, I don't think so. E. On 03/02/23 at 4:29 pm during an interview with Licensed Practical Nurse (LPN) #1, LPN #1 was asked if R #19 was on Transmission Based Precautions, she stated, Nobody [residents in the facility] is [on TBP]. F. On 03/02/23 at 5:28 pm during an interview with the Director of Nursing (DON), When asked if R #19 was on TBP, she stated. No, it's [facility matrix] not accurate because he's [R #19] not on TBP. 41988

Based on observation, record review, and interview, the facility failed to ensure a medication that was placed on hold per physician order was not administered to 1 (R #17) of 6 (R #1,3,7,8,10 and 17) residents reviewed during random observation. This deficient practice is likely to result in adverse health consequences such as excessive dosing. The findings are: A. On 03/02/23 at 7:48 am during random observation of medication administration, Licensed Practical Nurse (LPN) #1 was observed administering one 20 mg (milligram) tab of Xarelto (a medication used to prevent blood clots from forming) when R #17 was presented with the medications R #17 identified the Xarelto tablet and questioned LPN #1 regarding the medication being on hold. LPN #1 confirmed she had handed R #17 the medication to be consumed and she further stated she should not have administered the medication cause it was on hold until 03/04/23. B. Record Review of Progress Notes dated 03/01/23 revealed that medication (Xarelto) was placed on hold following a esophagus [a muscular tube that connects your mouth to your stomach, allowing you to swallow food and liquids.] biopsy [a sample of tissue taken from the body in order to examine it more closely] and would restart on Saturday 03/04/23 C. On 03/02/23 at 8:00 am during interview with LPN #1, she confirmed that the medication was placed on hold by the physician on 03/01/23 and that it should not have been administered on 03/02/23.

Based on interview, the facility failed to give the resident council feedback on their concerns for 4 (R #1, 3, 12 and 15) of 4 (R #1,, 3, 12, and 15) residents reviewed in the resident Council Meeting Minutes. If the facility is not ensuring that the Resident Council grievances are responded to and resolved, then residents are likely to feel that their issues/concerns are not taken seriously. The findings are: A. On 03/01/23 at 9:59 am during an interview with R #15, he stated that all concerns that were brought to the facility resident council meeting were documented by a facility staff and then reviewed at the following months resident council meeting to see if the issues had been resolved. When asked if there was any other follow up after the meeting he stated. No, we don't find out if issues are resolved until the next months meeting. R #3 confirmed that the minutes are taken by a facility staff and the results of that meeting are brought to the next meeting and if they are not resolved at that time then the issues are put in the notes again and brought up at the next months meeting until issue is resolved and sometimes those issues are are never resolved. R #15 further stated that he would like to know the results of the issues/concerns. He (R #15) had brought it up at the resident council meeting in January that he would like a response in a timely manner (before the following month of the resident council meeting) and they would like to know what the resolution were to the issues. B. On 03/02/23 at 4:44 pm during an interview with the facility Administrator, he stated. All issues that are brought up go to the Social Services Director and we take action. We do not give responses in writing. I am assuming issues were addressed. I have been doing all the responses verbally and not anything on an official document when the issues are brought to my attention. We do not do formal grievances we address them as issues or concerns. Things that are brought up in resident council meetings are addressed but I do not have anything written down to acknowledge that issue/concerns have been addressed or that a rationale has been given as to why it was not addressed.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions by not: 1. Ensuring food items in the refrigerator, freezer, and dry storage were properly labeled and dated. 2. Ensuring food items in the refrigerator and freezer were properly stored and not expired. These deficient practices are likely to affect all 21 residents listed on the resident census list provided by the Administrator (ADM) on [DATE]. If the facility fails to adhere to safe food handling practices residents are likely to be exposed to foodborne illnesses. The findings are: A. On [DATE] at 12:00 pm during the initial tour of facility kitchen the following was observed: 1. 6- Large plastic bags of tater tots were not labeled or dated and stored in the freezer. 2. 1- Plastic bag of chile rellenos (breaded whole chilie) was not labeled or dated and stored in the freezer. 3. 1- Plastic storage bag labeled veal patties- [DATE] was stored in the freezer. 4. 2- Loaves of bread not labeled or dated and stored in the freezer. 5. 1- Small plastic storage bag of fish like product was not labeled or dated and stored in the freezer. 6. 1- Large plastic bin containing a large plastic storage bag filled with chicken breasts was not labeled or dated and stored in refrigerator one. 7. 2- Plastic containers of 1 pound (lb) Red Blossom Strawberries were expired, covered in mold, and stored in refrigerator 2. 8. 1- Large plastic storage bag of baby carrots dated [DATE] was stored in refrigerator 2. 9. 1- Large plastic tray of approximately 30 large tomatoes was not dated or labeled and stored in refrigerator 2. 10. 1-Plastic storage bag of Great Value-almond bark [DATE] was left open to air and stored in the dry storage. 11. 1- Large plastic container of hard taco shells was not labeled or dated and stored in the dry storage. 12. 1- Large plastic container of 15 oranges was not labeled or dated and stored in the dry storage. 13. 1- Large cardboard box of bananas was not not labeled or dated and stored in the dry storage. 14. 1- Large storage bin of sugar was not labeled or dated and stored in the kitchen. 15. 1- Large storage bin of flour was not labeled or dated and stored in the kitchen. B. On [DATE] at 12:55 pm during an interview with the Dietary Manager (DM), he confirmed all above findings and stated, It [food] should all be labeled and dated. DM also confirmed that expired and moldy food should be discarded and should not be stored in the kitchen.

Based on observation, record review, and interview the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #19 and 24 ) of 3 (R #13, 19, and 24) residents by: 1) Not developing a care plan to address assistance with Activities of Daily Living (ADL) for R #19 2) Not developing a care plan to address independent ADL care for R #24. Failure to develop and implement person-centered care plans for residents is likely to result in staff not being made aware of the needs and treatments of residents and is likely to result in decline in their abilities and failure to thrive. The findings are: Findings for R #19: A. Record review of R #19's face sheet revealed R #19 was admitted into the facility on [DATE]. B. Record review of R #19's care plan 11/01/21 revealed no care plan for ADL care or assistance with ADL care. C. On 02/01/22 at 9:43 am during an interview with R #19, he confirmed staff assists him with showers. D. On 02/03/22 at 10:28 am during an interview with Certified Nursing Assistant (CNA) #1, she stated He [R #19] takes them [shower] twice a week and he doesn't like them on [CONDITION(S)] days. He's supervision for showers. E. On 02/03/22 at 10:33 am during an interview with CNA #2, she stated, He [R #19] gets them [showers] twice a week. CNA #2 confirmed R #19 requires assistance with ADL care. F. On 02/03/22 at 10:40 am during an interview with Registered Nurse (RN) #1, she stated, We [nursing staff] help [Name of R #19] and assist with his showers. G. On 02/03/22 at 11:38 am during an interview with the Director of Nursing (DON), she confirmed R #19's ADL care was not care planned and should have been. Findings for R #24: H. Record review of R #24's face sheet revealed R #24 was admitted into the facility on [DATE]. I. Record review of R #24's care plan with a print date of 01/31/22 revealed no care plan for ADL care or independent ADL care. J. On 01/31/22 at 2:21 pm during an interview with R #24, he stated, So far I've never needed help [with showers]. I told them [staff] I'm good on my own. I mark the days [on a calendar] when I take a shower because they [staff] said I needed to let them know when I take a shower, so they can document it [shower]. R #24 confirmed he can take a shower independently. K. On 02/03/22 at 10:28 am during an interview with CNA #1, she stated, He [R #24] is independent on that [showers] and he'll [R #24] let us know and when we'll document it [after R #24 showers]. L. On 02/03/22 at 10:34 am during an interview with CNA #2, she stated, He's [R #24] independent [with showers] and he will let us know [after R #24 takes a shower]. M. On 02/03/22 at 10:40 am during an interview with RN #1, she stated, He's [R #24] independent [with showers]. N. On 02/03/22 at 11:39 am during an interview with the DON, she confirmed R #24's independent ADL care was not care planned and should have been.

Based on interview and record review, the facility failed to ensure that residents had the right to meet privately without staff present during Resident Council meetings for 10 (R #2, R #5, R #10, R #11, R #14, R #15, R #17, R #18, R #19 & R #24) of 10 (R #2, R #5, R #10, R #11, R #14, R #15, R #17, R #18, R #19 & R #24) residents interviewed during a Resident Council meeting. This deficient practice is likely to cause residents to feel uncomfortable and afraid of retaliation if they report or discuss all of their concerns and grievances while facility staff is present. The findings are: A. On 02/01/22 at 9:55 am during an interview with the facility Administrator, he stated, Facility staff must be present during resident council meeting to assist in taking notes and assist with anything they may need. Sometimes residents want snacks or to leave the meeting and staff is there to assist them. B. On 02/01/22 at 9:56 am during interviews with the all 10 residents present at the resident council meeting with the State Surveyor, all residents were presented with the question 'if they met or could meet for a resident council meeting in private without staff present', they all agreed that they have never met without staff present and were not told they could not meet without facility staff present. They further stated that they were told that there had to be a facility staff present to take notes. C. On 02/01/22 at 4:25 pm during an interview with the Social Services Manager she stated that staff is always present in the resident council and they (facility staff) had to take notes of the meeting and that was how it was always done. She further stated that it was a facility requirement that staff be present during resident council meeting to assist with any resident needs.

Based on record review and interview, the facility failed to ensure that 1 (R #35) of 1 (R #35) residents received respiratory care by incorrectly transcribing the physician's orders [REDACTED]. This deficient practice likely caused R #35 to experience respiratory distress. The findings are: A. Record review of R #35's nursing home record revealed the following: 1. Mininum Data Set ((MDS) dated [DATE] indicated an admitted [DATE]. 2. Admission physician's orders [REDACTED]. a. [DIAGNOSES REDACTED]. b. Order for [MEDICATION NAME] (inhalation solution used by people with a [DIAGNOSES REDACTED]. 3. Medication Administration Record (MAR) dated January 2012 indicated [MEDICATION NAME] BID PRN (as needed). 4. An Immediate Communication (IC) dated 02/08/12 at 12:01 pm to Dr. (name of Resident #35's doctor) noted "On resident's admitting orders, you ordered [MEDICATION NAME] BID. This was transferred incorrectly to the MAR as PRN. This has been corrected & reported as per protocol." 5. Progress Note dated 02/08/12 at 2:45 pm noted the following: a. Section S "Was c/o (complaining of) some chest tightness and some shortness of breath - was discovered that he hadn't been receiving Neb treatments as ordered." b. Section O "135/72 (blood pressure) P (pulse)=62 Wt. (weight) 194" (pounds) c. Section A: AFIB [MEDICAL CONDITIONS],[MEDICAL CONDITION](hypertension), [MEDICAL CONDITION] - O2 dependent. c. Section P "Cont. (continue) to wean [MEDICATION NAME] - Hold @ (at) 10 mg (milligrams) for a few wks (weeks). 6. The Care Plan dated 02/07/12 indicates decreased air exchange r/t (related to) [MEDICAL CONDITION]. (6) Give NEBS PRN as ordered, dated 01/31/12 7. Nurse's Note dated 02/10/12 indicates: "At 540 (5:40 am) res (resident) was found lying on the floor on his stomach, res unable to tell us what happened or if he was in pain....O2 (oxygen) Sat (saturation) when found was 58 assisted him to bed, he still offered no c/o (complaint of) pain O2 (increased) and even with mask at 6 lpm (liters per minute) he was only 70%. Res resp (respiration) labored, audible wheezing and gurgle, due to that it was difficult to determine lung sounds. Wife came to room a little after 0600 (6:00 am) and helped encourage intake and slow breathing. Duo-neb given at approximately (approx) 0600 with no results. At approx 0700 (7:00 am) notified Dr. (name of resident's doctor) of status, called ambulance to transport to ACF (acute care facility). ER (emergency room ) nurse notified. B. Record review of R #35's hospital record revealed the following: 1. Emergency Physician Record dated 02/10/12 noted a clinical impression of [MEDICAL CONDITION]-acute. 2. Record of Death dated 02/13/12 noted date of death [DATE] at 0720 (7:20 am). C. Record review of the Incident Report for R #35 dated 02/08/12 revealed "admitted for [MEDICATION NAME] BID, noted PRN on MAR. Resident missed 23 doses. Transcription error results in 23 omitted doses of [MEDICATION NAME] ordered BID. Missed on transcription, missed by auditing nurse & (and) nurses setting up new MARs." D. On 03/14/12 at 11:00 am, an interview was conducted with Licensed Practical Nurse (LPN) #4. LPN #4 stated that R #35's wife came to get LPN #4 because her husband was having trouble breathing. LPN #4 checked the MAR and the physician's orders [REDACTED]. LPN #4 went to set up the nebulizer treatment and found there was no setup for it. E. On 03/15/12 at 6:27 pm, an interview was conducted with R #35's doctor. When asked about when R #35 was admitted to the hospital from the nursing home, the doctor stated, "When he came to the ER, he was in severe respiratory distress." When asked if she thought that the withholding of 23 [MEDICATION NAME] treatments contributed to the resident's decline and eventual death, she stated, "Would have to say yes, it did contribute to his death."

Based on record review and interview, the pharmacist failed to identify and report an irregularity during the monthly drug regimen review regarding a respiratory medication for 1 (R #35) of 1 (R #35) residents. If the pharmacist does not identify and report irregularities, the facility is unable to act upon the irregularities, which presents a risk that residents will not be given medication properly. This deficient practice likely caused R #35 to experience respiratory distress. The findings are: A. Record review of R #35's nursing home record revealed the following: 1. Mininum Data Set ((MDS) dated [DATE] indicated an admitted [DATE]. 2. Admission physician's orders [REDACTED]. a. [DIAGNOSES REDACTED]. b. Order for DuoNebs (inhalation solution used by people with a [DIAGNOSES REDACTED]. 3. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 4. An Immediate Communication (IC) dated 02/08/12 at 12:01 pm to Dr. (name of Resident #35's doctor) noted "On resident's admitting orders, you ordered DuoNebs BID. This was transferred incorrectly to the MAR indicated [REDACTED]." 5. Nurse's Note dated 02/10/12 indicates: "At 540 (5:40 am) res (resident) was found lying on the floor on his stomach, res unable to tell us what happened or if he was in pain....O2 (oxygen) Sat (saturation) when found was 58 assisted him to bed, he still offered no c/o (complaint of) pain O2 (increased) and even with mask at 6 lpm (liters per minute) he was only 70%. Res resp (respiration) labored, audible wheezing and gurgle, due to that it was difficult to determine lung sounds. Wife came to room a little after 0600 (6:00 am) and helped encourage intake and slow breathing. Duo-neb given at approximately (approx) 0600 with no results. At approx 0700 (7:00 am) notified Dr. (name of resident's doctor) of status, called ambulance to transport to ACF (acute care facility). ER (emergency room ) nurse notified. B. Record review of the Monthly Drug Regimen Review dated 02/02/12 indicates No Irregularities and is signed by Consultant Pharmacist #1. C. Record review of R #35's hospital record revealed the following: 1. Emergency Physician Record dated 02/10/12 noted a clinical impression of Respiratory Failure-acute. 2. Record of Death dated 02/13/12 noted date of death [DATE] at 0720 (7:20 am). D. On 03/14/12 at 3:30 pm, an interview was conducted with the Director or Pharmacy, who provides pharmacy oversight to the facility. She stated their (the consultant pharmacy) role is to go into the facility, review records and make sure everything is being done correctly. She stated they review on a monthly basis, looking for any interactions in the medications and looking for too much sedation. When asked if the consultant pharmacist would have looked at the doctor's orders and compare them to the MAR indicated Yes, we would." When asked if a consultant pharmacist would have looked at the doctor's orders and compared to the MAR indicated Yes, he would have reviewed it and made sure everything was correct." E. On 03/15/12 at 7:15 am, an interview was conducted with Consultant Pharmacist #1, who visited the facility on 02/02/12. He indicated they (the consultant pharmacist) take each chart, check everything and make sure they are up to date. He stated "it was a really unusual case with (name of R #35) as I took (name of R #35's) doctor's orders and the meds from the VA (Veteran's Administration) and we (the consultant pharmacy) repackaged his home meds in the blister pack as an emergency transfer on 01/27/11. We did a one week supply until the (name of pharmacy) Plan D could be filled. I do look at new orders versus the MAR. Don't know what happened there. I just can't remember, but my procedure is to go through the labs, the doctor's orders and the MAR's. During that period of time I was negligent on getting my reports done timely as I was the only one here (at the consultant pharmacy)." F. On 03/15/12 at 6:27 pm, an interview was conducted with R #35's doctor. When asked about when R #35 was admitted to the hospital from the nursing home, the doctor stated, "When he came to the ER, he was in severe respiratory distress." When asked if she thought that the withholding of 23 DuoNeb treatments contributed to the resident's decline and eventual death, she stated, "Would have to say yes, it did contribute to his death."

Based on record review and interview, the facility failed to follow physician's orders to provide respiratory care for 1 (R #35) of 1 (R #35) residents. This deficient practice likely caused R #35 to experience respiratory distress. The findings are: A. Record review of R #35's nursing home record revealed the following: 1. Mininum Data Set ((MDS) dated [DATE] indicated an admitted [DATE]. 2. Admission Physician's Orders dated 01/27/12 indicated the following: a. [DIAGNOSES REDACTED]. b. Order for [MEDICATION NAME] (inhalation solution used by people with a [DIAGNOSES REDACTED]. 3. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 4. An Immediate Communication (IC) dated 02/08/12 at 12:01 pm to Dr. (name of Resident #35's doctor) noted "On resident's admitting orders, you ordered [MEDICATION NAME] BID. This was transferred incorrectly to the MAR indicated [REDACTED]." 5. Nurse's Note dated 02/10/12 indicates: "At 540 (5:40 am) res (resident) was found lying on the floor on his stomach, res unable to tell us what happened or if he was in pain....O2 (oxygen) Sat (saturation) when found was 58 assisted him to bed, he still offered no c/o (complaint of) pain O2 (increased) and even with mask at 6 lpm (liters per minute) he was only 70%. Res resp (respiration) labored, audible wheezing and gurgle, due to that it was difficult to determine lung sounds. Wife came to room a little after 0600 (6:00 am) and helped encourage intake and slow breathing. Duo-neb given at approximately (approx) 0600 with no results. At approx 0700 (7:00 am) notified Dr. (name of resident's doctor) of status, called ambulance to transport to ACF (acute care facility). ER (emergency room ) nurse notified. B. Record review of R #35's hospital record revealed the following: 1. Emergency Physician Record dated 02/10/12 noted a clinical impression of [MEDICAL CONDITION]-acute. 2. Record of Death dated 02/13/12 noted date of death [DATE] at 0720 (7:20 am). C. On 03/15/12 at 6:27 pm, an interview was conducted with R #35's doctor. When asked about when R #35 was admitted to the hospital from the nursing home, the doctor stated, "When he came to the ER, he was in severe respiratory distress." When asked if she thought that the withholding of 23 [MEDICATION NAME] treatments contributed to the resident's decline and eventual death, she stated, "Would have to say yes, it did contribute to his death."