August Healthcare at Iliff

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, record review, and review of facility policies and documentation, the facility failed to ensure one of 18 sampled residents (Resident (R) 235) received the care necessary to prevent falls. Specifically, the facility failed to put interventions in place to prevent further accidents after R235 fell on [DATE].

Inspectors wroteBased on interview, observation, material from the Centers for Disease Control and Prevention (CDC), and facility policy review, the facility failed to ensure two staff members followed transmission-based precautions (TBP) to prevent the potential for spread of COVID-19 for one (Resident (R) 183) of 37 residents reviewed for infection control. Staff failed to wear the appropriate personal protective equipment (PPE) when entering the room of the resident, who was on quarantine due to being a new admission to the facility with unknown COVID status.

Inspectors wroteBased on Staff Interview and Clinical Record Review, the facility staff failed to accurately document an assessment for one Resident, #95, in a sample of 33 Residents. For Resident #95, facility staff coded her discharge in the Minimum Data Set assessment as an unplanned discharge to the hospital, when she was instead discharged home.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed, for 1 resident (Resident #82) in the survey sample of 33 residents, to implement the care plan. For Resident #82, the facility staff failed to implement the care plan by positioning devices to prevent pressure over bony prominences (float heels).

Inspectors wroteBased on observation, staff interview, facility documentation and clinical record review, the facility staff failed to, for two residents (Resident #79 and Resident #47) in a survey sample of 33 residents, to provide a safe environment. 1. Resident #79 did not have on non skid shoes or socks. The resident had a recent fall. 2. For Resident #47, medications were left on the over bed table when the nurse left the room. In addition, the nurse left medications unattended on the medication cart.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure a system of prompt identification of potential diversion of controlled medications and provide safekeeping of hard scripts for all controlled medications for 2 residents (Residents #31 and #79) in a survey sample of 33 residents. 1. For Resident #31, the facility staff failed to send a hard copy script dated 6/5/18 for Lorazepam (for anxiety) 0.5 milligrams to the Pharmacy. 2. For Resident #79, the facility staff failed to send a hard copy script dated 6/5/18 for Oxycodone 2.5 milligrams to the Pharmacy. Oxycodone is an opioid narcotic pain medication.

Inspectors wroteBased on observation, staff interview and clinical record, the facility staff failed to ensure 1 resident (Resident #195) of 33 residents in the survey sample was free from significant medication errors. For Resident #195, blood pressure medication was not administered with a meal and was administered late.

Inspectors wroteBased on observation and facility documentation review, facility staff failed to store food in a clean and sanitary environment. The walk in refrigerator had vegetable matter stuck to the floor under shelving units. On 6/19/18 at 11:45a.m., a tour of the facility kitchen was conducted with Employee B, a cook in dining services. When examining the walk-in fridge, vegetable scraps were found underneath the left-hand shelving unit nearest the door. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 6/20/18. On the morning of 6/21/18, Surveyors were provided with a copy of the facility Food and Nutrition Services Cleaning Standards policy. This policy included a document entitled Dining Services Cleaning Schedule [name of facility] Nursing Center. A review of this document reveals that the Walk-Ins are to be cleaned daily by the PM Cook. [...]