DEVONSHIRE CARE CENTER

A revisit survey was completed on 5/20/26 for all previous deficiencies cited on 3/26/26. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 5/20/26 for all previous deficiencies cited on 3/26/26. The facility is in compliance with all regulations surveyed.

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a) This survey was conducted on April 23, 2026, for compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies;" NFPA 99, Health Care Facilities Code (2012); and all referenced standards. The facility will meet these requirements when the following deficiencies are corrected. This structure is a one (1) story, Type V (000) wood framed structure. The facility is protected throughout by an automatic fire sprinkler system and is classified as fully sprinklered. The drive through canopy area is protected by a separate wet anti-freeze loop pipe system. The facility was constructed in 1989. The facility is licensed for 84 beds and day of survey the census was 73. The long term care facility does not have a two-hour rated separation to the adjoining 24 bed assisted living facility. The assisted living facility fire alarm system is common with the long-term care building.

Through record review and interview, the facility did not maintain construction, smoke and fire barriers in accordance with NFPA 101, Life Safety Code (2012). Findings Include: During the record review, observations and interviews with the administrative director and maintenance personnel could not provide the facility's life safety plans during the survey. Without an accurate copy of the life safety plans. We can not verify that the construction type, fire, and smoke barriers are being maintained within the facility. Regulatory Reference: NFPA 101 20124.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance. 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initialfire development for the time needed to evacuate, relocate, or defend in place 4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, andshall remain operational. 4.5.5* Situation Awareness. Systems used to achieve the goals of Section 4.1 shall be effective in facilitating and enhancing situation awareness, as appropriate, by building management, other occupants and emergency responders of the functionality or state of critical building systems, the conditions that might warrant emergency response, and the appropriate nature and timing of such responses. 4.5.7 System Design/Installation. Any fire protection system, building service equipment, feature of protection, or safeguard provided to achieve thegoals of this Code shall be designed, installed, and approved in accordance with applicable NFPA standards. 4.6.1.2Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction. 4.6.8 Provisions in Excess of Code Requirements. Nothing in this Code shall be construed to prohibit a better building construction type, an additional means of egress, or an otherwise safer condition than that specified by the minimum requirements of this Code. 4.6.12 Maintenance, Inspection, and Testing. 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. This deficiency has the potential to affect all smoke compartments within the facility, and all residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Based on documentation review and staff interviews during the record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 101 (2012). Findings include: No documentation for 90 minute annual for emergency lighting Regulatory Reference: NFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 1/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficiency has the potential to affect all smoke compartments within the facility, and all residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Based on documentation review and staff interviews, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. Findings include: No documentation for 90 minute annual for emergency exit lighting Regulatory Reference: NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficiency has the potential to affect all smoke compartments within the facility, and all residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain hazard areas in accordance with NFPA 101, 99, 80, and 58. Findings include: No documentation for annual fire/smoke door inspectionClean Utility 100 hallway exit door "racked" and does not latch Clean Utility 400 hallway exit door "racked" and does not latch Exit door by laundry room does not latch Regulatory Reference: NFPA 101 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code NFPA 101 8.3.3.2* Fire protection ratings for products required to comply with 8.3.3 shall be as determined and reported by a nationally recognized testing agency in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies; ANSI/UL 10B, Standard for Fire Tests of Door Assemblies; ANSI/UL 10C, Standard for Positive Pressure Fire Tests of Door Assemblies; NFPA 257, Standard on Fire Test for Window and Glass Block Assemblies; or ANSI/UL 9, Standard for Fire Tests of Window Assemblies. NFPA 805.2.5.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly. 5.2.5.2 The following items shall be verified:(1)No open holes or breaks exist in surfaces of either the door or frame.(2)Slats, endlocks, bottom bar, guide assembly, curtain entry hood, and flame baffle are correctly installed and intact.(3)Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.(4)Curtain, barrel, and guides are aligned, level, plumb, and true.(5)Expansion clearance is maintained in accordance with manufacturer’s listing.(6)Drop release arms and weights are not blocked or wedged.(7)Mounting and assembly bolts are intact and secured.(8)Attachments to jambs are with bolts, expansion anchors, or as otherwise required by the listing.(9)Smoke detectors, if equipped, are installed and operational.(10)No parts are missing or broken.(11)Fusible links, if equipped, are in the location; chain/cable, s-hooks, eyes, and so forth, are in good condition (i.e., no kinked or pinched cable, no twisted or inflexible chain); and links are not painted or coated with dust or grease.(12)Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.(13)No field modifications to the door assembly have been performed that void the label. This deficiency has the potential to affect all smoke compartments within the facility, and all residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Based on observation and interview it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2. Findings include: Grill is not marked or chocked to identify location of grill under the hood suppression Regulatory Reference: NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer installation instructions. This deficiency has the potential to affect approximately 8 residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Based on observations and interviews, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. Findings include: No semi-annual fire sprinkler inspection report available Deficiencies noted on 3/5/26 report, “Items stored in front of riser, Items stored in front of FDC connection, No hydraulic calc plate. Suspect pipe schedule, No control valve signage” Sprinkler heads in main office and office storage room, 200 nurses station storage room, 300 storage room are dropping Sprinkler heads in cooler and freezer are 13 years old Appears they have expired sprinkler heads - need documentation showing they are within date and are compliant Regulatory Reference: NFPA 101 (2012)19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 9.7.6 Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25 (2011) 5.3.1.1.1.3* Sprinklers manufactured using fast-response elements that have been in service for 20 years shall be replaced, or representative samples shall be tested and then retested at 10-year intervals. NFPA 25 5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested. 25 5.3.1.1.1.6 Dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervals13.3.1* Each control valve shall be identified and have a sign indicating the system or portion of the system it controls. 13.3.2 Inspection. 13.3.2.1 All valves shall be inspected weekly. 13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. 13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised. 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible NFPA 13, 2013 Edition, Chapter 25, Section 25.5.1. The installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion resistant wire, chain, or other approved means. Such signs shall be placed at the alarm valve, dry pipe valve, preaction valve, or deluge valve supplying the corresponding hydraulically designed area. This deficiency has the potential to affect all smoke compartments within the facility, and all residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Based on observation and staff interviews during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. Findings include: Door seals not properly maintained in resident rooms leading to the corridor Regulatory Reference: NFPA 101 (2012) 19.3.6.3* Corridor Doors. 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:1 3/4 in. (44 mm) thick, solid-bonded core woodMaterial that resists fire for a minimum of 20 minutesThis deficiency has the potential to affect all smoke compartments within the facility, and all residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Through observation and interview during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1, NFPA 54 7.9.2.1 and NFPA 70. Findings include: Only one (1) out of four (4) dryers are labeled for high altitude | Gas orifice on dryer rated for 0-2000 feet in elevation in the laundry roomNo GFCI located in facility lounge by kitchen sink Regulatory Reference: NFPA 101 (2012)9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction.(3) In accordance with the manufacturer’s installation instructions. NFPA 101 (2012)9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. This deficiency has the potential to affect approximately 8 residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Based on the record review and interview, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6. The deficient practice affected all smoke compartments. Findings include: No fire drills recorded for 2nd or 3rd quarters Fire drills closer than an hour apart, not at varied times, no evening drills being conducted Regulatory Reference: NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect all smoke compartments within the facility, and all residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Through observation and interview during the survey, it was determined that the facility failed to maintain furnishings in accordance with NFPA 101 (2012) Life Safety Code. Findings include: No documentation of resident curtains being maintained as fire resistant Regulatory Reference: NFPA 101 (2012)19.7.5.1* Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1(see 19.3.5.11), and the following also shall apply:Such curtains shall include cubicle curtains. Such curtains shall not include curtains at showers and baths. Such draperies and curtains shall not include draperies and curtains at windows in patient sleeping rooms in smoke compartments sprinklered in accordance with 19.3.5. Such draperies and curtains shall not include draperies and curtains in other rooms or areas where the draperies and curtains comply with all of the following:Individual drapery or curtain panel area does not exceed 48 ft2 (4.5 m2)Total area of drapery and curtain panels per room or area does not exceed 20 percent of the aggregate area of the wall on which they are located. Smoke compartment in which draperies or curtains are located is sprinklered in accordance with 19.3.5. 19.7.5.6 Combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied. The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20 kW ignition source.* The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with the following:Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door and do not exceed the area limitations of 19.7.5.6(b), (c), or (d). Decorations do not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7. Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system in accordance with Section 9.7. Decorations do not exceed 50 percent of the wall, ceiling, and door areas inside patient sleeping rooms, having a capacity not exceeding four persons, in a smoke compartment that is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. (5)* They are decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present. This deficiency has the potential to affect all smoke compartments within the facility, and all residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Based on observation and staff interviews during the course of the survey, it was determined that the facility failed to maintain fire door assembly according to NFPA 101 (2012) and NFPA 80. Findings include: Hasp attached to a fire roll down door in kitchen to keep shut Regulatory Reference: NFPA 101 (2012) 19.7.6 Maintenance and Testing. See 4.6.12.4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 8.3.3 Fire Doors and Windows. 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. This deficiency has the potential to affect approximately 8 residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Based on record review and interview, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). Findings include: Polarity Retention | Not all rooms being tested | documentation shows that there were failures however, showing no correction Regulatory Reference: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect all smoke compartments within the facility, and all residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 ofthe Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8. Findings include: No documentation available for all weekly, monthly and annual inspections for generator | Not meeting NFPA 110 (2010) requirements Natural gas valve leading to the generator missing protected coverage Regulatory Reference: NFPA 101 (2012) 9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 (2010)8.1.1 The routine maintenance and operational testing program shall be based on all of the following:Manufacturer’s recommendationsInstruction MaterialsMinimum requirements of this chapterThe authority having jurisdiction8.4.1 EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing according of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. NFPA 99 (2012)6.4.1.2 Battery. Battery systems shall meet all requirements of Article 700 of NFPA 70, National Electrical Code. 6.4.4.1.3 Maintenance of Batteries. Batteries for on-site generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 6.4.4.1.1.4 Inspection and Testing. Criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C).(A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.(B) Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.(C) Test Personnel. The scheduled tests shall be conducted by competent personnel to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 6.4.4.2 Record Keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. NFPA 110 (2010)8.4.2.4 Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or until the water temperature and oil pressure have stabilized. 8.4.3 The EPS test shall be initiated by simulating a power outage using the test switch(es) on the ATSs or by opening a normal breaker. Opening a normal breaker shall not be required. 8.4.4 Load tests of generator sets shall include complete cold starts. 8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. A.5.6.4.5.1 It is recommended that lead-acid starting batteries be replaced every 24-30 months. 8.4.6 Transfer switches shall be operated monthly. A.7.9.7 Valving for natural gas-fueled prime movers should be configured so that the gas supply to the prime mover cannot be inadvertently or intentionally shut off by anyone other than qualified personnel such as the gas supplier. If valves are placed in an isolated area, a secure area or locking the valve(s) open is recommended. This deficiency has the potential to affect all smoke compartments within the facility, and all residents, visitors, and staff. The deficiency was discussed with the administrative director and maintenance personnel during the survey exit conference.

A survey with #CO2786824 was completed on 3/23/26 to 3/26/26. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure one (#11) of four residents out of 36 sample residents remained free from accidents. Resident #11 was admitted to the facility on 12/21/25 with diagnoses including parkinsonism, dementia, muscle weakness, a history of falls, and dysphagia (difficulty swallowing). On 1/28/26, Resident #11 sustained an unwitnessed fall from her electronic reclining chair. The facility recommended unplugging the resident’s chair to prevent her from using the remote control due to cognitive impairments. The director of nursing (DON) said on 3/26/26, at some time before the fall on 2/14/26, the resident’s electric chair was plugged back in (see interview below). On 2/14/26, the resident used the remote to the electronic reclining chair and sustained an additional unwitnessed fall. The resident was transferred to the hospital where she received staples to the laceration on her head and sustained a small hematoma (brain bleed). Specifically, the facility failed to ensure Resident #11’s fall interventions were consistently implemented to prevent a fall with major injury. Findings include:I. Facility policy and procedureThe Fall Management policy, dated 3/1/26, was provided by the nursing home administrator (NHA) on 3/26/26 at 6:10 p.m. The policy revealed in pertinent part,“Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. “Complete a thorough analysis of fall – time of day, location of fall, causative factors. Identify whether the interventions were in place at the time of the fall. “Educate and communicate implemented interventions to direct care staff via verbal report.”II. Resident #11A. Resident statusResident #11, age 82, was admitted to the facility on 12/21/25. According to the March 2026 computerized physician orders, diagnoses included a history of falls, diagnosis of Parkinson’s disease and dementia. The 2/21/26 comprehensive assessment revealed the resident had moderate cognitive impairment. The resident used a manual wheelchair. The resident required substantial assistance with personal hygiene, toileting, transferring and walking. The assessment documented Resident #11 had sustained two falls since admission to the facility with injuries. B. Record reviewThe activities of daily living (ADL) care plan, initiated 12/21/25, revealed Resident #11 had an ADL self-care performance deficit related to Parkinson’s disease and dementia. Pertinent interventions included providing assistance with mobility in a wheelchair, providing one-person maximum assistance with transfers and encouraging the resident to use the call light for assistance. The fall care plan, dated 1/6/26, documented Resident #11 was at risk for falls related to a previous fall with fracture and dementia. Pertinent interventions included anticipating and meeting the resident’s needs (initiated 12/21/25), assessing the resident’s needs for adaptive devices (initiated 12/21/25), ensuring the resident’s call light was in place (initiated 12/21/25), encouraging the resident to use her call light (initiated 12/21/25), ensuring there was adequate lighting in place (initiated 12/21/25), ensuring the resident was wearing appropriate footwear when ambulating (initiated 12/21/25), placing a fall mat next to the resident’s bed when in bed (initiated 2/6/26), providing therapy as needed (initiated 12/21/25), placing the electric recliner with a manual recliner for safety (initiated 2/16/26) and reviewing past falls (initiated 12/21/25). -However, the facility failed to ensure the staff were educated regarding the unplugging of the electric reclining chair to ensure it remained unplugged to prevent an additional fall. The facility investigation, dated 1/28/26 was provided by the NHA on 3/26/26 at approximately 2:00 p.m. The investigation documented Resident #11 sustained an unwitnessed fall in front of her electric reclining chair on 1/28/26. Resident #11 was assessed by the nurse and no injuries were reported, however the physician ordered the facility to send the resident to the hospital for an evaluation. The resident was transported to the hospital at 6:20 p.m. According to the emergency room physician progress notes, Resident #11 was monitored in the emergency department and received one liter of normal saline fluid intravenously for dehydration. The physician reported Resident #11 appeared more awake, alert and discharged back to the facility at 8:10 p.m. The resident’s representative was notified and stayed with the resident at the emergency department until discharge. The facility investigation, dated 2/14/26, was provided by the NHA on 3/26/26 at approximately 2:00 p.m. The investigation documented Resident #11 sustained an unwitnessed fall on 2/14/26 at 11:20 a.m. The resident was found lying on the floor on her right side with her head partially under the bedside table next to her with the legs of the table slightly under her right side. The residents’ recliner was elevated in the fully upright position. The resident had blood coming from the right side of her head. The investigation documented the licensed practical nurse (LPN) reported it appeared the recliner button was inadvertently pushed by the resident, and the recliner raised her up and she fell out of the chair and hit her head on the bedside table. Resident #11 stated she did not know exactly what happened and how she fell out of her chair. The investigation documented emergency medical services (EMS) were called, and the resident was transported to the emergency room. Resident #11 was assessed by a physician who reported the resident sustained a mechanical fall from her recliner and sustained a laceration to the right side of her head that required staples. A computed tomography (CT - imaging test) scan was completed. The emergency department physician reported the CT scan showed a mixed subdural chronic hematoma (a brain bleed from a previous event) and an acute (portion that was two millimeters without any effacement - a new brain bleed). The resident was monitored in the emergency room with her daughter present for another five hours and 35 minutes. The investigation documented the resident was determined to be neurologically stable and discharged back to the facility. III. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 3/25/26 at 12:33 p.m. CNA #4 said Resident #11 required two-person assistance with transfers from the bed to the reclining chair. CNA #4 said she reported any concerns regarding care of Resident #11 to the nurse. The director of nursing (DON) was interviewed on 3/26/26 at 3:44 p.m. The DON said Resident #11 had sustained two falls since admission. The DON said Resident #11 had an unwitnessed fall on 1/28/26, where she was found in front of her electric reclining chair. The DON said the resident was assessed by a nurse, EMS was notified, and the resident was transported to the emergency department. The DON said the resident returned to the facility after a few hours with no injury. The DON said the facility implemented an intervention of unplugging the resident’s electric reclining chair.-However, the facility failed to ensure the electric reclining chair was unplugged and the resident sustained an additional fall from the chair on 2/14/26, related to the resident using the remote (see record review above). The conversation between the facility staff and the resident about unplugging the electric reclining chair was not documented in the resident’s electronic medical record (EMR). The DON said Resident #11 sustained another fall on 2/14/26, where she was found on the floor by the chair with her head bleeding. The DON said the resident was transported to the hospital and assessed by the emergency physician. The DON said a CT scan was completed and sutures were placed on the right side of the Resident #11’s head. The DON said the CT scan was reviewed by the medical director (MD) who determined the CT scan showed no long-lasting concerns. The DON said the resident’s electric recliner was replaced on 2/15/26 with a manual recliner. The DON said the facility conducted a root cause analysis of the fall on 2/14/26. The DON said the facility determined Resident #11 used the electric reclining chair, which was plugged back in since 1/28/26. He said he thought the housekeeping staff might have plugged the chair in again when it should have remained unplugged after Resident #11 sustained the fall on 1/28/26. The DON said the electric reclining chair should have been removed from Resident #11’s room after the residents’ fall on 1/28/26 and replaced with the manual recliner. The MD was interviewed on 3/26/26 at 4:50 p.m. The MD said he had reviewed Resident #11’s hospital records from 2/14/26. He said the CT scan finding was not enough to cause any long lasting problems.

A recertification survey with complaint #CO2786823 and Incident #2795220, Incident #2795225, Incident #2795233, Incident #2795239 and Incident #2795261 was conducted on 3/23/26 to 3/26/26. Eight deficiencies were cited.

An Emergency Preparedness survey was conducted from 3/23/26 to 3/26/26. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure residents’ personal funds accounts were managed adequately for the facility and accessible to the residents for three (#7, #27 and #44) of three residents out of 36 sample residents. Specifically, the facility failed to ensure residents were educated on how to access their money on the weekends. Findings include: I. Resident interviewsResident #7 was interviewed on 3/23/26 at 2:40 p.m. He said the person who handled the money was not always at the facility. He said he was not aware of any times on the weekends when he could pull out his money. Resident #7 was interviewed a second time on 3/25/26 at 1:04 p.m. He said he normally went to the business office manager or the front desk to pull out his money. He said he could not get money out on the weekends. Resident #27 was interviewed on 3/25/26 at 1:07 p.m. She said she was not able to pull money out of her account on the weekends. Resident #44 was interviewed on 3/25/26 at 1:11 p.m. He said he had to pull money out before the weekend if he had any plans to go anywhere on the weekend. II. ObservationsDuring the survey process, a sign listing banking hours was not observed in the facility. III. Staff interviewsThe wound care nurse was interviewed on 3/26/26 at 11:12 a.m. She said she did work on weekends. She said when she did work on the weekends, the issue of pulling money out had not come up. She said during the week the residents would go to the front office. She said she was unsure of what the process was for the weekends. Licensed practical nurse (LPN) #2 was interviewed on 3/26/26 at 11:15 a.m. She said she did work on the weekends and during the week the residents usually went to the business office manager to pull out their money. She said she was unsure of the process of how residents accessed their money on the weekends. The business office manager was interviewed on 3/26/26 at 1:05 p.m. He said he was unsure if the residents had ever been educated on how to access their money on the weekends. He said he thought the residents were told when they first admitted to the facility. He said the facility did not have their banking hours posted anywhere. He said the residents were able to access their money on the weekend by going to the receptionist at the front desk. He said the facility had a receptionist seven days a week. He said the receptionist had access to the petty cash box. He said he was unsure if all of the staff knew the weekend process of how residents access their money. He said residents should be aware of how to access their funds on the weekends. The nursing home administrator (NHA) was interviewed on 3/26/26 at 1:22 p.m. She said the residents should be able to access their funds on the weekends. She said the facility would post their banking hours and would educate residents during resident council meetings. She said that all of the staff should know the process of how residents access their funds on the weekends because a resident can ask any staff member.

Based on observations, record review and interviews, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility’s most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the past three years. Specifically, the facility failed to ensure three years of survey and investigation findings were available for the public, and where individuals wishing to examine survey results did not have to ask to see them. Findings include: I. Resident interviewsThree residents (#12, #14 and #59) who were identified as alert and oriented by facility and assessment were interviewed on 3/25/26 at 10:15 a.m. Resident #12, Resident #14 and Resident #59 said they did not know where to find the results of recent survey findings. II. Observations and staff interviewThe facility’s survey results binder was not located in an area where individuals could examine results on 3/25/26 at 10:50 a.m. The nursing home administrator (NHA) provided a survey results binder on 3/25/26 at 11:00 a.m. The NHA said she had removed the binder from the facility’s lobby the previous day in order to ensure the binder was up to date with previous survey findings. -The survey results binder provided was found to contain results from the recertification survey on 3/7/24 and one complaint survey 6/30/25. The binder failed to include the facility’s last three years of complaint findings. The NHA said the complaint investigations and plans of correction for the past three years should have been included in the binder.

Based on record review and interviews, the facility failed to ensure three (#45, #58 and #27) of five residents were kept free from abuse out of 36 sample residents. Specifically, the facility failed to:-Protect Resident #45 and Resident #58 from physical by Resident #80; and,-Protect Resident #27 from physical abuse by Resident #21. III. Incident of physical abuse by Resident #80 towards Resident #58 on 11/15/25A. Facility investigation The facility investigation, dated 11/15/25, documented that at approximately 8:35 p.m. Resident #80 was observed grabbing Resident #58 from behind his right ear and scratching the back of his neck on the right side. The staff separated the residents. A one-to-one caregiver was initiated for Resident #80 when she was not in bed and 15-minute checks were initiated when she was in bed. Resident #58 was assessed for further injuries. Both residents’ representatives were informed of the incident, as well as the police. The facility investigation documented that Resident #80 was in a previous physical abuse allegation on 11/2/25 (see incident above). The facility investigation documented the SSD interviewed Resident #58 (alleged victim) on 11/17/25 at 10:50 a.m. about the incident with Resident #80. Resident #58 said he did not remember the incident and could not recall how he had gotten the scratch on the back of his neck. When the SSD asked if another resident had ever hurt him, Resident #58 told her no. When the SSD asked him if he was ever afraid or worried that something might happen to him or someone else he shook his head indicating no. The facility investigation documented Resident #80 was interviewed on 11/17/25 at 11:11 a.m. The investigation documented Resident #80 had a hard time maintaining focus and attention to the conversation due to her cognitive impairment. Resident #80 could not recall seeing Resident #58 in the lobby and she could not recall being upset with any other residents. The SSD interviewed the CNA that witnessed the incident between Resident #58 and Resident #80 on 11/21/25. The CNA said Resident #80 was speaking loudly to the other residents in the front lobby like she normally did. She said that both Resident #80 and Resident #58 were in the front lobby area. The CNA observed Resident #80 lean forward and grab Resident #58’s ear. The CNA reported she thought that Resident #80 was trying to get Resident #58’s attention. The CNA reported she separated the residents immediately. The CNA said that Resident #58 looked confused and wide-eyed but once he was away from Resident #80, he went back to his normal self. The CNA reported that Resident #58 did not verbalize being afraid. The CNA mentioned that Resident #80 was far from the nurses and CNAs that were taking care of her that day and felt that it would have been more efficient if Resident #80 stayed closer to the nurses’ station down her hall. The facility substantiated the allegation of physical abuse. The occurrence was witnessed by staff, Resident #58 had an injury to the back of his neck which was consistent with the CNAs account. B. Resident #58 (victim) 1. Resident statusResident #58, age greater than 65, was admitted on 1/4/22. According to the March 2026 CPO, diagnoses included Alzheimer’s disease, dementia and sensorineural hearing loss bilateral (gradual hearing loss in both ears). The 1/9/26 MDS assessment revealed Resident #58 had severe cognitive impairment with a BIMs score of three out of 15. The MDS assessment documented that Resident #58 did not have any aggressive behaviors, wandering or rejection of care. The MDS assessment documented that Resident #58 was dependent on staff for most of his ADLs. 2. Resident #58’s representative interviewResident #58’s representative was interviewed on 3/24/26 at 10:32 a.m. The representative said a few months ago a female resident (Resident #80) had scratched Resident #58. He said that he did not think that it was anyone’s fault. He said the facility let him know whenit happened. He said he felt that the facility did the best job that they could and that the facility worked very hard to make sure his loved one feels loved. 3. Record reviewThe elopement and wandering care plan, revised 7/15/25, documented Resident #58 was at risk for elopement, referring to attempting to leave the building. Pertinent interventions included participating in morning activities, monitoring the residents whereabouts, identifying patterns of wandering, and checking wander guard placement and functioning. The communication care plan, revised 7/15/25 documented Resident #58 had a communication problem referring to his diagnosis of bilateral hearing loss. The care plan documented he did not wear hearing aids. Pertinent interventions included in English, minimizing background noise, speaking on an adult level facing him and speaking clearly and slowly, and reporting any changes in ability to communicate. A nursing progress note, dated 11/15/25 at 9:22 p.m., documented Resident #58 sustained a scratch to the back of his neck by another resident (Resident #80). The note documented that the nurse on duty was informed and assessed the resident. A nursing progress note, dated 11/16/25 at 3:55 a.m., documented that the nurse was notified by the nurse working the 200 hall that Resident #80 had grabbed Resident #58 by his right ear from behind and scratched the back of his neck. The residents were separated and messages were left for the NHA and the DON. The residents’ representatives were called, as well as the authorities. The note documented Resident #80 did not sustain any injuries. C. Resident #80 (assailant) 1. Record reviewA nursing note, dated 11/16/25 at 3:54 a.m., documented that the nurse was called to the 200 unit (on 11/15/26) because Resident #80 had grabbed Resident #58’s ear and scratched his neck. The note documented that the nurse left messages for the NHA, the DON and the residents’ representatives and the authorities were contacted. The note documented that Resident #80 did not obtain any injuries from the incident. A nursing note, dated 11/18/25 at 3:50 a.m., documented that Resident #80 had been on 15-minute checks and within line-of-sight while awake. D. Staff interviewsCNA #6 was interviewed on 3/25/26 at 3:35 p.m. CNA #6 said Resident #80 went up and down the halls looking for a doctor. She said she would knock on doors and wander. She said Resident #80 was not aggressive, but would talk really loud because she could not hear very well. She said Resident #80 sometimes tried to grab other residents to try and get their attention. She said Resident #80 would do that often when she was in the lobby area and the residents were close together. She said she did not remember Resident #80 grabbing Resident #58. The NHA, the DON and the SSD were interviewed together on 3/26/26 at 3:35 p.m. The SSD said that Resident #80 was seen grabbing Resident #58’s ear from behind and she scratched his neck. She said after that happened, the facility did a medical workup on Resident #80 to see if she had a fracture on her left arm. She said Resident #80 would often complain of pain. Resident #80 was unable to verbalize what was bothering her due to her cognitive ability. She said that activities would not hold her attention for long, she said even with one-on-one activities she would lose interest. The SSD said that Resident #80’s behaviors would start “out of the blue.” She said the resident did not have any signs of when she would become agitated.

Based on observations, record review and interviews, the facility failed to ensure one (#11) of four residents out of 36 sample residents remained free from accidents. Resident #11 was admitted to the facility on 12/21/25 with diagnoses including parkinsonism, dementia, muscle weakness, a history of falls, and dysphagia (difficulty swallowing). On 1/28/26, Resident #11 sustained an unwitnessed fall from her electronic reclining chair. The facility recommended unplugging the resident’s chair to prevent her from using the remote control due to cognitive impairments. The director of nursing (DON) said on 3/26/26, at some time before the fall on 2/14/26, the resident’s electric chair was plugged back in (see interview below). On 2/14/26, the resident used the remote to the electronic reclining chair and sustained an additional unwitnessed fall. The resident was transferred to the hospital where she received staples to the laceration on her head and sustained a small hematoma (brain bleed). Specifically, the facility failed to ensure Resident #11’s fall interventions were consistently implemented to prevent a fall with major injury. Findings include:I. Facility policy and procedureThe Fall Management policy, dated 3/1/26, was provided by the nursing home administrator (NHA) on 3/26/26 at 6:10 p.m. The policy revealed in pertinent part,“Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. “Complete a thorough analysis of fall – time of day, location of fall, causative factors. Identify whether the interventions were in place at the time of the fall. “Educate and communicate implemented interventions to direct care staff via verbal report.”II. Resident #11A. Resident statusResident #11, age 82, was admitted to the facility on 12/21/25. According to the March 2026 computerized physician orders, diagnoses included a history of falls, diagnosis of Parkinson’s disease and dementia. The 2/21/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident used a manual wheelchair. The resident required substantial assistance with personal hygiene, toileting, transferring and walking. The MDS assessment documented Resident #11 had sustained two falls since admission to the facility with injuries. B. Record reviewThe activities of daily living (ADL) care plan, initiated 12/21/25, revealed Resident #11 had an ADL self-care performance deficit related to Parkinson’s disease and dementia. Pertinent interventions included providing assistance with mobility in a wheelchair, providing one-person maximum assistance with transfers and encouraging the resident to use the call light for assistance. The fall care plan, dated 1/6/26, documented Resident #11 was at risk for falls related to a previous fall with fracture and dementia. Pertinent interventions included anticipating and meeting the resident’s needs (initiated 12/21/25), assessing the resident’s needs for adaptive devices (initiated 12/21/25), ensuring the resident’s call light was in place (initiated 12/21/25), encouraging the resident to use her call light (initiated 12/21/25), ensuring there was adequate lighting in place (initiated 12/21/25), ensuring the resident was wearing appropriate footwear when ambulating (initiated 12/21/25), placing a fall mat next to the resident’s bed when in bed (initiated 2/6/26), providing therapy as needed (initiated 12/21/25), placing the electric recliner with a manual recliner for safety (initiated 2/16/26) and reviewing past falls (initiated 12/21/25). -However, the facility failed to ensure the staff were educated regarding the unplugging of the electric reclining chair to ensure it remained unplugged to prevent an additional fall. The facility investigation, dated 1/28/26 was provided by the NHA on 3/26/26 at approximately 2:00 p.m. The investigation documented Resident #11 sustained an unwitnessed fall in front of her electric reclining chair on 1/28/26. Resident #11 was assessed by the nurse and no injuries were reported, however the physician ordered the facility to send the resident to the hospital for an evaluation. The resident was transported to the hospital at 6:20 p.m. According to the emergency room physician progress notes, Resident #11 was monitored in the emergency department and received one liter of normal saline fluid intravenously for dehydration. The physician reported Resident #11 appeared more awake, alert and discharged back to the facility at 8:10 p.m. The resident’s representative was notified and stayed with the resident at the emergency department until discharge. The facility investigation, dated 2/14/26, was provided by the NHA on 3/26/26 at approximately 2:00 p.m. The investigation documented Resident #11 sustained an unwitnessed fall on 2/14/26 at 11:20 a.m. The resident was found lying on the floor on her right side with her head partially under the bedside table next to her with the legs of the table slightly under her right side. The residents’ recliner was elevated in the fully upright position. The resident had blood coming from the right side of her head. The investigation documented the licensed practical nurse (LPN) reported it appeared the recliner button was inadvertently pushed by the resident, and the recliner raised her up and she fell out of the chair and hit her head on the bedside table. Resident #11 stated she did not know exactly what happened and how she fell out of her chair. The investigation documented emergency medical services (EMS) were called, and the resident was transported to the emergency room. Resident #11 was assessed by a physician who reported the resident sustained a mechanical fall from her recliner and sustained a laceration to the right side of her head that required staples. A computed tomography (CT - imaging test) scan was completed. The emergency department physician reported the CT scan showed a mixed subdural chronic hematoma (a brain bleed from a previous event) and an acute (portion that was two millimeters without any effacement - a new brain bleed). The resident was monitored in the emergency room with her daughter present for another five hours and 35 minutes. The investigation documented the resident was determined to be neurologically stable and discharged back to the facility. III. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 3/25/26 at 12:33 p.m. CNA #4 said Resident #11 required two-person assistance with transfers from the bed to the reclining chair. CNA #4 said she reported any concerns regarding care of Resident #11 to the nurse. The director of nursing (DON) was interviewed on 3/26/26 at 3:44 p.m. The DON said Resident #11 had sustained two falls since admission. The DON said Resident #11 had an unwitnessed fall on 1/28/26, where she was found in front of her electric reclining chair. The DON said the resident was assessed by a nurse, EMS was notified, and the resident was transported to the emergency department. The DON said the resident returned to the facility after a few hours with no injury. The DON said the facility implemented an intervention of unplugging the resident’s electric reclining chair.-However, the facility failed to ensure the electric reclining chair was unplugged and the resident sustained an additional fall from the chair on 2/14/26, related to the resident using the remote (see record review above). The conversation between the facility staff and the resident about unplugging the electric reclining chair was not documented in the resident’s electronic medical record (EMR). The DON said Resident #11 sustained another fall on 2/14/26, where she was found on the floor by the chair with her head bleeding. The DON said the resident was transported to the hospital and assessed by the emergency physician. The DON said a CT scan was completed and sutures were placed on the right side of the Resident #11’s head. The DON said the CT scan was reviewed by the medical director (MD) who determined the CT scan showed no long-lasting concerns. The DON said the resident’s electric recliner was replaced on 2/15/26 with a manual recliner. The DON said the facility conducted a root cause analysis of the fall on 2/14/26. The DON said the facility determined Resident #11 used the electric reclining chair, which was plugged back in since 1/28/26. He said he thought the housekeeping staff might have plugged the chair in again when it should have remained unplugged after Resident #11 sustained the fall on 1/28/26. The DON said the electric reclining chair should have been removed from Resident #11’s room after the residents’ fall on 1/28/26 and replaced with the manual recliner. The MD was interviewed on 3/26/26 at 4:50 p.m. The MD said he had reviewed Resident #11’s hospital records from 2/14/26. He said the CT scan finding was not enough to cause any long lasting problems.

Based on observations, record review and interviews, the facility failed to ensure two (#30 and #11) of 11 residents out of 36 sample residents received the nutritional care and services necessary to maintain their highest practicable level of well-being. Resident #30 was admitted to the facility on 11/12/25 with a diagnosis of dementia. Upon admission, the resident weighed 141.5 pounds (lbs) and was not identified to have nutritional concerns. On 12/10/25, the resident weighed 134.5 lbs, indicating a 7 lbs weight loss. The facility failed to address the residents' weight loss. On 12/17/25, the resident weighed 131 lbs, which indicated the resident sustained a 7.4% (10.5 lbs) weight loss in 30 days, which was considered severe. Per interviews with the registered dietitian (RD), the facility failed to identify the resident’s weight loss until 1/30/26. However, Resident #30 continued to lose weight. On 2/26/26, the resident weighed 121.5 lbs, which indicated a 14.13% (20 lbs) weight loss, which was considered severe. The facility failed to implement a nutritional intervention until 2/6/26, approximately two months after the resident began losing weight. Resident #11 was admitted on 12/21/25 with diagnoses of Parkinson’s disease and dementia. Upon admission, Resident #11 weighed 119 lbs. On 12/30/25 the resident weighed 117 lbs. On 2/4/26, the resident weighed 107 lbs, indicating a 18.9% (22 lbs) weight loss from 12/21/25 to 2/23/26, a period of two months, which was considered severe. The facility failed to address and implement nutritional interventions until 2/20/26, approximately two weeks after the resident sustained weight loss. Specifically, the facility failed to timely implement person-centered nutritional interventions for Resident #30 and Resident #11, who experienced severe weight loss. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation, on 3/23/26 to 3/26/26, resulting in the deficiency being cited as past noncompliance with a correction date of 3/13/26. I. Situation of harmResident #30 sustained a 7.4% (10.5 lbs) weight loss from 11/16/25 to 12/17/25 and 14.13 % (20 lbs) from 11/16/25 to 2/26/26, which was considered severe. The facility failed to identify the resident’s weight loss and implement person-centered nutritional interventions for approximately two months after the resident began losing weight. Resident #11 sustained a 18.9% (22 lbs) weight loss from 12/21/25 to 2/23/26, which was considered severe. The facility failed to identify the resident’s weight loss and implement person-centered nutritional interventions for approximately two weeks. II. Facility plan of correctionOn 3/26/26 at 10:47 a.m. the director of nursing (DON) provided a corrective action plan the facility implemented in response to residents’ weight loss. The corrective action plan documented the following:A. Identification of concern The facility identified there were concerns regarding weight loss on 3/1/26. B. Corrective action for affected residents included the following:-Reviewed weights for identified residents, reweights completed by 3/6/26 by certified nurse aide (CNA) leaders.-Notification of the provider and the RD regarding identified residents was completed on 3/6/26 by the assistant director of nursing (ADON).-Notified the corporate team of the concerning weights on 3/6/26 during the weekly weight meeting.-Checked the last calibration of the weight scale on 3/5/26 with the ADON and the maintenance assistant. Discussed community order weights to complete calibration, or a company coming into the community every three months. C. Identification of other residents having the potential to be affected:The facility identified all residents had the potential for deficient practice. D. Address measures or systemic changes to ensure the deficient practice will not recur:-Education was provided to the interdisciplinary team (IDT) on the weight management process completed by a registered nurse (RN) quality mentor on 3/6/26.-Education was provided to CNA staff on the weight management program by the CNA team lead.-Each resident would be weighed upon admission and weekly or per provider orders. The nursing management team would review triggered weight changes daily (Monday through Friday) in the clinical morning meeting.-Any concerning weights would be addressed with the RD. -Weekly IDT would complete a weight meeting and review any residents with weight concerns. Residents reviewed would be written on the weight log, and progress note entered into the EMR. The RD would review abnormal weights and review high-risk residents monthly and all residents quarterly. The team would implement interventions as needed, and the resident’s care plan would reflect the resident's weight concerns and interventions. E. Plan to monitor for sustained complianceThe DON/designee would audit abnormal weights weekly for 12 weeks, audits would be written on the weekly weight log. Any abnormal weights would be addressed with the RD.-The DON/designee would report findings from the audits to the QAPI (quality assurance and performance improvement) Committee monthly for 90 days. The QAPI committee would identify any trends and take corrective action as needed. The first weight meeting was on 3/6/26 with the IDT and the RD. The RN quality mentor joined and provided additional education. Supplement orders were entered in the residents’ electronic medical records (EMR). Education was provided to the team by the RN quality mentor on 3/6/26.-The facility documented the date of compliance was 3/13/26. III. Facility policy and procedureThe Weight Management policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 3/26/26 at 8:25 a.m. It read in pertinent part,"Residents are monitored for weight change on a regular basis. Results are reviewed and analyzed by the facility for interventions as appropriate. “Residents identified with weight change will be assessed by the interdisciplinary team (IDT), and further interventions will be implemented to minimize the risk for further weight change where possible and to promote weight stability. “Residents identified at risk for weight change will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, RD evaluation, and assisted dining.“The director of nursing or designee will analyze results for trends and patterns in residents identified with weight changes and report findings to the QAPI committee for review and recommendations.”IV. Resident #30A. Resident statusResident #30, age greater than 65, was admitted on 11/12/25. According to the March 2026 computerized physician orders (CPO), diagnoses included left femur fracture, chronic kidney disease, atrophy of the thyroid, essential hypertension, need for assistance with personal care and unspecified dementia. The 1/9/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The MDS assessment documented Resident #30 had no issues swallowing and could eat independently, without any setup assistance or verbal cues. The resident was 70 inches tall and weighed 134 lbs. The MDS assessment documented Resident #30 had not experienced any significant weight loss. B. Observations and representative interviewResident #30’s representative was interviewed on 3/24/26 at 9:11 a.m. The representative said she noticed Resident #30 had been losing weight, but did not know why. The representative said when she visited the facility, she encouraged Resident #30 to eat, and Resident #30 would eat the majority of her meals. The representative was observed asking Resident #30 if she had eaten yet, but Resident #30 did not answer. The representative said some days Resident #30 did not talk much. The representative said Resident #30 appeared sleepy. On 3/24/26, from 12:12 p.m. to 12:36 p.m., Resident #30 was continuously observed. Resident #30 was in the dining room for lunch. An unidentified staff member set a plate of spaghetti in front of Resident #30 and asked her if she wanted her food cut up. Resident #30 did not respond and the staff member walked away. Resident #30 sat in front of the plate for a few minutes without eating. Resident #30’s representative then assisted Resident #30 and cut up the spaghetti into smaller bites. Resident #30 ate around 25% of her meal and left the dining room. C. Record reviewThe nutrition care plan, initiated 11/24/25, identified Resident #30 was at risk for nutrition problems as a result of leaving more than 25% of her meals uneaten. The interventions included monitoring weights as ordered, offering food alternatives, providing the diet as ordered, monitoring food intakes and the RD was to evaluate as needed. The weight loss care plan, initiated 2/23/26, revealed Resident #30 had unplanned weight loss as a result of having poor oral intake. Pertinent interventions included alerting the RD if intake was poor for greater than 48 hours, providing supplements, monitoring oral intake and monitoring weekly weights. Resident #30’s weights were documented in the EMR as follows:-On 11/16/25, the resident weighed 141.5 lbs;-On 12/10/25, the resident weighed 134.5 lbs;-On 12/17/25, the resident weighed 131 lbs;-On 1/9/26, the resident weighed 134 lbs;-On 2/11/26, the resident weighed 127 lbs;-On 2/26/26, the resident weighed 121.5 lbs;-On 3/8/26, the resident weighed 123 lbs; and,-On 3/11/26, the resident weighed 118.5 lbs.-The resident sustained a 7.4% (10.5 lbs) weight loss, which was considered severe, from 11/16/25 to 12/17/25, in one month. -The resident sustained a 14.13% (20 lbs) weight loss, which was considered severe, from 11/16/25 to 2/26/26, in three months. -The facility failed to obtain an admission weight for four days after the resident was admitted to the facility. Resident #30’s March 2026 CPO revealed the following physician’s orders:Regular diet with regular consistency and thin liquids, ordered 11/12/25 and discontinued on 2/6/26. Regular diet with mechanical soft texture, thin liquids and fortified meals, ordered 2/6/26. Mighty shakes two times a day, ordered 2/20/26.-The facility failed to implement a nutritional intervention until 2/6/26, which was approximately two months after the resident first sustained severe weight loss. The 11/12/25 mini nutritional assessment documented Resident #30 had a normal nutritional status. On 11/13/25, Resident #30’s cognition was moderately impaired with a BIMS score of nine out of 15. The 1/5/26 mini-nutritional assessment documented Resident #30 was at malnourished nutritional status based on a measurement taken of her calf. On 1/5/26, Resident #30’s cognition was severely impaired with a BIMs score of four out of 15.-However, despite the facility identifying the resident was malnourished, the facility failed to implement any person-centered nutritional interventions. D. Staff interviewsThe RD was interviewed on 3/26/26 at 9:04 a.m. The RD said Resident #30 had multiple risk factors for nutritional concerns, such as diagnoses of dementia, a recent bone fracture and a low body mass index. The RD said Resident #30’s decline in weight was a result of poor oral intake due to dementia and difficulty staying engaged during meals. The RD said the direct care staff assisted in keeping the resident engaged during meals. The RD said she became involved in Resident #30’s care on 1/30/26, when the significant weight loss had been identified. -However, Resident #30 sustained a 7.4% (10.4 lbs) weight loss from 11/16/25 to 12/17/25, which was considered significant. The RD said no interventions were in place prior to the significant weight loss that she identified on 1/30/26, although the weights had been trending down since admission. The RD said she added the resident to the fortified food program on 2/6/26 and added supplements at the end of February 2026. The DON was interviewed on 3/26/26 at 10:47 a.m. The DON said he did not think the facility had implemented enough interventions to prevent weight loss for all residents in the facility, which was why he enacted a PIP (performance improvement plan) on 3/1/26. The DON said since enacting the action plan, many residents had stopped losing weight, and some had gained weight. The medical director (MD) was interviewed on 3/26/26 at 12:20 p.m. The MD said Resident #30’s weight change within her first month of admission was very significant and should have warranted intervention. The MD said the facility had not been doing a good job of managing residents’ weights. The MD said the facility recently identified systemic weight loss in the facility and was taking action to correct the issue with a QAPI and IDT approach. The MD said the facility had made progress in the management of residents’ weights, but was still developing successful systems. The activities director (AD) was interviewed on 3/26/26 at 4:14 p.m. The AD said she would sometimes help out as a CNA in the facility and was familiar with Resident #30. The AD said Resident #30's eating habits varied, based on her cognition level at the time. The AD said some days, Resident #30 was more distracted at mealtimes and needed frequent redirection from staff to eat. CNA #5 was interviewed on 3/26/26 at 4:15 p.m. CNA #5 said in recent weeks, Resident #30 needed increased cuing and encouragement to eat her food because she became distracted. CNA #5 said she often checked Resident #30’s meal tickets and had observed only 25% of the meal had been eaten. V. Resident #11A. Resident statusResident #11, age 82, was admitted on 12/21/25. According to the March 2026 CPO, diagnoses included Parkinson’s disease, dementia, muscle weakness and dysphagia (difficulty swallowing). The 2/26/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. Resident #11 required substantial assistance with personal hygiene, toileting, bed mobility, wheelchair assistance, transfers and eating. The MDS assessment revealed Resident #11 was 65 inches tall and weighed 98 lbs., was on a mechanically altered diet and had difficulty or pain with swallowing. B. Record reviewThe activities of daily living (ADL) care plan, initiated 12/21/25, documented Resident #11 had deficits related to Parkinsonism and dementia and Resident #11 required partial to moderate assistance with eating. The nutrition care plan, revised 3/10/26, documented Resident #11 had a swallowing problem related to coughing or choking during meals or swallowing medication. Pertinent interventions included providing assistance with meals using the hand over hand technique as needed. The poor oral intake care plan, initiated 1/6/26, revealed Resident #11 was at risk for poor fluid intake related to Parkinson’s disease and dementia. Pertinent interventions included encouraging fluid as tolerated. The unplanned/unexpected weight loss care plan, initiated 3/14/26, revealed Resident #11 had recent weight loss related to an acute illness and poor food intake. Pertinent interventions included alerting the RD if the resident’s intake was low for over 48 hours, providing supplements as ordered, alerting the RD if the resident was not consuming supplements as ordered, notifying the RD and the physician for weight loss, monitoring meal intake and monitoring weekly weights. The nutrition care plan, initiated 3/14/26, documented Resident #11 was malnourished related to her declining health status and leaving greater than 25% of her meals. Pertinent interventions included monitoring for symptoms of swallowing difficulties and providing Mighty Shake twice and a day and Boost Breeze twice a day. Resident #11’s weights were documented in the EMR as follows:-On 12/21/25, the resident weighed 119 lbs;-On 12/24/25, the resident weighed 117.2 lbs;-On 12/30/25, the resident weighed 117 lbs;-On 1/5/26, the resident weighed 116 lbs;-On 1/15/26 the resident weighed 114 lbs; -On 2/4/26 the resident weighed 107.5 lbs; -On 2/9/26, the resident weighed 106.5 lbs;-On 2/16/26, the resident weighed 101.5 lbs;-On 2/23/26, the resident weighed 97 lbs;-On 2/26/26, the resident weighed 97.5 lbs;-On 3/2/26, the resident weighed 98.5 lbs;-On 3/5/26 the resident weighed 97.8 lbs;-On 3/9/26 the resident weighed 97.5 lbs; and,-On 3/16/26 the resident weighed 96.5 lbs. -The resident had a 18.9% (22 lbs) weight loss from 12/21/25 to 2/23/26, a period of two months, which was considered severe. A review of Resident #11’s March 2026 CPO revealed the following physician’s orders:-Magic cup (frozen nutritional supplement), offer two times per day with lunch and dinner, ordered on 2/20/26. -Regular diet, pureed texture, regular/thin, fortified meals, ordered on 2/18/26.-Boost Breeze supplement (oral nutritional supplement), offer two times each day, ordered on 3/7/26. A nutrition progress note, dated 2/23/26, documented Resident #11 had lost 5% in 30 days. The note documented the resident’s body mass index was 16.7 (indicating the resident was underweight). The note documented Resident #11’s meal intake was between 0% to 25%, Resident #11 received Mighty Shake supplement three times each day, Magic cup supplement two times each day and fortified meals had recently been added. The note documented Resident #11 was being followed by the IDT.-However, review of Resident #11’s EMR revealed the facility did not implement a nutritional intervention until 2/18/26, which was approximately two weeks after the resident sustained significant weight loss. A nursing progress note, dated 2/24/26, documented the resident weighed 97 lbs. The note documented Resident #11’s diet texture changed and the resident was eating at a table in the dining room with meal assistance provided. The note documented the physician and the pharmacist had been notified of Resident #11’s weight loss. The nursing progress note, dated 2/27/26, documented Resident #11 weighed 97.5 lbs pounds The IDT progress note, dated 3/6/26 at 3:33 p.m., documented a nutrition review meeting was held to review Resident #11’s weights, skin, nutrition plan and interventions. The note documented interventions including fortified meals and Magic Cup supplements twice daily. The note documented a new intervention to add an eight ounces Boost Breeze supplement two times each day. D. Staff interviewsCNA #4 was interviewed on 3/25/26 at 12:33 p.m. CNA #4 said Resident #11 needed help with eating her pureed meal and the resident liked the magic cup supplement. CNA #4 said Resident #11 was offered Boost and Mighty Shake supplements between meals, but sometimes did not drink the supplements when offered. CNA #4 said she reported Resident #11’s meal intake to the nurse. The RD was interviewed on 3/26/25 at 9:20 a.m. The RD said the facility had implemented a plan to address weight loss in the last two months. She said there had been further improvement in weight loss after initiating meetings to review weekly weights. The RD said she began participating in virtual phone meetings weekly to review weight and skin concerns with the dietary manager and a nurse. The RD said the facility began weighing all residents weekly and she began reviewing residents for any changes, including weight loss of 5% or more and she documented the information in the residents’ care plans. The RD said Resident #11 was at high risk as her weight had been under 100 lbs since February 2026. The DON was interviewed on 3/26/26 at 10:59 a.m. the DON said Resident #11’s weight loss was related to her diagnosis of Parkinson’s disease, dementia, weakness and poor oral intake. The DON said there were recent improvements with the facility’s nutritional practices related to assessment for residents’ weight loss, including the initiation of facility audits, weekly weight monitoring for all residents and specific multidisciplinary review of residents with any documented weight loss. The DON said adjustments had been made to individualized care plans, including for Resident #11. The DON said interventions for Resident #11 included fortified foods, Mighty Shake supplements twice a day and chocolate milk at meals.

Based on observations, interviews, and record review, the facility failed to provide tube feeding management according to professional standards for one (#6) of one resident reviewed out of 36 sample residents. Specifically, the facility failed to:-Ensure the correct tube feeding formula was administered;-Ensure tube placement before tube feed administration; and-Provide flushes and water administration according to the physician’s orders. Findings include:I. Facility policy and procedureThe Enteral Tube Feeding via Continuous Pump policy, revised 2/23/24, was provided by the nursing home administrator (NHA) on 3/26/26 at 11:04 a.m. It read in pertinent part, “Steps in the procedure: 1. Place the equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. 2. Wash hands and dry thoroughly. 3. Wear clean gloves. 4. Position the head of the bed at 30 degrees to Fahrenheit (F) 45 degrees F (semi-Fowler’s position) for feeding, unless medically contraindicated. 5. Check the label on the enteral formula against the physician's order. 6. Attach enteral feeding pump set to bag and prime tubing. Clamp tubing. 7. Clamp enteral tube. Remove the plug. 8. Verify placement of the tube per current professional standards. 9. If anything suggests improper tube positioning, do not administer feeding or medication. Notify the charge nurse or physician. 10. When correct tube placement has been verified, flush tubing with at least 30 ml (milliliter) warm water (or prescribed amount). 11. Remove the syringe and clamp tubing. Initiate Feeding.”II. Resident #6A. Resident StatusResident #6, age 89, was admitted on 10/2/25. According to the March 2026 computerized physician’s orders (CPO), diagnoses included unspecified severe protein-calorie malnutrition, alcohol dependence, Alzheimer's disease, and benign prostatic hyperplasia (non-cancerous enlargement of the prostate). The 1/5/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 of 15. The MDS documented Resident #6 had pain or difficulty swallowing. Resident #6 received greater than 51% of his food and 501 ml of his fluid intake via a feeding tube. B. Record reviewReview of Resident #6’s CPO revealed the following orders for his tube feed management:-Resident is to be NPO (nothing by mouth), only tube feeds, ordered 3/10/26.-Administer 250 ml of water after nutrition administration four times a day for hydration, ordered 12/11/25. -Jevity 1.5 calorie (cal)/fiber oral liquid nutritional supplement 270 ml enterally four times a day, ordered 10/16/25. Resident #6’s tube feeding management care plan, initiated 10/2/25, revealed the resident had dysphagia (difficulty swallowing). The care plan documented the resident had poor fluid intake related to the resident’s NPO status. Pertinent interventions included to administer the tube feeding and water flushes per the physician’s order and to give water through the gastric tube per the physician’s orders. III. Observations and interviewsOn 3/24/26 at 4:32 p.m., licensed practical nurse (LPN) #3 administered a tube feeding to Resident #6. LPN #3 said she had opened the tube feed formula bottle at 10:00 a.m. the same morning. The tube feed formula bottle read Glucerna 1.2 cal with carbsteady. -However, the physician’s orders were for Jevity 1.5 cal formula tube feed. LPN #3 connected the tube feeding to Resident #6’s gastric tube and pressed start on the tube feeding pump.-However, LPN #3 did not ensure the gastric tube was in place before administering the tube feeding. LPN #3 did not flush the gastric tube with 30 ml of water or administer 250 ml of water per the physician’s order prior to administering the tube feed. On 3/25/26 at 10:01 a.m. LPN #2 administered tube feed to Resident #6. LPN #2 flushed Resident #6’s gastric tube with 250 ml of water before administering the formula. LPN #2 said Resident #6 was not allowed to eat ordrink by mouth, and his only hydration was water administered through the gastric tube. LPN #2 said Resident #6’s physician orders included administration of 250 ml of water before and after tube feeding.-However, the physician’s order was to administer 250 ml of water after tube feeding. IV. Staff interviewsLPN #3 was interviewed on 3/25/26 at 11:18 a.m. LPN #3 said after the observation on 3/24/26 at 4:32 p.m. she recognized something was not correct with the tube feeding. LPN #3 said she checked the physician’s orders and discovered the order was for Jevity 1.5 cal. LPN #3 said she went into Resident #6’s room, discontinued the incorrect tube feed formula, and then administered the correct tube feed formula per the physician’s orders. LPN #3 said she should have double-checked the label on the tube feed formula bottle before administration to Resident #6. The director of nursing (DON) was interviewed on 3/25/26 at 11:18 a.m. The DON said he did not know LPN #3 had administered the incorrect tube feeding. The DON said LPN #3 should have notified someone after the error. The DON said tube feeds should be flushed with water before and after tube feed formula administration to prevent the gastric tube from clogging. The DON said the tube placement should be assessed before nutrition administration.

Based on observations, interviews, and record review, the facility failed to maintain proper storage of medications for three out of three medication carts and one of three medication storage rooms. Specifically, the facility failed to:-Label insulin pens with the date they were opened;-Label inhalers with the date they were opened;-Discard opened medications for residents who had been discharged; and,-Discard expired medications Findings include:I. Professional referenceAccording to the manufacturer Arkray USA, inc, revised 2019, Performing a Control Solution Test, retrieved on 3/30/26 from,https://cdn.boundtree.com/btm/products/Bound_Tree_Arkray_Assure_Prism_Multi_Control_Solution_Directions_for_Use_8854369468446.pdf,“Check the expiration dates printed on the bottle. When you first open a control solution bottle, record the discard date (date opened plus [3] months) in the space provided on the label.“Out of range results may occur due to the following factors... When the control solution is past its discard date.”According to the manufacturer Biocon Biologics, 2023, Patient Information-Storing the Insulin Glargine yfgn pen, retrieved on 3/30/26 from, https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=3ac85ebb-5594-59c8-77fd-df254329d151&type=display#section-18m, “Only use your pen for up to 28 days after its first use. Throw away the Insulin Glargine yfgn pen you are using after 28 days, even if it still has insulin left in it.”According to the manufacturer Eli Lily, 2026, Highlights of Prescribing Information, retrieved on 3/30/26 from, https://pi.lilly.com/us/humalog-pen-pi.pdf,“When stored at room temperature, Humalog (insulin lispro) can only be used for a total of 28 days, including both not in-use (unopened) and in-use (opened) storage time.”According to the manufacturer GlaxoSmithKline, 2017, Highlights of Prescribing Information, retrieved on 3/30/26, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/204275s012lbl.pdf, “Discard Brea Ellipta six weeks after opening the foil tray or when the counter reads “0”, whichever comes first.”II. Facility policy and procedureThe Medication Storage policy, revised November 2020, was provided by the nursing home administrator (NHA) on 3/26/26 at 11:21 a.m. It read in pertinent part, “The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.“Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.” III. Observations and interviewsOn 3/24/26 at 2:15 p.m. the 200 hall medication cart was observed with licensed practical nurse (LPN) #5. The following was observed:-A used Ellipta inhaler for Resident #42 was not labeled with the date it was opened. LPN #5 said she did not know how long the medication was good for after it was opened. LPN #5 placed the medication back into the cart.-A used insulin lispro pen for Resident #15 with an opened date of 1/21/26. LPN #5 said the insulin pen was expired based on the opened date on the pen. LPN #5 said insulin pens were good for 30 days after they were opened, and an expired insulin pen could be less effective.- A used insulin lispro pen for Resident #27 was not labeled with the date it was opened. On 3/24/26 at 2:34 p.m. the medication cart that was used for the 100 and 400 hallway was observed with LPN #4. The following was observed:-Two nitroglycerine 0.4mg vials labeled with the name of a resident who had been discharged on 3/3/26.-A used insulin lispro pen for Resident #76 was not labeled with the date it was opened. LPN #4 labeled the pen with the date 3/23/26. LPN #4 said she assumed the insulin was opened the day before because she had not opened it, and she knew the facility had gotten a new shipment of medication the day before.-A used insulin glargine pen for Resident #41 was not labeled with the date it was opened. LPN #4 labeled the insulin pen with the date 3/23/26. LPN #4 said she labeled the pen based on the same assumption as the insulin lispro for Resident #76On 3/24/26 at 2:46 p.m. the medication storage room for the 100 and 400 hallway was observed with LPN #4. The following was observed:-A Tuberculin Purified Protein 5 TU (tuberculin units) per 0.1 milliliter (ml) vial with an opened date of 2/9/26. LPN #4 said she thought the medication might be expired. LPN #4 placed the medication back into the medication refrigerator. On 3/24/26 at 3:15 p.m. the 300 hallway medication cart was observed with LPN #3. The following was observed:-An open glucometer test control solution labeled 11/29/25. LPN #3 said testing the glucometers was a night shift nurse’s duty, and she did not know how long the solution was good for after opening. LPN #3 said she would have to ask the director of nursing (DON) how long the medication can be used for after it is opened. LPN #3 placed the solution back into the medication cart. IV. Staff interviewsThe clinical resource nurse was interviewed on 3/24/26 at 3:15 p.m. The clinical resource nurse said she had discarded the unlabeled insulin pens. The DON was interviewed on 3/25/26 at 10:40 a.m. The DON said LPN #4 should have discarded the unlabeled insulin pens instead of labeling them herself. The DON said LPN #4 had not opened the medications, which meant she did not know with certainty when the medications were opened. The DON said glucose control solutions should be used within 30 days of opening, and the glucose control solutions should have been discarded.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to ensure: -Food was held at the correct temperature;-Hand hygiene was conducted during meal service and dishwashing; -The kitchen was clean and sanitary; and, -Food was labeled and stored correctly in the walk-in refrigerator, freezer, reach-in refrigerator, and dry storage area. Findings include:I. Failure to hold food at the correct temperatureA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 3/31/26. It revealed in pertinent part, “Time/Temperature control for safety food, hot and cold holding at 135 degrees F (Fahrenheit) or higher and 41 degrees F and lower.” (Chapter 3)B. Facility policy and procedureThe Food Wholesomeness policy and procedure, revised December 2021, was provided by the nursing home administrator (NHA) on 3/26/26 at 8:25 a.m. It read in pertinent part, “Cold foods are kept between 34 to 41 degrees F prior to serving and frozen foods are kept at 0 degrees F or below.”C. ObservationsDuring a continuous observation on 3/24/26, beginning at 5:00 p.m. and ending at 6:01 p.m., the following was observed during the meal service in the main kitchen:At 5:00 p.m. the kitchen staff began serving room trays. A tray of small soufflé cups with sour cream in them was sitting on a metal cart next to the service line. The tray of soufflé cups were not sitting on ice. At 5:22 p.m. the tray of sour cream remained sitting on the cart and the soufflé cups have been put on trays and sent out to the residents. At 5:54 p.m. the assistant dietary manager prepared the test tray for the five surveyors and used one of the soufflé cups of sour cream. At 6:01 p.m. the five surveyors evaluated the test tray and the temperature of the sour cream was 74 degrees F. D. Staff interviews The assistant dietary manager was interviewed on 3/25/26 at 2:46 p.m. She said the soufflé cups of sour cream should have been on ice. She said any dairy products should be on ice during meal service. II. Failure to perform hand hygiene appropriately during meal service and dishwashingA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 3/31/26. It revealed in pertinent part, “ The Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20/25 read in pertinent part, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands." (2-301.15)B. Facility policy and procedureThe Food Wholesomeness policy and procedure, revised December 2021, was provided by the NHA on 3/26/26 at 8:25 a.m. It read in pertinent part, “Food is handled properly with frequent handwashing and proper sanitation guidelines. Handwashing signs are posted above handwashing sinks and employees have handwashing techniques reviewed regularly and at orientation.”C. ObservationsOn 3/23/26 at 11:50 a.m. an unidentified dietary staff member entered the kitchen, did not wash or sanitize her hands, prepared a plate, and then wiped her nose with the back of her hand. She then immediately came out of the kitchen and served the plate to a resident. On 3/23/26 at 11:59 a.m. the same unidentified dietary staff member entered and exited the kitchen using the door handle to enter and pushing the door to exit the kitchen. The dietary staff member did not sanitize or wash their hands before continuing to serve the residents’ meals. During a continuous observation on 3/24/26, beginning at 5:00 p.m. and ending at 6:01 p.m., the following was observed during the meal service in the main kitchen:At 5:00 p.m. cook (CK) #3 began preparing room trays. At 5:10 p.m. CK #3 s moved the room tray cart around the kitchen while wearing gloves. Without changing gloves or performing hang hygiene, CK #3 continued to prepare the room trays. At 5:15 p.m. CK #3 walked away from the service line to talk to another dietary staff member. During this time, CK #3 touched multiple different surfaces (preparation tables, meal trays and the reach-in refrigerator) without changing her gloves. At approximately 5:22 p.m. the kitchen staff began to serve the residents who were in the dining room. CK #3 was still wearing the same gloves that she was wearing when she touched multiple items in the kitchen. At 5:31 p.m. an unidentified dietary staff member came into the kitchen and grabbed silverware and a napkin, she did not wash her hands. At 5:41 p.m. CK #3 touched three premade cheeseburgers with her gloved hand (the same pair of gloves as before). At 5:44 p.m. DA #1, who was washing dishes at the three-compartment sink went from dirty dishes to clean dishes without washing his hands. D. Staff interviewsDA #1 was interviewed on 3/25/26 at 2:40 p.m. He said he was unsure if he needed to wash his hands when going from dirty dishes to clean dishes. He said he was recently hired. The assistant dietary manager was interviewed on 3/25/26 at 2:46 p.m. She said the staff should be changing their gloves any time they change tasks or touch other surfaces. She said staff should wash their hands when they change their gloves. She said the staff should wash their hands when they go from dirty dishes to clean dishes. She said that CK #3 should not have touched the cheeseburgers. III. Failure to ensure the kitchen was clean and sanitaryA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 3/31/26. It revealed in pertinent part,“Physical facilities shall be cleaned as often as necessary to keep them clean.“Plumbing fixtures such as handwashing sinks, toilets, and urinals shall be cleaned as often as necessary to keep them clean. “Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. “Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable.“Refuse, recyclables, and returnables shall be removed from the premises at a frequency that will minimize the development of objectionable odors and other conditions that attract or harbor insects and rodents.“Equipment, food-contact surfaces and utensils shall be clean to sight and touch.” (Chapter 4, 5 and 6)B. Facility policy and procedureThe Food Wholesomeness policy and procedure, revised December 2021, was provided by the NHA on 3/26/26 at 8:25 a.m. It read in pertinent part, “Kitchen and serving areas are clean at all times. A cleaning schedule is followed and initialed when tasks are done.“Rags are stored in clean areas and when in use, in proper sanitation and soap solutions.“Foods are stored under cleanable conditions.”C. ObservationsOn 3/23/26 at 8:44 a.m. an environmental tour of the kitchen and dishroom was conducted, the following was observed:-Two wet towels were on the preparation tables, one of the towels was next to a staff member who was cutting cake. -The floor leading from the dish room to the door that went outside had a large strip where the tiles were pulled up. The threshold of the door that went outside of the building was crumbling leaving enough space underneath the door to see directly outside. -The cove base was missing in the dishroom.-The large trash can in the food preparation area did not have a lid on it. -The large mixer was not covered, not in use and had sleeves of styrofoam bowls sitting on top of the mixer. On 3/24/26 at 5:00 p.m. the following was observed:-DA #1 was wiping the counter and wiping the debris off the counter onto the plate dolly, which was full of clean plates being used for meal service. The plate dolly was not covered and was open to air. -The plate dolly had large amounts of food debris on it, on all sides. -The large trash can was overflowing with trash and did not have a lid on it-The floor underneath the three-compartment sink was warped and the tile was coming up. There were small holes in the grout where the tiles were coming up around the drain on the floor. Where the floor meets the wall, the wall was crumbling and peeling. -The large mixer was not covered and had the sleeves of styrofoam bowls on top of it. D. Staff interviewsCK #3 was interviewed on 3/25/26 at 2:38 p.m. She said that the plate dolly got cleaned during the evening shift. She said that the day shift used it and the evening shift cleans it. The assistant dietary manager was interviewed on 3/25/26 at 2:46 p.m. She said the plate dolly was cleaned two times a day and whenever it needed to be. She said sanitizer towels should be kept in the sanitizer buckets when they were not being used. She said that the large mixer never had a cover on it due to daily use. She said that they did not have a current cleaning checklist but they were working on making one. IV. Failure to ensure foods were labeled and stored appropriately in the walk-in freezer, walk-in refrigerator, reach-in refrigerator and dry storage area. A. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), was retrieved on 3/31/26. It revealed in pertinent part,“Food packaged in a food establishment shall be labeled, label information shall include: the common name of the food, or absent a common name, an adequately descriptive identity statement. “Food shall be protected from contamination by storing the food in a clean, dry location, where it is not exposed to splash, dust, or other contamination and at least six inches above the floor. “Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.” (Chapter 3)B. Facility policy and procedureThe Food Wholesomeness policy and procedure, revised December 2021, was provided by the NHA on 3/26/26 at 8:25 a.m. It read in pertinent part, “Foods not in original containers are labeled and dated with opening and suggested to have a use by date.“Foods are stored under cleanable conditions.”C. ObservationsOn 3/23/26 at 8:44 a.m. the following was observed in the main kitchen:In the dry storage area a box of hot dog buns was sitting directly on the floor. In the reach-in refrigerator:-A bowl of chopped hard-boiled eggs was not dated.-A small container of pre-poured sauces in soufflé cups were not labeled or dated. In the walk-in refrigerator:-A shallow pan of pre-poured sauces in soufflé cups were not labeled or dated. -Two personal lunch boxes that were not labeledIn the walk-in freezer:-Approximately four boxes of frozen vegetables were sitting directly on the floorIn the second dry storage area there were two cans of stewed tomatoes with fist-sized dents and one can of jellied cranberry sauce with a dent on the side right by the top of the can, they were sitting with all of the other canned goods. On 3/25/26 at approximately 2:30 p.m. the following was observed in the main kitchen:In the reach-in refrigerator, asmall container of pre-poured soufflé cups were labeled as tarter sauce however, when the container was pulled down there was a couple of soufflé cups that did not have dates on them and were sour cream. D. Staff interviewsThe assistant dietary manager was interviewed on 3/25/26 at 2:46 p.m. She said the soufflé cups were normally dated on the lids and the containers the staff put them in normally would have the description of what was in the soufflé cups and dated. She said boxes of food should never be stored on the floor. She said staff normally would inspect the canned goods and would put the dented cans in the dietary manager’s office so they could be reimbursed for them.

A complaint survey, prompted by #CO2650047 was conducted on 10/27/25 to 12/9/25. One deficiency was cited. The actual exit date was 10/28/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/9/25.

Based on record review and interviews, the facility failed to maintain accurately documented medical records for two (#1 and #2) of three residents reviewed out of three sample residents. Specifically, the facility failed to ensure Resident #1 and Resident #2 wound assessments were documented accurately and include weekly measurements to reflect progression of the wounds in the residents medical records. Findings include:I. Facility policy and procedureThe skin and wound care management policy, undated, was provided by the director of nursing (DON) on 10/28/25 at 10:18 a.m. It read in pertinent part, “The purpose of this procedure was to provide guidelines for the care of wounds to promote healing. “The following information should be recorded in the resident’s medical record. The date and time the wound care was given, the position in which the resident was placed, any change in the resident’s condition, all assessment data such as wound bed color, size, and drainage. Obtained when inspecting the wound. If the resident refused the treatment and the reason why.“Notify the supervisor if the resident refuses the wound care. Report other information in accordance with facility policy and professional standards of practice.”II. Resident #1 A. Resident statusResident #1, age greater than 65, was admitted on 7/14/25 and discharged on 10/16/25. According to the October 2025 computerized physician orders (CPO), the diagnoses included pulmonary embolism (sudden blockage of a lung artery, usually caused by a blood clot), type two diabetes, atrial fibrillation (irregular heart rhythm where the chambers of the heart beat chaotically and out of sync with the lower chamber), muscle weakness and needing assistance with personal care. The 7/18/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 15 out of 15. She required substantial or maximal assistance with lower body dressing and putting on and taking off footwear. B. Record reviewA review of Resident #1's treatment administration record (TAR) revealed the following treatment orders:-Wound care to the back of the left heel. Cleanse with in-house wound cleanser, apply medihoney to wound bed and secure with adhesive foam dressing. Change daily and as needed every day. Order date 8/5/25. -Wound care to the weeping areas of the bilateral lower extremities. Apply absorbent pads to bilateral lower extremities, secure with ACE bandage and change four times a day and as needed. Order date 8/5/25 and discontinued date 9/10/25. -Wound care to the bilateral lower extremities. Cleanse legs with wound cleanser, apply Dermaphor to dry skin on legs, apply DermaSyn/Ag (an antimicrobial wound gel) to eschar and slough area wound beds only, cover with Telfa, secure with ACE wrap, every day. Ordered 9/10/25. Skin/wound notes documented on for the month of August, September and October of 2025 to date revealed wound assessments were completed for Resident #1. The note documented open areas to the bilateral lower extremities. The skin/wound notes provided no additional information. The skin/wound notes failed to document an assessment of the wounds with measurements, the wound progression and treatment effectiveness. The notes only provided the location of the wounds to the resident’s bilateral lower extremities. The facility failed to ensure skin assessments were focused and detailed. III. Resident #2A. Resident statusResident #2, age 61, was admitted on 4/30/2025 and readmitted on 9/29/2025. According to the October, 2025 CPOs, diagnoses include cellulitis of the left lower limb, sepsis, muscle weakness and difficulty walking. The 10/2/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required partial to moderate assistance with lower body dressing and putting on and taking off shoes and socks. B. Record reviewA review of Resident #2's TAR revealed the following treatment orders:-Wound care. Cleanse wound area, pat dry, apply xeroform to areas on left leg, heel, and foot/toes, apply ABD (highly absorbant wound dressing), wrap with Kerlix then ACE wrap. Order date 5/2/25. A skin/wound note documented on for the month of August, September and October of 2025 to date revealed wound assessments were completed for Resident #1. The note documented a left lower leg vascular wound. The skin assessment did not include any additional information. The skin/wound notes failed to document an assessment of the wounds with measurements, the wound progression and treatment effectiveness. The notes only provided the location of the wound to the left lower extremity. The facility failed to ensure skin assessments were focused and detailed. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 10/27/25 at 3:44 p.m. LPN #1 said skin assessments were done once per week. She said skin assessments should include the wound measurements and other wound details. LPN #1 said she was wound care certified. She said she was recently hired by the facility for the position of wound nurse. She said each wound should have a documented complete assessment and a monthly tracking sheet for the providers to review. She said she had noticed a lack of details in the nursing skin assessment. The director of nursing (DON) and registered nurse (RN) #1 were interviewed together on 10/28/25 at 3p.m. The DON said he had worked at the facility for a little over a month and a half. The DON said he identified areas of the facility that needed improvement including having a wound nurse responsible for documenting accurate wound assessments. The DON said he was unsure who the wound nurse was prior to his arrival, however he did hire a new wound nurse last week. The DON said he wrote a performance improvement plan for the facility's lack of wound documentation.-However, current deficient practice was identified during the survey process with Resident #1 and Resident #2. See record review above. The DON said Resident #1 and Resident #2 wound assessments should include measurements and progression of the wounds in order to determine healing or deterioration. The DON said a full assessment of wounds should be completed each week due to the delicate nature of the skin for residents. RN #1 said LPN #1 was hired as the new facility wound nurse and was wound certified. The DON said the facility physician was responsible for determining what treatment was needed for wound care and relied on the skin assessment details to figure out if the current treatment was effective. The DON said the nurses should document any change of condition and notify the provider of the assessment. The DON said he was concerned the skin assessments did not include a description of the wounds from when the wound was first identified and the first wound care clinic visit. The medical director (MD) was interviewed on 10/28/25 at 1:31p.m. The MD said he was employed as the medical director and the in-house physician for the past year. The MD said his duties included seeing residents, conducting assessments and providing treatment when needed. He said assessments for wounds should include details such as visual assessment on the wound, comparative measurements, presence of drainage, vital signs, presence of odor or warmth, presence of edema, description of the tissue and pedal pulses if the wounds were vascular. He said he had limited experience with wound care and relied on the nursing staff to document, assess and report any changes to a resident’s skin integrity. He said it was his understanding RN #1 was in charge of the wound care at the facility. He said the wound treatment was ordered based on his and the nursing assessment. The MD said he sought a referral to the wound clinic for Resident #2 because the resident’s wounds were not improving with the current treatment. He said he was unsure of the wound care and skin assessment tracking the facility was doing and assumed the nursing staff would be following, monitoring and tracking the resident assessments. He said he ordered an antibiotic for Resident #2’s wounds and wound cultures after the facility nursing staff reported a foul smell coming from the wound. He said the wound culture was positive for pseudomonas. He said he was not aware of any documentation issues. He said he did not know the nurses were not documenting the wound assessments accurately and completely.

A complaint survey, prompted by #CO2683825 was conducted on 12/8/25 to 12/9/25. One deficiency was cited.

Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#1) of three residents out of eight sample residents. Specifically, the facility failed to:-Ensure Resident #1’s Medical Orders for Scope of Treatment (MOST) form was completed accurately; and,-Ensure Resident #1’s MOST form matched the resident’s wishes and the physician’s order for a do not resuscitate (DNR) code status. Findings include: I. Facility policy and procedure The Advanced Directives policy, revised February 2024, was provided by the director of nursing (DON) on 12/9/25 at 2:05 p.m. It read in pertinent part, “The facility recognizes advance directives, every attempt will be made to honor the resident’s wishes unless to do so would violate the state or federal law. “The advance directive and cardiopulmonary resuscitation (CPR) decisions will be reviewed in writing on admission and annually, when requested by the resident, or as needed.”II. Resident #1 A. Resident status Resident #1, age 84, was admitted on 9/4/25. According to the November 2025 computerized physician orders (CPO), diagnoses included dementia, type 2 diabetes mellitus, paroxysmal atrial fibrillation (irregular heart beat), essential hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery (build up of fats, cholesterol and other substances along the walls of the heart arteries), dysphagia (difficulty swallowing food or liquids) and osteoporosis. The 9/9/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental score (BIMS) score of zero out of 15. She required moderate assistance with toileting, showering and personal hygiene. She required supervision with oral hygiene and set up assistance with eating. B. Record reviewReview of Resident #1’s November 2025 CPO revealed the resident’s physician’s orders for cardiopulmonary resuscitation were DNR, ordered 9/4/25, which indicated the resident/resident’s representative did not wish for the resident to receive CPR. Review of Resident #1’s Medical Orders for Scope of Treatment (MOST) form, which was signed upon the resident’s admission to the facility on 9/4/25, revealed the following:Section A, (for CPR preferences) was marked yes for CPR, which indicated the resident/resident’s representative wished for the resident to receive CPR. -However, the physician’s order indicated the resident was a DNR (see physician’s order above). Below the “Yes” for CPR box were directions indicating selecting “Yes” required choosing “Full Treatment” for medication interventions in Section B. -However, Section B on Resident #1’s MOST form was marked ”Comfort-focused treatment” and the primary goal was to maximize comfort. -Although the MOST form directions indicated section B should have been marked full treatment with the primary goal to prolong life by all medically effective means, Resident #1’s MOST form was marked incorrectly and emphasized comfort focused treatment. -Review of Resident #1’s comprehensive care plan did not indicate Resident #1’s CPR wishes. Review of Resident #1’s 9/6/25 initial psychosocial assessment indicated her CPR status was DNR. Review of Resident #1’s 9/10/25 care conference indicated her CPR status was DNR. Review of Resident #1’s 11/29/25 hospital transfer form indicated her CPR status was “see MOST form.”-However, Resident #1’s MOST form was marked that the resident wished to receive CPR, which did not match the resident’s physician order which indicated the resident was a DNR status. The 11/29/25 nurse progress note revealed Resident #1 had increased difficulty breathing and was seen by the nurse practitioner on 11/28/25 with new orders for nebulizer treatments only. At lunch on 11/29/25, Resident #1 started having increased difficulty breathing and then vomited. The nurse assisted Resident #1 to her room, cleaned her up and administered duo-neb (a nebulizer breathing medication) treatment without positive effects and Zofran for nausea. Vital signs were obtained and were within normal limits except oxygen saturations were 87 %to 90 % on 2 liters of oxygen per minute. A call was placed to the on-call provider who gave the order to send Resident #1 to the hospital for an evaluation. The responsible party and the DON were notified. The responsible party wanted an update once she was evaluated at the hospital. Resident #1 was transported at this time by the facility bus and accompanied by the driver and the receptionist. Resident #1 was actively vomiting on departure, respirations were very labored and the color around her mouth was pale. She was responsive when spoken to. A call was placed to the hospital emergency room and a report was given. The 11/29/25 hospital emergency room report revealed Resident #1 came from a nursing facility by van for shortness of breath and vomiting. The nurse at the nursing facility reported she had vomited brown liquid and was not responding upon arrival to the emergency room. Resident #1 was brought into a bed where she began to become unresponsive and immediately started vomiting what appeared to be feculent material. The resident had a room air saturation of 85%. The emergency room report documented that when reviewing the code information from the nursing facility, the form was filled out but was somewhat confusing as it said the resident’s desire was CPR but also was comfort measures. At 2:47 p.m., the resident’s oxygen flow rate was 2 liters per minute via nasal cannula and oxygen was 85%. After a very brief initial encounter in the emergency room she became agonal respirations without a pulse. Intravenous (IV) was to be established as she had poor IV access and intraosseous (IO) was started in her left tibia and she had full CPR and was being bagged by respiratory therapy. She was in asystole and remained in asystole after two separate doses of epinephrine. She was never in ventricular fibrillation or never had electrical activity on the monitor and the code was called and she died in the emergency department. The assessment plan was cardiac arrest and aspiration pneumonia due to inhalation of food and vomit.-Resident #1 was administered CPR in the emergency room based on her MOST form which indicated the resident wished to receive CPR, however, per the resident’s November 2025 CPO, the resident had a physician’s order for DNR (see physician’s order above). III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 12/9/25 at 12:42 p.m. LPN #1 said the nurse who admitted the resident was responsible for completing the MOST form. He said he did not receive much training and he shadowed another nurse before he completed a MOST form on his own. He said after the MOST form was completed by the nurse, the MOST form went into the physician’s box and the physician signed the form when he was in the building. LPN #1 said the physician came once a week. He said if the MOST form was not signed and he needed the code status, he talked to his unit manager or the DON. LPN #1 said once the MOST form was completed, the form went in a MOST binder that included the resident’s face sheet. He said the medical records department reviewed the MOST form for completeness. LPN #1 said he was not familiar with Resident #1 and did not know her code status. LPN #2 was interviewed on 12/9/25 at 12:55 p.m. LPN #2 said the nurse who admitted the resident was responsible for completing the MOST form. She said she did not receive training at this facility and at previous facilities she saw social services complete the MOST forms. LPN #2 said the MOST form was completed at admission. LPN #2 said once the form was completed by the nurse, it went in the physician’s box for the physician to sign the form when he was in the building. LPN #2 said once the physician signed the MOST form, the form was placed in the MOST binder for all residents in the unit. LPN #2 said she did not know how often the MOST form was reviewed. LPN #2 said she was familiar with Resident #1. She said she did not know Resident #1’s code status by memory. LPN #2 reviewed Resident #1’s MOST form and said it was marked yes for CPR, which meant life-sustaining measures should have been used if needed. LPN #2 said the second section of the MOST form did not match what was written in the first box. LPN #2 said the second section should have been marked full treatment indicating the primary goal to prolong life by all medically effective means. The DON was interviewed on 12/9/25 at 1:06 p.m. The DON said the nurse who admitted the resident was responsible for completing the MOST form. The DON said nurses received at least annual training on advanced directives. The DON said the MOST form was completed at the time of admission. The DON said the form went in the physician’s box for the physician to sign when he was in the building. The DON said if the nurse needed to reference the MOST form when it was not signed, the nurse should treat the resident as a full code and contact the DON. The DON said he would contact the physician to see if they would be able to come in prior to their next visit to sign the MOST form. The DON said once the MOST form was signed, the form was placed in the MOST binder for all residents in the unit. The DON said medical records reviewed the form. The DON said the MOST form was reviewed quarterly at the care conference. The DON was familiar with Resident #1. The DON said he did not know Resident #1’s code status. The DON looked at Resident #1's MOST form and the DON said the form was confusing. The DON said the nurse who completed Resident #1’s MOST form was new to the facility when they completed the MOST form and no longer worked at the facility. The DON said he could see how the hospital staff was confused on the MOST form and based on Resident #1’s MOST form, he would have provided CPR for the resident. The DON said Resident #1’s wishes were for DNR and that was why the resident had a physician’s order for DNR and not CPR.

A survey prompted by complaint #CO2683826 was completed 12/8/25 to 12/9/25. No deficiencies were cited.

A complaint survey, prompted by #CO40492 was conducted on 6/30/25. No deficiencies were cited.

A survey for Incident #40101 was conducted on 5/20/25. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure an environment free of accident hazards for one (#1) of three residents reviewed for accidents/hazards out of three sample residents. Specifically, the facility failed to prevent Resident #1 from eloping on 4/27/25. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/20/25, resulting in the deficiency being cited as past noncompliance with corrective action date of 4/27/25. I. Elopement incident on 4/27/25Resident #1 who was at risk for elopement, required 15-minute checks related to his elopement risk. The staff on the long term care (LTC) side of the facility, where Resident #1 resided, were to observe Resient #1 and document his behaviors every 15 minutes. On 4/27/25 at approximately 9:58 a.m. Resident #1 was taken to the church service that was held in the assisted living (AL) community by certified nurse aide (CNA) #2. The AL side of the community did not have a wanderguard system in place. Resident #1 was left unattended and out of staff sight on the AL side of the facility, where he exited the facility via a door which led to an unsecured area of the facility grounds. Resident #1 was able to leave the facility without staff supervision. At approximately 11:15 a.m. the nursing home administrator (NHA) and the director of nursing (DON) were notified by the staff that Resident #1 was missing. The facility began a search of the facility for Resident #1. When Resident #1 was not located inside the facility the search was extended to the facility grounds outside. Family and local police notified Resident #1 was missing. Facility staff then began to search for Resident #1 in the surrounding neighborhood via automobiles. The DON went towards the residents previous living address which was seven blocks from the facility, Resident #1 was not located. At approximately 12:15 p.m. Resident #1 was found three blocks (0.3 miles) away from the facility by staff in the opposite direction from his prior living address. Resident #1 was immediately placed on a one-to-one caregiver for safety upon his return. II. Facilities plan of correctionThe corrective action plan implemented by the facility in response to Resident #1's elopement on 4/27/25 was provided by the NHA on 5/20/25 at 4:21 p.m. It revealed in pertinent part:A. Action to correct the deficient practice for Resident #1On 4/27/25 12:15 p.m. Resident #1 was placed on a one-to-one with staff and referrals were sent to other facilities that had locked units. Resident #1's wanderguard was reviewed and functioning correctly on 4/27/25. All of the doors that were equipped with a wanderguard system were checked and working appropriately. The doors that were not equipped with wanderguard were equipped with chimes on 4/27/25 and were checked every hour to ensure the chimes were functioning properly. A log was to be kept. Chime logs were to be in place until Mag Locks (specifically designed locks for doors to create a secure environment) were in place and functioning appropriately. The elopement binder was reviewed to ensure all residents who were at risk for elopement were identified in the binder. B. Identify others at riskThe facility reviewed other residents at risk for elopement and identified any resident with a wanderguard were at risk for the alleged deficient practice. C. Systemic changesThe facility completed staff education on 4/27/25 in preventing resident elopement, emergency procedure for a missing resident, wandering and elopement policies and procedures via electronic education software. The staff development coordinator (SDC)/designee educated the activities staffon residents at risk for elopement and that they should not be left unattended during an activity. All staff were educated by the SDC on 4/27/25 on residents who were identified as an elopement riskshould not be taken to the AL side of the facility forany reason unless they were supervised and not left unattended. D. Ongoing monitoringThe NHA/designee was to ensure the door check logs were completed three times a week for one month, then weekly for one month, or until substantial compliance was met. Starting on 5/7/25, the main entrance door was switched to chime mode (sounds like a door bell) during business hours and when the receptionist was working. The main entrance door was switched to alarm mode at the end of reception shift. The activities director (AD) was to monitor activities that were on the AL side of the facility to ensure the residents who were at risk for elopement were not left unsupervised/unattended. The DON/designee would review three residents at risk for elopement weekly, then monthly for three months or until substantial compliance is met. This review included: a physician's order was in place for a wanderguard, consent was obtained and a care plan was in place. The NHA/designee, the SDC/designee and the DON/designee would report any issues identified through the audits in the QAPI.III. Facility policy and procedureThe Elopement and Wandering policy and procedure, dated 2/29/24, was received from the NHA on 5/20/25 at 4:32 p.m. It revealed in pertinent part, "To ensure the safety and well being of all residents with potential elopement risk. "It is the goal of the facility to provide a safe environment using the least restrictive measure available in caring for residents who are exhibiting elopement behavior. The facility defines wanders as residents who move around the facility in a non-goal directed manner, but do not make efforts to leave the premises. Elopers are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks. "A Wander/Elopement assessment will be completed on all residents upon admission to the facility. The outcome is shared with the interdisciplinary team during the initial care conference, or earlier if the elopement risk is of immediate concern. The elopement risk is assessed quarterly or as needed with change of condition. Nursing staff will address initial elopement risk concerns in the baseline care plan. If the resident is identified as an elopement risk, the following will be maintained: Elopement Resident Identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder. Implementing and care planning interventions to address safety and decrease risk of elopement. A Physical Restraint Use Consent shall be obtained from the resident's responsible party if an electronic device is utilized..Physician order will be required for the use of monitoring the device. The order will include checking placement of device every shift and checking function of device daily. The care plan will be updated to include that an electronic alarm system is used for resident's safety."IV. Resident #1A. Resident statusResident #1, age 73, was admitted on 4/22/25. According to the May 2025 computerized physician orders (CPO), diagnoses included dementia (abnormal memory) with behavioral disturbances, Wernicke's encephalopathy (neurological deficiency caused by Vitamin B1 deficiency) and amnesia (loss of memory). The 4/26/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status score (BIMS) of six out of 15. He required supervision/touch assistance assistance with dressing, transfers, ambulation, personal hygiene and bed mobility. He required set-up assistance with meals. The MDS identified the resident had wandering behaviors daily. B. ObservationsOn 5/20/25 at 9:50 a.m. the facility tour revealed the LTC side and the AL side of the facility were open to all residents at all times. The wanderguard system was installed on all doors on the LTC side which led to the exterior of the facility. There was one wanderguard device in the hallway at the entry of the AL side of the facility from the LTC side. The AL side of the facility did not have any wander guard devices on any of the doors leading to the exterior of the facility. C. Record reviewReview of the May 2025 CPO, revealed the following physician's orders:Apply wanderguard to prevent the resident from going out of the facility unassisted. Monitor presence of wanderguard every shift for dementia and exit seeking, ordered on 4/22/25. Check wanderguard every shift for placement and functioning for wandering, ordered 4/22/25. The baseline care plan, initiated on 4/22/25, documented the resident was an elopement risk related to dementia, exit seeking and poor safety awareness. The care plan documented the goal was to minimize the risk of the resident leaving the facility. Pertinent interventions includedplacing the resident's identification form in the elopement binder, identifying patterns of wandering, distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books, monitoring the residents location every 15 minutes, documenting wandering behavior and attempted diversional interventions in behavior log, wander alert and checking the placement of the resident's wanderguard every shift. The 4/22/25 admission elopement risk assessment documented the resident was exit seeking and attempting to leave the facility immediately upon admission. Resident #1 was a high elopement risk due to dementia and poor safety awareness. The 4/22/25 physical restraint/assistive device evaluationdocumented the resident was to use a wanderguard for elopement risk. The assessment indicated the reasons the resident neededto use a physical restraint was related to his delirium/acute confusion, exit seeking and leaving the building. This placed the resident at an increased risk for injury due to dementia and poor safety awareness. It documented Resident #1 allowed the placement of a wanderguard but was unable to remember why. Review of the 15-minute checks documentation revealed the 15-minute checks were initiated on admission on 4/22/25 at 3:00 p.m. The facility completed the 15-minute checks as recommended until 4/27/25 at 10:15 a.m. On 4/27/25 at 10:00 a.m. the documentation indicated Resident #1 was in the 400 hall lobby. -There was no documentation that indicated the 15-minute checks were completed from 10:15 a.m. to 1:00 p.m. Review of Resident #1 progress notes in the electronic medical record (EMR) reveled:On 4/27/25 at 10:07 a.m. a nursing note documented resident continued to wander. Resident #1 attempted to exit from the back door. Resident #1's wanderguard was on and functioning properly. Resident#1 was easily redirected however only for a minute or two. Resident #1 did not want to participate in any suggested activities. On 4/27/25 at 2:32 p.m. a change of condition summary for providers documented Resident #1 had eloped from the facility. Resident #1 was found a few blocks from the facility with no adverse effects noted on assessment. Resident #1 was placed on a one-to-one monitoring by staff. All door alarms were routinely checked every 30 minutes by staff. On 4/27/25 at 2:49 p.m. a nursing progress note documented Resident #1 was wandering through the hallways this shift and was attempting to leave the facility through different doors. Resident #1's wanderguard was on and functioning properly. Resident #1 was only redirectable for short periods of time. The writer indicated they asked CNA to take Resident #1 to church services in the dining room. When the writer was rounding on Resident #1, he was not found in church services. Activities aide (AA) #1 said Resident #1 left with a CNA. The facility and the facility grounds were searched and Resident #1 was not found. A CNA said she did not take Resident #1 out of church services. The writer then notified the NHA, the resident's family and the police department. Several staff members searched for Resident #1 using vehicles. On 4/27/25 at 3:01 p.m. a nursing progress note documented the police and the resident's family were notified that Resident #1 was missing. Several staff members searched the surrounding neighborhood in vehicles. Resident #1 was found by the maintenance supervisor. Resident #1 returned to the facility with staff assistance. Nursing staff completed a skin and pain assessment. Resident #1 was placed on a one-to-one with staff for monitoring. All of the facility doors and alarms were placed on 30-minute checks. On 4/28/25 at 10:57 a risk management note documented on 4/27/25 Resident #1 eloped from the facility. The interdisciplinary team determined the cause of elopement was due to Resident #1's cognition and exit seeking behaviors. Resident #1 was placed on a one-to one caregiver. The facility sent referrals to locked facilities for Resident #1's safety. The physician and family were aware of the situation. V. Staff interviewsThe assisted living administrator was interviewed on 5/20/25 at 3:10 p.m. She said the facility held a church service in the AL dining room on Sundays where both residents from the AL and LTC side were able to attend. The assisted living administrator said once the residents passed the double doors in the hallway to the AL side the wanderguard system no longer worked. She said there was not a wanderguard system on the AL side of the facility. The assisted living administratorsaid the facility now has started the process of implementing wanderguards on all doors in the AL side which lead to the exterior of the building. The NHA, the DON and the regional director of operations (RDOO) were interviewed together on 5/20/25 at 3:53 p.m. They said Resident #1 was missing for approximately 20 minutes prior to the NHA being notified of the missing resident. The staff conducted a building wide search when a resident was missing. The NHA said if the resident was not located within the building they expanded to the facility grounds and then the surrounding neighborhood. The DON said Resident #1 was found approximately three blocks or 0.3 miles from the facility by the maintenance director. The DON said once Resident #1 returned to the facility he was assessed by a nurse for pain and injuries. Resident #1 did not sustain any injuries. The NHA said Resident #1 was last seen by staff at the church service being held on the AL side of the facility. The NHA said the facility held a church service that combined the AL residents with the long term care residents. The NHA said the LTC side of the facility had a wanderguard system placed on all exit doors, however the AL side did not have wanderguard system installed on their exit doors at the time of Resident #1's elopement. The NHA said a staff member assisted Resident #1 to the church service being held in the ALdining room. The NHA said the staff member would have had to turn off the last alarm in the hallway once they entered into the AL side of the facility. The NHA said once they were past that alarm there was not another system in place to prevent a resident from exiting the building through AL doors to the community. The NHA said based on the investigation it was determined CNA #2 assisted Resident #1 to the AL side for church services, although the church services was ending, and left Resident #1 there. The NHA said CNA #2 returned to their assigned floor on the LTC side of the facility and beganproviding care to another resident. The NHA said activities assistant (AA) #1 had started to assist residents out of the AL dining room as church services had ended and Resident #1 was left unsupervised in an unsecured part of the facility. The NHA said tt was determined during investigation that Resident #1 exited the AL side of the building through a door that was not equipped with a wanderguard system that led the resident to an unsecured area of the facility grounds, which allowed the resident to leave the facility. The NHA saidit was determined by the facility and the resident's family that Resident #1 was better suited for a secure unit related to his behaviors and his elopement on 4/27/25. The NHA said the facility began sending out referrals to locked facilities for Resident #1's safety. Qualified medication administration personnel (QMAP) #1 was interviewed on 5/20/25 at 5:30 p.m. QMAP #1 said she worked on theAL side of the community. QMAP #1 said she can turn off the wanderguard alarm in the hallway of the AL side of the building. QMAP #1 said if she found a resident from the LTC side she would turn off the alarm and assistthe resident back to the LTC side. She said she would ensure a staff member knew where the resident was found. QMAP #1 said she did not see a lot of residents from the LTC side on the AL side, except on Sundays whena church service was held in the AL dining room. QMAP #1 said AA #1 was present for the church service. QMAP #1 said she saw the staff come to get the residents after the service ended and assistedthem to the LTC side of the facility. AA #1 was interviewed on 5/20/25 at 6:12 p.m. She said the church service started at 9:00 a.m. on Sundays in the main dining room on the AL side of the facility. AA #1 said she helped transport residents to and from the church services if they needed assistance. AA #1 said she did not invite Resident #1 to services ashe was new to thefacility and they were still getting to know him. AA #1 said the church service was finishedwhen CNA #2 assisted Resident #2 to the dining room on the AL side. AA #1 said she told CNA #2 the servicewas ended, but CNA #2 left Resient #1 in the dining room and left the area. AA #1 said she was starting to assist residents back to the LTC side of the facility and the last time she saw Resident #1 was at approximately 9:58 a.m. AA #1 said she had saw CNA #2 and told her that services had ended and to assistResident #1 back to the LTC side. AA #1 said when she returned to the AL dining room,Resident #1 was not there. AA #1 said she continued with her daily activities schedule with a second church service of a different denomination starting at 10:30 a.m. on the LTC side. AA #1 said the church service was about an hour long in the facility and she kepta log of the residents who attended the services. AA #1 said she would see staff peek into activities at times when residents were on 15-minute checks. AA #1 said she was not aware Resident#1 was missing till the middle of the second church service that had started at 10:30 a.m. AA #1 said she assisted in the search for Resident #1. at approximately 11:45 a.m. once she finished the second church service and assisted residents back to their room. CNA #2 was interviewed on 5/20/25 at 6:28 p.m. She said she was asked by the nurse to take Resident #1 to the church services on the AL side. CNA #2 said she informed the nurse the services started at 9:00 a.m. and would be finishing soon, but the nurse still said to take Resident #1 there. CNA #2 said she took the resident to the AL side and turned off the last wanderguard alarm in order to get the resident to the dining room. CNA #1 said the church service was still going on so she left Resident #1 there,returned to her assigned wing and assisted other resident needs. CNA #2 said she was busy with resident cares and thought the AA #1 had assisted Resident #1 back. CNA #2 said she was informed by another CNA that Resident #1 was missing and then she was assigned to help look for Resident #1. CNA #1 said she was in her hallway alone with the nurse from before 10:00 a.m. to 10:30 a.m. as the other CNA was not available.