FOWLER HEALTH CARE

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is licensed for 45 beds and is a one-story, Type V (111) structure. The facility is protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system, having a municipal water supply. The Level 2 generator serves both existing and new portions of the building. The facility constructed a new fully sprinklered split-level addition in 2007, the upper level of which is used for business offices for support services. The lower or basement-level portion is used for storage, and the main-level includes the maintenance, repair shop, and garage. The 2007 addition is separated from the long-term care unit by a 2-hour firewall. The residents do not use the upper level, the lower level, or the garage and maintenance shop. The southeast wing of the existing building houses the secured unit. The secured unit door release with the activation of the fire alarm system or loss of power, and a card reader key-operated system is integral to the employee identification card carried by all staff. The older section of the facility was surveyed on May 01, 2026, using the National Fire Protection Association (NFPA) Life Safety Code (2012) chapter 19, "Existing Health Care Occupancies".

Based on observation during the survey, it was determined that the facility failed to maintain a hazardous area in accordance with NFPA 101, Section 19.3.2.4, and NFPA 99, potentially affecting 38 of 38 residents. Specifically, the basement furnace room. The findings include: On 5/01/2026 from approximately 11:00 p.m. to 2:00 p.m., a facility tour was conducted with the nursing home maintenance director. The furnace room, which opened to the corridor, had two penetrations in the wall. The maintenance director stated that he was not aware of these openings and recognized that they would allow smoke to travel into the corridor in the event of a fire in the furnace room. Regulatory ReferenceNFPA 101: 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. NFPA 101: 19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:(1) Boiler and fuel-fired heater rooms(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)(3) Paint shops(4) Repair shops(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)(6) Rooms with collected trash in volume exceeding 64 gal (242 L)(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard NFPA 101: 8.7.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:(1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3(2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7(3) Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43 Findings were discussed with the NHA and the Maintenance Director at survey exit.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25,5.3.1.1.2 and NFPA 101, 19.7.6, and 4.6.12, potentially affecting 38 of 38 residents. Findings. Sprinkler heads in both kitchen walk-ins were loaded (collection of debris that could impede/alter function) and expired in 2018. The sprinkler main line piping support hanger was disconnected from the ceiling. Observation and Interviews. On 5/01/2026 from approximately 11:00 p.m. to 2:00 p.m., a facility tour was conducted with the nursing home maintenance director. The tour identified:-The DOM agreed that the loaded sprinkler heads in the kitchen cooler and freezer would impede each device’s ability to detect heat to start water flow.-The DOM acknowledged that the sprinkler heads in the walk-in freezer and walk-in cooler had expired in 2018, respectively. Regulatory ReferenceNFPA 101: 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. NFPA 101: 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. NFPA 25: 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat-responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. Findings were discussed with the NHA and the DOM at survey exit.

Based on observation during the survey, it was determined that the facility failed to maintain portable fire extinguishers in accordance with NFPA 10, Section 7.2.4.1, potentially affecting 38 of 38 residents throughout the facility. The findings include The DOM acknowledged the written record requirements and stated that the servicing company only provides the number of units inspected on their report. Regulatory Reference NFPA 10: 7.2.4.1 Personnel making manual inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action. Findings were discussed with the NHA and the DOM at survey exit. The DOM acknowledged that some requirements, such as the time, were not met, and stated he was uncertain about the exact time requirements.

Based on record review and interview, the facility failed to conduct fire drills in accordance with National Fire Protection Association (NFPA) 101 requirements, potentially affecting 38 of 38 residents. The facility conducted 2 out of the 4 required quarterly fire drills during the same time period. The findings include: On 5/01/2026, at approximately 9:30 a.m., the Director of Maintenance (DOM) provided the fire drill records, which were presented with all maintenance records for the year. The interview with the DOM confirmed that the facility staffed three shifts per day. Records of the fire drills indicated two were conducted within the same hour during the second shift in both the first and third quarters (April 2025 through April 2026). Regulatory ReferenceNFPA 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. Findings were discussed with the NHA and the DOM at survey exit. The DOM acknowledged that some requirements, such as the time, were not met, and stated he was uncertain about the exact time requirements.

A recertification survey with complaint #CO2788963 was completed on 4/13/26 to 4/15/26. Four deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/13/26 to 4/15/26. Three deficiencies were cited.

Based on observations, record review and interviews, the facility failed to develop and implement emergency preparedness policies and procedures based on the emergency plan that identified the provision of subsistence needs for staff and residents, whether they evacuate or shelter in place, include but are not limited to the following: food, water, medical and pharmaceutical supplies and have alternate sources of energy to maintain the following: temperatures to protect patient health and safety and for the safe and sanitary storage of provisions, emergency lighting, fire detection, extinguishing, and alarm systems and sewage and waste disposal. Specifically, the facility failed to:-Implement policies and procedures to address provisions needed for evacuation, which included medications on hand for immediate use in the event of an emergency where providers would not be able to deliver regular resources in a timely manner; and,-Ensure the facility’s portable radios and emergency lighting (lamps and flashlights) were in working order. Findings include:I. Facility policy and procedureThe Emergency Preparedness Plan (EPP), Tornado/Severe Weather Procedures policy, revised 12/18/25, was provided by the nursing home administrator (NHA) on 4/14/26 at 4:30 p.m. It read in pertinent part, “Have a battery powered portable radio available to backup commercial and auxiliary electrical power systems.”II. Facility plan and interviewThe facility’s EPP manual was reviewed with the NHA and the plant director on 4/14/26 at 3:19 p.m. -The EPP manual did not reveal information about how residents’ medications would be provided to the residents in the event of an evacuation. The NHA said there was no specific information or policies in writing which addressed a plan for the provision of residents’ medications in the event of an evacuation. III. Staff interviews and facility observationsThe facility’s emergency supplies were observed with the NHA and the plant director on 4/14/26 at 4:15 p.m. The plant director said there were several flashlights for nursing staff to use in the event of a power outage. -A plastic container under a desk at the nurses’ station was opened by the plant director and contained one battery powered lamp which did not illuminate when turned on.

Based on interviews and record review of the emergency preparedness plan (EPP), the facility failed to develop and implement emergency preparedness policies and procedures which addressed safe evacuation from the facility, which included consideration of care and treatment needs of evacuees, staff responsibilities and transportation needs. Specifically, the facility failed to ensure a documented plan to meet the transportation needs of all residents in the event of evacuation. Findings include:I. Record reviewThe facility’s emergency preparedness plan (EPP) binder was provided by and reviewed with the nursing home administrator (NHA) on 4/14/26 at 3:19 p.m. -The EPP binder failed to contain a plan to address the transportation needs of residents in the event of evacuation. II. Staff interviewThe NHA was interviewed on 4/14/26 at 4:00 p.m. The NHA said the facility had not documented the transportation needs of residents in the event of an evacuation emergency. The NHA said the facility had three vehicles available to assist with evacuation and each vehicle could transport four residents. He said the facility could transport 12 residents with these vehicles. The NHA said additional arrangements were needed to ensure safe evacuation for all of the residents, as there were 36 residents at the facility. The NHA was interviewed a second time on 4/15/26 at approximately 11:00 a.m. The NHA said he had contacted the school district’s superintendent to assist with the facility’s transportation needs in the event of evacuation.

Based on interviews and record review, the facility failed to develop and maintain an emergency preparedness communication plan which included a method for sharing information and medical documentation for residents under the facility’s care, as necessary with other health providers to maintain the continuity of care. Specifically, the facility failed to have a communication plan for sharing information and medical documentation with other health providers to maintain the continuity of care for residents. Findings include:I. Record reviewThe emergency preparedness plan (EPP) binder was provided by and reviewed with the nursing home administrator (NHA) on 4/14/26 at 3:19 p.m. -The EPP binder failed to contain a communication plan for sharing information and medical documentation with other health providers to maintain the continuity of care for residents. II. Staff interviewThe NHA was interviewed on 4/15/26 at 12:58 p.m. The NHA said the facility did not have a documented plan for sharing residents’ information with other health providers to maintain continuity of care.

Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#3) of two residents reviewed for hearing out of 29 sample residents. Specifically, the facility failed to follow up on a post-eligibility treatment of income (PETI) request in order to obtain a hearing aid in a timely manner for Resident #3. Findings include:I. Facility policy and procedureThe Audiology and Ancillary Services policy and procedure, undated, was provided by the nursing home administrator (NHA) on 4/15/26 at 12:07 p.m. It read in pertinent part, “The purpose of this policy is to provide a process for identifying, arranging, and documenting audiology services for residents who need hearing-related care. “The facility will provide or arrange audiology services for residents as needed and as ordered by a physician or other authorized provider, when required. Services may be provided by a licensed audiologist or through a contracted provider. Audiology services may include hearing evaluations, hearing aid recommendations, hearing aid checks, communication recommendations, and follow-up related to hearing concerns.“A resident may be referred for audiology services when hearing concerns are identified by nursing, therapy, the provider, the resident, or the resident’s representative.“A provider order will be obtained when required.“The facility will coordinate audiology services based on the resident’s needs and provider availability.“Audiology recommendations will be shared with the care team and added to the resident’s care plan as appropriate.“All services, recommendations, and follow-up will be documented in the medical record.”II. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 10/2/25. According to the April 2026 computerized physician orders (CPO), diagnoses included unspecified hearing loss, supraventricular tachycardia (a cardiovascular condition characterized by a fast heart rate), muscle wasting and atrophy, unspecified dementia and major depressive disorder. The 1/7/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He was independent with eating and required moderate assistance with toileting and personal hygiene, and maximum assistance with transfers. He used a wheelchair or a walker for locomotion. The MDS assessment documented that he had minimal hearing difficulty. B. Observation and resident interviewResident #3 was interviewed in his room on 4/13/26 at 12:29 p.m. The resident said he developed a hearing deficit upon his admission to the hospital from the facility. He said that after returning to the facility, he reported the issue to the social services director (SSD). Resident #3 said he had been waiting for assistance with obtaining a hearing aid for several months. Resident #3 said he had completed an audiology appointment several months ago, during which a hearing aid was recommended by the audiologist. Resident #3 said he got frustrated and angry when he could not hear. He said it had become difficult to hold a conversation with others unless they spoke louder. Resident #3 said he was not offered any accessories to facilitate better communication with others while he waited for his hearing aid. C. Record reviewThe speech and communication care plan, initiated 10/3/25 and revised 1/9/26, revealed that Resident #3 usually understood but may miss some parts or the intent of a message due to significant hearing loss in the left ear. Interventions included speaking distinctly and rephrasing or simplifying language, repeating information or adjusting tones if the resident was not able to understand, providing a quiet, non-hurried environment, free of background noise and distractions and audiology consults and evaluations as needed. The 2/19/26 audiology patient visit note revealed Resident #3’s pure-tone testing bilateral (a hearing assessment that measures the softest sounds a person can hear) suggested mild sloping to moderate sensorineural hearing loss (a permanent inner ear damage) and recommended a hearing aid and retesting if concerns changes.-There was no documentation in Resident #3’s electronic medical record (EMR) to indicate that the facility had obtained a physician’s order for a hearing aid after the 2/19/26 audiology visit. III. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 4/14/26 at 2:50 p.m. CNA #5 said Resident #3 had a hearing impairment. CNA #5 said staff had to speak louder for Resident #3 to hear them when they were communicating with him. CNA #5 said Resident #3 often became agitated due to his inability to hear during care. The SSD was interviewed on 4/14/26 at 3:56 p.m. The SSD said Resident #3 attended an audiology appointment on 2/19/26. She said a post-eligibility treatment of income (PETI) cash request was filed on 2/24/26, but the resident had not yet received a formal letter indicating whether the request was approved. The SSD said that if a formal letter was not received within a couple of weeks, the standard procedure was to follow up with the office. However, the SSD said she had not followed up on the request and acknowledged that she should have done so. The director of nursing (DON) was interviewed on 4/15/26 at 10:14 a.m. The DON said Resident #3 had a hearing impairment and had been seen by an audiologist. She said Resident #3 did not have a physician’s order for a hearing aid. The DON said staff had to speak clearly and louder for the resident to hear. The DON said Resident #3 had not been provided with any accessories while he waited for a hearing aid. The SSD was interviewed a second time on 4/15/26 at 5:02 p.m. The SSD said she had not documented her action at the time the PETI was filed. The SSD said her understanding of the PETI cash process was that the amount was based on the monthly resident portion and the money must accumulate over time. The SSD said the resident’s portion of the cost of the hearing aid was $1,100.00 and estimated that it would take three months for the required funds to be available for Resident #3. The SSD said the delay in the PETI cash funding should not serve as a barrier to the resident obtaining his hearing aid.

Based on observations, record reviews and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for four (#4, #7, #22 and #2) of six residents reviewed for respiratory care out of 29 sample residents. Specifically, the facility failed to ensure that Resident #4, Resident #7, Resident #22 and Resident #2 received oxygen therapy in accordance with their physician's orders. Findings include:I. Professional referenceAccording to Nursing Skills, Open Resources for Nursing (Open RN), Ernstmeyer K, Christman E, editors. Eau Claire (WI): Chippewa Valley Technical College; published 11/11/21, accessed on 4/20/26 from https://www.ncbi.nlm.nih.gov/books/NBK593208/,“Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. (Chapter 11)“Devices such as high flow oximetry masks, CPAP (continuous positive airway pressure), BiPAP (bilevel positive airway pressure), or mechanical ventilation may be initiated by the respiratory therapist or provider to deliver higher amounts of inspired oxygen. (Chapter 11)“Manage oxygen therapy and equipment: If the patient is already on supplemental oxygen, ensure the equipment is turned on, set at the required flow rate, correctly positioned on the patient, and properly connected to an oxygen supply source. If a portable tank is being used, check the oxygen level in the tank. Ensure the connecting oxygen tubing is not kinked, which could obstruct the flow of oxygen. Feel for the flow of oxygen from the exit ports on the oxygen equipment.” II. Facility policy and procedureThe Oxygen Administration policy, revised October 2010, was provided by the nursing home administrator (NHA) on 4/15/26 at 11:41 a.m. It read in pertinent part, "The purpose of this procedure is to provide guidelines for safe oxygen administration."The general guidelines require verifying that there is a physician’s order, reviewing the physician’s orders, or the facility protocol for oxygen administration. Preparing appropriate equipment, ensuring safety by removing flammable items and posting warning signs, selecting and applying the correct oxygen delivery device, monitoring the resident for tolerance and complications, documenting all relevant details, and educating the resident and others about oxygen safety precautions."III. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on 7/20/22. According to the April 2026 computerized physician orders (CPO), diagnoses included interstitial pulmonary disease (disorders causing progressive inflammation and irreversible scarring of the lung tissue), muscle weakness, depressive episodes, acute cystitis without hematuria (inflammation of the bladder), and hypo-osmolality (a condition characterized by an abnormal low concentration of solutes in the blood or other body fluid) and hyponatremia (a condition characterized by low sodium levels in the blood). The 1/20/26 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She required maximum assistance with transfers, set-up assistance with eating and moderate assistance with personal hygiene and toileting. The assessment revealed the resident was receiving oxygen therapy. B. Observation and resident interviewOn 4/13/26 at 3:28 p.m. was in her room. There was a nasal cannula (a tubing device that delivers oxygen through the nose) in her nose and connected to a room oxygen concentrator. The oxygen concentrator was set to 2 liters per minute (LPM) of oxygen. Resident #4 said she used oxygen at all times during the day and at night. She said the staff members set the oxygen liter flow. Resident #4 said the staff switched her to the portable oxygen tank when she left her room and put her back on the oxygen concentrator when she returned to her room. On 4/14/26 at 11:04 a.m. Resident #4 was lying down on her bed with a nasal cannula in her nose. The nasal cannula was connected to the oxygen concentrator, which was set at 2 LPM. On 4/15/26 at 9:15 a.m. Resident #4 was sitting in her recliner in her room with a nasal cannula in her nose. The nasal cannula was connected to the oxygen concentrator, which was set at 2 LPM. Resident #4 said she did not know how many liters of oxygen she was receiving. She said a staff member assisted her into her recliner and applied the nasal cannula to her nose. C. Record reviewThe respiratory/oxygen care plan, initiated 4/29/24 and revised 4/8/26, revealed that Resident #4 was at risk for respiratory distress related to interstitial lung disease. Interventions included administering oxygen per the medical director’s (MP) order. A review of Resident #4’s April 2026 CPO revealed the following physician’s order:Oxygen via nasal cannula at 1 LPM at bedtime, ordered 4/9/25.-However, observations on 4/13/26, 4/14/26 and 4/15/26 revealed Resident #4 was receiving 2 LPM of oxygen during the day, not 1 LPM at night as ordered by the physician (see observation above). D. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 4/15/26 at 9:15 a.m. CNA #4 said she was able to verify the residents’ oxygen orders in the residents’ electronic medical records (EMR) and adjust their oxygen flow rates per the physician’s orders. CNA #4 said she did not verify the physician’s order for Resident #4’s oxygen at the beginning of her shift. She said Resident #4 was receiving 2 LPM of oxygen-However, the physician’s order for Resident #4 indicated the resident should be on 1 LPM of oxygen at night (see physician’s order above). Registered nurse (RN) #2 was interviewed on 4/15/26 at 9:20 a.m. RN #2 said Resident #4 was on continuous oxygen related to a respiratory illness. He said Resident #4 received oxygen at all times. RN #2 said it was necessary to follow the physician’s order because oxygen was considered a medication. RN #2 said several medical complications, such as hypoxia (low blood oxygen levels) and hyperoxia (too much oxygen levels), could develop when residents’ oxygen orders were not followed accurately as prescribed. RN #2 said he did not know why Resident #4’s physician’s order for oxygen indicated the resident only wore oxygen at bedtime because the resident had been on continuous oxygen for a long time. RN #2 said he would call the physician to clarify the resident’s oxygen order. IV. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on 11/14/23. According to the April 2026 CPO, diagnoses included anemia, chronic systolic congestive heart failure, chronic atrial fibrillation, chronic obstructive pulmonary disease (COPD), and muscle weakness. The 2/17/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision and assistance with eating, personal hygiene and transfers and set-up assistance with toileting. The assessment indicated the resident required oxygen therapyB. Observations and resident interviewResident #7 was interviewed on 4/13/26 at 1:38 p.m. Resident #7 said she always used oxygen continuously. Resident #7 said the facility staff regulated her oxygen liter flow rate and she believed she had a physician’s order for 2 LPM. Observation of the oxygen concentrator connected to Resident #7’s nasal cannula revealed the oxygen concentrator was set at a flow rate of 3 LPM.On 4/14/26 at 9:28 a.m. Resident #7's oxygen concentrator was set at a flow rate of 3 LPM.On 4/15/26 at 9:25 a.m. the resident’s oxygen concentrator was set at a flow rate of 2 LPM.C. Record reviewThe respiratory care plan, initiated 5/31/24 and revised 10/23/25, revealed that Resident #7 required oxygen therapy at night related to chronic respiratory failure with hypoxia. Interventions included administering oxygen and medications as ordered by the physician, observing oxygen precautions and reporting any abnormalities to the physician. A review of Resident #7’s April 2026 CPO revealed the following physician’s order: Oxygen at 1 LPM at bedtime via nasal cannula, ordered 4/9/25.-However, observations on 4/13/26, 4/14/26 and 4/15/26 revealed Resident #7 was receiving 3 LPM and 2 LPM of oxygen continuously, not 1 LPM at bedtime as ordered by the physician. D. Staff interviewsRN #2 was interviewed a second time on 4/15/26 at 9:34 a.m. RN #2 said Resident #7 was receiving continuous oxygen and confirmed that the resident’s room concentrator was set to 2 LPM. RN #2 verified the physician’s order and confirmed that the order read 1 LPM of oxygen at bedtime. RN #2 said he would immediately clarify the resident’s oxygen orders with the physician. RN #2 said he did not verify the oxygen liter flow rate that Resident #7 was receiving at the beginning of his shift. The director of nursing (DON) and the chief nursing officer were interviewed together on 4/15/26 at 9:50 a.m. The DON said residents had their initials written on a label that was attached to their portable oxygen tanks with an indication of how many LPM of oxygen each resident was on. The DON said staff were required to check the residents’ oxygen liter flow rates at the beginning of their shift. The DON said CNAs were not trained to alter or change the oxygen liter flow rates. The DON said nurses were able to change the liter flow rates of oxygen orders when necessary, document the changes and inform the physician if a change was needed. The DON said she did not know why Resident #4 and Resident #7’s oxygen orders indicated they were only on oxygen at bedtime because they were receiving continuous supplementary oxygen. The DON said insufficient or excessive oxygenation could result in medical complications for residents with respiratory diseases. The chief nursing officer said oxygen was a form of medication and required a physician’s order to administer. She said the facility would conduct a full-house audit of all residents receiving supplementary oxygen and ensure they were receiving the correct oxygen liter flow rates.

Based on observations and interviews, the facility failed to store, distribute, and serve food in a sanitary manner in two of two kitchen refrigerators. Specifically, the facility failed to ensure nutritional beverages were labeled and dated when opened in the kitchen nourishment refrigerator and the walk-in refrigerator. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 4/22/26 read in pertinent part, "A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request. (Chapter 3-29). II. Facility policy and procedureThe Food Receiving and Storage policy and procedure, revised November 2022, was provided by the nursing home administrator (NHA) on 4/15/26 at 12:16 p.m. It read in pertinent part, “All food stored in the refrigerators or freezers shall be covered, labeled and dated with used by date.“Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.“Beverages are dated when opened and discarded after twenty-four hours.“III. ObservationsOn 4/13/26 at 8:50 a.m. the following was observed at the main kitchen nourishment fridge and the walk-in refrigerator during the initial kitchen tour and the follow-up observation. In the nourishment refrigerator the following was observed:One opened container of thickened apple juice that was not dated;One container of thickened orange juice that was not dated;One opened container of lemon-flavored thickened water that was not labeled;-One opened container of tomato juice that was not dated; and,-One opened container of unsweetened black tea that had a use-by date of 8/21/25. In the walk-in refrigerator, there was one opened sweet baby barbecue container that was undated. On 4/14/26 at 1:00 p.m. the following was observed at the main kitchen nourishment fridge and the walk-in refrigerator during the initial kitchen tour and the follow-up observation. In the nourishment refrigerator the following was observed:One opened container of thickened apple juice that was not dated;One container of thickened orange juice that was not dated;One opened container of lemon-flavored thickened water that was not labeled;-One opened container of tomato juice that was not dated; and,-One opened container of unsweetened black tea that had a use-by date of 8/21/25. In the walk-in refrigerator, there was one opened sweet baby barbecue container that was undated. On 4/15/26 at 12:21 p.m. the following was observed in the main dining room during lunch observation. During the lunch service, there was a container full of ice that had a gallon of milk, tomato juice and apple juice. The staff were serving these drinks to residents. The beverage containers were opened, but were undated. III. Staff interviewsDietary aide (DA) #2 was interviewed on 4/15/26 at 1:10 p.m. DA #2 said all opened beverages should be dated and labeled, however did not know why they should be dated and labeled. She said she looks for the expiration date on the carton. The dietary manager (DM) was interviewed on 4/15/26 at 1:30 p.m. The DM said the kitchen staffshould have all opened juice cartons dated and labeled to be aware of how long it has been opened to avoid distributing contaminated beverages to any resident. She said all kitchen staff and dietary aides were trained to understand the importance of labeling. She said the staff might have forgotten to label those beverages in the nourishment refrigerators. The DM said she would immediately provide education to the kitchen staff and dietary aides to ensure open beverages were labeled and dated properly.

Based on observations and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to: -Ensure staff performed appropriate hand hygiene in the dining room while assisting residents with eating; -Ensure housekeeping staff used appropriate hand hygiene practices while cleaning the residents' rooms; and, -Ensure housekeeping staff cleaned high-touch surfaces in residents’ rooms. Findings include: I. Failed to ensure staff performed appropriate hand hygiene while assisting residents in the dining roomA. Facility policy and procedureThe Handwashing policy, revised October 2025, was received from the nursing home administrator (NHA) on 4/15/26 at 4:00 p.m. The policy read,“All personnel are trained on the importance of handwashing. Wash your hands after contact with the resident or in the resident's environment. The use of gloves does not replace handwashing or hand hygiene. B. ObservationsOn 4/13/26 at 11:15 a.m. certified nurse aide (CNA) #1 was observed assisting three residents with eating in the dining room.-CNA #1 failed to perform appropriate hand hygiene between any residents. II. Housekeeping failuresA. Facility policy and procedureThe Cleaning And Disinfection Of Environmental Services policy, revised August 2019, was received from the NHA on 4/15/26 at 4:00 p.m. The policy read,“Non-critical contaminated areas can be decontaminated where they are used. Housekeeping surfaces such as desk tops will be cleaned regularly. Non-critical surfaces will be disinfected with an Environmental Protection Agency (EPA)-registered intermediate hospital disinfectant with the dwell time as follows on the label.”B. ObservationsOn 4/15/26 at 10:00 a.m., the housekeeping director was cleaning room #3. The housekeeping director sprayed the bathroom with Virex diversity disinfectant spray and proceeded to clean the resident’s bathroom. When the housekeeping director finished cleaning the bathroom, she took off her gloves. Without performing hand hygiene, the housekeeping director began cleaning the resident’s room. -The housekeeping director failed to perform hand hygiene after cleaning the bathroom and removing her gloves prior to beginning cleaning in the resident’s room. The housekeeping director made the resident’s bed, gathered the trash and swept and mopped the floor. The housekeeping director did not perform hand hygiene after exiting room #3. -The housekeeping director failed to clean the high touch surface areas in the room, including the resident’s bedside table, the residents' call light, the bed control and the door knobs.-Additionally, the housekeeping director failed to perform appropriate hand hygiene after cleaning the resident’s room. III. Staff interviewsCNA #1 was interviewed on 4/13/26 at 2:15 p.m. CNA #1 said she should have washed her hands in between helping each of the three residents she was assisting with eating in the dining room. She said she should have washed her hands before assisting another resident. The housekeeping director was interviewed on 4/15/26 at 10:20 a.m. The housekeeping director said that the CNAs would clean the residents’ bedside tables. She said she cleaned the residents’ call lights once a week, along with the bed controls. She said she realized that the high contact areas should be cleaned daily. She said she would change her cleaning to include the bedside table, call light, bed controls, and door knobs to a daily disinfection cleaning. The director of nursing (DON) was interviewed on 4/15/26 at 5:04 p.m. She said that the staff assisting residents with eating should regularly perform hand hygiene. The DON said if staff were assisting more than one resident with eating, they should perform hand hygiene in between residents. The DON said the housekeepers should perform hand hygiene after removing gloves and sanitize high-contact areas in residents’ rooms daily. The NHA was interviewed on 4/15/26 at 5:15 p.m. The NHA said that the housekeeping staff should disinfect the high-contact surfaces in the residents’ rooms on a daily basis.

A survey with #CO2788964 was completed on 4/13/26 to 4/15/26. No deficiencies were cited.

A complaint survey, prompted by #CO39787 was conducted 5/1/25 to 5/5/25. No deficiencies were cited.

A revisit survey was completed on 5/20/24 for all previous deficiencies cited on 3/13/24. The facility is in compliance with all regulations surveyed.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag K-000) are informational only, and are a representation of the facility's general characteristics. The facility, licensed for 45 beds on the date of this survey, is a one-story, Type V (111) structure. The facility is protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system, having a municipal water supply, and is classified as fully sprinklered. The automatic fire sprinkler system, as well as the generator, serve both the existing and new portions of the building. The facility constructed a new fully sprinklered split-level addition in 2007, the upper-level of which used as business offices for support services. The lower or basement-level portion is used for storage, and the main-level includes the maintenance repair shop and garage. The 2007 addition is separated from the long-term care unit by a 2-hour firewall. The residents do not use the upper-lever, the lower level, or the garage and maintenance shop area. The southeast wing of the existing building houses the secured unit. The secured unit doors release with activation of the fire alarm system or loss of power, and a card reader key-operated system integral to the employee identification cards carried by all staff. The survey concluded April 03, 2024 for compliance to prescriptive fire safety requirements contained in Chapter 19 of the 2012 edition of NFPA 101, the Life Safety Code, for Existing Health Care Occupancies. The deficiencies cited was discussed with the Administrator and Director of Maintenance during the exit conference conducted at the end on-site survey.

STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times in accordance with Life Safety Code 101 Section 19.2.2.2.4, 7.2.1.5.3. This deficient practice could affect all residents, staff and visitors within the facility if the Means of Egress is not maintained throughout the facility. The Country Club storage room is equipped with locking/latching devices were two releasing operation were required to operate the door. Life Safety Code 101 Section 7.2.1.5.3. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. The Director of Maintenance acknowledged the condition of the door during the time of the tour.

STANDARD not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following. The inspectors test connection did not terminate in a smooth bore corrosion resistant orifice giving a flow equivalent to one sprinkler of a type having the smallest orifice installed on the particular system outside of the Country Club room. NFPA 101 2012 Edition Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are installed, inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility.

STANDARD not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following. The inspectors test connection did not terminate in a smooth bore corrosion resistant orifice giving a flow equivalent to one sprinkler of a type having the smallest orifice installed on the particular system outside of the Country Club room. NFPA 101 2012 Edition Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are installed, inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility.

This STANDARD is not met as evidenced by: Through observation during the walkthrough of the survey it was determined that the facility failed to meet the Utilities- gas and electric requirements in accordance with NFPA 101 and NFPA 54. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one (1) smoke compartment. The Orifices installed on the dryers are not sized correctly currently set for 0-2000 feet according to dryer data plate. NFPA 54, section 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 instructionsThe deficient items were discussed with the Maintenance Staff during the exit conference.

STANDARD not met: Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain the trans-filling of oxygen from one cylinder to another in accordance with NFPA 99 - Health Care Facilities, 11.5.2.3. This deficient practice could affect all residents and staff within the facility should a fire emergency was to occur. The following evidenced this:The oxygen trans-filling room not mechanically ventilated correctly per NFPA 99. 9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction. 9.3.7.5.3.2 Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm). 9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) off the floor and adjacent to the cylinder or containers. The Director of Maintenance acknowledged the ventilation issue during a tour of the facility.

A recertification survey with complaint #CO33902 was completed on 3/11/24 to 3/13/24. Six deficiencies were cited.

An Emergency Preparedness survey was conducted from 3/11/24 to 3/13/24. Two deficiencies were cited.

Based on record review and interviews, the facility failed to have an annual review of the complete emergency preparedness plan (EPP). Specifically, the facility failed to have an annual review of the EPP. Findings include: I. Record review The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) on 3/13/24 at 11:00 a.m. Review of the EPP revealed the facility did not have an annual review of the EPP. II. Staff interview The EPP was reviewed with the NHA on 3/13/24 at 11:00 a.m. The NHA said the facility did not have an annual review of the EPP. The NHA said she did not know the last time the EPP was reviewed. She said it was important to keep the EPP updated. The NHA said it was important to review and if necessary update the EPP annually and as needed to keep up with the requirements.

Based on record review and interview, the facility failed to conduct exercises to test the emergency plan annually. Specifically, the facility failed to conduct a full-scale exercise that is community based annually and conduct an additional exercise annually. Findings include:I. Testing The emergency preparedness plan (EPP) was provided by the nursing home administrator (NHA) on 3/13/243 at 11:00 a.m. Review of the EPP revealed the facility had not conducted a full scale exercise or an additional exercise in the past year. II. Staff interview The EPP was reviewed with the NHA on 3/13/24 at 11:00 a.m. The NHA said the facility had not participated in a full-scale exercise that was community based annually and conducted an additional exercise annually. The NHA said she was not aware a full scale exercise that was community based or a secondary exercise were required annually. The NHA said it was important to train and test the EPP annually to keep up with the requirements and ensure the EPP was effective.

Based on observations, record review and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served in the dining room. Findings include: I. Facility policy and procedureThe Respect and Dignity policy, revised February 2021 was provided by the nursing home administrator (NHA) on 3/13/24 at 3:54 p.m., It read in pertinent part, "Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem."II. Meals served timely A. Posted mealtimes The posted meal times for the main dining room were scheduled to begin breakfast at 7:00 a.m. to 9:00 a.m., lunch at 11:00 a.m. to 1:00 p.m. and dinner at 5:00 p.m. to 6:00 p.m. B. Resident observations and interviews On 3/11/24 at 11:05 a.m. Resident #4 arrived at the dining room for lunch. He sat at his dining table waiting patiently for his meal as he watched the other residents eat and leave the dining room. Resident #4 said he usually had to wait for quite a while before he was served. Resident #4 said he thought the staff had forgotten about him as he continued waiting to be served. Resident #22 was observed waiting at the dining table for 35 minutes. The resident said she usually had to wait for a while before she received her meal. C. Additional observations 3/11/24 -At 4:00 p.m. six residents were sitting in the dining room. Four of the residents were sitting in wheelchairs. -At 4:05 p.m. Resident #4 arrived at the dining room in his wheelchair. The resident sat by his dining table waiting to be served. -At 4:15 p.m. there were 10 residents seated by their dining tables. Three of the residents had been served and they were eating dinner. -At 4:20 p.m. some of the staff started passing out drinks and others started taking resident's meal orders. -At 4:30 p.m. Resident #3 arrived at the dining room and sat across the dining table with Resident #4. The two residents stared at each other as they waited for their dinner. -At 4:40 p.m. Resident #3 was served dinner and he started eating as Resident #4 sat across the dining table watching his tablemate eat his dinner. -At 4:44 p.m. Resident #4 received his dinner and started eating. The resident left the dining room shortly after being served and ate only about 20% of his meal. 3/12/24-At 10:45 a.m. residents started arriving at the dining room.-At 11:00 a.m. 13 residents were waiting in the dining room ready for lunch.-At 11:00 a.m. Resident #22 arrived at the dining room.-At 11:15 a.m. the facility staff were all standing around the dining area counter with none of them interacting with the residents who were seated at the dining room.-At 11:30 a.m. Resident #22 received her lunch 30 minutes after she arrived at the dining room. III. Staff interview The dietary manager (DM) was interviewed on 3/12/24 at 1:05 p.m. The DM said the facility practiced open dining seating and meals were served on a first come first served basis. The DM said staff would take orders as soon as the residents arrived and pass the meal order to the cook. She said the problem with the dining room meal times was the miscommunication between the kitchen and staff assisting in the dining room. The DM said the facility staff should have been in the dining room earlier enough to know which resident arrived first. She said she would educate the staff to ensure residents who were seated at the same dining table received their meals promptly. The regional registered dietitian (RRD) was interviewed on 3/12/24 at 1:12 p.m. She was told of the observations above. Th

Based on record review and interviews, the facility failed to notify the provider according to physician orders for one (#28) of five residents reviewed for unnecessary medications out of 17 sample residents. Specifically, the facility failed to notify and document Resident #28's elevated blood sugar levels to the provider as directed on the physician's order. Findings include: I. Facility policy and procedures The Hypoglycemia or Hyperglycemia policy and guidelines, revised 2011, was provided by the nursing home administrator (NHA) on 3/13/24 at 3:54 p.m. The policy read in pertinent part,"The facility would ensure medications were administered per established physician's parameters. Staff would document all labs/treatments in nurse's notes and on the medication sheets."II. Resident #28 A. Resident status Resident #28, over 65, was admitted on 3/15/23. According to the March 2024 computerized physician orders (CPO), diagnoses included type II diabetes mellitus, personal history of traumatic brain injury, unspecified dementia and long-term (current) use of insulin. The 12/24/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required staff assistance for bed mobility, grooming, toileting, and one-person assistance with transfers with a gait belt. The resident had no behaviors. The resident was administered insulin for seven days and injections for seven days. B. Record review The physician's order dated 1/8/24 at 2:15 p.m. revealed to administer Humalog U-100 unit/milliliter insulin (insulin lispro) once in the evening, inject 13 units subcutaneously. Notify physician if blood glucose is less than 60 or greater than 400. (<60 or >400) Order dated 1/8/24 at 2:15 p.m. Administer lantus solostar U-100 insulin 30 units/milliliter subcutaneously at bedtime and notify physician if blood glucose was less than 60 or greater than 400 (<60 or >400). The care plan for diabetes mellitus was revised on 12/28/23. The interventions were for staff to administer Humalog per physician's order and notify physician if blood glucose was (<60 or >400). The January 2024 medications administration record (MAR) revealed on 1/1/24 that Resident #28 blood sugar level was 464 over the parameter set in the physician's order and on 1/20/24 the resident blood glucose level obtained was 504 above the physician's order parameters. The February 2024 MAR revealed on 2/14/24 that Resident #28 blood sugar level was 412 over the parameter set in the physician's order and on 2/29/24 the resident blood glucose level obtained was 407 above the physician's order parameters. -There was no documentation in the nursing progress note indicating that the provider was notified. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/13/24 at 3:30 p.m. The LPN said the four dates on the resident's MARs revealed the resident insulin levels were elevated above the parameters indicated on the physician's order and there should be documentation that the physician was notified. She said nurses should follow physician orders. She said not documenting that the physician was notified indicates that it did not happen. She said insulin parameters were important because the resident might have experienced high blood sugar levels which would require the physician to adjust the amount of insulin to administer. She said not notifying the physician for the proper dose of insulin could cause the resident to experience shock, become comatose or have an increase in symptoms related to her diagnosis. The director of nursing (DON) was interviewed on 3/13/24 at 3:50 p.m. The DON said the four dates on the resident's MARs revealed the resident's blood glucose levels were elevated above the parameters on the physician's order and the staff should have

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #3, CNA #4 and CNA #5. Findings include:I. Record reviewCNA #2 (hired on 6/1/21), CNA #3 (hired on 10/2/21), CNA #4 (hired on 2/11/19) and CNA #5 (hired on 11/2/21) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Staff interviewThe nursing home administrator (NHA) was interviewed on 3/12/24 at 1:30 p.m. She said she could not locate the performance reviews for CNA #2, CNA #3, CNA #4 and CNA #5. She said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward she would ensure the performance reviews were completed annually to ensure best care was being delivered to the residents.

Based on observations and interviews the facility failed to store, distribute and serve food in a sanitary manner in two of two kitchen nourishment refrigerators. Specifically, the facility failed to ensure nutritional beverages were labeled and dated when opened in the kitchen nourishment refrigerators. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, "A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request." (Retrieved 3/14/24). II. Observation On 3/11/24 at 9:47 a.m. the following was observed at the main kitchen nourishment refrigerators during the initial kitchen tour:-In the first nourishment refrigerator, there were two opened undated and with no labels of thickened liquid containers.-In the second nourishment refrigerator, there were four cartons of opened juice containers, (one apple juice, one tomato juice, one grape juice and one orange juice) there were no labels and they were not dated. On 3/12/24 at 10:21 a.m. the following was observed at the main kitchen nourishment refrigerators during the follow-up visit to the kitchen:-In the first nourishment refrigerator, there were two opened undated and with no labels of thickened liquid containers.-In the second nourishment refrigerator, there were four cartons of opened juice containers, (one apple juice, one tomato juice, one grape juice and one orange juice) there were no labels and they were not dated. III. Staff interviews The dietary manager (DM) was interviewed on 3/12/24 at 11:30 a.m. The DM said the kitchen staff should have all opened juice cartons dated and labeled to be aware of how long it has been opened to avoid distributing contaminated beverages to any resident. She said the kitchen staff were trained to understand the importance of labeling. She said the staff might have forgotten to label those beverages in the nourishment refrigerators. The DM said she would educate the kitchen staff to ensure open cartons and containers were labeled and dated properly. The regional registered dietitian (RRD) was interviewed on 3/12/24 at 11:51 a.m. The RRD said all opened dairy products and food kept in the refrigerators were to be labeled and dated. She said undated food items and beverages could potentially get someone sick when opened for a long period and had become contaminated. The RRD said she had advised the DM to provide education to all the kitchen staff to ensure all food items and opened beverages were dated when kept in the refrigerator.

Based on record review and interviews, the facility failed to ensure mandatory submission of direct care staffing based on payroll roll data. Specifically, the facility failed to ensure staffing data entered in the Payroll-Based Journal (PBJ) system was accurate. Findings include:The facility had a change of staff during the first quarter. I. Record reviewThe PBJ stuffing report for quarter one (10/1/23 to 12/31/23) showed the following triggered area:-Failed to Submit Data for the QuarterII. InterviewThe nursing home administrator (NHA) was interviewed on 3/13/24 at 10:45 a.m. She said during the last quarter there had been a staff change. She said she tried to submit the data, however, it was not submitted correctly. When she went back to the system to correct the errors, she was unable to make the necessary corrections and the data was not accepted. She said she had not had any issues submitting data since the incident. She said it was important to submit the data timely and correctly.

Based on observations and staff interviews, the facility failed to provide adequate ventilation by means of mechanical ventilation for one resident bathroom and two resident shower rooms. Specifically, the facility failed to ensure resident bathroom vents were free from lint and the exhaust fans were functioning. Findings include: I. Facility policy The Exhaust Fan and Ventilation policy, dated 1/25/24, was provided by the nursing home administrator (NHA) on 3/13/24 at 3:54 p.m. The policy read in pertinent part, "The facility would check all exhaust fans in bathrooms, shower room soiled and clean utility rooms, janitor's closets, kitchen, and sink and laundry areas and oxygen room."The facility would ensure that airflow is sufficient enough to hold a piece of paper to the vent when operating."Clean vents using vacuum and air compressor to remove all dust." II. Observation An observation of the resident environment was completed on 3/12/24 at 12:40 p.m. The exhaust fans in shower room #1 had no audible sound and was not functioning. As a measure of checking the function of each fan, a small square of single ply toilet paper was placed against the vent. The exhaust fans were unable to hold the toilet tissue in place which indicated the fans did not function properly. The vent in shower room #2 had lint and cobwebs around the surface. The bathroom vent in room #10 had lint and cobwebs around the surfaces of the vent. III. Staff Interview The environmental tour was conducted with the maintenance director (MTCE) on 3/13/24 at 11:40 a.m. The MTCE said the exhaust fan in one of the resident's main shower rooms was not functioning. The MTCE said he would have to check the motors on all halls to see why the vent in the shower room was not functioning as it should. The MTCE said the ventilation fans in every resident's shower rooms and bathrooms should be in good working condition. He said the vents in the resident's toilet and the resident's shower rooms should be clean.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/22/2024 and 01/28/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/06/2023 and 11/12/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.