RIVERDALE POST ACUTE — Colorado Facility Report

Inspections

Deficiencies

Actual Harm or Above

109

Occurrences

June 16, 2026

Last Inspection

S/S C Minimal potentialS/S D/E/F Potential for harmS/S G Actual harm

The most recent inspection of RIVERDALE POST ACUTE on record is dated June 16, 2026. Across 28 published inspections, state surveyors cited 67 deficiencies, 1 of which reached actual harm or immediate jeopardy.

Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.

Provider Information

Status

Active

Facility Type

SNF/NF Dual Certification

Administrator

Nef, Broderick

Owner

RIVERDALE HEALTHCARE, LLC

Phone

(303) 659-2253

Payor Source

Medicare, Medicaid, Private Pay

City

BRIGHTON

ZIP

80601-2547

Inspections & Citations

28 inspections · 67 deficiencies

6/16/2026Complaint Survey · ID 23604D-H11 deficiency▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO3026391, Incident #2995561, Incident #2995599, Incident #2995625 and Incident #2995640 was completed on 6/15/26 to 6/16/26. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0689Free of Accident Hazards/Supervision/Devices▼

Findings

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#1) of three residents reviewed for accident hazards out of nine sample residents. Specifically, the facility failed to ensure neurological assessments were completed after Resident #1’s unwitnessed fall, which resulted in a head injury. Findings include:I. Facility policy and procedureThe Head Injury policy, revised October 2025, was provided by the nursing home administrator (NHA) on 6/16/26 at 4:15 p.m. It read in pertinent part, “It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury.“Assess residents following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum: vital signs, general condition and appearance, neurological evaluation for changes in physical functioning, behavior, cognition, level of consciousness, dizziness, nausea, irritability, slurred speech or slow to answer questions, evaluation of the head, eyes, ears, and nose for significant changes in vision hearing, smell or bleeding, any injuries to head, neck, eyes, or face including lacerations, abrasions or bruising, pain assessment.“Perform neurological checks as indicated or as specified by the physician.”II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 3/30/26. According to the June 2026 computerized physician orders (CPO), diagnoses included dementia, heart disease, malnutrition and dysphagia (difficulty swallowing). The 4/1/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required supervision from staff for eating, walking at least 10 feet and transfers and moderate assistance for hygiene, showering and dressing. B. Resident interview and observationOn 6/15/26 at 1:30 p.m. Resident #1 was walking in the hallway immediately outside of her room. Resident #1’s skin had large yellow areas (bruises) on both of her cheeks and forehead, each at least three centimeters (cm) to four cm wide by three cm to four cm long. In the center of both yellow areas on each cheek was a small purple one cm by one cm area. Resident #1 said she could not remember well, but she said she had fallen one night. Resident #1 said she hurt her head and had head pain after she fell. C. Record reviewA nursing progress note, dated 5/23/26 at 3:09 a.m., documented that at 2:00 a.m., staff members heard a loud noise from Resident #1’s room and found the resident lying on the floor next to her bed. It documented Resident #1 said when she stood up from bed, she lost her balance and fell. It documented a four cm by four cm hematoma (a collection of blood from an injury) with a small abrasion on the right side of her forehead. A document for Resident #1 titled Neurological Record was provided by the NHA on 6/16/26 at 12:45 p.m. The document revealed the following instructions: document the date and time of each assessment, including level of consciousness, pupil response, motor functions and hand grasps, extremities, pain response and vital signs. It documented the initial assessment was to be completed in the resident’s electronic medical record (EMR), and then written (hard copy/paper) documentation every 15 minutes for one hour, every 30 minutes for two hours, every hour for two hours and then every shift for 72 hours. Initial assessments were documented on the form. Review of the Neurological Record for Resident #1 revealed complete written documentation of the neurological shift assessments was missing at the following times following the resident’s fall on 5/23/25:-On 5/24/26, the day shift and evening shift assessments did not include documentation for Resident #1’s level of consciousness , pupil response, hand grasps, motor response and pain response and it was not signed by the nurse.-On 5/24/26, the night shift assessment documented Resident #1 refused pupil response and motor assessments, however, there was no documentation in the EMR that the physician was notified of Resident #1’s refusal of these assessments.-On 5/25/26, the day shift and evening shift assessments did not include documentation for Resident #1’s level of consciousness, pupil response, hand grasps, motor response and pain response.-On 5/25/26, the night shift assessment documented Resident #1 refused pupil response and motor assessments, however, there was no documentation in the EMR that the physician was notified of Resident #1’s refusal of these assessments. -On 5/26/26, the day shift assessment did not include documentation for Resident #1’s level of consciousness, pupil response, hand grasps, motor response and pain response. A nursing progress note, dated 5/26/26 at 2:05 p.m., documented Resident #1 had worsening confusion, inability to walk, headache and dizziness and was unable to lay flat. It documented that she was responsive to questions. Physician’s orders were received and Resident #1 was transferred to the hospital. III. Staff interviewsThe director of nursing (DON) was interviewed on 6/16/26 at 2:50 p.m. The DON said the physician was notified of Resident #1’s fall on 5/23/26. The DON said after Resident #1 was transferred to the hospital on 5/26/26, she (the DON) reviewed the documentation for Resident #1’s neurological assessments and found there was missing documentation of the assessments. The DON said each scheduled neurological assessment should have been completed and the physician notified if Resident #1 refused assessments at any time. The DON said she had not met with licensed practical nurse (LPN) #2 to review the missed documentation of Resident #1’s neurological assessment. The DON said she reviewed the missed documentation and provided education to RN #1 and certified nurse aide with medication authority (CNA-Med) #1. The DON said education was provided to all nursing staff to ensure neurological assessments were completed and documented, however, she had not reinforced education for contacting the physician if residents refused any part of the neurological assessments. Registered nurse (RN) #2 was interviewed on 6/16/26 at 6:20 p.m. RN #2 said he was Resident #1’s nurse on the night she fell (on 5/23/26). RN #2 said after the fall, Resident #1 had a large hematoma on the right side of her head. RN #2 said Resident #1 told him that she stood up and her legs gave out. RN #2 said he contacted the physician and began neurological checks per the facility’s protocol.

Plan of correction · submitted by the facility

1. Corrective Action for Affected ResidentsResident #1 was evaluated in the emergency room on 5/26/26. She had a CT (computer tomography) exam which showed no brain injury. 2. Identification of Other ResidentsResidents with head injuries are at risk. All residents with head trauma in the last 14 days were reviewed by the DON (director of nursing) for completed neurological checks. Any residents with incomplete neurological checks were reported to the PCP (primary care physician) for further evaluation if indicated. 3. Systematic ChangesThe DON/designee educated the licensed nurses on completing neurological checks per policy, notifying the PCP if a resident refuses and documenting the notification in the progress notes. 4. MonitoringThe DON/designee will review all neurological records 3x/week for 4 weeks, weekly x4 weeks, and monthly thereafter for any concerns related to incomplete neurological checks. This will be documented on an audit tool. The QAPI (quality assessment performance improvement) committee will review the neurological check audits monthly to identify trends and recommend further action. 5. Compliance date 7/15/26

6/16/2026Licensure Complaint Survey · ID 23604E-H1No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A survey with #CO3026392 was completed on 6/15/26 to 6/16/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 5.7.4 ACCIDENT PREVENTION AND ATTENTIONThe facility shall:A) Investigate all causes of accidents;B) Monitor the resident's response to the accident and obtain a physical and/or mental health evaluation from a practitioner, if needed;C) Identify all residents at high risk for accidents and develop an individualized care plan for each of them to prevent future accidents; andD) Evaluate and revise the plan as needed.

Plan of correction

The state did not require a plan of correction for this citation.

4/22/2026Complaint Survey · ID 22F5BD-H12 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO2963232, #CO2793030, #CO2990249 was conducted on 4/22/26. Two deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0812Food Procurement,Store/Prepare/Serve-Sanitary▼

Findings

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to serve the residents meals at appropriate temperatures. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 4/28/26. It revealed in pertinent part, “Time/Temperature control for safety food shall be maintained at 135 degrees F (Fahrenheit) or above and 41 degrees F or less.” (3-501.16 ) II. Facility policy and procedureThe Food Preparation and Service policy, revised November 2022, was provided by the nursing home administrator (NHA) on 4/22/26 at 6:11 p.m. The policy read in pertinent part, “When verifying food temperatures, staff use a thermometer which is both clean, sanitized, and calibrated to ensure accuracy.“The danger zone for food temperatures is above 41 degrees F and below 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness.“The longer foods remain in the “danger zone” the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous food (PHF) must be maintained at or below 41 degrees F or at or above 135 degrees F.“Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held in the temperature danger zone are discarded after four hours.“The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff.”III. ObservationsDuring a continuous observation of the lunch meal service on 4/22/26, beginning at 10:45 a.m. and ending at 12:01 p.m., the following was observed:At 10:48 a.m. four plates were already assembled with salad chicken and hawaiian roll each ready to be placed on the meal cart. At 10:49 a.m. the dietary manager (DM) started checking temperatures of food lined up on the steam table ready for the meal service. The following temperatures were recorded:-The chicken salad was 55 degrees F-The soft and bite chicken salad was 55 degrees F-The pureed chicken salad was 45 degrees FAt 10:53 a.m. cook (CK) #1 placed the four plates assembled onto the meal cart. At 10:54 a.m. CK #1 resumed assembling meal plates with wedge chicken salad and a hawaiian roll.-CK #1 continued assembling meal plates with wedge chicken salad at an inappropriate holding temperature. IV. Resident interviewResident #1 was interviewed on 4/22/26 at 9:45 a.m. Resident #1 said he ate his meals in his room and they were always cold when delivered. Resident #1 said he did not eat them and tried to buy food from outside of the facility. V. Record reviewReview of the April 2026 food temperature log revealed the following;-Temperatures were not documented during breakfast service on 4/1/26, 4/2/26, 4/3/26, 4/4/26, 4/5/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/18/26 and 4/19/26-Temperatures were not documented during lunch service on 4/1/26, 4/2/26, 4/3/26, 4/4/26, 4/5/26, 4/6/26, 4/7/26, 4/11/26, 4/12/26, 4/18/26 and 4/19/26-Temperatures were not documented during dinner service on 4/5/26, 4/6/26, 4/7/26, 4/12/26, 4/13/26, 4/14/26 and 4/19/26. VI. Staff interviewsCK #1 was interviewed on 4/22/26 at 3:55 p.m. CK #1 said she checked the food temperatures after cooking. She said she verified the temperatures on the steam table prior to meal service to ensure the food remained at proper holding temperatures. CK #1 said she documented the temperature checks in the food temperature log. She said the holding temperature should be 38 degrees F or lower for cold food and 165 degrees F or higher for hot food. CK #1 said if the food was not the proper temperature, she would reheat the hot food and put the cold food in the fridge. She said to maintain proper holding temperatures at the steam table, she ensured there was enough ice in the pan for cold food. For hot food, she ensured the water level was properly maintained so the pan remained submerged in water. CK #1 said she should not have served the wedge chicken salad at a holding temperature of 55 degrees F due to the potential risk of foodborne illness to residents. She said she placed ice in the pan but the room was very hot without adequate ventilation. The DM was interviewed on 4/22/26 at 4:05 p.m. The DM said the cook checked the food temperatures after removal from the oven and prior to the meal service. He said hot food such as chicken and turkey should be held at 165 degrees F or higher, and beef at 155 degrees F or higher. The DM said cold food should be held at 40 degrees F or below. He said the wedge chicken salad should not have a holding temperature of 55 degrees F. The DM said the April 2026 food temperature log was not consistently completed correctly as cooks sometimes forgot to fill it out. The DM said he had provided education to the cooks regarding proper temperature monitoring and documentation.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 5/11/2026, Resident #1 was interviewed by Dietary Director/Designee regarding meal temperature concerns and filled out concerns on a grievance form to ensure follow through. The Dietary Director/Designee ensured that the hot plates are holding a correct temperature for food waiting to be served. The Dietary Director made sure the kitchen refrigerator was in the appropriate temperature range. Identifying other Residents having the Potential to be Affected: On 5/11/2026, the Dietary Director/designee completed a full audit of the meal temperature logs to ensure they are completed correctly and accurate temperatures are being captured. Measures put into place or Systemic Changes: On 5/6/2026, the Director of Dietary Services/designee provided education to the dietary department on meal temperatures. The education included making sure that meal temperatures are accurately captured and logged. Plan to Monitor Performance: Beginning 5/11/2026, the Dietary Director/designee will conduct weekly audits for 12 weeks on an excel auditing log, to conduct audits of the food temperature log to verify that temperatures are documented for breakfast, lunch, and dinner service and that documented temperatures are within safe ranges (41 degrees F or below for cold food and 135 degrees F or above for hot food). The quality assurance performance improvement (QAPI) committee will review monitoring results monthly to identify trends and recommend action related to any deficient practice for 3 months. Date of Compliance: 05/31/2026

0880Infection Prevention & Control▼

Findings

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to:-Contact the physician for clarification on what type of precaution Resident #3 needed; and,-Communicate the precautions to the staff clarify and communicate Resident #3’s isolation precautions. I. Facility policy and procedure The Multidrug-Resistant Organisms policy, dated December 2024, was received from the nursing home administrator (NHA) on 4/22/26 at 6:11 p.m. It read in pertinent part, “Multidrug-resistant organisms (MDROs) are bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs. Infection means the organism is present and is causing illness. Colonization means that the organism is present in or on the body but is not causing illness. “The following strategies are based on current recommendations for MDRO prevention and control:“Implement systems to designate residents known to be colonized or infected with a targeted MDRO and to notify receiving healthcare facilities or personnel prior to transfer of such residents within or between facilities. “Implement Contact Precautions (CP) routinely for all residents colonized or infected with a targeted MDRO. When active surveillance cultures are obtained as part of an intensified MDRO control program, implement contact precautions until the surveillance culture is reported negative for the targeted MDRO. “Implement Enhanced Barrier Precautions for certain MDRO-colonized/infected residents whose site of colonization or infection can be appropriately contained and who can observe good hand hygiene practices.”II. Record reviewReview of Resident #3’s April 2026 computerized physician orders (CPO) revealed the following physician’s orders:-Isolation Precautions: Isolation with: Contact precautions related to MDRO (GI), ordered on 3/23/36.-Enhanced Barrier Precautions (EBP): Gown and Glove use during all high-contact resident care or activities due to MDRO, ordered 3/26/26. Review of Resident #3’s comprehensive care plan did not reveal what type of isolation precautions the resident was on. The communication note, documented on 4/22/26 at 6:14 p.m. revealed the director of nursing (DON) contacted the physician. The note revealed Resident #3 had a history of respiratory MDRO and the physician said enhanced barrier precautions (EBP) were sufficient at that time.-The facility failed to contact the physician for clarification on what type of precaution the resident needed when there were two different physician ordered precautions and failed to communicate the precautions to the staff. III. ObservationsOn 4/22/26 at 2:26 p.m. Resident #3’s room was observed. There was not an EBP or contact precaution signs on the door or surrounding area. On 4/22/26 at 4:29 p.m. Resident #3’s room was observed. There was not an EBP or contact precaution signs on the door or surrounding area. -Interviews revealed it was the facility’s process to place a sign on the resident’s door to indicate what precautions the resident was on (see interviews below)IV. Staff interviewsCNA #2 was interviewed on 4/22/26 at 1:56 p.m. CNA #2 said the staff used to have to wear a gown and gloves in Resident #3’s room. She said Resident bt #2 did not have MDRO anymore, so the staff did not need to wear PPE. CNA #2 said staff were told they only had to worry when Resident #2 had a cold. CNA #2 said a previous nurse, who was no longer at the facility, said the MDRO was in Resident #3’s feces and urine. -However, Resident #3 still required EBP.Licensed practical nurse (LPN) #1 was interviewed on 4/22/26 at 2:19 p.m. LPN #1 said it was not required to wear PPE when providing care to Resident #3. LPN #1 said she was not aware of any infection he had. LPN #1 said if residents required contact precautions, there would be an order for it in the system. CNA #1 was interviewed on 4/22/26 at 4:42 p.m. CNA #1 said Resident #3 moved rooms at some point. CNA #1 said earlier that day (4/22/26), Resident #3 was then moved back to his original room. CNA #1 said that when Resident #3 first got to the facility, he had isolation precautions and PPE hanging on the outside of his door for staff to put on before going into the room. CNA #1 said once Resident #3 moved to his new room, she did not know what happened to the signs and PPE that he previously had on his door. CNA #1 said she did not know whether or not Resident #3 had contact or EBP precautions signs or PPE on his door at the time of the interview. CNA #1 said she thought Resident #1 had MDRO in his urine. CNA #1 said she wore a gown and gloves when assisting Resident #3 in the bathroom. LPN #1 was interviewed again on 4/22/26 at 4:22 p.m. LPN #1 said she looked at the order and saw there were two orders which showed both EBP and contact precautions. LPN #1 said normally the medication administration record (MAR) or treatment administration record (TAR), would alert nurses if residents should have been on precautions. LPN #1 said nothing popped up on the MAR or TAR to notify her that Resident #3 had isolation precautions so she was not aware he needed them. LPN #1 said no one told her about required precautions in morning report. LPN #1 used the computer and navigated to Resident #3’s orders. LPN #1 said there were two orders for isolation precautions. She said the order directed staff to utilize EBPs and one called for contact precautions related to MDRO (GI). LPN #1 said she did not know which to use so she would follow up with the director of nursing (DON) and physician to figure out what to do. LPN #1 said she was not sure who implemented precautions at the facility. LPN #1 said she had not reached out to the physician or the DON at that point. The DON and regional clinical resource were interviewed together on 4/22/26 at 6:20 p.m. The DON said the housekeeping director was responsible for placing isolation signage and PPE equipment on resident’s doors. The DON said once the housekeeping director was made aware of a new admission who required PPE, they would place signage and PPE on the resident's door to be used. The DON said if a resident had isolation precautions, there should be a care plan related to that topic. The DON said if the resident moved rooms, the signage and PPE equipment should still be implemented at the new room. The DON said in order for precautions to be discontinued, there would need to be a physician’s note indicating that the resident no longer had symptoms or required isolation precautions. The DON said negative lab results would also be needed to discontinue precautions. The DON said the electronic medical record indicated Resident #3 had MDRO in the sputum. The DON said staff should have been wearing PPE during cares for Resident #3. The DON said CNAs were informed about precautions through shift change and reports to one another. The DON said nurses were made aware of precautions through doctor’s orders. The regional clinical resource said nurses also received reports from one another and the MAR also alerted nurses of precautions. The DON said she clarified with the medical director and concluded that Resident #3 should be on EBP precautions. The DON said the contact precautions order was discontinued. The DON said they checked to see what precautions were on Resident #3’s door and said unfortunately there was no PPE or signage indicating Resident #3 was on precautions. The DON said there should have been signs on the door and that is how the facility identified isolation precautions. The DON said staff would immediately implement EBPs. The DON said the facility would also create a care plan related to Resident #3’s MDRO and EBPs.

Plan of correction · submitted by the facility

Corrective Action Resident #3. On 4/22/26 the DON (director of nursing) clarified the physician orders for EBP (enhanced barrier precautions) only, and wrote a care plan for EBP isolation. Identification of Others Residents requiring all types of isolation have the potential to be affected. The DON/designee reviewed the medical record including orders and physician notes to determine which residents required isolation. The DON updated all orders, care plans, and verified required signage and PPE (personal protective equipment) was in place for all residents requiring isolation. Systemic Changes The DON/designee educated the nursing staff on ensuring there are physician orders to start and stop isolation, a care plan and the use of PPE in different types of isolation in rooms. The DON/designee will review new admissions and residents with a change in condition in the daily clinical meeting to determine if isolation orders, care plans, correct signage and PPE are in place as required. Monitoring The DON/designee will audit the resident orders and care plans 3x/week for 4 weeks, weekly for 4 weeks, monthly for 3 months to ensure residents requiring isolation have a physician orders and care plan in place. This will be documented on an audit tool. The DON/designee will audit 5 resident rooms per week for 4 weeks, weekly for 4 weeks, monthly for 3 months and thereafter as determined by the QAPI committee for use of appropriate accurate signage for isolation rooms. This will be documented on an audit tool. The QAPI committee will review the isolation audits for PPE, orders and care plans monthly to identify trends and recommend action related to any deficient practice for 3 months and monthly thereafter if determined by the committee, there are continued concerns with infection control. Completion date 5/31/26

4/22/2026Licensure Complaint Survey · ID 22F5C0-H11 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint survey, prompted by #CO2793032 was conducted on 4/22/26. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1301Dietary Services - General Standards▼

Findings

Plan of correction · submitted by the facility

9999Final ObservationsSurveyor note▼

Findings

Plan of correction

The state did not require a plan of correction for this citation.

2/19/2026Licensure Complaint Survey · ID 1E454C-H1No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A survey with #CO2734234 was completed on 2/17/26 to 2/19/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

2/19/2026Complaint Survey · ID 1E4549-H11 deficiency▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO2734233, #CO2741081, Incident #2741321, Incident #2741335, Incident #2741345, Incident #2741358, Incident #2741378, Incident #2741400 and Incident #2741416 was completed on 2/17/26 to 2/19/26. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0600Free from Abuse and Neglect▼

Findings

Based on observations, record review and interviews, the facility failed to ensure two (#5, and #8) of six residents reviewed out of 13 sample residents were kept free from resident-to-resident physical abuse. Specifically the facility failed to: -Protect Resident #8 from physical abuse by Resident #14; and, -Protect Resident #5 from physical abuse by Resident #9. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and Procedure, revised April 2021, was provided by the nursing home administrator (NHA) via email on 2/19/26 at 2:15 p.m. It read in pertinent part, “Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident’s symptoms.“The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: facility staff; other residents; consultants; volunteers; staff from other agencies; family members; legal representatives; friends; visitors; and/or any other individual.“Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.“Implement measures to address factors that may lead to abusive situations, for example: adequately prepare staff for caregiving responsibilities; provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; instruct staff regarding appropriate ways to address interpersonal conflicts; and help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.”II. Incident of physical abuse by Resident #14 towards Resident #8 on 1/31/26A. Facility investigationThe facility abuse investigation report was provided by the NHA on 2/17/26 at 5:15 p.m. The investigation documented the date of the incident as 1/31/26 at 11:00 p.m. The investigation revealed that Resident #14 made contact with Resident #8 with a coke can to the side of Resident #8’s face. This took place in the men’s secured unit dining area. The residents were separated and placed on frequent monitoring by the facility. The police, the physician and all appropriate parties were notified. The investigation documented Resident #8 had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. Resident #8 had a history of behavioral issues related to dementia . The investigation documented Resident #14 was cognitively intact with a BIMS score of 14 out of 15 and had a history of behavioral issues related to dementia. The incident was not witnessed by staff. The victim (Resident #8) was evaluated for changes in condition and assessed by a nurse on 2/1/26. Resident #8 sustained a skin tear to the left corner of the eye and was treated. The physician recommended to monitor the laceration and bruising to the left eye area every shift for three days. The investigation documented Resident #8 was interviewed and said Resident #14 did not like him doing the trash, so Resident #14 hit him in the face. The investigation documented the facility attempted to interview Resident #14 twice, but the resident refused to talk or engage. Resident #14 stated he would not talk about it. The investigation documented abuse questionnaires were completed for other residents stating they felt safe in the facility. The investigation documented Resident #8 was placed on 15-minute checks and was offered psychosocial support. The investigation documented Resident #14 was placed on 15-minute checks. The resident’s care plan was reviewed by the interdisciplinary (IDT) team. The resident was offered psychosocial support. The resident’s medication regimen was to be reviewed for any potential changes.-However there were no updates to Resident #14’s behavioral care plan to prevent further recurrence (see record review below). The investigation documented the incident was to be discussed in QAPI (quality assurance and performance improvement) to identify potential changes that could have been implemented to prevent a recurrence. The investigation documented contact was made between the residents and the abuse allegation was substantiated. B. Resident #14 (assailant) 1. Resident statusResident #14, age greater than 65, was admitted on 9/27/22 and readmitted on 9/20/25. According to the February 2026 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, type 1 diabetes mellitus, anxiety disorder and heart failure. The 12/17/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required supervision or touching assistance for toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene, rolling left and right, sitting to lying, sitting to stand, chair to bed transfers, toilet transfers, and walking. He required setup or clean up assistance with eating. The assessment revealed he had potential indicators of psychosis, including delusions. He had behavioral symptoms including physical behavioral symptoms directed toward others four to six days per week, verbal behaviors one to three days per week, and other behavioral symptoms not directed toward others one to three days per week. He had rejection of care behaviors one to three days per week. 2. Record reviewResident #14’s behavioral care plan, revised 1/31/26, revealed the resident was involved in an altercation on 1/31/26. The care plan documented the residents were separated and assessed for acute injury. Interventions included the staff de-escalated Resident #14’s aggressive mood by returning with him to his room, initiated 1/31/26. -However there were no preventative interventions to prevent a recurrence. The 1/31/26 at 11:30 p.m. IDT behavior note, documented as a late entry, revealed Resident #14 was found in the dining room with a crushed soda can in his hand. The note documented he stated he had hit Resident #8 for trying to take it from him. The note documented the residents were separated and assessed for acute injury. The staff de-escalated Resident #14’s aggressive mood by returning with him to his room. The physician, power of attorney (POA) and leadership were notified. The note documented the risk factors included dementia, history of aggression and medications. C. Resident #8 (victim) 1. Resident statusResident #8, age greater than 65, was admitted on 3/21/19 and readmitted on 5/23/23. According to the February 2026 CPO, diagnoses included dementia with behavioral disturbance, anxiety disorder, chronic obstructive pulmonary disease (COPD) and congestive heart failure. The 2/4/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. He required setup or clean-up assistance with eating, toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene, rolling left and right, sit to stand transfers, bed to chair transfers, and use of manual wheelchair. The assessment revealed he had potential indicators of psychosis including delusions. He had no behavioral symptoms, rejection of care or wandering according to the assessment. 2. Record reviewResident #8’s behavioral care plan, revised 4/7/23, revealed he had behavioral issues related to his dementia. Pertinent interventions included providing the opportunity for positive interaction and attention by stopping and talking with him as passing by, monitoring behavior episodes and attempting to determine the underlying cause, considering the location, time of day, persons involved, and situations, documenting behavior and potential causes and the residents feelings and reported concerns. The 1/31/26 at 11:30 p.m. IDT note, documented as a late entry, revealed Resident #8 was struck in the left eye with a soda can by another resident who thought that Resident #8 was trying to take his soda. Interventions included the residents were separated and assessed for acute injury. Resident #8 had a small cut to the left outside corner of his eye; the wound was cleaned and patted dry. The POA and administration were notified. The note documented risk factors included Resident #8 said he was not trying to take the soda can and did not know why he was struck. D. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 2/19/26 at 10:15 a.m. CNA #1 said she worked on the men’s secured unit, where Resident # 8 and Resident #14 resided. CNA #1 said she was informed about the altercation between Resident #8 and Resident #14 and that Resident #14 had smashed his soda into the face of Resident #8 unprovoked. CNA #1 said the staff had not been provided with any new prevention techniques or interventions to apply to Resident #14’s behaviors to prevent a recurrence. CNA #2 was interviewed on 2/19/26 at 10:25 a.m. CNA #2 said she worked on the men’s secured unit. CNA #2 said she was told about the altercation between Resident #8 and Resident #14, so that she could be aware to keep them separated. CNA #2 said that Resident #14 had hit Resident #8 with a soda can in his face. CNA #2 said the only prevention she could think of was to try to keep the two residents separated and she had not been told of anything else. III. Incident of physical abuse by Resident #9 towards Resident #5 on 2/10/26A. Facility investigationThe facility abuse investigation report was provided by the NHA on 2/17/26 at 5:15 p.m. The investigation documented the date of the incident as 2/10/26 at 3:30 p.m. The investigation revealed that at approximately 3:00 p.m. Resident #9 was wandering/walking past Resident #5’s room in the hallway of the men’s secured unit. At this point, the residents both got verbally aggressive with each other. This led to Resident #9 making contact with Resident #5’s head. The residents were immediately separated from each other during the course of the investigation. The residents were placed on frequent monitoring. Both residents were evaluated for any changes in condition from the altercation. The police, the physician and all appropriate parties were notified. -However there were no updated interventions to prevent further recurrence. Resident #5’s BIMS score was a 13 out of 15 and the resident had no history of behaviors. Resident #9 had severe cognitive impairments and had a history of behaviors. The investigation documented the resident had a history of verbal aggression toward staff and may become resistant to cares. The investigation documented the behaviors may be triggered by feeling rushed, loss of control, unfamiliar staff, changes in routine, or unmet needs. The investigation documented without appropriate interventions, behaviors may escalate and place Resident #9 and others at risk. The investigation documented the incident was not witnessed by staff. Resident #5 was evaluated for changes in condition and assessed by a nurse immediately. There were no signs or symptoms of injury noted, no redness, bruising, or skin injury. Resident #5 denied pain. Resident #5 appeared well and at baseline. Resident #5 was interviewed outside his room in the hallway. He said Resident #9 cussed at him. Resident #5 said he told Resident #9 not to speak to him that way and he had never done anything to him. Then Resident #9 hit Resident #5, causing Resident #9 to fall. Resident #5 said he called out for help and the staff was there immediately to help separate them. Resident #5 said he knew that Resident #9 just needed help and was not angry with him. Resident #5 said he felt safe and well cared for and supported. Resident #9 was interviewed and was unable to answer questions. The investigation documented the resident appeared to be confused. Resident #9 was provided with psychosocial support, and physical assessment with no injuries noted. The investigation documented abuse questionnaires were completed for other residents stating they felt safe in the facility. The investigation documented Resident #5 was placed on 15-minute checks and was offered psychosocial support. The investigation documented Resident #9 was placed on 15-minute checks. The resident’s care plan was reviewed by the IDT team. The resident offered psychosocial support. The investigation documented the resident’s medication regimen to be reviewed for any potential changes.-However there were no updates to Resident #9’s behavioral care plan to prevent further recurrence. The investigation documented the incident to be discussed in QAPI to identify potential changes that could have been implemented to prevent a recurrence. The investigation documented the facility determined that contact was made between the residents. B. Resident #9 (assailant) 1. Resident statusResident #9, age greater than 65, was admitted on 7/16/24. According to the February 2026 CPO, diagnoses included vascular dementia, severe, with behavioral disturbance, insomnia and pulmonary embolism. The 1/21/26 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. He required substantial/maximal assistance with shower/bathing. He required partial/moderate assistance with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. He required supervision or touching assistance with rolling left and right, sitting to lying, sitting to standing, chair to bed transfers, toilet transfers, eating, and walking. The assessment revealed he had potential indicators of psychosis including delusions. He had no behavioral symptoms, rejection of care or wandering according to the assessment. 2. Record reviewReview of Resident #9’s behavior toward staff care plan, revised 1/8/26, revealed the resident had a history of physical and verbal aggression toward staff and may become resistant to care. The care plan documented without appropriate interventions, behaviors may escalate and place Resident #9 and others at risk. Pertinent interventions included care in pairs. If resistant to care, ensure his safety and approach at a later time. Request sent for psychiatric medication review to psychiatric nurse practitioner (NP) and psychiatrist, initiated 2/17/26 (during survey).-Review of the comprehensive care plan did not reveal a care plan focus for the resident’s behaviors directed towards other residents. The 2/10/26 at 3:49 p.m. IDT behavior note, documented as a late entry, revealed Resident #9 was hit by another resident (Resident #5) in the hallway. The note documented the nurse checked on both resident's right away and staff members had already separated both of the residents. The note documented the interventions documented vital signs were initiated and within normal baseline limits and a neurological assessment was done with no abnormal findings noted at this time. The resident's emergency contact, the physician and the NHA were notified. The note documented the risk factors included a history of aggressive behavior, medications and dementia diagnosis. The 2/10/26 at 7:12 p.m. nurse note revealed that at 3:30 p.m. the nurse was notified by the certified nurse aide with medication authority (CNA-Med) that this resident was hit by another resident in the hallway. The nurse went to check on both residents right away and staff members had already separated both residents. Resident #9 refused to answer any questions. The nurse assessed the resident for injuries and notified the director of nursing (DON) for a head to toe assessment, vital signs were initiated and within normal baseline, a neurological assessment was done with no abnormality noted at this time. The resident's emergency contact was notified, and the physician and NHA were notified. The 2/11/26 at 4:33 p.m. nurse note revealed the resident received physical aggression. Staff were monitoring the resident’s vital signs and neurological assessments were within normal baseline limits. The resident denied pain.-Resident #9’s progress notes indicated that Resident #9 was hit by Resident #5. However, the facility investigation indicated that only Resident #5 was hit. C. Resident #5 (victim) 1. Resident statusResident #5, age greater than 65, was admitted on 1/14/26. According to the February 2026 CPO, diagnoses included fracture of left forearm, type 2 diabetes mellitus, dementia with behavioral disturbance and bipolar disorder. The 1/16/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. He was dependent for lower body dressing. He required substantial/maximal assistance for toilet transfers, shower transfers, shower/bathing, toileting hygiene, upper body dressing and for wheeling manual wheelchair. He required partial/moderate assistance with oral hygiene and personal hygiene. He required supervision/touching assistance for sit to stand transfers and chair to bed transfers. The assessment documented he had no behavioral symptoms, rejection of care or wandering according to the assessment. 2. Record reviewResident #5’s behavioral care plan, initiated 2/17/26 (during the survey), revealed the resident exhibited and was at risk for behavioral symptoms due to bipolar disorder and dementia with behavioral disturbance. Pertinent interventions included providing activities assessment for diversional activities, anticipating the resident’s needs and meeting promptly, documenting and recording behavioral episodes, encouraging the resident to verbalize his feelings, obtaining psychiatric consultation as indicated, sending a referral for counseling services. The 2/10/26 at 6:44 p.m. nurse note revealed that at 3:30 p.m. the nurse was notified by the CNA-Med that this resident was hitting another resident (Resident #5) in the hallway. The nurse went to check on both residents right away and staff members had already separated them. When the resident was asked, he said the other resident cursed bad words to him and he hit him on his face. The writer assessed the resident for injuries and notified the DON for a head to toe assessment, vital signs were initiated and within normal baseline limits, a neurological assessment was done with no abnormality noted. The resident's emergency contact, physician and the NHA were notified. The 2/11/26 at 10:01 a.m. IDT behavioral note, documented as a late entry, revealed Resident #9 was wandering past Resident #5’s room and they were verbally aggressive with each other, causing Resident #9 to strike out at Resident #5 and making contact with his head. The note documented the residents were separated, assessed and placed on 15-minute checks. Resident #9 was assisted to his room. D. Staff interviewsCNA #1 was interviewed on 2/19/26 at 10:17 a.m. CNA #1 said of all the residents in the men’s secured unit, Resident # 9 was very mean and she was a little scared of him. CNA #1 she was told about the altercation between Resident #5 and Resident #9. CNA #1 said she did not know if both residents were hit or just Resident #5 but that Resident #9 ended up on the floor. CNA #2 was interviewed on 2/19/26 at 10:28 a.m. CNA #2 said she was told about the altercation between Resident #9 and Resident #5 and that Resident #9 had hit Resident #5 in the face. CNA #2 said she was not sure how Resident #9 ended up on the floor. CNA #2 said she was not given any techniques to prevent a further recurrence other than to watch and keep them separated. IV. Additional staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 2/19/26 at 10:32 a.m. LPN #1 said she had not worked on the men’s unit for a while so she had not been informed about any of the resident-to-resident altercations that had occurred recently. LPN #1 said it probably would be a good idea to know so that she could watch out and keep certain residents apart or be aware of any interventions. The NHA, the DON and the social services assistant (SSA) were interviewed together on 2/19/26 at 12:15 p.m. The NHA said a QAPI meeting was held on 2/10/26 and the next one would be held on 3/10/26. The NHA said the facility normally went through all reportable incidents and discussed them at the QAPI meetings. The NHA said they had not discussed the 2/10/26 incident in QAPI yet between Resident #5 and Resident #9 but would do so at the 3/10/26 meeting. The NHA said the process for an abuse investigation consisted of reporting to him (the abuse coordinator), he would report to the State agency, and then begin an investigation. The NHA said the facility had a risk management report that the nurse completed and then it was discussed with IDT. The DON said she filled out the IDT notes but she did not not understand the intervention section and had thought it was for immediate intervention and not done to prevent a recurrence. The NHA said in January 2026 the facility did a root cause analysis for the men’s unit to try to decrease incidents and decided to make more space in the hallways. The DON said there was no root cause analysis section on each individual IDT note, so no root cause analysis was being done after each incident to determine the preventative intervention. The DON said the care plans could be updated from the IDT notes, but since the IDT notes only documented the immediate interventions, the care plans were not being updated with interventions to prevent a recurrence. The DON said it would be better to determine a preventative intervention based on a root cause and then she could get appropriate interventions that matched and then evaluate the effectiveness of the interventions. The NHA said there should be updates added to the care plan after each incident to help prevent a recurrence of abuse at least within five days, or sooner to prevent a recurrence. The NHA said with the incident between Resident #5 and Resident #9, Resident #9 had wandered through the hallway and passed Resident #5’s room and started arguing with him, Resident #9 made contact with Resident #5 and then Resident #9 lost his balance and fell. The NHA said following this incident, Resident #9’s care plan should have had an updated approach to prevent recurrence and protect the residents, but acknowledged it had not been done. The NHA said the social services department would be responsible for updating the care plans after an incident. The NHA and the DON said they were not aware that Resident #9’s behavioral care plan was only for behaviors toward staff and that there should be a care plan added that would address physical and verbal aggression toward residents. The DON said for the incidents with Resident #8 and Resident #14, she had only put in the immediate interventions on the IDT note, which included that the residents were separated and assessed for acute injury and staff de-escalated Resident #14’s aggressive mood by returning him to his room. The DON said no further abuse prevention interventions were added to Resident #14’s care plan because she did not know she needed to add anything other than the immediate actions taken. The NHA said that Resident #14 had hit Resident #8 in the head with a soda can. The NHA said the facility would do a lot better at making sure interventions were specific to the residents in preventing a recurrence beyond the immediate deescalation. The DON said she would make the time to get to the risk management reports sooner and complete the IDT notes to get the interventions in place to prevent a recurrence and also educate the staff as well to check the care plan to prevent further occurrences. The NHA said the facility would do an audit from all the incident cases from January 2026 and February 2026 and add late interventions to prevent further occurrences. The NHA said the social services department would be responsible for adding all of the preventative interventions.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 3/13/2026, the Director of Nursing (DON) or designee will have conducted comprehensive assessments of Residents #5, #14, #8, #9 to evaluate their current physical and psychosocial status following the resident-to-resident physical abuse incidents. By 3/13/2026, the SSD (social service director) or designee will have reviewed and updated the care plans for Residents #14 and #9 to include current behavioral triggers, effective de-escalation techniques, and specific monitoring requirements identified through the abuse investigations. By 3/13/2026, the DON or designee coordinated with the attending physicians to review and optimize behavioral medications for Residents #14 and #9 as clinically indicated. Identifying other Residents having the Potential to be Affected: By 3/13/2026, the IDT (interdisciplinary team) will interview all residents on the unit where the alleged abuse occurred to identify any further concerns related to abuse. The IDT will investigate further reports or allegations of abuse as indicted. Measures put into place or Systemic Changes: By 3/13/2026 the DON (director of nursing)/designee will provide in-service education on: Abuse prevention and reporting requirements Proper supervision of residents with known behavioral issues Recognition and immediate reporting of inappropriate sexual behaviors De-escalation techniques for aggressive residents Proper documentation of behavioral incidents Plan to Monitor Performance: The IDT team will complete ambassador round programs and will interview 10% of the residents in the building weekly if there have been any unreported cases of abuse. This would roughly be 10 residents who are interviewed weekly. The NHA will report monitoring results to the Quality Assurance Performance Improvement (QAPI) committee monthly for 3 months or until substantial compliance is achieved and maintained. The QAPI committee will make additional recommendations as needed. All monitoring will be documented via a spreadsheet audit form. Date of Compliance: 3/27/2026

1/22/2026Complaint Survey · ID 1E19FA-H12 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO2644984, #CO2650854, #CO2673896, Incident #2688368, Incident #2694667, Incident #2694684, Incident #2721965, Incident #2721993, Incident #2722007, Incident #2722033, Incident #2722061, Incident #2723916 and Incident #2723920 was completed on 1/20/26 to 1/22/26. Two deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0761Label/Store Drugs and Biologicals▼

Findings

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards. Specifically, the facility failed to:-Ensure medication and treatment carts was kept locked when not being monitored by nursing staff;-Ensure residents’ medications were stored in a locked cabinet when not being monitored by the medication administration nurse; and,-Ensure residents’ medications were not prepoured into medication cups, stacked on top of one another on the medication cart and left unattended in a common area of the facility. Findings include:I. Facility policy and procedureThe facility policy for medication storage was requested on 1/22/26 at 3:48 p.m., however, the policy was not provided by the end of the survey on 1/22/26. II. ObservationsOn 1/20/26, from 1:00 p.m. to 2:00 p.m., and again on 1/21/26, from 9:48 a.m. to 11:20 a.m., the treatment cart closest to the front entrance was observed to be unlocked and unmonitored by nursing staff. On 1/22/26, from 12:15 p.m. to 12:30 p.m., the medication cart was observed to be unlocked. The assigned medication nurse, registered nurse (RN) #1, was not in sight of the medication cart. On top of the medication cart was a prefilled insulin syringe and several paper medication cups labeled with different residents’ names. Each of the medication cups contained residents’ medication. Each paper medication cup was stacked on top of each other so that the bottom of the cup was touching the surface of another resident's medication. In addition, there was a plastic medication cup containing an unknown medication at the top of the stack of prepoured medication cups. The director of nursing (DON) was notified of the concern when the medication administration nurse did not return to the cart for an extended period of time. The DON immediately called for RN #1 to return to the medication cart and educated RN #1 on proper medication administration and storage. The DON talked to RN #1 regarding unattended medications and RN #1 was brought to the medication cart and shown the unsecured medications. RN #1 said she had just left the cart unattended to go into the supply room. The DON informed RN #1 that leaving medications on top of a medication cart was unacceptable. On 1/22/26 at 2:55 p.m. the treatment cart closest to the front entrance was observed to be unlocked and unmonitored by RN #1. III. Staff InterviewsLicensed practical nurse (LPN) #2 was interviewed on 1/22/26 at 3:00 p.m. LPN #2 said both the treatment and the medication carts should be kept locked when not being monitored by the floor nurse. He showed the contents of the treatment cart, which included wound care supplies and prescription medications. LPN #2 said he had the keys to the cart if he needed something out of it and then locked the cart and said it was to be locked at all times. The DON was interviewed on 1/22/26 at 1:35 p.m. The DON said the expectation was for the nurses to keep the medication and treatment carts locked when not being accessed by the nurse. The DON said prepouring of medications was not allowed. The DON said all nursing staff would receive education on the expectation for proper medication storage.

Plan of correction · submitted by the facility

Corrective Action On date 2/112026, Director of Nurse (DON)/Designee completed an audit on South medication/treatment carts to verify carts were locked if unattended and no pre-poured medications. Identification of others On date 2/11/2026, DON/Designee completed an audit on all other medication/treatment carts to verify carts were locked if unattended and no pre-poured medications. Systemic Changes By 2/20/26 Director of Staff Development (DSD)/Designee will educate nurses/medication aides on not pre-pouring medications and/or leaving medications on the top of the medication cart and locking the medication cart prior to walking away. Monitoring An audit tool was created using a spreadsheet and beginning 2/13/2026, the unit manager/designee will complete medication cart audits 3 times weekly for 30 days, then weekly for 60 days. The DON will review results monthly and report findings to QAPI for 3 months. The QAPI committee will decide as to the frequency of on-going monitoring.

0880Infection Prevention & Control▼

Findings

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to follow proper infection control practices during wound care for Resident #4. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Guideline For Hand Hygiene In Health Care Settings, (2/27/24) retrieved on 2/3/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety,“Efficacy of Promotion and Impact of Improved Hand Hygiene: evidence supports the belief that improved hand hygiene can reduce health-care–associated infection rates. Failure to perform appropriate hand hygiene is considered the leading cause of health-care–associated infections and spread of multiresistant organisms and has been recognized as a substantial contributor to outbreaks.”II. ObservationsOn 1/22/26 at 10:00 a.m. licensed practical nurse (LPN) #1 was observed performing wound care for Resident #4. The following was observed: LPN #1 gathered and brought all wound care supplies and the physician’s order for wound care from the resident’s chart into Resident #4’s room. -LPN #1 did not perform hand hygiene before opening the facility’s treatment cart, touching the treatment supplies and bringing the wound care supplies to the resident’s room. LPN #1 placed the wound care supplies on top of Resident #4’s bedside table. -LPN #1 did not sanitize the table's surface prior to laying out and setting up the wound care treatment supplies on top of the table. -LPN #1 placed the wound care scissors obtained from the wound care cart on Resident #4’s bedside table without sanitizing the wound care scissors LPN#1 proceeded to put on gloves without performing hand hygiene and removed Resident #4’s wound dressing. The wound dressing was slightly soiled with yellow discharge from the wound. After removing Resident #4’s old wound dressing, LPN#1 opened a bottle of sterile saline with the same soiled gloves she removed the old dressing with and set the bottle on the unclean bedside table. -LPN #1 did not perform hand hygiene prior to opening the bottle of saline. After handling the saline bottle, LPN #1 removed her soiled gloves, but did not perform hand hygiene. LPN #1 proceeded to reach into the box of clean unused gloves (without performing hand hygiene) and pulled out a new pair of gloves. LPN #1 put on the new pair of gloves without performing hand hygiene. After putting on the new pair of gloves, LPN #1 proceeded to pour saline on a clean gauze pad to clean Resident #4’s open wound. LPN #1 picked up the wound care scissors from the resident’s soiled bedside table and used the scissors to cut an antimicrobial dressing material that she then placed onto Resident #4’s open wound. -LPN #1 did not sanitize the wound care scissors prior to cutting the antimicrobial dressing and putting it onto the resident’s wound. LPN #1 next applied an ointment to Resident #4’s wound and covered the wound with a foam covered bandage, an ace wrap and a hard plastic brace. LPN#1 proceeded to wrap the brace and the resident’s arm with another ace bandage and cut off the velcro with the unsanitized scissors. III. Staff interviewsThe director of nursing (DON) was interviewed on 1/22/26 at 1:35 p.m. The DON said poor wound care practices were not acceptable and she would educate the nursing staff on proper infection control practices when performing wound care.

Plan of correction · submitted by the facility

Corrective Action On 2/13/2026 Direct of Staff Development (DSD)/designee met with LPN to complete wound dressing change education and competency. Identification of others All residents with wound dressing changes could be affected by alleged deficient practice. System Change By 2/20/2026 DSD/Designee completed wound competency education with all licensed nurses. Monitoring Beginning on 2/23/2026 Unit Manager/Designee will audit using an auditing tool via spreadsheet, licensed nurse providing dressing care twice weekly for 90 days. The Director of Nursing (DON) will review the results monthly and report findings to QAPI for three months. The QAPI committee will decide as to the frequency of on-going monitoring.

1/22/2026Licensure Complaint Survey · ID 1E19FD-H1No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A survey with #CO2714739 was completed on 1/20/26 to 1/22/26. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 5.19.3 MEDICATION REQUISITION AND STORAGE POLICIESThe facility shall designate in written policies, approved by the governing body, the person authorized to requisition, receive, control and manage medications. The facility shall protect each resident's medications from use by other residents, visitors,and staff. 26.7 HANDWASHINGPersonnel shall wash their hands before and after contact with a resident, after contact with a contaminated object or waste and adhere to the CDC Guidelines for Hand Hygiene in Health-Care Settings, 2002, which is incorporated by reference consistent with section 1.3 of thischapter.

Plan of correction

The state did not require a plan of correction for this citation.

12/1/2025Complaint Survey · ID 2TY6112 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO2570131; #CO2573675, Incident #1929901, Incident #2570020, Incident #2573424, Incident #2573457, Incident #2592583, Incident #2592748, Incident #2621282, Incident #2621298, Incident #2627594 and Incident #2631133 was completed on 9/30/25 to 12/1/25. Two deficiencies were cited. The actual exit date was 10/1/25. 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 12/1/25.

Plan of correction

The state did not require a plan of correction for this citation.

0600Free from Abuse and Neglect▼

Findings

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 12/31/2025, the Director of Nursing (DON) or designee will have conducted comprehensive assessments of Residents #4, #8, #11, #16, #17, #18, and #19 to evaluate their current physical and psychosocial status following the resident-to-resident physical abuse incidents. On By 12/31/2025, the SSD (social service director) or designee reviewed and updated the care plans for Residents #17, #19, #5, and #12 to include current behavioral triggers, effective de-escalation techniques, and specific monitoring requirements identified through the abuse investigations. By 12/31/2025, the DON or designee coordinated with the attending physicians to review and optimize behavioral medications for Residents #17, #19, #5, and #12 as clinically indicated. Identifying other Residents having the Potential to be Affected: By 12/31/2025, the IDT (interdisciplinary team) will interview all residents to investigate if there have been any unreported cases of abuse. Measures put into place or Systemic Changes: By 12/31/2025 the DON (director of nursing)/designee will provide in-service education on: Abuse prevention and reporting requirements Proper supervision of residents with known behavioral issues Recognition and immediate reporting of inappropriate sexual behaviors De-escalation techniques for aggressive residents Proper documentation of behavioral incidents Plan to Monitor Performance: The IDT team will complete ambassador round programs and will interview 10% of the residents in the building weekly if there have been any unreported cases of abuse. This would roughly be 10 residents who are interviewed weekly. The NHA will report monitoring results to the Quality Assurance Performance Improvement (QAPI) committee monthly for 3 months or until substantial compliance is achieved and maintained. The QAPI committee will make additional recommendations as needed. All monitoring will be documented via the audit form. Date of Compliance: 12/31/2025

0609Reporting of Alleged Violations▼

Findings

Based on record review and interviews, the facility failed to report alleged violations of physical abuse to the State Survey and Certification Agency in accordance with state law for two (#6 and #17) of 17 residents reviewed for abuse out of 18 sample residents. Specifically, the facility failed to ensure incidents of alleged physical abuse involving Resident #6 and Resident #17 were reported to the State Survey Agency (SSA). III. Resident #17A. Resident statusResident #17, age 72, was admitted on 6/3/24. According to the September 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, adult failure to thrive and senile degeneration of the brain. The 8/29/25 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 required substantial assistance from staff for most activities of daily living (ADL). The MDS assessment documented the resident did not have physical or verbal behaviors directedat others or other behavioral symptoms not directed toward others during the assessment period. B. Record reviewA progress note, dated 8/31/25 at 7:20 p.m., revealed a nurse was standing at her cart when she looked down the hall and observed Resident #17 attempting to kick another resident (Resident #19). Resident #19 was holding Resident #17’s legs and pulling at them. The nurse ran down the hall and immediately separated the residents with assistance from another staff member. Neither resident had any apparent signs of injury. Resident #17 refused to take off his coat so the nurse could perform a skin assessment. Resident #17 was assisted to a position near the nurse’s cart for close observation. The facility investigation, dated 8/31/25, was provided by the NHA on 9/30/25 at 4:30 p.m. The investigation revealed the following:On 8/31/25 at 7:20 p.m. a nursing staff member saw Resident #17 and Resident #19 engaging in a physical altercation. Resident #19 was holding Resident #17’s legs and pulling them. Nursing staff members immediately separated the residents and attempted to assess them. Resident #17 was placed near the nurses’ station for close observation. Resident #17 told a member of the nursing staff that Resident #19 had hit him in the face. No injuries were noted to either resident at the time. The NHA, the physician, the on-call nurse, and the residents’ representative were all notified within three hours of the incident on 8/31/25. Interviews with the nursing staff, after the incident on 9/2/25, revealed Resident #17 was kicking his legs at Resident #19 when Resident #19 grabbed his legs.-However, the facility failed to provide documentation to indicate the incident on 8/31/25 was reported to the SSA.C. Staff interviewsThe NHA was interviewed on 10/1/25 at 5:14 p.m. The NHA said he was the abuse coordinator for the facility. He said he was responsible for reporting incidents of alleged abuse to the SSA The NHA said incidents of potential abuse should be reported to him within 24 hours of the incident occurring so he was able to report the incident to the SSA. The NHA said the facility’s management team evaluated each allegation of abuse to determine if it met the requirements to be reported to the SSA.-However, the facility abuse investigation documented the NHA was notified regarding the incident on 8/31/25 and failed to report it to the SSA.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: On 12/11/2025, the Nursing Home Administrator (NHA) or designee reported the incidents involving Resident #6 (9/9/25 physical altercation with Resident #21) and Resident #17 (8/31/25 physical altercation with Resident #19) to the occurrence reporting portal. The NHA or designee documented the reports in each resident's medical record and maintained copies of the reporting documentation in the facility's abuse investigation files. Identifying other Residents having the Potential to be Affected: By 12/31/2025, the IDT team will interview all residents to investigate if there have been any unreported cases of abuse. By 12/31/2025, the IDT will interview every staff member to investigate if there have been any unreported cases of abuse. Measures put into place or Systemic Changes: By 12/31/2025, the DON/ Designee will provide an in-service education on: Identification of abuse, including sexual abuse Immediate reporting requirements to the Administrator and State Survey Agency Timeline requirements for reporting different types of abuse allegations Process for protecting residents when abuse is alleged Plan to Monitor Performance: Beginning on 12/10/2025, the NHA (nursing home administrator)/designee will review the facilities 24-hour report 5x a week for 90 days to ensure that there are no abuse allegations that are not reported. If there is a abuse allegation found in the report, the NHA/designee will immediately report it on the reporting portal and education will be provided to the staff who failed to notify the NHA.The NHA will report monitoring results to the Quality Assurance Performance Improvement (QAPI) committee monthly for 3 months or until substantial compliance is achieved and maintained. The QAPI committee will make additional recommendations as needed. All monitoring will be documented via the audit form. Date of Compliance: 12/31/2025

9/22/2025Revisit: Recertification Survey · ID 4LDQ22No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

An desk revisit was conducted and all deficiencies have been corrected, other than the deficiencies that have waivers. No other deficiencies written and no response is needed.

Plan of correction

The state did not require a plan of correction for this citation.

5/13/2025Revisit: Complaint, Recertification Survey · ID 4LDQ12No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A revisit survey was completed on 5/13/25 for all previous deficiencies cited on 3/26/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

5/13/2025Revisit: State Licensure Survey · ID P9LU12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 5/13/25 for all previous deficiencies cited on 3/26/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/22/2025Recertification Survey · ID 4LDQ2115 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on April 22nd, 2025, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a one (1) story, Type II (000) (II-B) construction. The facility was constructed in 1955 and has no basement. The facility is licensed for 105 beds, and the census on the date of this survey was 94. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry pipe fire sprinkler systems. The dry-pipe fire suppression system protects the attic spaces and the exterior canopy. This facility is classified as fully sprinklered. The results of this survey were discussed with the Administrator and Maintenance staff during the exit conference.

Plan of correction

The state did not require a plan of correction for this citation.

0221Patient Sleeping Room DoorsS/S D▼

Findings

Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress. This affects 1 out of 4 smoke compartments, affecting 27 of 105 residents and an indeterminable number of staff and visitors. During an interview and observations with the maintenance director, it was noted that the asphalt leading into the parking lot from the courtyard near the administration building needs to be repaired to allow the egress gate to open fully. NFPA 101 7.5.4.3 Each required accessible means of egress shall be continuous from each accessible occupied area to a public way or area of refuge in accordance with 7.2.12.2.2.7.2.1.3 Floor Level. 7.2.1.3.1 The elevation of the floor surfaces on both sides of a door opening shall not vary by more than 1/2 in. (13 mm), unless otherwise permitted by 7.2.1.3.5 or 7.2.1.3.6.7.2.1.3.2 The elevation of the floor surfaces required by 7.2.1.3.1 shall be maintained on both sides of the door openings for a distance not less than the width of the widest leaf. The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/22/2025, the Maintenance Director will have initiated repairs to the asphalt leading into the parking lot from the courtyard near the administration building to allow the egress gate to open fully. The repair work will have been completed by 7/22/2025, and the gate was tested to ensure proper operation and full range of motion. Identifying other Residents having the Potential to be Affected: By 7/30/2023, the Maintenance Director will have conducted a facility-wide inspection of all means of egress, including gates, doorways, and pathways to identify any similar issues that could affect resident evacuation. Measures put into place or Systemic Changes: The Maintenance Director implemented a new monthly inspection protocol for all facility egress points, including documentation of surface conditions and gate functionality. A preventive maintenance schedule has been established to address parking lot and pathway surfaces quarterly or as needed. Plan to Monitor Performance: The Maintenance Director will conduct weekly inspections of all egress points for the next 4 weeks, then monthly thereafter, to ensure proper operation and maintenance of egress pathways. Results of these audits will be reported to the Quality Assurance and Performance Improvement (QAPI) committee monthly for review and additional recommendations as needed.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/30/2025, the Maintenance Director will have initiated repairs to the asphalt leading into the parking lot from the courtyard near the administration building to allow the egress gate to open fully. The repair work will have been completed by 7/30/2025, and the gate was tested to ensure proper operation and full range of motion. Identifying other Residents having the Potential to be Affected: By 7/30/2023, the Maintenance Director will have conducted a facility-wide inspection of all means of egress, including gates, doorways, and pathways to identify any similar issues that could affect resident evacuation. Measures put into place or Systemic Changes: The Maintenance Director implemented a new monthly inspection protocol for all facility egress points, including documentation of surface conditions and gate functionality. A preventive maintenance schedule has been established to address parking lot and pathway surfaces quarterly or as needed. Plan to Monitor Performance: The Maintenance Director will conduct weekly inspections of all egress points for the next 4 weeks, then monthly thereafter, to ensure proper operation and maintenance of egress pathways. Results of these audits will be reported to the Quality Assurance and Performance Improvement (QAPI) committee monthly for review and additional recommendations as needed.

0222Egress DoorsS/S E▼

Findings

Based on observation and staff interviews, it was determined that the facility failed to maintain locking arrangements and delayed egress doors. This affected 2 out of 4 smoke compartments, 27 of 105 residents, and an indeterminable number of staff and visitors. During the walk-through with the director of maintenance (DoM) and the administrator, the following was observed:The locking arrangement for memory care needs to be in access control or delayed egress. Both courtyard's delayed egress doors do not open within 15 seconds. 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following:(1)Locks complying with 19.2.2.2.5 shall be permitted.(2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.(3)*Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.(4)Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted.(5)Approved existing door-locking installations shall be permitted. 19.2.2.2.5.1* Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 19.2.2.2.6.19.2.2.2.5.2* Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:(1)Staff can readily unlock doors at all times in accordance with 19.2.2.2.6.(2)A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.(3)*The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7.(4)The locks are electrical locks that fail safely so as to release upon loss of power to the device.(5)The locks release by independent activation of each of the following:(a)Activation of the smoke detection system required by 19.2.2.2.5.2(2)(b)Waterflow in the automatic sprinkler system required by 19.2.2.2.5.2(3)7.2.1.6.1 Delayed-Egress Locking Systems. 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met:(1)The door leaves shall unlock in the direction of egress upon actuation of one of the following:(a)Approved, supervised automatic sprinkler system in accordance with Section 9.7(b)Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6(c)Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6(2)The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism.(3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions:(a)The force shall not be required to exceed 15 lbf (67 N).(b)The force shall not be required to be continuously applied for more than 3 seconds.(c)The initiation of the release process shall activate an audible signal in the vicinity of the door opening.(d)Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only.(4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:PUSH UNTIL ALARM SOUNDSDOOR CAN BE OPENED IN 15 SECONDS(5)The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9. The administrator and maintenance director discussed the deficient items at the exit conference

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: The Director of Maintenance (DOM) conducted an inspection of all egress doors in the facility by 7/22/2025 All non-compliant door hardware was identified and replaced with code-compliant hardware. The courtyard egress doors were repaired to ensure proper sealing. The memory care women's patio door was replaced with an approved fire-rated door assembly with proper hardware. Identifying other Residents having the Potential to be Affected: All residents have the potential to be affected by this deficient practice. The DOM completed a facility-wide door audit by 7/22/2025 to identify any additional doors requiring modification or replacement to ensure compliance with NFPA requirements. Measures put into place or Systemic Changes: The DOM will implement a comprehensive door maintenance program that includes monthly inspections of all egress doors, fire doors, and associated hardware. New preventive maintenance checklist implemented to track door inspections and repairs Updated facility policy on door maintenance and locking arrangements to ensure compliance with NFPA requirements Plan to Monitor Performance: The DOM will conduct weekly audits of 25% of all egress doors for proper operation and compliance for 4 weeks, then monthly audits thereafter The Maintenance Department will maintain documentation of all door inspections and repairs in a centralized log Any identified issues will be corrected immediately and documented The Director of Maintenance will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive months.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: The Director of Maintenance (DOM) conducted an inspection of all egress doors in the facility by 7/30/2025 All non-compliant door hardware was identified and replaced with code-compliant hardware. The courtyard egress doors were repaired to ensure proper sealing. The memory care women's patio door was replaced with an approved fire-rated door assembly with proper hardware. Identifying other Residents having the Potential to be Affected: All residents have the potential to be affected by this deficient practice. The DOM completed a facility-wide door audit by 7/30/2025 to identify any additional doors requiring modification or replacement to ensure compliance with NFPA requirements. Measures put into place or Systemic Changes: The DOM will implement a comprehensive door maintenance program that includes monthly inspections of all egress doors, fire doors, and associated hardware. New preventive maintenance checklist implemented to track door inspections and repairs Updated facility policy on door maintenance and locking arrangements to ensure compliance with NFPA requirements Plan to Monitor Performance: The DOM will conduct weekly audits of 25% of all egress doors for proper operation and compliance for 4 weeks, then monthly audits thereafter The Maintenance Department will maintain documentation of all door inspections and repairs in a centralized log Any identified issues will be corrected immediately and documented The Director of Maintenance will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive months.

0291Emergency LightingS/S F▼

Findings

Based on the records review and the interview, the facility failed to inspect and test all emergency lighting. The deficient practice affected four out of four smoke compartments, and all residents, staff and visitors within the facility. The facility was unable to furnish documentation for annual 90-minute testing for emergency lighting. The maintenance director stated 90-minute testing for emergency lighting was not conducted. 19.2.9 Emergency Lighting. 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9. 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. The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/22/2025, the Maintenance Director conducted an inspection of all emergency lighting units throughout the facility. A qualified contractor was engaged to perform the required 90-minute duration testing of all emergency lighting units. Identifying other Residents having the Potential to be Affected: All residents, staff, and visitors have the potential to be affected by this deficient practice. A facility-wide assessment of emergency lighting systems was completed by 7/22/2025. Measures put into place or Systemic Changes: The Maintenance Director will implement a new emergency lighting testing program that includes: Monthly 30-second functional tests Annual 90-minute duration tests A preventive maintenance schedule has been created in the facility's work order system New testing documentation forms have been implemented Plan to Monitor Performance: The Maintenance Director will conduct weekly audits of emergency lighting testing documentation for 4 weeks, then monthly for 3 months Results will be tracked and trended Any identified issues will be corrected immediately The Administrator will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/30/2025, the Maintenance Director conducted an inspection of all emergency lighting units throughout the facility. A qualified contractor was engaged to perform the required 90-minute duration testing of all emergency lighting units. Identifying other Residents having the Potential to be Affected: All residents, staff, and visitors have the potential to be affected by this deficient practice. A facility-wide assessment of emergency lighting systems was completed by 7/30/2025. Measures put into place or Systemic Changes: The Maintenance Director will implement a new emergency lighting testing program that includes: Monthly 30-second functional tests Annual 90-minute duration tests A preventive maintenance schedule has been created in the facility's work order system New testing documentation forms have been implemented Plan to Monitor Performance: The Maintenance Director will conduct weekly audits of emergency lighting testing documentation for 4 weeks, then monthly for 3 months Results will be tracked and trended Any identified issues will be corrected immediately The Administrator will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

0293Exit SignageS/S F▼

Findings

Based on observation and interview, the facility failed to have UL-listed exit signs on both courtyard egress doors. The deficient practice affected 2 out of 4 smoke compartments. The deficient practice could affect 4 out of 4 smoke compartments, 105 of 105 residents, and an indeterminable number of staff and visitors. During an interview and observations with the maintenance director, it was noted that both courtyard exit gates have approved exit signage. Life Safety Code 19.2.10.1. Means of egress shall have signs in accordance with section 7.10. The directional indicator shall be located outside of the Exit legend, not less than 3/8 in. (1cm) from any letter. The directional indicator shall be of a chevron type. The directional indicator shall be identifiable as a directional indicator at a distance of 40 ft. (12.2m). A directional indicator larger than the minimum established in this paragraph shall be proportionately increased in height, width and stroke. The directional indicator shall be located at the end of the sign for the direction indicated. 7.10.1.2 Exits. 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. 7.10.1.3 Exit Door Tactile Signage. Tactile signage shall be provided to meet all of the following criteria, unless otherwise provided in 7.10.1.4:(1) Tactile signage shall be located at each exit door requiring an exit sign.(2) Tactile signage shall read as follows: EXIT.(3) Tactile signage shall comply with ICC/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities. 7.10.1.2.2* Horizontal components of the egress path within an exit enclosure shall be marked by approved exit or directional exit signs where the continuation of the egress path is not obvious. 7.10.1.5.1 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. 7.10.1.9 Mounting Location. The bottom of new egress markings shall be located at a vertical distance of not more than 6 ft 8 in. (2030 mm) above the top edge of the egress opening intended for designation by that marking. Egress markings shall be located at a horizontal distance of not more than the required width of the egress opening, as measured from the edge of the egress opening intended for designation by that marking to the nearest edge of the marking. 7.10.2 Directional Signs. 7.10.2.1* A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 7.10.5 Illumination of Signs. 7.10.5.1* General. Every sign required by 7.10.1.2, 7.10.1.5, or 7.10.8.1, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode. The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/22/25, the Director of Maintenance/designee removed the non-UL listed exit signs from both courtyard egress doors and replaced them with UL-listed exit signs that are luminescent. Identifying other Residents having the Potential to be Affected: By 7/22/25, the Director of Maintenance will have conducted a facility-wide audit of all exit signs to ensure they are UL-listed and properly illuminated. This audit included all four smoke compartments as all residents have the potential to be affected. Measures put into place or Systemic Changes: The facility's preventive maintenance program has been updated to include monthly inspections of all exit signs. Plan to Monitor Performance: The Director of Maintenance or designee will conduct weekly audits of all exit signs for the first month, then monthly audits for three months to ensure continued compliance. The Safety Committee Chairperson will report monitoring results to the Quality Assurance Performance Improvement (QAPI) committee monthly for three months and then quarterly thereafter. The QAPI committee will review for further recommendations and need for continued monitoring until substantial compliance is achieved and maintained.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/30/25, the Director of Maintenance/designee removed the non-UL listed exit signs from both courtyard egress doors and replaced them with UL-listed exit signs that are luminescent. Identifying other Residents having the Potential to be Affected: By 7/30/25, the Director of Maintenance will have conducted a facility-wide audit of all exit signs to ensure they are UL-listed and properly illuminated. This audit included all four smoke compartments as all residents have the potential to be affected. Measures put into place or Systemic Changes: The facility's preventive maintenance program has been updated to include monthly inspections of all exit signs. Plan to Monitor Performance: The Director of Maintenance or designee will conduct weekly audits of all exit signs for the first month, then monthly audits for three months to ensure continued compliance. The Safety Committee Chairperson will report monitoring results to the Quality Assurance Performance Improvement (QAPI) committee monthly for three months and then quarterly thereafter. The QAPI committee will review for further recommendations and need for continued monitoring until substantial compliance is achieved and maintained.

0321Hazardous Areas - EnclosureS/S F▼

Findings

Based on observation and interview, the facility failed to maintain the fire rating of hazardous areas. The deficient practice affected 4 out of 4 smoke compartments. During walk-through with the director of maintenance (DoM) and the administrator, the following was observed:1. The boiler room had scab patches to fill ceiling penetrations, and multiple walls had penetrations lacking an approved fire-stopping system. 2. The soffit outside the boiler room had a penetration. 3. The laundry room ceiling had multiple, large vent penetrations that required approved fire-stopping systems. 4. The laundry room wall facing the building exterior had open vents. 5. Patching was completed in some penetrations in the boiler room and laundry room walls with non-fire-rated spray foam. 6. The kitchen door next to the tray return was not fire-rated. The DoM and administrator acknowledge the above observations during interviews completed with the walk-through. 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 Code8.7.1.1* 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:Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3Protecting the area with automatic extinguishing systems in accordance with Section 9.7Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 4319.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4. The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: The Director of Maintenance (DoM)/desingee will have initiaited repairs for the boiler room soffit and scab patches repairs, the laundry rooms ceiling vent penetration and open vents, the non-fire-rated patching in the laundry room/boiler room, and a fire rated kitchen door by 7/22/2025. The DoM will ensure the work is able to be within a month of receiving the bids for the projects. Identifying other Residents having the Potential to be Affected: The DoM conducted a facility-wide inspection of all fire doors and barriers by 7/22/25 to identify any additional deficiencies requiring correction. This inspection included all resident rooms, utility areas, and hazardous areas throughout the facility. Measures put into place or Systemic Changes: The DoM will implement a comprehensive fire door inspection and maintenance program. Periodic door inspections have been added to the TELS inspection list. Plan to Monitor Performance: The DoM will conduct weekly fire door inspections for 4 weeks, then monthly thereafter. Any identified issues will be corrected immediately and documented. The Administrator will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: The Director of Maintenance (DoM)/desingee will have initiaited repairs for the boiler room soffit and scab patches repairs, the laundry rooms ceiling vent penetration and open vents, the non-fire-rated patching in the laundry room/boiler room, and a fire rated kitchen door by 7/30/2025. The DoM will ensure the work is able to be within a month of receiving the bids for the projects. Identifying other Residents having the Potential to be Affected: The DoM conducted a facility-wide inspection of all fire doors and barriers by 7/30/25 to identify any additional deficiencies requiring correction. This inspection included all resident rooms, utility areas, and hazardous areas throughout the facility. Measures put into place or Systemic Changes: The DoM will implement a comprehensive fire door inspection and maintenance program. Periodic door inspections have been added to the TELS inspection list. Plan to Monitor Performance: The DoM will conduct weekly fire door inspections for 4 weeks, then monthly thereafter. Any identified issues will be corrected immediately and documented. The Administrator will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

0341Fire Alarm System - InstallationS/S E▼

Findings

Based on observation and interview, it was determined that the Fire Alarm system was installed improperly. The deficient practice could affect 2 out of 4 smoke compartments, 53 out of 105 residents, and an indeterminable number of staff and visitors. 1. During observation and interview, it was noted that the fire alarm horns and strobes were mounted 45 inches off the floor. 2. During observation and interview, it was noted that the fire alarm strobe is blocked in the corridor of memory care. NFPA 101 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 72 18.5.4 Appliance Location. 18.5.4.1* Wall-mounted appliances shall be mounted such that the entire lens is not less than 80 in. (2.03 m) and not greater than 96 in. (2.44 m) above the finished floor or at the mounting height specified using the performance-based alternative of 18.5.4.5.18.5.4.2 Where low ceiling heights do not permit mounting at a minimum of 80 in. (2.03 m), visible appliances shall be mounted within 6 in. (150 mm) of the ceiling. The room size covered by a strobe of a given value shall be reduced by twice the difference between the minimum mounting height of 80 in. (2.03 m) and the actual, lower mounting height. The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/22/2025, the Director of Maintenance initiated the following corrective actions: All fire alarm horns and strobes mounted at 45 inches were immediately raised to the required height of 80-96 inches above the finished floor. The blocked fire alarm strobe in the memory care corridor was immediately unblocked and the area cleared of all obstructions. Identifying other Residents having the Potential to be Affected: By 7/30/2025, the Director of Maintenance conducted a facility-wide audit of all fire alarm system components to identify any additional mounting height issues or blocked devices. All residents have the potential to be affected by improper fire alarm system installation. Measures put into place or Systemic Changes: The Director of Maintenance will implement a new fire safety inspection checklist that includes verification of proper mounting heights for all fire alarm devices. Plan to Monitor Performance: The Director of Maintenance will conduct monthly audits of 25% of all fire alarm devices for proper mounting height and accessibility for 3 months. Results of all audits will be reported monthly to the Quality Assurance and Performance Improvement (QAPI) committee for review and additional actions as needed until substantial compliance is achieved and maintained for 3 consecutive months. The Safety Committee designee will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/30/2025, the Director of Maintenance initiated the following corrective actions: All fire alarm horns and strobes mounted at 45 inches were immediately raised to the required height of 80-96 inches above the finished floor. The blocked fire alarm strobe in the memory care corridor was immediately unblocked and the area cleared of all obstructions. Identifying other Residents having the Potential to be Affected: By 7/30/2025, the Director of Maintenance conducted a facility-wide audit of all fire alarm system components to identify any additional mounting height issues or blocked devices. All residents have the potential to be affected by improper fire alarm system installation. Measures put into place or Systemic Changes: The Director of Maintenance will implement a new fire safety inspection checklist that includes verification of proper mounting heights for all fire alarm devices. Plan to Monitor Performance: The Director of Maintenance will conduct monthly audits of 25% of all fire alarm devices for proper mounting height and accessibility for 3 months. Results of all audits will be reported monthly to the Quality Assurance and Performance Improvement (QAPI) committee for review and additional actions as needed until substantial compliance is achieved and maintained for 3 consecutive months. The Safety Committee designee will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

0345Fire Alarm System - Testing and MaintenanceS/S F▼

Findings

Based on document review, observation and interview, it was determined that the Fire Alarm system was not maintained. The deficient practice could affect 4 out of 4 smoke compartments, 105 out of 105 residents, and an indeterminable number of staff and visitors. 1. Record review revealed that smoke detectors throughout the facility failed during the annual inspection. Specifically, the C9, N6 SE0 above FACP Se10 RM 52, SW2 corridor, and medical storage failed. 2. Upon interview and record review, one fire alarm zone was broken due to a sprinkler pipe break. Brighton Fire placed the facility on firewatch, which was never reported to the Colorado Division of Fire Protection and Control (DFPC). 3. Record review revealed that the facility could not produce a semi-annual fire alarm inspection. 4. A record review of the annual fire alarm inspection documented that the admin area, generator shed, kitchen, laundry room, main entrance, nurse ' s stations, and attic detectors were not tested. 5. Multiple trouble indicators were observed on the fire control room fire alarm panel. During the observation and interview, the smoke detector in room 54 was noted to be soiled. 6. Room 3 ' s smoke detector was observed partially detached from the wall, and Room 35 was missing a smoke detector. 9.6.1.8 Protection of Fire Alarm System. 9.6.1.8.1* In areas that are not continuously occupied, and unless otherwise permitted by 9.6.1.8.1.1 or 9.6.1.8.1.2, automatic smoke detection shall be installed to provide notification of fire at the following locations:(1)Each fire alarm control unit(2)Notification appliance circuit power extenders(3)Supervising station transmitting equipment9.6.2.9 Where a total (complete) coverage smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm and Signaling Code, shall be provided in all occupiable areas in environments that are suitable for proper smoke detector operation. NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction. 10.12.6 Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:(1)Fire alarm control unit for protected premises alarm systems(2)Building fire command center for in-building fire emergency voice/alarm communications systems(3)Central station or remote station location for systems installed in compliance with Chapter 2614.5.3 The frequency of cleaning of system equipment shall depend on the type of equipment and the local ambient conditions. 9.6.2.10.1.2 The installation of smoke alarms in sleeping rooms shall be required where required by Chapters 11 through 43. The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/22/2023, the facility immediately Will have received bids and scheduled to replace all failed smoke detectors in locations C9, N6 SE0, FACP Se10 RM 52, SW2 corridor, and medical storage, have the broken fire alarm zone repaired and restored to full functionality, have the soiled smoke detector in room 54 cleaned and tested, have Room 3's partially detached smoke detector properly secured, have Room 35's missing smoke detector replaced, and all trouble indicators on the fire control room panel investigated and resolved. Identifying other Residents having the Potential to be Affected: The Director of Maintenance conducted a facility-wide inspection of all smoke detectors, fire alarm components, and fire safety systems by 7/22/2025 to identify any additional issues requiring correction. Measures put into place or Systemic Changes: The Director of Maintenance will implement a comprehensive fire alarm testing and maintenance program that includes: Monthly visual inspections of all smoke detectors Semi-annual professional fire alarm inspections starting 7/2025 and again in 1/2026Annual complete system testing including all zones and components starting 1/2026 and to be completed annually thereafterAny other fire alarm systems that need to be done semiannually will be done in 7/2025 and all annual inspections will be done in 1/2026Documentation of all inspections and maintenance in a centralized log The Director of Maintenance will maintain a preventive maintenance schedule for all fire safety equipment Plan to Monitor Performance: The Director of Maintenance will conduct weekly audits of fire alarm system components for the first month, then monthly thereafter Results of all monitoring will be reported to the Quality Assurance Performance Improvement (QAPI) committee monthly until substantial compliance is achieved and maintained for three consecutive months The Safety Officer will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor compliance until substantial compliance of the set-forth protocol is achieved.

0353Sprinkler System - Maintenance and TestingS/S F▼

Findings

Based on document review, observation and interview, it was determined that the Fire Sprinkler system was not maintained. The deficient practice could affect 4 out of 4 smoke compartments, 105 out of 105 residents, and an indeterminable number of staff and visitors. 1. Upon document review, the annual report shows that the water flow pressure switch does not report to the fire alarm panel. 2. Upon document review, the semi-annual report notes that the water flow function testing is not being conducted. 3. Upon observation of the spare sprinkler box in the riser room, the box contains sprinkler heads that are 50 years old. 4. During observation, escutcheons throughout the facility are missing or greater than 1/8th ' ' from the wall or ceiling located in: Boiler room Activity room Kitchen RM 53Rm3Room 42Memory Care Room 15Memory Care Room 27Memory Care Room 305. Room 15 has a recessed sprinkler head 6. Upon observation there are painted sprinkler heads located in:Room 44Memory Care Room 137. During observation of room 4 there was a TV box obstructing a sprinkler head in the closet. 8. Upon observation and interview there are wires on the sprinkler pipe in room 31 and on the exterior pipe in the courtyard outside the women ' s memory care. 9. Upon observation and interview the sprinkler line in the Activities Center is improperly secured. The hangers holding the piping are loose and not supporting the sprinkler fire. 10. Upon interview and observation it was noted that there are corroded sprinkler heads throughout the entire kitchen and memory care room 22. 11. During observation and interview with the maintenance director the sprinkler heads have a manufacturer date of 2002. 12. Upon interview and observation with the maintenance director and kitchen staff, the walk-in cooler and freezer sprinklers are more than ten years old. 4.1.4* Corrections and Repairs. 4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. 13.2.6.2 Vane-type and pressure switch–type waterflow devices shall be tested semiannually. 15.7 Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:(1)Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.(2)Supervisors have been advised that protection is restored.(3)The fire department has been advised that protection is restored.(4)The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.(5)The impairment tag has been removed. 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. 9.7.1 Automatic Sprinklers. 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:(1)NFPA 13, Standard for the Installation of Sprinkler Systems(2)NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes(3)NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in HeightNFPA 25, 5.2.1.1.5 Escutcheons and coverplates for recessed, flush, and concealed sprinklers shall be replaced with their listed escutcheon or coverplate if found missing during the inspection. NFPA 13 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of thefollowing 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. 8.8.6* Clearance to Storage (Extended Coverage Upright and Pendent Spray Sprinklers). 8.8.6.1 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater. NFPA 25 5.2.3 Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level. 5.2.3.1 Hangers and seismic braces shall not be damaged or loose. 5.2.3.2 Hangers and seismic braces that are damaged or loose shall be replaced or refastened. 5.2.3.3* Hangers and seismic braces installed in concealed spaces such as above suspended ceilings shall not require inspection. 5.2.3.4 Hangers and seismic bracing installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdownNFPA 13 9.1.1.4.1 Unless permitted by 9.1.1.4.2 or 9.1.1.4.3, the components of hanger assemblies that directly attach to the pipe or to the building structure shall be listed. 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. 5.3.1.1.1.1 Test procedures shall be repeated at 10-year intervals. 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 intervalsThe administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: The Director of Maintenance (DoM) will have taken the following actions: Contacted licensed fire protection contractor by 722/2025 to repair water flow pressure switch connection to fire alarm panel Initiated semi-annual water flow function testing by 7/22/2025 Removed and replaced all 50-year-old sprinkler heads from spare sprinkler box on 722/2025 Installed proper escutcheons in boiler room and throughout facility by 7/22/2025 By 7/22/2025 the facility will ensure recessed sprinkler head in room 15 has been replacedBy 7/22/2025 the facility will remove painted sprinkler heads in room 44 and room 13. By 7/22/2025 the facility will remove the TV box obstructing a sprinkler head in room 4. By 7/22/2025 the facility will relocate the wires on the sprinkler pipe in room 31 and on exterior pipe in outside courtyard. By 7/30/2025 the facility will ensure the sprinkler line in activities center is secured appropriately. By 7/22/2025 the facility will ensure replacement the corroded sprinkler heads that were identified in the kitchen and in room 22 and sprinkler heads that have an expired manufacturer date. By 7/22/2025 the facility will review to see if the walk-in cooler and freezer are in compliance. If they are found to not be in compliance, they will be replaced. Identifying other Residents having the Potential to be Affected: All residents, staff, and visitors have the potential to be affected by fire sprinkler system deficiencies. Measures put into place or Systemic Changes: The DoM will implement a comprehensive sprinkler system maintenance program including: Monthly inspections of all sprinkler components Quarterly testing of water flow switches Semi-annual testing of all system functions Annual third-party inspection and testing The DoM will maintain a current inventory of proper replacement sprinkler heads Plan to Monitor Performance: The DoM will conduct weekly audits of sprinkler system components and maintenance records for 4 weeks, then monthly for 2 months, then quarterly thereafter. Results will be reported to the Safety Committee monthly and to the Quality Assurance Performance Improvement (QAPI) Committee quarterly. The QAPI Committee will analyze data for patterns/trends and need for additional corrective action until substantial compliance is achieved and maintained.

0372Subdivision of Building Spaces - Smoke BarrieS/S F▼

Findings

Based on document review, observation, and interview, it was determined that fire-resistant construction was not maintained. The deficient practice could affect 4 out of 4 smoke compartments, 105 out of 105 residents, and an indeterminable number of staff and visitors. During the walk-through with the director of maintenance (DoM) and the administrator, the following was observed:1. Penetrations in the Riser room ceiling and walls 2. In the kitchen, caulking is used for the sprinkler line from the tray return, which needs to be an approved fire-stopping system, and caulking is required for the corner of the tray return. 3. The Fire Alarm Control Room has plastic accordion doors, not a fire door. 4. The med room in East Hallway has penetrations in the wall around all sprinkler pipes. 5. The nursing office has ceiling and wall penetrations in the closet. 6. The breakroom has penetrations in the ceiling filled with foam that is not an approved fire-stopping system. 7. There are penetrations in the corridor above the nurse's station 8. The ceiling is falling outside of the memory care nurses' station. 9. Memory Care Med Room has penetrations in the ceilings and walls 10. The east hallway's sprinkler gutters are incomplete, exposing piping and wall assemblies. NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. NFPA 101, 8.3.1.2 Fire barriers shall comply with one of the following:(1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.(2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier. 8.3.2.3 Interior walls and partitions of nonsymmetrical construction shall be evaluated from both directions and assigned a fire resistance rating based on the shorter duration obtained in accordance with ASTM E 119, Standard Test Methods for Fire Tests of Building Construction and Materials, or ANSI/UL 263, Standard for Fire Tests of Building Construction and Materials. When the wall is tested with the least fire-resistive side exposed to the furnace, the wall shall not be required to be subjected to tests from the opposite side. 8.3.1.3 Walls used as fire barriers shall comply with Chapter 7 of NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply. 19.1.1.3.2 Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following:(1)Design, construction, and compartmentation(2)Provision for detection, alarm, and extinguishment(3)Fire prevention procedures and planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8.19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. 19.3.1.2 Unprotected vertical openings in accordance with 8.6.9.1 shall be permitted. 19.3.1.5 Unprotected openings in accordance with 8.6.6 shall not be permitted. 8.6.5* Required Fire Resistance Rating. The minimum fire resistance rating for the enclosure of floor openings shall be as follows (see 7.1.3.2.1 for enclosure of exits):(1)Enclosures connecting four or more stories in new construction — 2-hour fire barriers(2)Other enclosures in new construction — 1-hour fire barriers(3)Existing enclosures in existing buildings — 1/2-hour fire barriers(4)Enclosures for lodging and rooming houses — as specified in Chapter 26(5)Enclosures for new hotels — as specified in Chapter 28(6)Enclosures for new apartment buildings — as specified in Chapter 30The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/22/2025, the Director of Maintenance initiated the following corrective actions: The facility will ensure all facility penetrations have been appropriately repaired and filled to met fire-stopping requirements, including all fire-rated caulking. The ceiling outside nurses station will be repaired to prevent any falling or sagging. The fire alarm control room doors will have been replaced with with a fire door. Identifying other Residents having the Potential to be Affected: By 7/30/2025, the Director of Maintenance conducted a facility-wide audit of areas for potential penetrations. The Director of maintenance audit to make sure completion of ceiling outside nurse station and door repairs to fire door. All residents have the potential to be affected by this. Measures put into place or Systemic Changes: The Director of Maintenance will implement a new fire safety inspection checklist that includes proper fire-stopping protection and fire doors. Plan to Monitor Performance: The Director of Maintenance will conduct weekly environmental rounds to look for potential penetrations weekly for 4 weeks and monthly for 2 months afterward. Results of all audits will be reported monthly to the Quality Assurance and Performance Improvement (QAPI) committee for review and additional actions as needed until substantial compliance is achieved and maintained for 3 consecutive months. The Safety Committee designee will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

0374Subdivision of Building Spaces - Smoke BarrieS/S F▼

Findings

Based on document review, observation, and interview, it was determined that fire-rated door assemblies were not maintained. The deficient practice could affect 4 out of 4 smoke compartments, 105 out of 105 residents, and an indeterminable number of staff and visitors. 1. The facility was unable to furnish documentation for annual fire door inspections. 2. During observations and interviews, it was noted that the rolled-down fire door in the kitchen has not been inspected. 3. Upon observation and interview, the wooden door to the walk-in cooler and freezer outside needs to be fixed. The door does not seal, the hardware is not UL-listed, and it is broken along the bottom. 4. During observation and interviews, it was noted that the laundry room fire door has louvers/venting, causing the door to lose its fire rating. 5. During observation and interview, it was noted that the Dirty Utility room ' s fire door will not seal and has improper hardware. 6. During the walk-through with the director of maintenance (DoM) and the administrator, it was observed that the doors to patient rooms 46 and 48 would not seal. 7. Upon observation and interview, it was noted that the memory care women ' s patio door has no approved fire-rated hardware, and the rated assembly is damaged. 8. Courtyard Egress doors do not seal. 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 CodeNFPA 101 8.3.3.2.3* Labels on fire door assemblies shall be maintained in a legible condition. NFPA 101 8.3.3.4 Floor fire door assemblies shall be tested in accordance with NFPA 288, Standard Methods of Fire Tests of Floor Fire Door Assemblies Installed Horizontally in Fire Resistance–Rated Floor Systems, and shall achieve a fire resistance rating not less than the assembly being penetrated. Floor fire door assemblies shall be listed and labeled. NFPA 80 5.2* Inspections. 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.5.2.3 Functional Testing. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of doorbeing subject to testingNFPA 80 5.2.14.1 Self-closing devices shall be kept in working conditionat all times. NFPA 101, 19.3.6.3.1 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. NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. NFPA 101, 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.(2)Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7NFPA 80 :7.1.4 Operation of Doors. 7.1.4.1 The doors shall swing easily and freely on their hinges. 7.1.4.2 The latches shall operate freely. NFPA 80 5.2.13 Prevention of Door Blockage. 5.2.13.3 Blocking or wedging of doors in the open position shall be prohibited. 5.2.14 Maintenance of Closing Mechanisms. 5.2.14.1 Self-closing devices shall be kept in working condition at all times. 5.2.14.2 Swinging doors normally held in the open position and equipped with automatic-closing devices shall be operated at frequent intervals to ensure operation. 5.2.14.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. 5.2.14.3.1 Resetting of the automatic-closing device shall be done in accordance with the manufacturer ' s instructions. 5.2.14.3.2 A written record shall be maintained and shall be made available to the AHJ.5.2.14.3.3 When the annual test for proper operation and full closure is conducted, rolling steel fire doors shall be drop-tested twice. 5.2.14.3.4 The first test shall be to check for proper operation and full closure. 5.2.14.3.5 A second test shall be done to verify that the automatic-closing device has been reset correctly. 5.2.14.4 Fusible links or other heat-actuated devices and release devices shall not be painted. 5.2.14.5* Paint shall be prevented from accumulating on any movable part. 7.3.2* Frames for Flush-Mounted Doors. 7.3.2.1 Only labeled frames of the structural steel type shall be used for flush-mounted doors. 7.3.2.2 The frames shall be erected before the wall is built. 11.3.5 Access to, and clearances between, surrounding construction and a rolling steel fire door shall allow for required testing and maintenance. 5.2.3 Functional Testing. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting. 5.2.5 Horizontally Sliding, Vertically Sliding, and Rolling Doors. 5.2.5.1 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. 5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions. 5.2.7 Assembly shall be reset after a successful test. 5.2.8 Resetting of the release mechanism shall be done in accordance with manufacturer ' s instructions. 5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay. 5.2.10 Tin-clad and kalamein doors shall be inspected for dry rot of the wood core. 5.2.11 Chains or cables employed shall be inspected for excessive wear and stretching. The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/22/2025, the Director of Maintenance initiated the corrective actions: Contacted licensed fire door contractor to inspect and repair all identified deficient doors Removed non-compliant hardware from memory care women's patio door and replaced with UL-listed components Repaired seals on patient room doors 46 and 48 Replaced damaged door and hardware on walk-in cooler/freezer Removed louvers from laundry room fire door and replaced with proper fire-rated door Repaired Dirty Utility room door seals and hardware Repaired courtyard egress door seals Documentation for annual fire door inspections will either be located or facility will obtain the correct documentation. Identifying other Residents having the Potential to be Affected: By 7/30/2025, the Director of Maintenance conducted a facility-wide inspection of all fire doors and smoke barriers to identify any additional deficiencies requiring correction. All residents have the potential to be affected by this deficient practice. Measures put into place or Systemic Changes: Contracted with licensed fire door inspection company to conduct annual inspections Implemented new fire door inspection policy and procedure Implemented work order system for immediate reporting of fire door deficiencies Implemented fire door documentation review upon inspections. Plan to Monitor Performance: The Director of Maintenance will: Conduct weekly fire door inspections and documentation review for 4 weeks Then conduct bi-weekly inspections for 8 weeks The Director of Maintenance will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly. The QAPI committee will review findings and make additional recommendations as needed until substantial compliance is achieved and maintained.

0511Utilities - Gas and ElectricS/S F▼

Findings

Based on document review, observation, and interview, it was determined that the electrical wiring was not maintained. The deficient practice could affect 4 out of 4 smoke compartments, 105 out of 105 residents, and an indeterminable number of staff and visitors. 1. During document review and interviews with the maintenance director, it was noted that two fire dampers failed upon inspection. 2. During the walk-through with the director of maintenance (DoM) and the administrator, the following was observed: outlets in room 49 and the therapy room are falling out. 3. During observation and interview, it was noted that there is exposed wiring outside of room 49, the memory care medicine room, and in the west corridor of memory care, which has exposed fire alarm wiring. NFPA 101 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. NFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and workmanlike manner. The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 5/30/25, the Director of Maintenance repaired the loose outlets in room 49 and the therapy room, properly secured and enclosed all exposed wiring outside room 49, the memory care medicine room, and in the west corridor of memory care, and a licensed contractor was contacted to repair the two failed fire dampers Identifying other Residents having the Potential to be Affected: The Director of Maintenance conducted a facility-wide inspection by 7/22/25 to identify any additional electrical hazards or fire damper issues that could affect all residents, staff, and visitors. All electrical outlets, wiring, and fire dampers were inspected. Measures put into place or Systemic Changes: A new preventive maintenance program was implemented by 7/22/25 that includes monthly inspections of all electrical outlets and exposed wiring Quarterly fire damper inspections have been added to the preventive maintenance schedule A licensed electrical contractor will conduct semi-annual facility-wide electrical systems inspections Plan to Monitor Performance: The Director of Maintenance will: Conduct weekly audits of 10% of facility electrical outlets and wiring for 4 weeks, then monthly for 3 months Report findings to the Quality Assurance and Performance Improvement (QAPI) committee monthly for 3 months The QAPI committee will review audit results and make additional recommendations as needed until substantial compliance is achieved and maintained The Maintenance Supervisor will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 5/30/25, the Director of Maintenance repaired the loose outlets in room 49 and the therapy room, properly secured and enclosed all exposed wiring outside room 49, the memory care medicine room, and in the west corridor of memory care, and a licensed contractor was contacted to repair the two failed fire dampers Identifying other Residents having the Potential to be Affected: The Director of Maintenance conducted a facility-wide inspection by 7/30/25 to identify any additional electrical hazards or fire damper issues that could affect all residents, staff, and visitors. All electrical outlets, wiring, and fire dampers were inspected. Measures put into place or Systemic Changes: A new preventive maintenance program was implemented by 7/30/25 that includes monthly inspections of all electrical outlets and exposed wiring Quarterly fire damper inspections have been added to the preventive maintenance schedule A licensed electrical contractor will conduct semi-annual facility-wide electrical systems inspections Plan to Monitor Performance: The Director of Maintenance will: Conduct weekly audits of 10% of facility electrical outlets and wiring for 4 weeks, then monthly for 3 months Report findings to the Quality Assurance and Performance Improvement (QAPI) committee monthly for 3 months The QAPI committee will review audit results and make additional recommendations as needed until substantial compliance is achieved and maintained The Maintenance Supervisor will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

0712Fire DrillsS/S F▼

Findings

Based on document review, observation, and interview, it was determined that the facility failed to conduct fire drills. The deficient practice could affect four out of four smoke compartments, 105 out of 105 residents, and an indeterminable number of staff and visitors. During the document review, the facility failed to conduct quarterly fire drills for each shift. 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. The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/22/2023, the Director of Maintenance initiated immediate fire drills on all shifts to ensure staff familiarity with emergency procedures. Identifying other Residents having the Potential to be Affected: All residents, staff, and visitors have the potential to be affected by this deficient practice. Measures put into place or Systemic Changes: The Director of Maintenance developed a comprehensive fire drill schedule by 7/22/2025 ensuring quarterly drills on all shifts. Fire drill schedule has been incorporated into the facility's preventive maintenance calendar with automatic reminders. Plan to Monitor Performance: The Maintenance Director will audit fire drill records monthly for 3 months, then quarterly thereafter to ensure compliance with required frequency. Results of these audits will be reported monthly to the Quality Assurance Performance Improvement (QAPI) Committee.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/30/2023, the Director of Maintenance initiated immediate fire drills on all shifts to ensure staff familiarity with emergency procedures. Identifying other Residents having the Potential to be Affected: All residents, staff, and visitors have the potential to be affected by this deficient practice. Measures put into place or Systemic Changes: The Director of Maintenance developed a comprehensive fire drill schedule by 7/30/2025 ensuring quarterly drills on all shifts. Fire drill schedule has been incorporated into the facility's preventive maintenance calendar with automatic reminders. Plan to Monitor Performance: The Maintenance Director will audit fire drill records monthly for 3 months, then quarterly thereafter to ensure compliance with required frequency. Results of these audits will be reported monthly to the Quality Assurance Performance Improvement (QAPI) Committee.

0914Electrical Systems - Maintenance and TestingS/S F▼

Findings

Based on document review, observation, and interview, it was determined that the facility failed to maintain proper electrical practices.. The deficient practice could affect four out of four smoke compartments, 105 out of 105 residents, and an indeterminable number of staff and visitors. During document review, interviews, and observations, it was noted that no written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care was conducted annually. NFPA Standard: 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). The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: All resident rooms and areas where deep sedation or general anesthesia is administered were inspected and tested by a qualified electrician by 7/22/2025. Any identified deficiencies were immediately corrected to ensure resident safety. Identifying other Residents having the Potential to be Affected: All resident rooms and clinical areas in the facility have the potential to be affected. The Director of Maintenance conducted a facility-wide audit of all electrical receptacles and systems on 7/22/2025 to identify any additional areas requiring testing or maintenance. Measures put into place or Systemic Changes: The Director of Maintenance has implemented a comprehensive electrical testing schedule that includes: Monthly testing of all hospital-grade receptacles Documentation of all testing results and repairs Quarterly preventive maintenance inspections New electrical testing logs have been implemented to track all required testing and maintenance. Plan to Monitor Performance: The Director of Maintenance will conduct weekly audits of electrical testing logs to ensure compliance with testing schedules. The Maintenance Supervisor will conduct monthly quality assurance reviews of 10% of all electrical testing documentation. Results of all audits will be reported monthly to the Quality Assurance and Performance Improvement (QAPI) committee for review and additional recommendations if needed. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive months. The Director of Maintenance will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: All resident rooms and areas where deep sedation or general anesthesia is administered were inspected and tested by a qualified electrician by 7/30/2025. Any identified deficiencies were immediately corrected to ensure resident safety. Identifying other Residents having the Potential to be Affected: All resident rooms and clinical areas in the facility have the potential to be affected. The Director of Maintenance conducted a facility-wide audit of all electrical receptacles and systems on 7/30/2025 to identify any additional areas requiring testing or maintenance. Measures put into place or Systemic Changes: The Director of Maintenance has implemented a comprehensive electrical testing schedule that includes: Monthly testing of all hospital-grade receptacles Documentation of all testing results and repairs Quarterly preventive maintenance inspections New electrical testing logs have been implemented to track all required testing and maintenance. Plan to Monitor Performance: The Director of Maintenance will conduct weekly audits of electrical testing logs to ensure compliance with testing schedules. The Maintenance Supervisor will conduct monthly quality assurance reviews of 10% of all electrical testing documentation. Results of all audits will be reported monthly to the Quality Assurance and Performance Improvement (QAPI) committee for review and additional recommendations if needed. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive months. The Director of Maintenance will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

0918Electrical Systems - Essential Electric SysteS/S F▼

Findings

Based on document review, observation, and interview, it was determined that the facility failed to maintain the emergency power generator properly. The deficient practice could affect four out of four smoke compartments, 105 out of 105 residents, and an indeterminable number of staff and visitors. During the document review with the director of maintenance (DoM) and the administrator, the following was noted:1. Monthly voltage testing is not being conducted. When staff are performing the test, they use a trickle charger. 2. Monthly load bank testing has not been conducted throughout the year. 3. The facility was unable to produce the annual load bank testing report. 4. The monthly transfer switch time is not being conducted monthly. NFPA 110-8.3.7.1 Maintenance of lead acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in leu of the testing of specific gravity when applicable or warranted. 8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using oneof the following methods: (1) Loading that maintains the minimum exhaust gastemperatures as recommended by the manufacturer (2) Under operating temperature conditions and at not lessthan 30 percent of the EPS nameplate kW rating2010 NFPA 110 8.4.9.5.3For spark-ignited EPSs, loading shall be the available EPSS load. 8.4.9.6 The test required in 8.4.9 shall be permitted to be combined with one of the monthly tests required by 8.4.2 and one of the annual tests required by 8.4.2.3 as a single test. 8.4.9.7 Where the test required in 8.4.9 is combined with the annual load bank test, the forest 3 hours shall be at not less than the minimum loading required by 8.4.9.5 and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS. 2010 NFPA 110 8.3.5 Transfer switches shall be subjected to a maintenance and testing program that includes all of the following operations: Checking the connectionsInspection or testing for evidence of overheating and excessive contact erosionRemoval of dust and dirtReplacement of contacts when required8.4.6 Transfer switch shall be operated monthly. 8.4.6.1 The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position. The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action Taken: By 7/22/2025, the facility contracted with a certified generator service company to conduct immediate testing and implement a comprehensive maintenance program. The following actions were completed: Full voltage testing conducted without use of trickle charger Monthly load bank testing schedule established, and first test completed Annual load bank test performed with documentation Transfer switch timing test conducted and documented New testing logs implemented to track all required maintenance activities Identification of Other Areas with Potential to be Affected: The Director of Maintenance conducted a complete review of all emergency power system components and maintenance records by 7/22/2025. This review included: Assessment of battery systems and charging equipment Evaluation of all transfer switches Review of all generator maintenance documentation Inspection of fuel systems and supply lines Systemic Changes and Measures Implemented: Contracted with Power Solutions Inc. for monthly professional generator maintenance services Implemented new maintenance schedule meeting NFPA 110 requirements: Weekly inspections Monthly load testing (30 minutes at minimum 30% capacity) Monthly transfer switch timing tests Annual load bank testing Created electronic maintenance logging system for tracking all required testing Updated emergency power system policy and procedure manual Monitoring and Quality Assurance: The Director of Maintenance will conduct weekly audits of generator testing logs and maintenance records. The Facility Engineer will perform monthly quality assurance reviews of all emergency power system documentation. Results will be reported monthly to the Safety Committee and quarterly to the QAPI Committee. The QAPI Committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive quarters.

Plan of correction · submitted by the facility

Corrective Action Taken: By 7/30/2025, the facility contracted with a certified generator service company to conduct immediate testing and implement a comprehensive maintenance program. The following actions were completed: Full voltage testing conducted without use of trickle charger Monthly load bank testing schedule established, and first test completed Annual load bank test performed with documentation Transfer switch timing test conducted and documented New testing logs implemented to track all required maintenance activities Identification of Other Areas with Potential to be Affected: The Director of Maintenance conducted a complete review of all emergency power system components and maintenance records by 7/30/2025. This review included: Assessment of battery systems and charging equipment Evaluation of all transfer switches Review of all generator maintenance documentation Inspection of fuel systems and supply lines Systemic Changes and Measures Implemented: Contracted with Power Solutions Inc. for monthly professional generator maintenance services Implemented new maintenance schedule meeting NFPA 110 requirements: Weekly inspections Monthly load testing (30 minutes at minimum 30% capacity) Monthly transfer switch timing tests Annual load bank testing Created electronic maintenance logging system for tracking all required testing Updated emergency power system policy and procedure manual Monitoring and Quality Assurance: The Director of Maintenance will conduct weekly audits of generator testing logs and maintenance records. The Facility Engineer will perform monthly quality assurance reviews of all emergency power system documentation. Results will be reported monthly to the Safety Committee and quarterly to the QAPI Committee. The QAPI Committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive quarters.

0927Gas Equipment - Transfilling CylindersS/S D▼

Findings

Based on document review, observation, and interview, it was determined that the facility failed to provide proper personal protective equipment in the oxygen transfilling room. The deficient practice could affect 1 out of four smoke compartments, 27 out of 105 residents, and an indeterminable number of staff and visitors. During observation and interviews, it was noted that the oxygen transfilling room was missing the proper personal protective equipment. 11.5.2 Gases in Cylinders and Liquefied Gases in Containers. 11.5.2.1 Qualification and Training of Personnel. 11.5.2.1.1* Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained on the risks associated with their handling and use. 11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel. 11.5.2.1.3 Continuing education programs shall include periodic review of safety guidelines and usage requirements for medical gases and their cylinders. 11.5.2.1.4 Equipment shall be serviced only by personnel trained in the maintenance and operation of the equipment. 11.5.2.1.5 If a bulk cryogenic system is present, the supplier shall provide annual training on its operation. 11.5.2.3.2 Transfilling to liquid oxygen portable containers at 344.74 kPa (50 psi) and under shall include the following:(1)The area is well ventilated and has noncombustible flooring.(2)The area is posted with signs indicating that smoking in the area is not permitted.(3)The individual transfilling the liquid oxygen portable container has been properly trained in the transfilling procedure.(4)The guidelines of CGA P-2.6, Transfilling of Low-Pressure Liquid Oxygen to be Used for Respiration, are met. The administrator and maintenance director discussed the deficient items at the exit conference.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/22/25, the Director of Maintenance will have stocked the oxygen transfilling room with appropriate personal protective equipment including safety goggles, face shields, and protective gloves as required for safe oxygen handling. Identifying other Residents having the Potential to be Affected: All residents requiring oxygen therapy have the potential to be affected. The Director of Maintenance conducted a facility-wide assessment of all areas where medical gases are stored and handled to ensure proper PPE is available. Measures put into place or Systemic Changes: The maintenance director will ensure there is posted signage in oxygen transfilling room detailing required PPE. Plan to Monitor Performance: The Director of Maintenance will conduct checks of the oxygen transfilling room weekly for 1 month, and monthly thereafter to ensure proper PPE is available and maintained. Results will be tracked and documented using a PPE compliance monitoring tool. The Director of Nursing will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

Plan of correction · submitted by the facility

Corrective Action for Affected Residents: By 7/30/25, the Director of Maintenance will have stocked the oxygen transfilling room with appropriate personal protective equipment including safety goggles, face shields, and protective gloves as required for safe oxygen handling. Identifying other Residents having the Potential to be Affected: All residents requiring oxygen therapy have the potential to be affected. The Director of Maintenance conducted a facility-wide assessment of all areas where medical gases are stored and handled to ensure proper PPE is available. Measures put into place or Systemic Changes: The maintenance director will ensure there is posted signage in oxygen transfilling room detailing required PPE. Plan to Monitor Performance: The Director of Maintenance will conduct checks of the oxygen transfilling room weekly for 1 month, and monthly thereafter to ensure proper PPE is available and maintained. Results will be tracked and documented using a PPE compliance monitoring tool. The Director of Nursing will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.

3/26/2025State Licensure Survey · ID P9LU111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure survey was completed on 3/23/25 to 3/26/25. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0704Res Care - Accident Prevention and Attention▼

Findings

Based on observations, record review and interviews, the facility failed to ensure three (#97, #37 and #47) of eight residents reviewed for accident hazards out of 36 sample residents remained as free from accidents as possible. Resident #97, who was known to be at risk for falls, was admitted on 11/18/22 with diagnoses of dementia, hearing impairment, unsteady and shuffling gait, and right sided weakness. The facility initiated a fall care plan which included interventions of anticipating and meeting the resident's needs, encouraging rest periods when signs of fatigue were noted, ensuring that the resident wore appropriate footwear when ambulating and keeping the resident in line of sight as needed. Resident #97 sustained falls with injury on 12/30/24 (abrasion to the right side of his head), 1/12/25 (laceration to his head) and 1/19/25 (abrasion to the back of his head). Resident #97 was sent to the emergency department (ED) for evaluation and treatment after each of the three falls. However, the facility failed to implement new fall interventions until 1/22/25 (after the third fall), when an intervention of a soft helmet for the resident to wear while awake was initiated. On 2/22/25 Resident #97 experienced another fall while ambulating in the hallway which resulted in a laceration to the back of his head and required the resident to again be sent to the ED for evaluation and treatment of a subarachnoid hemorrhage (bleeding into the space between the brain and the arachnoid membrane, one of the protective layers covering the brain). The facility failed to implement any new fall interventions upon the resident's return to the facility on 2/23/25. On 2/24/25 Resident #97 experienced another fall on 2/24/25 that resulted in a large amount of bleeding to the resident's head in the same area as the resident's laceration that resulted from his fall on 2/22/25. The resident still had staples in his head from the previous fall on 2/22/25. The resident was again sent to the ED where he received six additional sutures for treatment of the laceration. The resident returned to the facility on 2/24/25 and the facility ordered a medical grade ribcap helmet (a medical grade helmet which offers 360 degree protection to the head). Staff interviews during the survey (see interviews below) revealed Resident #97 was not wearing the soft helmet initiated on 1/22/25 when he fell on 2/22/25 and 2/24/25 and the facility failed to ensure Resident #97 was encouraged to wear his safety helmet prior to his falls on 2/22/25 and 2/24/25. Due to the facility's failure to implement timely and effective interventions following each of Resident #97's falls, and the facility's failure to ensure care planned interventions were followed, the resident sustained head injuries, which required transfer to and treatment in the ED, from multiple falls. Additionally, the facility failed to ensure staff transferred Resident #37 and Resident #47 appropriately, according to their documented transfer status. Findings include:I. Facility policy and procedureThe Fall and Fall Risk, Managing policy, revised March 2018, was provided by the nursing home administrator (NHA) on 3/25/25 at 3:25 p.m. It read in pertinent part, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling."Environmental risk factors that contribute to the risk of falls include wet floors, poor lighting, incorrect bed height or width, obstacles in the footpath, improperly fitted or maintained wheelchairs and footwear that is unsafe or absent. Resident conditions that may contribute to the risk of falls include fever, infection, delirium and cognitive impairment, pain, lower extremity weakness, poor grip strength, medication side effects, orthostatic hypertension, functional impairments, visual deficits and incontinence. Medical factors that contribute to the risk of falls include arthritis, heart failure, anemia, neurological disorders and balance and gait disorders."If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling."The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not have been previously identified."II. Resident #97A. Resident statusResident #97, age greater than 65, was admitted on 11/18/22. According to the March 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, chronic kidney disease, hearing loss, repeated falls and encephalopathy (medical conditions affecting brain function). The 2/6/25 facility assessment revealed Resident #97 had severe cognitive impairment. He needed substantial assistance with transfers, used a walker and needed supervision or touching assistance with ambulation. B. Record reviewResident #97's fall care plan, initiated 11/22/22, documented he was at risk for injury related to falls, a diagnosis of dementia, hearing impairment, unsteady and shuffling gait and right sided weakness. Pertinent interventions included anticipating and meeting the resident's needs (initiated 11/22/22), encouraging rest periods when signs of fatigue were noted (initiated 11/22/22), ensuring that the resident wore appropriate footwear when ambulating, (initiated 11/22/22), educating the resident, family and caregivers about safety reminders and what to do if a fall occurred (initiated 7/7/23), resident to be in line of sight as needed (initiated 3/6/24), soft helmet while awake (initiated 1/22/25), staff to ensure the resident was not too close to others while walking in the hallway (initiated 1/22/25) and medical-grade helmet (initiated 2/24/25). A review of Resident #97's electronic medical record (EMR) revealed the following progress notes:A 12/30/24 charting note, documented at 8:00 p.m,. revealed that Resident #97 had a fall. The resident was using a walker, going too fast and lost his balance. The resident was wearing non-skid socks on both feet and his walker was in front of him. The resident hit his head, either on the dresser or the night stand, and had an abrasion to the right side of his head and an egg-sized lump. The resident was not taking any anti-coagulant medications (blood thinners). The resident had major difficulty attempting to walk to his bed and kept holding his head at the site of impact. The resident was sent out to the ED for evaluation. A 12/31/24 charting note, documented at 11:15 p.m., revealed that Resident #97 returned from the hospital at 11:15 p.m. The resident had another fall while in the hospital.-The facility failed to initiate any new fall interventions following the resident's 12/30/24 fall (see care plan above). A 1/3/25 weekly summary note, documented at 9:55 a.m., indicated that Resident #97 had no falls or injuries the previous week.-However, the resident progress notes documented the resident had a fall on 12/30/24 that resulted in an abrasion to the right side of his head and an egg-sized lump. A 1/10/25 progress note, documented at 11:36 a.m., revealed that the floor staff observed Resident #97 with worsened balance, leaning to the right side, and staff had to watch the resident closely and provide physical support when walking at times with a walker. A 1/13/25 interdisciplinary team (IDT) note, documented at 9:41 a.m., revealed that on 1/12/25 at 2:00 a.m., Resident #97 was seen sliding to the floor by a certified nurse aide (CNA). Resident #97 hit the back of his head and sustained a laceration to the head without a change of consciousness. The resident was sent to the ED for evaluation.-The facility failed to initiate any new fall interventions following the resident's 1/12/25 fall (see care plan above). A 1/19/25 charting note, documented at 6:45 p.m., revealed that Resident #97 had a fall in the hallway while other residents were gathering for a cigarette break. The resident hit his head multiple times on the wall when he fell. Neurological assessments and frequent checks were initiated and the resident was found to have an abrasion to the back of his head approximately three centimeters (cm) in diameter. The nurse on the unit notified the physician and the resident was sent to the ED for further evaluation. A 1/24/25 note, documented at 11:40 a.m., revealed that Resident #97 continued on therapy services three times a week for a fall and decreased strength. The resident continued to use a four-wheeled walker for ambulation and did very well unless he was tired. Staff encouraged the resident to rest between meals and when he was noticeably becoming unstable, as evidenced by the resident beginning to veer to the right and run into walls. The resident could be difficult to redirect due to a language barrier and dementia diagnosis. A 2/21/25 progress note, documented at 6:43 p.m. revealed that Resident #97 continued to use a walker to ambulate in the hallways. He was encouraged to wear a helmet and to take rest breaks through the day, but was resistant to this guidance.-However, the resident's fall care plan failed to indicate the resident refused to wear his helmet or take rest breaks (see care plan above). A 2/22/25 progress note, documented at 3:15 a.m., revealed that Resident #97 was walking in the hallway with a walker and fell on his back, resulting in a laceration to the back of his head. Pressure was applied to stop the bleeding. The resident was able to squeeze a staff member's hand and sit upright on his own. A registered nurse (RN) was notified. The resident was sent to the hospital for treatment and evaluation. -The progress note failed to document if Resident #97 was wearing a protective soft helmet, per the care planned interventions on 1/22/25 (see care plan above). -The facility failed to document refusals by Resident #97 to wear the care planned soft helmet or attempts by staff to encourage the resident to wear it.-The facility failed to initiate any new fall interventions following the resident's 2/22/25 fall (see care plan above). A 2/23/25 progress note, documented at 12:04 p.m., revealed that Resident #97 was readmitted to the facility, was confused and wandering frequently between hallways and his room. The resident required frequent staff monitoring for high risk of falling. A 2/23/25 progress note, documented at 4:10 p.m., revealed that Resident #97 returned to the facility from the hospital for treatment of a subarachnoid hemorrhage following a fall at the facility. The resident had sutures on the back of his head. A 2/24/25 progress note, documented at 6:50 p.m., revealed that a staff member was called tocome and help with Resident #97 due to a fall and a large amount of bleeding to the resident's head. The resident still had staples in his head from his previous fall on 2/22/25. Staff applied pressure to the resident's wound and the resident was sent out to the ED for further evaluation. A 2/24/25 progress note, documented at 11:43 p.m., revealed that Resident #97 returned to the facility with a head laceration that was repaired with six additional sutures. The resident had a 10 cm laceration to the back of his head and returned to the facility at 10:05 p.m.-The progress note failed to document if Resident #97 was wearing a protective soft helmet, per the care planned interventions on 1/22/25. -The facility failed to document refusals by Resident #97 to wear the care planned soft helmet or attempts by staff to encourage the resident to wear it. A 2/25/25 nurse's note, documented at 4:07 p.m., revealed that a ribcap helmet was ordered for Resident #97and staff were to encourage the resident to wear the helmet, and the resident's care plan was updated. The resident was to have a one-to-one sitter until the helmet was received. A 2/28/25 progress note documented, at 9:31 a.m., revealed that Resident #97's therapy for fall risk had been discontinued. The resident had fallen in the past week with head injuries and had been under one-to-one staff supervision. According to the hospital physician, the resident had a history of stroke which caused him to walk with weight on his heels and he was prone to falling backward. Review of Resident #97's post-fall assessments revealed the following:A 12/30/24 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had multiple falls the last six months and strayed off the straight path of walking but failed to document the resident used a walker. A 1/15/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk and strayed off the straight path of walking. However, the post-fall assessment documented the resident had one to two falls in the last six months, contrary to the previous assessment on 12/30/24 that documented he had multiple falls in the same time frame. The 1/15/25 assessment additionally failed to document the resident used a walker. A 1/20/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had multiple falls in the last six months and strayed off the straight path of walking. However, the resident's use of psychotropic medications and laxatives were not documented on the assessment and the assessment failed to document that the resident used a walker. A 2/25/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had one to two falls in the last six months and the resident's use of psychotropic medications and laxatives were not indicated on the assessment. The assessment documented the resident used a walker. -However, the resident had five falls in the last 60 days (see above) and was ordered risperidone starting 1/30/25, neither of which was indicated on the assessment. The assessment additionally failed to document the resident strayed off the straight path of walking as indicated on the previous post fall assessments (12/30/24, 1/15/25, 1/20/25). The fall investigations for Resident #97's falls on 2/22/25 and 2/24/25 were provided by the NHA on 3/24/25 at 3:23 p.m. -The fall investigations failed to document if Resident #97 was wearing a soft helmet as a fall prevention. C. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 3/25/25 at 2:55 p.m. LPN #4 said Resident #97's fall on 2/22/25 occurred near the end of her shift. LPN #4 said the resident would walk around with a walker several times during the course of the night. LPN #4 said he would take his walker and follow around the edge of the wall, catching the wheel of his walker on the wall, and he would do that several times during the night. LPN #4 said she told the CNAs to keep an eye on Resident #97 and that the resident had a history of falling backwards. LPN #4 said when Resident #97's fall occurred on 2/22/25, she was at the medication cart and passing medications. She said the resident was bleeding a lot from his head and was sent to the hospital. LPN #4 said there was a physician's order for the resident to wear a helmet from a previous fall, but the helmet did not fit and the resident would not wear it. LPN #4 said the order was discontinued and he did not have a current order for a helmet. LPN #4 said she had the CNAs check the room for a helmet but they were unable to locate one. CNA #8 was interviewed on 3/25/25 at 3:00 p.m. CNA #8 said when Resident #97 fell on 2/24/25, staff were getting a group of residents together to smoke and Resident #97 was ambulating with a walker. CNA #8 said Resident #97 was supposed to have a special helmet but the resident took the helmet off. CNA #8 said the resident was on every 15-minute checks and was supposed to be getting a hard helmet. CNA #8 said the resident did wear the grippy socks. She said he was not wearing a helmet when he fell a second time on 2/24/25. The director of nursing (DON) and the NHA were interviewed together on 3/26/25 at 10:20 a.m. The DON said the facility had a soft shell to fit inside the normal hat Resident #97 wore regularly. The DON said it was care planned to encourage Resident #97 throughout the shift to wear his protective helmet and there was no set amount of times to remind him. -However, the care plan did not indicate staff were to encourage the resident to wear his protective helmet (see care plan above). The DON said staff tried to anticipate Resident #97's behavior. The DON said a soft shell helmet would benefit Resident #97 more when he was ambulating. The DON said the resident did not wear the rib cap helmet in the bed due to skin breakdown. The DON said Resident #97 swatted at his hand when he had tried to put the helmet on him. The NHA said Resident #97 was not wearing his helmet when he fell on 2/22/25. III. Resident #37A. Resident statusResident #37, age greater than 65, was admitted on 10/7/19. According to the March 2025 CPO, diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke), type 2 diabetes mellitus, dementia, anxiety, difficulty walking and heart failure. The 12/31/24 facility assessment revealed the resident was severely cognitively impaired. The resident was dependent on care for all activities of daily living (ADL) except eating, where she needed set up assistance. The facility assessment did not document use of a mechanical lift or prior falls. B. Record reviewResident #37's fall care plan, revised 11/6/24, documented she was at high risk for falls due to incontinence, paralysis, psychoactive drug use, was unaware of safety needs and declined therapy. Pertinent interventions, revised 4/1/24, included to anticipate and meet Resident #37's needs. A fall mat intervention was initiated 10/11/24. Resident #37's ADL care plan, revised 7/16/24, documented she had a self care performance deficit due to hemiplegia and dementia. Pertinent interventions, initiated 7/16/24, included that Resident #37 was totally dependent on staff for repositioning and turning in bed and required a hoyer lift (mechanical lift) with two staff members for transfers. A 3/23/25 nursing progress note, documented at 7:30 p.m., revealed that a CNA was transferring Resident #37 into bed. The CNA then came out of the room and said the resident was on the floor. The CNA said that she lowered the resident to the floor. Resident #37's 3/23/25 fall investigation was provided by the NHA on 3/24/25 at 3:23 p.m. The fall investigation documented Resident #37's fall happened during a transfer and the CNA said the resident tripped over oxygen tubing and the floor mat was also in the way during the transfer.-However, per Resident #37's ADL care plan, the resident was supposed to be a two-person transfer with a hoyer lift (see care plan above). Resident #37's 3/24/25 post-fall assessment documented the resident's gait analysis as unable to independently come to a standing position. C. Staff interviewsCNA #3 was interviewed on 3/25/25 at approximately 3:00 p.m. CNA #3 said Resident #37 needed a mechanical lift for transfers and the assistance of two staff members to transfer. CNA #3 said she was aware Resident #37 had fallen previously. CNA #3 said Resident #37 could transfer while standing from her bed to her chair but needed to have two staff members assist her closely and she usually used the mechanical lift for transfers. The DON was interviewed on 3/26/25 at 10:20 a.m. The DON said Resident #37's care plan indicated the mechanical lift was to be used to transfer Resident #37. The DON said it was against company policy to transfer Resident #37 without the mechanical lift. The DON said the facility staff directly transferred the resident to her bed without the mechanical lift on 3/23/25 and one CNA was present in the room at the time instead of two. IV. Resident #47A. Resident statusResident #47, age less than 65, was admitted on 6/7/21. According to the March 2025 CPO, diagnoses included multiple sclerosis (a disease that causes breakdown of the protective covering of nerves), history of traumatic brain injury, epilepsy and encephalopathy (a medical condition that affects brain function). The 2/13/25 facility assessment revealed the resident was moderately cognitively impaired. The resident was dependent on staff for most ADLs. The assessment documented the resident was dependent on staff for all transfers. B. Record reviewThe functional abilities care plan, revised 8/1/24, revealed Resident #47 required staff assistance with ADLs due to his multiple sclerosis and history of traumatic brain injury. Pertinent interventions included Resident #47 requiring extensive total assistance with bathing and showering and requiring a hoyer lift with two staff members for transfers, revised 10/18/24. The fall care plan, initiated 12/16/24 and revised 2/12/25, revealed Resident #47 was at risk for falls due to altered balance while standing, a history of falls and an unsteady gait. Pertinent interventions included having two staff members to assist with transfers with a hoyer lift (initiated 4/29/24), engaging with Resident #47 and reminding him to stay seated until the hoyer lift transfer was complete (initiated 6/30/24) and only using the hoyer lift for transfers (initiated 2/6/25).-However, the resident had already had an intervention for transfers with two people and a hoyer lift which was initiated on 4/29/24, 10 months prior to the hoyer lift intervention implemented on 2/6/25. The facility fall report, dated 12/31/24 at 10:45 a.m., revealed Resident #47 was receiving a shower when he fell. An unidentified CNA was transferring Resident #47 to a chair when the resident slipped, the CNA was unable to hold him and the resident fell. According to the CNA, Resident #47 hit his head on the wall. No injuries or bruises were observed during the nurse's assessment and Resident #47's range of motion and behavior were at baseline. The RN was notified. The report documented physiological factors contributing to the fall included weakness. A change in condition form, dated 12/31/24 at 11:57 a.m., revealed Resident #47 fell in the shower room. Resident #47 slipped during a transfer and fell down. Resident #47 hit his head on the wall during the fall. Resident #47 was not in distress and his vital signs were within normal limits. A post-fall rehabilitation screening, dated 12/31/24 at 1:55 p.m., revealed Resident #47 fell during an assisted transfer. Resident #47 was dependent for transfers, and the physical therapist recommended using a mechanical lift and rolling shower chair for showers.-However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above). An interdisciplinary team (IDT) note, dated 1/2/25 at 9:32 a.m., revealed that on 12/31/24 at approximately 10:45 a.m., Resident #47 was in the shower room with a shower aide and slipped on the floor. The CNA reported Resident #47 hit his head. Risk factors included the lift protocol was notfollowed and Resident #47 was impulsive and had poor safety awareness. Prior interventions included having physical therapy evaluate Resident #47, a floor mat by Resident #47's bedside and his bed in the lowest position. Interventions put into place included re-educating staff on the facility's lift policy. The facility fall report, dated 2/6/25 at 6:43 p.m., revealed Resident #47 had a witnessed fall. The report documented an unidentified CNA called the nurse into Resident #47's room around 4:30 p.m. to assist the resident on the floor in his room. The nurse entered Resident #47's room and observed him lying down on the floor. The RN in the building was called to assess Resident #47. No physical injuries were noted at the time and Resident #47 said he was tired and wanted to stay in bed. Resident #47 was assisted by four staff members back into bed, his vital signs were taken and a neurological assessment was performed. An IDT note, dated 2/7/25 at 10:32 a.m., revealed that on 2/6/25 at 6:43 p.m., Resident #47 was assisted to the floor by a CNA during a transfer due to weakness. No pain or injuries were identified. Resident #47 was assisted back into his bed per his request by four staff members. Resident #47 stated he was tired. Risk factors included weakness, dementia and a history of falls. Prior interventions included having physical therapy evaluate and treat Resident #47, a floor mat on Resident #47's bedside and his bed in lowest position, and re-educating the staff on the facility lift policy. Interventions initiated included only using a hoyer lift for transfers.-However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above). A post-fall rehabilitation screening, dated 2/7/25 at 1:49 p.m., revealed Resident #47 was attempting to transfer during the fall. The physical therapist recommended using a mechanical lift for improved safety with transfers. -However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above). C. Staff interviewsCNA #5 was interviewed on 3/26/25 at 9:30 a.m. CNA #5 said Resident #47 needed to be transferred using a hoyer lift. CNA #5 said Resident #47 could stand with two staff members assisting him early in the mornings, and mainly needed to use the hoyer lift after lunch.-However, according to the resident's care plan, the resident was to be a hoyer lift for all transfers (see care plan above). CNA #2 was interviewed on 3/26/25 at 10:13 a.m. CNA #2 said Resident #47 usually needed to use a hoyer lift to transfer. CNA #2 said in the mornings, if Resident #47 felt good he could stand, but he generally needed to use the hoyer lift. CNA #2 said they would often only have one CNA to operate a hoyer lift rather than two, but over the last two months they had enough staff to have two staff members operating the hoyer lifts. LPN #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said Resident #47 needed to transfer with the hoyer lift, but sometimes had good days where he did not need to use the lift. LPN #1 said Resident #47 needed to use the hoyer lift since he had a decline the month prior.-However, according to the resident's care plan, the resident had been care planned to use a hoyer lift for transfers since 4/29/24 (see care plan above). The director of rehabilitation (DOR) was interviewed on 3/26/25 at 12:56 p.m. The DOR said Resident #47 needed to be transferred with a hoyer lift at all times. The facility assessment coordinator (FAC) was interviewed on 3/26/25 at 3:36 p.m. The FAC said Resident #47 needed to be transferred using the hoyer lift exclusively. The FAC said Resident #47 had multiple sclerosis and was wheelchair-bound when he was admitted but had experienced a continuous decline in mobility. The FAC said Resident #47 used to transfer by stand and pivot method but had a few falls in which his legs buckled under him. The FAC said Resident #47's fall in February 2025 was related to a transfer during which he tried to self-transfer and was caught by the facility staff. The FAC said Resident #47's fall in December 2024 occurred as a CNA was transferring him in the shower room and he fell. The DON was interviewed on 3/26/25 at 4:40 p.m. The DON said Resident #47 needed to be transferred with a hoyer lift at all times. The DON said Resident #47 used to transfer via stand and pivot a year prior (2024). The DON said Resident #47's fall on 12/31/24 went directly against the facility's no-lift policy. The DON said Resident #47 was a known hoyer lift user and the resident could not coordinate balancing weight on his legs. The DON said the CNA was trying to transfer Resident #47 to his wheelchair when he fell on 12/31/24. The DON said Resident #47's fall on 2/6/25 was unwitnessed. The DON said Resident #47 had rolled out of bed and onto the floor.-However, the facility fall report documented Resident #47's fall as witnessed, and the IDT note on 2/7/25 documented the fall occurred during a transfer and the CNA lowered the resident to the floor due to weakness (see record review above).

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Corrective Action Resident #97 discharged on 3-2-25. On 4/25/2025 Resident #47 transfer status reviewed by Director of Rehab/designee and remains a Hoyer transfer. Care plan reviewed and remains accurate. On 4/5/2025 Resident #37 transfer status reviewed by Director of Rehab/designee. Care plan reviewed and updated. Identification of others By 4-21-25 the MDS nurse/designee will review the current transfer status of residents and verify it is documented in the ADL care plan and on the Kardex under transferring. By 4-21-25 the Director of Nursing (DON)/designee will review the falls that occurred in the last 60 days for interventions related to fall circumstance. If there is not a current intervention one will be implemented. Systemic Changes On 4-18-25 Director of Nursing (DNS)/designee completed education to clinical staff on fall prevention, transferring residents per their transfer status, transfer status is located in the residents ADL care plan and Kardex under transferring and fall interventions. Monitoring Beginning 4-22-25, an audit tool will be utilized to monitor residents who fall for the proper transfer status, the fall circumstance and intervention placed as result of fall. This will include observations of transfers and will be documented via audit form. Audit will be completed five times a week for 90 days. DNS to review results monthly and report findings to QAPI x 3 months. QAPI committee will decide as to the frequency of on-going monitoring.

3/26/2025Complaint, Recertification Survey · ID 4LDQ1120 deficiencies▼

0000Initial CommentsSurveyor note2 building records▼

Findings · record 1 of 2

A recertification survey with complaint #CO39419, #CO39564, Incident #39361, Incident #39466, Incident #39604 and Incident #39607 was conducted on 3/23/25 to 2/26/25. Twenty deficiencies were cited.

Findings · record 2 of 2

An Emergency Preparedness survey was conducted from 3/23/25 to 3/26/25. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0550Resident Rights/Exercise of RightsS/S E▼

Findings

Based on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity by providing care in a dignified, respectful and individualized manner for one (#26) of four residents reviewed out of 36 sample residents and on one of three units. Specifically, the facility failed to: -Ensure residents who were prescribed a puree diet received the menu options as listed on the main menu or according to their preference and prescribed diet order; and,-Provide residents on the Aspen unit with non-disposable beverage cups at meals. Findings include:I. Failed to ensure residents who were prescribed a puree diet, received the menu options as listed on the main menu or according to their preference and prescribed diet orderA. Facility policy and procedureThe Resident Food Preferences policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/26/25 at 11:32 a.m. It read in pertinent part, "Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and meal times. Nursing staff will document the resident's food and eating preferences in the care plan."B. Resident representative interviewResident #26's representative was interviewed on 3/24/25 at 2:42 p.m. The resident representative said she could never find the puree diet menu. The resident representative said she had tried sitting down with Resident #26 and selecting things from the menu he would like, but when Resident #26 received his tray, he did not receive the menu items he had ordered. The resident's representative said she never knew what food items were on Resident #26's plate, so she would have the resident guess what he was eating. C. Observations and test trayDuring a continuous observation on 3/25/25, beginning at 11:10 a.m. and ending at 12:37 p.m., the following was observed during the meal preparation and service in the main kitchen: The posted menu was beef tostada with shredded lettuce and tomato and fruit crisp. At 11:12 a.m. cook (CK) #1 assembled a meal plate with mashed potatoes and puree meat and placed the meal in the serving window. The resident's meal ticket documented the resident was on a mechanical soft diet with puree meat and' cheeseburger' was written on the ticket. Restorative aide (RA) #1 looked at the meal and told CK #1 the resident ordered a cheeseburger and walked away from the serving window. At 11:13 a.m. RA #1 picked up the meal plate from the serving window and delivered it to the resident without a cheeseburger on the plate. At 12:35 p.m. a puree test tray was provided. The puree texture test tray consisted of puree beef, mashed potatoes, pureed peas and carrots and chocolate pudding for dessert. -The puree test tray did not include puree fruit crisp or puree noodles as documented on the diet modification spreadsheet. D. Record reviewThe facility menus and puree daily standards were provided by the NHA on 3/24/25 at 3:24 p.m. The puree daily standards documented high quality leftovers from the previous meal/day would be saved and pureed to proper consistency following International Dysphagia Diet Standardization initiative IDDSI) standard for the next meal period. Lunch was pureed and served for dinner and dinner for lunch (the following day). Breakfast would be pureed fresh daily and the puree items were tossed after each meal period. The menu diet modification spreadsheet was provided by the dietary director (DD) on 3/26/25 at 5:00 p.m. The spreadsheet documented that for the lunch meal served on 3/25/25 the puree lunch included puree beef and noodles with sauce, and a puree fruit crisp and puree green chili stew. -However, the residents were served puree beef, mashed potatoes, puree peasand carrots and chocolate pudding. E. Staff interviewsRA #1 was interviewed on 3/25/25 at 11:45 a.m. RA #1 said she did not know why the resident did not receive a cheeseburger with his meal. She said she thought maybe it was because the resident would also have puree bread with puree meat (of his cheeseburger). The DD and the NHA were interviewed together on 3/26/25 at 12:00 p.m. The DD said the staff pureed leftover food served at the previous meal for residents prescribed a puree diet. The DD said the test tray consisted of roast beef, mashed potato and peas and carrots. The DD said he did talk to the dietary staff after lunch on 3/25/25 and educated the staff to serve the resident a puree burger if that was the resident's preference. The DD said the resident had a mechanical soft diet order with an additional order for puree texture meat. The NHA said he thought the dietary staff pureed food from the previous meal so the staff could have the puree items ready to go ahead of time. The NHA said he had not previously heard any concerns about the puree food items. II. Failed to provide residents on the Aspen unit with non-disposable beverage cups at meals. A. ObservationsOn 3/25/25 at 11:30 a.m. the residents in the Aspen women's secured unit were served their meals. The residents were served their milk, punch and coffee in paper and styrofoam cups instead of plastic cups. On 3/25/25 at 5:00 p.m. the residents on the Aspen women's secured unit were served their meals. The residents were served their beverages in paper and styrofoam cups instead of plastic cups. On 3/26/25 at 11:30 a.m. the residents in the Aspen women's secured unit were served their noon meals. The residents were again served all of their beverages in paper and styrofoam cups instead of plastic cups. B. Staff interviewsCertified nurse aide (CNA) #10 was interviewed on 3/25/25 at 12:00 p.m. CNA #10 said the residents on the women's secured unit always received both paper and styrofoam cups for their beverages. She said it had something to do with the kitchen, however she said she was not sure of the exact reason. Licensed practical nurse (LPN) #2 was interviewed on 3/26/25 at approximately 12:00 p.m. LPN #2 said the kitchen always sent paper cups for the residents' beverages on the women's secured unit. She said she was not sure of the reason. She said the men's secured unit received washable non-disposable plastic cups.

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality, including providing equal access to quality care regardless of diagnosis, severity of condition, or payment source. Corrective Action for Affected Residents: On 3/28/2025, Resident #26's meal preferences were reviewed and updated in the dietary system to ensure proper puree consistency meals are provided according to the menu and resident's preferences. The dietary manager ensured that Resident #26 receives pureed versions of menu items selected, including pureed cheeseburger when requested. On 3/30/2025, additional cups were ordered so that all residents could be provided with non-disposable beverage cups for all meals going forward. Identifying other Residents having the Potential to be Affected: On 3/30/2025, the Dietary Manager conducted an audit of all residents receiving pureed diets to ensure they are receiving proper menu options according to their preferences. By 4/18/2025, an audit was conducted of all units to ensure appropriate non-disposable cups were being utilized for resident beverages during meals. Measures put into place or Systemic Changes: The Dietary Manager provided in-service education to dietary staff by 4/21/2025 regarding: Proper preparation and service of pureed meals according to menu options Ensuring pureed meals match resident preferences and menu selections Proper documentation of pureed meal modifications Use of non-disposable cups for all resident beverages The facility has implemented a new pureed diet menu system that clearly identifies pureed alternatives for each menu item. The Dietary Manager has ensured an adequate supply of non-disposable cups is available on all units. Plan to Monitor Performance: The Dietary Director or designee will conduct random meal audits 3 times a week of mechanically altered meals for proper texture and consistency for 4 weeks, then weekly for 8 weeks. The Dietary Manager or designee will conduct weekly audits of proper cup usage during meals on all units for 4 weeks, then monthly for 3 months. All the monitoring will be done via auditing form. The NHA (nursing home administrator) will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly for review and recommendations until substantial compliance is achieved and maintained for 3 consecutive months.

0575Required PostingsS/S C▼

Findings

Based on observations and interviews, the facility failed to post, in a form and manner accessible and understandable to residents, a list of names, addresses (mailing and email) and telephone numbers of all pertinent State Agencies and advocacy groups. Specifically, the facility failed to have the State Agencies contact information posted in a readable font size and placed in an area that had ease of access for the residents. Findings include:I. Resident council interviewSix residents (#54, #86, #85, #69, #4 and #25) who frequently attended the monthly resident council meetings and were identified as alert and oriented by facility and assessment were interviewed on 3/25/25 at 10:35 a.m. All residents in attendance said they did not know how to file a complaint with the State Agency. II. ObservationsOn 3/26/25 at 5:33 p.m. postings in the lobby of the main unit included the facility abuse coordinator information, the ombudsman contact information, the state agency phone number and website address, and a list of the residents' rights. -However, observations did not reveal any postings including the mailing and email addresses of the State Agency nor the contact information for adult protective services, state licensure office and the Medicaid fraud control unit. III. Staff interviewsThe social services director (SSD) was interviewed on 3/26/25 at 12:53 p.m. The SSD said she was not responsible for maintaining the information posted in the lobby but would sometimes update the ombudsman information. The SSD said the nursing home administrator (NHA) was responsible for maintaining the postings in the lobby. The NHA was interviewed on 3/26/25 at 5:15 p.m. The NHA said he managed the information posted in the lobby. The NHA said he knew he was required to have the daily nurse staffing, ombudsman information and abuse reporting information posted. The NHA said he reviewed the postings and said he could not find any information posted regarding the Medicaid fraud control unit.

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to post and maintain all required information including names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups in a form and manner accessible and understandable to residents and resident representatives. Corrective Action for Affected Residents: On 3/26/2025, the Administrator posted complete contact information including mailing addresses, email addresses, and phone numbers for all required agencies including the State Survey Agency, State licensure office, adult protective services, Office of the State Long-Term Care Ombudsman program, protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. The postings were placed in the main lobby at an appropriate height and in a readable font size accessible to all residents. The postings include a clear statement regarding residents' right to file complaints with the State Survey Agency. Identifying other Residents having the Potential to be Affected: The Administrator conducted a facility-wide audit on 3/26/2025 to ensure all required postings were present, readable, and accessible throughout the facility. Measures put into place for Systemic Changes: The Administrator will in-service all department heads by 04/21/2025 on the requirements for facility postings, including specific content requirements, placement, and accessibility standards. The Administrator created a monthly checklist for verification of all required postings. Plan to Monitor Performance: The Administrator or designee will audit all facility postings weekly for the first month, then monthly x2 months to ensure compliance with posting requirements. Results of these audits will be documented on an audit tool. The Administrator will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly for three months. The QAPI committee will evaluate the effectiveness of the plan and make changes as needed until substantial compliance is achieved and maintained.

0583Personal Privacy/Confidentiality of RecordsS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to keep resident medical records in a secure and confidential manner. Specifically, the facility failed to ensure resident meal tickets were stored privately and not accessible to guests to review in order to protect the confidentiality of resident information. Findings include:I. Observations During a continuous observation on 3/25/25, beginning at 11:10 a.m. and ending at 12:37 p.m., the following was observed during the meal preparation and service in the main kitchen and dining room:At 11:10 a.m. resident meal trays were being assembled in the main kitchen by cook (CK) #1. Resident meal tickets were observed in two separate places in the service window between the kitchen and main dining room. The meal tickets were on the left side of the serving counter and on the right side on top of the steam table. The meal tickets contained resident names and physician prescribed diet orders. At 11:37 a.m. a resident representative approached the service window in the dining room and picked up the resident meal tickets on the left side of the serving counter and looked through them. The resident's representative then picked up the resident meal tickets on the right side of the team table and looked through them. At 11:38 a.m. the resident's representative asked CK #1 if he had seen a resident's meal ticket. The resident's representative said usually when she looked through the resident meal tickets she could find the resident's meal ticket sooner because it was located closer to the top.-Facility staff failed to ensure the resident meal tickets were kept in a secure and confidential manner in the dining room and not accessible to guests of the facility. II. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 3/25/25 at 11:46 a.m. CNA #2 said a guest at the facility should not look through resident meal tickets because the meal tickets contained protected information that included the residents names, room numbers and diet orders. The dietary director (DD) and the nursing home administrator (NHA) were interviewed together on 3/26/25 at 12:00 p.m. The DD said the resident's representative should not have looked through resident meal tickets because the residents privacy was not maintained. The NHA said it had not been previously brought to his attention that a resident's representative had previously looked through the meal tickets. The regional clinical resource (RCR) was interviewed on 3/25/25 at 12:00 p.m. The RCR said facility staff were trained on resident privacy but she was unsure if resident meal tickets were included in the training.

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to ensure resident privacy and confidentiality of personal and medical records, including meal tickets containing protected health information. Corrective Action for Affected Residents: On 3/25/25, the Dietary Director immediately removed all meal tickets from public view at the service window and implemented a new system where meal tickets are kept in a secure location accessible only to authorized staff members. A message was sent to all families by 4/21/25 regarding the facility's policy on meal ticket confidentiality. Identifying other Residents having the Potential to be Affected: The Dietary Director conducted an audit on 3/26/25 of all areas where meal tickets are stored or displayed to ensure they are maintained in a confidential manner. Measures put into place or Systemic Changes: On 4/18/25, the Director of Nursing/designee will provide in-service education to all staff members regarding HIPAA compliance and the proper handling of resident meal tickets containing protected health information. Education provided to staff on 4/18/2025 on location of meal tickets going forward. Plan to Monitor Performance: The Dietary Manager will conduct audits 2x week for 30 days of meal ticket handling practices during all meal services, then weekly for 1 month, and monthly for one month. The NHA will review results of these audits and report to monthly to the Quality Assurance and Performance Improvement (QAPI) committee for review and additional recommendations as needed until substantial compliance is achieved and maintained for three consecutive months. All monitoring will be documented via auditing form.

0600Free from Abuse and NeglectS/S E▼

Findings

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Corrective Action for Affected Residents: On 3/21/25, Resident #62 was moved back to the secured all-male unit to prevent further incidents of sexual abuse On 4/16/2025, Residents #59 and #39 were assessed for any psychological impact and monitored for signs of distress On 2/28/25, Residents #34 and #97 were immediately separated. Resident #97 was discharged from the facility shortly thereafter. On 3/10/25, Resident #58 was transferred to the hospital after the incident with Resident #42 On 3/10/25, Resident #42 was assessed for injuries. On 4/16/2025, the Social Services Director followed up with the resident for any psychological impact. Identifying other Residents having the Potential to be Affected: By 4/18/2025, the IDT (interdisciplinary team) will interview all residents to investigate if there have been any unreported cases of abuse. Measures put into place or Systemic Changes: On 04/18/2025 the DON (director of nursing)/designee will provide in-service education on: Abuse prevention and reporting requirements Proper supervision of residents with known behavioral issues Recognition and immediate reporting of inappropriate sexual behaviors De-escalation techniques for aggressive residents Proper documentation of behavioral incidents Plan to Monitor Performance: The IDT team will complete ambassador round programs and will interview 10% of residents weekly if there have been any unreported cases of abuse. The NHA will report monitoring results to the Quality Assurance Performance Improvement (QAPI) committee monthly for 3 months or until substantial compliance is achieved and maintained. The QAPI committee will make additional recommendations as needed. All monitoring will be documented via auditing form.

0609Reporting of Alleged ViolationsS/S D▼

Findings

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#62) of nine residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to report an incident of potential sexual abuse involving Resident #62 to the State Survey Agency (SSA). Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 3/23/25 at 12:41 p.m. It read in pertinent part, "Residents have the right to be free from abuse."The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report any allegations within timeframes required by federal requirements."II. Resident #62A. Resident statusResident #62, age 65, was admitted on 6/19/2020. According to the March 2025 computerized physician orders (CPO), diagnoses included sexual dysfunction and major depressive disorder. The 12/17/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident needed setup or cleanup assistance for most activities of daily living (ADL). The MDS assessment documented the resident did not have physical or verbal behaviors directed toward others or other behavioral symptoms not directed toward others. B. Record reviewThe behavioral care plan, initiated 7/17/2020 and revised 4/14/23, revealed Resident #62 made verbally explicit comments and suggestions toward staff, masturbated in front of staff, asked female staff members if he could touch them or if the staff could touch him in a sexually inappropriate way. Pertinent interventions included explaining or reinforcing why his behavior was inappropriate or unacceptable, administering medications as ordered, educating staff on the importance of respecting Resident #62's wishes and emphasizing sexual outlet was a normal function, monitor behavioral episodes and attempt to determine an underlying cause, redirecting any inappropriate public exposure and intervening as necessary to protect the rights and safety of others. The antipsychotic medication care plan, revised 12/30/24, revealed Resident #62 required an antipsychotic medication as evidenced by inappropriate sexual behavior, delusions and hallucinations. Pertinent interventions included administering antipsychotic medications as ordered, observing Resident #62's mood and response to the medication, and observing and recording the effectiveness of the drug treatment as indicated. A progress note, dated 3/21/25 at 12:39 p.m., revealed an unidentified CNA witnessed Resident #62 masturbating in another resident's room. The other residents slept through the situation and did not wake up. The CNA relocated Resident #62 away from the room and told the resident he could not perform those actions in others' rooms. The director of nursing (DON) spoke with Resident #62 and gave him choices to ensure his safety and the safety of others, and the resident agreed to relocate to the all-male secured unit. The nursing staff were to continue to monitor Resident #62 for hypersexual behaviors. The facility's incident investigation, undated, was provided by the NHA on 3/24/25 at 4:21 p.m. The investigation included a statement from certified nurse aide (CNA) #4, which revealed on 3/21/25 between 1:30 a.m. and 2:00 a.m., CNA #4 observed Resident #62 as he was halfway into Resident #39 and Resident #59's room. Resident #62 had exposed his genitals and was masturbating in the room. CNA #4 took Resident #62 back to his room and told him he could not be in other residents' rooms. Resident #39 was interviewed by the NHA on 3/21/25. Resident #39 said she did not have any incidents of abuse to report. Resident #39 said she felt safe in the facility. Resident #39 said she did not notice any disturbances during her sleep. Resident #39 said there was nothing else she wanted to share. Resident #59 was interviewed by the NHA on 3/21/25. Resident #59 said she did not have any incidents of abuse to report. Resident #59 said she felt safe in the facility. Resident #59 said she did not notice any disturbances during her sleep. Resident #59 said there was nothing else she wanted to share.-However, the facility failed to report the sexual abuse incident to the State Agency. III. Staff interviewsThe DON was interviewed on 3/26/25 at 4:40 p.m. The DON said the incident involving Resident #62 happened overnight on 3/21/25. The DON said he received a call from CNA #4 who told him she was in another resident's room, heard a noise, and saw Resident #62 halfway in the doorway of Resident #59 and Resident #39's shared room. CNA #4 said Resident #62 had his genitals exposed and was masturbating. The DON said when he came in later on the morning of 3/21/25, the facility staff interviewed Resident #62 and discussed what his next steps would be. The DON said he notified the NHA of the incident immediately. The NHA was interviewed on 3/26/25 at 5:15 p.m. The NHA said any allegations of abuse needed to be reported to him regardless of the time. The NHA said if he was not available, abuse allegations should be reported to the nurse on-call. The NHA said any abuse allegations needed to be reported to the State Agency within 24 hours. The NHA said after reporting the allegation, the facility staff would launch an investigation, ask for staff statements, and interview any residents within the vicinity of the incident. The NHA said he was notified the morning of 3/21/25 about Resident #62's incident the night prior. The NHA said he got a statement from the CNA who witnessed the incident and that he interviewed Resident #59 and Resident #39 and they were both asleep. The NHA said he asked both of the residents if they felt safe and if they had witnessed any abuse, and neither resident expressed any knowledge of the situation. The NHA said he had not reported the incident to the State Agency as he had reached out to one of the facility's clinical consultants and was told the incident was not abuse.

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events involve abuse or result in serious bodily injury, or not later than 24 hours if the events do not involve abuse and do not result in serious bodily injury. Corrective Action for Affected Residents: On 4/14/2025, the facility reported the abuse allegation involving Resident #62 to the State Survey Agency. The resident was immediately moved to an all-male secured unit for enhanced monitoring and supervision. The facility completed interviews with Residents #39 and #59 to ensure their safety and well-being. Identifying other Residents having the Potential to be Affected: By 4/21/2025, the IDT team will interview all residents to investigate if there have been any unreported cases of abuse. Measures put into place or Systemic Changes: On 04/18/2025, the DON will provide an in-service education on: Identification of abuse, including sexual abuse Immediate reporting requirements to the Administrator and State Survey Agency Timeline requirements for reporting different types of abuse allegations Process for protecting residents when abuse is alleged Plan to Monitor Performance: The IDT team will complete ambassador round programs and will interview 10% of residents weekly if there have been any unreported cases of abuse. Beginning on 4/21/2025, the NHA(nursing home administrator)/designee will review any allegations of abuse to verify investigations are complete and reported to state agencies and police 5x week for 90 days. All monitoring will be documented via auditing form. The NHA will report audit findings to the Quality Assurance Performance Improvement (QAPI) Committee monthly for three months. The QAPI Committee will evaluate the effectiveness of the plan and make changes as needed until substantial compliance is achieved.

0656Develop/Implement Comprehensive Care PlanS/S E▼

Findings

Based on record review and interviews, the facility failed to develop a comprehensive care plan for three (#1, #75 and #249) of six residents out of 36 sample residents for services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to:-Ensure a comprehensive care plan was developed to address Resident #1's use of supplemental oxygen and a peripherally inserted central catheter (PICC); and,-Ensure a comprehensive care plan was developed to address Resident #75 and Resident #249's insomnia. Findings include:I. Facility policy and procedureThe Comprehensive Person-Centered Care Plans policy, revised March 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:42 p.m. The policy read in pertinent part, "The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment."Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change."The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition and at least quarterly."II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 2/21/2020. According to the March 2025 computerized physicians orders (CPO), diagnoses included schizoaffective disorder (mental illness), vascular dementia and cellulitis of the left lower limb. The 2/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required supervision to maximum assistance for most activities of daily living (ADL). B. Resident and resident representative interviewResident #1 and her representatives were interviewed together on 3/23/25 at 10:33 a.m. The resident's representatives said Resident #1 had an infection in her leg which became swollen and was treated with antibiotics. The resident's representatives said the facility placed a PICC line for the antibiotics. The resident's representatives said Resident #1 usually had her nasal cannula on and that she had been treated for pneumonia the week prior. Resident #1 said she needed supplemental oxygen all the time. C. Record reviewThe end of life care plan, initiated 3/24/25 (during the survey process), revealed Resident #1 was receiving hospicare care. Pertinent interventions included providing supplemental oxygen as ordered.-Review of the comprehensive care plan, revised 3/24/25, did not reveal any focus or other interventions related to Resident #1's use of supplemental oxygen.-Review of the comprehensive care plan, revised 3/24/25, did not reveal any focus or interventions related to Resident #1's PICC line or maintenance of the PICC line. Review of the March 2025 CPO revealed the following physician's orders:Midline intravenous (IV) placement, ordered 3/7/25;Radiographs to check for midline (PICC) placement, ordered 3/7/25;Normal saline flush solution, with instructions to use 10 milliliters (ml) intravenously two times a day for cellulitis/pneumonia. Flush before and after medication, ordered 3/7/25;Vancomycin IV solution 750 milligrams (mg) per 150 ml, with instructions to use 750 mg intravenously every 12 hours for cellulitis for ten days, ordered 3/6/25 and discontinued 3/13/25;Vancomycin IV solution 500 mg per 150 ml, with instructions to use 1000 mg intravenously every 12 hours for cellulitis until 3/17/25, ordered 3/6/25;PICC line dressing change every seven days, ordered 3/25/25 (during the survey process); and,Oxygen 4 liters per minute (LPM) via nasal cannula. Check oxygen saturation each shift and as needed. Notify healthcare provider if saturation is less than 90%, ordered 3/23/25 (during the survey process). A progress note, dated 3/5/25 at at 10:14 a.m., revealed Resident #1 was receiving supplemental oxygen. A progress note, dated 3/7/25 at 10:14 a.m., revealed Resident #1 was ordered to receive an IV antibiotic and a PICC line was requested. A progress note, dated 3/13/25 at 3:44 p.m., revealed Resident #1 was receiving continuous supplemental oxygen via nasal cannula. D. Staff interviewsThe MDS coordinator (MDSC) was interviewed on 3/26/25 at 3:30 p.m. The MDSC said she reviewed the care plan and confirmed Resident #1's care plan did not address her use of oxygen or the use of the PICC line. The MDSC said the care plan should have interventions to elevate the head of the bed, ensure they were following physician's orders and also to check oxygen saturation levels. The MDSC said the care plan needed to include interventions for the PICC line that included keeping the line patent and monitoring for infections and directions for flushing. III. Resident #75A. Resident statusResident #75, age 78, was admitted on 2/5/25. According to the March 2025 CPO, diagnoses included dementia with anxiety, adult failure to thrive, insomnia and depression. The 2/11/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident required supervision or touching assistance with most ADLs. The assessment documented the resident took several high-risk medications including antidepressants, antianxiety, antipsychotic, anticonvulsants, and opioids. B. Record reviewReview of Resident #75's comprehensive care plan, revised 2/25/25, did not reveal any focus or interventions related to her diagnosis of insomnia or use of medications to treat her insomnia. Review of the March 2025 CPO revealed the following orders:Trazodone 100 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia associated with depression, ordered 2/5/25;Melatonin 3 mg oral tablet, instructions to give two tablets by mouth one time a day for insomnia, ordered 2/5/25 and discontinued 3/25/25 (during the survey process); and,Melatonin 3 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia, ordered 3/25/25. C. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 12:45 p.m. LPN #1 said Resident #75 received trazadone for insomnia. She said the resident complained of not being about to sleep. She said the resident's hours of sleep were tracked. She said she slept during the day and that could affect her sleeping at night. She said the care plans were updated by the MDSC. The MDSC was interviewed on 3/26/25 at 3:30 p.m. The MDSC said each resident had a plan of care. She said the plan of care began on the admission with a baseline care plan. She said she was responsible to complete the care plan, however, the nurses and other departments were responsible to update the care plan as needed. The MDSC reviewed the care plan for Resident #75 and confirmed there was not a care plan for insomnia. She said a care plan to help with interventions for sleep should be written. IV. Resident #249 A. Resident statusResident #249, age 77, was admitted on 2/27/25. According to the March 2025 CPO, diagnoses included dementia with severe agitation, insomnia and alcohol dependence with alcohol induced persisting. The 3/4/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. The resident required supervision or touching assistance with most ADLs. The assessment documented the resident was prescribed several high-risk medications including antidepressants, antipsychotic, and opioids. B. Record reviewReview of Resident #249's comprehensive care plan, revised 3/19/25, did not reveal any focus or interventions related to her diagnosis of insomnia. Review of the March 2025 CPO revealed the following orders:Trazodone 50 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia associated with depression, ordered 3/6/25. C. Staff interviewsLPN #2 was interviewed on 3/26/25 at 12:45 p.m. LPN # 2 confirmed Resident #249 received trazadone for insomnia. She said her sleep hours were tracked. She said due to her dementia diagnosis, she sundowned and she was up at night at times. The MDSC was interviewed on 3/26/25 at 3:30 p.m. The MDSC reviewed the care plan for Resident #249 and confirmed there was no care plan for insomnia. She said a care plan to help with interventions for sleep should be written.

Plan of correction · submitted by the facility

0678Cardio-Pulmonary Resuscitation (CPR)S/S D▼

Findings

Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#50) of three residents reviewed for advanced directives out of 36 sample residents. Specifically, the facility failed to document Resident #50's refusal to complete a medical orders for scope of treatment (MOST) form (a legal document that allows individuals to outline their wishes for medical interventions and end-of-life care, ensuring their preferences are followed in the event of a serious illness or decline in health) upon admission to the facility or that the resident's resuscitation choices were discussed with the resident or the resident's representative. Findings include:I. Resident #50A. Resident statusResident #50, age greater than 65, was admitted on 2/10/25. According to the March 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease with airway obstruction), chronic respiratory failure, type 2 diabetes mellitus, opioid dependence, history of venous thrombosis and embolism (condition involving blood clots), hypertension and stage 2 and stage 3 pressure ulcers. The 2/14/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was dependent on care for hygiene and bed mobility and needed set-up assistance for eating. B. Record reviewA review of Resident #50's March 2025 CPO revealed Resident #50 had a physician's order for full code (resuscitation status indicating cardiopulmonary resuscitation (CPR) should be conducted if the resident's heart stopped beating), ordered 3/24/25 (during the survey). A review of Resident #50's 2/18/25 interdisciplinary team (IDT) care conference summary documented Resident #50 attended the care conference. The care conference summary revealed a section of preferred intensity of care and advanced directives with the following options to review: advanced directives, current wishes and physicians orders for life sustaining treatment.-The advanced directives, current wishes and physician's orders for life-sustaining treatment sections were not documented to indicate whether or not the facility had discussed them with the resident or the resident's representative during the care conference. Additionally, the care conference summary included a progress note section which documented a summary of Resident #50's overall care and progress. The progress note section documented "Code status." -However, the facility failed to document what Resident #50's actual code status (CPR versus no CPR) was in the progress note summary.-Review of Resident #50's electronic medical record (EMR) failed to reveal documentation to indicate the resident refused to sign a MOST form upon his admission to the facility on 2/10/25. II. Staff interviewsThe director of nursing (DON) and the regional clinical resource (RCR) were interviewed together on 3/24/25 at 10:30 a.m. The DON said Resident #50 declined to initiate a MOST form upon his admission to the facility (2/10/25) and the residents' declination was documented in his care conference notes.-However, review of the care conference notes did not reveal that the resident's declination to sign the MOST form or the resident's resuscitation choices had been discussed (see record review above). The RCR said the default physician's order for a resident who did not have a completed MOST form would include an order for a full code (all life sustaining treatments) status. III. Facility follow upOn 3/26/25 at 5:26 p.m. an email was received from the RCR confirming the facility did not have documentation that specifically mentioned Resident #50's refusal to review or sign a MOST form or that the resident's resuscitation choices had been discussed with the resident or the resident's representative.

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy that personnel provide basic life support, including CPR, to residents requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. Corrective Action for Affected Residents: On 3/24/2025, Resident #50's MOST (medical orders for scope of treatment) form was completed and documented in the medical record with a physician's order confirming full code status. The Director of Nursing reviewed the resident's care conference documentation and updated it to accurately reflect the resident's resuscitation choices and code status preferences. Identifying other Residents having the Potential to be Affected: By 4/18/2025, the SSD (social services director) will conduct a comprehensive audit of all current residents to identify those who have not been offered a MOST form or whose advance directives and code status are not properly documented. All identified residents will be offered the opportunity to complete a MOST form and have their resuscitation preferences clearly documented by 4/18/2025. Measures put into place or Systemic Changes: On 04/28/2025 the SSD will provide in-service education on: Proper documentation of residents' code status and advance directives The requirement to offer and document MOST form completion/declination upon admission Plan to Monitor Performance: The SSD/Designee will audit 10% of resident records weekly for 4 weeks, then monthly for 2 months to ensure: MOST forms are offered and documented upon admission Code status is accurately reflected in physician orders Care conference documentation includes discussion of advance directives and resuscitation choices Medical record documentation accurately reflects residents' preferences All monitoring will be documented via auditing form. The SSD will review audit results and report findings to the Quality Assurance and Performance Improvement (QAPI) committee monthly. The QAPI committee will analyze the data and make additional recommendations as needed until substantial compliance is achieved and maintained.

0684Quality of CareS/S D▼

Findings

Based on record review and interviews, the facility failed to ensure one (#1) of one resident received treatment and care in accordance with professional standards of practice out of 36 sample residents. Specifically, the facility failed to obtain a physician's order and provide routine maintenance and care for a peripherally inserted central catheter (PICC) for Resident #1. Findings include:I. Professional referenceAccording to The National Institutes of Health (NIH) PICC Line Placement (1/10/24), retrieved on 4/2/25 from https://www.ncbi.nlm.nih.gov/books/NBK573064/, "Dressings should be changed at least once weekly or per policy and manufacturer's guidelines. After each use, the PICC line should be flushed with normal saline and heparin solution."Nurses are responsible for day-to-day care, education, and monitoring of patients with PICC lines, reporting any concerns promptly."Careful monitoring and maintenance of these lines are paramount in preventing procedural complications."II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 2/21/2020. According to the March 2025 computerized physicians orders (CPO), diagnoses included schizoaffective disorder, vascular dementia and cellulitis of the left lower limb. The 2/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required supervision to maximum assistance for most activities of daily living (ADL). B. Resident representative interviewResident #1's representatives were interviewed on 3/23/25 at 10:33 a.m. The resident's representatives said Resident #1 had an infection in her leg which became swollen and was treated with antibiotics. The resident's representatives said the facility placed a PICC line for the antibiotics. C. Resident interview and observationsResident #1 was interviewed on 3/24/25 at 9:38 a.m. Resident #1 said she had a shower earlier that morning (3/24/25). Resident #1's PICC line dressing was pulling away from her skin around the top and sides and was visibly soiled with brown material. A date was written on the bandage, but the date was mostly washed away and it was difficult to read the date. Resident #1 was interviewed again on 3/25/25 at 8:53 a.m. Resident #1 said the dressing on her PICC line had not been changed that morning (3/25/25) or the day prior (3/24/25). Resident #1's PICC line dressing was pulling away from her skin around the top and sides and was visibly soiled with brown material. A date was written on the bandage, but the date was mostly washed away and it was difficult to read the date. Resident #1 was interviewed a third time on 3/26/25 at 9:37 a.m. Resident #1 said the nursing staff had changed her PICC line dressing that morning (3/26/25). Resident #1 said the nursing staff flushed her PICC line once a day. D. Record reviewReview of the comprehensive care plan, revised 3/24/25, did not reveal any focus or interventions related to Resident #1's PICC line or maintenance of the PICC line. Review of the March 2025 CPO revealed the following physician's orders:Midline intravenous (IV) placement, ordered 3/7/25. Radiographs to check for midline (PICC) placement, ordered 3/7/25. Normal saline flush solution, with instructions to use 10 milliliters (ml) intravenously two times a day for cellulitis/pneumonia. Flush before and after medication, ordered 3/7/25. Vancomycin IV solution 750 milligrams (mg) per 150 ml, with instructions to use 750 mg intravenously every 12 hours for cellulitis for ten days, ordered 3/6/25 and discontinued 3/13/25. Vancomycin IV solution 500 mg per 150 ml, with instructions to use 1000 mg intravenously every 12 hours for cellulitis until 3/17/25, ordered 3/6/25. PICC line dressing change every seven days, ordered 3/25/25 (during the survey). A progress note, dated 3/7/25 at 10:14 a.m., revealed Resident #1 was ordered to receive an IV antibiotic and a PICC line was requested. A progress note, dated 3/7/25 at 12:58 p.m., revealed a PICC line was placed in Resident #1's right arm. The nurse requested a physician's order for radiographs to check the placement of the PICC line and a physician's order to flush the PICC line.-The progress note did not indicate the nurse requested a physician's order for PICC line dressing changes. A progress note, dated 3/10/25 at 1:05 p.m., revealed Resident #1 was able to receive her antibiotics IV since she had been cleared to use the PICC line for medication administration. Resident #1's PICC line did not show any signs or symptoms of redness, swelling or infection. A progress note, dated 3/18/25 at 11:19 p.m., revealed Resident #1 had completed her course of IV antibiotics. Resident #1's PICC line was still in place, had been flushed, and did not have any redness noted to the area.-There was no documentation in the resident's electronic medical record (EMR) to indicate Resident #1's PICC line dressing had been changed since it was initially inserted on 3/7/25. E. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said Resident #1 was on IV antibiotics in early March 2025 to treat her cellulitis. LPN #1 said Resident #1's physician thought the resident should have her PICC line in place for a few more days following the end of her antibiotic treatment on 3/17/25, but she said it would likely be discontinued that day (3/26/25). LPN #1 said Resident #1's PICC line dressing was changed the night prior (3/25/25), and had been changed every week. LPN #1 said Resident #1 still needed a physician's order for the PICC line dressing. LPN #1 said the resident should have a physician's order in place to change the PICC line dressing each week.-However, there were no dressing changes documented in Resident #1's EMR from 3/7/25 through 3/25/25 (see record review above).-Additionally, there was no physician's order to change the PICC line until 3/25/25, during the survey (see record review above). The director of nursing (DON) was interviewed on 3/26/25 at 7:11 p.m. The DON said Resident #1 had her PICC line in place for at least two weeks. The DON said the resident needed to have an order from the physician for a PICC line prior to the line being placed. The DON said the facility usually put in a physician's order for weekly PICC line dressing changes at the same time as the physician's order for the PICC line itself. -However, the order for weekly PICC line dressing changes was not added to Resident #1's CPO until 3/25/25, during the survey (see record review above).

Plan of correction · submitted by the facility

0689Free of Accident Hazards/Supervision/DevicesS/S G▼

Findings

Based on observations, record review and interviews, the facility failed to ensure three (#97, #37 and #47) of eight residents reviewed for accident hazards out of 36 sample residents remained as free from accidents as possible. Resident #97, who was known to be at risk for falls, was admitted on 11/18/22 with diagnoses of dementia, hearing impairment, unsteady and shuffling gait, and right sided weakness. The facility initiated a fall care plan which included interventions of anticipating and meeting the resident's needs, encouraging rest periods when signs of fatigue were noted, ensuring that the resident wore appropriate footwear when ambulating and keeping the resident in line of sight as needed. Resident #97 sustained falls with injury on 12/30/24 (abrasion to the right side of his head), 1/12/25 (laceration to his head) and 1/19/25 (abrasion to the back of his head). Resident #97 was sent to the emergency department (ED) for evaluation and treatment after each of the three falls. However, the facility failed to implement new fall interventions until 1/22/25 (after the third fall), when an intervention of a soft helmet for the resident to wear while awake was initiated. On 2/22/25 Resident #97 experienced another fall while ambulating in the hallway which resulted in a laceration to the back of his head and required the resident to again be sent to the ED for evaluation and treatment of a subarachnoid hemorrhage (bleeding into the space between the brain and the arachnoid membrane, one of the protective layers covering the brain). The facility failed to implement any new fall interventions upon the resident's return to the facility on 2/23/25. On 2/24/25 Resident #97 experienced another fall on 2/24/25 that resulted in a large amount of bleeding to the resident's head in the same area as the resident's laceration that resulted from his fall on 2/22/25. The resident still had staples in his head from the previous fall on 2/22/25. The resident was again sent to the ED where he received six additional sutures for treatment of the laceration. The resident returned to the facility on 2/24/25 and the facility ordered a medical grade ribcap helmet (a medical grade helmet which offers 360 degree protection to the head). Staff interviews during the survey (see interviews below) revealed Resident #97 was not wearing the soft helmet initiated on 1/22/25 when he fell on 2/22/25 and 2/24/25 and the facility failed to ensure Resident #97 was encouraged to wear his safety helmet prior to his falls on 2/22/25 and 2/24/25. Due to the facility's failure to implement timely and effective interventions following each of Resident #97's falls, and the facility's failure to ensure care planned interventions were followed, the resident sustained head injuries, which required transfer to and treatment in the ED, from multiple falls. Additionally, the facility failed to ensure staff transferred Resident #37 and Resident #47 appropriately, according to their documented transfer status. Findings include:I. Facility policy and procedureThe Fall and Fall Risk, Managing policy, revised March 2018, was provided by the nursing home administrator (NHA) on 3/25/25 at 3:25 p.m. It read in pertinent part, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling."Environmental risk factors that contribute to the risk of falls include wet floors, poor lighting, incorrect bed height or width, obstacles in the footpath, improperly fitted or maintained wheelchairs and footwear that is unsafe or absent. Resident conditions that may contribute to the risk of falls include fever, infection, delirium and cognitive impairment, pain, lower extremity weakness, poor grip strength, medication side effects, orthostatic hypertension, functional impairments, visual deficits and incontinence. Medical factors that contribute to the risk of falls include arthritis, heart failure, anemia, neurological disorders and balance and gait disorders."If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling."The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not have been previously identified."II. Resident #97A. Resident statusResident #97, age greater than 65, was admitted on 11/18/22. According to the March 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, chronic kidney disease, hearing loss, repeated falls and encephalopathy (medical conditions affecting brain function). The 2/6/25 minimum data set (MDS) assessment revealed Resident #97 had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He needed substantial assistance with transfers, used a walker and needed supervision or touching assistance with ambulation. B. Record reviewResident #97's fall care plan, initiated 11/22/22, documented he was at risk for injury related to falls, a diagnosis of dementia, hearing impairment, unsteady and shuffling gait and right sided weakness. Pertinent interventions included anticipating and meeting the resident's needs (initiated 11/22/22), encouraging rest periods when signs of fatigue were noted (initiated 11/22/22), ensuring that the resident wore appropriate footwear when ambulating, (initiated 11/22/22), educating the resident, family and caregivers about safety reminders and what to do if a fall occurred (initiated 7/7/23), resident to be in line of sight as needed (initiated 3/6/24), soft helmet while awake (initiated 1/22/25), staff to ensure the resident was not too close to others while walking in the hallway (initiated 1/22/25) and medical-grade helmet (initiated 2/24/25). A review of Resident #97's electronic medical record (EMR) revealed the following progress notes:A 12/30/24 charting note, documented at 8:00 p.m,. revealed that Resident #97 had a fall. The resident was using a walker, going too fast and lost his balance. The resident was wearing non-skid socks on both feet and his walker was in front of him. The resident hit his head, either on the dresser or the night stand, and had an abrasion to the right side of his head and an egg-sized lump. The resident was not taking any anti-coagulant medications (blood thinners). The resident had major difficulty attempting to walk to his bed and kept holding his head at the site of impact. The resident was sent out to the ED for evaluation. A 12/31/24 charting note, documented at 11:15 p.m., revealed that Resident #97 returned from the hospital at 11:15 p.m. The resident had another fall while in the hospital.-The facility failed to initiate any new fall interventions following the resident's 12/30/24 fall (see care plan above). A 1/3/25 weekly summary note, documented at 9:55 a.m., indicated that Resident #97 had no falls or injuries the previous week.-However, the resident progress notes documented the resident had a fall on 12/30/24 that resulted in an abrasion to the right side of his head and an egg-sized lump. A 1/10/25 progress note, documented at 11:36 a.m., revealed that the floor staff observed Resident #97 with worsened balance, leaning to the right side, and staff had to watch the resident closely and provide physical support when walking at times with a walker. A 1/13/25 interdisciplinary team (IDT) note, documented at 9:41 a.m., revealed that on 1/12/25 at 2:00 a.m., Resident #97 was seen sliding to the floor by a certified nurse aide (CNA). Resident #97 hit the back of his head and sustained a laceration to the head without a change of consciousness. The resident was sent to the ED for evaluation.-The facility failed to initiate any new fall interventions following the resident's 1/12/25 fall (see care plan above). A 1/19/25 charting note, documented at 6:45 p.m., revealed that Resident #97 had a fall in the hallway while other residents were gathering for a cigarette break. The resident hit his head multiple times on the wall when he fell. Neurological assessments and frequent checks were initiated and the resident was found to have an abrasion to the back of his head approximately three centimeters (cm) in diameter. The nurse on the unit notified the physician and the resident was sent to the ED for further evaluation. A 1/24/25 note, documented at 11:40 a.m., revealed that Resident #97 continued on therapy services three times a week for a fall and decreased strength. The resident continued to use a four-wheeled walker for ambulation and did very well unless he was tired. Staff encouraged the resident to rest between meals and when he was noticeably becoming unstable, as evidenced by the resident beginning to veer to the right and run into walls. The resident could be difficult to redirect due to a language barrier and dementia diagnosis. A 2/21/25 progress note, documented at 6:43 p.m. revealed that Resident #97 continued to use a walker to ambulate in the hallways. He was encouraged to wear a helmet and to take rest breaks through the day, but was resistant to this guidance.-However, the resident's fall care plan failed to indicate the resident refused to wear his helmet or take rest breaks (see care plan above). A 2/22/25 progress note, documented at 3:15 a.m., revealed that Resident #97 was walking in the hallway with a walker and fell on his back, resulting in a laceration to the back of his head. Pressure was applied to stop the bleeding. The resident was able to squeeze a staff member's hand and sit upright on his own. A registered nurse (RN) was notified. The resident was sent to the hospital for treatment and evaluation. -The progress note failed to document if Resident #97 was wearing a protective soft helmet, per the care planned interventions on 1/22/25 (see care plan above). -The facility failed to document refusals by Resident #97 to wear the care planned soft helmet or attempts by staff to encourage the resident to wear it.-The facility failed to initiate any new fall interventions following the resident's 2/22/25 fall (see care plan above). A 2/23/25 progress note, documented at 12:04 p.m., revealed that Resident #97 was readmitted to the facility, was confused and wandering frequently between hallways and his room. The resident required frequent staff monitoring for high risk of falling. A 2/23/25 progress note, documented at 4:10 p.m., revealed that Resident #97 returned to the facility from the hospital for treatment of a subarachnoid hemorrhage following a fall at the facility. The resident had sutures on the back of his head. A 2/24/25 progress note, documented at 6:50 p.m., revealed that a staff member was called tocome and help with Resident #97 due to a fall and a large amount of bleeding to the resident's head. The resident still had staples in his head from his previous fall on 2/22/25. Staff applied pressure to the resident's wound and the resident was sent out to the ED for further evaluation. A 2/24/25 progress note, documented at 11:43 p.m., revealed that Resident #97 returned to the facility with a head laceration that was repaired with six additional sutures. The resident had a 10 cm laceration to the back of his head and returned to the facility at 10:05 p.m.-The progress note failed to document if Resident #97 was wearing a protective soft helmet, per the care planned interventions on 1/22/25. -The facility failed to document refusals by Resident #97 to wear the care planned soft helmet or attempts by staff to encourage the resident to wear it. A 2/25/25 nurse's note, documented at 4:07 p.m., revealed that a ribcap helmet was ordered for Resident #97and staff were to encourage the resident to wear the helmet, and the resident's care plan was updated. The resident was to have a one-to-one sitter until the helmet was received. A 2/28/25 progress note documented, at 9:31 a.m., revealed that Resident #97's therapy for fall risk had been discontinued. The resident had fallen in the past week with head injuries and had been under one-to-one staff supervision. According to the hospital physician, the resident had a history of stroke which caused him to walk with weight on his heels and he was prone to falling backward. Review of Resident #97's post-fall assessments revealed the following:A 12/30/24 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had multiple falls the last six months and strayed off the straight path of walking but failed to document the resident used a walker. A 1/15/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk and strayed off the straight path of walking. However, the post-fall assessment documented the resident had one to two falls in the last six months, contrary to the previous assessment on 12/30/24 that documented he had multiple falls in the same time frame. The 1/15/25 assessment additionally failed to document the resident used a walker. A 1/20/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had multiple falls in the last six months and strayed off the straight path of walking. However, the resident's use of psychotropic medications and laxatives were not documented on the assessment and the assessment failed to document that the resident used a walker. A 2/25/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had one to two falls in the last six months and the resident's use of psychotropic medications and laxatives were not indicated on the assessment. The assessment documented the resident used a walker. -However, the resident had five falls in the last 60 days (see above) and was ordered risperidone starting 1/30/25, neither of which was indicated on the assessment. The assessment additionally failed to document the resident strayed off the straight path of walking as indicated on the previous post fall assessments (12/30/24, 1/15/25, 1/20/25). The fall investigations for Resident #97's falls on 2/22/25 and 2/24/25 were provided by the NHA on 3/24/25 at 3:23 p.m. -The fall investigations failed to document if Resident #97 was wearing a soft helmet as a fall prevention. C. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 3/25/25 at 2:55 p.m. LPN #4 said Resident #97's fall on 2/22/25 occurred near the end of her shift. LPN #4 said the resident would walk around with a walker several times during the course of the night. LPN #4 said he would take his walker and follow around the edge of the wall, catching the wheel of his walker on the wall, and he would do that several times during the night. LPN #4 said she told the CNAs to keep an eye on Resident #97 and that the resident had a history of falling backwards. LPN #4 said when Resident #97's fall occurred on 2/22/25, she was at the medication cart and passing medications. She said the resident was bleeding a lot from his head and was sent to the hospital. LPN #4 said there was a physician's order for the resident to wear a helmet from a previous fall, but the helmet did not fit and the resident would not wear it. LPN #4 said the order was discontinued and he did not have a current order for a helmet. LPN #4 said she had the CNAs check the room for a helmet but they were unable to locate one. CNA #8 was interviewed on 3/25/25 at 3:00 p.m. CNA #8 said when Resident #97 fell on 2/24/25, staff were getting a group of residents together to smoke and Resident #97 was ambulating with a walker. CNA #8 said Resident #97 was supposed to have a special helmet but the resident took the helmet off. CNA #8 said the resident was on every 15-minute checks and was supposed to be getting a hard helmet. CNA #8 said the resident did wear the grippy socks. She said he was not wearing a helmet when he fell a second time on 2/24/25. The director of nursing (DON) and the NHA were interviewed together on 3/26/25 at 10:20 a.m. The DON said the facility had a soft shell to fit inside the normal hat Resident #97 wore regularly. The DON said it was care planned to encourage Resident #97 throughout the shift to wear his protective helmet and there was no set amount of times to remind him. -However, the care plan did not indicate staff were to encourage the resident to wear his protective helmet (see care plan above). The DON said staff tried to anticipate Resident #97's behavior. The DON said a soft shell helmet would benefit Resident #97 more when he was ambulating. The DON said the resident did not wear the rib cap helmet in the bed due to skin breakdown. The DON said Resident #97 swatted at his hand when he had tried to put the helmet on him. The NHA said Resident #97 was not wearing his helmet when he fell on 2/22/25. III. Resident #37A. Resident statusResident #37, age greater than 65, was admitted on 10/7/19. According to the March 2025 CPO, diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke), type 2 diabetes mellitus, dementia, anxiety, difficulty walking and heart failure. The 12/31/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. The resident was dependent on care for all activities of daily living (ADL) except eating, where she needed set up assistance. The MDS assessment did not document use of a mechanical lift or prior falls. B. Record reviewResident #37's fall care plan, revised 11/6/24, documented she was at high risk for falls due to incontinence, paralysis, psychoactive drug use, was unaware of safety needs and declined therapy. Pertinent interventions, revised 4/1/24, included to anticipate and meet Resident #37's needs. A fall mat intervention was initiated 10/11/24. Resident #37's ADL care plan, revised 7/16/24, documented she had a self care performance deficit due to hemiplegia and dementia. Pertinent interventions, initiated 7/16/24, included that Resident #37 was totally dependent on staff for repositioning and turning in bed and required a hoyer lift (mechanical lift) with two staff members for transfers. A 3/23/25 nursing progress note, documented at 7:30 p.m., revealed that a CNA was transferring Resident #37 into bed. The CNA then came out of the room and said the resident was on the floor. The CNA said that she lowered the resident to the floor. Resident #37's 3/23/25 fall investigation was provided by the NHA on 3/24/25 at 3:23 p.m. The fall investigation documented Resident #37's fall happened during a transfer and the CNA said the resident tripped over oxygen tubing and the floor mat was also in the way during the transfer.-However, per Resident #37's ADL care plan, the resident was supposed to be a two-person transfer with a hoyer lift (see care plan above). Resident #37's 3/24/25 post-fall assessment documented the resident's gait analysis as unable to independently come to a standing position. C. Staff interviewsCNA #3 was interviewed on 3/25/25 at approximately 3:00 p.m. CNA #3 said Resident #37 needed a mechanical lift for transfers and the assistance of two staff members to transfer. CNA #3 said she was aware Resident #37 had fallen previously. CNA #3 said Resident #37 could transfer while standing from her bed to her chair but needed to have two staff members assist her closely and she usually used the mechanical lift for transfers. The DON was interviewed on 3/26/25 at 10:20 a.m. The DON said Resident #37's care plan indicated the mechanical lift was to be used to transfer Resident #37. The DON said it was against company policy to transfer Resident #37 without the mechanical lift. The DON said the facility staff directly transferred the resident to her bed without the mechanical lift on 3/23/25 and one CNA was present in the room at the time instead of two. IV. Resident #47A. Resident statusResident #47, age less than 65, was admitted on 6/7/21. According to the March 2025 CPO, diagnoses included multiple sclerosis (a disease that causes breakdown of the protective covering of nerves), history of traumatic brain injury, epilepsy and encephalopathy (a medical condition that affects brain function). The 2/13/25 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS assessment score of 12 out of 15. The resident was dependent on staff for most ADLs. The assessment documented the resident was dependent on staff for all transfers. B. Record reviewThe functional abilities care plan, revised 8/1/24, revealed Resident #47 required staff assistance with ADLs due to his multiple sclerosis and history of traumatic brain injury. Pertinent interventions included Resident #47 requiring extensive total assistance with bathing and showering and requiring a hoyer lift with two staff members for transfers, revised 10/18/24. The fall care plan, initiated 12/16/24 and revised 2/12/25, revealed Resident #47 was at risk for falls due to altered balance while standing, a history of falls and an unsteady gait. Pertinent interventions included having two staff members to assist with transfers with a hoyer lift (initiated 4/29/24), engaging with Resident #47 and reminding him to stay seated until the hoyer lift transfer was complete (initiated 6/30/24) and only using the hoyer lift for transfers (initiated 2/6/25).-However, the resident had already had an intervention for transfers with two people and a hoyer lift which was initiated on 4/29/24, 10 months prior to the hoyer lift intervention implemented on 2/6/25. The facility fall report, dated 12/31/24 at 10:45 a.m., revealed Resident #47 was receiving a shower when he fell. An unidentified CNA was transferring Resident #47 to a chair when the resident slipped, the CNA was unable to hold him and the resident fell. According to the CNA, Resident #47 hit his head on the wall. No injuries or bruises were observed during the nurse's assessment and Resident #47's range of motion and behavior were at baseline. The RN was notified. The report documented physiological factors contributing to the fall included weakness. A change in condition form, dated 12/31/24 at 11:57 a.m., revealed Resident #47 fell in the shower room. Resident #47 slipped during a transfer and fell down. Resident #47 hit his head on the wall during the fall. Resident #47 was not in distress and his vital signs were within normal limits. A post-fall rehabilitation screening, dated 12/31/24 at 1:55 p.m., revealed Resident #47 fell during an assisted transfer. Resident #47 was dependent for transfers, and the physical therapist recommended using a mechanical lift and rolling shower chair for showers.-However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above). An interdisciplinary team (IDT) note, dated 1/2/25 at 9:32 a.m., revealed that on 12/31/24 at approximately 10:45 a.m., Resident #47 was in the shower room with a shower aide and slipped on the floor. The CNA reported Resident #47 hit his head. Risk factors included the lift protocol was not followed and Resident #47 was impulsive and had poor safety awareness. Prior interventions included having physical therapy evaluate Resident #47, a floor mat by Resident #47's bedside and his bed in the lowest position. Interventions put into place included re-educating staff on the facility's lift policy. The facility fall report, dated 2/6/25 at 6:43 p.m., revealed Resident #47 had a witnessed fall. The report documented an unidentified CNA called the nurse into Resident #47's room around 4:30 p.m. to assist the resident on the floor in his room. The nurse entered Resident #47's room and observed him lying down on the floor. The RN in the building was called to assess Resident #47. No physical injuries were noted at the time and Resident #47 said he was tired and wanted to stay in bed. Resident #47 was assisted by four staff members back into bed, his vital signs were taken and a neurological assessment was performed. An IDT note, dated 2/7/25 at 10:32 a.m., revealed that on 2/6/25 at 6:43 p.m., Resident #47 was assisted to the floor by a CNA during a transfer due to weakness. No pain or injuries were identified. Resident #47 was assisted back into his bed per his request by four staff members. Resident #47 stated he was tired. Risk factors included weakness, dementia and a history of falls. Prior interventions included having physical therapy evaluate and treat Resident #47, a floor mat on Resident #47's bedside and his bed in lowest position, and re-educating the staff on the facility lift policy. Interventions initiated included only using a hoyer lift for transfers.-However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above). A post-fall rehabilitation screening, dated 2/7/25 at 1:49 p.m., revealed Resident #47 was attempting to transfer during the fall. The physical therapist recommended using a mechanical lift for improved safety with transfers. -However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above). C. Staff interviewsCNA #5 was interviewed on 3/26/25 at 9:30 a.m. CNA #5 said Resident #47 needed to be transferred using a hoyer lift. CNA #5 said Resident #47 could stand with two staff members assisting him early in the mornings, and mainly needed to use the hoyer lift after lunch.-However, according to the resident's care plan, the resident was to be a hoyer lift for all transfers (see care plan above). CNA #2 was interviewed on 3/26/25 at 10:13 a.m. CNA #2 said Resident #47 usually needed to use a hoyer lift to transfer. CNA #2 said in the mornings, if Resident #47 felt good he could stand, but he generally needed to use the hoyer lift. CNA #2 said they would often only have one CNA to operate a hoyer lift rather than two, but over the last two months they had enough staff to have two staff members operating the hoyer lifts. LPN #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said Resident #47 needed to transfer with the hoyer lift, but sometimes had good days where he did not need to use the lift. LPN #1 said Resident #47 needed to use the hoyer lift since he had a decline the month prior.-However, according to the resident's care plan, the resident had been care planned to use a hoyer lift for transfers since 4/29/24 (see care plan above). The director of rehabilitation (DOR) was interviewed on 3/26/25 at 12:56 p.m. The DOR said Resident #47 needed to be transferred with a hoyer lift at all times. The MDS coordinator (MDSC) was interviewed on 3/26/25 at 3:36 p.m. The MDSC said Resident #47 needed to be transferred using the hoyer lift exclusively. The MDSC said Resident #47 had multiple sclerosis and was wheelchair-bound when he was admitted but had experienced a continuous decline in mobility. The MDSC said Resident #47 used to transfer by stand and pivot method but had a few falls in which his legs buckled under him. The MDSC said Resident #47's fall in February 2025 was related to a transfer during which he tried to self-transfer and was caught by the facility staff. The MDSC said Resident #47's fall in December 2024 occurred as a CNA was transferring him in the shower room and he fell. The DON was interviewed on 3/26/25 at 4:40 p.m. The DON said Resident #47 needed to be transferred with a hoyer lift at all times. The DON said Resident #47 used to transfer via stand and pivot a year prior (2024). The DON said Resident #47's fall on 12/31/24 went directly against the facility's no-lift policy. The DON said Resident #47 was a known hoyer lift user and the resident could not coordinate balancing weight on his legs. The DON said the CNA was trying to transfer Resident #47 to his wheelchair when he fell on 12/31/24. The DON said Resident #47's fall on 2/6/25 was unwitnessed. The DON said Resident #47 had rolled out of bed and onto the floor.-However, the facility fall report documented Resident #47's fall as witnessed, and the IDT note on 2/7/25 documented the fall occurred during a transfer and the CNA lowered the resident to the floor due to weakness (see record review above).

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality, including providing equal access to quality care regardless of diagnosis, severity of condition, or payment source. Corrective Action Resident #97 discharged on 3-2-25. On 4/25/2025 Resident #47 transfer status reviewed by Director of Rehab/designee and remains a Hoyer transfer. Care plan reviewed and remains accurate. On 4/25/2025 Resident #37 transfer status reviewed by Director of Rehab/designee. Care plan reviewed and updated. Identification of others By 4-21-25 the MDS nurse/designee will review the current transfer status of residents and verify it is documented in the ADL (activities of daily living) care plan and on the Kardex under transferring. By 4-21-25 the Director of Nursing (DON)/designee will review the falls that occurred in the last 60 days for interventions related to fall circumstance. If there is not a current intervention one will be implemented. Systemic Changes On 4-18-25 Director of Nursing (DNS)/designee completed education to clinical staff on fall prevention, transferring residents per their transfer status, transfer status is located in the residents ADL care plan and Kardex under transferring and fall interventions. Monitoring Beginning 4-22-25, an audit tool will be utilized to monitor residents who fall for the proper transfer status, the fall circumstance and intervention placed as result of fall. Audit will be completed five times a week for 90 days. This audit will include observation of transfers to ensure they are completed properly. Monitoring will be documented via auditing form. DNS to review results monthly and report findings to QAPI x 3 months. QAPI committee will decide as to the frequency of on-going monitoring.

0692Nutrition/Hydration Status MaintenanceS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to ensure one (#50) of three residents out of 36 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Specifically, the facility failed to weigh Resident #50, who was identified to have potential nutrition problems, upon admission to monitor the resident's nutritional status. Findings include:I. Facility policy and procedureThe Weight Assessment and Interventions policy, revised March 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 9:09 a.m. It read in pertinent part, "Residents weights are monitored for undesirable or united weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team (IDT). Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. "Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist and the resident or resident's legal surrogate. If a resident declines to participate in a weight loss goal, the dietitian will document the resident's wishes and those wishes will be respected."II. Resident #50Resident #50, age greater than 65, was admitted on 2/10/25. According to the March 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease with airway obstruction), chronic respiratory failure, type 2 diabetes mellitus, opioid dependence, history of venous thrombosis and embolism (condition involving blood clots), hypertension and stage 2 and stage 3 pressure ulcers. The 2/14/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was dependent on care for hygiene and bed mobility and needed set-up assistance for eating. The MDS assessment documented the resident did not refuse care. The MDS assessment did not have a recorded weight. III. Resident interviewResident #50 was interviewed on 3/25/25 at 3:35 p.m. Resident #50 said he had lost weight and used to be overweight. He said he could not remember anyone asking to weigh him at the facility. IV. Record reviewResident #50's nutritional care plan, documented the resident had potential nutritional problems due to a diagnosis of diabetes mellitus type 2 with a medication in place, a diagnosis of COPD, history of a right above knee amputation and wounds. Pertinent interventions included to notify the physician of significant or severe weight loss or weight gain, initiated 2/17/25. According to the March 2025 CPO the resident had a physician's order to be weighed weekly times four weeks, ordered 2/10/25. The 2/17/25 nutritional risk assessment documented the resident weighed 186 pounds (lbs) in the hospital on 2/1/25 (prior to admission). The assessment documented the resident refused an admission weight. It documented to obtain a weight as the resident allowed and to monitor the residents weights for trends. The resident's usual body weight (UBW) was documented as unknown and the resident's estimated protein needs of 102 grams (g) of protein were calculated to support wound healing. The assessment also documented diet alone was not enough to meet the resident's estimated calorie and protein needs and the resident's meal intakes were varied. The goal was for the resident to meet estimated nutritional needs and for healing and weight stabilisation was acceptable, and to monitor weight for trends and follow up for significant changes. The assessment documented recommendations to add liquid protein 30 milliliters (ml) twice a day.-However, a review of Resident #50's electronic medical record (EMR) revealed no additional recorded weights or attempts to obtain a weight for Resident #50 until 3/24/25 (during the survey) when the facility documented the resident refused to be weighed. The only documented refusal of weight by Resident #50 was in the 2/17/25 nutritional risk assessment. V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 3/25/25 at 3:22 p.m. LPN #1 said when a resident was admitted to the facility they should be weighed the first three days per facility protocol. LPN #1 said if a resident's weights were stable then they would be weighed monthly after that. LPN #1 said that a provider could put in an order for more frequent weights based on the resident's initial weights. Certified nurse aide (CNA) #3 said she tried to weigh Resident #50 and he refused to be weighed. CNA #3 said it was difficult to weigh the resident because they needed two staff members to lift him and the resident said it was painful for him. CNA #3 said if a resident refused to be weighed the CNA told a nurse so the nurse could follow up with the resident before documenting the resident refused. -However, review of Resident #50's EMR did not include documentation indicating the facility had attempted to weigh the resident other than the 2/17/25 nutrition assessment (see record review above).

Plan of correction · submitted by the facility

0693Tube Feeding Mgmt/Restore Eating SkillsS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#96) of three residents reviewed out of 36 sample residents. Specifically, the facility failed to ensure Resident #96 was assessed to ensure her safety while self-administering her tube feedings. Findings include:I. Facility policy and procedureThe Enteral Nutrition (feeding tube) policy, revised November 2018, was provided by the nursing home administrator (NHA), on 3/26/25 at 11:43 a.m. It read in pertinent part, "Adequate nutritional support through enteral nutrition is provided to residents as ordered."Staff caring residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as aspiration, skin breakdown around the insertion site, and clogging of the tube."Residents receiving enteral nutrition are periodically reassessed for the continued appropriateness and necessity of the feeding tube. Results of these assessments are documented and any changes are made to the care plan."II. Resident statusResident #96, age less than 65, was admitted on 2/13/25. According to the March 2025 computerized physician orders (CPO), the diagnoses included moderate protein-calorie malnutrition, eating disorder and adult failure to thrive. The 2/18/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview status (BIMS) score of 12 out of 15. The resident was independent for eating and required supervision or touching assistance for all other activities of daily living (ADL). The assessment documented the resident was receiving 51% or more of her calories through a feeding tube and 501 cubic centimeters (cc) a day of fluid through a feeding tube. III. Observations and resident interviewOn 3/25/25 at 9:16 a.m. Resident #96 said she administered her own bolus tube feedings. Resident #96 was administering her tube feeding by herself and no staff were present in the room. At 5:28 p.m. Resident #96 had just depressed the plunger of a syringe into her feeding tube. No staff were present in Resident #96's room. IV. Record reviewThe enteral nutrition care plan, initiated 2/17/25 and revised 3/4/25, revealed Resident #96 required enteral nutrition related to her eating disorder. Pertinent interventions included checking the tube placement every shift and prior to feeding or administering medications, providing enteral nutrition as ordered, flushing the tube with 30 milliliters (ml) of water before and after medication administration and monitoring the resident for any nausea, vomiting, or discomfort with each feeding. The ADL care plan, initiated 3/4/25, revealed Resident #96 had a self-care performance deficit due to her eating disorder and failure to thrive. Resident #96 was very private but needed supervision for safety. Pertinent interventions included Resident #96 administered her own tube feeding as she did not eat by mouth and providing/encouraging fluids. The nutrition care plan, initiated 2/17/25 and revised 3/4/25, revealed Resident #96 had a nutritional problem due to her eating disorder, malnutrition and anxiety. The care plan documented Resident #96 refused to allow staff to administer her tube feedings. Pertinent interventions included providing enteral nutrition and water flushes per physician's order. Review of the March 2025 CPO revealed the following physician's orders for Resident #96:Tube Feeding: Nutren 2.0 (enteral feeding formula) or equivalent, give one carton four times per day via bolus per PEG (percutaneous endoscopic gastrostomy) tube, ordered 2/17/25. Check PEG tube placement before use, ordered 2/13/25;Keep head of bed elevated at least 30 degrees during tube feedings and for at least thirty minutes after tube feed administration, ordered 2/13/25;G-tube (feeding tube) site: cleanse with normal saline, pat dry and apply split gauze every shift. Notify provider if signs or symptoms of infection occur, ordered 2/13/25; and, Enteral feed: flush 30 ml of water before and after tube feeding administration four times daily, ordered 2/17/25. The nutritional risk assessment, dated 2/15/25 at 4:58 p.m., revealed Resident #96 said she had been self-administering her tube feeding for three weeks prior to admitting to the facility, was taught how to do so when she was in the hospital and had no questions regarding her tube feeding. The nursing staff reported Resident #96 was particular with her treatments, as she did not allow the staff to administer her tube feedings and often refused to have her PEG tube checked. The registered dietitian (RD) recommended offering snacks between meals and having staff monitor Resident #96 as she self-administered her tube feeding and water flushes.-Review of Resident #96's electronic medical record (EMR) did not reveal any assessments indicating Resident #96 was evaluated and safe to self-administer her tube feedings or physician's orders for the resident to self-administer. V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 9:42 a.m. LPN #1 said Resident #96 did not let the nursing staff provide her with any treatment and wanted to do her treatments herself. LPN #1 said the nursing staff should be at Resident #96's bedside to monitor the resident during her tube feedings to ensure the resident was administering the feeding and water flushes correctly and according to the physician's order. LPN #1 said there should be a physician's order for Resident #96 to self-administer her tube feedings. LPN #1 said Resident #96's physician was aware she was administering her own tube feedings. LPN #1 said there had not been any formal assessment completed or documented in Resident #96's EMR indicating she was able to self-administer her tube feedings. LPN #1 said Resident #96's tube feeding care and self-administration of tube feedings should be on her care plan. The director of nursing (DON) was interviewed on 3/26/25 at 11:00 a.m. The DON said the nursing staff should be in the room with Resident #96 whenever she administered her own tube feeding. The DON said Resident #96 should not have been self-administering her tube feedings independently and without supervision from the nursing staff. The DON said Resident #96 should be evaluated to ensure she was completing all of the steps involved in administering her tube feeding correctly. The DON said Resident #96's physician had watched her self-administer her tube feeding and did not have any concerns at the time. The DON said Resident #96's self-administration and staff supervision should be on her care plan.

Plan of correction · submitted by the facility

0758Free from Unnec Psychotropic Meds/PRN UseS/S E▼

Findings

Based on record review and interviews, the facility failed to ensure three (#95, #75 and #249) of five residents out of 36 sample residents were as free from unnecessary medications as possible. Specifically, the facility failed to:-Ensure consents were obtained that included the risks versus benefits for psychotropic medications for Resident #95, Resident #75 and Resident #249; and.-Ensure Resident #95 and Resident #75 had behavior monitoring in place for the use of psychotropic medications. Findings include:I. Facility policy and procedureThe Psychotropic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. It revealed in pertinent part, "Drugs in the following categories are considered psychotropic medications and are subject to specific prescribing, monitoring, and review requirements: anti-psychotics, anti-depressants, anti-anxiety medications and hypnotics. "Residents, families and/or the representative are involved in the medication management process, including: indications for use, dose, duration, adequate monitoring for effectiveness and adverse consequences, and preventing, identifying and responding to adverse consequences. "Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. "Use of psychotropic medications may be appropriate in specific circumstances, such as for enduring conditions and/or new admissions where the resident is already on a psychotropic medication. "Residents receiving psychotropic medications are monitored for adverse consequences and residents (and/or representatives) have the right to decline treatment with these medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives."II. Resident #95A. Resident statusResident #95, age 69, was admitted on 1/31/25. According to the March 2025 computerized physician's orders (CPO), diagnoses included acute and chronic respiratory failure and major depressive disorder. The 2/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision or touching assistance with most activities of daily living (ADL). The assessment documented the resident took several high-risk medications including antidepressants, hypnotics and anticonvulsants. B. Resident and representative interviewResident #95 was interviewed on 3/26/25 at 12:26 p.m. Resident #95 said her representative signed all of her documents on admission. Resident #95 said she was not sure what documents her representative signed. Resident #95's representative was interviewed on 3/26/25 at 3:19 p.m. The representative said she did not think the facility staff reviewed any medication side effects with her. The representative said she did not remember signing any medication consent forms. C. Record reviewThe antidepressant care plan, initiated 2/20/25, revealed Resident #95 was taking an antidepressant medication to treat her diagnosis of major depressive disorder. Pertinent interventions included educating Resident #95 and her representatives on the risks, benefits, and side effects of the drugs being given, giving the antidepressant medication as ordered, monitoring and documenting ongoing signs or symptoms of depression, and monitoring and documenting medication side effects. The hypnotic care plan, initiated 2/20/25, revealed Resident #95 was taking a hypnotic medication to treat her insomnia (difficulty sleeping). Pertinent interventions included administering the medication as ordered and monitoring and documenting medication side effects. Review of the March 2025 CPO revealed the following physician's orders:Mirtazapine 30 milligram (mg) tablets instructions to give 30 mg by mouth at bedtime for depression, ordered 1/31/25; Venlafaxine extended release 150 mg oral tablet, instructions to give 150 mg by mouth one time a day for depression, ordered 2/1/25; Venlafaxine extended release 37.5 mg oral tablet, instructions to give 37.5 mg by mouth one time a day for depression, ordered 2/1/25; and,Zaleplon 5 mg oral capsule, instructions to give 5mg by mouth at bedtime for insomnia, ordered 1/31/25 and discontinued 3/12/25.-Review of the March 2025 CPO, as well as Resident #95's electronic medical record (EMR), did not reveal any orders for antidepressant or hypnotic medication side effect monitoring or monitoring of target behaviors for depression.-Review of Resident #95's EMR did not reveal any psychoactive medication consent forms. III. Resident #75A. Resident statusResident #75, age 78, was admitted on 2/5/25. According to the March 2025 CPO, diagnoses included dementia with anxiety, adult failure to thrive, insomnia and depression. The 2/11/25 MDS assessment revealed the resident was cognitively intact with a BIMS assessment score of 14 out of 15. The resident required supervision or touching assistance with most ADLs. The assessment documented the resident took several high-risk medications including antidepressants, antianxiety, antipsychotic, anticonvulsants, and opioids. B. Resident and representative interviewResident #75 and her representative were interviewed together on 3/26/25 at 12:25 p.m. Resident #75 said she did not remember signing any consent forms for her anxiety medications. Resident #75 and her representative said did not remember signing any forms with any medication side effect information. C. Record reviewThe antianxiety medication care plan, initiated 2/25/25, revealed Resident #75 was taking an antianxiety medication to treat her anxiety disorder. Pertinent interventions included monitoring and documenting medication side effects, and observing Resident #75's mood and response to the medication. The antidepressant care plan, initiated 2/25/25, revealed Resident #75 was taking an antidepressant medication. Pertinent interventions included administering the medication as ordered, monitoring and documenting medication side effects and observing Resident #75's mood and response to the medication. The antipsychotic care plan, initiated 2/25/25, revealed Resident #75 was taking an antipsychotic to treat her depression. Pertinent interventions included administering the medication as ordered, monitoring and documenting medication side effects and monitoring target behaviors. Review of the March 2025 CPO revealed the following physician's orders:Olanzapine 5mg oral tablet, instructions to give one tablet by mouth at bedtime for depression, ordered 2/5/25;Trazodone 100mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia associated with depression, ordered 2/5/25;Fluoxetine 60mg oral tablet, instructions to give 60mg by mouth one time a day for depression, ordered 2/6/25;Melatonin 3mg oral tablet, instructions to give two tablets by mouth one time a day for insomnia, ordered 2/5/25 and discontinued 3/25/25 (during the survey process); and,Melatonin 3mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia, ordered 3/25/25.-Review of the March 2025 CPO, as well as Resident #75's EMR, did not reveal any orders for antidepressant or hypnotic medication side effect monitoring or monitoring of target behaviors for depression.-Review of Resident #75's EMR did not reveal any psychoactive medication consent forms. IV. Staff interviews Licensed practical nure (LPN) #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said Resident #75 was on several sleep medications and one of them was recently discontinued. LPN #1 said Resident #75's physician had just lowered her dose of melatonin from 6 mg to 3 mg.-However, review of Resident #75's EMR did not reveal any psychoactive consent forms pertaining to any sleep aides or changes in sleep aide doses. LPN #1 was interviewed again on 3/26/25 at 1:13 p.m. LPN #1 said when a resident started a new psychoactive medication the nursing staff would monitor their behaviors and for any side effects for two weeks. LPN #1 said this was monitored in the treatment administration record (TAR). LPN #1 said residents needed to have a signed consent form for any psychoactive medications prior to the medication being administered. LPN #1 said Resident #95 was on a few psychoactive medications for her depression. LPN #1 reviewed Resident #95's EMR and said she did not see any antidepressant side effect or behavior monitoring in her TAR. LPN #1 said she did not see any orders for antidepressant side effect or behavior monitoring in Resident #95's EMR.LPN #5 was interviewed on 3/26/25 at 2:46 p.m. LPN #5 said when a resident was prescribed psychotropic medications the staff monitored the resident's behavior and for any side effects. LPN #5 said this was usually documented in the resident's TAR, and a physician's order was obtained for side effects and behavior monitoring was usually in the CPO. LPN #5 said behavior and side effect monitoring were performed for psychotropic medications as the nursing staff and physicians wanted to ensure the medications were working appropriately, ensure the resident's symptoms are not worsening, and ensure the medication is not causing any side effects. LPN #5 said behavior and side effect monitoring was performed so the practitioner could adjust the medication dose as needed or stop the medication altogether. LPN #2 was interviewed on 3/26/25 at 3:30 p.m. LPN #2 said when she received an order for a new psychotropic medication or a change in dosage she confirmed the order before documenting it on a list at the nurse's station. LPN #2 said the list was used to notify the nurse on the next shift to monitor the resident for adverse reactions and behavior monitoring and document it in their EMR. LPN #2 said she had never obtained consent for a new medication or a change in medications. The director of nursing (DON) was interviewed on 3/26/25 on 3:35 p.m. The DON said the facility nurses did not obtain the consent forms when a resident had orders for a new psychoactive or change in a psychoactive medication/dosage. The DON said the unit managers and nursing leadership, including himself, obtained consent either from the resident or the resident representative before the initiation of the medication. The DON said the psychoactive medication consent was a form that is filled out on the EMR. The DON said if the consent form was not in the EMR it was not obtained. The DON was interviewed again on 3/26/25 at 4:40 p.m. The DON said behavior and side effect monitoring were initiated on admission or within 24 hours of starting a psychoactive medication. The DON said target behavior monitoring was used to see if the treatment was effective and to find the lowest effective dose of medication interventions. The DON reviewed Resident #95's orders and said she was not able to find any orders for behavior or side effect monitoring. IV. Resident #249 A. Resident statusResident #249, age 77, was admitted on 2/27/25. According to the March 2025 CPO, diagnoses included severe unspecified dementia with agitation and Wernicke's encephalopathy (severe neurological disorder caused by thiamine deficiency). The baseline care plan, initiated 2/28/25, revealed the resident was cognitively impaired due to a diagnosis of dementia. It documented she had a history of falls, was taking psychoactive medications and needed assistance with ADLs. B. Record reviewThe psychoactive drug care plan, initiated on 3/19/25, documented the resident required an antipsychotic medication related to dementia with behaviors (delusions and inappropriate behaviors in public). Interventions included administering antipsychotic medications as ordered, attempting gradual dose reductions as indicated/ordered or if condition improved, utilizing non-pharmacological approaches prior to medication administration, such as providing a quiet and dark environment, assessing pain/discomfort, providing back rubs, offering warm beverages, encouraging out of room activity, providing activity materials of choice, going outdoors, encouraging family/friend visitation and encouraging her to verbalize feelings. Observe for and document the effectiveness of treatment, and report signs of medication side effects (including insomnia) or adverse reactions. The anti-depressant care plan, initiated on 3/19/25, documented the resident was prescribed an antidepressant medication related to anxiety and post-traumatic stress disorder (PTSD). Pertinent interventions included administering anti-depressant medications as ordered, monitoring/documenting side effects and effectiveness, educating family/caregivers about risks, benefits, side effects and/or toxic symptoms of the anti-depressant medications, and monitoring/documenting/reporting to the physician any ongoing signs and symptoms of depression unchanged by medication use. Review of the March 2025 CPO revealed the following physician's orders:Trazadone hydrochloride (hcl) oral tablet 50 mg, give one tablet by mouth at bedtime for insomnia, may use half of a 100 mg tablet, ordered 3/6/25; and,Zyprexa oral tablet 10 mg (Olanzapine), give 0.5 tablet by mouth in the afternoon for dementia with agitation for four days and give one tablet by mouth in the afternoon for dementia with agitation, ordered 3/20/25.-Review of Resident #249's EMR did not reveal documentation indicating consent forms were obtained prior to the administration of the trazadone and Zyprexa. C. Staff interviewsLPN #2 was interviewed on 3/26/25 at 3:30 p.m. She said when she received a physician's order for a new psychotropic medication or a change in dosage, she confirmed the order. She said she notified the oncoming nurse to monitor and document adverse reactions and behaviors. She said she had never obtained consent for a new medication or a change in medications. The DON was interviewed on 3/26/25 on 3:35 p.m. He said when a resident was prescribed a new psychoactive drug or a change in a psychoactive medication/dosage, the nurses did not obtain consent. He said the unit managers and nursing leadership, including himself, obtained consent either from the resident or the resident's representative before the initiation of the change. He said the consent was a form that was filled out in their EMR system for informed consent for psychoactive medication. He said if it was not there, it was not done.

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality, including providing equal access to quality care regardless of diagnosis, severity of condition, or payment source. Corrective Action: By 4-21-25 Unit Manager (UM)/designee obtained psychotropic consent for resident #95. By 4-21-25 Unit Manager (UM)/designee added behavior monitoring for psychotropic medications for resident # 95 By 4-21-25 Unit Manager (UM)/designee obtained psychotropic consent for resident #75. By 4-21-25 Unit Manager (UM)/designee added behavior monitoring for psychotropic medications for resident #75. Resident #249 discharged from facility on 4-11-25. Identification of Others: By 4-21-25 Unit Manager (UM)/designee reviewed residents on psychotropic medications for consent and behavior monitoring. Systemic Changes: On 4-18-25 Director of Nursing (DNS)/designee will educate nursing staff to obtain psychotropic consent utilizing the Informed consent – Psychoactive Medication evaluation upon admission and with changes in psychotropic medications. Behavior monitoring will be added MAR (medication administration record)/TAR (treatment administration record) upon admission and with changes in psychotropic medications. Monitoring: Beginning on 4-22-25, Unit Manager (UM) designee will print and audit the order listing report for residents who were started on psychotropic to verify psychotropic consent was obtained and behavior monitoring was initiated x 5 week for 90 days. DNS to review results monthly and report findings to QAPI x3 months. QAPI committee will decide as to the frequency of on-going monitoring.

0759Free of Medication Error Rts 5 Prcnt or MoreS/S D▼

Findings

Based on observations, record review and interviews, the facility failed to ensure the medication administration error rate was not greater than five percent (%). Specifically, the facility's medication administration error rate was 6.06%, or two errors out of 33 opportunities for error. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed., E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment."Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication."II. Observations On 3/25/25 at 8:56 a.m. licensed practical nurse (LPN) #3 was preparing and administering medications for Resident #52. The resident had physician's orders for the following medications:Omeprazole delayed release oral capsule 40 mg (milligram), give one capsule via percutaneous endoscopic gastrostomy tube (PEG) tube two times a day for gastroesophageal reflux disease (GERD), ordered 1/20/25.-LPN #3 administered omeprazole 20 mg, not omeprazole 40 mg as indicated in the physician's order. Lidocaine 4% external patch, apply topically (to the skin) to the left shoulder every morning and at bedtime for pain, ordered 3/19/25.-LPN #3 applied the lidocaine patch to Resident #52's right shoulder, not the left shoulder as indicated in the physician's order. III. Staff interviewsLPN #3 was interviewed on 3/25/25 at 11:56 a.m. LPN #3 said she thought she had put the lidocaine patch on Resident #52's left shoulder, but she said because of the position the resident was lying in, she accidentally placed it on the resident's right shoulder instead. She said she gave one capsule of omeprazole 20 mg to Resident #52 and she should have given two capsules because she needed 40 mg. She said she should have given the resident another 20 mg capsule of omeprazole. The director of nursing (DON) was interviewed on 3/26/25 at 4:15 p.m. The DON said physician's orders should be double-checked when administering medications.

Plan of correction · submitted by the facility

0805Food in Form to Meet Individual NeedsS/S E▼

Findings

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet orders of puree and mechanical soft as indicated on their meal tray cards. Findings include:I. Facility policy and procedureThe Therapeutic Diets policy, undated, was provided by the nursing home administrator (NHA) on 3/26/25 at 11:32 a.m. It read in pertinent part, "Diet orders should match the terminology used by the food and nutrition services department. A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet. If a mechanically altered diet is ordered, the provider will specify the texture modification. The dietitian, nursing staff and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets."II. Record reviewThe menu extensions and modifications for modified texture diets were provided by the dietary director (DD) on 3/26/25 at 5:00 p.m. The menu extensions documented the following modifications for the mechanically altered food items served during lunch meal service on 3/25/25:-The regular diet included beef tostadas, shredded lettuce and tomato, ground green chili stew and fruit crisp.-The "mechanically altered diet" included puree beef tostadas, no lettuce and tomato, ground green chili stew and sliced peaches.-However, the modified texture diet menu extensions did not specifically state a mechanical soft altered diet as listed on the resident's meal tickets, but listed a "mech altered" diet. The extensions also included IDDSI mince and moist level five and soft and bite size level six which the facility had not yet transitioned to use (see the interviews below). III. Meal service observation and test trayDuring a continuous observation on 3/25/25, beginning at 11:10 a.m. and ending at 12:37 p.m., the following was observed during the meal preparation and service in the main kitchen: The posted menu was beef tostada with shredded lettuce and tomato and fruit crisp. At 11:21 a.m. a resident's lunch plate was assembled by cook (CK) #1 with a crisp, fried tostada shell topped with ground beef and a fruit crisp was placed on the tray by dietary aide (DA) #1. The meal ticket on the tray documented a mechanical soft-ground texture and the tray was placed in a cart for delivery. -However, according to the meal extensions, the resident should have received a pureed beef tostada. (see meal extensions above)All 11:22 a.m. a residents meal tray was assembled by CK #1. DA #1 placed a fruit crisp on the tray. The meal ticket on the tray documented a mechanical soft-ground texture and the tray was placed in a cart for delivery.-However, according to the meal extensions, the resident should have received peach slices, not fruit crisp (see meal extensions above). At 11:33 a.m. a resident's lunch plate was assembled by CK #1 with a crisp, fried tostada shell topped with ground beef. The meal ticket on the tray documented a mechanical soft-ground texture.-However, according to the meal extensions, the resident should have received a pureed beef tostada. (see meal extensions above)At 12:00 p.m. a puree plate was prepared and served to a resident. The plate consisted of puree meat, mashed potatoes and a puree green vegetable. The resident's meal ticket documented a puree diet texture.-The puree vegetable served to the resident included peas which should not have been pureed (see interview below). At 12:16 p.m. the DD said to CK #1 that the fried tostada shells were a choking hazard. At 12:20 p.m. the DD removed the puree meat from the steam table and placed the puree meat in afood processor to blend the food. The DD said he wanted to make sure the food was the right consistency. The puree meat was placed back in the steam table for meal service. At 12:00 p.m. a puree plate was prepared and served to a resident. The plate consisted of puree meat, mashed potatoes and a puree green vegetable.-The puree vegetable served to the resident included peas which should not have been pureed (see interview below). At 12:31 p.m. The DD said to CK #1 that for a mechanical soft diet texture the tortilla should always be bite size and soft while he cut a soft flour tortilla and placed the pieces on a plate. The DD said he had not reviewed the modified texture diet menu extensions.-However, according to the meal extensions, the resident should have received a pureed beef tostada and not a cut-up soft flour tortilla. (see meal extensions above)At 12:35 p.m. a puree test tray was provided. The puree texture test tray consisted of puree beef, mashed potatoes, pureed peas and carrots and chocolate pudding for dessert. -The puree vegetable served to the resident included peas which should not have been pureed (see interview below).-The peas and carrots provided on the test tray had visible pieces of carrots and peas in the puree peas and were not smooth. The puree meat had small visible lumps. IV. Staff interviewsCK #1 and the DD were interviewed together on 3/25/25 at approximately 12:30 p.m. (during meal service). CK #1 said the facility had a book of modified texture diet menu extensions in the kitchen. The DD said the facility had modified texture diet menu extensions but he needed to check with the registered dietitian (RD) to see if the modified texture diet menu extensions were correct. The DD and the NHA were interviewed together on 3/26/25 at 12:00 p.m. The DD said the facility was transitioning to IDDSI and was in the process of training the staff to the proper standards on IDDSI. The DD said the residents prescribed a puree diet had received puree peas and carrots for lunch on 3/25/25. The DD said the staff should not have pureed the peas and he noticed the puree peas after the meals had been sent to residents. The DD said a food with a hull, such as peas, should not be pureed. The DD said the facility would transition to minced and moist level five and soft and bite size level six diet textures (of IDDSI diets) to replace the mechanical soft diet texture the facility used. The DD said he was notified during lunch by facility staff the modified diet textures were incorrect, but it was too late to do anything about it. The DD said if modified textures were served incorrectly the residents were at risk for choking. The NHA said all staff were trained during their initial onboarding on how to recognize modified textures.

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to ensure that each resident receives food prepared in a form designed to meet their individual needs, including mechanically altered diets as prescribed. Corrective Action for Affected Residents: On 3/25/25, the Dietary Director immediately discontinued serving fried tostada shells to residents on mechanical soft diets. On 4/18/25, the Registered Dietitian completed a comprehensive review of all residents with prescribed mechanically altered diets to ensure their diet orders matched their assessed needs. All affected residents' diet orders were verified and updated as needed in their medical records and meal tickets. Identifying other Residents having the Potential to be Affected: By 4/21/25, the Registered Dietitian/designee conducted a facility-wide audit of all residents for compliance in IDDSI diet verbiage. Measures put into place or Systemic Changes: The Dietary Director will provide in-service education to dietary staff on 04/18/2025 on: Proper preparation of mechanically altered diets IDDSI standards and guidelines Correct interpretation of diet orders and meal tickets Foods that should not be pureed (e.g., foods with hulls) Proper consistency requirements for pureed foods The Registered Dietitian has updated the modified texture diet menu extensions to clearly specify preparation methods for each diet texture by 04/21/2025. The Director of Nursing/designee will provide in-service education on 04/18/2025 on: Proper diet texture verification before meal service Recognition of appropriate food consistencies Protocol for reporting dietary concerns Plan to Monitor Performance: The Dietary Director or designee will conduct random meal audits that will include observation 3 times a week of mechanically altered meals for proper texture and consistency for 4 weeks, then weekly for 8 weeks. The Registered Dietitian/designee will review 10% of residents with altered diets meal tickets weekly for 12 weeks to ensure alignment with prescribed diets. The monitoring will be documented via audit form. Results of these audits will be reported monthly to the Quality Assurance and Performance Improvement (QAPI) committee by the Dietary Director. The QAPI committee will analyze data for patterns and trends and make recommendations for continued monitoring or modification of interventions as needed until substantial compliance is achieved and maintained.

0812Food Procurement,Store/Prepare/Serve-SanitaryS/S F▼

Findings

Based on observations, record review and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and in three of three unit nourishment refrigerators. Specifically the facility failed to:-Ensured the nourishment room refrigerators were maintained at a safe temperature;-Ensure health shakes were labeled in the unit nourishment refrigerators; and,-Ensure the floor, walls and ice machine in the main kitchen were maintained in a clean and sanitary condition. Findings include:I. Ensure safe cold food holding temperatures were maintained and health shakes were labeled in the nourishment refrigeratorsA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 4/2/25, read in pertinent part, "Except during preparation, cooking, or cooling, or when time is used as the public health control time/temperature control for safety food shall be maintained at 135 degrees fahrenheit (F) or above at 41 F or less." (3-501.16)B. ObservationsOn 3/23/25 at 10:30 a.m. the following was observed in a south unit nourishment refrigerator and freezer:-Six health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed health shakes; -There was brown liquid splattered on the sides and spilled on the bottom of the freezer and inside the door shelf; and, -A box of turkey pot pie was in the freezer with an expiration date of 12/21/23 with a name written on the box. On 3/23/25 at 2:25 p.m. the following was observed in the south unit nourishment refrigerator:-There was brown liquid splattered on the sides and spilled on the bottom of the freezer and inside the door shelf; -A box of turkey pot pie in the freezer with an expiration date of 12/21/23; and,-Nine health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed health shakes. The March 2025 (3/1/25 to 3/25/25) temperature log for the south unit nourishment refrigerator was reviewed. The temperatures were recorded as follows:-On 3/11/25 the temperature was 42 F.-On 3/12/25 the temperature was 46 F.-On 3/15/25 the temperature was 42 F.-On 3/17/25 the temperature was 45 F.-On 3/18/25 the temperature was 48 F.-On 3/19/25 the temperature was 45 F.-On 3/21/25 the temperature was 43 F.-The recorded refrigerator temperatures were above the acceptable cold holding temperature of 41 F and there was no evidence to indicate the temperature was corrected (see professional reference above). An unidentified certified nurse aide (CNA) looked at the frozen turkey pot pie with the expiration date of 12/21/23 and said the resident whose name was written on the box was no longer at the facility and placed the expired product back in the freezer. On 3/25/25 at 2:40 p.m. the following was observed in the men's secured unit nourishment refrigerator:-Three health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed healthsakes. On 3/25/25 at 2:45 p.m. the following was observed in the Aspen unit nourishment refrigerator :-Seven health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed healthsakes. The March 2025 (3/1/25 to 3/25/25) temperature log for the aspen unit nourishment refrigerator was reviewed. The temperatures were recorded as follows:-On 3/11/25 the temperature was 42F.-On 3/14/25 the temperature was 42 F.-On 3/15/25 the temperature was 42 F.-On 3/17/25 the temperature was 48 F.-On 3/18/25 the temperature was 46 F.-The recorded refrigerator temperatures were above the acceptable cold holding temperature of 41 F and there was no evidence to indicate the temperature was corrected (see professional reference above). C. Staff interviewsThe director of nursing (DON) was interviewed on 3/25/25 at approximately 3:25 p.m. The DON said the dietary staff managed the unit nourishment refrigerators. CNA #2 was interviewed on 3/25/25 at approximately 2:30 p.m. CNA #2 said the overnight nursing staff checked the nourishment refrigerator temperatures and removed expired products. Certified nurse aide with medication aide (CNA-Med) #1 said the night shift usually checked the nourishment refrigerator temperatures and she said she would check the temperatures of the nourishment refrigerators again for accuracy. The dietary director (DD) and the nursing home administrator (NHA) were interviewed together on 3/26/25 at 12:00 p.m. The NHA said the dietary department was responsible for recording the nourishment refrigerators temperatures and checking for expired products. The NHA said the nourishment refrigerator in the south unit was running a high temperature (out of range) because the thermometer was in the door but they moved the thermometer back inside the refrigerator. She said when they moved the thermometer the temperature was reading within normal limits. The DD said that unit refrigerator temperatures and maintenance of the product would be corrected. The DD said since the refrigerator temperatures were running high, the staff should take the temperature of the food in the refrigerator to ensure it was a safe temperature, and if the food was not a safe temperature after 30 minutes the food would be discarded. The DD said he was going to go through the product in the unit refrigerators and clean them out. The NHA said he was not sure if the facility provided education to the CNAs on refrigerator temperature maintenance so they would notice if the temperature was out of range during their use of the refrigerators. II. Maintain a clean and sanitary kitchen environmentA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved 4/2/25 read in pertinent part, "Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: smooth, durable, and easily cleanable for areas where food establishment operations are conducted; and nonabsorbent for areas subject to moisture such as food preparation areas, walk-in refrigerators, warewashing areas, and areas subject to flushing or spray cleaning methods." (6-101.11)B. Facility policy and procedureThe Sanitization policy, revised November 2022, was provided by the NHA on 3/26/25 at 11:32 a.m. It read in pertinent part, "All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris and protected from rodents and insects. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Ice machines and ice storage containers are drained,cleaned and sanitized per manufactures instructions."C. ObservationsThe initial kitchen tour was conducted on 3/23/25 at 9:10 a.m. The following was observed:-Approximately ten missing coving tiles (a curved tile that transitions the floor to the wall) behind the ice machine extending under the clean side of the dish machine table. The pipe extending from the back of the ice machine was dripping onto the floor instead of the drain and created standing water that pooled into the grout between the existing floor tiles. Four coving tiles were damaged and separated from the wall. The wall behind the ice machine was bowed out into the kitchen; -The aluminum filter on the back of the ice machine was caked with brown debris; and,-A large section extending approximately ten feet long and a foot wide revealed an exposed, uneven and rough concrete floor that was missing kitchen floor tiles. A kitchen walk through was conducted in the main kitchen on 3/25/25 from 11:10 a.m. through 1:30 p.m. The following was observed:-Approximately ten missing coving tilesbehind the ice machine and extending under the clean side of the dish machine table (a curved tile that transitions the floor to the wall) were missing. The pipe extending from the back of the ice machine was dripping onto the floor instead of the drain and created standing water that pooled into the grout between the existing floor tiles. Four coving tiles behind the ice machine were damaged and separated from the wall. The wall behind the ice machine was bowed out into the kitchen; -The aluminum filter on the back of the ice machine was caked with brown debris; and,-A large section extending approximately ten feet long and a foot wide revealed an exposed, uneven and rough concrete floor that was missing kitchen floor tiles. D. Staff interviewsThe NHA was interviewed on 3/25/25 at approximately 3:30 p.m. The NHA said he was not aware that the filter on the back of the ice machine had not been cleaned and had not seen the tiles behind the dish machine. He said he was not aware the ice machine was dripping onto the floor. The NHA said the kitchen floor was missing tiles because a broken pipe had been repaired and the facility would repair the floor in house. The DON was interviewed on 3/25/25 at approximately 3:30 p.m. The DON said it looked like the ice machine had been moved from where it usually sat..The DD and the NHA were interviewed together on 3/26/25 at 12:00 p.m. The NHA said he was not sure if the ice machine filter had been assigned to anyone to clean. He said it was possible the ice machine filter should have been cleaned as part of the regular clean performed by their contacted vendor. E. Facility follow upOn 3/26/25 at 11:32 a.m. the NHA provided documentation that the facility reached out to a local vendor on 2/20/25 for a quote on epoxy chip coating (seamless) the kitchen floor. No further documentation was provided if the local vendor provided the quote.

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, including maintaining proper food temperatures, labeling requirements, and maintaining clean and sanitary conditions in food service areas. Corrective Action for Affected Residents: By 4/18/2025, the following immediate actions were taken: All nourishment room refrigerators were audited for proper temperature control All health shakes were properly labeled with expiration dates Expired turkey pot pie was removed and discarded Ice machine filter was cleaned and sanitized Standing water behind ice machine was cleaned and dried Identifying other Residents having the Potential to be Affected:An audit of all nourishment rooms and kitchen areas was completed on 4/18/2025 to identify any additional areas requiring correction. Measures put into place or Systemic Changes: The Dietary Director will provide in-service education on 04/18/2025 on: Proper temperature monitoring and documentation Food labeling requirements Cleaning schedules and responsibilities Reporting maintenance issues Bids were received for installation of new flooring and wall repair 4/14/2025. Capex funding application to be submitted by 4/25/2025. The goal date for completion is 5/2/2025 Plan to Monitor Performance: Temperature logs will be reviewed 5x a week by Dietary Director/designee 4 weeks and 2x a week for 8 weeks Weekly sanitation audits of kitchen and nourishment refrigerators by Dietary Director using an audit form to document. This will include observation of the refrigerators. Results of all audits will be reported monthly to the Quality Assurance Performance Improvement (QAPI) committee for review and additional interventions if needed. The QAPI committee will continue to monitor compliance until substantial compliance is achieved and maintained for 3 consecutive months.

0847Entering into Binding Arbitration AgreementsS/S E▼

Findings

Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for three (#54, #85 and #96) of four residents out of 36 sample residents. Specifically, the facility failed to:-Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #54, Resident #85 and Resident #96 and/or their representatives understood the agreement before signing the arbitration agreement; and,-Ensure the facility staff provided evidence Resident #54, Resident #85 and Resident #96 and/or their representatives acknowledged understanding of the components of the agreement. Findings include:I. Facility policy and procedureThe Binding Arbitration Agreement policy, November 2023, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. The policy read in pertinent part, "Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Residents (or their representatives) have the right to make informed decisions about the important aspects of their health, welfare and safety."The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a form and manager that he or she understands, taking into consideration the resident's (or representative's) language, literacy and stated preference for learning."After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document. A signature alone is not sufficient acknowledgement of understanding. The resident (or representative) must verbally acknowledge understanding, and the verbal acknowledgement documented by the staff member who explains the agreement."II. Resident interviewsResident #54 and Resident #85 were interviewed during a group interview on 3/25/25 at 10:30 a.m. Resident #54 and Resident #85 said they did not know what an arbitration agreement was and did not remember signing an arbitration agreement. Resident #96 was interviewed on 3/25/25 at 3:00 p.m. Resident #96 said she did not remember signing an arbitration agreement when she signed her paperwork upon admission. Resident #96 said she did not know what an arbitration agreement was and that she had no difficulties or disputes with the facility. IV. Record reviewThe NHA provided a list of residents who signed arbitration agreements on 3/23/25 at 10:55 a.m. -The list documented Resident #54 and Resident #85 signed an arbitration agreement. However, the list of residents was created in June 2024 and not updated to include residents that had admitted since. The admissions coordinator (AC) provided an additional list of residents who signed arbitration agreements on 3/25/25 at approximately 2:00 p.m. Resident #96 signed the arbitration agreement on 2/13/25IV. Staff interviewsThe AC and the business office manager (BOM) were interviewed together on 3/26/25 at 12:20 p.m. The AC said she reviewed and read aloud to the resident or the responsible party that signed the admission paperwork and the arbitration agreement. -However, the facility failed to provide documentation of acknowledgement by the residents or their representatives that they understood the arbitration agreement.

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to ensure that binding arbitration agreements are thoroughly explained to residents and/or their representatives in a form and manner they understand, and that acknowledgment of this understanding is properly documented before signing the agreement, in accordance with 483.70(m)(1)(2)(i)(ii)(3)-(5). Corrective Action for Affected Residents: By 4/18/2025, the Director of Admissions met with Residents #54, #85, and #96 to thoroughly explain the binding arbitration agreement, its purpose, and implications. Identification of Others The facility audited all current residents who admitted in the last 30 days who signed arbitration agreements and verified that they thoroughly and accurately understood the arbitration agreement prior to signing. Systemic Changes On or before 4/18/2025, facility will educate the Director of Admissions to ensure that they thoroughly and accurately explain arbitration agreements to future residents prior to receiving a signature or declination. The Director of Admissions shall write a progress note documenting thorough and accurate explanation of arbitration agreements. Monitoring Written Audits using spreadsheets of all future signed arbitration agreements will be completed by the Director of Admissions and/or designee with the oversight from the Nursing Home Administrator weekly for 4 weeks, monthly for 2 months, and periodically thereafter to ensure residents are thoroughly and accurately explained the arbitration agreement. Any identified concerns will be addressed immediately. Results of the audits are to be brought to the monthly Quality Assurance and Performance Improvement Program to ensure compliance.

0848Binding Arbitration AgreementsS/S F▼

Findings

Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement contained the required components. Specifically, the facility failed to:-Ensure the arbitration agreement presented to residents contained language that provided for the selection of a venue that was convenient to both parties; and,-Provide for the selection of a neutral arbitrator agreed upon by both parties. Findings include:I. Facility policy and procedureThe Binding Arbitration Agreement policy, dated November 2023, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. The policy read in pertinent part, "Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Residents (or their representatives) have the right to make informed decisions about the important aspects of their health, welfare and safety."Arbitration agreements provide for the selection of a neutral arbitrator, which is agreed upon by both parties. A neutral arbitrator is an impartial, unbiased party decision maker, without the appearance of any conflicts of interest, contracted with and agreed to by both parties to resolve their dispute. Residents (or representatives) are given the opportunity to suggest an arbitrator and venue. If the facility disagrees with the resident's suggested arbitrator(s) and/or venue, the facility will document the reason and provide that documentation to the resident (or representative). "Arbitration agreements provide for the selection of a venue that is both convenient to and suitably meets the needs of both parties. The venue will be agreed upon by both parties. When selecting a venue for consideration, ' convenience' for the resident (or representative) may be determined by his or her ability to get to the venue."II. Facility's binding arbitration agreementA copy of the facility's binding arbitration agreement was provided by the NHA on 3/23/55 at 10:55 a.m. The agreement read in pertinent part, "The arbitration shall be administered and conducted by a contracted provider in accordance with its comprehensive arbitrations rules and procedures. Within 15 days after a claim for arbitration is made, the demand shall be filed by the contracted provider (dispute resolution specialist) and a single arbitrator will be selected from a list provided by the named provider pursuant to its rules to conduct the arbitrations. The arbitrator shall have the jurisdiction to decide whether the claims may be arbitrated pursuant to this agreement. The hearing arising under this voluntary arbitration agreement shall be held in the county where the facility is located."-The facility's binding arbitration agreement failed to include the selection of a neutral arbitrator agreed upon by both parties and failed to contain language that provided for the selection of a venue that was convenient to both parties. III. Staff interviewsThe admission coordinator (AC) was interviewed on 3/26/25 at 12:20 p.m. The AC said the facility's arbitration agreement did not include information indicating a resident could speak with federal, state, local, surveyors or ombudsman. She said the information was included in the facility's admission agreement (a separate document) instead. The AC said there was no language in the facility's arbitration agreement regarding a selection of venue by both parties.

Plan of correction · submitted by the facility

0849Hospice ServicesS/S D▼

Findings

Based on record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#26) of five residents out of 36 sample residents. Specifically, the facility failed to ensure the hospice agency notes regarding Resident #26's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency. Findings include:I. Facility-Hospice contractThe contract between the facility and the hospice services company, dated 7/10/23, was provided by the nursing home administrator (NHA) on 3/25/25 at 3:08 p.m. It read in pertinent part, "The hospice and nursing facility shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving services under this agreement. Each clinical record shall completely, promptly, and accurately document all services provided to, and events concerning, each hospice patient. The hospice and the nursing facility shall each retain such records. Each such record shall be readily available and systematically organized to facilitate retrieval by either party."II. Resident #26A. Resident statusResident #26, age 83, was admitted on 9/25/24. According to the March 2025 computerized physician orders (CPO), diagnoses included respiratory failure, vascular dementia and adult failure to thrive. The 12/31/24 minimum data set (MDS) assessment documented the resident had both short-term and long-term memory impairments and had severely impaired daily decision-making skills, per staff assessment. The resident was dependent on staff for most activities of daily living (ADL). The MDS assessment indicated the resident was receiving hospice services. B. Record reviewThe March 2025 CPO revealed a physician's order for Resident #26 indicating the resident was admitted to hospice services on 9/25/24. The end of life care plan, revised 10/15/24, revealed Resident #26 required hospice care and was at risk for rapid decline in ADLs. Pertinent interventions included coordinating Resident #26's needs with hospice staff. A hospice notebook was provided by licensed practical nurse (LPN) #1 on 3/25/25 at 4:09 p.m. Review of the notebook revealed three visits from the hospice social worker dated 1/13/25, 2/12/25 and 3/14/25.-However, the notebook did not reveal any documentation from the hospice nursing staff regarding their visits and the care they provided.-Review of Resident #26's electronic medical record (EMR) failed to reveal any progress notes from the hospice services provider. Hospice nursing notes, dated 12/23/24 through 3/26/25, were provided by the director of nursing (DON) on 3/26/25 at 6:06 p.m. The hospice notes documented the care that was provided to Resident #1 at each hospice visit.-However, the hospice nursing notes were not in the hospice binder accessible to the facility staff. III. Staff interviewsLPN #1 was interviewed on 3/25/25 at 4:12 p.m. LPN #1 said when the hospice staff visited residents, their notes should be placed in the hospice notebook. LPN #1 said the hospice documents did not get uploaded anywhere into the residents' EMRs. LPN #1 said hospice certified nurse aides (CNAs) visited Resident #26 two to three days per week. LPN #1 was interviewed again on 3/26/25 on 10:34 a.m. LPN #1 verified there were no notes from any hospice CNA visits in Resident #26's hospice binder. LPN #1 said there should be notes from each visit from the hospice staff in the resident's hospice binder. -However, there were no notes documented from the hospice CNAs in Resident #26's hospice notebook (see record review above). CNA #5 was interviewed on 3/26/25 at 9:30 a.m. CNA #5 said the hospice staff reported to the CNA or nurse on duty after each visit to let them know what care they performed with Resident #26. CNA #5 said this information was also written down in the hospice binder. CNA #5 said the hospice staff communicated what care they performed so the facility's nursing staff could chart it in the resident's EMR, or attend to the resident if they needed medications or were not feeling well. CNA #2 was interviewed on 3/26/25 at 10:13 a.m. CNA #2 said some of the hospice CNAs did not tell the facility staff what care they provided for Resident #26 during their visits or if his incontinence brief needed to be changed. CNA #2 said the facility had a binder in which the hospice staff recorded everything they did when they came to assist Resident #26. CNA #2 said the hospice staff communicated with the facility staff to note any changes with Resident #26, ensure he was not left soiled and to make sure he got the care he needed. The DON and the regional clinical resource (RCR) were interviewed together on 3/26/25 at 4:40 p.m. The DON said the hospice staff emailed the facility recommendations after each visit. The DON said the hospice CNA visits and documentation were the social services department's responsibility. The DON said the hospice binders for each resident should contain the resident's plan of care and nursing recommendations from hospice. The RCR said the hospice binders for each resident should also contain visit summaries, chaplain notes and the hospice CNA visits.-However, Resident #26's hospice binder did not contain the plan of care, CNA visits or any documentation aside from the hospice social worker visits (see record review above).

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Corrective Action: On 3/26/25, the Director of Nursing (DNS) obtained missing hospice nursing notes for Resident #26 from the hospice provider. These notes were uploaded to the resident’s documents tab. Identifying others: By 4/18/2025, the Health Information Manger (HIM) conducted an audit of all current residents receiving hospice services to identify any missing hospice documentation. All identified gaps in documentation were addressed by obtaining missing documentation from the respective hospice providers. Audit focused on the last 30 days. Systemic Changes: Hospice binders were created for each resident on hospice services. Binders will be located on the unit in which the resident resides. A sign in form to include date, hospice staff, discipline, visit comments. The HIM will obtain hospice notes weekly and upload them into the residents document tab. By 4-21-25, A letter will be sent to our current hospice providers and will be shared with any new partnerships. On 4-18-25 The director of Nursing (DNS)/designee will provide education to clinical staff on hospice binder’s locations and the sign in form, records will be obtained and uploaded to the residents chart. Monitor: Beginning 4-21-25, an audit tool was created and the HIM will conduct weekly audits and document all hospice residents' documentation for completeness for 4 weeks, then monthly for 2 months. Social Services Director (SSD) to review results monthly and report findings to QAPI x3 months. QAPI committee will decide as to the frequency of on-going monitoring.

0880Infection Prevention & ControlS/S E▼

Findings

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on three of three units. Specifically, the facility failed to:-Ensure housekeeping staff followed appropriate hand hygiene processes when cleaning resident rooms;-Ensure high touch surfaces in residents' rooms were cleaned; -Ensure housekeeping staff followed proper cleaning techniques when cleaning residents' bathrooms; and,-Ensure enhanced barrier precautions (EBP) were followed for Resident #1, who had a peripherally inserted central catheter (PICC). Findings include:I. Housekeeping failuresA. Professional referencesAccording to the Centers for Disease Control and Prevention (CDC), CDC Clinical Safety, Hand Hygiene for Healthcare Worker (2/17/24), retrieved on 4/1/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety, "Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal."According to Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, retrieved on 3/21/25 fromhttps://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext,"High-touch surfaces are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). "Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment."B. ObservationsDuring a continuous observation on 3/26/25, beginning at 9:40 a.m. and ending at 10:27 a.m., the following was observed:The housekeeper (HK) sanitized her hands and donned (put on) gloves. The HK took her keys out of her pocket and opened the top of the supply cart. She grabbed a spray bottle of sanitizer and entered the bathroom in room #19, a double-occupancy room. She sprayed the surfaces of the toilet and sink. -The HK contaminated her clean gloves by touching her keys. -The HK failed to lift up the toilet seat and spray the rim of the toilet bowl with sanitizer. The HK cleaned the surfaces of the furniture on side B of the bedroom, changing gloves before each new cloth was used. She swept side B, changed gloves, then swept side A. She mopped half of side A, changed gloves, and cleaned the surfaces and handles of the dresser, bedside table and the door handles. She entered the bathroom and wiped down the vanity and fixtures with a clean towel. -The HK failed to sanitize her hands in between glove changes. At 9:58 a.m. the HK took a bucket with a scrub brush from underneath the supply cart. She poured sanitizer into the toilet bowl and flushed it. She scrubbed the inside of the toilet bowl with the brush. She then used the brush to scrub the top and outsides of the toilet bowl and finished by scrubbing the inside of the toilet again.-The HK failed to use proper cleaning technique by cleaning from a dirty area to a clean area and back to a dirty area. After cleaning the toilet, the HK put the scrub brush back into the bucket and returned it to the cart. She donned new gloves and mopped the bathroom floor. She changed gloves again and mopped the rest of side A, turned off the bedroom lights and exited the room.-The HK failed to sanitize her hands in between glove changes.-The HK failed to clean and sanitize the high touch areas in room #19, including door knobs, light switches and call lights. At 10:08 a.m., the HK entered the bathroom of the adjacent room, room #18. She followed the same procedure, spraying the surfaces in the bathroom, then cleaning side B and side A separately, changing gloves in between each step. At 10:21 a.m, she took the same bucket and scrub brush from underneath the supply cart. She poured sanitizer into the toilet bowl and flushed it, using the same technique to clean the toilet. She scrubbed the inside of the toilet bowl with the brush. She then used the brush to scrub the top and outsides of the toilet bowl and finished by scrubbing the inside of the toilet bowl again. After cleaning the toilet, she put the scrub brush back into the bucket and returned it to the cart. -The HK failed to sanitize her hands in between glove changes.-The HK again failed to use proper cleaning technique by cleaning from a dirty area to a clean area and back to a dirty area. -The HK failed to clean and sanitize the high touch areas in room #18, including door knobs, light switches and call lights, and used the same scrub brush for multiple residents' toilets. C. Staff interviewsThe HK was interviewed in Spanish on 3/26/25 at 10:27 a.m. The HK said she used the same toilet scrub brush for all the rooms in the hallway. The housekeeping supervisor (HKS) was interviewed on 3/26/25 at 12:46 p.m. The HKS said she started her position a month ago and she had scheduled a meeting for the following day (3/27/25) to discuss policies, procedures and expectations. She said she told staff that when they were in doubt, they should change them out (their gloves). The HKS said every time gloves were taken off, the hands should be sanitized. The HKS said high touch surfaces should be cleaned daily as part of the regular cleaning procedures. She said toilet scrub brushes were only used for the inner toilet bowl and cleaning cloths should be used on the outside of the toilet bowl. She said currently, there was only one toilet scrub brush per unit. The HKS said she wanted each room to have their own separate toilet brush/plunger combination. II. Failure to identify and follow EBPA. Professional referenceThe Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 4/2/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part,"Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities."EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status."B. Observations On 3/24/25 at 9:22 a.m. restorative aide (RA) #1 was sitting on Resident #1's bed while Resident #1 was doing a physical therapy exercise in her chair. Resident #1 had a peripherally-inserted central catheter (PICC) line hanging from her right arm. RA #1 removed a gait belt from around her waist and put the gait belt around Resident #1. RA #1 grabbed the gait belt and assisted Resident #1 to a standing position from her recliner so the resident was standing in front of her walker. RA #1 grabbed Resident #1's arm at her PICC site to support the resident as she walked. RA #1 quickly let go of the resident's arm but continued holding onto the gait belt around the resident's waist.-RA #1 failed to wear a gown or gloves when she was working with Resident #1. -Additionally, there was no PPE observed in Resident #1's room or outside the resident's room for staff to put on when providing high contact care with the resident. C. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 3/26/25 at 10:13 a.m. CNA #2 said residents that needed EBP had a bag containing PPE on their door and a sign indicating what precautions they were on. CNA #2 said nursing staff needed to wear a gown and gloves when entering the room of any residents on EBP. CNA #2 said residents were on EBP when they had a urinary catheter or needed tube feeding. CNA #2 said she was not sure if Resident #1 needed EBP, but she said no one told her about the resident needing any precautions. Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said EBP were used for residents with urinary catheters, tube feedings and PICC lines. LPN #1 said nursing staff needed to wear a mask, gown and gloves when working with residents who needed EBP.RA #1 was interviewed on 3/26/25 at 2:36 p.m. RA #1 said she needed to wear a gown and gloves when working with residents on EBP and disinfect her hands between working with each resident. RA #1 was not sure what the reasons were which caused a resident to require EBP. The infection preventionist (IP) was interviewed on 3/26/25 at 5:53 p.m. The IP said that EBP should be used with any resident that had an indwelling device, such as a PICC line, gastrostomy tube or urinary catheter. She said EBP should additionally be used for residents with wounds or multi-drug resistant organisms (MDROs) in their urine. She said every shift the nurse was required to document that EBP was in place for their residents who were on EBP. The IP said she put in the initial physician's order for EBP for residents, which consisted of wearing a gown and gloves any time staff performed direct care with a resident, such as when they changed dressings, performed incontinence care or bathed a resident. She said EBP was to prevent transmission of infectious organisms. The IP said she did not think that Resident #1 had a PICC line anymore. The director of nursing (DON) was interviewed on 3/26/25 at 7:11 p.m. The DON said Resident #1 had EBP in place when the facility was accessing her PICC line to administer antibiotics, but she said the resident had not had EBP in place since the resident completed her antibiotics and the staff were no longer administering medications through the PICC line. The DON said Resident #1 still needed EBP during dressing changes for the PICC line.

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Corrective Action for Affected Residents: On 4/9/2025, Resident #1's PICC line was discontinued, eliminating the need for enhanced barrier precautions (EBP). By 4/17/2025 Housekeeping staff in-serviced on: Proper hand hygiene between glove changes High-touch surface cleaning protocols Proper cleaning sequence (clean to dirty) Individual toilet brush use per resident room Proper cleaning and disinfection techniques Identifying other Residents having the Potential to be Affected: The Infection Preventionist reviewed all residents with indwelling devices by 4/18/2025 to ensure appropriate EBP signage and PPE supplies were in place Measures put into place or Systemic Changes: The Director of Nursing/designee will provide in-service education on 4/18/2025 on: Enhanced barrier precautions requirements Proper PPE use during high-contact resident care activities Identification of residents requiring EBP The Housekeeping Supervisor will in-service all housekeeping staff by 4/18/2025 on: Proper hand hygiene between glove changes High-touch surface cleaning protocols Proper cleaning sequence (clean to dirty) Individual toilet brush use per resident room Proper cleaning and disinfection techniques Plan to Monitor Performance: Beginning on 4/21/2025 the Infection Preventionist/designee will audit using audit tool for use of EBP weekly for 8 weeks, then monthly for 1 months. This audit will be monitoring whether EBP is being used effectively by staff. This will include observations and will be documented via audit form. The Housekeeping Supervisor will conduct random weekly observations of housekeeping staff for 4 weeks, then monthly for 2 months to monitor: Hand hygiene compliance Proper cleaning techniques High-touch surface cleaning Individual toilet brush usage The Director of Nursing will report audit findings to the Quality Assurance Performance Improvement (QAPI) committee monthly for review and recommendations until substantial compliance is achieved and maintained for 3 consecutive months.

0921Safe/Functional/Sanitary/Comfortable EnvironS/S E▼

Findings

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure resident rooms, bathrooms, dining room furniture and hallways received necessary maintenance repairs. Findings include:I. Facility policy and procedureThe Safe and Homelike Environment policy, undated, was provided by the nursing home administrator (NHA) on 3/25/25 at 1:53 p.m. The policy read in pertinent part, "The facility will provide a safe, clean, and comfortable homelike environment. This ensures that the resident can receive care and services safely and that the physical layout maximizes resident independence and does not pose a safety risk. Environment refers to any location in the facility that is frequented by residents. A homelike environment is one that de-emphasizes the institutional character of the setting. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable living environment. Furniture in disrepair will be reported to maintenance promptly."II. Aspen common/dining areaOn 3/23/25 at 9:15 a.m. the following observations were made of the Aspen common area:-Nine dining room chairs had seat cushions that were ripped and peeling; and, -Four of the six dining room tables had scratched and peeling surfaces and the underlying particle board was exposed. III. Ceiling and door frame in the Mountain View hallwayOn 3/23/25 at 9:30 a.m. the following observations were made in the Mountain View hallway:-There was rotted wood along the bottom of the double doorway frame in the hallway; and, -The ceiling near the exit sign above the double doorway had water spots and was bowing downward. IV. Resident rooms and bathroomsA. ObservationsOn 3/24/25 at 9:46 a.m. room #54 was observed. One of the residents who resided in the room was lying in bed. There were four raised and rough patches on the wall next to his bed, approximately three inches in diameter. There was a pink spot on the wall approximately 18 inches long and three inches high next to a vertical wall light approximately the same size. There were two round quarter inch holes in the wall and multiple scuff marks. There was a health shake container on the floor and two wet wipes next to a small trash can on the floor under a tray table. On 3/24/25 at 9:55 a.m. room #47 was observed. The walls on the opposite side of one of the residents' beds had multiple lines where a light brown liquid had spilled down and dried on the walls. There were seven spots of a yellow chunky substance splattered on the corner of the wall directly adjacent to the dried spill. On 3/24/25 at 2:37 p.m. room #46 was observed. There was a hole in the wall approximately four inches long by one inch tall, surrounded by peeling paint and broken plaster. On 3/25/25 at 5:36 p.m. room #13's bathroom was observed. There was hard water staining covering several square inches of the floor to the left of and behind the toilet. The baseboard was separating from the wall and had approximately a one centimeter gap between the baseboard and the wall. The area where the water inlet for the toilet met the wall had several inches of corrosion and hard water buildup, and the wall showed signs of water damage where several inches of paint were peeling away from the wall. On 3/25/25 at 5:42 p.m. room #23's bathroom was observed. There was a towel folded up and placed over a section of the floor to the left of the toilet. The flooring around the towel had areas of hard water buildup and several gnats were flying in the area of the towel. On 3/25/25 at 5:52 p.m. the maintenance director (MTD) lifted the towel on the floor in room #23's bathroom to examine the flooring underneath. Approximately 15 to 20 gnats flew out from between the floor and the towel. On 3/26/25 at 8:57 a.m. room #27 was observed. The room had no curtains on the windows. There were three largebrown stains on the tile floor near bed A. The heating vent along the far wall was broken with brown stains and portions of the metal covering were falling off. On 3/26/25 at 10:10 a.m., the lid to the toilet tank in room #18 was observed. The toilet tank lid did not fit and was the wrong shape for the tank. It was half-off, leaving an opening into the tank. The wall next to the toilet had an area approximately three feet long with peeling paint and cracks. The wall under the sink had a large horizontal crack extending from the toilet tank to the plumbing. There were large yellow/brown water stains on the wall under the sink. Yellow caulking lined the top of the white vanity and wall, partially covering cracks in the paint. B. Resident interviewsOne of the residents who resided in room #54 was interviewed on 3/24/25 at 9:46 a.m. The resident said he was unable to see his trash basket and so he dropped his trash on the floor. The resident who resided in room #47 was interviewed on 3/24/25 at 9:55 a.m. The resident said he was unable to see the wall in his room that had drips on it. He said he had asked for a dead miller moth to be removed from the overhead light in his room and it never happened. One of the residents who resided in room #27 was interviewed on 3/26/25 at 9:00 a.m. The resident said she used to have curtains on her windows, but she said the facility had taken them off a while ago and never replaced them. She said the room was always cold and the curtains might have helped keep it warmer. She said the heat vent looked like it was broken and unused, but she said it worked. V. Staff interviewsThe NHA was interviewed on 3/25/25 at approximately 3:40 p.m. The NHA said housekeeping could clean spills on the walls as well as other staff, such as a certified nurse aide (CNA), if they were in a resident's room. The NHA said he was not aware of the maintenance concerns items and holes in the walls in rooms #46, #47 and #54. The MTD was interviewed on 3/25/25 at 5:52 p.m. The MTD said he had not been made aware of any issues with the bathroom in room #13. The MTD said he had not gone into the room since he started at the facility, as he had not received any work orders for that room or otherwise been invited into the room by the residents. The MTD said there was not any standing water under the towel in room #23 but there was a definite issue with the toilet leaking. The MTD was interviewed again on 3/26/25 at 1:29 p.m. The MTD said there was no standing water near the toilet in room #13 but that the area had significant staining. The MTD said room #23's bathroom was being decontaminated by the housekeeping staff. The MTD was interviewed a third time on 3/26/25 at 5:00 p.m. The MTD said he knew about all of the maintenance repair issues in room #27, room #18, in the Mountain View hallway and the furniture in the Aspen unit dining room. He said the building was old and every time he started to fix one issue, another major and more important issue arose.

Plan of correction · submitted by the facility

RIVERDALE POST ACUTE makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. RIVERDALE POST ACUTE is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes RIVERDALE POST ACUTE's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in accordance with 483.90(i). Corrective Action for Affected Residents: By 04/25/2025, maintenance repairs were completed in rooms #13, #18, #23, #27, #46, #47, and #54. By 04/25/2025, nine dining room chairs with damaged cushions were ordered to replace the damaged ones. By 04/25/2025, the rotted wood along the bottom of the double doorway frame in Mountain View hallway will be repaired On 04/25/2025, the water-damaged ceiling near the exit sign was repaired Identifying other Residents having the Potential to be Affected: All residents have the potential to be affected by alleged deficient practice. All other room repairs will be entered as work orders during the monitoring process of the plan of correction. Measures put into place or Systemic Changes: The Director of Nursing/designee will provide in-service education on 04/18/2025 on: Proper reporting of maintenance issues through the work order system Immediate cleaning of spills and stains on walls and surfaces Plan to Monitor Performance: Beginning 4/21/2025, the maintenance director will conduct weekly environmental rounds using audit tool for 12 weeks. These rounds will consist of room inspections for any potential needed repairs to help create a homelike environment. The Administrator will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly for three months, then quarterly thereafter. The QAPI committee will analyze the data and make recommendations for additional interventions as needed until substantial compliance is achieved and maintained. Date of Compliance: 04/25/2025

2/12/2025Revisit: Complaint Survey · ID 0GUP12No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A revisit survey was completed on 2/12/25 for all previous deficiencies cited on 1/14/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

2/12/2025Revisit: Licensure Complaint Survey · ID W04412No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 2/12/25 for all previous deficiencies cited on 1/14/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

1/14/2025Complaint Survey · ID 0GUP111 deficiency▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO38820, #CO38871 and #CO38903 was completed on 1/13/25 to 1/14/25. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0689Free of Accident Hazards/Supervision/DevicesS/S E▼

Findings

Based on observations, record review and interviews, the facility failed to ensure one of three units were free from accident hazards. Specifically, the facility failed to ensure the alarm on the door to the outside secured patio was functioning properly. Findings include:I. Facility policy and procedureOn 1/13/25 at 12:49 p.m. the director of nursing (DON) said the facility followed the state guidelines for the secured unit. The DON provided a copy of the state guidelines, which read read in pertinent part, "Any facility that has one or more resident care units that are secured to prohibit free egress of residents shall comply with the standards in this section in addition to all other applicable requirements of this chapter."Staff in the secure environment shall be experienced and trained in the particular needs and care of its residents."The facility shall identify its method for securing the area and establish and implement procedures for monitoring the effectiveness of the security system."II. ObservationsOn 1/13/25 at 12:15 p.m. the back door on the all-male secured unit was observed. The back door was not visible from the nurse's station. There were no cameras near the door to transmit a live visual for the staff at the nurse's station. The alarm on the door was broken and did not audibly alert staff if the door was opened. The back door provided direct access to a courtyard with uneven surfaces. When standing inside there was a keypad on the right side of the door. The keypad was used to reset the door lock and turn off the alarm. Above the door was a long thin green flashing light. When the door arm was pushed on the green light flashed from green to red several times. During this time the door could be pushed open. When the door was closed, it was locked from the outside. The courtyard had a covered smoking area. The courtyard also had a wooden gate which opened to a field. The wooden gate had an alarm system that the facility staff nor facility management knew how to operate, nor where to turn off the gate alarm and reset it (see interviews below). On 1/13/25 at 12:15 p.m. certified nurse aide (CNA) #2 pushed on the door crossbar and when the lights flashed from red to green, the door was able to be pushed open. CNA #2 stepped outside into the courtyard and no alarms sounded to notify the staff that the door had been opened. Three male residents noticed the door open and quickly attempted to walk through the opened door. On 1/13/25 at 4:10 p.m., CNA #4 was seated next to the door to the outside patio on the secured unit. CNA #4 said they were assigned to stay by the door until 10:00 p.m. and then another staff member was to take her place for the next shift. On 1/14/25 at 3:00 p.m. the corporate consultant nurse (CCN), the nursing home administrator (NHA) and the DON demonstrated that the door was fixed. The alarm sounded loudly when the door was opened. III. Staff interviewsCNA #1, CNA #2 and CNA #3 were interviewed together on 1/13/25 at 12:20 p.m. CNA #1 said the alarm had not sounded when the door was opened by a resident for several months. CNA #1 said the staff rounded hourly on the 35 residents and tried to keep an eye on the three residents who often pushed on the door crossbar and attempted to get outside. CNA #1 said to keep an eye on three men meant to hope to know where they were located at all times. CNA #1 said they had never been trained on how to set or reset the egress door in the secured unit. CNA #1 said the residents in the male secured unit must be supervised when outside because the ground was uneven, which had concrete walk ways, and rock gardens that could be tripped on. CNA #2 said about 10 out of the 35 men in the secured unit went out to smoke seven times per day. CNA #2 said the men were escorted outside by two staff members, while one staff member walked up and down the hallway in front of the egress door to keep men from pushing on the door to follow the smokers outside. CNA #2 said it was difficult to keep an eye on everything on the secured unit and to make sure no one escaped. CNA #2 said they were never trained how to set or reset the door so that it locked. CNA #2 said the alarm did not work to notify the staff if a resident opened the door. CNA #3 said the alarm and door system had not worked properly for several weeks. CNA #3 said the old maintenance director was told many times but the door was never fixed. CNA #3 said a previously facility ownership company had trained staff how to use the door and its alarm, but there had been no training with the new company. CNA #5 was interviewed on 1/13/25 at 3:50 p.m. CNA #5 said in the seven months of working in the facility on the memory care unit the alarm never sounded to alert the staff if a resident went out the door from the secured unit to the outside. CNA #4 said one time a few weeks prior she found two residents sitting unattended outside in the courtyard and she brought them back inside. She said the alarm did not sound to warn staff that the door was opened. The DON was interviewed on 1/13/25 at 4:00 p.m. The DON said the courtyard to the male resident's secured unit should never have residents in it unsupervised. The DON said he was unaware the alarm was broken to the egress door on the secured unit. The NHA, the CCN and the DON were interviewed together on 1/13/25 at 4:05 p.m. The NHA, the CCN and the DON said the corporate plant operations manager (CPOM) and the facility environmental service director (ESD) had begun a plan to immediately fix whatever was broken on the door, as well as the alarm that was identified during the survey. The NHA said until the door was fixed correctly a CNA would sit next to the door to ensure the resident's safety. The NHA said the staff would be placed outside the door until the alarm was fixed and had been tested several times. The NHA was interviewed on 1/14/25 at 9:30 a.m. The NHA said the door and alarm had been fixed. He said a CNA would sit outside the door until the door had several safety inspections. The NHA said an action plan was created for the door on the memory care unit. The NHA said the action plan included how the facility staff would be trained on how the doors and alarms operated. (see action plan below). The NHA said none of the 35 men on the secured unit should be in the courtyard unsupervised. The ESD was interviewed on 1/14/25 at 2:15 p.m. The ESD said he started working at the facility seven days ago. The ESD said he was part of the team that fixed the door the previous night on 1/13/25. The ESD said the alarm had not sounded and a part was ordered. He said the part arrived today on 1/14/25and was immediately put in the alarm system. The ESD said the egress door and alarm worked correctly now. He said he would check the door daily for a week to make sure the door alarm worked correctly. The ESD said the NHA had an action plan for the door to be checked weekly. He said he used a computer system to enter maintenance orders. The ESD said today he and the NHA implemented that the NHA would receive work orders also from the maintenance system. The ESD said he had an assistant who came in today to learn about the security systems for the door in the secured unit. The NHA was interviewed on 1/14/25 at 2:20 p.m. The NHA said no one told him that the door on the secured unit had not operated correctly, nor did anyone inform him about the alarm not sounding. The NHA said he assumed the staff verbally told the prior maintenance director and that person never told anyone or fixed the situation. The NHA said he reviewed the electronic work order system and did not see any maintenance requests for the door. The NHA said the gate in the courtyard was also updated at the time the egress door alarm was fixed. D. Facility follow-upThe facility action plan was provided via email on 1/14/25 at 10:27 a.m. from the NHA. It revealed in pertinent part,The identification of the problem: The exit door on the Mountain View unit (men's secured unit) to the outside courtyard no longer alarms. When the door was pushed the red/green light would blink back and forth. The door was not secured and could be opened. The alarm to the outside gate would only alarm when pressure was being applied. Once the magnet disengaged it stopped alarming. Identification of other potential problems/concerns: This could be a potential hazard due to residents attempting to exit seek going unnoticed. This could also have caused a potential concern if a resident was able to leave the facility, enter into the courtyard and then would be unable to get back into the facility. Corrective action or systemic changes: Upon knowledge of the issue with the door, a staff member was placed next to the door going to the courtyard. The staff member that monitored the exit, was responsible to to log any residents that attempted to exit seek out the door. On 1/13/25 the regional director of plant operations (RDPO) upon assessment utilized the alarm to gate (the) secure door. The courtyard door was functioning during testing. The door would continue to be monitored until the QAPI (quality assurance and performance improvement meeting) was completed. Upon resolving the door, the staff would monitor the residents who went outside for smoking and would be marked on roster upon entering the courtyard and again at completion of smoke break to verify resident count. This will remain in place until the gate is secured, and the alarm is functioning. An alarm part was ordered on 1/13/2025 to repair the alarm system. The part is scheduled to arrive at the facility on 1/14/25. On 1/14/25 the ESD will reach out to (company name) to address the gate. The goal is for it to function with an alarm until code was entered to resolve the alarm. NHA was added to (name) computer work order system, the program where maintenance requests and other facility information is stored. Education was provided to staff on door process and utilizing (maintenance requests) work order communications and informing the ESD.Responsible party and corrective action/completion: The NHA and the ESD would be responsible for ensuring completion and repair of the alarm system at the door. The completion date for repairing the door alarm is 1/15/25."-However, the action plan was not created until 1/13/25, during the survey.

Plan of correction · submitted by the facility

Corrective Action On 1-13-2025, Maintenance Director (MD), placed the alarm on secure door and ordered second alarm to replace gate alarm. On 1-14-25, MD obtained alarm part and replaced gate alarm. On 1-17-25, Door Specialties corrected the courtyard gate to have keypad to resolve gate alarm. Identification of Others On 1-21-25, MD assessed and corrected alarms to non-secure doors on south unit. Systemic Change Egress doors to be monitored utilizing maintenance monitoring system (TELs). On 1-31-25, the Director of Staff Development (DSD), will educate staff on entering work requests into maintenance monitoring system, door/gate alarm process. Monitoring Beginning on 1-14-25, MD/designee will audit via audit form the secured unit door 5x week for 30 days, then 2x week for 60 days. Nursing Home Administrator (NHA) to review results monthly and report findings to QAPI x 3 months. The QAPI committee will decide as to the frequency of on-going monitoring.

1/14/2025Licensure Complaint Survey · ID W044111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A survey prompted by complaint #CO39004 was completed on 1/13/25 to 1/14/25. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

2302Secure Environment▼

Findings

Based on record review and interviews, the facility failed to ensure compliance with secure environment requirements for three (#2, #4 and #8) of five residents reviewed for secure unit placement out of seven sample residents. Specifically, the facility failed to ensure the designated team who was responsible for evaluating the placement of residents in a secured environment included an independent reviewer with mental health or social worker training who was not a facility staff member. Findings include:I. Policy and procedure The Secured Environment Placement policy, implemented on 1/14/25 (during the survey), was provided via email by the nursing home administrator (NHA) on 1/14/25 at 1:05 p.m. It read in pertinent part,"This policy outlines the procedures and guidelines for initial placement and continued stay in a secured environment and to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being."Each facility will develop a designated team to evaluate placement of a resident in a secure environment. The team shall include, at a minimum, the director of nursing or designee, a social services staff member, the administrator or designee and an individual (with mental health or social work training as appropriate to the needs of the residents) who is not a facility staff member."Residents will be assessed on admission, to determine the appropriateness of the secured environment."Residents will be reassessed 30 days after initial admission, to determine the appropriateness of the secured environment."Residents should be reassessed every six months, or sooner if there is a change in condition, to determine the continued appropriateness of the secured environment."An independent outside reviewer with mental health or social work training as appropriate to the needs of the residents, who is not a facility staff member, will assist with evaluation to determine appropriateness of placement in the secured environment with initial evaluation, change of condition, and continued stay."II. Resident #2A. Resident statusResident #2, age 70, was admitted on 12/24/24 and discharged to the hospital on 1/9/25. According to the January 2025 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), vascular dementia, type 2 diabetes, major depressive disorder, generalized anxiety, chronic obstructive pulmonary disease (COPD), difficulty in walking and post-traumatic stress disorder (PTSD). The 1/9/25 facility assessment revealed the resident had moderative cognitive impairment. He had delusions. He had verbal behavioral symptoms directed towards others. He required assistance with bathing, dressing and toilet use. He used a front wheel walker for mobility. B. Record ReviewThe initial evaluation for Resident #2's secured neighborhood placement, dated 12/28/24, was signed by social services director (SSD) #1, the NHA, and an independent reviewer who was an activity director consultant (ADC).-The evaluation did not include a signature from an individual with mental health or social services knowledge who did not work for the facility. C. Staff interviewThe ADC was interviewed on 1/13/25 at 1:25 p.m. via the phone. The ADC said she did not have a degree in mental health or social services. The ADC said she was an activity director and had a consultation business for activities. The ADC said she came to the facility monthly to only provide activities consultation. The ADC said she currently did activities for people with behavioral needs. The ADC said the facility asked her to sign as the independent reviewer for the secured unit placement evaluations. The ADC said she had signed several resident placements for the secured neighborhood for the facility. III. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on 8/30/24. According to the January 2025 CPO, diagnoses included dementia, mild, with psychotic disturbances, hypertension (high blood pressure), depression and emphysema. The 12/3/24 facility assessment revealed the resident had severe cognitive impairment. He was often socially isolated, had physical and verbal behavioral symptoms directed towards others, and wandered daily. He required supervision assistance with dressing, eating and oral hygiene. B. Record reviewThe initial evaluation for Resident #4's secured neighborhood placement, dated 8/30/24, was signed by the facility's director of nursing (DON), the NHA, SSD #1, and SSD #2, who worked for the same corporation but in another building.-The evaluation did not include a signature from an individual with mental health or social services knowledge who did not work for the facility or the corporation. C. Staff interviewSSD #2 was interviewed on 1/14/25 at 11:52 a.m. via the phone. SSD #2 said she was unaware a company employee was not considered an independent reviewer for the secure neighborhood placement evaluations. SSD #2 said she was paid by the same company as the facility where she signed secured placement evaluations as an independent reviewer. IV. Resident #8A. Resident statusResident #8, age 73, was admitted on 9/5/24. According to the January 2025 CPO, diagnoses included dementia with other behavioral disturbances and seizures. The 12/3/24 facility assessment revealed the resident had severe cognitive impairment. He had delusions, sometimes had social isolation, and rejected care from staff daily. He required supervision with oral hygiene, toileting and dressing. B. Record reviewThe initial evaluation for Resident #8's secured neighborhood placement, dated 12/20/24, was signed by SSD #1, the NHA and the ADC (as the independent reviewer. -The evaluation did not include a signature from an individual with mental health or social services knowledge who did not work for the facility or the corporation. V. Additional staff interviewsThe DON and SSD #1 were interviewed together on 1/14/25 at 11:00 a.m. The DON and SSD #1 said they were unaware the independent reviewer for the secured neighborhood placement evaluations could not be a company employee. The DON and SSD #1 said they were unaware that the ADC, who was an activity director, did not have the required degrees to appropriately evaluate resident placement for the secured unit. The NHA and the corporate consultant nurse (CCN) were interviewed together on 1/14/25 at 12:00 p.m. The NHA and the CCN said they were unaware the independent reviewer for secured unit placement evaluations needed a background in mental health or social services. The NHA and the CCN said they did not know the independent reviewer for the evaluations could not be a company employee. The NHA said he knew the ADC was an activity director. The CCN said she would find an independent reviewer who did not work for the company and who also had the appropriate background in mental health or social services. VI. Facility action planThe facility's 1/13/25 action plan was provided via email by the NHA on 1/14/25 at 1:05 p.m. It read in pertinent part, "Identification Problem or Concern:"It was brought up to the NHA, DON, and SSD that the independent reviewer for placement in the secure unit does not meet all the qualifications necessary to fill that role."Identification of other potential problems/concerns:"This could be a potential concern in ensuring the need for a secure unit for the resident. Each resident should have the proper documentation of the need for a secure unit."Corrective Action or Systemic changes:"Within 14 days, the facility will identify an outside independent reviewer with mental health and/or social work experience and background. Within 30 days, we will meet with IDT (interdisciplinary team) and an independent reviewer to reestablish placement for the secure unit."Responsible Party and corrective action/completion date:"The facility SSD will take the lead as the primary responsible party. The NHA and DON will also ensure that proper corrective action is completed. The completion date for reestablishing secure unit placement for all residents in the secured units is 2/13/25."Monitoring and Performance Improvement"After completion, the secure unit placements will be reviewed and audited monthly for 90 days. The IDT team will address the corrective action in the February 2025 QAPI (quality assurance and performance improvement) meeting."-However, the facility's action plan was not created until 1/13/25, during the survey.

Plan of correction · submitted by the facility

S2302 Corrective Action Resident #2 discharged 1-9-25. Resident #4 Evaluation for secure neighborhood placement completed. Resident #8 Evaluation for secure neighborhood placement completed. Identification of Others By 2-3-25, all residents residing on the secure unit will have an Evaluation for secure neighborhood placement. Systemic Changes On 1-14-25, Regional Director of Clinical Services (RDCS) created a Secured Environment Placement policy. On 1-31-25, the Nursing Home Administrator (NHA) educated Interdisciplinary Team (IDT) on policy and process for secure neighborhood placement. Monitoring Beginning on 2-5-25, the Social Services Director (SSD), will audit via audit form residents who admit to the secure unit for Evaluation for secure neighborhood placement 1x week for 90 days. NHA to review results monthly and report findings to QAPI x 3 months. The QAPI committee will decide as to the frequency of on-going monitoring.

10/9/2024Complaint Survey · ID ZS6111No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A survey prompted by Incident #37498 was conducted 10/9/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

8/19/2024Revisit: Complaint Survey · ID 49ZS12No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A revisit survey was completed on 8/19/24 for all previous deficiencies cited on 7/23/24. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

7/23/2024Complaint Survey · ID 49ZS111 deficiency▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO33671, #CO36794, and #CO36796 was conducted on 7/23/24. One deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0925Maintains Effective Pest Control ProgramS/S E▼

Findings

Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to take the appropriate measures to control a fly infestation in the kitchen and dining room. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, pp. 95 (updated 1/8/24), retrieved on 7/25/24 from https://www.cdc.gov/infection-control/hcp/environmental-control/environmental-services.html#cdc_generic_section_6-6-pest-control, "Cockroaches, spiders, and mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. "From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on eliminating food sources, indoor habitats, and other conditions that attract pests, excluding pests from entering the indoor environments; and applying pesticides as needed. "Insect habitats are characterized by warmth, moisture, and availability of food. Cockroaches, in particular, and anywhere in the facility where water or moisture is present." II. Facility policy and procedure The Pest Control policy, revised November 2022 was provided by the nursing home administrator (NHA) on 7/23/24 at 2:15 p.m. It read in pertinent part, "The facility shall maintain an effective and ongoing pest control program to ensure that the building is kept free of insects and rodents." III. Observations and interviews A. Resident interviews and observations Resident #7 was interviewed on 7/23/24 at 11:53 a.m. Resident #7 was seated in the dining room eating her lunch. Several flies were landing on the table where the resident's food was placed. One fly landed on the resident's hand as she held her fork. Another fly was hovering around her head and shoulder area. Resident #7 said the flies bothered her all the time and she did not like it. She said she had complained about the flies to the management, however, she said the facility seemed unable to prevent flies from entering the dining room. She said she did not appreciate that the flies walked on her skin. Resident #7 said the flies were getting on her last nerve and they were gross. Resident #5 was interviewed on 7/23/24 at 12:00 p.m. Resident #5 self-propelled himself into the dining room. The resident had a green fly swatter across his lap. He said he did not like that there were so many flies in the dining room bothering him when he was trying to eat his meal. He said he brought a fly swatter with him all the time. Resident #8 was interviewed on 7/23/24 at 12:20 p.m.. Resident #8 said the flies were taking over the facility's dining room. The resident said he hurried through eating his lunch to avoid flies touching his food. Resident #8 was finishing his coffee in the dining room. Resident #8 said he and other residents had reported the issue several times to the staff and it seemed the facility was unable to prevent the flies from coming into the dining room. B. Kitchen and dining room observations On 7/23/24 at 10:34 a.m. there were several flies in the main kitchen where lunch was being prepared. The back door of the kitchen, leading to the area where trash dumpsters were kept, had no screens and was open, enabling flies into the kitchen area and the dining room. There were several flies hanging on the kitchen ceiling and flying all over the kitchen and the dining room. At 11:45 a.m., the staff started serving beverages to the residents whohad arrived in the dining room. There were flies on several dining room tables flying from one table to the other. Flies were observed walking on residents' bodies. IV. Staff interviews Dietary aide (DA) #1 was interviewed on 7/23/24 at 12:39 p.m. DA #1 said the back door of the kitchen was opened to allow steam from the beef pot pie to evaporate. She said there were several flies in the kitchen and they had been a problem. The dietary manager (DM) was interviewed on 7/23/24 at 12:45 p.m. The DM said the flies continued to be a problem in the kitchen and dining room area. The DM said there were several flies flying around the kitchen and walking on the ceiling. He said the flies were unsanitary and they could contaminate the food preparation surfaces, which could cause illness to residents and staff. The DM said the facility was aware of the fly infestation and had implemented several measures, such as insect zappers and a frequent exterminator, however, he said the flies continued to be an issue. The NHA and the director of nursing (DON) were interviewed together on 7/23/24 at 12:59 p.m. The NHA said flies were still a problem at the facility. The NHA said the facility had been dealing with flies due to the location of the facility. He said the facility was located in a cattle community which made it difficult to eradicate the fly infestation. The NHA said he had implemented several interventions, such as an electrical insect control system by the back door of the kitchen and several places throughout the facility and using a professional exterminator, which had helped reduce the number of flies in the building but had not completely resolved the issue. The NHA said he received an estimate for the introduction of screen doors in the kitchen and the dining room and was working on getting screen doors. The DON said Resident #5 enjoyed roaming around with his fly swatter in his hands. The NHA said the maintenance and housekeeping managers were recently terminated and the facility was working on hiring their replacements. The NHA said he was initiating education for the kitchen staff to ensure the kitchen's back door remained closed at all times to prevent flies from entering the kitchen through it.

Plan of correction

The state did not require a plan of correction for this citation.

12/19/2023Revisit: Recertification Survey · ID 1JBN22No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

An onsite revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

Plan of correction

The state did not require a plan of correction for this citation.

10/27/2023Revisit: Complaint, Recertification Survey · ID 1JBN12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 10/27/23 for all previous deficiencies cited on 7/27/23. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

8/31/2023Complaint Survey · ID YPXC11No deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

A complaint survey, prompted by #CO33422 was conducted on 8/30/23 - 8/31/23. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

8/17/2023Recertification Survey · ID 1JBN219 deficiencies▼

0000INITIAL COMMENTSSurveyor note▼

Findings

INITIAL COMENTS (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). This survey was conducted on August 17, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a one (1) story, Type II (000) (II-B) construction. The facility was constructed in 1955 and has no basement. The facility is licensed 105 beds and the census on the date of this survey was 94. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry pipe fire sprinkler systems. The dry-pipe fire suppression system protects the attic spaces and the exterior canopy. This facility is classified as fully sprinklered. The results of this survey was discussed with the Administrator and Maintenance staff during the exit conference.

Plan of correction

The state did not require a plan of correction for this citation.

0211Means of Egress - GeneralS/S D▼

Findings

Based on observation and staff interview, it was determined that the facility failed to maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This was evidenced by the following: 1. Southeast exit from memory care has a secured gate that does not swing in the direction of travel to reach a public way. NFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101, 7.2.1.4.2* Swing Direction. Door leaves required to be of the side-hinged or pivoted-swinging type shall swing in the direction of egress travel. This deficient practice could affect all residents, staff and visitors throughout the smoke compartment should this exit discharge be needed during an emergency. The exit deficiency was discussed during the exit conference.

Plan of correction · submitted by the facility

1. Community moved hinge to the exit fencing to assure proper egress on 9/2/23.2. Maintenance director was educated on proper way of egress for doors on or before 9/25/233. Maintenance Director or designee will complete a monthly audit on proper egress of community doors 4. Results of the audit will be reviewed monthly x3 and will be presented during QAPI for advisement 5. Compliance established 9/25/23

0293Exit SignageS/S D▼

Findings

Based on observation and staff interview, it was determined that the facility failed to maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. This deficient practice could affect all residents, staff and visitors throughout the smoke compartment if the exit cannot be identified during an emergency. This was evidenced by the following:1. Exit sign is not illuminated in the female memory care corridor. NFPA 101, 7.10.5.2.1 Every exit sign shall be continuously illuminated as required under the provisions of Section 7.8, unless otherwise provided in 7.10.5.2.2. The exit sign deficiency was discussed during the exit conference.

Plan of correction · submitted by the facility

1. Community ordered new exit sign for female memory care corridor on 9/6/232. Maintenance Director was educated on appropriate operating exit signage on or before 9/25/23.3. Maintenance Director will c all audit exit signage for proper operation weekly. 4. Results of the audit will be reviewed monthly x3 during QAPI for advisement 5. Compliance established 9/25/23

0321Hazardous Areas - EnclosureS/S D▼

Findings

Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 101, Section 19.3.2.4 and NFPA 99, 11.5.1.1.4. This was evidenced by the following:1. Beauty Salon door missing "No Oxygen" signage to prevent oxygen from being used near a heat sourceNFPA 99, 11.5.1.1.4 Non-medical appliances that have hot surfaces or sparking mechanisms shall not be permitted within oxygen delivery equipment or within the site of intentional expulsion. This deficiency has the potential to affect all occupants and staff within the smoke compartment. This deficiency was discussed during the survey and again during the exit conference.

Plan of correction · submitted by the facility

1. Community ordered "No Oxygen" signage on 9/6/23, community currently has paper sign in place until professional signage arrives. 2. Maintenance Director was educated on having "No Oxygen" signage outside of Beauty Supply on or before 9/25/233. Maintenance Director or designee will audit signage outside of beauty shop monthly. 4. Results of the audit will be reviewed monthly x3 during QAPI for advisement 5. Compliance established on 9/25/23

0324Cooking FacilitiesS/S D▼

Findings

Based on observation 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. This was evidence by the following:1. No records or documentation for annual blow down testing. 2. Hood suppression system nozzles not aligned with cooking surfaces. 3. Kitchen hood shows excessive accumulation of grease and requires cleaning. NFPA 96, 11.6.2* Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to remove combustible contaminants prior to surfaces becoming heavily contaminated with grease or oily sludge. NFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure the appliance is returned to an approved design location. NFPA 96, 12.1.2.2* Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior re-evaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire extinguishing system. This deficient practice could affect all residents, and staff should a fire occur and the suppression system fails to operate effectively due to non-code compliant positioning of cooking appliance. The deficiency was discussed during the exit conference.

Plan of correction · submitted by the facility

1. Community scheduled a blown down testing and hood cleaning to be completed prior to 9/25/23, on 9/5/23 community assured that Hood suppression nozzles were aligned with cooking surfaces. 2. The Maintenance Director and Dietary Manager were educated on maintaining proper kitchen practices regarding maintaining kitchen hood suppression system and cooking appliance restraints. 3. Community will audit kitchen blow down testing and hood cleaning monthly to determine if scheduled services are needed. 4. Community will review the results of the audits monthly x3 during QAPI for advisement. 5. Compliance established on 9/25/23

0345Fire Alarm System - Testing and MaintenanceS/S F▼

Findings

Based record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the NFPA 101, Life Safety Code Section 21.3.4, 9.6.1.5, and NFPA 72. This was evidenced by:1. No records or documentation for 2-year smoke detector sensitivity testing. 2. Main FACP indicates a "Trouble" condition on the panel. 3. Covered smoke detectors found in construction areas near nurses station. NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, 14.2.1.1.2 Inspection, testing, and maintenance programs shall verify correct operation of the system. NFPA 72, 14.4.5.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. NFPA 72, 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. NFPA 72, 14.4.5.3.2 Sensitivity shall be checked every alternate year. This deficiency was discussed during the exit conference.

Plan of correction · submitted by the facility

1. Community provided record of smoke sensitivity being completed on 7/19/23. FACP panel was called and trouble condition was cleared on 8/23/23, plastic bags were removed from construction area on 8/17/23.2. Maintenance director was educated on smoke sensitivity requirements, and how to contact fire panel company as well as appropriate smoke detector practices on or before 9/25/23.3. Maintenance director will maintain fire alarm system records to be audited by NHA monthly. 4. Results of the audit will be reviewed monthly x3 during QAPI for advisement 5. Compliance established 9/25/23

0353Sprinkler System - Maintenance and TestingS/S F▼

Findings

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with Life Safety 101, Section 21.3.5 and NFPA 25, 4.1.4.1 & 14.2.1. This was evidence by the following. 1. No records or documentation for fire sprinkler 5-year internal pipe inspection. 2. Kitchen fire sprinklers are loaded with grease and dust. 3. Dry pendant fire sprinkler in kitchen cooler shows evidence of leaking. 4. Storage too close to fire sprinkler in linen closet near room 52. NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. Section 21.3.5 and NFPA 25, 5.2.1 NFPA 25, 4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. NFPA 25, 14.2.1 Inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main, and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. The deficiencies were discussed during the exit conference.

Plan of correction · submitted by the facility

1. Community will schedule a fire sprinkler 5 year internal pipe inspection on or before 9/25/23, community will clean or schedule to have fire sprinklers cleaned in kitchen on or before 9/25/23, additionally community will repair the fire sprinkler in kitchen cooler that shows evidence of leaking on or before 9/25/23. Lastly community removed items being stored in linen closet on 8/17/23.2. Maintenance Director will be educated on 5 year internal pipe inspection, cleanliness of sprinklers in community, sprinkler checks, and appropriate storage parameters on or before 9/25/23.3. Community Maintenance Director or designee will implement auditing of monthly checks on fire sprinkler heads to assure they are in safe working condition. 4. Community will review the results of the audits in QAPI monthly x3 for advisement 5. Compliance established 9/25/23 4

0712Fire DrillsS/S F▼

Findings

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Sections 19.7.1.6 and 4.7.4. This was evidenced by the following: 1. No records or documentation of fire drills for all shift in all quarters. NFPA 101 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. NFPA 101, 4.7.4. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. 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 was discussed during the exit conference.

Plan of correction · submitted by the facility

1. Community will develop a plan to complete fire drills for all shifts for all quarters to attain and maintain compliance. 2. Maintenance director will be educated on fire drill policy and practices that support community compliance on or before 9/25/233. NHA or designee will audit the fire drill log monthly to assure that fire drills are being completed accurate, and timely in accordance to life safety code. 4. The results of the audit will be present a QAPI for advisement 5. Compliance established 9/25/23

0911Electrical Systems - OtherS/S D▼

Findings

Based on observation, it was determined that the facility failed to maintain proper electrical practices in accordance with NFPA 101, 9.1.2, and NFPA 70, National Electrical Code Section 110.12. This was evidenced by the following deficiencies:1. Open electrical junction boxes and exposed wiring in construction area near the nurses station. NFPA 101, Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical CodeNFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and workmanlike manner. This deficient practice could affect all occupants and staff throughout the smoke compartment if improper maintenance of electrical equipment causes a fire. The deficiency was discussed during the exit conference.

Plan of correction · submitted by the facility

1. Community completed construction resulting in the covering of wire on 8/30/232. Maintenance Director was educated on covering all wires during construction on or before 9/25/23.3. Maintenance Director or designee will create best practices sheet to provide to all construction teams completing work moving forward 4. Compliance established 9/25/23

0918Electrical Systems - Essential Electric SysteS/S F▼

Findings

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1. No records or inadequate documentation of generator battery monthly conductance testing. 2. No records or inadequate documentation of monthly generator testing. NFPA 110, 8.3.7.1 The required monthly testing and recording of electrolyte specific gravity or conductance results (Reserve Capacity, "RC") of the lead acid batteries in connection with the emergency power supply system (generator) were not completed as required. The emergency power supply system provides power for emergency lighting. Ref: 2012 NFPA 101 Section 21.2.9, 7.9.2.4, 4.6.12.1 / 2010 NFPA 110 Section 8.3.7.1NFPA 110, 8.4.1 EPSSs, including all appurtenant components shall be inspected weekly and exercised under load at least monthly. This deficiency has the potential to affect all occupants, which might include staff, residents, and visitors should the generator fail to start during an emergency. This was discussed during the record review and again during the exit conference.

Plan of correction · submitted by the facility

1. Community complete a generator test on 8/21/232. Maintenance Director was educated on timely completion of the test on or before 9/25/233. Maintenance Director will complete a monthly test and documentation will be audited by NHA.4. Results of the audit will be reviewed monthly x3 during QAPI for advisement 5. Compliance established 9/25/23

7/27/2023Complaint, Recertification Survey · ID 1JBN119 deficiencies▼

0000Initial CommentsSurveyor note2 building records▼

Findings · record 1 of 2

A recertification survey with complaint #CO31662, #CO32823, #CO32824, #CO32868 and #CO32972 was completed on 7/24/23-7/27/23. Nine deficiencies were cited.

Findings · record 2 of 2

An Emergency Preparedness survey was conducted from 7/24/23-7/27/23. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0550Resident Rights/Exercise of RightsS/S E▼

Findings

Based on observations, interviews and record review, the facility failed to ensure resident's had the right to a dignified existence. Specifically, the facility failed to provide a dignified living experience adequate by answering resident call lights timely in two of three units that resulted in call light response times up to two hours and 55 minutes. Findings include:I. Facility policyThe Answering the Call Light policy, revised October 2010, was provided by the nursing home administrator (NHA) on 7/27/23 at 1:07 p.m. It read in pertinent part, "When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. Report all defective call lights to the nurse supervisor promptly. Answer the resident's call light as soon as possible. Be courteous in answering the resident's call. Steps in the procedure: turn off the signal light; identify yourself and call the resident by his or her name; list to the resident's request; do what the resident asks of you if permitted; if uncertain ask the nurse supervisor for assistance."II. Resident census and conditionsAccording to the 7/24/23/23 Resident Census and Conditions of Residents report, the resident census was 93 and the following care needs were identified:-55 residents needed assistance of one or two staff with bathing and 35 residents were dependent. Three residents were independent.-60 residents needed assistance of one or two staff members for toilet use and three residents were dependent; 30 residents were independent.-68 residents needed assistance of one or two staff members for dressing and two were dependent; 23 residents were independent.-55 residents needed assistance of one or two staff members and seven were dependent for transfers; 31 residents were independent.-58 residents needed assistance of one or two staff members with eating and 35 were independent. III. Resident interviews and observationsResident #12 was interviewed on 7/24/23 at 11:28 a.m. He said there were not enough staff and a registered nurse was needed on Mountain View. He said the facility used a lot of agency nurses and CNAs. Resident #25 was interviewed on 7/24/23 at 1:46 p.m. She said she waited one to one and a half hours for staff to answer her call light. Resident #57 was interviewed on 7/24/23 at 1:56 p.m. He said he waited up to two hours for his call light to be answered and CNAs told him there were problems with the call lights and the lights turned off by themselves before the staff could respond. He said sometimes he used his cellphone to call the front desk for help. He waited two hours for his light to be answered once and had an incontinence episode as a result. He said there were more issues having a call light answered timely after dinner. Resident #79 was interviewed on 7/24/23 at 2:30 p.m. He said he waited at least an hour to have his call light answered and in the morning he was not able to get out of bed because the staff were too busy to help him. He said staff told him he had to wait in the morning because the staff were busy helping with breakfast service. Resident #81 was interviewed on 7/24/23 at 2:30 p.m. She said she waited up to two hours for her call light to be answered. She said she thought the wait had to do with the timing of the duties staff had to complete. Resident #46 was interviewed on 7/24/23 at 3:49 p.m. He said there were not enough staff to take care of all the residents in the facility. IV. Record reviewCall light response times from 7/19/23 to 7/26/23 were provided by the nursing home administrator on 7/26/23 at 2:30 p.m. The staff response times longer than 20 minutes to Resident #57's room after he pushed his call button for assistance were as follows:-On 7/19/23 26 minutes.-On 7/20/23 26 minutes.-On 7/20/23 55 minutes.-On 7/21/23 one hour and six minutes.-On 7/22/23 44 minutes.-On 7/23/23 25 minutes.-On 7/24/23 24 minutes.-On 7/25/23 53 minutes. The staff response times longer than 20 minutes to Resident #79 and Resident #81's shared room after the residents pushed the call button for assistance were as follows:-On 7/20/23 one hour and nine minutes.-On 7/21/23 at 6:27 a.m. 44 minutes.-On 7/21/23 at 8:38 a.m. 40 minutes.-On 7/21/23 at 8:03 p.m. 26 minutes.-On 7/22/23 one hour and 23 minutes.-On 7/23/23 one hour and 55 minutes.-On 7/24/23 at 4:01 a.m. 35 minutes.-On 7/24/23 at 8:29 a.m. 57 minutes.-On 7/24/23 at 3:18 p.m. two hours and 55 minutes.-On 7/26/23 at 5:00 a.m. 49 minutes.-On 7/26/23 at 5:56 a.m. 35 minutes. The staff response times longer than 20 minutes to Resident #72's room after she pushed his call button for assistance were as follows:-On 7/19/23 35 minutes.-On 7/20/23 32 minutes. -On 7/21/23 one hour and 20 minutes. -On 7/22/23 47 minutes.-On 7/23/23 at 2:55 p.m. 57 minutes.-On 7/23/23 at 4:24 p.m. one hour.-On 7/25/23 one hour. V. Staff interviewsRegistered nurse (RN) #2 was interviewed on 7/26/23 at 2:00 p.m. She said the CNAs used pagers but the nurses did not and she was unsure if both of the CNAs on that unit had pagers on them, but she thought at least one CNA did. She said staff used the computer monitor in the office to see if a resident had pushed their call button and staff should be checking the monitor. She said not all the residents on the Aspen unit used their call lights. CNA #8 was interviewed on 7/26/23 at 2:35 p.m. She said call lights were triggered on a computer screen at the nurses' station and the computer made a noise the CNAs responded to. She said the CNAs did not carry pagers on the unit. CNA #3 was interviewed on 7/27/23 at 12:41 p.m. and said the CNAs did not carry pagers although they were supposed to. She said the pagers did not work most of the time. CNA #3 said the CNAs listened for noise from the computer when they walked by the nurses' station or they looked at the computer screen to see if a call light was triggered. The NHA and infection preventionist (IP) were interviewed on 7/27/23 at 11:00 a.m. The NHA said the CNAs should all have pagers. She said she did review the call light logs and saw some extended wait times. She said two of the residents required a hoyer and extensive care and the facility had issues in which staff provided resident care and call lights were left on. She said she could not speak to any of the extended wait times as to the exact reason but there were a couple residents that have staff cell phone numbers for concerns. She said the call lights were only able to be shut off on the wall in the resident's room and staff were to walk by the monitor at the nurses station to see if any residents pushed their call button. She said the monitor made a sound when a resident pushed their call button. The NHA said if there was a concern regarding long response time to call lights, an audit was done but not on a regularly scheduled basis. If a concern was found a grievance was filled out. She said there were times the facility did not have enough pagers and consequently new pagers were ordered. That one person missing a pager could have been an agency staffing or additional staff issue to grab. The IP said if the facility did not have enough pagers for each CNA, management would would make sure each unit had at least one pager. She said if a resident needed assistance from two staff members, a call light in a resident's room should stay on until the second staff person entered the room to assist but the process was not consistent. She said staff were able to silence the pagers but the pagers still flashed if a resident's call light was on, and the pagers had vibrate as well as a sound option. She said the staff did take the pagers home occasionally.

Plan of correction

The state did not require a plan of correction for this citation.

0600Free from Abuse and NeglectS/S E▼

Findings

Based on interviews and record review, the facility failed to ensure freedom from resident-to-resident abuse for three (#71, #43 and #10) of six residents reviewed out of 35 sample residents. Specifically the facility failed to ensure Residents #71, #43 and #10 were free from abuse by Resident #39. All four residents lived in the secure unit. Cross-reference F744, dementia care services. Findings include:I. Facility policyThe Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy, last revised in April 2021, was provided by the nursing home administrator (NHA) on 7/24/23. It read in pertinent part:"Protect residents from abuse by anyone including, but not limited to: other residents. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents. Identify and investigate all possible incidents of abuse."II. Abuse incidents involving Resident #39 against other residentsFacility investigation reports and medical record documentation revealed the following:A. Physical abuse incident #1 on 6/11/23 at 9:20 a.m.-Resident #39 (assailant) and Resident #71 (victim)On 6/11/23 at approximately 9:20 a.m. Resident #71 and Resident #39 were observed by a certified nurse aide (CNA) as they stood by the locked door in the secure unit. The CNA was on the opposite side of the locked door and was not able to intervene because the door was blocked by the residents and it would not open. The CNA witnessed "a fist fly" and Resident #71 hit the wall. Resident #39 grabbed Resident #71. The CNA attempted to get another staff's attention to help. Resident #71 was sent to the emergency room 6/11/23 after an altercation with Resident #39. The after visit summary listed the reasons for Resident #71's treatment as "assault victim." Resident #71 was diagnosed and treated for a scalp laceration. The discharge summary from the hospital read:"Your vital signs were reassuring. There is no evidence of traumatic injury on the CT (computerized tomography which includes a series of x-ray images taken from different angles) of your head, C-spine, chest abdomen pelvis. There was an incidental finding of an aortic aneurysm. There was a very small laceration on your scalp that did not require sutures or staples. Keep the area clean and dry. It is okay to wash with shampoo. No hydrogen peroxide. Tylenol up to 650 mg every four to six hours as needed for pain. Return to the ER (emergency room) for new or worsening concerns and otherwise follow-up with your primary care doctor."An interdisciplinary team (IDT) note was entered for Resident #71 in the facility's charting system on 6/12/23 at 8:39 p.m. by the NHA. The behavior observed was documented as "physical aggression received." The interventions were "resident (#71) was sent to the emergency room for evaluation and treatment. No head injury identified." The risk factors were "resident (#71) with confusion and intrusive behaviors observed prior to other resident (#39) responding by pushing resident (#71) back causing this resident (#71) to fall."-The IDT note was inaccurate based on the hospital report which documented a closed head injury and scalp laceration (above). An IDT note was entered for Resident #39 on 6/12/23 at 8:45 p.m. by the NHA. The behavior observed was documented as "physical aggression towards other resident." The interventions were "staff maintained distance between residents. Re-direction and police contacted. Frequent checks." The risk factors were "resident (#39) highly responsive to others. Resident responsive to other resident's intrusive behaviors as resident (#71) in close proximity and reaching down to touch him (#39) resident (#39) responds by pushing hand back causing other resident (#71) to lose balance and fall."The summary of the investigation read in pertinent part: "incident was witnessed by a staff member on the other side of the door. Video was reviewed." The facility documented abuse was unsubstantiated.-However, abuse should have been substantiated because the incident was witnessed and documented accordingly and Resident #71 was injured according to the hospital report. B. Physical and verbal abuse incident #2 on 6/11/23 at 4:25 p.m.-Resident #39 (assailant) and Resident #10 (victim)On 6/11/23 at 4:25 p.m. Resident #39 and Resident #10 were in the dining room. The registered nurse (RN) witnessed Resident #10 say something to someone behind him as he approached the medication cart. As Resident #10 received his medications Resident #39 "snuck up behind" Resident #10 and kicked him on the right thigh. The RN placed herself between the residents. Resident #39 was angry and said "I will kill you" and "I do not care, I will kill him." Resident #10 told the RN he had not said anything to Resident #39 when she asked Resident #10 what he said when he approached the medication cart. Immediate actions taken by the RN were documented as ensuring both residents were separated and attempting to calm the situation by talking to both residents. An internal investigation was initiated 6/11/23 and police were contacted. The summary of the investigation said "although physical contact was observed video monitoring reviewed showed resident (#39) kicking motion in response to (#10) flickering lights. No pain, injury, or fear identified."An interdisciplinary team (IDT) note was entered for Resident #10 on 6/12/23 at 9:29 p.m. by the NHA. The behaviors observed were documented as "resident received physical aggression from another resident." The interventions were documented as "staff immediately maintained separation of residents. Frequent checks. Police contacted." The risk factors were documented as "resident (#10) observed flickering lights on and off in the dining room. Other resident (#39) observed to respond to this resident's (#10) behavior by kicking foot out to try to get this resident (#10) to stop turning light on and off."An IDT note was entered for Resident #39 on 6/12/23 at 9:36 p.m. by the NHA. The behaviors observed were documented as "physical aggression toward another resident." The interventions were documented as "residents immediately separated. Frequent checks continue for this resident." The risk factors were documented as "resident highly responsive to behaviors of others. Resident appeared agitated by other resident (#10) flickering lights on and off in dining room. Resident (#39) observed to kick leg out making contact with other resident (#10)."The facility unsubstantiated abuse.-However, abuse should have been substantiated as it was witnessed and documented accordingly (above). C. Physical and verbal abuse incident #3 on 6/13/23 at 8:30 p.m.-Resident #39 (assailant) and Resident #43 (verbal assailant, victim of physical abuse)On 6/13/23 at 8:30 p.m. Resident #43 stood up out of his wheelchair. The licensed practical nurse (LPN) who witnessed the incident asked Resident #43 to sit so he would not fall. Resident #43 refused to sit down. Resident #39 told Resident #43 he needed to sit down because he would fall. Resident #43 was angered and called Resident #39 an (expletive). Resident #39 was upset and kicked Resident #43 in the thigh. Resident #43 told the LPN "he kicked me." The LPN approached Resident #39 and he said "he deserved to be kicked." The residents were separated, checked for injuries, and 15 minute checks were initiated. The LPN noted no injuries to either resident. The summary of the investigation was not documented by the facility. An IDT note for Resident #39 was entered by the social services director (SSD) #2 on 6/19/23 at 10:38 p.m. The behavior observed was "Resident (#39) was observed attempting to assist staff with redirecting another resident (#43), the other resident (#43) became upset with Resident #39. Resident #39 then attempted to kick out at the other resident (#43). The interventions were documented as "staff intervened, frequent checks, and anticipate needs. Staff re-education provided." The risk factors were "poor safety awareness and lacks insight to his current condition. An IDT note for Resident #43 was entered by the SSD #2 on 6/19/23 at 10:42 a.m. The behavior observed was entered as "staff were trying to have Resident #43 sit down so he would not fall. Resident #43 was refusing to sit down when another resident (#39) stated that he needed to sit down because he would fall. Resident #43 became angered and was cursing at the resident (#39), which upset the resident (#39) and he attempted to kick out at Resident #43." The interventions were "anticipate his needs, staff to be proactive when behaviors are being observed, frequent checks, redirect or remove from situations as needed." The risk factors were documented as "lack of insight to his current condition, poor safety awareness, difficult to redirect at times."The facility unsubstantiated abuse.-However, verbal abuse and physical abuse should have been substantiated as it was witnessed. III. Record reviewA. Resident #39 statusResident #39, age 70, was admitted on 4/12/22. According to the July 2023 computerized physician orders (CPO) diagnoses included senile degeneration of the brain (decreased ability to think, concentrate, or remember), mood disorder due to known physiological condition (traumatic brain injury), anxiety disorder, depression, and dementia with other behavioral disturbance. The 5/17/23 minimum data set (MDS) assessment showed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #39 had hallucinations, verbal aggression toward others, and behavioral symptoms not directed toward others (hitting himself, screaming out, rummaging) that occurred daily. These behaviors were documented as putting others at risk for receiving physical aggression, significant intrusion of other residents' privacy or activities, and significantly disruptive to the living environment. Resident #39's care plan, last revised on 3/13/23, identified a behavioral problem and was aggressive toward peers and staff due to his traumatic brain injury and dementia. Resident #39 had poor impulse control and had a potential to be physically aggressive toward staff and other residents. His triggers were listed as he reacted to how others spoke to him, spoke about him, curse words, and being approached from behind.-Resident #39's care plan was not revised after the two abuse incidents on 6/11/23 and the abuse incident on 6/13/23. B. Resident #71 statusResident #71, age 84, was admitted on 11/18/22. According to the July 2023 CPO diagnoses included dementia with other behavioral disturbance. The 6/26/23 MDS assessment showed the resident had a severe cognitive impairment with a BIMS score of four out of 15. The resident had delusions, other behavioral symptoms not directed toward others, disorganized thinking and inattention (difficulty focusing). Resident #71's care plan, last revised on 4/5/23, identified risk for impaired communication due to English not being his primary language. The facility provided a translation device for the resident to communicate what he needed to staff, however Resident #71 could not communicate with other residents who did not speak other languages. The care plan said Resident #71 was at risk for injuries or altercations related to his cognition and he was unable to understand other residents' boundaries. C. Resident #43 statusResident #43, under age 65, was admitted on 4/17/23. According to the July 2023 CPO diagnoses included sequelae of cerebral infarction (residual effects or conditions produced by a stroke), dysarthria and anarthria (severe motor speech disorder), depression, personal history of a traumatic brain injury, and unspecified head injury. The 4/21/23 MDS showed the resident had mild cognitive impairment with a BIMS score of 11 out of 15. Resident #43 had other behavioral symptoms not directed at others however it was not documented that he put himself or others at risk due to the behaviors. Resident #43's care plan, last revised on 5/2/23, said he had poor safety awareness and attempted to self transfer from his wheelchair or walk. He became verbally aggressive toward other residents and wandered into other residents' rooms.-Resident #43's care plan was not updated after the abuse incident on 6/13/23. D. Resident #10Resident #10, age 64, was admitted on 9/27/22. According to the July 2023 CPO diagnoses included depression and dementia with other behavioral disturbances. The 6/29/23 MDS showed the resident had no cognitive impairment with a BIMS score of 14 out of 15. Resident #10 had other behavioral symptoms not directed at others however it was not documented that he put himself or others at risk due to the behaviors. Resident #10's care plan, last revised on 6/13/23, identified the resident had a behavioral problem related to his diagnosis of dementia. Resident #10 was very intrusive toward residents and staff. He was at risk of receiving physical or verbal aggression from other residents since he approached residents from behind and touched them playfully.-Resident #10's care plan was not revised regarding the abuse incident on 6/11/23. IV. Family/guardian interviewResident #10's guardian was interviewed over the phone on 7/25/23 at 2:29 p.m. He said this was the only facility to not "kick (Resident #10) out due to his physical aggression." He said Resident #10 was very unpredictable and his behaviors were hard to address. V. Staff interviewsSSD #2 was interviewed on 7/26/23 at 10:38 a.m. She said Resident #10 was "hit and miss every day." She said sometimes he participated in activities and interacted with other residents in a positive manner and other days he was physically or verbally aggressive to other residents. SSD #2 said the CNAs provided consistency for Resident #10 but he was still unpredictable. If other residents bumped into Resident #10 or if he perceived them as "being mean" to him then he would be triggered and act out. She said Resident #71 was a people watcher and enjoyed observing other residents while walking around. Resident #71 was not aware of other residents' boundaries or personal space due to his diagnoses and language barrier. The SSD #2 said Resident #10 was very playful and had a lack of safety awareness which sometimes upset other residents. She said Resident #43 was verbally aggressive at times but usually forgot which room was his or had a lack of safety awareness which caused other residents to physically or verbally attack him. The director of nursing (DON) was interviewed on 7/27/23 at 12:14 p.m. She said the facility had daily huddles and IDT meetings so the facility could come together as a team and then staff received the details of the huddles and IDT meetings. If necessary the DON provided one-on-one training to the floor staff for assistance with residents who had physical aggression. The DON said, "We (the staff) cannot change their (residents) behaviors but we can change our reactions to the behaviors." She said Resident #39 had poor vision and staff were trained to stay in front of him and use a normal tone of voice. She said staff were instructed to give Resident #39 an option of where he sat so he could come and go as he pleased. The CNAs kept the hallway traffic to a minimum so the hallways remained open. A CNA stayed around the area Resident #39 was in to keep a close eye on him. The DON said the CNAs were told to move the victim after an altercation because Resident #39 would not move and both the victim and aggressor were placed on 15 minute checks. She said when Resident #39 and Resident #71 had an altercation it happened really fast. Resident #39 attempted to go through the unit's locked door and Resident #71 got in Resident #39's space and attempted to assist Resident #39 open the door. Resident #39 appeared to feel threatened and attacked him. The facility provided more training for the staff. If Resident #39 did not leave the locked door alone staff were askedto just open the door and let Resident #39 go on a big walk around the facility but she said she was unsure if staff walked with Resident #39 around the facility or if he used his wheelchair and propelled himself alone. However the DON said there was a nurses' station in the middle of the facility and the staff that worked there would keep an eye on Resident #39 as he propelled himself. She said it was an expectation for staff to watch Resident #39 when he was around other residents he had previous issues with. CNA #3 was interviewed on 7/27/23 at 12:41 p.m. She said after an altercation it was easier to have the victim removed from the area because the aggressor attacked her when she attempted to redirect them somewhere else. CNA #3 said, "Resident #39 does not have any triggers that I know of. We (the CNAs) just have to tell based on his mood or behavior. If Resident #39 states he is not handsome then we know it will be a rough day." She said the care plans were not printed on the unit and the facility's charting system was not a reliable method to access care plans. She said the CNAs tried to keep a close eye on Resident #39 but they were not always fast enough to prevent altercations. VI. Facility follow-up documentationThe NHA provided follow-up documentation on 7/28/23 at 10:05 p.m. via email which included the following: "Significant attempts made to consider resident behaviors to prevent risk to self and others monthly. Medical director, behavioral health services, and ombudsman involvement utilized to reduce risks. Resident's (#39) son actively involved and in agreement with all efforts of facility. Three occurrences reviewed in survey facility found to be unsubstantiated based on occurrence manual guidelines. First occurrence no physical contact made. Fall occurred based on startle response. No physical contact made. Second and third occurrences although physical contact was made there was no pain, fear, or injury identified per occurrence reporting guidelines did not meet criteria for abuse."-However, the findings including staff witness statements, medical record documentation and hospital report, did not support the NHA's statement that abuse was unsubstantiated.

Plan of correction

The state did not require a plan of correction for this citation.

0687Foot CareS/S D▼

Findings

Based on resident interview, record review and staff interviews the facility failed to ensure one (#81) of five residents reviewed out of 35 sample residents receive proper foot care and treatment according to standards of practice. Specifically, the facility failed to ensure Resident #81 was seen by the podiatrist timely for toenail care. Findings include:I. Facility policyThe Referral Agreements policy, revised October 2008, was provided by the nursing home administrator (NHA) on 7/27/23 at 1:07 p.m. It read in pertinent part, "To facilitate referrals, the facility has entered into referral agreements with agencies that will provide services to residents. The scope of agencies and the agreements are consistent with the needs of the facility's resident population. Inquiries concerning the availability and use of referral agencies should be directed to social services or to the Administrator."II. Resident statusResident #81, age under age 65, was admitted on 11/8/22. According to the July 2023 computerized physician orders (CPO), diagnoses included traumatic brain injury, left side paralysis and fractures of the third and fourth lumbar vertebra (back). The 6/27/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with brief interview for mental status (BIMS) 15 out of 15. She was totally dependent on staff and needed assistance from two people for hygiene and bathing. She needed extensive assistance from two people for dressing. III. Resident interview and observationResident #81 was interviewed on 7/24/23 at 2:30 p.m. She said she needed to see a podiatrist and staff looked at her feet every day when they changed the wraps on her feet. She said it had been three to four months since a podiatrist had last visited. She said the social services department could put her name on a list to be seen by the podiatrist. Resident #81's feet were wrapped and her toes were exposed. Her toenails were observed to be thick, yellow and had ridges. Two toenails on her left and one toenail on her right foot had dark brown color and were raised off the toenail bed. IV. Record reviewThe ancillary services care plan, was initiated 10/6/22 and revised 11/25/22, documented Resident #81 was acceptable to see podiatry. Pertinent interventions included Resident #81 was to be offered ancillary services as needed, social services to follow up with Resident #81 quarterly and as needed for any ancillary services, initiated 10/6/22 and revised 2/18/23. A review of Resident #81's podiatry visits revealed podiatry visits were attempted for Resident #81 on 1/11/23, 3/28/23 and 7/17/23. All visits were documented as the resident was not in her room and unavailable to be seen. An 2/14/23 IDT (interdisciplinary team) progress note documented Resident #81 had a podiatry visit on 1/11/23 and the progress note was located in the resident's medical record. -However, the note documented the resident was not in her room for the visit. -A review of Resident #81's progress notes did not reveal refusals of podiatry care by Resident #81. There was no documentation that Resident #81 was out of the building during podiatry visits. V. Staff interviewsRegistered nurse (RN) #1 was interviewed on 7/27/23 at 11:18 a.m. She said she would check Resident #81's skin assessment to see if there were any notes on Resident #81's toes. She said a certified nurse aide (CNA) should tell a nurse if they think something was wrong with a resident's toes and a skin assessment including the resident's toe nails should have been completed on shower days. She said usually a nurse changed the wraps on Resident #81's feet. The social services director (SSD) and social services assistant (SSA) #2 were interviewed on 7/27/23 at 11:45 a.m. The SSD said Resident #81 was very vocal and advocated for her needs. She said Resident #81 was unable to propel herself in her wheelchair and staff would pass her concerns to the social services staff. She said the nurses came directly to the office and then the social services staff sent a message to podiatry and or other visiting ancillary services for other appointments. She said the CNA and nurse being the first point of contact should notify the SSD if there were any concerns with resident toes. SSA #2 said the podiatrist went door to door and knocked on resident doors and let her know which residents refused and which residents were not in their room. She said the podiatrist did knock on all residents' doors at least twice and if a resident refused care the podiatrist wrote refused in the visit notes. She said podiatry visits used to be listed on the facility bulletin that was passed out daily to the residents and any residents who had needs were added to the list. She said Resident #81 had a history of refusing care. -Documentation of Resident #81 refusal of podiatry care was requested and not provided. CNA #2 was interviewed on 7/27/23 at 1:35 p.m. She said a shower aide would typically check the resident's nails in the shower. She said if there were any issues with a resident's nails she would report to the nurse. She said the Resident #81 had fungus on her toenails and the resident had previously told her that two of her toenails fell off. CNA #2 said she reported that Resident #81's toenails had fallen off to a nurse. She was unsure how long ago it was. She said she could see the resident's exposed toes when she cared for her. -A review of the progress notes and skin assessments did not reveal any documented regarding Resident #81's toenails falling off.

Plan of correction

The state did not require a plan of correction for this citation.

0730Nurse Aide Peform Review-12 hr/yr In-ServiceS/S E▼

Findings

Based on record review and interview, the facility failed to conduct yearly certified nurse aide (CNA) performance reviews and provide training based on the annual reviews for five (#2, #4, #5, #6 and #7) of five CNA training files reviewed. Specifically, the facility failed to provide performance evaluation reviews annually and provide 12 hours of regular in-service education on the outcome of these reviews for CNAs hired prior to July 2022. Findings include: I. Record reviewUpon review of five CNA training files, it was identified none of the five CNAs had evidence a performance review was completed and annual competencies or associated training totaling 12 hours per year was completed. CNAs reviewed included CNA #2, CNA #4, CNA #5, CNA #6 and CNA #7. The inservice records were reviewed starting July 2022 and documented the title of the inservice and date of completion, but failed to show total hours completed. II. Staff interviewThe nursing home administrator (NHA) was interviewed on 7/27/23 at 12:30 p.m. She said the competencies were included in the online inservice as post inservice questions required before the inservice itself was considered completed.-The post in-service questions and answers were not able to be printed or viewed for verification. The NHA acknowledged the inservice records did not show staff completed 12 hours of in-services, only inservice titles and dates of completion. She said during morning meeting management determined what areas staff needed more competency training in. An all staff meeting agenda was then created and the all staff meeting was used for in-services and staff competencies. The NHA said a new inservice program documented the hours for each in-service for each employee that was going to be utilized in the future.

Plan of correction · submitted by the facility

Staff members files were reviewed, and staff education was provided on completing annual trainings. All staff members were identified as at risk of like concerns. Community leadership will compete an all-staff education covering 12 annual trainings on or before 9/8/2023. The NHA and or designee will complete a monthly audit to assure staff are completing and attend schedule trainings to achieve compliance. The audit will be maintained x 3 months with results forwarded to QAPI Committee for review and suggestion as needed. Compliance established 9/8/23

0744Treatment/Service for DementiaS/S E▼

Findings

Based on record review and interviews the facility failed to ensure three (#39, #10 and #71) of six residents reviewed for dementia care of 32 sample residents received the appropriate dementia care treatment and services to maintain their highest practical physical, mental, and psychosocial well-being. Specifically the facility failed to:-Assess, identify and implement measures to engage Residents #39, #10 and #71 activities to help prevent resident-to-resident altercations; -Update care plans following resident to resident abuse incidents for Resident #39, #10 and #71; and,-Ensure interventions were implemented to prevent Resident #39 from abusing other residents further. Findings include:I. Resident #39 A. Resident statusResident #39, age 70, was admitted on 4/12/22. According to the July 2023 computerized physician orders (CPO) diagnoses included senile degeneration of the brain (decreased ability to think, concentrate, or remember), mood disorder due to known physiological condition (traumatic brain injury), anxiety disorder, depression, and dementia with other behavioral disturbance. The 5/17/23 minimum data set (MDS) assessment showed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #39 had hallucinations, verbal aggression toward others, and behavioral symptoms not directed toward others (hitting himself, screaming out, rummaging) that occurred daily. These behaviors were documented as putting others at risk for receiving physical aggression, significant intrusion of other residents' privacy or activities and significantly disruptive to the living environment. B. Record reviewResident #39's care plan, last revised on 3/13/23, identified a behavioral problem and was aggressive toward peers and staff due to his traumatic brain injury and dementia. Resident #39 had poor impulse control and had a potential to be physically aggressive toward staff and other residents. His triggers were listed as he reacted to how others spoke to him, spoke about him, curse words, and being approached from behind. The care plan documented Resident #39 lived on a secured unit due to his diagnosis of dementia. Interventions on his care plan said:"Staff to intervene preventatively separating resident from others in common areas as observed to prevent future unprovoked response,-Staff to intervene promptly when in dining room if resident is in close proximity to others or grabs other residents' items to prevent escalation of behaviors,-Staff to be proactive when hearing or witnessing verbal aggression from others toward Resident #39, or visa versa, and intervene immediately,-Staff to be present when resident is located in the dining room to protect the resident's rights and rights of other residents,-Frequent checks following any verbal or physical aggression observed or reported for 72 hours."-However the facility failed to have a care plan specifically for Resident #39's dementia care. Specific interventions were not documented regarding engaging Resident #39, identifying unmet needs, identifying potential triggers and therefore effectively avoiding and intervening before aggressive behavior began. Resident #39 was involved in a resident-to-resident incident with Resident #10 on 6/11/23. Resident #39 was involved in a resident-to-resident incident with Resident #71 on 6/11/23. Resident #39 was involved in a resident-to-resident incident with Resident #34 on 6/13/23.(See below and cross-reference F600 freedom from abuse.)-Resident #39's care plan was not revised after the two abuse incidents on 6/11/23 and the abuse incident on 6/13/23. Resident #39 was still involved in altercations with the interventions in place. According to pertinent interdisciplinary progress notes in the resident's medical record:On 4/18/23 at 1:00 p.m. Resident #39 had a physical altercation with another resident at lunch. He attempted to kick and punch the other resident. No injuries were noted andthe residents were separated. Resident #39 was counseled and "agreed to not show verbal or physical aggression going forward."On 4/20/23, at an unidentified time, Resident #39 received physical aggression from another resident. On 4/24/23, at an unidentified time, Resident #39 was identified as the aggressor with another resident. On 5/5/23 at 1:09 p.m. Resident #39 was sitting in the hallway in his wheelchair when another resident came up to Resident #39 and cursed at him. The resident grabbed at Resident #39's wheelchair. Resident #39 swung at the other resident and made contact with him. The resident also made contact with Resident #39, hitting him in the shoulder a couple of times. The residents were separated and no injuries were noted. On 5/8/23 at 3:34 p.m. Resident #39 intermittently became angry and attempted to open the door to leave the locked unit many times. He blocked the door and hallway. Staff attempted distraction techniques and Resident #39 said "you are trying to deceive me." Resident #39 would often block the door and pathway. Staff monitored him to ensure there was no physical altercation with other residents. On 5/23/23 a progress note documented a decrease in Resident #39's Ativan (anti-anxiety medication) and an increase in Risperdal (antipsychotic medication). On 5/26/23 at 6:05 p.m. Resident #39 tried to escape through the door to another unit. When staff tried to help him he started attacking the certified nurse aide (CNA) several times. On 5/26/23 at 8:48 p.m. staff documented the resident seemed to be easily angered and argumentative under a charting note for the decrease of Ativan and increased Risperdal. On 5/27/23 at 3:59 p.m. under a charting note for the decrease of Ativan and increased Risperdal Resident #39 was observed being combative with staff and threatening other residents. On 5/31/23 at 12:25 a.m. under a charting note for the decrease of Ativan and increased Risperdal Resident #39 was easily agitated at times with care. On 5/31/23 at 11:50 p.m. under a charting note for the decrease of Ativan and increased Risperdal Resident #39 was easily agitated at times. On 6/11/23 at approximately 9:20 a.m. Resident #39 initiated verbal and physical aggression toward another resident. Interdisciplinary (IDT) notes documented the victim entered Resident #39's space which caused Resident #39 to react which caused the other resident to fall. On 6/11/23 at 4:25 p.m. Resident #39 initiated physical aggression toward another resident. IDT notes documented the other resident flickered the lights in the dining room on and off which angered Resident #39 and led to physical aggression. On 6/13/23 Resident #39 initiated physical aggression toward another resident. The IDT notes documented the other resident called Resident #39 a name that led to physical aggression. On 7/2/23 at 11:14 a.m. Resident #39 attempted to open the unit's locked door and said he needed to go home. He blocked the door and made verbal threats. II. Resident #71 A. Resident statusResident #71, age 84, was admitted on 11/18/22. According to the July 2023 CPO diagnoses included dementia with other behavioral disturbances. The 6/26/23 MDS assessment showed the resident had a severe cognitive impairment with a BIMS score of four out of 15. The resident had delusions, other behavioral symptoms not directed toward others, disorganized thinking and inattention (difficulty focusing). B. Record reviewResident #71's care plan, last revised on 4/5/23, identified risk for impaired communication due to English not being his primary language. The facility provided a translation device for the resident to communicate what he needed to staff, however Resident #71 could not communicate with other residents who did not speak other languages. The care plan said Resident #71 was at risk for injuries or altercations related to his cognition and he was unable to understand other residents' boundaries.-However, Resident #71 did not have a care plan specifically regarding dementia care. Specific interventions were not documented regarding engaging Resident #39, identifying unmet needs, assisting with communicating with other residents and keeping Resident #71 safe from other residents' potentially aggressive behaviors. III. Resident #10A. Resident statusResident #10, age 64, was admitted on 9/27/22. According to the July 2023 CPO diagnoses included depression and dementia with other behavioral disturbances. The 6/29/23 MDS showed the resident had no cognitive impairment with a BIMS score of 14 out of 15. Resident #10 had other behavioral symptoms not directed at others however it was not documented that he put himself or others at risk due to the behaviors. B. Record reviewResident #10's care plan, last revised on 6/13/23, identified the resident had a behavioral problem related to his diagnosis of dementia. Resident #10 was very intrusive toward residents and staff. He was at risk of receiving physical or verbal aggression from other residents since he approached residents from behind and touched them playfully. His interventions were listed as the following:"Caregivers provide an opportunity for positive interaction and attention. Stop and talk with him as passing by.-Firm limits with the resident regarding touching other residents. Staff to intervene immediately to prevent others from responding reactionary or aggressively towards this resident.-The resident was provided with fidget spinners and he is to be encouraged to have him in his pocket when he is walking in the hallway and in the dining room to prevent him from touching his peers.-Staff to set firm limits and boundaries to protect the rights of others.-Intervene as necessary to protect the rights and safety of others."-Resident #10's care plan was not revised regarding the abuse incident on 6/11/23 (see above). The care plan also did not have detailed interventions for how staff should handle the behaviors associated with his dementia. According to pertinent interdisciplinary progress notes in the resident's medical record:On 1/16/23 Resident #10 started Risperdal. On 1/16/23 at 1:13 p.m. Resident #10 said inappropriate words to the nurse and reached out to touch people. On 1/16/23 at 2:41 p.m. a note documented "no bathing activity documented in seven days. Staff to continue to offer bathing options of the resident's choice and continue to re-approach."On 1/24/23 at 6:50 p.m. the resident continued to be intrusive to others and continued to attempt to touch other residents. On 1/26/23 at 12:19 a.m. the resident continued to be intrusive to others and continued to attempt to touch other residents. On 1/27/23 at 3:26 a.m. the resident continued to be intrusive to others and continued to attempt to touch other residents. On 3/20/23 at 10:22 a.m. Resident #10 refused to shower. Staff continued to re-approach the resident throughout the day and offered shower alternatives and encouraged good hygiene. On 4/18/23 at 10:04 a.m. Resident #10 had been hoarding expired foods, medicine cups and other items he refused to show staff. The CNA threw away a couple of bags of expired chips. On 4/25/23 at 10:39 a.m. Resident #10 occasionally touched other residents jokingly to which the resident was counseled not to do it. On 4/26/23 at 6:00 a.m. Resident #10 occasionally touched other residents jokingly to which the resident was counseled not to do it. On 4/26/23 at 9:44 p.m. a note was documented for monitoring the resident's increase in Risperdal that said there was no change to the resident's behaviors. He continued to grab out at other people and was argumentative with staff at times when staff tried to redirect him. On 4/28/23 at 12:17 a.m. a note was documented for monitoring the resident's increase in Risperdal that said there was no change to the resident's behaviors. Resident #10 continued to attempt to grab out at other people. On 4/29/23 at 11:23 p.m. the resident was up at times during the evening. At approximately 9:15 p.m. Resident #10 acted like he was going to throw something at another resident. Resident #10 walked by the resident and flicked him in the ear which angered the other resident. 05/16/23 at 7:42 p.m. Resident #10 walked to the nurse's medication cart and proceeded to remove used medication cups, which were used by other residents, out of the trash can. The nurse educated Resident #10 on unsafe practice and the resident said "I do not care" and walked back to his room with the used medication cups. On 5/23/23 at 6:19 a.m. Resident #10 refused a shower and all shower alternatives. On 6/11/23 at 6:55 p.m. Resident #10 was the victim of a resident-to-resident incident. The IDT notes documented the video cameras on the unit were reviewed. Resident #10 was seen flickering the dining room lights on and off which angered Resident #39 and led to the incident. IV. Staff interviewsSocial services director (SSD) #2 was interviewed on 7/26/23 at 10:38 a.m. She said Resident #39 was "hit and miss every day." She said sometimes he participated in activities and interacted with other residents in a positive manner and other days he was physically or verbally aggressive to other residents. SSD #2 said the CNAs provided consistency for Resident #39 but he was still unpredictable. If other residents bumped into Resident #39 or if he perceived them as "being mean" to him then he would be triggered and act out. She said Resident #71 was a people watcher and enjoyed observing other residents while walking around. Resident #71 was not aware of other residents' boundaries or personal space due to his diagnoses and language barrier. SSD #2 said Resident #10 was very playful and lacked safety awareness which sometimes upset other residents. -However SSD #2 did not discuss dementia care training or methods to engage the residents following person-centered dementia care guidelines. The director of nursing (DON) was interviewed on 7/27/23 at 12:14 p.m. She said the facility had daily huddles and IDT meetings so the facility could come together as a team and then staff received the details of the huddles and IDT meetings. If necessary the DON provided one-on-one training to the floor staff for assistance with residents who had physical aggression. The DON said, "We (the staff) cannot change their (residents') behaviors but we can change our reactions to the behaviors." She said Resident #39 had poor vision and staff were trained to stay in front of him and use a normal tone of voice. She said staff were instructed to give Resident #39 an option of where he sat so he could come and go as he pleased. The CNAs kept the hallway traffic to a minimum so the hallways remained open. A CNA stayed around the area Resident #39 was in to keep a close eye on him. The DON said the CNAs were told to move the victim after an altercation because Resident #39 would not move and both the victim and aggressor were placed on 15 minute checks. The DON said when Resident #39 and Resident #71 had an altercation, it happened quickly. Resident #39 attempted to go through the unit's locked door and Resident #71 got in Resident #39's space and attempted to assist Resident #39 open the door. Resident #39 appeared to feel threatened and attacked him. The facility provided more training for the staff. If Resident #39 did not leave the locked door alone staff were asked to just open the door and let Resident #39 go on a big walk around the facility but she said she was unsure if staff walked with Resident #39 around the facility or if he used his wheelchair and propelled himself alone. However, the DON said there was a nurses' station in the middle of the facility and the staff that worked there would keep an eye on Resident #39 as he propelled himself. She said it was an expectation for staff to watch Resident #39 when he was around other residents he had previous issues with.-However the DON did not discuss dementia care training or methods to engage the residents following the person-centered dementia care guidelines. CNA#3 was interviewed on 7/27/23 at 12:41 p.m. She said after an altercation it was easier to have the victim removed from the area because the aggressor attacked her when she attempted to redirect them somewhere else. CNA #3 said, "Resident #39 does not have any triggers that I know of. We (the CNAs) just have to tell based on his mood or behavior. If Resident #39 states he is not handsome then we know it will be a rough day." She said the care plans were not printed on the unit and the facility's charting system was not a reliable method to access care plans. She said the CNAs tried to keep a close eye on Resident #39 but they were not always fast enough to prevent altercations.

Plan of correction

The state did not require a plan of correction for this citation.

0791Routine/Emergency Dental Srvcs in NFsS/S D▼

Findings

Based on interviews and record review the facility failed to provide timely dental services to meet resident needs for one (#10) of three residents reviewed for dental services out of 35 sample residents. Specifically, the facility failed to assist Resident #10 schedule a consultation for an oral surgeon to have his remaining teeth removed and to get fitted for dentures after the facility received the referral. Findings includeI. Facility policyThe Availability for Dental Services policy, revised August 2007, was provided by the nursing home administrator (NHA) on 7/27/23 at 12:00 p.m. and read in pertinent part:"Oral healthcare and dental services will be provided for each resident;-Social services will be responsible for making necessary dental appointments;-All requests for routine and emergency dental services should be directed to social services to assure that appointments can be made in a timely manner."II. Resident statusResident #10, age 64, was admitted on 9/27/22. According to the July 2023 computerized physician order diagnoses included depression, gastro-esophageal reflux disease without esophagitis (stomach contents that come back up through the throat to the mouth without swelling) and dementia with other behavioral disturbances. The 6/29/23 minimum data set (MDS) assessment showed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #10 had no dental issues identified. III. Resident interviewResident #10 was interviewed on 7/24/23 at 2:29 p.m. He said he asked the facility to have all of his teeth pulled to receive dentures. Resident #10 showed he was missing multiple teeth and had a lot of rotten teeth. Resident #10 said it was hard to eat certain foods. He said the facility told him he had to pick if he wanted top or bottom dentures. He said the facility never explained why he would not be able to receive dentures for the top and bottom of his mouth. Resident #10 said he was angered and frustrated the facility would not assist with a full set of dentures. IV. Record reviewMedical record review revealed Resident #10 was seen at the dentist on 3/7/23 and the facility uploaded the dental order to the facility's charting system on 3/8/23. The dental order read in pertinent part:"New patient exam. Multiple decayed and necrotic (rotten) teeth. Patient is interested in replacing teeth. Conversation with patient concerning recommended treatment for FMX (removal of all remaining teeth) and F/F (full top and full bottom set of dentures). Patient to be seen by oral surgeon for FMX and placed back on schedule for follow-up and F/F fabrication once complete."V. Staff interviewSocial services director (SSD) #2 was interviewed on 7/26/23 at 10:38 a.m. She said all dental requests were received by herself for the unit she oversaw. She looked up Resident #10's dental documentation and said it must have been entered when she was off of work for a period of time. SSD #2 said she was not aware Resident #10 needed an appointment scheduled to see an oral surgeon. She said the facility "dropped the ball" and she was going to get the order entered into the charting system and an appointment scheduled. SSD #1 and SSD #2 were interviewed on 7/27/23 at 12:35 p.m. SSD #1 said she recently took over the position but was not aware of the oral surgeon referral needed for Resident #10. SSD #2 told SSD #1 the order was entered into the charting system and an oral surgeon would be contacted. SSD #2 said she was not aware the facility's dental policy showed the social services staff were responsible for scheduling dental appointments but she would follow up.

Plan of correction · submitted by the facility

Resident #10 was scheduled immediately to see a dentist. All other resident identified at risk of like concerns were interviewed and appointments were set as needed. The SSD is responsible for setting appointments for resident with dental care needs and was educated on compliance of follow related to dental care needs of residents on or before 9/8/2023The NHA and or designee will monitor concerns related to dental care needs of residents and will continue to review grievances related to dental follow x3 months with results being forwarded to QAPI committee for review and suggestions as needed or until substantial compliance is achieved. Compliance established 9/8/2023.

0804Nutritive Value/Appear, Palatable/Prefer TempS/S E▼

Findings

Based on observation and interviews, the facility failed to ensure that each resident received food that was palatable, attractive, and an appetizing temperature. Specifically, the facility failed to:-Ensure food was palatable and attractive when delivered to residents; -Ensure food was served at a safe and appetizing temperature; and,-Provide condiments with meals. Findings include:I. Resident interviewsResident #56 was interviewed on 7/24/23 at 10:13 a.m. The resident said she had received burnt eggs. The resident said lunch was usually yucky and the food was runny and cold. Resident #25 was interviewed on 7/24/23 at 10:18 a.m. Resident #25 said the food was horrible and she tried not to eat what they had available at the facility. She said her daughter brought in food because the facility's food was very bad. Resident #45 was interviewed on 7/24/23 at 10:31 a.m. The resident said the food was bad and the bananas were overripe. Resident #24 was interviewed on 7/24/23 at 10:42 a.m. The resident said the food was bad and she would not eat it. She said if she ate the food she felt sick afterward. Resident #31 was interviewed on 7/24/23 at 11:09 a.m. The resident said he avoided the food and he had found a hair in the food. II. Test trayA test tray of the lunch meal was performed on 7/26/23. The tray left the kitchen at 11:43 a.m. and was delivered to the unit and was served after the last resident was served at 12:21 p.m. The meal was Western omelet, hash browns, toast and apple crisp. The meal test tray for palatability was tried by four surveyors: -The omelet was 112 degrees F (farenheit); the eggs were overcooked, rubbery, cold and bland.-The hash browns were 104 degrees F; the hash browns were bland, cold, plain and dry.-The toast was 89 degrees F; the toast was cold and soggy. -The tray did not come with apple crisp.-The tray did not come with condiments, salt, pepper, butter or jelly. III. ObservationDuring continuous kitchen observation 7/26/23 from 10:12 a.m. to 11:43 a.m. There were not enough plates prepared for use and the last 10-15 plates went out without being on the plate heater. Some of the plates had been sitting on the metal holding tray. IV. Staff interviewThe dietary supervisor (DS) was interviewed on 7/27/23 at 1:54 p.m. He said the facility had a problem with not having enough dishes.

Plan of correction · submitted by the facility

Resident #56, #25, #45, #24, #31 Food Preferences were re-evaluated immediately with update to individualized plan of care. All other residents identified at risk of like concerns. All residents reviewed for Food preference completed with last year and updated as needed. Dietary staff were re-educated on Plating food to include separating cold items from warm items to improve temperature, texture and appearance of food service on or before 9/8/2023. Dietary staff were re-educated on temping, texturizing and appropriate tasting at point of service to ensure palatability on or before 9/8/2023. The Nutrition Services Director is responsible for auditing temperatures at point of service, at the beginning of cooking and at end of service as well as providing regular test trays at point of service x 3 months with results forwarded to QAPI Committee for review and suggestion as needed. Compliance established 9/8/2023.

0806Resident Allergies, Preferences, SubstitutesS/S D▼

Findings

Based on interview and observation the facility failed to ensure resident food preferences for one (#24) out of five sample residents were honored out of 35 sample residents. Specifically, the facility failed to provide Resident #24 with the preferred vegetarian diet. Findings include:I. Facility policy and procedureThe Resident Food Preferences policy and procedure, revised 2017, was delivered by the nursing home administrator (NHA) on 7/26/23 at 12:40 p.m. It read in pertinent part: "Upon the resident's admission the dietitian or nursing staff will identify a resident's food preferences. "Nursing staff will document the resident's food and eating preferences in the care plan."The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night."The facility's Quality Assessment and Performance Improvement (QAPI) committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation."II. Resident #24A. Resident statusResident #24, over age 65, was admitted to the facility on 5/23/18. According to the July 2023 computerized physician orders (CPO) the diagnoses include major depressive disorder, and hypothyroidism. The 5/23/23 minimum data set (MDS) assessment documented the resident had no cognitive deficit with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident interviewResident #24 was interviewed on 7/2423 at 10:42 a.m. The resident said she was vegetarian and the facility used to provide her with food choices to her preference but they had stopped. She said she usually only ate the oatmeal or nothing at all because the other options made her feel sick. C. ObservationsOn 7/27/23 at 11:12 a.m. the resident was observed to receive jello and apple slices for lunch rather than the offered meal. The resident was not offered another choice for a meal. D. Record reviewThe care plan for nutrition documented the resident had minimal nutritional risk despite her preferred pattern of meal skipping and multiple food restrictions and avoidances. Interventions include Obtain food preferences and offer as able. Offer resident the vegetarian options as well and provide daily preference. III. Menu extensionsThe menu failed to show a specific vegetarian diet. IV. Staff interviewThe social services director (SSD) and social services assistants (SSA) #1 were interviewed on 7/27/23 at 11:43 a.m. The SSD said the facility attempted to purchase resident #24 food items that suited her preferences but have been unable. SSA #1 said the staff has not been able to obtain a list of items to purchase for the resident. The dietary supervisor (DS) was interviewed on 7/27/23 at 1:54 p.m. The DS said for the vegetarian meals the staff would take the meat out of the meal. The DS said Resident #24 liked baked potatoes or peanut butter and jelly sandwiches. The DS said the facility ordered gluten free items for another resident but did not purchase items specifically for Resident #24.

Plan of correction

The state did not require a plan of correction for this citation.

0925Maintains Effective Pest Control ProgramS/S F▼

Findings

Based on observations, interviews and record review, the facility failed to maintain an effective program of pest management to ensure the facility was free of pests. Specifically, the facility failed to ensure the main kitchen, dining rooms, resident rooms and hallways were free from flies on three out of three units. Findings include:I. Professional referencesAccording to the Colorado Retail Food Establishment Rules and Regulations (last amended 1/1/19) retrieved on 8/1/23 from https://cdphe.colorado.gov/environment/food-regulations, "The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by routinely inspecting incoming shipments of food and supplies, routinely inspecting the premises for evidence of pests, using methods, if pests are found, such as trapping devices or other means of pest control, and eliminating harborage conditions."If the windows or doors of a food establishment, or of a larger structure within which a food establishment is located, are kept open for ventilation or other purposes or a temporary food establishment is not provided with windows and doors as specified, the openings shall be protected against the entry of insects and rodents by properly designed and installed air curtains to control flying insects"According to the Center for Disease Control's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, last updated July 2019 and retrieved on 8/1/23 from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, "Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (route) passing pathogens from one source to another. From a public health and hygiene perspective, arthropods (insects) and vertebrate pests should be eradicated from all indoor environments, including health-care facilities."II. Facility policyThe Pest Control policy, revised May 2008, was provided by the nursing home administrator (NHA) on 7/27/23 at 1:07 p.m. It read in pertinent part, "This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Windows are screens at all times. Maintenance services assist, when appropriate and necessary in providing pest control services."III. Resident interviews and observationsOn 7/23/23 at 11:32 a.m. residents sat in the dining room with their lunches. A resident told certified nurse aide (CNA) #3 "These darn flies!" CNA #3 said, "I know, they are horrible." Flies were everywhere as meals were served. The meal cart doors were opened and flies were in the meal cart as CNAs were delivering trays to residents' rooms. A resident swatted flies on the dining room table with his baseball hat and a magazine. At 12:34 p.m. flies were observed around the dining room as the residents played bingo. On 7/24/23 at 11:45 a.m. the back door to a patio was opened several times and left open. The NHA attempted to close the outside door however, residents continued to go in and out the door and did not latch it. Flies were observed throughout the dining room and hallways, while residents were served lunch. At 12:03 p.m. a family member exited a resident's room and informed CNA #3 flies landed in the resident's food while he was eating. Resident #57 was interviewed on 7/24/23 at 1:30 p.m. He said flies were a real problem at the facility, the flies would get into the food and there was a dead fly on the window sill (the dead fly was observed on the window sill). He said he wanted the dead fly removed and the window sill cleaned. Residents #79 and #81 were interviewed in their shared room on 7/24/23 at 2:30 p.m. Resident #79 said flies were bad in the facility. He said he had spoken to the facility management about the flies. Resident #79 and Resident #81 had flyswatters during the interview. Resident #79 said the fly swatters were provided by another resident. Resident #81 said the flies were in their room all the time. During the interview, the Resident #79 and Resident #81 were observed using their flyswatters during the interview to swat away flies. There were two flies in the room that landed on the bed and the residents. On 7/25/23 at 2:00 p.m. the door to the outdoor smoking patio was observed to be accessed from the main dining room and had an air curtain (air blowing device to prevent insects) installed above it. Upon entering the outdoor smoking patio from the dining room, the air curtain did not turn on and the air curtain did not turn on upon return inside to the dining room from the outdoor smoking patio. During continuous observation of the kitchen and lunch tray delivery on 7/26/23 from 10:12 a.m. until 12:21 p.m. there were multiple flies in the kitchen and hallways. There were flies on clean and sanitized items such as plates, small plates, inside of plate cover, cups, juice pitchers and serving utensils that were hanging over the prep tables. At 12:03 p.m. a resident sitting at the nurses station was swatting at flies with a fly swatter. At 12:13 p.m. licensed practical nurse (LPN) #2 was swatting away flies with her hand while at the medication cart. At 12:15 p.m. CNA #1 said the flies were terrorizing the staff. On 7/26/23 at approximately 1:30 p.m. Resident #81 was observed sitting in the dining room and used a fly swatter to swat away a fly that was flying around her. At 2:00 p.m. flies were observed in the locked unit's kitchenette. During the survey from 7/24/23 to 7/27/23 it was observed there were flies throughout the three facility units and three facility dining rooms. IV. Staff interviewsSocial services director (SSD) #2 was interviewed on 7/26/23 at 10:38 p.m. She said the facility was located in between some farms and the flies were a problem every summer. She said some of the residents who smoked propped the outside door open and staff would have to close it but that was how the flies got into the locked unit of the facility. She said the facility was informed they could not use fly glue strips so they used fly swatters and a spray on the door frames that deterred flies from going near it. SSD #2 said nothing worked for the flies and they dealt with it every year. Cook (CK) #2 was interviewed on 7/26/23 at 11:20 a.m. CK #2 said the number of flies was worse than before. She said it was due to the back door, located off the dining room, had been left open and the flies came to get to the heat and the food. She said the facility could not get rid of them. The dietary supervisor (DS) was interviewed on 7/27/23 at 1:54 p.m. The DS said the flies were the worst the staff had ever seen. He said the facility had a hard time keeping the back door shut off the dining room, so the flies kept coming in. The maintenance supervisor was not available during the survey to be interviewed. The nursing home administrator (NHA) was interviewed on 7/27/23 at 12:31p.m. She said the facility had fly issues for some time and the issue resolved temporarily when visitation was limited because of less door traffic in the facility. She said there was a cow pasture next to the facility and the door was left open or propped for frequent trips to the smoking area outside the dining room. She said there were air curtains on the east side of the building and at the door to the smoking patio. She said the air curtains were not blowing the day before and the facility called someone to look at the air curtains. She said there were fly lights in the hallways, the facility had monthly pest control visits and more frequently if needed and the facility had outside fly traps. She said during summer the flies were very difficult to manage. V. Facility follow-up The NHA provided pest control records on 7/28/23 that showed a pest control company provided service to the facility twice a month from July 2022 through February 2023 and on 7/27/23 (the last day of survey). The record from 7/27/23 revealed the following facility conditions with corresponding recommendations:-On 2/20/23 the kitchen insect light was not working or bulbs needed to be replaced; the recommendation was to replace the bulbs.-On 3/31/23 food debris and crumbs were in the kitchen corner; the recommendation was to remove the debris and crumbs.-On 4/18/23 cracks and holes were found in an exterior wall; the recommendation was to seal cracks and holes to deny pest entry and harborage.-On 5/2/23 tall weeds or grass should be kept mowed low to deny harborage to rodents, spiders and insects; the recommendation was to mow tall weeds or grass to deny harborage to rodents, spiders and insects.-On 5/2/23 kitchen doors were left open; the recommendation was to keep the door closed when not in use. The pest control record from 7/27/23 revealed the previous conditions still existed during the inspection on 7/27/23 and the recommendation was to address the documented contributing conditions to support the pest management program.

Plan of correction · submitted by the facility

Concerns related to flies in the community were addressed to prevent continuation of pest in the communities. All residents are at risk regarding deficient practice. The Maintenance Director is responsible for assuring community is free from pest when pest concerns arise, Maintenance Director will assist NHA is creating a pest control schedule that address community pest concerns on or before 9/8/2023The NHA and or designee will monitor the pest control logs, and manage all recommendations made from pest control company to remedy concerns with flies x3 months or until community reaches compliance with results being forward to QAPI committee for review and suggestions as needed or until substantial compliance is achieved. Compliance established 9/8/2023

1/17/2023Focused Infection Control, Other-Fed Survey · ID ZTT9111 deficiency▼

0884Reporting - National Health Safety NetworkS/S F▼

Findings

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 01/09/2023 and 01/15/2023, 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.

Plan of correction

The state did not require a plan of correction for this citation.

Reportable Occurrences

109 records

6/16/2026Physical Abuse · ID 26020312034Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/16/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed client (B) hit client (A) in the back of the head with a rock. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the client, transferred the client to the hospital, and conducted interviews. Client (A) sustained bump on the head and was evaluated at the hospital. The client was diagnosed with a bruise and received pain medication. Client (B) admitted to hitting client (A) but did not provide a reason for hitting them. Staff reported client (B) historically became agitated after a family visit and had just completed a family visit when they walked up to client (A) and hit them. The facility implemented a plan for increased safety monitoring whenever client (B) has a family visit and completed medication reviews. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/24/2026 · released to the public 8/3/2026.

6/7/2026Physical Abuse · ID 26020312032Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/7/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) hit client (A) when client (A) wandered into client (B)’s room. During the course of the investigation, the healthcare entity notified law enforcement, assessed the client, conducted interviews, and reviewed video footage. Client (A) had redness on their chest but no other visible injuries. Due to cognitive impairment neither client could recall the event or provide any information. Video footage did not show any alteration or interaction between the clients. The facility completed a medication review and adjustment and initiated increased safety monitoring. The facility was unable to confirm physical abuse occurred due to inconclusive evidence. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/23/2026 · released to the public 7/30/2026.

5/27/2026Physical Abuse · ID 26020312031Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/27/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed client (B) hit their roommate client (A) after a verbal disagreement. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the client, conducted interviews, and reviewed records. Client (A) sustained a skin tear to the top lip requiring first aid treatment. Client (B) was transferred to the hospital for behavioral assessment, returned to the facility, and could not recall the event. The facility continued increased safety monitoring, completed a room change, initiated 1:1 observation for client (B), and completed referrals for alternative placement for client (B). The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/17/2026 · released to the public 7/24/2026.

5/27/2026Physical Abuse · ID 26020312030Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/26/26 the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) pulled on client (A)’s shirt causing them to fall to the ground. During the course of the investigation, the healthcare entity notified law enforcement, assessed the client, conducted interviews, and reviewed video footage. Client (A) did not sustain any visible injuries and was unable to recall the event. Client (B) reported client (A) wandered into their room and they lightly pulled on client (A)’s shirt to try to direct them out of the room. The facility initiated increased safety monitoring, moved client (A) to a different unit, and completed medication reviews. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/24/2026 · released to the public 8/3/2026.

4/22/2026Physical Abuse · ID 26020312028Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/22/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. When the client was found with bruising on the wrist they reported staff #1 twisted their wrist. During the course of the investigation, the healthcare entity notified law enforcement, suspended staff, assessed the client, and conducted interviews. The client was assessed and found to have a healing fracture in their wrist, the date of the fracture could not be determined. Staff #1 denied the allegations and reported the client was aggressive toward them and when additional staff redirected them the client grabbed their own wrist and squeezed. Staff witnesses denied seeing staff #1 harm the client and confirmed the information provided by staff #1. Record review showed the client had a history of falls and reporting unsubstantiated allegations. The facility initiated increased safety monitoring, completed a medication adjustment, and removed staff #1 from the client’s care team. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/20/2026 · released to the public 7/27/2026.

4/17/2026Physical Abuse · ID 26020312027Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/17/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) hit client (A) on the back of the head. During the course of the investigation, the healthcare entity notified law enforcement, assessed the clients, conducted interviews, and reviewed records. Client (A) did not sustain any visible injuries. Due to cognitive impairment neither client could recall the event. The client who allegedly witnessed the event, could not not recall the event or provide any details to support the allegation. The facility was unable to confirm physical abuse occurred due to lack of evidence. The facility implemented increased safety monitoring and installed a camera system in the common areas of the facility. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/2/2026 · released to the public 7/13/2026.

4/14/2026Physical Abuse · ID 26020312026Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/17/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed a verbal altercation between two clients culminating in physical contact occurring between them. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the clients, and conducted interviews. Neither client sustained visible injuries nor could either client recall the event. The facility implemented 1:1 observation for the alleged assailant and initiated communication with their former facility to learn more about previous effective interventions. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/24/2026 · released to the public 7/1/2026.

4/13/2026Physical Abuse · ID 26020312025Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/14/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (A) was found on the ground and reported they were pushed by client (B) when they tried to redirect client (B) out of their room. During the course of the investigation, the healthcare entity notified law enforcement, assessed the client, conducted interviews, and reviewed records. Client (A) had no visible injuries. Client (A) later reported they were pushing client (B)’s wheelchair out of their room when client (B) locked the brakes, causing them to fall. Client (B) could not recall the event due to cognitive impairment. The facility was unable to confirm physical abuse due to varying accounts provided by client (A) and no one witnessing the event. The facility initiated additional interventions to prevent wandering and educated staff regarding redirection when wandering occurs. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/24/2026 · released to the public 7/1/2026.

4/11/2026Physical Abuse · ID 26020312024Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/13/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, two clients had a verbal disagreement resulting in client (B) scratching client (A) on the face. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the client, and conducted interviews. Client (A) sustained three scratches requiring first aid treatment. Due to cognitive impairment neither client could recall the event. The facility started increased safety monitoring, completed a medication adjustment, and educated staff regarding keeping the clients separated. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/24/2026 · released to the public 7/1/2026.

4/5/2026Physical Abuse · ID 26020312023Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/6/26 the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) pushed their roommate client (A) causing them to fall to the ground. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the client, conducted interviews, and started increased safety monitoring. Client (A) sustained bruising around the eye and swelling to the face. Additional testing was ordered for client (A) to ensure no additional internal injuries occurred. Record review showed client (B) was undergoing medication adjustments at the time of the event. The facility implemented a room change, continued increased safety monitoring, completed a medication review, and educated staff regarding monitoring the clients to prevent reoccurrence. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/1/2026 · released to the public 7/13/2026.

4/1/2026Physical Abuse · ID 26020312020Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/1/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (A) pushed client (B) and client (B) responded by grabbing client (A)’s wrists. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the client, conducted interviews, and started increased safety monitoring. Neither client sustained visible injuries. Client (B) reported client (A) couldn’t find their phone and accused them of taking the phone. Client (A) could not recall the event due to cognitive impairment. The facility implemented a room change, continued increased monitoring, found client (A)’s phone, and provided a lanyard for the phone. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/30/2026 · released to the public 7/13/2026.

3/29/2026Equipment Malfunction · ID 26020312019Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/29/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported equipment malfunction. Reportedly, the client fell out of the bed due to a dip in the bed and the bed rail being positioned improperly. During the course of the investigation, the healthcare entity removed and inspected the bed, assessed the client, and reviewed records. The client was uninjured and could not recall the details of the unwitnessed event. The bed was found to have no malfunctions and to be in good working order, there was not an improperly placed bed rail. The facility determined the cause of the fall was muscle spasms with leg extension. The facility completed an audit of all the beds in the facility, educated staff, and placed the bed back in service. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/15/2026 · released to the public 6/22/2026.

3/29/2026Verbal Abuse · ID 26020312018Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/29/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported verbal abuse of a client. Reportedly, client (B) was verbally aggressive towards client (A), causing client (A) to report a desire to self-harm. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, and initiated 1:1 monitoring for client (A). Due to cognitive impairment client (B) could not recall the event. Client (A) reported emotional distress when client (B) called them mean names. The facility was unable to determine if a negative verbal interaction occurred between the clients due to conflicting client interviews and lack of eye witnesses. The facility offered psychological support services to client (A), implemented a plan to keep distance between the clients, and updated care plans. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/17/2026 · released to the public 6/24/2026.

3/22/2026Physical Abuse · ID 26020312017Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/22/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) pushed client (A) causing them to fall to the ground and bump their head. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, transferred the client to the hospital, conducted interviews, and reviewed records. Client (A) sustained a laceration to the back of the head and received treatment at the hospital. Client (B) reported the event occurred due to client (A) initially pushing them. Client (A) could not recall the event. The facility implemented increased safety monitoring as well as a plan to keep distance between the two clients. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/11/2026 · released to the public 6/19/2026.

3/14/2026Physical Abuse · ID 26020312016Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/14/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff observed client (B) make physical contact with client (A)’s back. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, assessed the client, and started increased safety monitoring. Client (A) did not sustain any visible injuries and did not recall the event due to cognitive impairment. Client (B) refused to discuss the event. The facility rearranged staff work areas to increase hallway monitoring and continued pursuing alternative placement for client (B). The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity

Publication

Sent to facility 6/10/2026 · released to the public 6/18/2026.

3/9/2026Physical Abuse · ID 26020312015Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/9/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. The client reported unknown assailants came into their room at night and hit them in the shoulder with a leather strap and hammer. During the course of the investigation, the healthcare entity notified law enforcement, assessed the client, reviewed records, and conducted interviews. The client, who has a history of chronic pain, did not have any visible injuries. The client who has a history of hallucinations, indicated the voices in their head told them this event occurred but they do not recall being hit by anyone. The community determined the client experienced increased chronic pain but did not find evidence that they had been harmed by anyone. The facility reviewed medications, scheduled additional pain assessments for the affected area, and provided psychological support services. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/9/2026 · released to the public 6/18/2026.

2/28/2026Physical Abuse · ID 26020312013Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/2/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) sat on client (A)’s legs causing them pain. During the course of the investigation, the healthcare entity notified law enforcement, assessed the client, and conducted interviews. Client (A) reported they were sleeping in bed when client (B) sat on their legs in an unprovoked action. Client (B) was transferred to the hospital for psychiatric evaluation and stabilization. The facility educated staff, offered therapeutic support to client (A), and provided new personalized activities for client (B). The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/9/2026 · released to the public 6/18/2026.

2/14/2026Physical Abuse · ID 26020312011Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 2/15/26 the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, two clients made physical contact with each other. During the course of the investigation, the healthcare entity notified law enforcement, conducted interviews, and assessed the clients. Neither client sustained visible injuries. Due to cognitive impairment neither client recalled the event. The facility educated staff and reviewed care plans. The facility determined contact occurred but did not result in any injuries. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe

Publication

Sent to facility 5/28/2026 · released to the public 6/4/2026.

2/10/2026Physical Abuse · ID 26020312010Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 2/10/26, the healthcare entity investigated a reportable event of physical abuse of a client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 2/19/26, Event ID 1E4549-H1. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/22/2026 · released to the public 4/29/2026.

2/1/2026Misappropriation of Property · ID 26020312009Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 2/3/26, the healthcare entity investigated a reportable event of misappropriation of client property. Reportedly, client (B) stole money and cigarettes from client (A). During the course of the investigation, the healthcare entity conducted interviews and reviewed records. Client (A) who is cognitively intact refused to discuss any details of the event or confirm/deny missing items. Client (B) denied the allegation. The facility stores all cigarettes for clients, so the facility can confirm that cigarettes were not stolen. The facility offered to reimburse client (A) and started increased safety monitoring. The facility was unable to confirm misappropriation of property took place due to inconclusive evidence. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 2/19/26, Event ID 1E4549-H1.

Publication

Sent to facility 4/22/2026 · released to the public 4/29/2026.

1/31/2026Physical Abuse · ID 26020312008Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/31/26, the healthcare entity investigated a reportable event of physical abuse of a client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 2/19/26, Event ID 1E4549-H1. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/22/2026 · released to the public 4/29/2026.

1/26/2026Physical Abuse · ID 26020312007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/26/26, the healthcare entity investigated a reportable event of physical abuse of a client. Staff witnessed client (B) hit client (A) in the upper body region. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the client, conducted interviews, and started increased safety monitoring. Client (A) did not sustain any visible injuries. Due to cognitive impairment neither client could recall the event. The facility implemented increased safety monitoring and educated staff regarding keeping the clients separated. The facility determined physical contact occurred but did not result in any injuries. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. This is the third physical altercation between these two clients, please see case IDs 25020312063 and 25020312062 for additional information. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 2/19/26, Event ID 1E4549-H1.

Publication

Sent to facility 5/7/2026 · released to the public 5/18/2026.

1/25/2026Physical Abuse · ID 26020312006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/25/26, the healthcare entity investigated a reportable event of physical abuse of a client. Reportedly, client (B) hit client (A) in the head with a shirt. During the course of the investigation, the healthcare entity conducted interviews, notified law enforcement, and assessed the client. Client (A) had no visible injuries. Client (B) denied the allegations. The facility completed a room move and stated increased safety monitoring. The facility was unable to determine if any contact was made between the clients due to inconclusive evidence. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 2/19/26, Event ID 1E4549-H1 .

Publication

Sent to facility 4/28/2026 · released to the public 5/5/2026.

1/23/2026Physical Abuse · ID 26020312005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/24/26, the healthcare entity investigated a reportable event of physical abuse of a client. Staff witnessed client (B) slap client (A) in the back with an open hand. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the client, and conducted interviews. Due to cognitive impairment neither client recalled the event. Client (A) did not sustain any visible injuries. The facility implemented increased safety monitoring and reviewed care plans. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 2/19/26, Event ID 1E4549-H1 .

Publication

Sent to facility 5/11/2026 · released to the public 5/18/2026.

12/30/2025Physical Abuse · ID 25020312063Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/31/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) made physical contact with client (A) after client (A) attempted to take client (B)’s drink. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the client, conducted interviews, and started increased safety monitoring. Due to cognitive impairment neither client could recall the event and neither sustained visible injuries. The facility determined physical contact occurred, but did not result in any injuries. The facility implemented 1:1 monitoring for client (B) until additional interventions could be determined. The event was not substantiated. Client (B) was involved in a previous occurrence, please see case ID 25020312062 for additional information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/23/2026 · released to the public 3/30/2026.

12/26/2025Physical Abuse · ID 25020312062Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/29/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (B) made contact with the back of client (A)’s head after they ran into each other in the hallway. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the clients, conducted interviews, and started increased safety monitoring. Neither client had visible injuries. Due to cognitive impairment, neither client could recall the event. The facility determined physical contact occurred between the clients, but did not result in any injuries. The facility educated staff and increased monitoring in the hallways to prevent clients from blocking the area. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/23/2026 · released to the public 3/30/2026.

12/3/2025Physical Abuse · ID 25020312060Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/3/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed client (B) wandered into client (A)’s room which led to an argument and physical contact between the clients. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the clients, started increased safety monitoring, and conducted interviews. Client (A) sustained a small scratch on their forehead. Due to cognitive impairment neither client recalled the event and could not provide any additional details. The facility completed a room change, implemented 1:1 monitoring for client (B), and reviewed additional wandering interventions. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/10/2026 · released to the public 3/17/2026.

11/29/2025Physical Abuse · ID 25020312059Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/1/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, two clients had a verbal altercation, resulting in client (B) hitting client (A) in the face. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the clients, started increased safety monitoring, and conducted interviews. Client (A) did not have any visible injuries and denied pain. Client (B) did not recall the event due to cognitive impairment. The facility determined physical contact occurred but did not result in any injury. The facility implemented 1:1 monitoring for client (B), reviewed medications, and educated client (A) regarding provoking others. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/4/2026 · released to the public 3/11/2026.

11/23/2025Physical Abuse · ID 25020312058Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/24/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, two clients had a verbal altercation regarding seating arrangements resulting in a physical altercation. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, and started increased safety monitoring. Staff reported they didn’t see the event start but walked into the room to find the two clients on the floor fighting each other. Neither client sustained visible injuries but one client declined to be assessed for injury. Neither client could recall what led to the event or provide any details about the event. The facility adjusted the seating arrangements so the clients sit separately, completed a referral for counseling services, reviewed and adjusted medications, and educated staff. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/25/2026 · released to the public 3/6/2026.

11/2/2025Sexual Abuse · ID 25020312057Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/2/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. Reportedly, client (B) attempted to perform a sexual act on their roommate client (A). During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, and started increased safety monitoring. Client (A) reported client (B) came to his side of the room, touched his genital area on the outside of his clothing, and then fell. Client (B) could not recall the event. The facility could not determine if contact was made between the two clients. The facility offered therapy services to client (A), implemented 1:1 supervision for client (B), and completed a room change. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/19/2026 · released to the public 2/26/2026.

10/29/2025Verbal Abuse · ID 25020312056Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/29/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported verbal abuse of a client. Reportedly, after a verbal altercation between roommates, client (B) threatened client (A). During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, started increased safety monitoring, and conducted interviews. Client (A) could not recall the event. Client (B) acknowledged a verbal altercation but denied threatening client (A). The facility completed a room change, started behavioral monitoring, and educated the client. The facility determined a verbal altercation occurred but could not determine if a threat was made. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/4/2026 · released to the public 2/11/2026.

10/26/2025Verbal Abuse · ID 25020312055Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 10/27/25, the healthcare entity investigated a reportable event of verbal abuse of a client. Staff witnessed a verbal altercation between two clients, resulting in client (B) threatening to hit client (A) with their cane. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement and conducted interviews. The facility determined both clients were verbally aggressive but neither was fearful of the other. The facility educated staff and clients, and client (B) continued to pursue a previously planned move out of the facility. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 1/22/26, Event ID 1E19FA-H1.

Publication

Sent to facility 2/19/2026 · released to the public 2/26/2026.

10/22/2025Physical Abuse · ID 25020312054Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/23/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. When bruising was found on client (A)’s hand they reported their roommate client (B) had hit them on the hand causing the bruise. During the course of the investigation, the healthcare entity notified law enforcement, conducted interviews, started increased safety monitoring, and assessed the client. Record review indicated the client takes medication that can lead to increased bruising and that bruising is consistent with recent blood draws. Client (A) was unable to recall any details about the allegation and client (B) denied hitting their roommate. The facility implemented a room change and updated care plans. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/1/2026 · released to the public 2/9/2026.

10/16/2025Verbal Abuse · ID 25020312053Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 10/16/25, the healthcare entity investigated a reportable event of verbal abuse of a client. Staff witnessed a verbal altercation between two clients resulting in client (B) threatening to physically harm client (A). During the course of the investigation, the healthcare entity notified law enforcement and conducted interviews. The facility provided emotional support for client (A), completed a room move, started increased safety checks, performed room sweeps, and educated staff. The facility determined a threat was made towards client (A) but did not result in fear or harm. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 1/22/26, Event ID 1E19FA-H1

Publication

Sent to facility 2/24/2026 · released to the public 3/3/2026.

10/13/2025Physical Abuse · ID 25020312051Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/14/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. After the client was found with a bruise on the arm they alleged staff had prodded them with an item from the nightstand to get them into bed. During the course of the investigation, the healthcare entity notified law enforcement, conducted interviews and a room search, and assessed the client. The client had 3 dime shaped bruises above the wrist. The client was unable to describe the staff involved, the item used, or when the event occurred. The client had recently been to the hospital and the bruising was consistent with having an IV connected to the skin. Record review indicated a history of unsubstantiated allegations. The client was discharged to the hospital for stabilization and upon return the facility continued to provide a two person care model. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 1/23/2026 · released to the public 1/30/2026.

10/11/2025Physical Abuse · ID 25020312050Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/11/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed client (B) slap client (A) in the back. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, and assessed the client. Staff interviews indicated client (B) was confused by an action of client (A) and perceived it as a threat. The facility implemented a 1:1 supervision model for client (B) along with referrals to other facilities that may be a more appropriate fit. The event was substantiated. Client (A) was involved in a previous occurrence event, please see case ID 25020312024 for further information. Client (B) was involved in a previous occurrence event, please see case ID 25020312047 for further information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 1/20/2026 · released to the public 1/27/2026.

10/9/2025Missing Person · ID 25020312049Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/9/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a missing client. The at-risk client was missing from their room after breaking the screws on the window, climbing out of the window, and breaking a part of the fence in the courtyard. During the course of the investigation, the healthcare entity conducted a search, notified law enforcement, and conducted interviews. The client was found approximately 1.5 hours later in the field behind the facility. The client declined assessment upon their return. The facility implemented one to one supervision until the team can review supervision needs, added brackets to the client’s window, made the fencing more secure, added an alarm outside the client’s window, and updated the care plan. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/2/2025 · released to the public 12/9/2025.

9/30/2025Physical Abuse · ID 25020312046Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/30/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. The client alleged staff hit their head o when rolling them over to get the remote. During the course of the investigation, the healthcare entity notified law enforcement, assessed the client, conducted interviews, and started increased safety monitoring. The client’s description of the alleged assailant did not match any staff or visitors in the facility, so an alleged assailant was not identified. Interviews revealed the client was receiving care in a two person model and staff acknowledged that the client's head lightly touched the wall when the client moved, and the client laughed about it and did not complain. An assessment revealed a pain complaint related to chronic back pain but no other injuries noted. The facility continued a two person care model, completed a referral for mental health supports, and conducted a medication review. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 1/8/2026 · released to the public 1/15/2026.

9/18/2025Physical Abuse · ID 25020312047Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/1/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Client (A) alleged they had been hit in the arm with a cane by their roommate. During the course of the investigation, the healthcare entity assessed the client, notified law enforcement, completed a temporary room change, and conducted interviews. Client (A) had a bruise on their arm and indicated this event happened a couple weeks prior to the report being made. Client (B) admitted to hitting client (A) and indicated it was in response to client (A) threatening them. Staff interviews indicated neither client reported this event at the time it occurred nor had staff observed the bruise on client (A)’s arm. The facility completed a permanent room change, made a referral for behavioral health services, and educated staff. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 1/16/2026 · released to the public 1/23/2026.

9/17/2025Physical Abuse · ID 25020312044Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/17/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed client (B) make contact with client (A)’s head, client (A) was wearing a protective helmet at the time. In response, client (A) made contact with client (B)’s chest area. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, and assessed the clients. Due to cognitive impairment neither client provided additional details about the event. Neither client sustained any visible injuries. The facility determined physical contact occurred, but did not result in injury to either client. The facility scheduled an interdisciplinary team meeting to discuss if any interventions need to be added to either care plan. The event was not substantiated. Client (A) was identified in multiple occurrence cases prior to this one, please see the following case IDs for additional information: 25020312003, 25020312004, and 25020312022. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/29/2025 · released to the public 1/5/2026.

9/14/2025Physical Abuse · ID 25020312042Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/15/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. After one client wandered into the incorrect room, staff witnessed client (B) striking client (A). During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, and assessed the clients. Client (A) did not sustain any visible injuries and did not report any pain. The facility continued increased monitoring related to wandering. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/22/2025 · released to the public 12/29/2025.

9/10/2025Physical Abuse · ID 25020312041Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 9/10/25, the healthcare entity investigated a reportable event of physical abuse of a client. Reportedly, client (A) kicked their roommate client (B). During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, implemented a room move, conducted interviews, and assessed the clients. Both clients alleged they were kicked by the other client and both clients denied kicking the other client. Neither client had any visible injuries. The facility made the room change permanent and reviewed and updated care plans. The facility was unable to determine if any physical contact occurred. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 12/1/25, Event ID 2TY611.

Publication

Sent to facility 12/16/2025 · released to the public 12/23/2025.

8/31/2025Physical Abuse · ID 25020312061Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/15/25, the healthcare entity investigated a reportable event of physical abuse of a client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 12/1/25, Event ID 2TY611. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/17/2026 · released to the public 3/25/2026.

8/20/2025Sexual Abuse · ID 25020312040Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 8/20/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. Client (A) alleged their roommate client (B) touched their private parts over the previous few nights. During the course of the investigation, the healthcare entity implemented an immediate room changed, started increased monitoring, notified law enforcement, and conducted interviews. Client (A) reported no pain, has cognitive impairments, and did not provide any context regarding the allegations. Client (B) denied the allegations and reported they did not get out of bed during the night. The facility made the room move permanent and reviewed care plans. As there was no evidence to support the allegation, the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 11/23/2025 · released to the public 12/1/2025.

8/14/2025Physical Abuse · ID 25020312038Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 8/14/25, the healthcare entity investigated a reportable event of physical abuse of client (B) by client (A). This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 12/1/25, Event ID 2TY611. Client (A) was identified in another occurrence case. Please refer to case IDs 25020312003, 25020312004, 25020312022, and 25020312034 for further information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/10/2025 · released to the public 12/17/2025.

8/11/2025Diverted Drugs · ID 25020312037Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 8/11/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported diverted drugs. The facility discovered one client was missing one dose of Methadone and the narcotic documentation had been altered. During the course of the investigation, the healthcare entity suspended staff pending a drug test, conducted interviews, notified law enforcement, and reviewed documentation. The client was unharmed and the facility worked with the provider to replace the dose. Staff, who had a negative drug test, denied the allegation and denied altering the documentation. The facility was unable to determine if the medication was taken and could only confirm it to be missing. The facility provided education to all staff regarding narcotic policies and documentation .The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 11/23/2025 · released to the public 12/1/2025.

8/10/2025Physical Abuse · ID 25020312036Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 8/10/25, the healthcare entity investigated a reportable event of physical abuse of client (B) by client (A). This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 12/1/25, Event ID 2TY611. Client (A) was identified in another occurrence case. Please refer to case ID 25020312023 for further information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/10/2025 · released to the public 12/17/2025.

8/1/2025Physical Abuse · ID 25020312035Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 8/1/25, the healthcare entity investigated a reportable event of physical abuse of a client. When bruising was found on client (B) they alleged their roommate client (A) had bumped into them with their wheelchair. During the course of the investigation, the healthcare entity completed an immediate room change, notified law enforcement, conducted an interview, and assessed the client. Client (A) denied ever bumping into their roommate on accident or on purpose. The facility determined contact may have occurred but did not believe it to be knowingly or with the intent to harm. The facility made the room changes permanent and updated care plans. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 12/1/25, Event ID 2TY611.

Publication

Sent to facility 12/10/2025 · released to the public 12/17/2025.

7/29/2025Physical Abuse · ID 25020312034Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/29/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, when client (B) wandered into client (A)’s room, client (A) reacted by pushing over the wheelchair of client (B) causing them to fall. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, started increased monitoring, and conducted an assessment and interviews. Due to cognitive impairment neither client could recall the event. Client (B) did not sustain any visible injuries. The facility determined client (A) acted as a reaction and not with ill intent. The interdisciplinary team for Client (B) will evaluate interventions to prevent wandering. The event was not substantiated. Client (B) has been involved in 3 previous occurrence events, please see case ID 25020312003, 25020312043, and 25020312022 for more information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 10/30/2025 · released to the public 11/6/2025.

7/25/2025Verbal Abuse · ID 25020312033Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/25/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported verbal abuse of a client. Client (B) alleged their roommate client (A) threatened to hit them. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, started increased monitoring, and completed a room change. Client (A) denied the allegations and indicated they made a request about the television volume only. The facility reviewed care plans and made the room change permanent. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 10/29/2025 · released to the public 11/6/2025.

7/24/2025Sexual Abuse · ID 25020312031Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/24/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. The client alleged staff touched their private parts when checking his incontinence brief. During the course of the investigation, the healthcare entity notified law enforcement, suspended staff, and conducted interviews. The facility staff checked the incontinence brief appropriately and the client recently stated receiving incontinence supports and was not used to this type of support. The facility reviewed the care plan and educated staff regarding explaining all steps of the care process. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 11/11/2025 · released to the public 11/19/2025.

7/24/2025Physical Abuse · ID 25020312032Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 7/24/25, the healthcare entity investigated a reportable event of physical abuse of a client. Staff witnessed client (A) throw a cup and bag at client (B) and try to spit on them. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, and assessed the client. The facility determined none of the items thrown made contact with client (B) nor did the spit make contact. The facility updated care plans and started increased monitoring. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. Client (A) was identified in another occurrence case. Please refer to case ID 25020312028 for further information. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 12/1/25, Event ID 2TY611.

Publication

Sent to facility 12/10/2025 · released to the public 12/17/2025.

7/9/2025Physical Abuse · ID 25020312028Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/9/25, the healthcare entity investigated a reportable event of physical abuse of a client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 12/1/25, Event ID 2TY611. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/10/2025 · released to the public 12/17/2025.

7/7/2025Physical Abuse · ID 25020312027Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/7/25, the healthcare entity investigated a reportable event of physical abuse of a client. Reportedly, client (A) and client (B) had a physical altercation resulting in one client grabbing the arm of the other client. During the course of the investigation, the healthcare entity separated the clients who were roommates at the time, notified law enforcement, conducted interviews, and assessed the clients. Client (A) declined to participate in the interview, and client (B) reported the disagreement started over a drink. One client sustained a scratch to the forearm. The facility implemented a room change, started increased monitoring, and updated care plans. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. Client (A) was identified in another occurrence case. Please refer to case ID 25020312024 for further information. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 12/1/25, Event ID 2TY611.

Publication

Sent to facility 12/10/2025 · released to the public 12/17/2025.

6/20/2025Physical Abuse · ID 25020312024Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 6/20/25, the healthcare entity investigated a reportable event of physical abuse. Staff witnessed client (A) make physical contact with client (B) after a brief verbal altercation. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, conducted interviews, started increased monitoring and assessed the clients. Due to cognitive impairment neither client could recall the event. The facility determined physical contact occurred but did not result in injury to either client. The facility updated care plans and educated staff. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department review of the occurrence investigation was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 12/1/25, Event ID 2TY611.

Publication

Sent to facility 12/10/2025 · released to the public 12/17/2025.

6/18/2025Physical Abuse · ID 25020312023Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/18/25, the healthcare entity investigated a reportable event of physical abuse of a client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 12/1/25, Event ID 2TY611. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/10/2025 · released to the public 12/17/2025.

6/7/2025Physical Abuse · ID 25020312022Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/7/25, the healthcare entity investigated a reportable event of physical abuse of a client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 12/1/25, Event ID 2TY611. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 12/10/2025 · released to the public 12/17/2025.

6/3/2025Physical Abuse · ID 25020312025Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/3/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. After a verbal altercation, client (A) pushed their roommate client (B), causing them to fall out of their wheelchair. During the course of the investigation, the healthcare entity separated the clients, completed an assessment, notified law enforcement, and conducted interviews. Client (B) was transported to the hospital and diagnosed with a hip fracture. The facility implemented a room change to keep clients on different wings of the facility, updated care plans, and educated clients regarding dispute resolution. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/29/2025 · released to the public 10/6/2025.

5/28/2025Physical Abuse · ID 25020312021Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/28/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed client (A) make physical contact with client (B) after a verbal altercation. During the course of the investigation, the healthcare entity separated the clients, notified law enforcement, and conducted interviews. Client (B) sustained no visible injuries. Client (A) was transported to the hospital for stabilization support. The facility implemented a room change, updated care plans, and added noise canceling headphones for client (A). The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/29/2025 · released to the public 10/6/2025.

4/10/2025Physical Abuse · ID 25020312012Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/12/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, the client had a straight catheter placed despite expressing she did not want one. During the course of the investigation, the healthcare entity notified law enforcement, suspended staff, conducted interviews, and completed an assessment. Assessment revealed mild irritation to the vaginal area, unknown if it is from catheter procedure or another procedure. Interviews with 3 staff in the room revealed that when the client asked to stop, the catheter had already been placed and staff offered to remove it, but the client declined. The staff returned to work, care plan reviewed and updated, and a plan for future catheter needs was developed. The event was not substantiated. The client was involved in another occurrence prior to this one, please see case ID 25020312010 for additional information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/3/2025 · released to the public 9/10/2025.

3/23/2025Physical Abuse · ID 25020312010Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/24/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of client (A) by client (B). During the course of the investigation, the healthcare entity separated the clients, placed them on frequent monitoring and notified police. Client (A) was assessed with no skin changes or pain after client (B) threw an object at them making contact. Client (A) did not express fear, and stated she felt safe. Client (B) admitted to throwing an object out of frustration. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/1/2025 · released to the public 7/8/2025.

3/21/2025Sexual Abuse · ID 25020312014Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/21/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. Staff witnessed client (A) engaging in self pleasuring behavior in the doorway of a room that was occupied by two female clients. During the course of the investigation, the healthcare entity notified law enforcement, conducted interviews, and implemented a temporary room change. Client (A) denied the allegation. The two alleged victims were sleeping in their room when this event occurred. The facility updated client (A)’s care plan and implemented a permanent move to an all male unit. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.

Publication

Sent to facility 8/19/2025 · released to the public 8/26/2025.

3/17/2025Physical Abuse · ID 25020312009Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 3/18/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client by an unknown person. During the course of the investigation, the healthcare entity conducted interviews, placed the client on consistent monitoring, and notified police. The client was assessed with bruising to his/her head, and told the staff member that a man had tried to fight them but could not provide a description of an alleged assailant. No staff witnessed any abuse and the client’s roommate stated no men had come into their room. The entity concluded that the client had fallen and reviewed his/her care plan for potential interventions. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/1/2025 · released to the public 7/8/2025.

3/10/2025Physical Abuse · ID 25020312008Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/10/25, the healthcare entity investigated a reportable event of physical abuse of client (A) by client (B). This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 3/26/25, Event ID 4LDQ11. This was the third physical abuse occurrence report client (B) had been involved with in 2025. For more information, refer to occurrence numbers 25020312003 and 25020312002. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/25/2025 · released to the public 7/3/2025.

3/1/2025Physical Abuse · ID 25020312007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 3/1/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of client (A) by client (B) who were roommates. During the course of the investigation, the healthcare entity conducted interviews, placed the clients on frequent monitoring, and checked the room for sharp objects and none were found. Client (A) was assessed with no stab marks or injuries. Client (A) reported to staff that client (B) stabbed them. Client (B) stated client (A) had flipped him/her off, and s/he poked them with their finger. Both clients refused to move, and agreed to involve staff to address any future conflicts. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/25/2025 · released to the public 7/3/2025.

2/22/2025Brain Injury · ID 25020312006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 2/24/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation, the healthcare entity sent the client to the hospital after the client had an unwitnessed fall while ambulating in the hallway and was bleeding from their head with a laceration noted. The client was sent to the closest hospital, and then transferred to a higher level of care to another hospital. Diagnostic tests revealed the client had a brain bleed. Upon return to the facility, the client was given a helmet to wear while ambulating, and placed on one to one observation. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/21/2025 · released to the public 5/28/2025.

2/8/2025Physical Abuse · ID 25020312004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 2/8/25, the healthcare entity investigated a reportable event of physical abuse of client (A) by client (B). This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 3/26/25, 4LDQ11. This is the second physical abuse occurrence client (B) has been involved with in 2025. For more information, refer to occurrence number 25020312002. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/22/2025 · released to the public 6/5/2025.

2/8/2025Physical Abuse · ID 25020312005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 2/8/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client by an unknown person. During the course of the investigation, the healthcare entity conducted interviews, notified Adult Protective Services (APS), and assessed the client who had a bruise on his/her eye. The client stated someone had hit her, but didn’t know who it was, but did not think it was a staff member. Staff interviewed stated the client bumped her head, and there was no contact made by any family members that they were aware of. The client is confused due to her diagnosis. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/22/2025 · released to the public 6/5/2025.

1/20/2025Physical Abuse · ID 25020312003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 1/20/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of client (A) by client (B). During the course of the investigation, the healthcare entity separated the clients and placed them on frequent monitoring to prevent a recurrence. Client (A) was assessed with no injuries after client (B) made contact with him after he was being physically aggressive towards a staff member. The event was substantiated, and client (A) has since been discharged from the facility. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/5/2025 · released to the public 5/12/2025.

1/16/2025Physical Abuse · ID 26020312003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 1/19/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed a verbal altercation between two clients resulting in both clients pushing the other and one client falling to the ground. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, assessed the clients, conducted interviews, and started increased safety monitoring. Neither client sustained visible injuries. The facility updated care plans to include interventions for physical aggression, educated staff, and completed environmental changes to create more space in the common areas. The facility determined physical contact occurred but did not result in injury to either client. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/12/2026 · released to the public 5/19/2026.

12/28/2024Missing Person · ID 24020312044Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 12/28/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a missing person. The client learned that an at risk client was missing. During the course of the investigation, the healthcare entity notified law enforcement, conducted a search, and completed interviews. The client was located 2 hours later and had a bruise on the wrist, no other injuries noted. The client, who was new to the facility, indicated that they were trying to leave to go home. The client’s care plan was updated and they were moved to a secure unit. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/1/2025 · released to the public 6/9/2025.

12/26/2024Equipment Malfunction · ID 24020312042Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 12/26/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported equipment malfunction. During the course of the investigation, the healthcare entity assessed the client, completed interviews, and assessed the conditions of the equipment. Reportedly, the wooden guard that was covering the metal of the floor heater fell off. When the client fell their leg made contact with the metal piece of the heater causing a skin tear. The client received care at the local hospital and returned to the facility. The facility replaced the guard and assessed the conditions of all floor heaters to ensure the guards were in proper working order. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/26/2025 · released to the public 7/7/2025.

12/18/2024Physical Abuse · ID 25020312002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 1/19/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of client (A) by client (B). During the course of the investigation, the healthcare entity separated the clients and placed them on frequent monitoring. Both clients were assessed with no injury after client (B) hit client’s (A) face, and he retaliated by hitting client (B) back. Client (A) did not remember the interaction, and client (B) was unable to answer any questions due to his medical condition. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/24/2025 · released to the public 5/1/2025.

12/2/2024Equipment Malfunction · ID 24020312039Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 12/12/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported equipment malfunction. During the course of the investigation, the healthcare entity assessed the condition of the equipment and discontinued using the equipment. While self transferring from the bed to wheelchair, the bedside cane came off of the bed. The client was uninjured. The facility removed and replaced the bedside cane. The facility checked all bedside canes in the building and found them to be in working order. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/30/2025 · released to the public 6/6/2025.

11/24/2024Sexual Abuse · ID 24020312038Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 11/26/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported sexual abuse of a client. Reportedly, client (A) placed the hand of client (B) on his pants in the groin area. During the course of the investigation, the healthcare entity reported to law enforcement, conducted interviews, implemented increased safety monitoring, and reviewed video footage. Client (A) denied the allegation. Video footage of public areas did not reveal evidence of this event. The facility provided staff education and reviewed care plans. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/9/2025 · released to the public 6/16/2025.

11/10/2024Neglect · ID 24020312036Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 11/19/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported neglect of a client. A family member alleged that the staff did not respond in a timely manner and that scissors, a potentially dangerous item, was left under the client's bed. During the course of the investigation, the healthcare entity notified law enforcement, conducted interviews, and completed a search. Due to cognitive impairment the client was unable to provide any additional details. The client was found to be uninjured and unharmed. The facility did not locate scissors or any other dangerous items under the client's bed. As there was no evidence of harm or dangerous items, the event was not substantiate. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/5/2025 · released to the public 7/14/2025.

10/9/2024Physical Abuse · ID 24020312032Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/9/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (A) pushed client (B) resulting in client (B) falling to the ground. During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, completed an assessment, and conducted interviews. Client (B) had slight discoloration of the hand but sustained no other injuries. Due to cognitive impairment neither client could provide additional details about the event. An extra staff and extra activities were added to the unit. Safety monitoring continued for both clients. The event was substantiated. Client (A) was involved in two other events prior to this one, please see case ID 24020312023 and 24020312019 for additional information. Client (B) was involved in another event prior to this one, please see case ID 24020312027 for additional information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/30/2025 · released to the public 6/6/2025.

9/26/2024Physical Abuse · ID 24020312031Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/17/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (A) threw a banana at client (B) causing a red mark to the area that was struck. The act was unprovoked. During the course of the investigation, the healthcare entity kept the clients separated, conducted an assessment and interviews, and started 1:1 staff monitoring of client (A) for the remainder of the day. Through interviews, client (A) indicated client (B) was not a target but did admit to throwing the item in frustration. Client (A)’s actions were reckless, and the event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.

Publication

Sent to facility 6/24/2025 · released to the public 7/3/2025.

9/26/2024Physical Abuse · ID 24020312030Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 9/26/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation, the healthcare entity separated the clients, completed an assessment, and conducted interviews. Reportedly, client (B) wandered into client’s (A) room and laid in the bed, causing client (A) to become upset and strike client (B). Client (B) sustained a minor injury to the lip and did not require medical attention. The facility created a visual cue for client (B) in order to prevent future wandering. The facility reviewed and adjusted the client's (A) care plan and placed an extra staff on the unit. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/30/2025 · released to the public 6/6/2025.

9/24/2024Physical Abuse · ID 24020312029Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 9/25/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (A) and client (B) were in an unwitnessed altercation resulting in physical contact between them. During the course of the investigation, the healthcare entity separated the clients, completed an assessment, conducted interviews, and increased monitoring. While client (A) had no visible injury, they reported soreness in the area, requiring no medical treatment. The facility added extra staff to the unit and updated care plans. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/30/2025 · released to the public 6/6/2025.

9/17/2024Physical Abuse · ID 24020312028Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/17/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, there was physical contact between two clients. During the course of the investigation, the healthcare entity separated the clients, completed assessments, and conducted interviews. Client (A) sustained a skin tear that required first aid treatment. The facility provided increased monitoring for both clients and provided staff education. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/21/2025 · released to the public 5/28/2025.

9/3/2024Physical Abuse · ID 24020312027Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 9/4/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, client (A) pushed client (B) causing a fall resulting in a complaint of soreness to his wrist. During the course of the investigation, the healthcare entity staff separated the clients, conducted an assessment and interviews, and started safety checks. Tylenol was provided to client (B). Both clients had a cognitive impairment and could not state what triggered the interaction. Safety monitoring continued for both clients. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/8/2025 · released to the public 5/15/2025.

7/22/2024Physical Abuse · ID 24020312023Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 7/9/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation, the healthcare entity determined a client was hit by his peer as he walked by the unit entrance. The peer was placed on a line of sight support program to monitor his behaviors. Video footage confirmed unwanted physical contact was made between the two clients. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/3/2025 · released to the public 3/13/2025.

7/8/2024Physical Abuse · ID 24020312022Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 7/9/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation, the healthcare entity determined a client was hit by her peer as she walked by the peer’s room. The peer was placed on a one to one support program to monitor her behaviors and general client safety. The client remained upset with her peer after the event. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/5/2025 · released to the public 3/13/2025.

6/19/2024Physical Abuse · ID 24020312020Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 6/19/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation, the healthcare entity determined the client’s peer splashed water at the client because she felt the client was making fun of her speech impairment. The client’s peer was moved to a different room and the client was monitored for her safety. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/28/2025 · released to the public 3/9/2025.

6/16/2024Physical Abuse · ID 24020312019Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 6/19/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation, the healthcare entity separated the client’s peer and the client after the peer kicked him. The clients were assessed without complaints of pain or injury. Staff confirmed unwanted physical contact occurred between the clients. The facility increased one to one support programs for client safety. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/28/2025 · released to the public 3/9/2025.

6/8/2024Physical Abuse · ID 24020312018Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 6/7/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation, the healthcare entity determined staff separated the client and his peer after the peer hit the client in his arm multiple times. The client alleged that he bumped into his peer by accident. The event was substantiated for unwanted physical contact between the two clients. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/21/2025 · released to the public 2/28/2025.

6/7/2024Physical Abuse · ID 24020312017Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS: On 6/7/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation, the healthcare entity determined staff separated the client and her peer after the peer slapped the client in the arm. The client’s peer alleged the bump into her walker was intentional. The event was substantiated for unwanted physical contact between the two clients. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.

Publication

Sent to facility 2/21/2025 · released to the public 2/28/2025.

6/4/2024Physical Abuse · ID 24020312016Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 6/28/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation, the healthcare entity determined staff separated the client and her peer after the peer intentionally hit the client in the arm. The clients were placed on 15 minute checks and the client’s peer admitted to hitting the client. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/21/2025 · released to the public 2/28/2025.

5/27/2024Physical Abuse · ID 24020312015Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 5/27/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation, the healthcare entity determined two clients were in a physical altercation when staff intervened. The client’s peer was placed on a one to one support program and the client was assessed for injuries. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/12/2025 · released to the public 2/20/2025.

5/16/2024Physical Abuse · ID 24020312014Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 5/17/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. During the course of the investigation, the healthcare entity reported client (B) was sitting in a chair when client (A) became possessive and territorial of the chair. Client (A) got agitated and attempted to pull client (B) out of the chair, which resulted in client (B) falling to the ground. Staff separated the clients, conducted an assessment, and started direct safety monitoring. As client (B) complained of pain, she was transferred to the hospital for an evaluation. Diagnostic test results showed she suffered a re-injury to her knee. The injury would be managed through medications. The facility concluded the incident happened but due to client (A)’s dementia, management determined she did not act with intention. However, her actions were reckless. Staff ensured client (A) sat in a designated chair. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/2/2025 · released to the public 3/9/2025.

5/15/2024Physical Abuse · ID 24020312013Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 5/19/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. During the course of the investigation, the healthcare entity reported two roommates got into an altercation that resulted in client (A) complaining of pain. Staff provided direct monitoring with client (A) for 24-hours and then staff monitoring continued per both client's individualized plan of care. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/2/2025 · released to the public 3/9/2025.

4/7/2024Physical Abuse · ID 24020312011Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/7/24, resident (A) reportedly pinched resident (B) for sitting in her spot and in an attempt to get her to move. Staff intervened to separate the residents. With resident (B)’s cognitive impairment, she was not able to participate in a follow up interview about the event. No visible injuries were observed. Resident (A) had a history of being territorial over her perceived spaces and seating preferences. The facility substantiated the incident occurred and the alleged victim was pinched. Staff implemented line of sight monitoring for resident (A) to deter negative resident interactions. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The facility/agency complied with licensing standards for conducting an internal investigation of this Occurrence event and submitting a report of the findings to the Department. However, the licensing standard for timely reporting was not met.

Publication

Sent to facility 2/5/2025 · released to the public 2/12/2025.

3/13/2024Physical Abuse · ID 24020312006Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 3/13/24, the healthcare entity investigated a reportable event of sexual abuse and neglect involving two clients. During the course of the investigation, the healthcare entity reported male client (A) entered the locked unit during a time that the community was under a fire watch. He then entered female client (B)’s room and allegedly started to lift her shirt up. She yelled out for help. Staff redirected client (A) and implemented direct staff oversight of 2:1. The facility identified staff #1 had not been providing proper oversight of client (A) at the time of the incident. Client (B) did not consent to the touch and had been upset by client (A)’s actions. Client (A)’s medications were changed to help with hypersexual behaviors. Staff were re-trained on monitoring expectations. The event was substantiated. Two days earlier, client (A) had been involved in another alleged incident of sexual abuse (refer to event ID#24020312004 for further details). This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe. In addition, this event has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 10/9/24, inspection ID – ZS6111.

Publication

Sent to facility 3/13/2025 · released to the public 3/20/2025.

3/11/2024Sexual Abuse · ID 24020312004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS: On 3/11/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a sexual abuse event. During the course of the investigation, the healthcare entity reported staff witnessed client (A) undressing client (B), who was sleeping at the time. There was also an allegation of client (A) asking client (B) if he could touch his private area. Client (B) was found in his brief. Staff separated the clients and implemented 1:1 safety monitoring with client (A). Client (A) was moved to a private room. When asked about the incident, client (B) did not recall what occurred. A medication review occurred for client (A) due to instances of hypersexual behaviors. The event was substantiated. Two days later, client (A) was involved in a second incident of trying to touch a female client. Refer to event ID#24020312006 for further details. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/13/2025 · released to the public 3/20/2025.

11/13/2023Physical Abuse · ID 23020312043Reported on time: No▼

Occurrence summary

DESCRIPTION OF OCCURRENCE:On 11/13/23, resident (B) in their 70’s was getting snacks from their drawer. Allegedly, resident (A) in their 60’s approached and asked resident (B) to move out of the way. Resident (A) then hit resident (B) on the face causing injury. AGENCY/FACILITY ACTION:The facility conducted an internal investigation and notified the police and families. Residents (A) and (B) were immediately separated and a room move was completed. An assessment was completed which showed resident (B) had a mark on his face. Resident (B) stated that he was attempting to get a snack out of a drawer when resident (A) approached him asking him to move. Resident (A) became upset, and attempted to move resident (B) out of the way and hit them in the face. Resident (A) confirmed they asked resident (B) to move then hit the resident. Other residents were interviewed with no concerns noted. The facility concluded the allegation of physical abuse was substantiated. All staff were re-educated to monitor the residents' interactions to help prevent a recurrence when possible. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. The facility/agency complied with licensing standards for conducting an internal investigation of this Occurrence event and submitting a report of the findings to the Department. However, the licensing standard for timely reporting was not met. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency.

6/21/2023Physical Abuse · ID 23020312029Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 06/21/23 staff observed female resident (A), in her 50s, reach out and grab female resident (B)'s hair. Resident (B) was in her 70s. Resident (A) was severely cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and ombudsman. Staff responded and separated the residents. The residents were put on frequent checks. Resident (B) would not allow a thorough assessment but no bleeding or missing hair was observed. Both residents voiced dislike of the other. Resident (A) denied any fault in the altercation. Resident (B) had a history of trying to provoke a negative response from resident (A). The residents remained on frequent checks with redirection by staff to avoid the residents being in close proximity to each other. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the facility/agency acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/10/2023 · released to the public 11/17/2023.

6/13/2023Physical Abuse · ID 23020312028Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 06/13/23 male resident (A), in his 70s, and male resident (B), in his 50s, were involved in a verbal altercation. Resident (B) yelled at resident (A), who then kicked resident (B). The residents were both cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. The residents were separated and put on frequent checks. Resident (B) was assessed and had no visible injuries. Resident (A) said resident (B) "deserved to be kicked". Resident (A)'s medications were to be reviewed due to his recent increase in outbursts toward others. The incident seemed to have been triggered by staff trying to redirect resident (B) from standing up due to his fall risk. Resident (A) became involved in telling resident (B) not to stand and this agitated resident (B). Staff were educated to offer alternative areas to re-direct residents to avoid others. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/10/2023 · released to the public 11/17/2023.

6/11/2023Physical Abuse · ID 23020312026Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 06/11/23 male resident (A), in his 70s, hit male resident (B) causing him to lose his balance and fall backwards. Resident (B) was in his 80s. Both residents were severely cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. The residents were separated and put on frequent checks. Resident (B) was assessed and had a small area of bleeding on the back of his head. He was sent to the hospital to rule out a head injury. None was identified. Resident (B) did not remember the incident when interviewed. Camera footage was reviewed. It showed resident (A) attempting to exit the secure unit. Resident (B) was standing close to him. Resident (B) appeared to be trying to help resident (A) exit the unit. Resident (A) appeared to be startled by resident (B) and lifted hit hands to swat resident (B)'s away from him. This startled resident (B) who stumbled backwards. Resident (A)'s medications were reviewed and adjusted. Both residents remained on frequent checks. Staff were educated to intervene immediately when residents are observed seeking to exit the unit. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/10/2023 · released to the public 11/17/2023.

5/24/2023Physical Abuse · ID 23020312025Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 05/24/23 staff observed male resident (A), in his 70s, getting up from the floor in the dining room. Resident (B), his his 60s, said resident (A) had hit him. Both residents had severe cognitive impairment. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and families/guardians. The residents were separated and put on frequent checks. The residents were assessed and neither had any visible injuries. There were no witnesses to the incident. Resident(B) said he did not know why resident (A) swung his hand, hitting him. A short time later, resident (B) could not remember the incident. Resident (A) denied stating and altercation with resident (B) and a short time later, he also could not remember the incident. Resident (A)'s medications were reviewed and adjusted. Staff were educated to maintain distance between the residents to prevent another altercation. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 7/20/2023 · released to the public 7/27/2023.

5/13/2023Physical Abuse · ID 23020312023Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 5/13/23, resident (B), in her 70s, reported that resident (A) pinched her arm when passing by her in the hall. Resident (A) was in her 50s. Both residents were cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and families/guardians. The alleged incident was not witnessed. The residents were separated and put on frequent checks. Resident (B) was assessed and had a reddened area to the back of her arm. Resident (B) said the incident was unprovoked. Resident (A) denied the incident occurred. The residents had a known history of disliking each other. The residents were to remain on frequent checks. Staff were to assist resident (A) in the hallway to avoid proximity to others. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/6/2023 · released to the public 11/13/2023.

4/30/2023Physical Abuse · ID 23020312021Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 04/30/23 a staff member was standing behind male resident (B). Male resident (A) reached around and grabbed resident (B) causing him to lose his balance. The staff member assisted in lowering resident (B) to the floor. Resident (A) was in his 70s and resident (B) was in his 80s. Both residents were severely cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and families/guardians. The residents were separated and put on frequent checks. Resident (B) was assessed and had no visible injuries. Both residents blamed the other for starting the conflict. Video monitoring confirmed the staff member's version of what happened. There was no audio monitoring available. Staff were to continue to intervene rapidly to prevent further escalation of resident behaviors and set limits when behaviors could negatively impact others. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 8/7/2023 · released to the public 8/14/2023.

4/18/2023Physical Abuse · ID 23020312019Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 04/18/23 male resident (A) kicked male resident (B) on his buttocks. Both residents were in their 70s and cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and families/guardians. The residents were in the hallway arguing. Resident (A) then kicked resident (B). Staff separated them. Resident (B) was assessed and had no visible injury. The residents were put on frequent checks. Resident (B) had a recent GDR (Gradual Dose Reduction) of one of his medications that might have had an impact on intrusive/provoking behaviors. A review of the resident's medications was requested. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 7/20/2023 · released to the public 7/27/2023.

3/15/2023Physical Abuse · ID 23020312015Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 03/15/23 male resident (A) in his 70s, hit male resident (B) in the face. Resident (B) was in his 60s. Both residents were cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and families/guardians. Staff heard raised voices in the hall and responded. The residents were separated. Camera footage showed resident (A) hitting resident (B). Resident (B) was assessed and had an abrasion to his right cheek. No treatment was necessary. Resident (B) said he did not know what had upset resident (A). Resident (A) did not remember the incident. Resident (A) was to remain on frequent staff checks. Staff were to assist resident (A) when he was propelling in common areas where other residents were present. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 7/18/2023 · released to the public 7/25/2023.

3/6/2023Physical Abuse · ID 23020312014Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 03/06/23 male resident (B), in his 40s, reported female resident (A) had him. Resident (A) was in her 50s. Resident (A) was severely cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and families/guardians. The residents were separated. Resident (B) was assessed and had no injuries. Video camera footage was reviewed and showed resident (B) instigating the incident. Resident (A) was yelling at resident (B) to leave her alone. Resident (B) kept moving closer to resident (A) who was swinging her arm out to keep resident (B) away. Resident (B) continued to move closer and resident (A) struck him. The residents were put on frequent checks. Staff were educated to intervene and re-direct immediately when hearing raised voices to avoid further escalation of behaviors. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 7/18/2023 · released to the public 7/25/2023.

2/22/2023Physical Abuse · ID 23020312012Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 02/22/23 staff observed male resident (A) it male resident (B) on the side of his face. As staff approached, resident (A) hit resident (B) again. Both residents were in their 60s and were cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and families/guardians. The residents were separated and redirected. Resident (B) was assessed and had no visible injuries. Resident (B) said he did not know why resident (A) hit him. Resident (A) reported resident (B) said something that upset him so he swung at him. Camera footage was reviewed. It showed resident (A) bump into resident (B). Resident (B) said something to resident (A) who then hit resident (B). Seating in the dining room was being re-evaluated to avoid further incidents. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 6/7/2023 · released to the public 6/14/2023.

1/22/2023Physical Abuse · ID 23020312005Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 01/22/23 male resident (A), in his 60s, swung at male resident (B). Resident (B) was in his 70s. Resident (B) got up from his wheelchair, lost his balance and fell. Both residents were cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and families/guardians. The residents were separated and put on frequent checks. Resident (B) was assessed and had no visible injuries. Resident (A) said resident (B) was cursing at him and that was why he hit him. Resident (A)'s physician was asked to review his medications as his behaviors remained impulsive and responsive to outside stimuli. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 6/2/2023 · released to the public 6/9/2023.

1/18/2023Physical Abuse · ID 23020312004Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 01/18/23 female resident (B), in her 60s, reported female resident (A) had slapped her. Resident (A) was in her 50s. Both residents had diagnoses of mental illness. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and families/guardians and ombudsman. The residents were separated. Resident (B) was assessed and had no visible injuries. The residents were roommates. Resident (B) said resident (A) kept coming to her side of the room and then slapped her. Resident did not respond when questioned about the incident. A room change was made to prevent a recurrence. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 6/2/2023 · released to the public 6/9/2023.

1/1/2023Physical Abuse · ID 23020312001Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 01/01/23 male resident (A), in his 60s, and male resident (B), in his 70s, were involved in a physical altercation. The residents both were severely cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. The residents were in the hallway and staff responded to their yelling. The residents were separated and put on frequent checks. Resident (A) was assessed and had no injury. Resident (B) had a small cut to the side of his forehead that was cleaned and left open to air. Both residents accused the other of instigating the altercation. Video monitoring showed resident had started the incident and swung his cane at resident (A), who swung back. Resident (B)'s cane was removed and replaced with a walker. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 6/1/2023 · released to the public 6/8/2023.