GOOD SAMARITAN SOCIETY -- FORT COLLINS VILLAGE

INITIAL COMMENTS: (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This survey was conducted on December 10, 2025, to comply 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) construction. The original building is Type II (000) construction; the Weiss Therapy addition was added in 2000, the Chapel addition was added in 2003, and the Hoeger addition was added in 2007. All buildings are classified as Type V construction. There is an adjoining Assisted Living Building that is separated by a two-hour fire-rated construction. Existing life safety features that met the requirements for new construction at the time of licensure or certification shall be maintained and not diminished. The facility is licensed for 64 beds. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. This facility is classified as fully sprinklered. The results of this survey were discussed with the Administrator and the Maintenance Director during the exit conference.

STANDARD not met based on observation and staff interview during the survey; it was determined that the facility failed to continuously maintain the exit discharge and access means of egress to full use in case of an emergency. Life Safety Code 101 Section 19.2.1 and 7.2.1.7. The fire-rated panic hardware on the kitchen door has been removed and replaced with a slide-action lock. 7.2.1.7 Panic Hardware and Fire Exit Hardware. 7.2.1.7.1 Where a door assembly is required to be equipped with panic or fire exit hardware, such hardware shall meet all of the following criteria: (1) It shall consist of a cross bar or a push pad, the actuating portion of which extends across not less than one-half of the width of the door leaf.(2) It shall be mounted as follows:(a) New installations shall be not less than 34 in. (865 mm), and not more than 48 in. (1220 mm), above the floor.(b) Existing installations shall be not less than 30 in. (760 mm), and not more than 48 in. (1220 mm), above the floor.(3)It shall be constructed so that a horizontal force not to exceed 15 lbf (66 N) actuates the cross bar or push pad and latches. 7.2.1.7.2 Only approved panic hardware shall be used on door assemblies that are not fire-rated door assemblies. Only approved fire exit hardware shall be used on fire-rated door assemblies. New panic hardware and new fire exit hardware shall comply with ANSI/UL 305, Standard for Safety Panic Hardware, and ANSI/BHMA A156.3, Exit Devices. If the egress is not properly maintained, this deficiency could affect all residents, staff, and visitors within the smoke compartment during a fire emergencyThe exit discharge deficiency was discussed during the exit conference with the Administrator and Maintenance Director.

Standard not met. During the survey, it was observed that the facility failed to maintain sprinkler-protected hazardous areas in accordance with Life Safety Section 8.7.1, 19.3.2.1, and 19.3.2.1.1. The self-closing device has been removed from the library door, which is considered a hazardous area rated for one hour of separation due to the volume of combustibles. 2. The self-closing device has been removed from the Barber Shop door, which is considered a hazardous area rated for one hour of separation due to the volume of combustibles. 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrierhaving a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 Life Safety Code 101-19.3.2.1.3. The doors shall be self-closing or automatically closing. This deficiency may allow smoke and heat to transfer between the hazardous area and other parts of the building, potentially compromising the safety of all residents and staff within the primary smoke compartment. The Maintenance Director noted the absence of a self-closing device on the door during the survey.

STANDARD not met by observation and staff interviews during the survey. It was determined that the facility failed to maintain the marking of means of egress per the 20212 Life Safety Code 101- Section 7.10. The directional indicator for the gym exit sign is pointing in the wrong direction. Life Safety Code 19.2.10.1. Means of egress shall have signs per section 7.10. The directional indicator shall be outside 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. This deficient practice could affect all residents, staff, and visitors in one smoke compartment if code-compliant exit signage is not provided for building egress. The Maintenance Director acknowledged the deficiency of the exit signage during the facility tour.

STANDARD not met, as evidenced by the observation and staff interview during the facility tour. It was determined that the facility failed to maintain sprinkler-protected hazardous areas per 101 Life Safety Code Section 19.3.2.1. Smoke barrier ceiling in the boiler room has large pieces of drywall missing and no longer complies with the requirement that hazardous areas be separated from other spaces by smoke-resisting construction. Protection from Hazards. 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. This deficient practice could affect all residents and staff in all the smoke compartments, should there be smoke and heat transfer between the hazardous area and other portions of the building. The Maintenance Director acknowledged the missing drywall in the ceiling during the facility tour. He stated that a water leak had occurred, and the repairs have not been completed yet.

Standard not met. During the record review, it was determined that the facility did not comply with the corridor door requirements as outlined by (NFPA 101) and (NFPA 80). This deficiency could potentially impact occupants, including residents, staff, and visitors within the affected smoke compartments in the event of a fire emergency. At the time of the survey, there was no written record for the annual inspection, testing, or maintenance report of each fire door. NFPA 101 4.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance. Referenced Publications 2.2* NFPA Publications. NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition. This deficiency could potentially impact all residents, staff, and visitors within the affected smoke compartments in the event of a fire emergency. The annual door inspection was discussed during the survey with the Director of Maintenance and again at the exit conference.

STANDARD not met: The facility did not comply with the National Fire Protection Association 70 and the National Electrical Code, as observed during staff interviews and surveys regarding the maintenance of electrical equipment. The electrical receptacle (KTCH-R3) located in the kitchen is pulled out of the electrical box, exposing energized electrical connections. NFPA 70, National Electrical Code Article 370-25. Covers and Canopies in completed installations, each box shall have a cover, faceplate, or fixture canopy. This deficient practice could affect all residents in the smoke compartments due to increased potential hazards of electrical fire. The Maintenance Director acknowledged the electrical hazard during a tour of the facility.

STANDARD not met based on record review and documentation of inspection and testing of the non-hospital grade electrical outlets in patient care areas as required by sections 6.3.4.1.3 and 6.3.4.2.1.1 of NFPA 99, Health Care Facilities Code. No written test records of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care areas were 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 The 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). 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation orgeneral anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. This deficient practice could affect all residents, staff, and visitors throughout the facility if the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade were to fail due to a lack of testing. The non-hospital grade electrical outlets testing at the patient’s care areas deficiency was discussed with the Director of Maintenance during the survey.

STANDARD not met by record review and staff interviews during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced 2010 NFPA 110, Section 8.3.8 Maintenance and Operational Testing. The facility generator's annual analytical report indicates high levels of sulfur in the fuel system. NFPA 110, Section 8.3.8, a fuel quality test shall be performed at least annually using approved ASTM standards. This deficient practice has the potential to affect all residents throughout the facility in the event of power loss. The emergency generator deficiency item was discussed with the Maintenance Director during the survey and the exit conference with the Administrator.

A recertification survey was conducted from 9/22/25 to 12/4/25. Four deficiencies were cited. The actual exit date was 9/25/25, but unable to process before Federal government shutdown on 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 12/4/25.

An Emergency Preparedness survey was conducted from 9/22/25 to 12/4/25. No deficiencies were cited. The actual exit date was 9/25/25, but unable to process before Federal government shutdown on 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 12/4/25.

Based on record review and interviews, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for one (#43) of three residents reviewed for restorative services out of 29 sample residents. Specifically, the facility failed to ensure Resident #43 was provided with a splint or palm guard in her left hand to prevent potential worsening of her hand contracture (a condition of shortening and hardening of muscles, tendons or other tissue, often leading to deformity and rigidity of joints). Findings include:I. Facility policy and procedureThe Range of Motion (ROM) Sanford policy, revised 8/5/25 was received from the nursing home administrator (NHA) on 9/26/25 at 12:36 p.m. It read in pertinent part,“Based on the resident’s comprehensive assessment, the location will ensure that a resident entering without a limited range of motion will not experience reduction of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable.“In addition, the location will ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion as much as possible and to prevent further decrease in range of motion.”II. Resident #43A. Resident statusResident #43, age 82, was admitted on 5/1/25. According to the September 2025 computerized physician orders (CPO), diagnoses included type two diabetes, blindness in one eye, fibromyalgia (musculoskeletal pain and fatigue) and chronic congestive heart failure (weakened heart muscle). The 8/6/25 minimum data set (MDS) assessment identified Resident #43 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented Resident #43 was dependent on staff for toileting hygiene, lower body dressing, putting on/taking off footwear, and transferring to/from the bed to chair. B. Resident interview and observationResident #43 was interviewed on 9/25/25 at 9:20 a.m. Resident’s left hand was contracted and she was unable to extend all her fingers. The resident said she sometimes had her brace. She said her brace disappeared the other night but therapy was working on finding her a new one. C. Observations On 9/22/25 at 2:30 p.m. Resident #43 was not wearing her palm protector on left hand (a device used to prevent finger contractures). On 9/23/25 at 2:20 p.m. Resident #43 was wearing her palm protector on her left hand. On 9/25/25 at 9:10 a.m. Resident #43 was not wearing her palm protector. It was on her table in her room. D. Record reviewReview of Resident #43’s comprehensive care plan did reveal documentation that Resident #43 had a contracture. The care plan did not list any interventions for the management of the contracture. Review of Resident #43’s September 2025 CPO did not reveal a physician’s order for palm protector to prevent contractures. Review of Resident #43’s occupational therapy notes revealed the first palm protector was given to Resident #43 on 7/7/25. Resident #43 complained of left hand pain 8 out of 10 and did not bump it on anything. The nurse compared the right and left hand and the left looked slightly darker than the right. The OT placed a palm guard on Resident #43’s left hand to protect it and keep the hand in a better position. The nurse said they would keep an eye on it.-However, her care plan did not indicate how often and for how long the palm protector should be on. Review of Resident #43’s Kardex (staff directive tool) did not include information regarding a hand brace or palm protector. D. Staff interviews Registered nurse (RN) #3 was interviewed on 9/25/25 at 9:15 a.m. RN #3 said the RNs or the certified nurse aides (CNA) could put braces or palm protectors on residents. She said information on how and when to apply equipment should be in the treatment administration record (TAR). CNA #1 was interviewed on 9/25/25 at approximately 9:30 a.m. CNA #1 said Resident #43 should have her palm protector put on in the morning and taken off at night when she went to bed. CNA #1 said information on Resident #43’s brace and placement could be found on the care plan, physician’s orders or the Kardex. CNA #1 said usually there were pop ups (prompts) that the CNAs followed to make sure tasks were completed. CNA #1 said there were currently not pop ups for Resident #43’s palm protector. RN #2 was interviewed on 9/25/25 at approximately 9:30 a.m. RN #2 said there was not a physician’s order for a brace or palm protector for Resident #43. Occupational Therapist (OT) #1 was interviewed on 9/25/25 at 2:50 p.m. OT #1 said Resident #43 was admitted with a contracted index finger. She said that upon admission, best practice was to take measurements of resident’s contractures. She said she was not sure whether or not the therapy department took measurements. OT #1 said when the resident was admitted to the facility, the therapy team offered different things for her to wear to prevent contractures but she did not want them. OT #1 said that should have been documented. The interim director of nursing (DON) was interviewed on 9/25/25 at 4:27 p.m. The interim DON said when a resident was initially admitted to the facility and had contractures a care plan should have been created. The interim DON said the nursing staff should be updating the care plan and there should be a physician’s order for the brace or palm protector. The interim DON said if there was a physician’s order, a range of motion task would pop up on the CNA tasks and the CNAs would acknowledge it. The interim DON said this information should be on the Kardex sheet to reference. The interim DON said the therapy team should also evaluate the resident. The interim DON said once the therapy team had evaluated the resident, therapy should be educating nursing staff on the brace and then education should be passed on through verbal reports for the nursing staff. The interim DON said communication tools the staff used included white boards in the resident’s room, communication tabs in the electronic charting system and communication questions with the nurses or charge nurse. The interim DON said the charge nurse should verify the brace was on. The interim DON said there was not a restorative program at the facility currently. The interim DON did not know why the resident did not have a physician’s order for a palm protector and why her care plan was not updated with a palm protector intervention.

Based on observations, record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for two (#70 and #10) of five residents out of 29 sample residents. Specifically, the facility failed to: -Identify Resident #70 had a history of suicidal ideation in order to monitor for worsening signs and symptoms of depression or suicidal ideation; -Identify and implement effective interventions for Resident #10’s yelling behavior;-Ensure hours of sleep were monitored for Resident #10 while she was on antidepressant medications known to cause drowsiness; and, -Ensure Resident #70 and Resident #10 were offered mental health services. Findings include: I. Resident #70 A. Resident statusResident #70, age greater than 65, was admitted on 9/11/25. According to the September 2025 computerized physician orders (CPO), diagnoses included dementia, chronic myeloid leukemia (cancer of the blood and bone), depression and insomnia. The 9/17/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. He used a wheelchair and had an impairment on both the upper and lower extremities. He required supervision with eating and he required substantial assistance with showering, oral hygiene and personal hygiene. The MDS assessment revealed Resident #70 had little interest or pleasure in doing things, felt down, depressed or hopeless, and felt tired or had little energy on seven to 11 days during the assessment look-back period. The MDS assessment revealed the resident had thoughts he would be better off dead or hurt himself on two to six days during the assessment look-back period. The MDS assessment indicated the resident’s patient health questionnaire (PHQ-9 - a multi-purpose tool used for screening, diagnosing, monitoring and measuring the severity of depression) was seven out of 27, which indicated mild depression. B. Resident interview Resident #70 was interviewed on 9/25/25 at 10:28 a.m. Resident #70 said he was not happy at the facility. He said none of his relatives visited him. He said he would talk to a professional about how he felt about living at the new facility if he was given the chance. C. Record review Resident #70’s suicide statement care plan, initiated and revised on 9/25/25 (during the survey), revealed the resident made statements he was ready to die and felt he would be better off if he was gone. He denied suicidal ideation, intent and plan. Interventions included giving the resident adequate rest periods per the resident’s requests, discussing with the family and resident any concerns, fears and issues, attempting non-pharmacological interventions for depression, enjoying one-on-one conversations, going outside, watching history and nature television programs. -However, despite the resident’s expressions of not wanting to be here anymore and feeling bad about himself from the 9/17/25 MDS assessment the facility failed to assess and monitor the resident for signs and symptoms of depression and suicidal ideation. The 9/2/25 physician’s progress note revealed Resident #70 was seen for worsening depression. The resident expressed feeling not worthy and wanting to “get out of here.” He reported feeling sad and stating he was in a nursing home and nobody visited him except for his wife and she could only come so often. He reported difficulty finding enjoyment in activities at the nursing home. He reported he had fleeting suicidal thoughts including thinking about jumping in front of traffic or cutting his artery with a hacksaw. He mentioned sleep saved him and he fell asleep before he was able to act on any of these thoughts. The depression and suicidal ideation plan was discussion of antidepressant medication therapy. The medical power of attorney (MPOA) declined medication initiation at the visit. The physician encouraged frequent mood reassessment once the resident moved to a new facility. The physician recommended implementing increased safety precautions and added orders for more frequent safety checks by staff every two hours and staff removed sharp objects and potential self harm tools from the resident’s room and coordinating with facility staff to encourage resident engagement in daily activities. The 9/9/25 referral discharge physician orders revealed Resident #70v may benefit from behavioral health consultation if his mood did not improve following the move. Send last progress notes so the future provider was aware. The 9/13/25 PHQ-9 score revealed a score of nine out of 27 which indicated mild depression. He had little interest or pleasure in doing things on seven to 11 days, felt down, depressed or hopeless on two to six days, felt tired or had little energy on 12 to 14 days, trouble concentrating on things seven to 11 days and moving or speaking so slowly that other people could have noticed occurred on two to six days during the assessment look back period. -Review of Resident #70’s electronic medical record (EMR) failed to identify that a suicide lethality assessment was completed after the 9/17/25 PHQ-9 assessment revealed the resident had thoughts he would be better off dead and the facility failed to document that the resident was scheduled to be seen for his depression and suicidal ideation. II. Resident #10 A. Facility policy and procedure The Psychotropic Medications policy and procedure, revised 5/12/25, was provided by the nursing home administrator (NHA) on 9/26/25 at 12:36 p.m. It read in pertinent part, “Based on a comprehensive assessment of a resident, the location must ensure that residents who use psychotropic drugs receive behavioral interventions, unless clinically contraindicated, in aneffort to discontinue these drugs. Throughout the administration of the psychotropic medications, the following must be completed: mood and behavior documentation must continue in order to monitor the effect the medication has on the behavior. Monitor for effectiveness and potential adverse consequences. The reduction committee will review the need for psychotropicmedications at least every three months and document the rationale for continuing the medication. The committee also will need to evaluate the resident’s target symptoms and the effect of the medication on the severity, frequency and other characteristics; any changes in the resident’s function during the last quarter; this can be done by reviewing the minimum data set (MDS) and whether the resident experienced any medication-related adverse consequences during the previous quarter.”B. Resident status Resident #10, age 88, was admitted on 3/30/21. According to the September 2025 CPO, diagnoses included dementia, chronic obstructive pulmonary disease, aortic stenosis, morbid obesity, lymphedema, disorder with mixed anxiety and depressed mood, insomnia and major depressive disorder. The 9/24/25 MDS assessment revealed the resident was cognitively impaired with a BIMS score of 12 out of 15. She had one impairment on her upper extremity and used a wheelchair. She required supervision with eating. She required substantial assistance with oral hygiene and personal hygiene. She was dependent on staff for toileting and showering. The assessment revealed the resident received an antipsychotic medication and an antidepressant medication. The assessment revealed the resident did not exhibit any behaviors and did not reject care. C. Resident interview Resident #10 was interviewed on 9/23/25 at 9:39 a.m. Resident #10 said the staff said she asked for help too much. She said staff said she needed too much personal care. She said staff did not always say that when she asked for help. She said staff said she asked for help too much off and on. Resident #10 was observed in her wheelchair next to her bed in herroom. D. Resident observations During a continuous observation on 9/23/25, beginning at 1:00 p.m. and ending at 1:49 p.m, Resident #10 was observed in her wheelchair next to her bed in her room. From 1:09 p.m. to 1:21 p.m. Resident #10 said please help three times, help me three times and help over ten times.-However, no staff members went into the resident’s room to see what the resident needed. At 1:24 p.m. an unknown certified nurse aide (CNA) walked in and walked out at 1:25 p.m. At 1:26 p.m. Resident #10 said help two times. At 1:29 p.m. the same unknown CNA went into Resident #10’s room with CNA #2. At 1:32 p.m. Resident #10 was observed in her bed. At 1:44 p.m. Resident #10 had two visitors enter her room. At 1:49 p.m. Resident #10’s visitor asked an unknown CNA who was in the hallway outside of Resident #10’s room if the resident could get up in her wheelchair. The CNA got the resident. During a continuous observation on 9/24/25, beginning at 3:00 p.m. and ending at 4:00 p.m. Resident #10 was observed in her bed with both of her eyes open. At 3:12 p.m. Resident #10 said hello two times. -However, no staff members went into the resident’s room to see what the resident needed. At 3:22 p.m. Resident #10 said help me three times. -However, no staff members went into the resident’s room to see what the resident needed. From 3:28 p.m. to 3:34 p.m. Resident #10 said help eight times. -However, no staff members went into the resident’s room to see what the resident needed. At 3:36 p.m. CNA #3 went into Resident #10’s room. At 3:46 p.m. Resident #10 was observed being escorted by CNA #3 to the common area. E. Record review Resident #10’s psychopharmacological medication care plan, initiated 8/26/21 and revised 6/13/25, revealed the resident used psychopharmacological medication related to major depressive disorder, dementia with behavior episodes and adjustment disorder with mixed anxiety. Interventions included consulting with pharmacy and healthcare providers to consider dosage reduction, discussing with healthcare providers and family the ongoing need for the use of the medication and monitoring the resident’s condition based on clinical practice guidelines or clinical standards of practice related to the use of psychotropic medications. Resident #10’s behavior symptom care plan, initiated 1/17/25 and revised 3/4/25, revealed the resident’s behavior included yelling out, banging on the wall, inappropriate comments to the staff during care. She denied care was given and stated nobody ever helped her when staff was recently in her room. Interventions included intervening as necessary to protect the rights and safety of others, approaching in a calm manner, diverting attention, removing the resident from the situation and taking her to alternate locations as needed, providing opportunities for positive interaction and attention, offering a warm blanket for comfort as needed, offering a weighted blanket for comfort as needed, repositioning as needed, assessing for pain, thirst, hunger and constipation and offering one on one reassurance and emotional support as needed. Resident #10’s cognitive deficit care plan, initiated 4/7/21 and revised 9/12/25, revealed Resident #10 exhibited forgetfulness and became upset and agitated with reminders. She had difficulty with timelines, she was repetitive with her concerns, and brought up past concerns after they had been resolved. She was unaware of current reality at times, such as saying she needed to be changed when staff just assisted her. She called out for help and then did not know what she needed help with. Interventions included enjoying one on one conversation especially about astrology, enjoying the presence of others, understanding consistent, simple and direct sentences, providing her with necessary cues, communicating with the resident regarding her capabilities and needs, asking yes or no questions, presenting just one thought, idea, question or command at a time and break tasks into one step at a time. Review of Resident #10’s September 2025 CPO revealed the following physician’s orders: Zoloft (antidepressant medication) 50 milligram (mg) tablet. Take one tablet by mouth one time a day for depression, ordered 3/1/25. Zyprexa (antipsychotic medication) 7.5 mg tablet. Take one tablet by mouth at bedtime for dementia with behaviors, ordered 6/13/24. Depakote 250 mg delayed release tablet. Take two tablets by mouth two times a day for dementia with behaviors, ordered 4/9/25. Mood monitoring: tearful, change in sleep habits, refusing medication, decrease in appetite, easily irritated with staff. Complete every shift for mood monitoring, ordered 6/9/24. Mood and behavior monitoring: calling out, tearful, accusations she is not being assisted, refusing medications or meals, irritable with staff, demanding behaviors, change in sleeping habits or self isolation. Complete every shift for mood and behavior monitoring, ordered 7/17/23. -A review of Resident #10’s EMR failed to reveal the resident’s hours of sleep were monitored. The 8/31/25 nurse progress note revealed Resident #10 had minimal yelling out. The 9/1/25 nurse progress note revealed the resident yelled out help throughout the night. The staff were attentive and responded quickly. The resident was forgetful what time it was during the day and thought it was daytime. Staff reassured the resident and she went back to sleep. The 9/2/25 nurse progress note revealed Resident #10 was in the family room with other residents calling out to go to bed after dinner and at shift change. The nurse told the resident many residents were requesting assistance to go to bed and everyone would have to wait until the CNAs were available to assist her. The resident acknowledged the information and she stopped calling out. The 9/10/25 nurse progress note revealed the resident was in the family room calling out for help. When asked how the nurse could help, the resident said she did not know. The resident was given a snack and a drink with a positive effect for 15 minutes. She continued to call out for help after the snack was consumed. The resident went to her room per her request. The resident was provided an additional blanket per her request. The resident had an illogical flow of ideas, changing subject, per baseline. Reassurance and emotional support were provided. The 9/16/25 care conference note revealed Resident #10 continued to call out, was unable to make needs known when approached and sometimes did not know why she was calling out. The 9/17/25 nurse progress note revealed the resident had minimal yelling during the shift. -There was no consistent documentation in Resident #10’s EMR regarding what interventions were attempted when the resident exhibited the identified behaviors and if the interventions were effective. -A review of Resident #10’s EMR failed to reveal the interdisciplinary (IDT) team met to review the resident’s psychotropic medications, what behaviors were being monitored, what non-pharmacological interventions were used to help manage the resident’s psychiatric behavior symptoms and the resident’s response to the interventions attempted. IV. Staff interviews CNA #2 was interviewed on 9/25/25 at 5:36 p.m. CNA #2 said she was familiar with Resident #70. CNA #2 said Resident #70 did not have any behaviors. CNA #2 said she was not aware of any signs or symptoms of depression or a history of suicidal ideation or attempts for the resident. Licensed practical nurse (LPN) #1 was interviewed on 9/25/25 at 4:21p.m. LPN #1 said Resident #70 did not have any behaviors. LPN #1 said he was not aware of any signs or symptoms of depression or a history of suicidal ideation or attempts for the resident. The social services director (SSD) was interviewed on 9/25/25 at 3:52 p.m. The SSD said she started working at the facility in February 2025 and this was her first nursing facility social worker position. She said she had a consultant she collaborated with asneeded. The SSD said she was responsible for completing the social services section of the MDS assessment. She said she recently hired a part-time social services assistant. The SSD said if the assistant completed the assessment, the SSD reviewed the section with her assistant. The SSD said if a resident answered yes to feeling better off dead or had little interest or pleasure in doing things, felt down, depressed or hopeless, she talked to the resident further to learn more about why the resident had those feelings. She said she would document the conversation as a progress note. The SSD said during the conversation she would complete a suicide ideation assessment to determine if the resident had a suicide plan. The SSD said after she talked to the resident, she would implement interventions to help the resident and it was documented in the resident’s care plan. She said mental health services were one intervention. The SSD said she would have a physician’s order for mental health services. The SSD was familiar with Resident #70. She said she completed the MDS social services assessment for Resident #70. She said when the resident answered yes to feeling better off dead, she talked to him for an hour to learn why he answered yes. The SSD said he did not feel better off dead, he said he hated being in a new facility, he missed his wife and he talked about how he missed his independence. The SSD said she thought she documented the conversation as a progress note. The SSD reviewed Resident #70’s progress notes during the interview and she said did not see a progress note that documented her conversation with the resident about his suicidal statements. The SSD said based on her conversation with Resident #70 and reviewing his chart, the resident had depression. The SSD said she should arrange for Resident #70 to see mental health services and she should collaborate with nursing staff so the nursing staff could monitor his depression. The SSD said nursing staff monitored depression through a physician’s order and documented the depression monitoring on the resident’s treatment administration record (TAR). The SSD said she collaborated with the IDT regarding what resident behaviors needed to be monitored. The SSD said the IDT reviewed residents who were on psychotropic medications during the psychotropic pharmacy meeting. The SSD said she was responsible for the psychotropic pharmacy meetings. She said residents were reviewed prior to the residents starting a psychotropic medication, quarterly and as needed. She said she took handwritten notes at the meetings and she did not document the meeting notes in the individual resident’s EMR. The SSD said typical interventions were resident specific and personalized based on what interventions were effective for the resident. The SSD said sitting with the resident, holding the resident’s hand, talking with the resident, repositioning, music, changing the music, a stress ball, a teddy bear, aromatherapy, a warm blanket and sitting in the sunshine were examples of interventions for residents. The SSD said interventions should be offered whenever the resident wanted and needed interventions. The SSD said she was familiar with Resident #10. The SSD said Resident #10 called out for help repetitively and if staff did not respond, she called out louder. The SSD said she had not determined effective interventions to reduce Resident #10’s behavior of calling out for help. She said saw the physician’s orders for Resident #10 to be seen for individual counseling and mental health services. The SSD said she was unable to determine when Resident #10 was seen for individual counseling and mental health services.

Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#8) of three residents reviewed for hospice services out of 29 sample residents. Specifically, the facility failed to:-Establish an effective communication process, including how the communication would be documented between the facility and the hospice services provider for Resident #8; and,-Ensure the hospice agency’s care notes were easily accessible to the facility staff and included consistent documentation of the hospice care visits in Resident #8’s electronic medical record (EMR). Findings include:I. Facility policy and procedureThe Hospice Care policy and procedure, revised 11/1/24, was received from the nursing home administrator (NHA) on 9/26/25 at 12:36 p.m. It read in pertinent part, “Hospice care addresses symptom management, coordination of care, communication and decision making, clarification of goals of care, and quality of life for the dying resident and their family. Hospice care is provided by an interdisciplinary team (IDT) approach to address the physical, psychosocial, spiritual, and medical care to help someone with a terminal illness live as well as possible for as long as possible, increasing quality of life.”II. Facility-Hospice contractReview of Resident #8’s EMR revealed a contract between the facility and the hospice services company, which was signed by the resident’s representative on 2/21/25. It read in pertinent part, “A coordinated comprehensive plan of care shall be jointly developed by the facility and hospice. Hospice participation in the care plan conference and input from the hospice representative are required.”III. Resident #8A. Resident statusResident #8, age greater than 65, was admitted on 2/7/25. According to the September 2025 computerized physician orders (CPO), diagnoses included dementia, Parkinson's disease, cerebral ischemia (not enough blood flow to the brain leading to brain cell damage), cervical disc degeneration, osteoporosis, anxiety, anemia and hypertension. The 8/13/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident required maximum assistance with activities of daily living (ADL) and had a performance deficit related to incontinence, activity intolerance, aggressive behavior, confusion, dementia, and limited mobility. The assessment documented that the resident was receiving hospice services. B. Record reviewThe September 2025 CPO revealed a physician’s order for Resident #8 to be admitted to hospice care services on 2/7/25 due to cerebral ischemia (not enough blood flow to the brain, causing brain cell damage). Review of Resident #8’s end-of-life care plan, initiated 9/5/25, revealed the resident was receiving hospice services for end-of-life comfort care. The hospice agency’s phone number was included in the care plan.-However, the care plan did not include interventions related to the coordination of the resident’s specific needs with hospice staff. -The care plan did not include documentation related to the specific care needs the hospice services company would be providing to the resident. Review of Resident #8’s EMR failed to reveal documentation of the hospice service company’s visits with the resident and what care was provided to the resident during the visits. IV. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 9/24/25 at 3:45 pm. CNA #3 said the hospice provider would perform some ADL care with Resident #8. CNA #3 said he did not know when hospice would come to the facility and provide care to the resident. CNA #3 said he did not keep track of the hospice care provided to the resident. He said if it was a bath day and the resident had not had a bath, the hospice agency’s bath team would give Resident #8 a bath. Licensed practical nurse (LPN) #2 was interviewed on 9/23/24 at 10:20 a.m. LPN #2 said the Resident #8 was receiving hospice services. LPN #2 said Resident #8 would sometimes get music therapy from the hospice provider. LPN #2 said she would need to call the hospice agency’s phone number if she had questions or concerns regarding the resident. LPN #2 said she would call the hospice agency for a change in the condition of the resident. LPN #2 said she when she called the hospice agency she could request that the hospice nurse come and see Resident #8 to evaluate the resident due to a change in condition. She said she did not know how often the hospice nurses or hospice CNAs came to see the resident. LPN #2 said she did not have a reference form to refer to for information on who and when hospice provided care for the resident. LPN #2 said she did not have access to the hospice agency’s notes in order to see what hospice services were provided during each hospice visit. The hospice registered nurse (RN) was interviewed on 9/24/25 at 3:10 p.m. The hospice RN said she documented her notes in her iPad, and then the notes were sent to the hospice services agency. The hospice RN said the facility would contact the hospice nurse for medication refills. The hospice RN said she did not share her visit notes with the facility; the notes were only documented in the hospice agency’s EMR. The hospice RN said she would get a call from the facility for falls, comfort care questions or if the resident was combative with personal care. The hospice RN said Resident #8 had impulsive behavior at times. The interim director of nursing (DON) was interviewed on 9/25/25 at 4:45 p.m. The interim DON said Resident #8 was receiving hospice services. The interim DON said the hospice contract indicated what services the hospice company provided to residents. The interim DON did not know the exact services that were provided by the hospice agency, what discipline within the hospice agency provided them or how often specific services were provided to Resident #8. The interim DON said in order for the facility staff to communicate with the hospice agency, a phone call would be made to the agency. The interim DON said when the hospice agency had a question or concern with a resident, they would call the facility.

Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two (#16 and #48) of the five residents reviewed for antibiotic use out of 29 sample residents. Specifically, the facility failed to track and monitor the use of long-term antibiotics for Resident #16 and Resident #48. Findings include:I. Professional reference According to The Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes (2025), retrieved on 9/29/25 fromhttps://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html?CDC_AAref_Val=https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html"To track how and why antibiotics are prescribed, providers perform reviews on resident medical records for new antibiotics started to determine whether the clinical assessment, prescription documentation, and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians."II. Facility policy and procedureThe Antibiotic Stewardship policy, dated 7/8/25, was received from the nursing home administrator (NHA) on 9/25/25 at 11:04 am. It read in pertinent part, “To guide Good Samaritan Society-Fort Collins Village locations for antibiotic stewardship plans. To decrease the incidence of multidrug-resistant organisms (MDRO). Promote appropriate use while optimizing the treatment of infections and reducing the possible adverse events associated with antibiotic use. To provide standard definitions to be used as guidelines when initiating antibiotics.”III. Resident #16A. Resident status Resident #16, age greater than 65, was admitted on 9/29/22. According to the September 2025 computerized physician order (CPO), diagnoses included congestive heart failure, atrial flutter, long-term anticoagulant use, chronic kidney disease, hyponatremia, urgency of urination and overactive bladder. The 9/3/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of ten out of 15. The assessment revealed the resident was on an antibiotic. B. Resident interview Resident #16 was interviewed on 9/24/25 at 10:03 a.m. She said she did not currently have a urinary tract infection (UTI). The resident said she was not sure the last time she had a UTI. She said when she had a UTI in the past, it made her feel uncomfortable. She said she was not on any antibiotics currently. C. Record review Review of Resident #16’s September 2025 CPO revealed the following physician's order:Cephalexin (antibiotic) tablet 250 milligram (mg). Give 1 tablet by mouth one time a day for UTI prophylaxis (to prevent an infection from occuring), ordered 12/9/22. The physician's order for the Cephalexin failed to indicate a stop date for the use of the antibiotic. The antibiotic therapy care plan, revised 12/7/23, revealed the resident was on antibiotic therapy related to UTI prevention. Pertinent interventions included monitoring/documenting signs or symptoms of UTI.Review of Resident’s #16 EMR did not reveal documentation regarding the physician's justification for the long-term use of an antibiotic. Review of Resident #16’s EMR did not reveal documentation to indicate the facility's infection preventionist (IP) completed an antibiotic use assessment or documented the McGeer's criteria met to justify the physician's order for Cephalexin. Review of the IP infection surveillance documents from 6/25/25 to 8/25/25 revealed that the facility identified residents with active infections. -However, Resident #16 was not included on the infection surveillance documents. The 6/20/25 pharmacist note documented Resident #16 had received an antimicrobial agent, Cephalexin 250 mg once a day, since December 2022 for the prevention of UTI. The note documented prolonged use of antibiotics for infection prophylaxis increased the risk of resistance and the development of C. difficile infection.-However, review of the resident’s EMR did not reveal documentation that the facility took action to clarify the antibiotic use for Resident #16. IV. Resident #48A. Resident status Resident #48, age greater than 65, was admitted on 3/9/23. According to the September 2025 CPO, diagnoses included vascular dementia, atrial fibrillation, prediabetes, muscle weakness and lack of coordination. The 9/10/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of one out of 15. The assessment revealed the resident was on an antibiotic. B. Record reviewReview of Resident #48’s September 2025 CPO revealed the following physician’s order;Cipro Oral Tablet 250 MG (Ciprofloxacin HCl): Give 250 mg by mouth in the evening for UTI prophylaxis, ordered 2/18/24.-The physician's order for the Cipro failed to indicate the duration for the use of the antibiotic., The antibiotic therapy care plan, revised 8/6/23, revealed the resident was on antibiotic therapy related to UTI prevention. Pertinent interventions included encouraging fluid intake and monitoring/documenting/reporting signs or symptoms of UTI. Review of the Resident #48’s EMR did not reveal documentation regarding the physician's justification for the long-term use of an antibiotic. Review of Resident #48’s EMR did not reveal documentation to indicate the facility's IP completed an antibiotic use assessment or documented that McGeer's criteria were met to justify the physician's order for Cipro. The 6/21/25 pharmacist note documented that Cipro was started in February 2024 and was a long-term antibiotic. The note documented the evidence supporting prophylactic antibiotic use for recurrent UTI in older adults was lacking and the harms of long-term use may outweigh the benefits in older adults.-However, there was documentation that the facility reviewed the use of the long-term use of Cipro for Resident #48. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/25/25 at 10:40 a.m. LPN #1 said Resident #16 had been on an antibiotic since she started working at the facility. LPN #1 said there was a question as to why the antibiotic was prescribed prophylactically for UTI, without an end date. LPN #1 said Resident #16 had not experienced a UTI while at the facility. LPN #1 said she was not aware of Resident #16 ever having a UTI. The IP and the NHA were interviewed together on 9/25/25 at 4:42 p.m. The IP said the facility's process for monitoring and tracking infections and antibiotic use included mapping of current infections and outbreaks. The IP said the medical director reviewed antibiotic use as needed. The IP said if the resident's family refused to stop antibiotic use, it would continue prophylactically per family request. The IP said the process for prophylactic antibiotic use was continued by the family of the resident, even though the facility had an antibiotic stewardship program.

An abbreviated survey, promoted by #CO38971, was completed on 1/16/2025. No deficiencies were cited. No response is required. This structure is a one (1) story, Type II (000) construction. The original building is Type II (000) construction, the Weiss Therapy addition was added in 2000, the Chapel addition was added in 2003 and the Hoeger addition was added in 2007. All buildings are classified as Type V construction. There is an adjoining Assisted Living Building that is separated by a two-hour fire rated construction. Existing life safety features that met the requirements for new construction at the time of licensure or certification shall be maintained and not diminished. The facility is licensed for 64 beds. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. This facility is classified as fully sprinklered.

A complaint survey, prompted by #CO38961 was conducted on 1/16/25. No deficiencies were cited.

A complaint survey, prompted by #CO37907 was conducted on 10/24/24. No deficiencies were cited.

A complaint survey, prompted by #CO37116 was conducted on 9/9/24. No deficiencies were cited.

A complaint survey, prompted by #CO36042 was conducted on 5/22/24. No deficiencies were cited.

A revisit to the 1/9/24 survey was completed on 3/27/2024. The facility was in compliance with the regulation surveyed.

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

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 January 23, 2024 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) construction. The original building is Type II (000) construction, the Weiss Therapy addition was added in 2000, the Chapel addition was added in 2003 and the Hoeger addition was added in 2007. All buildings are classified as Type V construction. There is an adjoining Assisted Living Building that is separated by a two-hour fire rated construction. Existing life safety features that met the requirements for new construction at the time of licensure or certification shall be maintained and not diminished. The facility is licensed for 64 beds and the census on the date of the survey was 48. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system. This facility is classified as fully sprinklered. The results of this survey were discussed with the Administrator and the Maintenance Director during the exit conference.

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. Kitchen stove and cooking equipment missing wheel docking blocks. NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of maintenance and cleaning, provided the appliances are returned to approved design location prior to cooking operations. NFPA 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 54, 9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer's installation instructions. 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 appliances. This deficiency was discussed during the exit conference.

Based record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. This was evidenced by:1. Fire alarm initiating and notification devices do not simultaneously deactivate when the fire alarm control panel is silenced. 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, 10.10.2 When an alarm signal deactivation means is actuated, both audible and visible notification appliances shall be simultaneously deactivated. Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors within the building should a delay occur in locating a fire throughout the facility. The deficiencies were discussed during the exit conference.

Based on observation during the survey, it was determined that the facility failed to maintain proper gas practices in accordance with Life Safety Section 9.1 and NFPA 54, 11.1.2. This was evidenced by the following:1. Gas orifice on dryers is rated for 0-2000 feet in elevation in first floor laundry room. NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction.(3) In accordance with the manufacturer's installation instructions. This deficiency was discussed during the exit conference.

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. Fire drills were not conducted during varying times and conditions. Time of drills were too close to previous drills on all shifts. 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.