BOULDER POST ACUTE

A revisit survey was completed on 4/21/26 for all previous deficiencies cited on 2/19/26. The facility is in compliance with all regulations surveyed.

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 March 17, 2026 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies." This structure is a mixed-level construction consisting of Type I (fire resistive), Type II (non-combustible), and Type V (wood frame) construction. The west wing of the facility is primarily three-story with the east main and east addition being one story with a basement level. The basement (east main and east addition) is at grade level on the south side. This facility was built in 1961. The facility is licensed for 162 beds and the census on the date of the survey was 134. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe fire sprinkler system utilizing two separate wet-pipe systems having east and west fire sprinkler risers. There is an anti-freeze loop that protects the front canopy. The facility is classified as fully sprinklered. The results of this survey were discussed with the Regional Director and Maintenance Director during the exit conference.

Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain hazard areas in accordance with NFPA 101, 99, 80, and 58. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,162 of 162 residents, and an indeterminable number of staff and visitors. 1. Observations and interviews with the maintenance director during the inspection indicated that the ceiling in the Third-floor "scary room" requires repair. 2. Observations during the inspection, including interviews with the maintenance director, indicated that the Maintenance shop lacks fire foam and/or scab patches. 3. During the inspection, observations and interviews with the maintenance director revealed that the fire door on the third floor by the elevator needs adjustment. 4. The record review, along with observations and interviews with the maintenance director, confirmed the requirement for an annual Life Safety inspection. NFPA 101 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code 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 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. 8.7.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3 Protecting the area with automatic extinguishing systems in accordance with Section 9.7 Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 434.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance. 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initialfire development for the time needed to evacuate, relocate, or defend in place 4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, andshall remain operational. 4.5.5* Situation Awareness. Systems used to achieve the goals of Section 4.1 shall be effective in facilitating and enhancing situation awareness, as appropriate, by building management, other occupants and emergency responders of the functionality or state of critical building systems, the conditions that might warrant emergency response, and the appropriate nature and timing of such responses. 4.5.7 System Design/Installation. Any fire protection system, building service equipment, feature of protection, or safeguard provided to achieve thegoals of this Code shall be designed, installed, and approved in accordance with applicable NFPA standards. 4.6.1.2Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction. 4.6.8 Provisions in Excess of Code Requirements. Nothing in this Code shall be construed to prohibit a better building construction type, an additional means of egress, or an otherwise safer condition than that specified by the minimum requirements of this Code. 4.6.12 Maintenance, Inspection, and Testing. 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. The administrator and maintenance director discussed deficient items at 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. The deficient practice affected all smoke compartments. The deficient practice affected 1 of 9 smoke compartments. The deficient practice could affect all smoke zones,8 of 162 residents, and an indeterminable number of staff and visitors. During the inspection, observations and interviews with the maintenance director revealed that restraints are missing from the kitchen equipment. NFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer installation instructions. The administrator and maintenance director discussed deficient items at the exit conference.

Based on a record review, observations, inspection, and interviews, 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. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,162 of 162 residents, and an indeterminable number of staff and visitors. During the inspection, observations and interviews with the maintenance director revealed that the fire alarm annunciation panel must be moved from the elevator mechanical room. The fire annunciator panel was installed without DFPC plan review or inspections, despite the facility having Boulder Fire-stamped plans on site. NFPA 10119.3.4 Detection, Alarm, and Communications Systems. 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 7210.18.1 Approval and Acceptance. 10.18.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. 10.18.1.2* At the authority having jurisdiction’s request, complete information regarding the system or system alterations, including specifications, type of system or service, shop drawings, input/output matrix, battery calculations, and notification appliance circuit voltage drop calculations, shall be submitted for approval. 10.18.1.3 Before requesting final approval of the installation, if required by the authority having jurisdiction, the installing contractor shall furnish a written statement stating that the system has been installed in accordance with approved plans and tested in accordance with the manufacturer’s published instructions and the appropriate NFPA requirements. 10.18.1.4* The record of completion form, Figure 10.18.2.1.1, shall be permitted to be a part of the written statement required in 10.18.1.3. When more than one contractor has been responsible for the installation, each contractor shall complete the portions of the form for which that contractor had responsibility. 10.18.1.5 The record of completion form, Figure 10.18.2.1.1, shall be permitted to be a part of the documents that support the requirements of 10.18.2.4. ASME A17.12.8.1 Equipment allowedElevator machine spaces, machine rooms, control spaces, and control rooms should only contain elevator equipment and associated control equipment. Other equipment such as TV antenna controls, radio transmission, telephone equipment, etc. Should not be in this room or space. Electronic and radio transmission equipment located in elevator machinery spaces, machine rooms, control spaces, and control rooms have been found to cause interference with elevator equipment. This requirement prevents unauthorized personnel from entering an area that is hazardous to those that are not trained in the safe maintenance or repair of the elevator equipment. Unauthorized persons may accidentally cause an elevator shutdown, trapping a passenger in a stalled car. They would also be exposed to the moving machinery, potentially causing injury to them. The prohibition against other equipment in the machinery spaces, machine rooms, control spaces, and control rooms reduces the fire load and the potential of fire and fire sprinkler activation. Firefighters require elevator services in emergencies, especially in high-rise buildings, thus the need to control the potential ignition sources in an elevator machine room. A fire in a basement machine room also would expose the hoistway to the fire as there is no way to provide fire-resistant construction between the hoistway and machine room. Elevator machine rooms are not permitted to be used as passageways to other areas inside and outside the building. For example, a scuttle used to check roof conditions is not allowed. The administrator and maintenance director discussed deficient items at the exit conference.

Based on a record review, observations, inspection, and interviews, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,162 of 162 residents, and an indeterminable number of staff and visitors. 1. The record review, along with observations and interviews with the maintenance director, indicates that sprinklers over 20 years old on all floors (installed 2000-2004) require replacement or testing. 2. The record review, observations, and interviews with the maintenance director revealed that ten sprinkler heads on the third floor and twenty on the fourth floor are over 50 years old (installed in 1972). 3. During the inspection, observations and interviews with the maintenance director revealed that the west riser control valve requires a control sign near the stairwells. 4. Observations and interviews with the maintenance director during the inspection revealed that the laundry drain valve requires lockout. 5. During the inspection, observations and interviews with the maintenance director revealed that the second-floor riser's hydraulic calculation plate is blank. 5.3.1.1.1.3* Sprinklers manufactured using fast-response elements that have been in service for 20 years shall be replaced, or representative samples shall be tested and then retested at 10-year intervals. NFPA 25 5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested. 13.3.1* Each control valve shall be identified and have a sign indicating the system or portion of the system it controls. 13.3.2 Inspection. 13.3.2.1 All valves shall be inspected weekly. 13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly. 13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised. 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible NFPA 13, 2013 Edition, Chapter 25, Section 25.5.1. The installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion resistant wire, chain, or other approved means. Such signs shall be placed at the alarm valve, dry pipe valve, preaction valve, or deluge valve supplying the corresponding hydraulically designed area. The administrator and maintenance director discussed deficient items at the exit conference.

Based on observations and a review of records, it was determined that the facility did not maintain fire extinguishers in accordance with NFPA 10. The deficient practice affected 1 of 9 smoke compartments. The deficient practice could affect all smoke zones,8 of 162 residents, and an indeterminable number of staff and visitors. Observations and interviews with the maintenance director during the inspection revealed that the Third-floor kitchen is missing the required K-Class fire extinguisher sign, or the existing sign is mounted too high. Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers5.5.5* Class K Cooking Media Fires. Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. 5.5.5.1 Class K fire extinguishers manufactured after January 1, 2002, shall not be equipped with extended wand–type discharge devices. 5.5.5.2 Fire extinguishers installed specifically for the protection of cooking appliances that use combustible cooking media (animal or vegetable oils and fats) without a Class K rating shall be removed from service. 5.5.5.3* A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher. NFPA 10 6.1.3.8 Installation Height. 6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. The administrator and maintenance director discussed deficient items at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,162 of 162 residents, and an indeterminable number of staff and visitors. The record review, along with observations and interviews with the maintenance director, indicates that the fire damper report was not available at the time of the survey. NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shallbe every 6 years. 6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment. 6.5.4 Full unobstructed access to the damper shall be verified and corrected as required. The administrator and maintenance director discussed deficient items at the exit conference.

Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6. The deficient practice affected all smoke compartments. The deficient practice affected all smoke compartments. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,162 of 162 residents, and an indeterminable number of staff and visitors. During the record review, observations, and interviews with the maintenance director, it was revealed that the time for the February fire drills was not documented at the time of the inspection. 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 deficient items at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 ofthe Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8. The deficient practice could affect all smoke zones,162 of 162 residents, and an indeterminable number of staff and visitors. During the record review, observations and interviews with the maintenance director revealed that the Weekly Inspection (NFPA 110-2010; 8.4.1) was noted as completed for the period of November 2024 to March 2025. NFPA 110-8.4 Operational Inspection and Testing. 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. The administrator and maintenance director discussed deficient items at the exit conference.

During the survey, it was determined that the facility failed to meet the oxygen safety requirements in accordance with NFPA 101 (2012) and NFPA 99 (2012). The deficient practice affected 1 of 9 smoke compartments. The deficient practice could affect all smoke zones,30 of 162 residents, and an indeterminable number of staff and visitors. 1. Observations and interviews with the maintenance director during the inspection revealed that the Oxygen room ventilation is non-operational. 2. Observations and interviews with the maintenance director during the inspection revealed that the "Empty" and "Full" cylinder signs were missing. NFPA 99 5.1.3.3.3 Ventilation. 5.1.3.3.3.1 Venting of Relief Valves. Indoor supply systems shall have all relief valves vented per 5.1.3.5.6.1(4) through (9). 5.1.3.3.3.2 Ventilation for Motor-Driven Equipment. The following source locations shall be adequately ventilated to prevent accumulation of heat:(1) Medical air sources (see 5.1.3.6)(2) Medical-surgical vacuum sources (see 5.1.3.7) (3) Waste anesthetic gas disposal (WAGD) sources (see 5.1.3.8.1)(4) Instrument air sources (see 5.1.3.9)5.1.3.3.3.3 Ventilation for Outdoor Locations.(A) Outdoor locations surrounded by impermeable walls shall have protected ventilation openings located at the base of each wall to allow free circulation of air within the enclosure.(B) Walls that are shared with other enclosures or with buildings shall be permitted to not have openings. NFPA 99 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. The administrator and maintenance director discussed deficient items at the exit conference.

A recertification survey with complaint #CO2707155, #CO2723158, Incident #2728503, Incident #2728576, Incident #2728614, Incident #2728631, Incident #2728658 and Incident #2728920 was conducted on 2/16/26 to 2/19/26. Six deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/16/26 to 2/19/26. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#1 and #8) of five residents out of 43 sample residents. Specifically, the facility failed to:-Obtain orders for Resident #1’s midline catheter (tube inserted into a vein to administer medication) dressing change;-Change Resident #1’s midline catheter dressing in a timely manner; and,-Follow physician’s orders for Resident #8’s sliding scale insulin. Findings include:I. Failed to obtain orders for Resident #1’s midline catheter dressing change and change the resident’s midline catheter dressing in a timely mannerA. Professional referenceAccording to Basic Nursing Thinking, Doing and Caring Treas, L., & Barnett, K., & Smith M. (2022) Basic Nursing Thinking, Doing and Caring (3rd ed.), p. 3531, “The replacement of transparent dressings should be done at least every five to seven days, or earlier as clinically indicated, for example when the dressing becomes damp, soiled or loose.” B. Resident #11. Resident statusResident #1, age 86, was admitted on 10/3/25. According to the February 2026 computerized physician orders (CPO), diagnoses included gastrostomy (surgical procedure to make an opening for a feeding tube), epilepsy, Alzheimer’s disease, dysphagia (difficulty swallowing) and pneumonitis due to inhalation of food and vomit. The 12/31/25 minimum data set (MDS) assessment indicated the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The staff assessment revealed the resident had memory problems with both long and short term memory. The MDS assessment indicated the resident was dependent on staff for all activities of daily living (ADL). 2. ObservationOn 2/16/26 at 4:45 p.m. licensed practical nurse (LPN) #7 entered Resident #1’s room to change her midline catheter transparent dressing. LPN #7 confirmed the date on the dressing was 2/6/26, which was the date the midline catheter was placed, ten days prior. LPN #7 said a midline catheter dressing should be changed every seven to 10 days. 3. Record reviewThe 2/6/26 nurse progress note documented a physician’s order was given by Resident #1’s physician for the resident to receive intravenous (IV) fluids. The resident’s midline catheter was placed on 2/6/26. Review of Resident #1’s February 2026 CPO revealed the following physician’s orders: Normal saline flush intravenous solution 0.9 percent (%), use one liter IV one time only for dehydration for one day, ordered 2/6/6. Midline dressing change of the left arm, in the evening, every seven days, ordered 2/17/26.-The February 2026 CPO did not include physician’s orders for midline catheter dressing changes for Resident #1 until 2/17/26 (during the survey), 11 days after the resident’s midline catheter was placed. C. Staff interviewsLPN #7 was interviewed 2/18/26 at 1:16 p.m. LPN #7 said a representative from the pharmacy came to the building to insert Resident #1’s midline catheter and said the dressing should be changed every seven to 10 days, but there was no documentation of this in Resident #1’s electronic medical record (EMR). LPN #7 said she followed up with the director of nursing (DON) and was told seven days was the standard of practice for the transparent dressing change. She said the physician’s order to change the resident’s midline catheter dressing was missed. The DON and the regional clinical resource were interviewed together on 2/18/26 at 3:50 p.m. The DON and the regional clinical resource both said the standard of practice for a transparent dressing change was seven days and as needed. The DON said Resident #1’s dressing should have been changed seven days after the initial dressing was placed (on 2/6/26), so it should have been changed on 2/13/26. The DON said physician’s orders addressing the midline catheter dressing should have been entered into Resident #1’s EMR.

Based on record review and interviews the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#1) of one resident reviewed with a feeding tube out of 43 sample residents. Specifically, the facility failed to ensure Resident #1 received her tube feedings per physician's orders. Findings include:I. Facility policy and procedureThe Enteral Tube Feeding via Continuous Pump policy, dated November 2018, was provided by the nursing home administrator (NHA) on 2/18/26 at 11:26 a.m. The policy read in pertinent part, “Verify that there is a physician’s order for this procedure, review the resident’s care plan and provide for any special needs of the resident, ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility.”II. Resident #1A. Resident statusResident #1, age 86, was admitted on 10/03/25. According to the February 2026 computerized physician’s orders (CPO), diagnoses included gastrostomy (surgical procedure to make an opening for a feeding tube), epilepsy, Alzheimer’s disease and dysphagia (difficulty swallowing). The 12/31/25 minimum data set (MDS) assessment revealed the resident had memory problems with both long and short term memory per staff assessment. The MDS assessment documented the resident was dependent on staff for all activities of daily living (ADL). The MDS assessment indicated Resident #1 received 51 percent (%) or more of her total calories through the feeding tube and her daily fluid intake was 501 cubic centimeter (cc) or more. B. Record reviewThe nutrition care plan, dated 10/7/25, documented Resident #1 had the potential for altered nutrition and/or hydration status related to the new gastrostomy tube (G tube), nothing by mouth (NPO) status, malnutrition, dementia and celiac disease. The pertinent interventions included administering nutrition related medications per physician order and monitoring for side effects, provide the enteral nutrition as ordered, monitoring the resident’s intake and outtake, monitoring labs when available and reporting significant changes to the physician, observing for signs/symptoms of malnutrition and dehydration and report to physician as needed and the registered dietitian (RD) to reassess as indicated. The enteral nutrition care plan, dated 10/7/25, documented Resident #1 required enteral nutrition related to seizure disorder, malnutrition and NPO status. Pertinent interventions included administering medications through the G tube as ordered, NPO per physician’s order, enteral nutrition as ordered, monitoring tolerance to enteral feeding, flush G tube with 30 milliliter (ml) water before and after medication administration and/or as ordered, elevating the head of bed to at least 30 degrees, monitoring for nausea/vomiting, abdominal distension or discomfort with each feeding and as needed, monitor labs when available and report significant changes to the physician, observing for signs/symptoms of malnutrition and dehydration, and referring to RD as indicated. Review of the February 2026 CPO revealed the following physician's orders:Administer Iso-source 1.5 per G tube through the pump. Rate was documented at 60 ml/hour (hr) for 20 hours. Starting at 8:00 a.m. and ending at 4:00 a.m. Administer total volume 1200 ml per 24 hours with free water flushes of 100 ml every six hours, ordered on 1/31/26 and discontinued on 2/5/26. Administer Iso-source 1.5 per G tube through the pump. Rate was documented at 60 ml/hr for 20 hours. Starting at 7:30 a.m. and ending at 3:30 p.m.. Administer total volume 1200 ml per 24 hrs with free water flushes of 100 ml every six hours, ordered on 2/5/26 and discontinued on 2/7/26. Administer Iso-source 1.5 per G tube through the pump. Rate was documented at 65 ml/hr for 20 hours. Starting at 7:30 a.m. and ending at 3:30 p.m. Administer total volume 1300 ml per 24 hours with free water flushes of 100 ml every six hours ordered on 2/8/26 and discontinued 2/19/26. Administer Iso-Source 1.5 per G tube through the pump. The rate was documented at 70 ml/hr x 20 hrs starting at 7:30 a.m. and ending at 3:30 p.m. Administer total volume 1400 ml per 24 hours with free water flushes of 100 ml every six hours, ordered on 2/19/26. Free water flushes through the feeding tube 100 ml every six hours, at 3:00 a.m., 9:00 a.m., 3:00 p.m. and 9:00 p.m. ordered on 2/5/26. Registered nurse (RN) #1’s progress note, dated 2/1/26, documented at 11:33 a.m. revealed the volume from the tube feeding pump read 208 ml. The note documented the nurse administered 32 ml feed bolus (dose given all at one) to equal 240 ml. Resident #1’s husband and daughter were in agreement. The note documented At 1:30 p.m. the nurse administered another food bolus of 50 ml and at 6:00 p.m. provided a food bolus of 45 ml per Resident #1’s husband’s request.-However, there was no physician's order for an as needed (PRN) bolus feeding. The progress note did not indicate the physician had provided an order for the bolus feeding or had been notified of the additional bolus feeding. There was no documentation the RD had been notified or consulted about the bolus feeding. RN #2’s progress note, dated 2/2/26, documented Resident #1’s tube feeding stopped at 3:30 a.m. and the resident received a total of 1050 ml tube feeding through the tube feeding pump. The nurse provided 150 ml bolus feeding in order to total 1200 ml of the feeding. -However, there was no physician’s order for a PRN bolus feeding. The progress note did not indicate the physician provided an order or was notified of the additional bolus feeding. There was no documentation the RD had been notified or consulted about the bolus feeding. A nursing progress note, dated 2/2/26, documented Resident #1’s tube feeding was paused during changes and repositioning and the tube feeding gets behind from the daily ordered intake. The nurse provided an additional 60 cc bolus at 4:00 p.m. Resident #1 began coughing and became nauseous. Her family refused anymore bolus feedings at that time.-However, there was no physician’s order for a PRN bolus feeding. The progress note did not indicate the physician had provided the order for the bolus feeding or had been notified of the additional bolus feeding. There was no documentation the RD had been notified or consulted about the additional bolus feedings. C. Staff interviewsLicensed practical nurse (LPN) #7 was interviewed on 2/18/26 at 1:16 p.m. LPN #7 said Resident #1 was admitted with the G tube and continuous feeding for 20 hours. LPN #7 said the standard practice was to follow the physician’s orders when treating a resident. She said the bolus feeding was decided on how much food was being provided in the 20 hours of continuous feeding compared to the total calculated amount the resident was supposed to receive. She said the feeding was turned off during personal care in order for staff to turn the resident and reposition her and the resident was not receiving the total amount of daily intake. She said the family had brought this to the nursing staff’s attention. LPN #1 said there was no physician’s order for the bolus feedings that were provided. The primary care physician (PCP) was interviewed on 2/18/26 at 2:30 p.m. The PCP said the RD had been monitoring the fluid and food intake closer than he had. He said he was aware of the bolus feeding after the nurses gave them. He said it would not be his preference to the bolus feeding with the continuous feeding. He said the nurses’ should have followed the plan of the continuous feeding. The PCP said he did not think the bolus feedings caused any harm. He said he did not find the resident to be malnourished as evidenced by her lab work and weights. The PCP expected the nurses’ to follow Resident #1’s orders and was open to the nurses’ calling to discuss orders or changes but in the end he expected orders to be followed. RN #1 was interviewed on 2/18/26 at 3:03 p.m. She said Resident #1 was on continuous tube feeding for 20 hours, off for four hours and then it was restarted. RN #1 said she discovered the resident was not meeting her caloric intake needs because of the time the feeding pump was turned off during personal care. RN #1 said she calculated how many mls she was behind and provided bolus feedings during her shift on 2/1/26 to catch up on the feeding intake amount. RN #1 said because Resident #1 had been receiving water boluses, which were scheduled four times a day; she did not feel she needed an order for the feeding boluses as she was not going over the recommended calculated feeding amount. She did not notify the RD or the PCP of the bolus feeding. RN #2 was interviewed on 2/28/26 at 3:19 p.m. RN #2 said she provided Resident #1 with a bolus of 130 ml per the family’s request. She said she did call the on-call but did not receive a call back and proceeded with the bolus administration. RN #2 said she would not administer medications without a physician's order even if a family requested it, however she said she gave the bolus this time because Resident #1 did not receive her calculated amount of feeding for the day. She did not notify the RD or the PCP of the bolus feeding. The RD was interviewed on 2/18/26 at 4:38 p.m. The RD said she assessed the caloric needs of residents on feeding tubes based on their weight, nutritional needs and lab results. She said If a resident was showing signs or symptoms of malnutrition (weight loss or negative lab work) she would reassess the residents’ needs and recalculate the feedings and increase the milliliter of food intake if needed. She said if a bolus was given she would expect there to be a physician's order for this. The RD said she would have expected to be notified of the bolus feeding or the calculations the nursing staff was using to provide the bolus feeding in order to reassess the resident, however; she was not notified of the bolus feedings until a few days later when she reassessed the resident’s intake and changed the tube feeding order. The director of nursing (DON) and the regional clinical resource were interviewed together on 2/18/26 at 3:50 p.m. The DON said she expected the nursing staff to follow the PCP’s orders. She said she was aware Resident #1 was on continuous feeding and said bolus feedings could be given to a resident who was on a continuous tube feeding to meet the needs of the resident. She said she would have expected the physician to be called to receive an order for the additional bolus feeding.

Based on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for two of six medication carts. Specifically, the facility failed to ensure inhaler medications and multi-use vials of injectable medications were marked with the date when the medications were opened. Findings include:I. Professional referenceAccording to the haloperidol deconate injection package insert, retrieved on 2/26/26 from https//fresenius-kabi.com/content/dam/fresenius-kabi/ca/products/product-documents/iv-drugs/haloperidol-injection-usp_/Product%20Monograph.pdf.coredownload.inline.pdf,“Multiple-dose vials: Discard unused portion 28 days after initial puncture.”According to the Spiriva Respimat (tiotropium bromide) inhaler package insert, retrieved on 2/26/26 from https://content.boehringer-ingelheim.com/DAM68a8a6b5-4e9a-4508-85d3-af101205009/spiriva%20respimat-us-pi-pdf,“After assembly, the Spiriva Respimat inhaler should be discarded, at the latest, three months after first use or when the locking mechanism is engaged, whichever comes first.”According to the Stiolto Respimat (tiotropium bromide and olodaterol inhalationspray) inhaler package insert, retrieved on 2/26/26 from https://pro.boehringer-ingelheim.com/us/products/respiratory/bipdr/stiolto-respimat-pi#page=18,“Three months after insertion of cartridge, throw away the Stiolto Respimat, even if it has not been used, or when the inhaler is locked, or when it expires, whichever comes first.”II. Facility policy and procedureThe Storage of Medication policy, revised 2020, was received from the regional clinical resource at 10:44 a.m. on 2/19/26. It revealed in pertinent part, “Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.”III. ObservationsOn 2/17/26 at 12:15 p.m. the second floor medication cart was observed with licensed practical nurse (LPN) #1. The following observations were made: -Two vials of haloperidol deconate 500 milligrams (mg)/5 ml vial for injection were not marked with the date they were opened; and,-One Spiriva (tiotropium bromide) inhaler was not marked with the date it was opened. On 2/17/26 at 3:20 p.m. the east third floor medication cart was observed with LPN#2. The following observations were made: -Two vials of haloperidol deconate 500 mg/5 ml vial for injection were not marked with the date they were opened;-One Spiriva Respimat (tiotropium bromide) inhaler was not marked with the date it was opened; and,-One Stiolto Respimat inhaler was not marked with the date it was opened. III. Staff interviewsLPN #1 was interviewed on 2/17/26 at 12:20 p.m. LPN #1 said the importance of having an open date on medications was to make sure the medication was still effective and not expired. LPN #2 was interviewed on 2/17/26 at 3:30 p.m. LPN #2 said the importance of writing the open date on the medications was to know when the medication would expire. The director of nursing (DON) was interviewed on 2/19/26 at 11:00 a.m. The DON said the open dates must be marked on medications to ensure medications were not expired and remained effective.

Based on record review, observations and interviews, the facility failed to ensure three (#53, #62 and #84) of three residents of 43 sample residents received food prepared in the form designed to meet their individual needs. Specifically, the facility failed to ensure Resident #53, Resident #62 and Resident #84, who were prescribed mechanically altered diets, had food prepared according to their diet orders. Findings include:I. Professional referenceThe International Dysphagia Diet Standardization Initiative (IDDSI) Patient Handout (January 2019), was retrieved on 2/24/26, from https://iddsi.org/Resources/Patient-Handouts It read in pertinent part,“Level two mildly thick drinks may be used if thin drinks such as water, milk, and others flow too quickly for you to swallow them safely. Some milk shakes and thick shakes may be this thickness level already, but other drinks may need thickener added to reach the correct thickness level. Mildly thick drinks flow at a slower rate. “Level five minced and moist food may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food, but are not able to chew it down into little pieces that are safe to swallow. Minced and moist only need a small amount of chewing and for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. It is important that minced and moist foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. These foods are eaten using a spoon or fork."Level six soft and bite-sized textures are used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow. Soft and bite-sized foods need a moderate amount of chewing, for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. The pieces are bite-sized to reduce choking risk. Soft and bite-sized foods are eaten using a fork, spoon or chopsticks.“An example of level six soft and bite-sized:“Meat cooked tender and chopped, so pieces are no bigger than 1.5 centimeter (cm) by 1.5cm lump size. If food cannot serve soft and tender, serve as minced and moist."Level six soft and bite-sized, for safety avoid these food textures that pose a choking risk for adults who need level six soft and bite-sized food:"Bread (no regular dry bread, sandwiches or toast of any kind). Use IDDSI level five minced and moist sandwich recipe to prepare bread; use pre-gelled 'soaked' breads that are very moist and gelled through the entire thickness;“Hard or dry food include nuts, raw vegetables, dry cakes, bread, dry cereal;“Crumbly bits include dry cake crumble, dry biscuits (add sauce to make these suitable);“Large or hard lumps of food include casserole pieces larger than 1.5 centimeter (cm) x 1.5 cm, fruit, vegetable, meat, pasta or other food pieces larger than 1.5 cm x 1.5 cm.”The International Dysphagia Diet Standardization Initiative (IDDSI) Framework: Food and Drink Testing of Abbott Nutrition Products (January 2023), was retrieved on 2/26/26, from www.abbottnutrition.com/content/dam/an/abbottnutrition/pdf/clinical-resources/nutrition-by-life-stage/adult-nutrition/IDDSI. The review of the table content revealed that none of the Ensure products meet the criteria for level two, mildly thick liquids. II. Facility policy and procedureThe Therapeutic Diet policy, dated October 2017, was provided by the nursing home administrator (NHA) on 2/19/26 at 11:04 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 a 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. Snacks will be compatible with the therapeutic diet.” III. Resident #62A. Resident statusResident #62, age greater than 65, was admitted on 1/10/25. According to the February 2026 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, protein-calorie malnutrition, generalized muscle weakness and palliative care. The 11/26/25 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 was dependent on staff for most activities of daily living (ADL). The MDS assessment indicated the resident did not have signs and symptoms of a swallowing disorder and required a mechanically altered diet. B. ObservationsOn 2/16/26 at 10:16 a.m. Resident #62 was sitting in a chair at a dining table in the common area with an open packet of saltine crackers in her hands and had crumbled one of the crackers onto the floor and into her shoes. At 1:05 p.m. CNA #3 spoke with Resident #62 to see if she wanted anything else to eat aside from the meal she had been served. CNA #3 offered Resident #62 chips, a granola bar or crackers. Licensed practical nurse (LPN) #6 was standing nearby and asked CNA #3 if Resident #62 had eaten her crackers from earlier, to which CNA #3 replied she had eaten four of her crackers. On 2/17/26 at 12:07 p.m. Resident #62 was served a lunch meal plate. The plate contained four meatballs approximately 1.5 inches in diameter, cooked spinach, mashed potatoes and noodles which were approximately 1.5 to 2 inches long. An unidentified staff member spoke with Resident #62 to see if she wanted to be seen by her physician, and when the resident refused, the staff member oriented Resident #62 to her meal tray before leaving. At 12:16 p.m. Resident #62 speared a meatball on her fork and attempted to feed herself. Resident #62 brought the meatball to her mouth and tried to take a bite of it but was unable to do so, and the meatball dropped into her lap and rolled onto the floor. C. Record reviewThe February 2026 CPO revealed the following physician’s order:Regular diet, Level 6 soft and bite-sized texture, thin liquids, ordered on 5/22/25. Resident #62’s nutrition care plan, revised 11/26/25, revealed Resident #62 was at risk for altered nutritional status due to her cognitive deficits, history of malnutrition and vitamin D deficiency. Pertinent interventions included providing Resident #62 her diet, supplements and vitamins per physician’s order and catering to her food preferences and offering alternatives as needed. D. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 2/18/26 at 1:03 p.m. CNA #3 said she had recently started working at the facility and had just finished her orientation. CNA #3 said she had mostly learned the differences between the different diet textures by looking at posters in the common area. CNA #3 said residents who had difficulty swallowing received pureed diet textures, and could not have regular texture food. CNA #3 said Resident #62 was on a soft and bite-sized or minced and moist diet texture. CNA #3 said residents on soft and bite-sized or minced and moist diet textures could have snacks including pudding, applesauce or ice cream. CNA #2 was interviewed on 2/18/26 at 1:31 p.m. CNA #3 said there were a lot of residents on her unit who received altered texture diets. CNA #3 said Resident #62 received an altered texture diet. CNA #3 said she relied on looking at the residents’ meal tickets and the poster on the wall to know what diet texture the residents were ordered and what it should look like. CNA #3 said residents who received soft and bite-sized or minced and moist diet textures could have snacks including soft cookies or fig cookie bars. CNA #3 said if those snacks were unavailable, the residents could have ice cream, pudding or applesauce. CNA #3 said the facility provided a lot of education to the nursing staff on diet textures. Licensed practical nurse (LPN) #5 was interviewed on 2/19/26 at 8:58 a.m. LPN #5 said the facility provided inservices on the different diet textures often. LPN #5 said residents who were ordered to have a soft and bite-sized diet texture could have chopped up fruits, oatmeal cookies chopped up and served with milk, or pudding. The registered dietitian (RD) was interviewed on 2/19/26 at 9:35 a.m. The RD said as far as she knew, the staff members serving residents their trays were trained on the different diet textures. The RD said the dietary staff should check the resident’s meal ticket while plating, and the dietary aides would check the meal ticket as well. The RD said she did not expect the nursing staff to check residents’ plates as they were delivering them, as she thought the two checks in the kitchen should be sufficient. The RD said Resident #62 was receiving a soft and bite-sized diet. The RD said she would expect residents receiving a soft and bite-sized diet to have small pieces of food cut up to the size recommended by the IDDSI for each menu item. The RD said she would have expected for Resident #62’s meatballs and pasta to be cut to the size recommended for her diet texture by the IDDSI. The RD said snacks for residents on a soft and bite-sized diet would need to be cut up into small pieces and be an appropriate texture for their diet. The RD said saltines would not be appropriate to serve a resident on a soft and bite-sized diet. The RD said the facility nursing staff were educated on the different diet texture guidelines during an all-staff meeting, but was not sure when the education was provided. The director of nursing (DON) and the regional clinical resource were interviewed together on 2/19/26 at 12:46 p.m. The DON said the facility had provided education on the different altered diet textures during an all-staff meeting, and the DM and RD had gone around the facility to do on-the-floor training with the facility staff at the time. The regional clinical resource said food served to residents receiving a soft and bite-sized diet texture needed to be able to be squished with a fork, and be cut into pieces smaller than 1.5 centimeters. The DON and the regional clinical resource said the nursing staff and any other staff serving meals should have an understanding of what the altered diet textures should look like. The DON and RCR said saltine crackers were not an appropriate snack for residents on a soft and bite-sized diet. IV. Resident #84A. Resident statusResident #84, age greater than 65, was admitted on 7/28/25. According to the February 2026 CPO, diagnoses included neurocognitive disorder with Lewi bodies and dysphagia. The 1/1/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 11 out of 15. The resident was dependent on staff for most activities of daily living (ADL). The MDS assessment indicated the resident did not have signs and symptoms of a swallowing disorder and required a mechanically altered diet. B. ObservationsOn 2/16/26 at 12:30 p.m.. Resident #84 was served chopped broccoli that did not meet the level five soft and bite sized IDDSI size recommendation of 1.5 cm by 1.5 cm. On 2/17/26 at 12:27 p.m. Resident #84 was served regular size noodles. C. Resident interviewResident #84 was interviewed on 2/16/26 at 1:48 p.m. He said he did not remember what he had for lunch. He said thickened apple juice was in his cup and he did not like it. He said he liked fruit punch, but did not get it. He said he would drink his protein drink if he can reach it. An unknown CNA entered the room, opened a protein drink that was sitting on the table and offered it to the resident.-The unidentified CNA did not thicken the protein drink. D. Record reviewThe February 2026 CPO revealed the following physician’s order:Regular diet, soft and bite-sized texture, mildly thick liquids, ordered on 7/28/25. Resident #62’s nutrition care plan, revised 7/29/25, revealed Resident #84 had difficulty chewing due to partial upper and lower dentures. Pertinent interventions included providing Resident #84 his diet, supplements and offering the diet as ordered. V. Resident #53A. Resident statusResident #53, age greater than 65, was admitted on 4/23/25. According to the February 2026 CPO, diagnoses included weakness on the right dominant side and dysphagia. The 1/1/26MDS assessment revealed the resident was cognitively impaired and a BIMS score was not conducted. The resident was dependent on staff for most activities of daily living (ADL). The MDS assessment indicated the resident did not have signs and symptoms of a swallowing disorder and required a mechanically altered diet. The resident was receiving hospice services. B. ObservationsOn 2/16/26 at 11:23 a.m. resident in bed on his left side, facing the wall, unopened chocolate protein drink observed on the table away from bed. At 1:55 p.m. Resident #53 was served chopped broccoli that did not meet the level five soft and bite sized IDDSI size recommendation of 1.5 cm by 1.5 cm. C. Record reviewThe February 2026 CPO revealed the following physician’s order:Regular diet, level five minced and moist texture, mildly thick liquids, ordered on 4/23/25. Resident #53’s nutrition care plan, revised 2/17/26, revealed Resident #53 was at risk for malnutrition due to a history of stroke and liver disorder. Pertinent interventions included providing Resident #53 his diet, supplements and offering diet as ordered. D. Staff interviewsCNA #5 was interviewed on 2/17/26 3:50 p.m. She said Resident #84 was on a soft and bite size diet, and nectar thick liquids. She said all drinks are mixed for him by CNAs. She said she used two packages of thickener per one paper cup of liquid. She said they also had a thickener that was premade. She pointed to the thickened liquid on the hydration cart, the label read honey consistency. CNA #5 said Resident #53 was also on a soft and bite size diet. She said the minced and moist diet was almost the same but meant for residents who did not have teeth. She said the minced and moist was softer and had smaller pieces. She said all protein drinks should be thickened before given to both residents. CNA #3 was interviewed on 2/17/26 at 4:15 p.m. She said Resident #53 was on a moist and minced diet and thickened liquids. She said a protein drink was given to him once, yesterday (2/16/26) in case he wanted anything besides the meal. She said Resident #53 did not eat or drink anything that was offered for lunch on 2/26/26. The RD was interviewed on 2/19/26 at 11:30 p.m.. She said protein drinks should be served chilled to ensure thickened consistency. - However, the manufacturer’s recommendation from the protein company indicated that none of their products meet the criteria for mildly thick liquids. Registered nurse (RN) #3 was interviewed on 2/9/26 at 1:30 p.m. She said Resident #84 was on a soft and bite size diet and thickened liquids. She said protein drink was not thickened, but should be given to the resident chilled as it has thickened consistency when chilled. She said all protein drinks were stored in the refrigerator. VI. Additional observations and interviewsDuring continuous observation on 2/17/26, beginning at 11:35 a.m. and ending at 12:45 p.m., the following was observed during the meal service in the main kitchen:The posted menu indicated residents on a regular diet would receive noodles with meatballs and gravy, cooked spinach which was substituted for cooked broccoli, and a roll. The menu indicated hot dogs were available as an alternative. -At 11:35 a.m. through 12:45 p.m. cook (CK) #2 plated the food, dietary aide (DA) #1 wrapped the plates and DA #2 was placing the plates in the carts. -CK #2 served residents who were prescribed level six soft and bite sized, regular sized noodles.-There were two food bins for the noodles, one bin contained regular noodles and one bin contained noodles for the level five minced and moist diet. There was not a bin for chopped noodles to meet the level five soft and bite sized IDDSI size recommendation of 1.5 cm by 1.5 cm.-There were two bins for the cooked spinach. One bin contained regular cooked spinach and the other bin contained the pureed spinach. There was not a bin for chopped spinach to meet the level five soft and bite sized IDDSI recommended size 1.5 cm by 1.5 cm. CK #2 said there was a substitution for the vegetable and he did not have the extension for the spinach. -CK #2 had cut up a hot dog for a level six soft and bite sized diet, however; after plating there were several pieces that were not the recommended size of 1.5 cm x 1.5 cm on the plate. Upon prompting the plate was removed from service and the hot dog was cut up into smaller pieces. VII. Additional staff interviewsDA #2 was interviewed on 2/18/26 at 9:00 a.m. She said she has not had the IDDSI training at this facility but was aware of different diet texture sizes from previous jobs. She said it was her job to double check the meal matched the diet ticket before placing them in the cart. CK #2 and DA #1 were interviewed together on 2/18/26 at approximately 10 a.m. DA #1 said she had not had any formal training on the IDDSI textures. She said her job was to wrap the plates with plastic wrap before they went into the cart and she checked that the meal matched the diet ticket. CK #2 said he had some texture training but mostly was learning from the other cooks on what to serve for the mechanically altered diets. The RD was interviewed on 2/19/26 at 9:33 a.m. She said she and the speech language pathologist (SLP) provided training on the IDDSI diet in the past, but was not sure if everyone had gone through the training. The RD said diet extensions provided the cook a resource to know what foods to plate for the different diets and textures and if there was a change to the menu the dietary manager (DM) was responsible to provide education to the servers on the extensions. The RD said there were checks in place during the meal service to ensure the meal matched the ticket. She said the cook was the first check as they plated the food, then the DA who wrapped the plate in plastic wrap was to ensure the meal matched the meal ticket and there was a third DA who was to check the plates against the meal ticket before placing the meals in the carts for delivery. The RD said all kitchen staff should be trained on diet and mechanically altered textures to avoid wrong diets/textures going to the residents. The RD said for the meal with noodles, meatballs and cooked spinach, she expected the noodles, and spinach to be chopped up. She said the meatballs and hot dogs should have been cut up for the soft and bite-sized diet to the level six soft and bite-sized size. The DM was interviewed on 2/19/26 at 10:00 a.m. The DM said meat, such as the meatballs and the hot dogs, should have been cut up to the correct size for the soft and bite-sized texture. The DM said since she started three weeks ago, she had trained the cooks on the IDDSI diets and planned on the rest of the dietary staff to go through the training. She has three scheduled training opportunities for all staff regarding the IDDSI diets. The DM said to ensure residents receive their correct diet and textures there were three people who check the plates before it goes to the floor, the cook who plated the food, the DA who wrapped the plates and another DA who puts the plate in the cart to be delivered.

Based on observations and interviews the facility failed to ensure food was distributed and served under sanitary conditions in the main kitchen. Specifically, the facility to ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination in the main kitchen. Findings include:I. Failed to ensure ready-to-eat foods were handled in a sanitary manner. A. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24) and retrieved on 2/23/26 read in pertinent part, “Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissues, spatulas, tongs, single-use gloves or dispensing equipment. (2-301.15)“Food employees shall clean their hands and exposed portions of their arms as specified under immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and before donning (putting on) gloves to initiate a task that involves working with food. (3-301.11)“If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.” (3-304.15)B. Facility policy and procedureThe Dietary Employee Personal Hygiene policy, revised 2025, was provided by the nursing home administrator (NHA) on 2/19/25 at 11:04 a.m. The policy read in pertinent part, “It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. Hands must always be washed after using the restroom, eating or drinking, using tobacco products, coughing, sneezing, blowing nose, before putting on gloves, after removing gloves, and after engaging in other activities that contaminate the hands and gloves are to be worn and changed appropriately to reduce the spread of infection.”C. ObservationDuring a continuous observation on 2/17/26, beginning at 11:35 a.m. and ending at 12:45 p.m., the following was observed during the service of the meal:Cook (CK) #2 was plating the food using utensils with bare hands. Without performing hand hygiene, he donned (put on) gloves sliced a hot dog and put it on the plate with the bun. He removed the gloves and went back to using utensils to serve, without washing his hands. He put on another pair of gloves, without washing his hands, to cut another hot dog and removed a bun from the bag the buns came in. He left the gloves on for the remainder of the service. During that time he picked up four grilled cheese sandwiches with the gloved hands, and used the same gloved hands to serve the food using the utensils. CK #2 used the same gloved hands to pull hot dog buns from their bag, open them with his gloved hands and plate the food. D. Staff interviewsThe dietary manager (DM) was interviewed on 2/19/26 at 10:00 a.m. The DM said she expected the dietary staff to put on gloves when touching food and to wash their hands before and after putting on the gloves. She expected that if the dietary staff put on gloves to handle food, the gloves would be removed after the single use and hands would be washed. The DM said she has provided in-services (training) on the topic of single use gloves and hand hygiene since she started three weeks ago.

Based on observations, record review, and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene while assisting residents with eating; and,-Don (put on) appropriate personal protective equipment (PPE) when entering Resident #1’s room, who was on transmission-based precautions; and,-Ensure housekeeping staff followed appropriate infection control guidelines when cleaning residents’ rooms. II. Failed to don appropriate PPE when entering Resident #1’s the room, who was on transmission-based precautionsA. ObservationsOn 2/17/26 at 11:40 p.m. the sign on Resident #1’s door read "Contact precautions, everyone must wear gloves and gown before entering the room." -At 11:41 a.m. CNA #4 entered the resident’s room without putting on a gown or gloves.-At 11:42 a.m. registered nurse (RN) #1 entered Resident #1’s room without putting PPE on. RN #1 was holding a large syringe containing a red liquid. At 11:45 a.m. CNA #4 exited Resident #1’s room, sanitized her hands, and left the area. -At 11:47 a.m. CNA #4 returned to the resident’s room with extra linens and entered the room. CNA #4 again did not put on a gown or gloves before entering the room. B. Staff interviewsRN #1 was interviewed on 2/17/26 at 1:05 p.m. RN #1 said Resident #1 was on enhanced barrier precautions (EBP)but she did not know why. She then said the resident was on contact isolation precautions and she did not know why. She said in both cases, whether the resident was on EBP or contact isolation precautions, a gown and gloves should be worn in the resident’s room. RN #1 said she had a busy day and she did not read the sign on the resident’s door which instructed staff to wear gloves and a gown before entering the room (see above). CNA #4 was interviewed on 2/17/26 at 1:10 p.m. CNA #4 said she put a gown and gloves on in the room, not outside because the resident was on contact precautions. She said the unit manager who was assigned to the resident’s room changed the sign several times and it was confusing what precautions the resident was on. Licensed practical nurse (LPN) #7 was interviewed on 2/18/26 at 2:03 p.m. LPN #7 said she was a unit manager assigned to Resident #1’s room. She said the resident was on contact precautions for multi-drug resistant organisms (MDROs) in the urine. She said the resident was on enhanced barrier precautions as well because she had indwelling devices such as a midline catheter and a gastrostomy tube. LPN #7 said both precautions required the same PPE of a gown and gloves. The IP was interviewed on 2/19/26 12:43 p.m. The IP said staff should have followed the precautions sign on Resident #1’s door. She said the resident was on droplet and contact precautions on Monday (2/16/26), later she was only on the contact precautions and currently was only on enhanced barrier precautions. She said for droplet precautions, a mask must be worn and for contact precautions, a gown and gloves should be put on before entering the room. The IP said she was responsible for placing signs on the residents’ doors for precautions and she provided education to staff when isolation precautions were initiated. However, she said at times, the task was delegated to the floor nurse when she was not available in the building.

A survey with #CO2707156 was completed on 2/16/26 to 2/19/26. No deficiencies were cited.

A survey prompted by #CO2596950 and Incident #2581653 was conducted on 9/30/25 to 10/1/25. No deficiencies were cited. The survey 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 11/26/25.

A survey for Incident #2662855 was conducted on 11/19/25 to11/20/25. No deficiencies were cited.

A revisit survey was completed on 6/11/25 for all previous deficiencies cited on 5/13/25. The facility is in compliance with all regulations surveyed.

A revisit to the 5/13/25 survey was completed on 6/11/25. The facility is in compliance with all regulations surveyed.

A survey for Incident #39936, Incident #39989 and complaint #CO40040 was completed on 5/7/25 to 5/13/25. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure two (#2 and #3) of four residents were free from abuse out of 10 sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #3 were free from physical abuse by each other. On 4/16/25 Resident #2 attempted to strike Resident #3. Resident #3 responded by grabbing Resident #2. Both residents fell to the ground. Resident #3 sustained a left humerus (shoulder) fracture. Resident #2 sustained bruising to his arm and an abrasion to his back. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, 2024, was provided by the nursing home administrator (NHA) on 5/7/25 at 10:15 a.m. via email. It read in pertinent part,"It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. "Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology."Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. "Serious bodily injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation."II. Physical abuse between Resident #2 and Resident #3 on 4/16/25A. Facility investigationThe 4/16/25 facility investigation was provided by the NHA on 5/12/25 at 9:15 a.m. The investigation documented Resident #2 and Resident #3 resided on a secured unit. Resident #2 had severe cognitive impairment, impaired communication ability and weighed 150.6 pounds. Resident #3 was cognitively intact and had delusions and hallucinations in regards to self and others. Resident #3 weighed 268.2 pounds, which was over a 100 pound difference between the two residents. The investigation documented that on 4/16/25 at approximately 4:00 a.m., Resident #3 was sitting in a recliner in the dining room. Resident #2 entered the dining room with clothing from his room and placed his clothing on the tables. Resident #3 asked Resident #2 what he was doing. Resident #2 responded with something inaudible on the video surveillance, while he pointed his finger at Resident #3. Resident #3 got up out of his recliner and moved toward Resident #2. Resident #2 swung at Resident #3 but missed contact. Resident #3 said to protect himself before he put his arms around Resident #2, both men grappled and both fell to the ground. The nurse who was seated at a nurses station and was not in view of the dining room heard noise that came from the dining room. Upon investigation, the nurse found both Resident #2 and Resident #3 on the ground. The nurse separated the residents. Resident #2 sustained a bruise to the posterior right arm and a linear abrasion to the mid-spine. Resident #3 sustained a non-displaced fracture to the left humerus. Both residents were placed on 15-minute checks. The investigation documented that it was determined by the medical director (MD) and a psychiatrist, that Resident #2 had a gradual dose reduction (GDR) of Zyprexa medication from 2.5 mg (milligrams), andthe decision was made to stop the medication completely in December 2024. Resident #2 was reviewed in the psychopharmacological meetings and it appeared to be successful for several weeks until a few days before the altercation. The investigation documented on 4/14/25 licensed practical nurse (LPN) #2 requested Resident #2 be put back on Zyprexa 2.5 mg and the GDR be stopped. The physicians agreed, based on Resident #2's behavior tracking. The Zyprexa was re-ordered for Resident #2. According to the physician's interviews, Zyprexa 2.5 mg, an antipsychotic medication had not been able to take effect in the two days from 4/14/25 until the incident on 4/16/25. The investigation documented Resident #2 and Resident #3 had not had an altercation with each other prior to the incident. B. Resident #2 1. Resident statusResident #2, age less than 65, was admitted on 9/5/23. According to the May 2025 computerized physician orders (CPO), diagnoses included bipolar disorder (mental illness) and alcohol-induced persisting dementia. The 4/4/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. He was independent with eating, toileting, personal hygiene and walking. 2. Record reviewThe 12/17/24 interdisciplinary team (IDT) psychotherapeutic review revealed Resident #2's Zyprexa 2.5 mg was discontinued that day (12/17/24). The cognitive impairment care plan, revised 1/9/25 revealed Resident #2 had cognitive impairments, exhibited cognitive loss related to alcohol-induced persisting dementia. He had short and long term memory loss, disorganized thinking, difficulty with word finding at times and was only oriented to himself. Pertinent interventions included monitoring the resident for changes in cognitive status, notifying the physician if changes in cognitive status were noticed, providing cognitive therapy, administering medications as ordered and notifying the physician if the resident's behavior interfered with daily functioning. The 3/30/25 IDT psychotherapeutic review revealed Resident #2 was stable, with no change after the discontinuation of Zyprexa. The 4/14/25 nursing progress note, documented at 4:14 a.m., revealed Resident #2 had increased agitation, was difficult to redirect and continually paced from his room to the dining room. Another 4/14/25 nursing progress note, documented at 6:00 a.m., revealed Resident #2 again displayed increased agitation in the dining room, threw chairs and tipped a table. Another 4/14/25 nursing progress note, documented at 10:52 a.m. revealed the resident's agitation had increased..The 4/14/25 behavioral progress note documented at 12:10 p.m., revealed Resident #2 voided in a trashcan in the dining room and when asked to stop he raised his voice and said no. Another 4/14/25 nursing progress note, documented at 2:10 p.m., revealed Resident #2 was more agitated than normal and he continued to pace the hallway. Another 4/15/25 nursing progress note, documented at 1:04 p.m., revealed Resident #2 was being monitored for Zyprexa use. Review of the April 2025 CPO revealed the following physician's order: Zyprexa oral tablet 2.5 mg, give at bedtime for angry outbursts, throwing chairs, and verbal aggression related to bipolar disorder, ordered 4/14/25. The 4/16/25 room notice notification revealed Resident #2 was moved to a private room due to increased agitation and paranoia about his belongings. At night he moved his belongings to the dining room to protect his items. The 4/16/25 nursing progress note, documented at 7:04 a.m., revealed Resident #2 was involved in a physical altercation with another resident (Resident #3) and fell to the floor. The residents were separated and placed on 15-minute checks. Resident #2 was assessed and denied any pain. The 4/18/25 nursing progress note revealed a follow-up head to toe skin assessment was completed on Resident #2 due to a fall that occurred on 4/16/25. The resident had a bruise to the back of his right arm measuring 5 centimeters (cm) by 4 cm by 0 cm. No open areas were noted. The resident denied pain. An abrasion to the resident's mid-spine measured 3 cm by 1.5 cm by 0 cm. The physician was notified. C. Resident #31. Resident status Resident #3, age less than 65, was admitted on 3/31/22. According to the May 2025 CPO, diagnoses included alcohol induced persisting dementia, anxiety disorder, hypertension (high blood pressure), seizures, alcohol abuse and gastro-esophageal reflux disease (GERD). The 3/7/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident had delusions, misconceptions or beliefs that were firmly held, contrary to reality. The resident was independent with eating, toileting and personal hygiene. 2. Resident interviewResident #3 was interviewed on 5/12/25 at 11:30 a.m. Resident #3 said he was in pain due to the incident with Resident #2 and he required surgery for his shoulder. 3. Record reviewThe behavior care plan, initiated 9/5/24 and revised 5/5/25, revealed Resident #3 could demonstrate agitation towards other residents, often due to his delusions and potentially altered perception. The resident required assistance with his activities of daily living (ADLs) related to his alcohol-induced dementia, delusional disorder and anxiety. The care plan documented the goal was that the resident would not demonstrate aggression towards others. Interventions included the staff were to seek to divert the resident's attention elsewhere and the staff were to work to anticipate triggers. The 4/16/25 nursing progress note, documented at 6:30 a.m. revealed Resident #3 had an altercation with another resident (Resident #2) and fell to the floor. Resident #3 said "I couldn't help it." He was placed on 15-minute checks, denied injury and refused a body assessment. Another 4/16/25 nursing progress note, documented at 8:14 a.m., revealed Resident #3 complained of pain in his shoulder and an Xray was ordered. Another 4/16/25 nursing progress note, documented at 4:23 p.m., revealed the Xray was positive for a fracture of Resident #3's left humeral head (shoulder). Physician's orders were received for a sling and a referral to an orthopedic surgeon was made. The 4/23/25 IDT progress note revealed Resident #3 was not the aggressor in the incident with Resident #2. -However, the facility investigation documented Resident #3 wrapped his arms around Resident #2 and both fell to the ground (see facility investigation above). The 4/23/25 pain assessment revealed Resident #3 had frequent and almost constant pain. The resident revealed his pain level was a 8 out of 10 on a pain scale of 1-10 recorded as the highest. VI. Staff interviewsThe psychiatrist was interviewed on 5/8/25 at 3:45 p.m. The psychiatrist said he had worked as Resident #2's psychiatrist when he lived in the community and continued to be involved with his care when he was admitted to the facility. He said because of Resident #2's alcohol use, he had dementia and needed the level of care provided in the facility. The psychiatrist said the resident continued with a small dose of Zyprexa (2.5 mg) after doing previous successful GDRs. The psychiatrist said the facility's IDT team, along with his involvement, decided to discontinue Zyprexa in December 2024. He said the Zyprexa was discontinued for a few months with success. He said in April 2025, Resident #2 started to show aggressive behavior, which was not normal for Resident #2. He said it was not just a bad day in April 2025 and it seemed his baseline was off. He said a few days before the altercation, he decided to put Resident #2 back on the Zyprexa. The psychiatrist said the Zyprexa was restarted two days before the aggressive behavior incident happened with Resident #3. The psychiatrist said two days prior to the incident was not long enough for the Zyprexa to take effect. The psychiatrist said Resident #2 was now doing well after the Zyprexa was restarted. The psychiatrist said the reason for the incident was due to Resident #2 and the GDR of Zyprexa. The psychiatrist said he had been Resident #3's psychiatrist for several years. The psychiatrist said Resident #3 was very delusional. The psychiatrist said Resident #3 was not agreeable to any medication changes. The psychiatrist said in his opinion, Resident #3 was not the reason for the altercation with Resident #2. The NHA was interviewed on 5/12/25 at 9:15 a.m. The NHA said he reviewed surveillance videos, along with resident and staff interviews for the investigation. LPN #2 was interviewed on 5/12/25 at 11:14 a.m. She said the day of the altercation (4/16/25) between Resident #2 and Resident #3, she was in her car in the parking lot at approximately 4:30 a.m. She said she received a phone call from the nurse who separated the residents. She said she immediately came into the building and went to the floor where the altercation occurred. She said she immediately called the NHA. She said she and the NHA watched the video surveillance cameras. She said the video surveillance revealed Resident #2 attempted to punch Resident #3 but the punch did not hit Resident #3. LPN #2 said Resident #3 then grabbed Resident #2 like a wrestler would do and Resident #3 put his arms around Resident #2 and both residents fell to the ground. She said she had worked with Resident #2 for a long time and there had never been an incident like the one that occurred. She said a few days prior, the nursing staff had called the physician to restart Resident #2's Zyprexa . LPN #2 said as the Zyprexa was restarted, the staff knew to observe and let Resident #2 pace down the hallway while his medication took effect. She said that was two days prior to the incident and the medication was likely to not have taken effect yet. She said Resident #2 sustained a bruise on his back and a small skin abrasion on his arm. She said Resident #2 was placed back on Zyprexa and he was no longer agitated like he was prior to the incident. LPN #2 said the surgeon had cancelled two appointments with Resident #3 due to the surgeon's schedule and an appointment was rescheduled again. She said the resident's family member wanted an appointment to be made with a specific surgeon. The director of nursing (DON) was interviewed on 5/12/25 at 11:55 a.m. She said Resident #2 had not had any physical violence prior to the incident on 4/16/25. The DON said in the March 2025 IDT psychopharmacological meeting, Resident #2's medications and behaviors were discussed. The DON said Resident #2 was reviewed in the psychopharmacological meeting in March 2025 to determine if the resident was tolerating not being on Zyprexa. The DON said the IDT team determined in the March 2025 meeting that they would continue with the discontinuation of the Zyprexa to determine if it was a successful GDR or not. The DON said in April 2025, after monitoring Resident #2's behaviors, LPN #2 spoke to the psychiatrist about Resident #2. The DON said it was determined by the psychiatrist to put Resident #2 back on the Zyprexa 2.5 mg. The DON said that was two days before the altercation with Resident #3, which was not enough time for the medication to work. The social services director (SSD) was interviewed on 5/12/25 at 1:00 p.m. The SSD said Resident #2 had not had any physical violence before the incident on 4/16/25. The SSD said Resident #2 and Resident #3 had not had any altercations with any other residents since the incident on 4/16/25. The facility's medical director (MD) was interviewed on 5/13/25 at 10:00 a.m. via the phone. The MD said the psychopharmacological IDT meetings at the facility had a lot of clinical professionals which included himself and a psychiatrist. The MD said he had permission from the psychiatrist to speak about the situation with Resident #2. The MD said the team discussed a low dose of Zyprexa. The MD said the team discussed that bipolar disorder was not the problem for the Zyprexa, but rather Resident #2's alcohol use. He said Resident #2 was documented to be in a good mood, and slept well. He said the team used shared decision making with the insight from the psychiatrist who had worked with Resident #2 in the community prior to his admission into the facility. The MD said the discontinued Zypreza GDR happened in December 2024. The MD said for several months Resident #2 seemed to do well without the medication, until in April 2025, the facility staff noted behavioral issues, and the Zyprexa medication was added back for Resident #2. The MD said it was added back two days prior to the incident with Resident #3 on 4/16/25, which was not enough time for the medication to take effect. The MD said the medication currently worked for Resident #2. The NHA was interviewed again on 5/13/25 at 11:50 a.m. The NHA said all staff were educated about resident-to-resident abuse after the incident on 4/16/25. The NHA said the staff were educated to visually watch the residents and when a resident went to the dining room, a staff member needed to watch the residents. The NHA said Resident #2's Zyprexa took effect and his behavior was back to his baseline. The NHA said a recliner was put in Resident #3's room with his approval. The NHA said on 5/13/25 (during the survey) he purchased and installed a camera to be put into the dining room on the second floor (where the incident between Resident #2 and Resident #3 occurred). The NHA said the camera would be connected to a monitor that the nursing staff could utilize as needed to observe residents in the dining room.

Based on observations, record review and interviews, the facility failed to ensure an environment free of accident hazards for one (#1) of one resident reviewed for accidents/hazards out of 10 sample residents. Resident #1, who was at risk for elopement, required 15-minute safety checks due to inappropriate behaviors with staff and residents unrelated to his elopement risk. The staff on the fourth floor where Resident #1 resided were to observe Resident #1 and document his behaviors with the 15-minute safety checks.-However, the two certified nurse aides (CNA) and one licensed practical nurse (LPN) on duty the night of 4/11/25 failed to perform Resident #1's 15-minute safety checks per facility protocol (see nursing home administrator's (NHA) interview below). On 4/11/25 at approximately 8:14 p.m. Resident #1 rode an elevator in the facility from the fourth floor down to the first floor, walked to the front door, opened the front door, which set off an alarm, and left the facility. A staff member heard the alarm and looked out a window, however, the staff member failed to go outside and search for anyone. When the staff member did not see anyone outside, the door was relocked and the alarm was reset. At approximately 4:00 a.m. on 4/12/25 (almost eight hours after the resident left the facility through the front door, setting off the alarm) a CNA noticed Resident #1 was gone around 4:00 a.m. on 4/12/25, notified the LPN and the staff began a search for the resident. However, staff failed to notify the NHA about the missing resident until 6:13 a.m., over two hours after the staff initially noticed the resident was missing. The local police department was notified to help with the search. The police found Resident #1 at approximately 8:15 a.m., 12 hours after he left the facility. Resident #1 was sitting on a curb in a neighborhood, was confused and was unable to tell the police what had happened during the previous 12 hours. The police took Resident #1 to the local hospital where he was evaluated, determined to have no injuries and sent back to the facility. Resident #1 was immediately placed in the facility's secure unit for safety upon his return to the facility. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from 5/7/25 to 5/13/25, resulting in the deficiency being cited as past noncompliance with a correction date of 4/12/25. I. Situation of serious harmThe facility failed to respond to an alarm on 4/11/25 at approximately 8:15 p.m. when Resident #1 opened the front door on the first floor and left the facility. A staff member did not investigate when he heard the front door alarm. The staff member looked out a window, and when the staff member did not see anyone, the door was relocked and the alarm was reset. Additionally, the facility failed to conduct 15-minute safety checks on Resident #1 on 4/11/25, which resulted in the facility not identifying the resident was missing until 4:00 a.m. on 4/12/25. Resident #1 was wandering in the community for approximately 12 hours before the police found him sitting on a curb in a neighborhood at approximately 8:15 a.m. on 4/12/25. The facility's failure to ensure staff conducted 15-minute safety checks on Resident #1 and responded to a door alarm appropriately created a situation for the likelihood of serious harm. II. Facility plan of correctionThe corrective action plan implemented by the facility in response to Resident #1's elopement on 4/11/25 was provided by the NHA on 5/5/25 at 10:00 a.m. It revealed the following:A. Immediate action to correct the deficient practice for Resident #1On 4/12/25 at 8:00 a.m. the facility conducted an investigation into the elopement of Resident #1. The facility interviewed all staff who were on duty, which included those who were responsible for the resident's direct care. The surveillance videos were reviewed to determine when the resident left through the front door, what happened with the staff member who did not go outside to investigate when the alarm went off and what the staff on the fourth floor had done from 8:00 p.m. on 4/11/25 until 6:00 a.m. on 4/12/25. Inspection of the door alarms determined the front door alarm had functioned properly. Resident #1 was taken to a local hospital by the police for a wellness check. The physician at the hospital documented the resident had no noted injury and was cleared to return to the facility. The facility managers, the medical director of the facility, and the representative for Resident #1 determined the resident needed to be placed in a secured unit. Placement was immediate upon the resident's arrival back to the facility from the hospital on 4/12/25. B. The facility identified deficient practice 1. The facility had been having difficulty with the door alarms going off randomly due to the wind. A company came out in March 2025 and assessed and repaired all doors leading to the exterior. Staff did not search the parking lot when the door alarm sounded on 4/11/25 around 8:00 p.m. Staff assumed that the alarm sounded due to another reason (see CNA #2's interview below). 2. Resident #1 had a history of exit seeking and had a care plan for the behavior. The resident was not placed on one-to-one supervision or placed in a secure unit with increased exit seeking behavior in the last month. The resident was already on 15-minute checks for behavior. However, the documentation on the 15-minute checks did not appear accurate. 3. Staff did not follow block assignments (caring for residents together as a team without a specific CNA being assigned to a specific group of residents). 4. Staff had a lack of education on the elopement/missing person policy, exit seeking behavior interventions and timely reporting of a missing person to the NHA.C. Immediate actionsThe NHA and the director of nursing (DON) were educated on appropriate interventions for residents with exit seeking behavior by the RDCS (regional director of clinical services) on 4/12/25. The IDT (interdisciplinary team) was educated by the NHA and the DON on 4/14/25 on appropriate interventions related to exit seeking behavior. The IDT reviewed and updated, if indicated, all residents for elopement risk and community risk assessment, completed on 4/15/25. The IDT reviewed the progress notes for the last 90 days for elopement attempts for residents determined to be at risk of elopement who were not in a secured unit. The IDT reviewed and updated the care plans for residents at risk of elopement, completed 4/16/25. The IDT reviewed all residents on 15-minute checks for any reason. Seven residents were identified. Progress notes and care plans for the last 90 days were reviewed for any unidentified concerns related to the reason they were on 15-minute checks or exit seeking, and care plans were updated as indicated, completed 4/15/25. Staff were educated on who was on 15-minute checks or one-to-one supervision and a list of those identified residents was placed in the residents' electronic medical records (EMR). The IDT updated the elopement binder, completed on 4/13/24 with a list of all residents at risk for elopement, their face sheets and a photo, if allowed. The binder is located at the front desk and lists are located in the communications tab in the EMRs. All facility doors were assessed and tested by the NHA on 4/12/25 for proper alarm function. On 4/12/25 the NHA added a camera and an extra noise chime to the first floor front door. On 4/12/25 staff on all shifts received education from the DON/designee on the process a missing person/elopement, timely notification of the nurse on call or NHA, process for 15-minute checks, door alarm response process, elopement and exit seeking behaviors and interventions and specific block assignments. Any staff, not on duty or on leave, will receive education on their next scheduled workday. Agency staff will be educated before the start of their shift. On 4/14/25 the regional director of maintenance assessed and tested all doors leading to the exterior for proper function and proper alarming. On 4/15/25 the staff will be educated on reporting to the NHA/DON residents who attempt to leave the facility. D. Actions to prevent occurrence/recurrenceAn elopement risk assessment will be completed on admission, change of condition, and quarterly by the IDT team. Residents determined at risk by the IDT will have a care plan in place to prevent elopement. The DON or designee will audit potential new admissions for elopement risk, determine if the facility can meet the resident's needs, and ensure a care plan with appropriate interventions is in place if appropriate. New staff hires will receive education on a missing person/elopement, timely notification of the nurse on call or NHA, process for 15-minute checks, door alarm response process, elopement and exit seeking behaviors and interventions, and specific block assignments, initiated 4/12/25. The NHA or designee will ensure the elopements binder is kept up-to-date with any new resident or change in resident elopement assessment. The NHA/designee will conduct monthly elopement drills with a designated missing resident and assess for timely staff reporting and response. The drills will be documented in a summary and include staff signatures. The drills will continue for six) months and thereafter as determined by the QAPI (quality assurance and performance improvement) committee. The NHA/designee will conduct weekly facility alarm drills, setting off the door alarms to assess for timely staff reporting and response. The drills will be documented in a summary and include staff signatures. The drills will continue for three months and thereafter, as determined by the QAPI committee. The DON/designee will audit all 15-minute check logs daily for three months, and weekly thereafter until determined by the QAPI committee there is substantial compliance that the logs are complete and signed by a licensed nurse. The audit will be documented on an audit tool. The DON/designee will conduct three random spot checks daily for three months, and weekly thereafter until determined by the QAPI committee there is substantial compliance to ensure the 15-minute check tool is accurate and matches the resident location/behavior. The DON audit will be documented on an audit tool. The unit managers will audit the progress notes five times per week for documented elopement attempts. The audit will be documented on an audit tool. Starting 4/15/25, the licensed nurses will sign off each shift on the 15-minute checks to ensure they are complete. Starting 4/l6/25, the licensed nurses on duty each shift will assign each CNA a block assignment of residents for the shift. The UM (unit manager) will spot check five times per week to ensure block assignments are in place and followed. The maintenance director (MTD) will conduct daily door alarm checks for proper function for one month, and weekly thereafter or as determined by the QAPI committee. The audits will be documented on an audit tool. A QAPI Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA (quality assessment and assurance) meeting for a minimum of three months or until the pattern of compliance is maintained. III. Facility policy and procedureThe Elopements and Wandering Residents policy, undated, was provided by the NHA on 5/7/25 at 10:15 a.m. via email. It read in pertinent part,"This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk."Elopement occurs when a resident leaves the premises or a safe area without authorization ( an order for discharge or leave of absence) and/or any necessary supervision to do so."The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner."The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary."Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team."The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan."Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff."Adequate supervision will be provided to help prevent accidents or elopements."Charge nurses and unit managers will monitor the implementation of interventions, response(s) to interventions, and document accordingly."The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff."Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. The designated facility staff will look for the resident."If the resident is not located in the building or on the grounds, the administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. "Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior."IV. Resident #1A. Resident statusResident #1, age 72, was admitted on 3/29/22. According to the May 2025 computerized physician orders (CPO), diagnoses included hypertension (high blood pressure), pre-diabetes, kidney disease, frontal temporal neuro cognitive disorder (a type of dementia, affecting the frontal and temporal lobes of the brain, responsible for behavior, personality, and language), gastro-esophageal reflux disease (GERD), muscle weakness and depressive episodes. The 1/29/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident did not reject care from staff. The resident was independent with eating, toileting, showering, and personal hygiene. The resident did not need any mobility devices to ambulate. The MDS assessment indicated the resident had not exhibited wandering behaviors and it was somewhat important for the resident to go outside when the weather was good. B. Resident representative's interviewResident #1's representative was interviewed on 5/7/25 at 3:27 p.m. via the phone. The representative said Resident #1 had a unique kind of dementia and required a lot of monitoring. The representative said she did not understand how the facility could not know the resident was missing for 12 hours. She said the family's biggest fear was that something could have happened to him. The representative said when the police found Resident #1, he was blocks away from the facility, sitting on a curb and he thought he was changing a tire on a truck. C. Record reviewResident #1's elopement/exit seeking/wandering care plan, initiated 3/10/25 revealed the resident was at risk for elopement related to dementia and other cognitive impairment. Resident #1 had a history of attempting to exit doors by pushing on them until they opened. The goal was for Resident #1 to not wander out of the facility. Interventions included providing the resident with redirection as needed (initiated 3/10/25), placing the resident on the secure unit (initiated 4/14/25), following the facility protocol if a wandering or elopement attempt occurred (initiated 4/15/25) and placing a photo of the resident in the elopement binder (initiated 4/15/25). The 1/28/25 wander elopement risk assessment revealed Resident #1 scored a 10 which indicated he was an elopement risk. The resident also had no elopement attempts. The 4/12/25 wander elopement risk assessment, conducted after Resident #1 eloped from the facility, revealed the resident scored a 22 and was deemed an elopement risk. The 3/1/25 nursing progress note revealed Resident #1 was on 15-minute checks for inappropriate behaviors with staff and other residents. The 3/7/25 nursing progress note revealed the resident continued to be on 15-minute checks for inappropriate sexual behaviors. The 3/6/25 community safety awareness evaluation revealed Resident #1 was severely impaired to make decisions. The resident was a potential risk due to dementia, loss of direction, fall, and generalized weakness. It was not safe for the resident to leave the facility out on pass.-Review of Resident #1's 15-minute check logs from 8:00 p.m. on 4/11/25 until 1:45 a.m. on 4/12/25 revealed a CNA documented the resident was present in the facility, however, the facility's video surveillance revealed the CNA did not check on the resident during that time (see NHA interview below).-There was no documentation that 15-minute checks were completed after 1:45 a.m. on 4/12/25. On 4/12/25 the evaluation for the secured unit placement documented the resident needed a secured unit due to habitual wandering or would wander out of their environment and was unable to find their way back. It was signed by the team members required for secured placement and included the resident representative's signature. V. Staff interviewsThe NHA was interviewed on 5/8/25 at 10:00 a.m. The NHA said on 4/12/25, he and the DON, LPN #2 and several others from the management team came in to investigate Resident #1's elopement and determine how it happened. The NHA said he immediately checked all of the doors and their alarms. The NHA said all of the alarms were working properly, which was why he did not call the maintenance director to come in and fix anything. The NHA said he viewed the facility's surveillance cameras during his investigation and conducted staff interviews. The NHA said Resident #1 was observed going out the front door at approximately 8:14 p.m. on 4/11/25. The NHA said all staff should round on all residents every two hours for care, but the staff on the fourth floor did not round on residents as they were supposed to do on 4/11/25. The NHA said Resident #1 was to be observed every 15 minutes and have his behaviors documented. The NHA said a CNA on the fourth floor documented on the 15-minute documentation sheet that Resident #1 was observed as ordered. The NHA said the video surveillance revealed the CNA never checked on Resident #1 on 4/11/25. The NHA said one CNA from the fourth floor left the facility in her car around 2:30 a.m. on 4/12/25 and abandoned her shift. The NHA said the two CNAs and the one LPN who were on duty the night of 4/11/25 no longer worked at the facility due to disciplinary actions which stemmed from the 4/11/25 incident. The NHA said the fourth floor LPN was notified around 4:00 a.m that Resident #1 was missing. He said had the LPN notified all of the staff, the entire facility staff could have looked everywhere for the resident in 10 minutes and not the two hours it took to call him. The NHA said LPN #2 was the one who called the NHA and the police. The NHA said all staff on 4/12/25 were educated on proper procedures for elopement which included, elopement and wandering policies, two hour rounding on residents and what to do with block assignments (requirements for each area), 15-minute checks and documentation, door alarms and the procedures should an alarm go off and notifying the NHA of a missing person. The NHA said all staff in all departments were notified that no one was allowed to work their shift until all training was completed. The NHA said alternating members of the management team stayed each day for all shifts, and trained all staff who entered the building. The NHA said the facility used a phone notification system for all staff to receive the emergent training message. The NHA said all staff that were on vacation were also notified and the last staff member who was on vacation received their training by 4/18/25. The NHA said agency staffing companies were notified that all staff must review the agency staffing book of all procedures pertinent to the investigation, prior to their designated shift, and sign that they read the material. The NHA provided copies of all of the training, along with signatures of the staff, and audits done that began on 4/12/25. CNA #2 was interviewed on 5/12/25 at 10:52 a.m. CNA #2 said he was working on the first floor on 4/11/25 when he heard the doorbell and the alarm sound at the front door. He said when he came to the front door the alarm was going off but no one was at the door. He said he looked out the large window and decided no one was outside. He said he did not leave the building to search the parking lot or nearby areas for a resident. He said he did not tell anyone about the incident. He said he thought someone rang the doorbell and probably grabbed the door to open it which set off the alarm. He said he made sure the door was closed and the alarm was reset. He said since the incident, he had received a lot of training so that the incident did not happen again. He said the facility put up an extra camera on 4/12/25 that pointed towards the front door. He said the new camera was connected to a camera on the first floor so that the front door could be monitored more closely. He said the camera on the first floor was to be with the nurse either at the nurses station or on the medication cart. He said the new monitor had an added alarm in it that sounded if the front door was opened. The NHA and the DON were interviewed together on 5/12/25 at 11:55 a.m. The DON said CNA #2 was educated about missing persons and searching the parking lot and surrounding areas after an alarm sounded. The NHA said all new staff received all of the updated training before they began to work in the facility. The NHA said he believed the facility had completed a thorough investigation and ensured that all staff were properly educated, beginning on 4/12/25. The NHA said all residents were reviewed for safety interventions, and proper monitoring procedures were in place so that the situation that occurred on 4/11/25 did not occur again.

A survey prompted by complaint #CO40139 was completed on 5/7/25 to 5/13/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure two (#2 and #3) of four residents were free from abuse out of 10 sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #3 were free from physical abuse by each other. On 4/16/25 Resident #2 attempted to strike Resident #3. Resident #3 responded by grabbing Resident #2. Both residents fell to the ground. Resident #3 sustained a left humerus (shoulder) fracture. Resident #2 sustained bruising to his arm and an abrasion to his back. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, 2024, was provided by the nursing home administrator (NHA) on 5/7/25 at 10:15 a.m. via email. It read in pertinent part,"It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. "Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology."Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. "Serious bodily injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation."II. Physical abuse between Resident #2 and Resident #3 on 4/16/25A. Facility investigationThe 4/16/25 facility investigation was provided by the NHA on 5/12/25 at 9:15 a.m. The investigation documented Resident #2 and Resident #3 resided on a secured unit. Resident #2 had severe cognitive impairment, impaired communication ability and weighed 150.6 pounds. Resident #3 was cognitively intact and had delusions and hallucinations in regards to self and others. Resident #3 weighed 268.2 pounds, which was over a 100 pound difference between the two residents. The investigation documented that on 4/16/25 at approximately 4:00 a.m., Resident #3 was sitting in a recliner in the dining room. Resident #2 entered the dining room with clothing from his room and placed his clothing on the tables. Resident #3 asked Resident #2 what he was doing. Resident #2 responded with something inaudible on the video surveillance, while he pointed his finger at Resident #3. Resident #3 got up out of his recliner and moved toward Resident #2. Resident #2 swung at Resident #3 but missed contact. Resident #3 said to protect himself before he put his arms around Resident #2, both men grappled and both fell to the ground. The nurse who was seated at a nurses station and was not in view of the dining room heard noise that came from the dining room. Upon investigation, the nurse found both Resident #2 and Resident #3 on the ground. The nurse separated the residents. Resident #2 sustained a bruise to the posterior right arm and a linear abrasion to the mid-spine. Resident #3 sustained a non-displaced fracture to the left humerus. Both residents were placed on 15-minute checks. The investigation documented that it was determined by the medical director (MD) and a psychiatrist, that Resident #2 had a gradual dose reduction (GDR) of Zyprexa medication from 2.5 mg (milligrams), andthe decision was made to stop the medication completely in December 2024. Resident #2 was reviewed in the psychopharmacological meetings and it appeared to be successful for several weeks until a few days before the altercation. The investigation documented on 4/14/25 licensed practical nurse (LPN) #2 requested Resident #2 be put back on Zyprexa 2.5 mg and the GDR be stopped. The physicians agreed, based on Resident #2's behavior tracking. The Zyprexa was re-ordered for Resident #2. According to the physician's interviews, Zyprexa 2.5 mg, an antipsychotic medication had not been able to take effect in the two days from 4/14/25 until the incident on 4/16/25. The investigation documented Resident #2 and Resident #3 had not had an altercation with each other prior to the incident. B. Resident #2 1. Resident statusResident #2, age less than 65, was admitted on 9/5/23. According to the May 2025 computerized physician orders (CPO), diagnoses included bipolar disorder (mental illness) and alcohol-induced persisting dementia. The 4/4/25 facility assessment revealed the resident had severe cognitive impairments. He was independent with eating, toileting, personal hygiene and walking. 2. Record reviewThe 12/17/24 interdisciplinary team (IDT) psychotherapeutic review revealed Resident #2's Zyprexa 2.5 mg was discontinued that day (12/17/24). The cognitive impairment care plan, revised 1/9/25 revealed Resident #2 had cognitive impairments, exhibited cognitive loss related to alcohol-induced persisting dementia. He had short and long term memory loss, disorganized thinking, difficulty with word finding at times and was only oriented to himself. Pertinent interventions included monitoring the resident for changes in cognitive status, notifying the physician if changes in cognitive status were noticed, providing cognitive therapy, administering medications as ordered and notifying the physician if the resident's behavior interfered with daily functioning. The 3/30/25 IDT psychotherapeutic review revealed Resident #2 was stable, with no change after the discontinuation of Zyprexa. The 4/14/25 nursing progress note, documented at 4:14 a.m., revealed Resident #2 had increased agitation, was difficult to redirect and continually paced from his room to the dining room. Another 4/14/25 nursing progress note, documented at 6:00 a.m., revealed Resident #2 again displayed increased agitation in the dining room, threw chairs and tipped a table. Another 4/14/25 nursing progress note, documented at 10:52 a.m. revealed the resident's agitation had increased..The 4/14/25 behavioral progress note documented at 12:10 p.m., revealed Resident #2 voided in a trashcan in the dining room and when asked to stop he raised his voice and said no. Another 4/14/25 nursing progress note, documented at 2:10 p.m., revealed Resident #2 was more agitated than normal and he continued to pace the hallway. Another 4/15/25 nursing progress note, documented at 1:04 p.m., revealed Resident #2 was being monitored for Zyprexa use. Review of the April 2025 CPO revealed the following physician's order: Zyprexa oral tablet 2.5 mg, give at bedtime for angry outbursts, throwing chairs, and verbal aggression related to bipolar disorder, ordered 4/14/25. The 4/16/25 room notice notification revealed Resident #2 was moved to a private room due to increased agitation and paranoia about his belongings. At night he moved his belongings to the dining room to protect his items. The 4/16/25 nursing progress note, documented at 7:04 a.m., revealed Resident #2 was involved in a physical altercation with another resident (Resident #3) and fell to the floor. The residents were separated and placed on 15-minute checks. Resident #2 was assessed and denied any pain. The 4/18/25 nursing progress note revealed a follow-up head to toe skin assessment was completed on Resident #2 due to a fall that occurred on 4/16/25. The resident had a bruise to the back of his right arm measuring 5 centimeters (cm) by 4 cm by0 cm. No open areas were noted. The resident denied pain. An abrasion to the resident's mid-spine measured 3 cm by 1.5 cm by 0 cm. The physician was notified. C. Resident #31. Resident status Resident #3, age less than 65, was admitted on 3/31/22. According to the May 2025 CPO, diagnoses included alcohol induced persisting dementia, anxiety disorder, hypertension (high blood pressure), seizures, alcohol abuse and gastro-esophageal reflux disease (GERD). The 3/7/25 facility assessment revealed the resident was cognitively intact. The resident had delusions, misconceptions or beliefs that were firmly held, contrary to reality. The resident was independent with eating, toileting and personal hygiene. 2. Resident interviewResident #3 was interviewed on 5/12/25 at 11:30 a.m. Resident #3 said he was in pain due to the incident with Resident #2 and he required surgery for his shoulder. 3. Record reviewThe behavior care plan, initiated 9/5/24 and revised 5/5/25, revealed Resident #3 could demonstrate agitation towards other residents, often due to his delusions and potentially altered perception. The resident required assistance with his activities of daily living (ADLs) related to his alcohol-induced dementia, delusional disorder and anxiety. The care plan documented the goal was that the resident would not demonstrate aggression towards others. Interventions included the staff were to seek to divert the resident's attention elsewhere and the staff were to work to anticipate triggers. The 4/16/25 nursing progress note, documented at 6:30 a.m. revealed Resident #3 had an altercation with another resident (Resident #2) and fell to the floor. Resident #3 said "I couldn't help it." He was placed on 15-minute checks, denied injury and refused a body assessment. Another 4/16/25 nursing progress note, documented at 8:14 a.m., revealed Resident #3 complained of pain in his shoulder and an Xray was ordered. Another 4/16/25 nursing progress note, documented at 4:23 p.m., revealed the Xray was positive for a fracture of Resident #3's left humeral head (shoulder). Physician's orders were received for a sling and a referral to an orthopedic surgeon was made. The 4/23/25 IDT progress note revealed Resident #3 was not the aggressor in the incident with Resident #2. -However, the facility investigation documented Resident #3 wrapped his arms around Resident #2 and both fell to the ground (see facility investigation above). The 4/23/25 pain assessment revealed Resident #3 had frequent and almost constant pain. The resident revealed his pain level was a 8 out of 10 on a pain scale of 1-10 recorded as the highest. VI. Staff interviewsThe psychiatrist was interviewed on 5/8/25 at 3:45 p.m. The psychiatrist said he had worked as Resident #2's psychiatrist when he lived in the community and continued to be involved with his care when he was admitted to the facility. He said because of Resident #2's alcohol use, he had dementia and needed the level of care provided in the facility. The psychiatrist said the resident continued with a small dose of Zyprexa (2.5 mg) after doing previous successful GDRs. The psychiatrist said the facility's IDT team, along with his involvement, decided to discontinue Zyprexa in December 2024. He said the Zyprexa was discontinued for a few months with success. He said in April 2025, Resident #2 started to show aggressive behavior, which was not normal for Resident #2. He said it was not just a bad day in April 2025 and it seemed his baseline was off. He said a few days before the altercation, he decided to put Resident #2 back on the Zyprexa. The psychiatrist said the Zyprexa was restarted two days before the aggressive behavior incident happened with Resident #3. The psychiatrist said two days prior to the incident was not long enough for the Zyprexa to take effect. The psychiatrist said Resident #2 was now doing well after the Zyprexa was restarted. The psychiatrist said the reason for the incident was due to Resident #2 and the GDR of Zyprexa. The psychiatrist said he had been Resident #3's psychiatrist for several years. The psychiatrist said Resident #3 was very delusional. The psychiatrist said Resident #3 was not agreeable to any medication changes. The psychiatrist said in his opinion, Resident #3 was not the reason for the altercation with Resident #2. The NHA was interviewed on 5/12/25 at 9:15 a.m. The NHA said he reviewed surveillance videos, along with resident and staff interviews for the investigation. LPN #2 was interviewed on 5/12/25 at 11:14 a.m. She said the day of the altercation (4/16/25) between Resident #2 and Resident #3, she was in her car in the parking lot at approximately 4:30 a.m. She said she received a phone call from the nurse who separated the residents. She said she immediately came into the building and went to the floor where the altercation occurred. She said she immediately called the NHA. She said she and the NHA watched the video surveillance cameras. She said the video surveillance revealed Resident #2 attempted to punch Resident #3 but the punch did not hit Resident #3. LPN #2 said Resident #3 then grabbed Resident #2 like a wrestler would do and Resident #3 put his arms around Resident #2 and both residents fell to the ground. She said she had worked with Resident #2 for a long time and there had never been an incident like the one that occurred. She said a few days prior, the nursing staff had called the physician to restart Resident #2's Zyprexa . LPN #2 said as the Zyprexa was restarted, the staff knew to observe and let Resident #2 pace down the hallway while his medication took effect. She said that was two days prior to the incident and the medication was likely to not have taken effect yet. She said Resident #2 sustained a bruise on his back and a small skin abrasion on his arm. She said Resident #2 was placed back on Zyprexa and he was no longer agitated like he was prior to the incident. LPN #2 said the surgeon had cancelled two appointments with Resident #3 due to the surgeon's schedule and an appointment was rescheduled again. She said the resident's family member wanted an appointment to be made with a specific surgeon. The director of nursing (DON) was interviewed on 5/12/25 at 11:55 a.m. She said Resident #2 had not had any physical violence prior to the incident on 4/16/25. The DON said in the March 2025 IDT psychopharmacological meeting, Resident #2's medications and behaviors were discussed. The DON said Resident #2 was reviewed in the psychopharmacological meeting in March 2025 to determine if the resident was tolerating not being on Zyprexa. The DON said the IDT team determined in the March 2025 meeting that they would continue with the discontinuation of the Zyprexa to determine if it was a successful GDR or not. The DON said in April 2025, after monitoring Resident #2's behaviors, LPN #2 spoke to the psychiatrist about Resident #2. The DON said it was determined by the psychiatrist to put Resident #2 back on the Zyprexa 2.5 mg. The DON said that was two days before the altercation with Resident #3, which was not enough time for the medication to work. The social services director (SSD) was interviewed on 5/12/25 at 1:00 p.m. The SSD said Resident #2 had not had any physical violence before the incident on 4/16/25. The SSD said Resident #2 and Resident #3 had not had any altercations with any other residents since the incident on 4/16/25. The facility's medical director (MD) was interviewed on 5/13/25 at 10:00 a.m. via the phone. The MD said the psychopharmacological IDT meetings at the facility had a lot of clinical professionals which included himself and a psychiatrist. The MD said he had permission from the psychiatrist to speak about the situation with Resident #2. The MD said the team discussed a low dose of Zyprexa. The MD said the team discussed that bipolar disorder was not the problem for the Zyprexa, but rather Resident #2's alcohol use. He said Resident #2 was documented to be in a good mood, and slept well. He said the team used shared decision making with the insight from the psychiatrist who had worked with Resident #2 in the community prior to his admission into the facility. The MD said the discontinued Zypreza GDR happened in December 2024. The MD said for several months Resident #2 seemed to do well without the medication, until in April 2025, the facility staff noted behavioral issues, and the Zyprexa medication was added back for Resident #2. The MD said it was added back two days prior to the incident with Resident #3 on 4/16/25, which was not enough time for the medication to take effect. The MD said the medication currently worked for Resident #2. The NHA was interviewed again on 5/13/25 at 11:50 a.m. The NHA said all staff were educated about resident-to-resident abuse after the incident on 4/16/25. The NHA said the staff were educated to visually watch the residents and when a resident went to the dining room, a staff member needed to watch the residents. The NHA said Resident #2's Zyprexa took effect and his behavior was back to his baseline. The NHA said a recliner was put in Resident #3's room with his approval. The NHA said on 5/13/25 (during the survey) he purchased and installed a camera to be put into the dining room on the second floor (where the incident between Resident #2 and Resident #3 occurred). The NHA said the camera would be connected to a monitor that the nursing staff could utilize as needed to observe residents in the dining room.