RIDGEVIEW POST ACUTE

A complaint survey, prompted by #CO2802632, Incident #2808172, Incident #2808248, Incident #2808260 and Incident #2975196 was completed on 4/6/26 to 4/8/26. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure one (#3) of four residents reviewed out of 16 sample residents was kept free from resident-to resident physical abuse. Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #4. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/6/26 to 4/8/26, resulting in the deficiency being cited as past noncompliance with a correction date of 3/25/26. I. Incident of physical abuse by Resident #4 toward Resident #3 on 1/19/26On 1/19/26 at 5:00 a.m. certified nurse aide (CNA) #3 heard activity from the room shared by Resident #3 and Resident #4. When CNA #3 entered the residents’ room, she observed Resident #4 was standing near Resident #3’s bed and was attempting to remove a pillow from beneath Resident #3’s head. CNA #3 separated the residents and assisted Resident #4 to her side of the room. Approximately 20 minutes later, CNA #3 saw Resident #4 take a pillow from her own bed and go to Resident #3 and Resident #4 hit Resident #3 three times with the pillow. Resident #3 was upset and was screaming “get her away from me!” CNA #3 intervened and redirected Resident #4. II. Facility action to correct the deficient practiceThe facility moved Resident #3 to a different room on 1/19/26 and Resident #4 was no longer assigned a roommate. Resident #4 continued with one-to-one supervision during waking hours and did not have any additional roommates after the incident between her and Resident #3. The facility implemented a new process after the 1/19/26 incident, which included staff obtaining and completing an abuse packet immediately after an incident. The facility discussed the 1/19/26 physical abuse incident between Resident #4 and Resident #3 in the facility’s monthly quality assurance performance improvement (QAPI) meeting.-However, on 3/22/26, Resident #4 had an encounter with another resident where Resident #4 held onto another resident’s arm lightly for a few seconds and then let go. The facility did not substantiate the encounter as abuse, however the encounter prompted the facility to provide further abuse education with staff (see below). On 3/24/26, the assistant director of nursing (ADON) provided education regarding redirecting residents using snacks and activitiesThe education included information about why redirection works, redirection instructions, helpful phrases to use, reminders and specific interventions for Resident #4, including offering snacks that she preferred, such as chocolate pudding and oatmeal cookies, redirection to her room and resident preferences for specific games. The education was only signed by 15 nursing staff members. However, on 3/25/26, the clinical resource nurse provided further in-depth education to all staff regarding abuse prevention and management. The education included definitions of abuse, tips for preventing abuse and who staff should report allegations of abuse to. The education was signed by 52 staff members from all disciplines. III. Facility policy and procedureThe Abuse Prevention and Reporting policy, revised June 2025, was provided by the nursing home administrator (NHA) on 4/7/26 at 2:32 p.m. It read in pertinent part, “It is the policy of this facility that residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect and exploitation.“Residents will not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff or other agencies serving the residents, family members or legal guardians, friends or other individuals.“All allegations of abuse are investigated.“Any staff member who has reasonable cause to believe or reason to suspect any situation that may be considered abuse will immediately report to the charge nurse. The staff member will intervene and ensure that the resident is safe. Make sure that all residents are kept safe during the investigation. “If a resident is the assailant, make sure that they are kept out of the reach of other residents and increase monitoring of the assailant.”IV. Facility investigation of the abuse incident between Resident #4 and Resident #3 on 1/19/26The facility’s abuse investigation was provided by the NHA on 4/7/26 at 9:00 a.m. The facility documented the date of the incident as 1/19/26 at 5:00 a.m. The facility investigation documented CNA #3 heard activity from the room shared by Resident #3 and Resident #4. It documented when CNA #3 entered the room, she observed Resident #4 was standing near Resident #3’s bed and was attempting to remove a pillow from beneath Resident #3’s head. It documented Resident #4 then picked up a pillow and made contact with Resident #3 with the pillow. It documented CNA #3 intervened and redirected Resident #4. The facility’s investigation concluded that there was a verbal exchange between Resident #3 and Resident #4 and Resident #4 used a pillow and made contact with Resident #3. It documented information that was obtained through interviews, chart review and assessments did not result with any significant findings. -However, a witness interview revealed Resident #3 was upset after the incident (see interview below) and Resident #3 was moved to a different room. V. Resident #4 (assailant)A. Resident statusResident #4, age 67, was admitted on 12/8/23. According to the April 2026 computerized physician orders (CPO), diagnoses included dementia, insomnia, chronic obstructive pulmonary disease (COPD - a lung disease) and depression. The 3/7/26 minimum data set (MDS) assessment identified Resident #4 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. Resident #4 required set-up assistance with eating, was able to transfer herself independently and required substantial assistance with dressing and showering. The MDS assessment identified Resident #4 had wandering behavior one to three days per week. B.Observation and interviewOn 4/6/26 at 10:15 a.m. Resident #4 was in her room. The resident had no roommate and had a CNA in her room providing one-to-one observation and assistance for the resident. The CNA was sitting in the corner of the room and Resident #4 was sitting up in her bed and was anxious, rocking back and forth. Resident #4 said her previous roommate made a lot of noise. Resident #4 said she did not remember any incidents with other residents, including her previous roommate, at the facility. C. Record reviewResident #4’s potential for behavior problem verbal/physical aggression related to dementia diagnosis care plan, revised 4/6/26, revealed Resident #4 had a history of being physically aggressive towards others, a history of saying she would “kill staff” and would make repetitive statements, such as “I hate you” and “I hate living here.” The care plan documented Resident #4 perseverated on various topics that made her upset, even if they had been addressed and resolved. The care plan documented Resident #4 had a history of being verbally rude to others around her, had thrown food, drinks and markers at other residents, had pulled the hair bow of another resident and had thrown and hit others with pillows. The care plan documented triggers for Resident #4 included touching her items, crowds, strangers or doing something from behind her. Pertinent care plan interventions included ensuring Resident #4’s hearing aids and glasses were used when needed, having the resident’s room located next to the nurses’ station, providing activities of interest, anticipating and meeting the resident’s needs, encouraging the resident to express feelings appropriately, decreasing interactions with other residents as able, keeping her at arm’s length from others when able, providing distraction and redirection as needed, educating family/caregivers on successful coping and interaction strategies, encouraging more days at her senior day care offsite facility and providing one-to-one observation with staff during waking hours. A nursing progress note, dated 1/19/26 at 1:46 p.m., documented the nurse was notified by a CNA that Resident #4 was witnessed throwing a pillow towards her roommate (Resident #3). The note documented the pillow made contact with Resident #3 before the CNA could intervene. The note documented the CNA separated the residents. The note documented Resident #4 was not interviewable after the incident due to her cognition. VI. Resident #3 (victim)A. Resident statusResident #3, age 72, was admitted on 12/27/24 and discharged on 1/29/26. According to the January 2026 CPO, diagnoses included dementia, COPD, stroke and kidney disease. The 1/1/26 MDS assessment revealed the facility was unable to complete a BIMS assessment for Resident #3. The MDS assessment revealed Resident #3 required set-up assistance with eating and required substantial assistance with dressing, showering and transferring. The MDS assessment identified Resident #3 had no behavior symptoms directed toward others. B. Record reviewResident #3’s potential behavioral problem, paranoia, accusatory behavior related to dementia and history of stroke, initiated 5/22/25, revealed Resident #3 at times yelled out about people on the television watching her and/or her friends, called out that she was naked when she was not and said water was cold when it was at normal temperatures. Pertinent interventions included medications as ordered with monitoring for side effects, anticipating need, approaching in a calm manner, redirecting the resident away from television when distressing to the resident, discussing behavior if reasonable, explaining and reinforcing why it was inappropriate and intervening as necessary to protect the rights and safety of others, removing the resident from the situation and taking resident to alternative location as necessary. A nursing progress note, dated 1/19/26 at 6:00 a.m., documented Resident #3 was a recipient of a physically aggressive behavior from her roommate. The note documented Resident #4 walked toward Resident #3, who was lying supine in bed. It documented Resident #4 made physical contact with Resident #3 three times before being separated by staff. It documented the incident had begun with a verbal exchange between the roommates. It documented Resident #3 said she was hit several times by her roommate for no reason and she did not hit back. The nursing note documented Resident #3 denied pain or discomfort as a result of the physical aggression by Resident #4. It documented that Resident #3 did not want to be in the same room with Resident #4 and therefore Resident #3 was moved to another room. A social services progress note, dated 1/19/26 at 1:00 p.m., documented Resident #3’s representative was notified regarding the incident between Resident #4 and Resident #3. The representative was advised of Resident #3’s room change, which occurred on the same day of the incident. VII. Staff interviewsCNA #3 was interviewed on 4/8/26 at 10:40 a.m. CNA #3 said she heard Resident #3 and Resident #4 arguing. She said she went into the residents’ room and saw Resident #4 was standing next to Resident #3’s bed and was trying to take Resident #3’s pillow from under her head. CNA #3 said she separated the residents and assisted Resident #4 to her side of the room. CNA #3 said about 20 minutes later she saw Resident #4 take a pillow from her own bed and go to Resident #3 and Resident #4 hit Resident #3 three times with the pillow. CNA #3 said she removed Resident #4 from the room in her wheelchair. CNA #3 said that Resident #3 was upset and was screaming “get her away from me!” The NHA, the director of nursing (DON) and the clinical resource nurse were interviewed together on 4/8/26 at 2:09 p.m. The NHA said Resident #4 had been without a roommate for a long time. The NHA said Resident #4 had previously had incidents with other residents sothe facility had given her a room by herself. He said the resident had not had any incidents with other residents for at least seven months (prior to the incident with Resident #3), so the facility developed a plan to determine if Resident #4 could transition back to having a roommate. The NHA said the situation with Resident #3 had been working out well and Resident #3 and Resident #4 shared a staff member who remained with them during the day, however, he said the incident 1/19/26 happened at night when the residents’ room was in view of the nurses’ station (directly across the hallway). The NHA said CNA #3 saw Resident #4 attempt to remove Resident #3’s pillow from underneath her head. He said CNA #3 separated her from Resident #3 and then Resident #4 later hit Resident #3 with Resident #4’s pillow. The NHA said CNA #3 then separated the residents and escorted Resident #4 from the room. The NHA said Resident #3 was not fearful, but was moved to another room as she did not want Resident #4 as a roommate any longer. The NHA said that Resident #3’s television was on and he thought that was the reason Resident #4 went over to Resident #3. The DON said if someone destroyed another resident’s peace early in the morning, he could see why the person whose peace was disrupted would be upset. The clinical resource nurse said the witness statement provided during an interview with CNA #3 was not signed by CNA #3 to confirm that she agreed with the statement. The NHA and the clinical resource nurse said they planned to ensure that witness interview statements were signed in the future. The DON said the facility had a new process which began after the 1/19/26 incident between Resident #3 and Resident #4 and included staff obtaining an abuse packet immediately after an incident. The DON said he was working with the nursing team on the process to ensure the staff members would write a statement when the incident occurred. The NHA said it made sense that Resident #3 would be upset after the incident and he said he guessed that she was upset and concerned about it at the time and this was why she was moved out of the room quickly. The NHA said multiple interventions were put into place for Resident #4 to prevent further incidents. The NHA said Resident #4 had not had a roommate since the incident between her and Resident #3. The NHA said the facility had arranged with Resident #4’s representative for her to reinitiate an adult day care program which Resident #4 had attended. The NHA said the nursing and CNA staff received reeducation for abuse and dementia care. The NHA said every abuse incident investigation was discussed in the facility’s quality assurance performance improvement (QAPI) meetings each month and a meeting had included the incident between Resident #4 and Resident #3.

Based on record review and interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with state law for four of four allegations of abuse. Specifically, the facility failed to:-Report an allegation of physical abuse between Resident #1 and Resident #2 on 11/18/25 within two hours of the incident; .-Report an allegation of physical abuse between Resident #3 and Resident #4 on 1/19/26 within two hours of the incident;-Report an allegation of physical abuse between Resident #5 and Resident #6 on 2/8/26 within two hours of the incident; and,-Report an allegation of physical abuse between Resident #4 and Resident #11 on 3/22/26 within two hours of the incident. Findings include:I. Facility policy and procedureThe Abuse Prevention and Reporting policy, revised June 2025, was provided by the nursing home administrator (NHA) on 4/7/26 at 2:32 p.m. It read in pertinent part,“The administrator/designee will complete the initial report to the state survey and certification agency within 24 hours electronically via the occurrence reporting portal and complete the report within five days from the initial report.”-However, the facility was required to report any abuse allegations within two hours of the incident. II. Record reviewThe facility investigations for four physical abuse allegations were provided by the NHA on 4/7/26 at 9:00 a.m. The investigations documented the following:The alleged physical abuse between Resident #1 and Resident #2 occurred on 11/18/25 at 8:20 a.m. -However, the facility reported the alleged abuse on 11/19/25 at 10:22 a.m., 26 hours after the incident occurred. The alleged physical abuse between Resident #3 and Resident #4 occurred on 1/19/26 at 5:00 a.m. -However, the facility reported the alleged abuse on 1/19/26 at 7:07 p.m., 14 hours after the incident occurred. The alleged physical abuse between Resident #5 and Resident # 6 occurred on 2/8/26 at 8:30 a.m. -However, the facility reported the alleged abuse on 2/8/26 at 9:40 p.m., 13 hours after the incident occurred. The alleged physical abuse between Resident #4 and Resident #11 occurred on 3/22/26 at 11:59 a.m. -However, the facility reported the alleged abuse on 3/23/26 at 11:56 a.m., 24 hours after the incident occurred. III. Staff interviewsThe NHA, the director of nursing (DON) and the clinical resource nurse were interviewed together on 4/8/26 at 2:09 p.m. The NHA said he thought the two hour rule for reporting abuse allegations applied only to those allegations which resulted in serious bodily harm. The NHA said he was provided guidance by a consultant on 4/7/26 that physical abuse allegations had to be reported within two hours. The NHA said he would look at the facility’s policy and change the policy accordingly if it did not align with the guidance that was provided to him. The clinical resource nurse said she showed the NHA the occurrence reporting manual. The clinical resource nurse said the facility missed the two hour reporting guidelines for the four physical abuse allegations.

A survey with #CO2802635 was completed on 4/6/26 to 4/8/26. No deficiencies were cited.

A Federal Monitoring Survey (FMS)/Resource Support Survey (RSS) was conducted on 4/6/26 through 4/8/26. Please refer to State Survey Agency (SSA) Event ID 22CD9C-H1.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a). The facility is one (1) story, Type V (000) construction, with a partial basement. The basement contains support services for laundry, storage, and facility maintenance. The facility was constructed in 1966 with an addition added in 1997. The facility is licensed for 112 beds and operates a secured unit at the time of this survey. The Census was 98 at the time of the survey, with 17 in the secured unit. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system that consists of a wet and dry pipe sprinkler system. This complaint survey, conducted on March 16, 2026 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies".

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101. The findings include: The facility sprinkler 4” piping was not installed in accordance with NFPA 13. The sprinkler in the basement area was not secured to the structure of the facility. Piping was supported by being connected to a bracket on a domestic water supply line. Recalled Global sprinkler heads were found on the sprinkler branch line covering the patio area of the facility. Regulatory reference: NFPA 101 (12) 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 13 (10)9.2.1.3* Building Structure. 9.2.1.3.1 Unless the requirements of 9.2.1.3.3 apply, sprinkler piping shall be substantially supported from the building structure, which must support the added load of the water-filled pipe plus a minimum of 250 lb (114 kg) applied at the point of hanging, except where permitted by 9.2.1.1.2, 9.2.1.3.3, and 9.2.1.4.1. 9.2.1.3.2 Trapeze hangers shall be used where necessary to transfer loads to appropriate structural members. 9.2.1.3.3* Flexible Sprinkler Hose Fittings. 9.2.1.3.3.1 Listed flexible sprinkler hose fittings and their anchoring components intended for use in installations connecting the sprinkler system piping to sprinklers shall be installed in accordance with the requirements of the listing, including any installation instructions. 9.2.1.4 Metal Deck. 9.2.1.4.1* Branch line hangers attached to metal deck shall be permitted only for the support of pipe 1 in. (25 mm) or smaller in size, by drilling or punching the vertical portion of the metal deck and using through bolts. This deficient practice affects all residents and all smoke compartments throughout the facility. This deficient practice was briefed to facility leadership at survey exit.

Based on observation, interview, and record review, the facility failed to maintain smoke barriers in accordance with the National Fire Protective Association (NFPA) 101 and 99, affecting 98 of 98 residents and five of five smoke zones. Specifically, the smoke barriers throughout the facility had penetrations that allowed the unresisted passage of smoke and fire from one zone to another. The findings include: Record ReviewAn inspection report, dated 3/11/2026, provided via email by the local fire inspector, documented the status of the building’s construction features as “fail.” The report cited significant penetrations in the smoke barriers in the attic space above the ceiling. The report documented that concerns about building fire safety were discussed with facility leadership prior to concluding the inspection. The inspection was signed by the building plant operations director (POD). On 3/16/2026 at 9:52 a.m., life safety building plans were requested from the facility maintenance assistant. He reported they were not available. They remained unavailable when requested from Life Safety Maintenance Resource (LSMR) (see interview below). The building’s census and conditions report, provided on 3/16/2026 at 11:50 a.m., documented the following:-Zero residents were independent with mobility.-Forty-nine residents were mobile via wheelchair and 23 residents were mobile with assistive devices.-Seventy-nine residents required transferring assistance and 20 were dependent for transferring. ObservationsOn 3/16/2026 at 10:20 a.m., the smoke barriers were observed with maintenance personnel. Penetrations were observed in all smoke barriers. Specifically:-The fire barrier between the Durango and Montrose areas of the building had multiple penetrations (5+). The largest penetration measures approximately 25”x31”.- The fire barrier between the Montrose and Durango areas of the facility had multiple penetrations (10+). The largest penetration measured more than 20”x 20”. - The fire barrier between Montrose and the dining room area of the facility had multiple penetrations (5+). The fire barrier between the dining room area and the Golden area of the facility had multiple penetrations (5+).- The fire barrier in the therapy area corridor had multiple penetrations (3+) The facility fire barrier was rated 2 hours due to 2 layers of 5/8th drywall. The barrier must be maintained as constructed. InterviewsA telephone interview with the deputy fire marshal (DFM) for the local fire department was conducted prior to the survey on 3/13/2026. The interview revealed:- He was onsite with two trainees on 3/11/2026. His primary concern was the lack of intact smoke barriers throughout the facility. -He said reduced staffing levels at night within the building in conjunction with degraded smoke barriers were his biggest concern due to the facility’s defend-in-place strategy. -Regardless of staffing and time of day, the absence of intact smoke barriers put residents, staff, and first responders at-risk for serious injury or death in the event of a fire.-The DFM said other concerns were recalled fire sprinklers, sections of replacement sprinkler pipe with improper hangers, and damaged subfloor within a storeroom.-The DFM said his concerns were made known to building staff prior to departure. On 3/16/2026 at 11:50 a.m., the LSMR said the local fire officials had made them aware of the penetrations throughout the above ceiling smoke barriers on 3/11/2026. Additional interviews with the LSMR throughout the investigation revealed:-The facility was a shelter-in-place building.-The facility had not started to physically correct the penetrations identified by the local fire officials, though the facility was aware of the deficient practice for days. -The LSMR verbalized the understanding of the smoke barrier’s role in containing smoke to a smoke compartment. He was unable to explain how shelter in place could work when all smoke barriers had penetrations.-He did not know when the above ceiling smoke barriers were last inspected. He speculated the penetrations could be years old; when they had HVAC upgrade work. The LSMR said the penetrations were not identified on prior life safety inspections.-The LSMR was unable to furnish building plans documenting the location of smoke barriers. He agreed this could make it difficult for staff to identify and inspect such areas routinely. -There was no documentation of facility-conducted smoke barrier inspections. On 3/16/2026 at 2:03 p.m., the memory care unit nurse said she was unaware of any concerns with the building's smoke barriers. She had not been directed to change procedure in the event of a fire alarm. If a fire happened in another part of the building, residents were to stay in memory care. If they had to evacuate, they were to go across the street. On 3/16/2026 at 2:07 p.m. staff nurse #2 said if there was a fire, staff should remove everyone within three doors of the fire. Staff and patients were to remain in the facility. She believed this was the procedure throughout the building. She reported no changes in fire procedure were made within the last week. She was unaware of any problems or concerns with the smoke barriers in the building. Regulatory Guidance: NFPA 101 (12)4.1* Goals. 4.1.1* Fire. A goal of this Code is to provide an environment for the occupants that is reasonably safe from fire by the following means:(1)*Protection of occupants not intimate with the initial fire development(2)Improvement of the survivability of occupants intimate with the initial fire development 4.2 Objectives. 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place. 4.2.2 Structural Integrity. Structural integrity shall be maintained for the time needed to evacuate, relocate, or defend in place occupants who are not intimate with the initial fire development. 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, and shall remain operational. 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. 19.3.6.2 Construction of Corridor Walls. 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8. NFPA 99 15.2 Construction and Compartmentation. Buildings or structures housing a health care facility shall meet the minimum construction and compartmentation requirements of the applicable building code; NFPA 101, Life Safety Code; or fire code acceptable to the authority having jurisdiction. This deficient practice affects all residents and all smoke compartments throughout the facility. This deficient practice was briefed to facility leadership at survey exit.

The facility also had a sinking for in the supply room. They were working to correct this issue. A letter from Rohr Engineering - Structural Observation Letter stated that:“Structural Assessment”Based on the porons of the structure that were visible and accessible at the me of the site visit, the apparent floor selement appears to be localized to the Central Supply Room and does not appear to be affecng the primary structural framing or load-bearing elements of the building. The extent of the selement appears to be contained within the central supply room. If any further selement is discovered, Rohr Engineering should be nofied immediately. Given these observaons, it is our professional opinion that the observed floor selement does notconstute a life-safety issue at the me of this evaluaon. The Central Supply Room should remainunoccupied unl the floor condion is further evaluated and appropriately remediated.

A survey with #CO2741597 was completed on 3/3/26 to 3/4/26. No deficiencies were cited.

A complaint survey, prompted by #CO2665235, #CO2741596, #CO2747307 and #CO2748491 was conducted on 3/3/26 to 3/4/26. No deficiencies were cited.

A survey for Incident #1919645 and Incident #1919646 was conducted on 8/19/25. No deficiencies were cited.

A complaint survey, prompted by #CO37979, #CO39321, #CO39790, #CO39802, Incident #39680 and Incident #39797 was completed on 4/24/25 to 4/28/25. No deficiencies were cited.

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

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