PARK FOREST CARE CENTER LLC

A complaint survey, prompted by #CO3023805 was conducted on 7/6/26 to 7/7/26. One deficiency was cited.

Based on observations, interviews and record review, the facility failed to ensure mechanical equipment was maintained in safe, operating condition for one (#2) of three residents reviewed for mechanical lifts out of three sample residents. Specifically, the facility failed to: -Ensure mechanical lift slings were routinely inspected, maintained and replaced according to the manufacturer's recommendations and professional standards, which resulted in a fall for Resident #2; and, -Ensure mechanical lifts were routinely maintained according to the manufacturer's recommendations. Findings include: I. Professional standardsThe Federal Drug Administration’s (FDA) Patient Lift Safety Guide, undated, was retrieved on 7/8/26 from https://www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf. It read in pertinent part, “Prepare equipment. Examine sling and attachment areas for tears, holes and frayed seams. Do not use sling with any signs of wear. Keep manufacturer’s instructions close to your lift and always follow them. “Sling Care. Do not share slings between patients unless slings are properly washed and disinfected. Do not use slings that are frayed, ripped or have holes. If the slings show signs of wear, replace it immediately. “Contact information. If you have problems operating your lift, contact the manufacturer or supplier. If you experience an injury, quality problem or use error when using a patient lift, file a voluntary report or online through MedWatch, the FDA safety information and adverse event reporting program.” II. Facility policy and procedureThe Preventative Maintenance Program policy and procedure, revised 2/10/26, was provided by the director of nursing (DON) on 7/7/26 at 4:29 p.m. It read in pertinent part, “The maintenance director is responsible for developing and maintaining a schedule of maintenance services to ensure equipment is maintained in a safe and operable manner. If preventative maintenance is required, the maintenance director shall decide what tasks need to be completed and how often to complete them. Documentation shall be completed for all tasks and kept in the maintenance director’s office for at least three years.” III. Manufacturer’s instructionsAccording to Invacare’s Reliant 450 and Reliant 600 (mechanical lift) user manual (2018), page 33-34, retrieved on 7/8/26 from https://www.vitalitymedical.com/pdf/user-manual-invacare-reliant-600-lift.pdf?srsltid=AfmBOoqJXY8z9DONxsV1-kze_obZPbcqmCcc6ug54isqvzpVt-b8_-2E, “The expected service life is eight years, presuming that the product is used daily and in accordance with safety instructions and maintenance instructions stated in this manual. Maintenance Safety Inspection Checklist: Regular cleaning will reveal loose or worn parts, enhance smooth operations and extend the lift expectancy. Follow the maintenance procedures described in this manual to keep your patient lift in continuous service. “Sling and hardware. Check all sling attachments each time it is used to ensure proper connection and patient safety. Inspect sling material for wear. Inspect straps for wear. “Keep lift and slings clean and in good working order. Any defect should be noted and reported to your dealer as soon as possible. Maintenance for the boom, the hangar bar, actuator assembly, cleaning and slings and hardware is recommended initially. Inspect and adjust monthly.” IV. Mechanical lift sling and mechanical lift maintenance failuresA. ObservationDuring a facility walkthrough on 7/6/26, an Invacare Reliant 450 mechanical lift was observed on the women’s unit at 2:18 p.m. with a handwritten note that read “Out of service 6/2/26.” Two Invacare Reliant 600 mechanical lifts were observed on the men’s unit at 2:22 p.m. -However, there was no maintenance record for the Invacare Reliant 450 mechanical lift on why it was out of service (see interviews below). B. Record reviewThe 2/10/26 witnessed fall incident report revealed licensed practical nurse (LPN) #1was called to Resident #2’s room at approximately 8:00 a.m. by certified nurse aide (CNA) #1. LPN #1 arrived to the room and Resident #2 was on the floor. CNA #1 said Resident #2 fell while transferring from the bed to the chair. CNA #1 said the sling snapped off the mechanical lift. CNA #1 reported the resident fell from the bottom first and then the upper part of his body fell from the lift. The 2/11/26 interdisciplinary (IDT) event note revealed Resident #2’s 2/10/26 incident was described as a witnessed fall during a Hoyer lift transfer. The root cause was a malfunction of equipment. The new intervention was that all Hoyer lift slings were replaced. A request of all work orders and routine maintenance records for all three mechanical lifts was made to the nursing home administrator (NHA) on 7/7/26 at 12:30 p.m. The records revealed the following: On 2/11/26, a staff member reported a Hoyer (mechanical) lift was very wobbly and unstable and rated the request a five. On 2/11/2026, a maintenance department employee documented that all bolts were tightened. -However, the record did not reveal which of the three mechanical lifts required service. On 5/28/26, a staff member reported a Hoyer lift’s hand-held level that opened the legs often closed when transferring residents, especially the heavy residents and rated the request a four. On 5/28/26, a maintenance department employee documented it as completed. -However, the record did not reveal which of the three mechanical lifts required service and did not describe what was done to fix the mechanical lift. An email revealed an outside maintenance company performed diagnostics for three mechanical lifts on 6/24/26. The email revealed a technician completed the diagnostics and found although the mechanical lifts were older models, they were in proper working order with no issues identified. -However, the facility did not provide documentation to indicate that the three mechanical lifts were routinely inspected and maintained on a monthly basis, per the manufacturer’s instructions (see manufacturer’s instructions above). C. Facility’s plan of correctionThe corrective action plan the facility implemented in response to the mechanical lift sling malfunction involving Resident #2 on 2/10/2026 was provided by the DON on 7/7/26 at 2:00 p.m. The corrective action plan identified the facility became aware of the issue on 2/10/26 and developed a performance improvement plan in response to Resident #2’s fall due to the sling snapping. The facility completed education to all clinical staff and a return demonstration of mechanical lift use was completed by all clinical staff. On 2/10/26, the facility provided in-service training for all nursing staff on the facility policy for lifts and safety. The DON or the nursing home administrator (NHA) monitored mechanical lift transfers during rounds weekly for four weeks and then monthly for three months and then quarterly. All mechanical lift slings were monitored by the DON to ensure they are in good working condition for 12 weeks. -However, during the survey, additional concerns related to the failure to maintain mechanical lifts in safe operating condition were observed (see observations above). V. Staff interviewsCNA #2 was interviewed on 7/6/26 at 3:26 p.m. CNA #2 said she last received mechanical lift training in February 2026 or March 2026. She said she had worked at the facility for almost two years. She said each resident had their own sling in their room and in the laundry room. She said if a mechanical lift required repair or maintenance, she notified maintenance through an online system. She said she wrote a description of what was wrong and rated the importance of the request on a scale of one to five. She said if a mechanical lift required repair or maintenance, she rated the request as a five because it was important for the mechanical lift to be fixed as soon as possible. CNA #2 said there were two automatic mechanical lifts and one manual mechanical lift. She said one of the mechanical lifts was currently out of order because the legs of the lift were poor quality and unreliable. She said before she used a mechanical lift, she made sure the battery was in operating order, the legs looked okay and the remote worked. CNA #2 said she did not know where the mechanical lift manuals were stored and she said she did not know how to access the manuals. LPN #1 was interviewed via phone on 7/7/26 at 10:11 a.m. LPN #1 said she was the nurse who first found Resident #2 after the resident’s fall on 2/10/26. She said the cause of the fall was due to the mechanical lift sling snapping. LPN #1 said she did not look at mechanical lift slings regularly, but more than one CNA had told her the slings were not in good condition. She said if there were any requests for sling replacements, the DON needed to be notified. CNA #1 was interviewed on 7/7/26 at 12:00 p.m. CNA #1 said the mechanical lift sling used to transfer Resident #2 (on 2/10/26) broke and the resident fell when he was close to sitting down on the chair. CNA #1 said she had worked at the facility for two years and the slings were never replaced (prior to the 2/10/26 incident) and they were not in good condition. CNA #1 said before the 2/10/26 incident with Resident #2, there was only one resident who had their own sling. She said for everyone else, staff used whatever sling they could find and there were never enough. CNA #1 said she reported the slings not being in good repair verbally, but she did not document the work order request. CNA #1 said the mechanical lifts frequently required maintenance and they were never fixed. Registered nurse (RN) #1 was interviewed via phone on 7/7/26 at 10:18 a.m. RN #1 said she was working the day of Resident #2’s 2/10/26 fall from the mechanical lift. RN #1 said the cause of the fall was the sling stitching fell apart and snapped. RN #1 said she was unsure how long the slings had been in use prior to the 2/10/26 incident. RN #1 said after the incident, all residents who required a mechanical lift received their own slings and were labeled using a Sharpie or a machine label maker. The former director of supplies was interviewed via phone on 7/7/26 at 10:24 a.m. The director of supplies said she stopped working at the facility in December 2025. She said she saw the conditions of the mechanical lift slings and requested the slings to be replaced by asking the maintenance director (prior to the incident with Resident #2 on 2/10/26). The director of supplies said the slings were washed daily and there were holes in the slings and they were old. The maintenance director was interviewed on 7/7/26 at 12:30 p.m. The maintenance director said he had worked at the facility for over 35 years. He said the facility had three mechanical lifts. The maintenance director said he was responsible for the maintenance of the mechanical lifts and the nursing staff was responsible for the maintenance of the mechanical lift slings. The maintenance director said he did not know what the manufacturer’s instructions were for how often routine maintenance should be completed on the mechanical lifts. The maintenance director said staff should submit a work order request when maintenance was needed on the mechanical lifts; however, most CNAs told him verbally about a mechanical lift concern while he was in the hallway. The maintenance director said he did not document every time a CNA told him something needed to be fixed on the mechanical lifts. The maintenance director said he should be better at documenting the work orders for the mechanical lifts. The maintenance director said the facility had had the three mechanical lifts for about ten years. He said he did not know the expected service life of the mechanical lifts. The maintenance director said the most frequent mechanical lift maintenance requests CNAs made were that there was hair in the wheels of the mechanical lift or that the mechanical lift’s batteries needed to be replaced. The maintenance director said he was not aware one of the mechanical lifts had an out of order sign on it. He said to his knowledge, all mechanical lifts were in working order. The NHA was interviewed on 7/7/26 at 1:46 p.m. The NHA said the maintenance department was responsible for the maintenance of mechanical lifts. He said staff should use the electronic work order process to make mechanical lift maintenance requests. He said the maintenance department should follow the manufacturer's instructions for routine maintenance of the mechanical lifts. The NHA said the 6/24/26 outside diagnostic maintenance of the mechanical lifts was completed because the facility was setting up new systems and they wanted to make sure all equipment was functional. The NHA said nursing staff was responsible for the maintenance of the slings. The DON and the NHA were interviewed together on 7/7/26 at 3:33 pm. The DON and the NHA said the DON was not at the facility on 2/10/26. The DON said the cause of Resident #2 falling to the floor was that the mechanical lift sling was not in good condition. The DON and the NHA said they were unable to verify how long the mechanical lift slings had been in use prior to 2/10/26. The DON said she was responsible for keeping track of all residents who required a mechanical lift sling and what size sling the resident required. The DON said each resident had at least two slings. The DON said there had been no further incidents related to mechanical lift sling failure since 2/10/26. The NHA said the maintenance record documentation should have been more clear in order to determine which mechanical lift was serviced and what maintenance was completed to resolve the work order.

A complaint survey, prompted by #CO2728861, #CO2729018, #CO2730114 and Incident #2730182, Incident #2730217, Incident #2730235 and Incident #2730243 was completed on 2/3/26 to 2/9/26. Four deficiencies were cited.

Based on record review and interviews, the facility failed to ensure one (#11) of three residents reviewed for feeding tube out of 22 sample residents received necessary care and services to remain free from neglect. Resident #11 was nonverbal and dependent on staff for nutrition and hydration through a gastrostomy tube (G-tube). The resident was unable to communicate needs, discomfort, or hunger and relied entirely on staff to provide ordered tube feeding. The physician’s orders revealed the resident required continuous enteral feeding with scheduled water flushes to meet the resident’s nutritional and hydration needs. On 1/28/26, the resident’s tube feeding was not administered beginning at 4:00 p.m. until 6:00 a.m. on 1/29/26. Record review revealed no documentation that the ordered tube feeding was provided during this time period. Nursing documentation reflected that the failure to administer the tube feeding was identified after the fact, and the physician was notified on 1/29/26. The facility failed to ensure follow-up and continuity of care to meet the resident’s nutritional needs during this extended period. The resident’s representative said the incident caused increased fear and anxiety regarding the resident’s care and said she was stressed by learning the resident’s tube feeding was not provided as ordered and said that had the resident been aware, he would have been mad and would have requested transfer to another facility. Specifically, registered nurse (RN) #3 and RN #4 failed to take necessary steps to ensure Resident #11 received his enteral nutrition, which was his sole means of nutrition.. Finding include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #11’s tube feeding prior to the onsite investigation conducted on 2/3/26 to 2/9/26. The deficiency was cited as past non-compliance with a correction date of 1/29/26. I. Facility investigationThe nursing home administrator (NHA) provided an investigation on 2/4/26 at 12:49 p.m. regarding the failure to administer ordered tube feeding to Resident #11. The investigation identified RN #3 and RN #4 as the staff responsible for not administering the resident’s tube feeding as ordered. An investigative report documented the initial reported incident on 1/28/26 and follow-up actions that included review of physician orders, record review, staff interviews, resident assessment, continuous education, in-servicing on tube feeding, neglect and reporting. The investigation, corrective actions, and facility wide education were completed on 1/29/26. On 1/28/26 at approximately 4:00 p.m., the resident’s tube feeding orders were not administered by the assigned RN. The oncoming shift was provided inaccurate information regarding the tube feeding being on hold, and the resident did not receive tube feeding per physician orders from 4:00 p.m. on 1/28/26 until 6:00 a.m. on 1/29/26. On 1/29/26 at 9:30 a.m., the facility identified the missed tube feeding. The interdisciplinary team (IDT) reviewed Resident #11’s physician’s orders, the medication administration (MAR) and the treatment administration record (TAR) to verify tube feeding orders and administration. The RN #1 completed a resident assessment and noted no concerns. The facility documented the resident was not interviewable and did not observe any behavioral changes. Interviews documented the day shift (RN #3) said there was no tube feeding formula in the facility, while the assistant director of nursing (ADON) and central supply visually observed tube feeding formula in the facility. The night shift (RN #4) said the day shift nurse advised the tube feeding order was on hold and did not follow up regarding supply status. The investigation documented the resident was not interviewed due to severe cognitive impairment and inability to communicate. The investigation documented RN #3 and RN #4 were identified as the staff responsible for placing the resident’stube feeding orders on hold and not administering tube feeding as ordered on 1/28/26. Documentation and interviews reflected RN #3 placed the tube feeding orders on hold, provided inaccurate information to the oncoming shift regarding the tube feeding being on hold, and did not ensure follow-up regarding tube feeding availability. Interviews documented RN #4 was informed the tube feeding order was on hold and did not follow up to verify tube feeding supply availability or clarify physician orders. The investigation documented interviews documented the day shift RN #3 said there was no tube feeding formula available in the facility. Interviews further documented the ADON and central supply visually observed tube feeding formula available in the facility on 1/28/26. The investigation documented interviews documented the night shift RN #4 said the day shift RN #3 advised the tube feeding order was on hold and said the night shift RN #4 did not follow up regarding tube feeding supply status. The investigation documented the ADON provided a written statement and it read in pertinent part that on 1/28/26 at 6:30 a.m., the ADON informed RN #3 and licensed practical nurse (LPN) #1 that tube feeding formula was scheduled for delivery that day and that formula was available in the facility for immediate use. The DON provided a written statement on 1/29/26 that read in pertinent part, on 1/29/26 at 8:53 a.m., the DON was notified the resident did not receive ordered tube feeding overnight beginning on 1/28/26. The DON contacted RN #3 by phone and RN #3 said there was no tube feeding formula available in the building. The statement documented the ADON confirmed that at 6:30 a.m. on 1/28/26, the resident’s tube feeding formula was scheduled for delivery that day and a 1000 milliliter bag of formula was available in the building for immediate use. RN #3 acknowledged the information and said she understood. -However, the resident’s order for continuous feeding at 75 ml per hour for 18 hours required 1350 milliliters, therefore the 1,000 milliliter supply was not sufficient to meet the ordered amount. The investigation documented several staff members throughout the facility were interviewed on 1/29/26. All staff interviewed denied concerns related to tube feeding supply availability and identified appropriate steps to take when supplies were unavailable, including contacting the pharmacy or central supply and clarifying physician orders when tube feeding was held. II. Facility plan of correctionA. Immediate action to correct the deficient practice for Resident #11The facility verified the physician’s orders for tube feeding and verified tube feeding formula was available. The facility assessed Resident #11 after identifying the missed tube feeding and documented no findings noted. The facility ensured tube feeding was restarted and provided per physician’s orders. B. Identification of other residentsOn 1/29/26 the facility reviewed tube feeding orders and documentation for residents receiving tube feeding to identify other residents who could be affected by the deficient practice. C. Systemic changesThe facility provided education and in-servicing on tube feeding, hydration, nutrition, neglect, and reporting requirements. On 1/29/26 the facility completed one-on-one training and competency checklist and evaluated nursing staff on tube feeding skills. D. MonitoringThe facility implemented weekly monitoring of tube feeding orders and tube feeding administration to ensure tube feeding was provided per physician orders. III. Facility policy and procedureThe Care and Treatment of Feeding Tubes Policy, implemented 12/1/25, was provided by the DON on 2/5/26 at 12:10 p.m. The policy read in pertinent part that, “Feeding tubes would be utilized according to physician orders, including the kind of feeding and its caloric value, volume, duration, and frequency of flushes.” The policy further read that enteral nutrition must be administered consistent with practitioner orders and that licensed nursing staff were responsible for administering tube feeding as ordered and monitoring the resident during tube feeding administration. IV. Resident #11A. Resident statusResident #11, age less than 65, was admitted on 1/19/26. According to the February 2026 computerized physician orders (CPO), the diagnoses included crushing injury of head, dysphagia (difficulty swallowing), hypotension (low blood pressure) and bradycardia (slower than normal heart rate). The 1/21/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. He was dependent on staff with completing all activities of daily living (ADL). B. Resident representative interviewThe resident representative was interviewed on 2/5/26 at 10:44 a.m. She said the DON informed her on 1/29/26 that Resident #11’s tube feeding was not administered because the facility ran out of his specific formula, however, they had a similar formula available and initiated that formula. She said she did not notice any changes in Resident #11’s condition or behavior around that time. She said she was concerned about his laboratory draws, especially if he went without fluids, as he was dependent on fluids through tube feeding. She said the event caused her significant stress and said Resident #11 would have been upset and would have asked her to move him to another facility. She said this incident increased her fear and anxiety regarding his care planning. She said she was concerned about how staff did not administer his tube feeding, which frightened her, and because of this incident she checked on him more frequently. C. Record review The tube feeding care plan, initiated 5/29/25, documented the resident required tube feeding related to dysphagia. Pertinent interventions included holding the feedings if the residual was between 250 ml and 500 ml, cleansing the percutaneous endoscopic gastrostomy tube (PEG tube) site with normal saline or wound cleanser, patting dry gently with clean gauze, administering extra 200 ml water flushes via G-tube four times a day and flushing 200 ml water via G-tube before and after continuous feeding two times a day, administering continuous Isosource 1.5 via G-tube at 75 ml per hour, obtaining and monitoring lab and diagnostic work as ordered and reporting results to the physician and follow up as indicated, consulting the registered dietitian (RD) quarterly and as needed to monitor caloric intake, estimating needs and making recommendations for changes to tube feeding as needed, and noting the resident was dependent with tube feeding and water flushes and staff were to refer to the physician’s orders for current feeding orders. The nutrition care plan, initiated 3/12/25 and revised 1/21/26, documented the resident had a nutritional problem or potential nutritional problem related to swallowing concerns. Pertinent interventions included obtaining and monitoring laboratory and diagnostic work as ordered and reporting results to the physician with follow up as indicated, monitoring, documenting and reporting to the physician as needed signs and symptoms of malnutrition, monitoring, documenting and reporting as needed signs and symptoms of dysphagia, and consulting the RD dietitian to evaluate and make diet change recommendations as needed. A review of progress notes dated 1/28/26 through 1/29/26 revealed the following:A nursing progress note, dated 1/28/26 at 8:28 p.m., revealed the enteral feed order was placed on hold. A nursing progress note, dated 1/29/26 at 4:39 p.m., revealed that the tube feeding remained on hold.-The 1/28/26 and 1/29/26 nursing progress notes did not indicate why the tube feeding was on hold. A review of a nursing progress note, dated 1/29/26 at 1:07 p.m., revealed the physician was notified that the resident’s tube feed order was not administered per the order on 1/28/26. The physician gave orders to continue tomonitor the resident and report any changes in condition. Review of the February 2026 CPO revealed the following physician’s order:Continuous Isosource 1.5 (or equivalent- Jevity 1.2) via G-tube at 75 milliliters per hour (ml/hr) for 18 hours. Start at 6:00 a.m. and run until midnight or until total volume of 1350 ml is reached ordered 2/3/26. V. Staff interviewsLPN #1 was interviewed on 2/4/26 at 3:47 p.m. LPN #1 said he had not experienced issues with insufficient medical supplies to complete resident care tasks and said certified nurse aides (CNA) had not reported running out of supplies. LPN #1 said when supplies were unavailable, staff were expected to contact the pharmacy or obtain supplies from central supply and said in an emergency, staff could obtain needed supplies from a local store. LPN #1 said tube feedings could be held for showers or medical procedures but said a physician order was required to hold or restart tube feeding. The DON was interviewed on 2/5/26 at 11:00 a.m. She said RN #3 did not hang the tube feeding that was due at 4:00 p.m. on 1/28/26 and passed that information to RN #4. She said RN #4 followed RN #3’s direction to hold the tube feeding. She said on the morning of 1/29/26 at about 8:50 a.m., while she was at the nurses’ station, RN #1 informed her that Resident #11 did not receive his nutrition because RN #3 had told RN #1 the tube feeding was on hold due to no supply of formula available in the building. The DON said she had spoken with the ADON on the morning of 1/28/26 regarding running low on formula, however, there was still 1,000 ml of formula in the building and staff were directed how to obtain it. She said after the event they took measures to ensure the resident maintained adequate nutritional intake, including obtaining a new order for an alternate formula that was available at the facility. She said if staff believed tube feeding cannot be administered due to lack of supplies, they are expected to notify the supply coordinator and the DON. She said the supply coordinator typically placed orders on Monday with expected delivery the next day on Tuesday, however, that week the supplies were not received until Wednesday for an unknown reason. The DON said the required process for handoff communication between shifts was for the nurse giving report to verbally communicated to the next shift and ensured orders were in place. She said she would never tell staff to hold orders and would ensure alternate orders were obtained to maintain continuity of care. She said when tube feeding was not administered as ordered, the physician and power of attorney would be notified. The DON said after the event they ordered laboratory tests for monitoring and results were within normal limits. She said they notified the physician and the physician was not concerned and did not give new orders. She said the laboratory results drawn on 1/29/26 were similar to those obtained on 1/6/26. She said the resident remained at baseline after the event and did not observe distress or behaviors. The DON said it was important for the resident to receive his tube feeding without lapse because he was nothing by mouth and received his nutrition and fluids through tube feeding and if he did not receive it, it could lead to dehydration or weight loss. She said a performance improvement plan was implemented in which a nurse manager audited and ensured supplies were available daily and on Fridays verified there were adequate supplies for the weekend and notified the DON if supplies were low. She said only the physician could hold a tube feeding and she expected the nurses to know this. The supply coordinator was interviewed on 2/5/26 at 12:05 p.m. She said she had worked at the facility for a little over one month. She said her first day of training was on 12/27/25 and she began working as a full time employee the first week of January 2026. She said she prepared the supply orders on 1/26/26 at 12:30 p.m. and the NHA submitted the order on 1/26/26. The supply coordinator said to avoid running out of tube feeding supplies, contingency plans were in place when scheduled deliveries were delayed, such as ordering extra supplies or borrowing from sister facilities. She said staff notified her either verbally or by leaving notes when they were running low on supplies, and she reviewed those daily and would place an order immediately. She said as long as the order was placed before 12:30 p.m., they expect delivery the next business day. The NHA was interviewed on 2/5/26 at 12:50 p.m. She said that Resident #11 was traditionally on Isosource 1.5 and on 1/28/26 the facility did not have Isosource 1.5 available but had Isosource 1.2 available, and the nurse did not hang the tube feeding. She said the nurse was provided information on the morning of 1/28/26 that the next shipment would be delivered between 10:00 a.m. and 2:00 p.m. The NHA said the facility had a system in place to ensure tube feeding supplies were available at all times by completing a sweep of the facility to locate supplies, maintained an additional supply room with extra stock, and if those resources were exhausted, reaching out to sister facilities that carried the same formulas. LPN #2 was interviewed on 2/9/26 at 10:41 a.m. She said she obtained tube feeding formula from the storage room located at each nurse’s station and, if none was available, she checked the central supply. She said if no formula was available, she would check other halls and notified her manager, and if after hours, contacted the on-call nurse for assistance. LPN #2 said she received education approximately two weeks ago regarding tube feeding, which included ensuring residents received the correct formula at the correct rate and notified the physician or pharmacy if she noticed inconsistencies in orders. She said when caring for a resident receiving tube feeding, she was expected to communicate with the previous nurse, reviewed progress notes, ensured the feeding was running as scheduled, checked residuals and notify the provider if residuals are greater than 250 ml. LPN #2 said if a nurse told her the order was on hold, she would ask the reason, document it, and contact the DON, pharmacy or the NHA for clarification. She said she would place tube feeding on hold and not hang it only if there was an order to hold or if the resident showed signs of abdominal discomfort, and she would notify the provider immediately. LPN #2 said two weeks ago there were prior supply issues in which limited formula was available and staff coordinated splitting available formula to ensure residents received their feedings. She said she checked the MAR and physician’s orders to determine the correct formula and rate. She said she would feel hungry and neglected if she missed getting her meals. LPN #2 said when caring for a resident who did not receive tube feeding, she would contact the physician to determine the reason and notify the DON, and if after hours, she would notify the on-call nurse. She said a tube feeding order could be placed on hold if there was a physician’s order, and if residual was above 250 ml then she would have called the physician for verification. LPN #2 said they had not had supply issues with residents who received tube feeding. She said the physician determined the type of formula and if an alternative formula had fewer calories, the physician would have determined the appropriate run rate. RN #2 was interviewed on 2/9/26 at 11:12 a.m. She said approximately two weeks ago she completed education related to tube feeding which included verifying flush rates, confirming tube placement, ensuring the correct resident and administering at the correct time. RN #2 said the dietary department or the physician determined the type of formula. She said if a resident required Isosource 1.5 and the facility only had Jevity 1.2 available, which would create a caloric deficit, she would speak with the RD to ensure the resident’s nutritionalneeds were met. She said she would also consult theRD if a resident receiving Isosource 1.5 was diabetic or experiencing weight gain. RN #2 said if staff were unable to locate formula in the facility after checking available supplies, she would involve leadership including the DON, NHA and charge nurses to obtain formula from nearby sister facilities, and they did not allow a resident to go without tube feeding. The NHA, DON and ADON were interviewed together on 2/9/26 at 1:30 p.m. The NHA said the facility was not notified that Resident #11’s tube feeding formula was out. The NHA said on 1/28/26 the facility received the Jevity 1.5 from their shipment. She said the facility identified that it did not have enough Jevity 1.5 available. She said the facility obtained Jevity 1.2 from a sister facility and had the physician’s orders updated to run Jevity 1.2 as a substitute.-However, the facility did not provide the resident with any enteral nutrition the night of 1/28/26. The NHA said the vendor dropped off the facility’s order at the front of the building and with the housekeeping department. She said she thought the facility’s central supply staff was notified of the delivery. The ADON said she told the nurses in the morning on 1/28/26 that the tube feeding formula would be delivered that day. The DON said Resident #11 had a 4:00 p.m. start on the day the order was placed on hold. The DON said she spoke to the nurses who worked on the women’s side of the facility. She said the nurses confirmed the tube feeding formula was available but was stored in the basement. She said the nurses went to the basement and retrieved the formula. The DON said once the LPN #2, who started at 6:00 a.m., received notification, LPN #2 called the physician to restart the tube feeding so the resident could receive nutrition. She said the physician provided orders for laboratory tests and to obtain the resident’s weight. The DON said that even a late start for a tube feeding was better than not starting the tube feeding at all. The DON said she spoke with the resident’s wife and updated her on the resident’s tube feeding status.

Based on observations, record review and interviews, the facility failed to ensure two (#5 and #2) of seven residents reviewed for accidents out of 22 sample residents received adequate supervision to prevent accidents. Resident #5 was admitted on 2/22/23 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, vascular dementia, unspecified severity, with other behavioral disturbance and unspecified symptoms and signs involving cognitive functions and awareness. Resident #5 was identified as a high fall risk. On 12/25/25, Resident #5 sustained an unwitnessed fall. On 12/29/25, the resident sustained an additional unwitnessed fall. The facility recommended implementing a communication board due to the resident’s difficult communication. However, observations during the survey revealed the staff did not utilize the communication board. Resident #5 sustained an additional fall on 1/1/26, where she hit the back of her head. The resident was transferred to the hospital and received five stitches to the back of her head. Upon return from the hospital, the physician documented the staff were ordering a low bed to help prevent falls. However, observations revealed the resident’s bed was not in the low position. The resident sustained an additional fall on 1/19/26. Specifically, the facility failed to:-Ensure person centered fall interventions were consistently implemented for Resident #5, who sustained multiple falls;-Ensure person centered fall interventions were implemented for Resident #2. Findings include: I. Facility policy and procedureThe Fall prevention program policy, dated 12/1/25, was provided by the nursing home administrator (NHA) on 2/5/26 at 2:38 p.m. It revealed in pertinent part, “Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.“The facility utilizes a standardized risk assessment for determining a resident’s fall risk. a. The risk assessment categorizes residents according to low, moderate, or high risk. b. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment.“Low/Moderate Risk Protocols:a. Implement universal environmental interventions that decrease the risk of resident falling,including, but not limited to:i. A clear pathway to the bathroom and bedroom doors.ii. The bed is locked and lowered to a level that allows the resident’s feet to be flat on the floor when the resident is sitting on the edge of the bed.iii. Call light and frequently used items are within reach.iv. Adequate lighting.v. Wheelchairs and assistive devices are in good repair.b. Implement routine rounding schedule.c. Monitor for changes in resident’s cognition, gait, ability to rise/sit, and balance.d. Encourage residents to wear shoes or slippers with non-slip soles when ambulating.e. Ensure eye glasses, if applicable, are clean and the resident wears them when ambulating.f. Monitor vital signs in accordance with facility policy.g. Complete a fall risk assessment every 90 days and as indicated when the resident’s condition changes.“High Risk Protocols:a. The resident will be placed on the facility’s Fall Prevention Program.i. Indicate fall risk on care plan.b. Implement interventions from Low/Moderate Risk Protocols.c. Provide interventions that address unique risk factors measured by the risk assessment tool:medications, psychological, cognitive status, or recent change in functional status.d. Provide additional interventions as directed by the resident’s assessment, including but not limited to:i. Assistive devicesii. Increased frequency of roundsiii. Sitter, if indicatediv. Medication regimen reviewv. Low bedvi. Alternate call system accessvii. Scheduled ambulation or toileting assistanceviii. Family/caregiver or resident educationix. Therapy services referral“Each resident’s risk factors and environmental hazards will be evaluated when developing theresident’s comprehensive plan of care.a. Interventions will be monitored for effectiveness.b. The plan of care will be revised as needed.“When any resident experiences a fall, the facility will:a. Assess the resident.b. Complete a post-fall assessment.c. Complete an incident report.d. Notify the physician and family.e. Review the resident’s care plan and update as indicated.f. Document all assessments and actions.g. Obtain witness statements in the case of injury.”II. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on 2/22/23. According to the February 2026 computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, vascular dementia, unspecified severity, with other behavioral disturbance, and unspecified symptoms and signs involving cognitive functions and awareness. The 2/2/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for a mental status score of zero out of 15. She required partial/moderate assistance with activities of daily living (ADL). The MDS assessment revealed the resident exhibited wandering behaviors on one to three days during the assessment look-back period. The MDS assessment revealed the resident had two or more falls without injury and one fall with injury since her time of admission to the facility. B. ObservationsDuring a continuous observation on 2/5/26, starting at 12:15 p.m. and ending at 1:02 p.m., the following were observed:At 12:15 p.m. Resident #5 was assisted to her room from lunch, and assisted to her bed. Resident #5 was left sitting on the side of her bed with her call light in reach. Resident #5 was not wearing a helmet during the observation. At 12:22 p.m. Resident #5 began to stand up and reach out for the blanket that was in her wheelchair. Resident #5 sat back down on the edge of the bed and placed the blanket on her bed. Resident #5 stood back up from the bed and reached out for her bedside table that was not within reach of her. Resident #5 sat back down on the edge of the bed and began to unlock the brakes on her wheelchair that was placed in front of her. Resident #5 stood up from the bed and placed one hand on her transfer pole while using her free hand to continue to unlock the wheelchair. Resident #5 was unstable on her feet. At 12:25 p.m. licensed practical nurse (LPN) #4 was prompted that Resident #5 was walking without assistance. LPN #4 entered Resident #5’s room and assisted her to the bathroom. LPN #4 placed Resident #5’s wheelchair in the doorway of the bathroom and told Resident #5 to call when she was done on the toilet. LPN #4 exited the room and did not return. Facility staff congregated in the hall near the nurses station, however no one came back to check on Resident #5. At 12:32 p.m. Resident #5 did not push her call light for assistance Resident #5 self transferred from the toilet to her wheelchair and began backing herself out of the bathroom getting her wheelchair stuck on the transfer pole in her room. At 12:46 p.m. Resident #5 self propelled to the bathroom and self transferred from the wheelchair to the toilet. Facility staff were sitting at the nurses’ station and talking with each other in the hallway. At 12:54 p.m. Resident #5 self transferred from the toilet back to her wheelchair and continued to self propel out into the hallway. At 1:02 p.m. Resident #5 was assisted back to her room, where staff left Resident #5 sitting in the middle of her room. Resident #5 self propelled back out into the hallway. On 2/9/26 at 9:32 a.m. Resident #5 was sitting in her wheelchair in the hallway by the nurses’ station. Resident #5 began to stand up from her wheelchair. LPN #3 intervened and asked Resident #5 if she would like to take a shower. Resident #5 agreed to the shower and attended activities after. C. Record review 1. Care plan The fall care plan, revised on 11/27/24, identified Resident #5 was a high risk for falls related to a history of frequent falls, impaired safety awareness, left sided weakness secondary to history of a cerebrovascular accident (stroke), seizure disorder and medication use. Pertinent interventions (revised on 12/1/25) included placing anti-rollbacks to the resident’s wheelchair, applying anti tippers to the resident’s wheelchair, applying grip tape and bright pink reflective tape to restroom floor, apply grip tape next to bed to help prevent falls/injuries, assisting Resident #5 with toileting every two hours for fall prevention, giving Resident #5 a soft touch call light to make it easier for her to call for assistance, ordering a helmet to try and prevent injury with future falls and moving the resident's room closer to nurses’ station to increase line of sight. The fall care plan, revised on 11/27/24, identified Resident #5 had sustained multiple falls prior to her long term care stay and during her stay related to poor safety awareness, unsteady gait, impulsivity, and poor cognition. The care plan documented Resident #5 falls were unavoidable. Pertinent interventions (revised on 1/2/26) included placing belongings within reach of Resident #5.-However during observations revealed person centered fall interventions were not consistently implemented for Resident #5 (see observations above). 2. Fall on 12/25/25 - unwitnessedThe 12/25/25 nursing progress note documented at 10:50 a.m. revealed Resident #5 had an unwitnessed fall. Staff heard a noise from Resident #5’s room and immediately responded. Resident #5 was found on the floor next to her bedside and wheelchair. Resident #5 was assessed and assisted from the floor. No injuries noted. 3. Falls on 12/29/25 - unwitnessed The 12/29/25 nursing progress note documented at 12:11 p.m. revealed the nurse was notified that Resident #5 had fallen in the bathroom while brushing her hair. The note documented no injuries were noted. The 12/29/25 nursing progress note documented at 6:03 p.m. revealed the nurse made aware that Resident #5 was found by a certified nurse aide (CNA). Resident #5’s wheelchair was at the door of the bathroom. Resident #5 was on the floor at the sink on her left side attempting to get up independently. No injuries were noted. The 12/30/25 interdisciplinary team (IDT) progress note was documented at 10:04 a.m. revealed the IDT met to discuss Resident #5’s fall on 12/29/25. A new intervention was put in place to use a communication board to aide in providing care for Resident #5’s basic needs in attempt to decrease Resident #5’s frustration while trying to communicate her needs. Resident #5 became angry when staff was unable to understand Resident #5. The note documented Resident #5 would get up out of her wheelchair and attempt to ambulate while being unsteady. Resident #5’s care plan was reviewed and updated. -However during observations made on 2/5/26 staff were not observed using a communication board with Resident #5 (see observations above). 4. Fall on 1/1/26 - unwitnessed The 1/1/26 nursing progress noted documented at 6:31 a.m. revealed Resident #5 was found sitting on the floor in her room at 4:30 a.m. Resident #5 was attempting to get out of bed for a drink of water and slipped. Resident #5 was wearing regular socks. The note documented the resident may need non-skid footwear while in bed. Resident #5’s tray table was moved closer to Resident #5’s bedside. Resident #5 was kept in the common area for better visualization until she requested to go back to bed. The 1/2/26 nursing progress note documented at 1:10 a.m. was struck out in error but revealed Resident #5 had an unwitnessed fall with injury. Staff heard a loud noise coming from Resident #5’s room. Resident #5 was found on her hands and knees in front of the bathroom door. Resident #5 was wearing proper footwear. The note documented the resident was transferring without her wheelchair and without staff assistance. The note documented blood was observed dripping from Resident #5’s chin. A laceration was identified on the right backside of Resident #5’s head. The registered nurse (RN) was notified to perform an assessment and emergency services were notified. The 1/2/26 nursing progress note documented at 3:20 a.m. revealed Resident #5 returned to the facility from the hospital after receiving five stitches to the laceration. Resident #5 was alert and oriented to the room. The 1/2/26 hospital summary revealed Resident #5 was treated for head injury involving a laceration that required stitches or staples. The 1/7/26 physician’s progress note documented Resident #5 had repeated falls. The note documented the staff were ordering the resident a low bed. The resident denied pain. The note documented the staff reported agitation and most of the resident’s falls occurred when she was attempting to use the bathroom. The note documented the hospice nurse indicated the resident was constipated and a laxative was ordered. -However, observations revealed the resident’s bed was not in a low position (see observations above). 5. Fall on 1/19/26 - unwitnessed The 1/19/26 nursing progress note documented at 12:06 a.m. revealed the nurse heard a loud thud and found Resident #5 sitting on the floor in her room next to the bed and her wheelchair. Resident #5 got herself into her wheelchair and declined to be assessed. Resident #5 continued to assist herself to the bathroom. The nurse provided a stand by assist while Resident #5 toileted. Resident #5 continued to deny the physical assessment. No injuries were observed. Neurological checks were implemented. D. Staff interviewsCNA #4 was interviewed on 2/9/26 at 9:45 a.m. CNA #4 said she used the Kardex (staff directive tool) to determine if a resident was at risk for falls. CNA #4 said fall interventions were also included on the Kardex. CNA #4 said good practice in general for anyone who was at a high fall risk was to ensure she was rounding timely. CNA #4 said she typically rounded every hour unless specified. CNA #4 said if she found a resident on the floor she would ensure the resident was safe and then notify the nurse immediately. CNA #4 said they then began 15-minute vital sign checks and documented them. CNA #4 said if the vital signs were not within normal limits, she would notify the nurse immediately. LPN #3 was interviewed on 2/9/26 at 10:30 a.m. LPN #3 said she gave Resident #5 activities to do, including a fidget board that she can play with or watching movies in her room. LPN #3 said Resident #5 could tell the staff what movie she wanted to watch. LPN #3 said Resident #5 also attended activities and the hospice staff came every other day. LPN #3 said hospice staff would l provide one-to-one with Resident #3 for up to three hours. LPN #3 said Resident #5 also enjoyed taking showers. LPN #3 said the showers helped relax Resident #5, however LPN #3 said Resident #5 was a private person so she also did not like to be watched especially when she was in the bathroom. LPN #3 said Resident #5 was capable of standing on her own, but was not stable enough to walk. LPN #3 said Resident #5 could show signs of aggression by reaching for the staff's ID badge or reaching for the staff's hair. LPN #3 said when a resident fell, the nurse would assess the resident and then notify family, provider. She said since Resident #5, she would also contact the hospice staff to inform them of the fall. LPN #3 said she would assess the residents vital signs and if the fall was unwitnessed she would begin a neurological assessments. The director of nursing (DON) was interviewed on 2/9/26 at 12:33 p.m. The DON said the facility would implement a plan to ensure Resident #5 was not left alone while toileting. The NHA and the DON were interviewed together on 2/9/26 at 3:04 p.m. The NHA said the staff needed to do more training on purposeful rounding. She said purposeful rounding would be beneficial in regards to the high amount of falls in the facility. The DON said getting ahead of the residents' needs before they tried to do things on their own would help reduce the amount of falls. The DON said in order to tell if an intervention was successful the DON said a big portion would be through feedback from the nursing staff. The NHA said they also discussed falls during their team leadership rounds, after morning meetings, and during each shift change a huddle at each nurses’ station to be able to provide training. III. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on 10/17/23. According to the February 2026 CPO, diagnoses included dementia, protein-calorie malnutrition and a history of falling. The 1/15/26 MDS assessment documented the resident was severely cognitively impaired with a BIMS score of zero out of 15. The resident required substantial/maximum assistance for chair to bed or bed to chair transfers, partial/moderate assistance for dressing including footwear, hygiene and bed mobility, and set up assistance at meals. The assessment documented the resident had a fall with injury and did not refuse care. B. ObservationsOn 2/4/26 a continuous observation was conducted from 2:36 p.m. to 3:40 p.m. At 2:36 p.m. Resident #2 was in bed in her room. The resident's wheelchair was next to her bed. The resident remained in bed until 3:40 p.m. A fall mat was not placed next to the bed while the resident was in bed and the bed was not in the lowest position. The fall mat was folded in half next to the wall in the residents’s room. On 2/5/26 Resident at 11:15 a.m. Resident #2 was observed in her room in her wheelchair sitting next to her bed. Resident #2 self transferred from her wheelchair into her bed, leaving the wheelchair at her bedside. The resident’s red locking pedal under the bed was up and the green pedal was down. On 2/5/26 at 11:30 p.m. the resident remained in bed. A fall mat was not on the floor next to the resident's bed. On 2/5/26 at 11:54 p.m. the resident remained in bed. A fall mat was not on the floor next to the resident’s bed. On 2/5/26 at 12:13 p.m. an unidentified staff member entered Resident #2’s room. The unidentified staff member looked at Resident #2, asked where the resident’s roommate was and then exited the room. The unidentified staff member did not place a fall mat next to the resident's bed, or ensure the resident’s bed was in a locked position (see CNA #2 interview below). On 2/5/26 at 12:30 p.m. Resident #2 remained in her bed. There was no fall mat on the floor by the bed and the bed remained in an unlocked position. On 2/9/26 at 10:17 a.m. Resident #2 was observed sitting in her wheelchair in her room. The resident had on regular socks and no shoes. The resident’s red locking pedal under the bed was up and the green pedal was down. (see CNA #2 interview below). C. Record reviewResident #2’s care plan, revised 1/15/25, documented the resident was at moderate risk for falls as related to her poor safety awareness secondary to dementia disease progression. Pertinent interventions included to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed and the resident needed prompt response to all requests for assistance (10/18/23); provide the resident with tennis shoes to help with ambulation (12/18/23); provide the resident wheelchair education to lock brakes prior to self transfer (revised 12/01/25); the resident was able to transfer independently, however, benefited from contact guard assist (CGA) to promote safety as she allowed (revised 12/01/25). Additional fall interventions added after the resident’s fall on 12/31/26 included to ensure the resident had proper footwear (1/2/26), a fall mat to be placed when the resident was in bed (1/12/26) and for the bed to be in the lowest position (1/20/26).-The resident’s care plan did not document the resident refused care planned interventions for falls. A reviewof the resident’s progress notes revealed the resident's sustained falls on 12/28/25, 12/31/25, 1/10/26 and 1/20/26:A 12/28/25 nursing progress note documented at 4:20 a.m. the nurse was notified at 4:15 a.m. that the resident stated that she had fallen. The resident claimed to have fallen on her bottom after returning to her bed from using the restroom. The resident stated that she had used the walker to transfer herself, and the resident was noted to be wearing non-slip socks. The resident stated she had pain in her left leg. A 12/29/25 nursing note at documented 7:08 a.m the resident had Xrays that showed moderately displaced fractures of the right superior and inferior pubic rami (pelvis). No dislocation was identified. There were moderate degenerative changes and bones were osteopenic. The physician was notified and orders were placed to send the resident to the ED.A 12/29/25 nursing progress note documented at 3:41 p.m. the facility received a call from the hospital that stated the resident received pelvis imaging and only found old fractures, no new fractures were identified. A 12/31/25 nursing progress note documented at 11:50 a.m. that the resident was found on the floor. A post-fall assessment was completed. There were no obvious deformities noted to any extremities. A neurological assessment was performed and the resident noted to be at her baseline. When asked if she struck her head, the resident shook her head “no.” The resident was observed yelling out in pain and guarding right hip and the nurse practitioner (NP) at the resident's bedside to complete an assessment. New orders were received to transfer the resident to the emergency department for further evaluation and to rule out an injury to the right hip. A 1/1/26 nursing progress note documented at 12:19 a.m. that the resident returned from the hospital at 6:35 p.m. via a stretcher with a diagnosis of hypokalemia, a stable pelvic fracture and weight bearing as tolerated. A 1/10/26 nursing progress note documented at 2:20 a.m. the resident was assessed for a fall with head involvement. The resident was observed while still on the floor and her baseline physical and cognitive function was intact. There were no new limb deformities, bruising or bleeding. A small hematoma was noted at the back of the head. No spinal tenderness was noted but the resident endorsed pain. A 1/10/26 nursing progress note documented at 2:30 a.m. that a CNA opened the door to the residents room to answer a call light at 2:15 a.m. and observed the resident fall out of bed onto her head. A RN assessed the resident. A hematoma was noted to the back of the resident’s head, and her right shin had a small skin tear with bruising. The nurse practitioner (NP) was notified with a recommendation to follow up with imaging later in the morning as the resident declined to go to the hospital. A 1/10/26 nursing progress note documented 4:35 a.m. an intervention was implemented to place a fall mat at the resident’s bedside while the resident was in bed. A 1/10/26 nursing progress note documented at 11:40 p.m. the nurse assessed the resident and the resident’s pupil response was non-reactive and the resident was unable to follow commands. The resident was observed to have altered mental status, the physician was notified and an order was placed to have the resident sent to the emergency department for further evaluation.-The nursing progress notes failed to document the date the resident returned to the facility or results of the emergency department evaluation. A 1/20/26 nurses note documented at 3:14 a.m. the staff heard the resident calling out and observed the resident sitting on her bottom on a fall mat next to her bed. The resident reported she was trying to roll over and get into a better position and rolled out of bed. The resident denied hitting her head and denied pain. The resident was assessed by an RN. An immediate intervention to replace the resident's bed with a high/low bed that lowered to thefloor was implemented. D. Staff interviewsCNA #2 was interviewed on 2/9/26 at 10:18 a.m. CNA #2 said when the green pedal on a resident’s bed was pushed down the bed was not locked. CNA #2 said Resident #2’s bed should be locked. -CNA #2 then used her food to push down on the red pedal under the bed to lock the bed. The DON, the NHA and regional clinical resource #2 were interviewed together on 2/9/26 at 3:05 p.m. The DON said Resident #2 could answer yes and no questions and was able to state her needs. The DON said the resident had a fall mat added to her care plan but did not know the resident self transferred and did not remember the self transfers being part of the facility’s IDT discussion for Resident #2’s falls. Regional clinical resource #2 said the facility did review Resident #2’s falls and her care plan including her fall mat intervention and talked further on 2/9/26 about Resident #2. The NHA said she did not know if the Resident #2’s bed was checked and locked at the time of the resident’s fall (on 12/31/25). Regional clinical resource #2 said the facility staff checked all the beds in the facility on 2/9/26 to ensure the beds were locked. She said the ordered a new bed from hospice for Resident #2 that included a specialty mattress and a remote control. She said the staff assisted Resident #2 in putting on non-skid socks in the morning (2/9/26 after the resident was observed without appropriate footwear per the resident’s care planned interventions). She said Resident #2 used contact guard assist in her care plan to assist and was able to transfer by herself. The DON said when the facility did fall investigations, if the staff were unable to gather the needed information from the fall reports they further discussed the resident’s falls with the staff during their daily meetings. The DON said the facility had provided education to the staff on purposeful rounding of the residents with the staff to look for improvement on getting ahead of residents needs before the residents tried to do things on their own. The DON said staff feedback was a good portion of the fall interventions and they discussed as a team if a fall intervention was not working.

Based on record review and interviews, the facility failed to ensure two (#1 and #10) of four residents reviewed, out of a total sample of 22 residents, remained free of significant medication errors. Specifically, the facility failed to:-Ensure staff timely and accurately updated Resident #1’s Methadone dose and indicated use in his electronic medical record (EMR) per external provider orders; -Ensure staff accurately administered and documented the dose of Methadone Resident #1 received in his medication administration record (MAR); -Ensure staff implemented and documented care interventions to identify, assess, monitor, or treat Resident #1’s specific triggering/craving behaviors related to his documented history of substance use disorder (SUD); -Ensure staff obtained a standing order to administer Narcan to Resident #1, who had a history of SUD and was currently prescribed opioid medications; and,-Ensure Resident #10’s antibiotic was administered per the provider’s order. Cross-reference F842: the facility failed to ensure staff maintained a complete and accurate medical record. A. Resident #10 status Resident #10, age less than 65, was admitted on 8/27/20. According to the February 2026 CPO, the diagnoses included neuronal ceroid lipofuscinosis (the accumulation of auto fluorescent lipopigment in neurons, leading to vision loss, seizures, cognitive decline, motor skill loss, and frequently, a shortened lifespan), pervasive developmental disorder unspecified, acute respiratory failure with hypoxia, and personal history of pneumonia (recurrent). The 10/30/25 MDS assessment revealed the resident had short term and long term memory impairment and had moderate impairment in making daily decisions. The resident was unable to recall the current season, staff’s names or faces, or where her room was located. She was completely dependent on staff for all activities of daily living (ADLs). B. Record reviewThe December 2025 MAR revealed the physician ordered Doxycycline Hyclate tablet 100 mg by mouth two times a day for an infection. Ordered on 12/24/25 and discontinued on 12/31/25. However, blanks on the MAR revealed Resident #10 did not receive the medication on the evening shift on 12/24/25 and the morning shift on 12/25/25. The evening shift on 12/25/25 documented a “9”, which indicated there was a corresponding progress note.-However the resident’s EMR did not include a progress note to provide an explanation as to why Resident #10 was not administered the medicationThe 12/26/25 nursing progress note documented at 1:12 a.m. revealed the antibiotic had not arrived from the pharmacy, however the MAR documented the medication was administered even though it had not arrived from the pharmacy. The 12/26/25 nursing progress note documented at 4:48 p.m. revealed Resident #10 was on continued monitoring for the start of doxycycline. C. Staff interviewsLPN #3 was interviewed on 2/4/26 at 12:47 p.m. LPN #3 said the administration of medications was documented on the MAR. She said she was unsure if blank boxes on the MAR meant the resident was not administered a medication. The DON was interviewed on 2/4/25 at 1:13 p.m. The DON said the blank spaces on the MAR indicated that the medication was not administered to the resident. She confirmed Resident #10 was not administered doxycycline on the days which had a corresponding black space on the December 2025 MAR. The DON said Resident #10’s medical record did not contain a progress note on the evening shift on 12/25/25 indicating the reason the resident was not administered doxycycline. The DON said the medication was delivered from the pharmacy on 12/26/25 and was administered on 12/26/25. She confirmed Resident #10 did not receive three doses of doxycycline.

Based on record review and interviews, the facility failed to maintain accurate and complete medical records for one resident (#1), of four residents reviewed out of a sample of 22 residents. Specifically, the facility failed to ensure Resident #1’s addiction provider notes were obtained and uploaded into the resident’s electronic medical record (EMR). Findings include:I. Facility policy and procedureThe Documentation In Medical Record policy and procedure, dated 12/1/25, was provided by the nursing home administrator (NHA) on 2/5/26 at 3:07 p.m. It read in pertinent part:“Policy: Each resident’s medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident’s progress through complete, accurate, and timely documentation.”II. Resident statusResident #1, age less than 65, was admitted on 8/18/25. According to the February 2026 computerized physician orders (CPO), the diagnoses included displaced fracture of fifth cervical (neck) vertebrae, functional quadriplegia (paralysis), post traumatic stress disorder (PTSD), schizophrenia, chronic pain due to trauma, and neuromuscular dysfunction of bladder. The 11/18/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He required partial assistance with bed mobility and transfers. He required substantial assistance with sit to stand and toileting. transfers. B. Record reviewA review of Resident #1’s February 2026 electronic medical record (EMR) revealed no documentation regarding the resident’s visits to the addiction provider visit notes since the resident’s admission to the facility on 8/18/25. Upon request, the NHA obtained and provided addiction provider visit notes for Resident #1, on 2/4/26 at 1:28 p.m., for the dates 9/18/25, 12/18/25, and 1/27/26. The provider visit notes documented the following:The 9/18/25 addiction provider note documented Resident #1 was seen for methadone dose optimization. It documented Resident #1 was currently taking methadone 30 milligram (mg) daily. It documented Resident #1 reported intense cravings and drug dreams. It documented the treatment plan was to increase Resident #1’s methadone to 40 mg daily. The 12/18/25 addiction provider note documented Resident #1 was seen for a dose adjustment of his methadone. It documented Resident #1 reported continued cravings while taking methadone 40 mg daily. It documented the treatment plan was to increase Resident #1’s methadone to 50 mg daily. The 1/27/26 addiction provider note documented Resident #1 was seen for a dose adjustment of his methadone. It documented Resident #1 reported sedation while taking Methadone 50 mg. It documented Resident #1 requested a dose decrease. It documented the treatment plan was to decrease Resident #1’s Methadone from 50 mg to 40 mg daily. Cross-referenced to F760 failure to prevent significant medication errors. III. Staff interviewsThe director of nursing (DON) was interviewed on 2/4/26 at 11:05 a.m. The DON said if a resident’s external provider changed any orders, facility staff should fill out a physician communication form, review the orders with the resident’s primary provider, and update the resident’s EMR as needed. The DON said the facility’s health information manager ceased working at the facility on 1/26/26. The DON said she was unsure what the complete process was for reviewing external provider notes and updating the resident’s EMR.The assistant director of nursing (ADON) was interviewed on 2/4/26 at 11:14 a.m. The ADON said when residents returned from external provider visits, transportation staff would hand a copy of the physician communication form to the resident’s floor nurse, unit manager, or ADON. The ADON said the resident’s nurse or nurse managers were responsible for reviewing the orders and updating them in the EMR. The DON was interviewed on 2/5/26at 11:05 a.m. The DON said after reviewing any external provider orders and updating the resident’s EMR, the nursing staff should place communication forms into the medical records box to be uploaded in the resident’s EMR. The DON said she was unsure if there was a backlog of resident records needing to be uploaded and/or how long one had been present. The DON said it was important to maintain an accurate medical record to ensure accurate treatment and continuity of care. The DON said a potential risk of not maintaining accurate medical records was the potential for untimely updates to resident care orders, which could lead to adverse resident care outcomes.

A survey prompted by #CO2728863 was completed on 2/3/26 to 2/9/26. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure two (#5 and #2) of seven residents reviewed for accidents out of 22 sample residents received adequate supervision to prevent accidents. Resident #5 was admitted on 2/22/23 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, vascular dementia, unspecified severity, with other behavioral disturbance and unspecified symptoms and signs involving cognitive functions and awareness. Resident #5 was identified as a high fall risk. On 12/25/25, Resident #5 sustained an unwitnessed fall. On 12/29/25, the resident sustained an additional unwitnessed fall. The facility recommended implementing a communication board due to the resident’s difficult communication. However, observations during the survey revealed the staff did not utilize the communication board. Resident #5 sustained an additional fall on 1/1/26, where she hit the back of her head. The resident was transferred to the hospital and received five stitches to the back of her head. Upon return from the hospital, the physician documented the staff were ordering a low bed to help prevent falls. However, observations revealed the resident’s bed was not in the low position. The resident sustained an additional fall on 1/19/26. Specifically, the facility failed to:-Ensure person centered fall interventions were consistently implemented for Resident #5, who sustained multiple falls;-Ensure person centered fall interventions were implemented for Resident #2. III. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on 10/17/23. According to the February 2026 CPO, diagnoses included dementia, protein-calorie malnutrition and a history of falling. The 1/15/26 comprehensive assessment documented the resident was severely cognitively impaired. The resident required substantial/maximum assistance for chair to bed or bed to chair transfers, partial/moderate assistance for dressing including footwear, hygiene and bed mobility, and set up assistance at meals. The assessment documented the resident had a fall with injury and did not refuse care. B. ObservationsOn 2/4/26 a continuous observation was conducted from 2:36 p.m. to 3:40 p.m. At 2:36 p.m. Resident #2 was in bed in her room. The resident's wheelchair was next to her bed. The resident remained in bed until 3:40 p.m. A fall mat was not placed next to the bed while the resident was in bed and the bed was not in the lowest position. The fall mat was folded in half next to the wall in the resident’s room. On 2/5/26 Resident at 11:15 a.m. Resident #2 was observed in her room in her wheelchair sitting next to her bed. Resident #2 self transferred from her wheelchair into her bed, leaving the wheelchair at her bedside. The resident’s red locking pedal under the bed was up and the green pedal was down. On 2/5/26 at 11:30 p.m. the resident remained in bed. A fall mat was not on the floor next to the resident's bed. On 2/5/26 at 11:54 p.m. the resident remained in bed. A fall mat was not on the floor next to the resident’s bed. On 2/5/26 at 12:13 p.m. an unidentified staff member entered Resident #2’s room. The unidentified staff member looked at Resident #2, asked where the resident’s roommate was and then exited the room. The unidentified staff member did not place a fall mat next to the resident's bed, or ensure the resident’s bed was in a locked position (see CNA #2 interview below). On 2/5/26 at 12:30 p.m. Resident #2 remained in her bed. There was no fall mat on the floor by the bed and the bed remained in an unlocked position. On 2/9/26 at 10:17 a.m. Resident #2 was observed sitting in her wheelchair in her room. The resident had on regular socks and no shoes. The resident’s red locking pedal under the bed was up and the green pedal was down. (see CNA #2 interview below). C. Record reviewResident #2’s care plan, revised 1/15/25, documented the resident was at moderate risk for falls as related to her poor safety awareness secondary to dementia disease progression. Pertinent interventions included to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed and the resident needed prompt response to all requests for assistance (10/18/23); provide the resident with tennis shoes to help with ambulation (12/18/23); provide the resident wheelchair education to lock brakes prior to self transfer (revised 12/01/25); the resident was able to transfer independently, however, benefited from contact guard assist (CGA) to promote safety as she allowed (revised 12/01/25). Additional fall interventions added after the resident’s fall on 12/31/26 included to ensure the resident had proper footwear (1/2/26), a fall mat to be placed when the resident was in bed (1/12/26) and for the bed to be in the lowest position (1/20/26).-The resident’s care plan did not document the resident refused care planned interventions for falls. A review of the resident’s progress notes revealed the resident's sustained falls on 12/28/25, 12/31/25, 1/10/26 and 1/20/26:A 12/28/25 nursing progress note documented at 4:20 a.m. the nurse was notified at 4:15 a.m. that the resident stated that she had fallen. The resident claimed to have fallen on her bottom after returning to her bed from using the restroom. The resident stated that she had used the walker to transfer herself, and the resident was noted to be wearing non-slip socks. The resident stated she had pain in her left leg. A 12/29/25 nursing note at documented 7:08 a.m the resident had Xrays that showed moderately displaced fractures of the right superior and inferior pubic rami (pelvis). No dislocation was identified. There were moderate degenerative changes and bones were osteopenic. The physician was notified and orders were placed to send the resident to the ED.A 12/29/25 nursing progress note documented at 3:41 p.m. the facility received a call from the hospital that stated the resident received pelvis imaging and only found old fractures, no new fractures were identified. A 12/31/25 nursing progress note documented at 11:50 a.m. that the resident was found on the floor. A post-fall assessment was completed. There were no obvious deformities noted to any extremities. A neurological assessment was performed and the resident noted to be at her baseline. When asked if she struck her head, the resident shook her head “no.” The resident was observed yelling out in pain and guarding right hip and the nurse practitioner (NP) at the resident's bedside to complete an assessment. New orders were received to transfer the resident to the emergency department for further evaluation and to rule out an injury to the right hip. A 1/1/26 nursing progress note documented at 12:19 a.m. that the resident returned from the hospital at 6:35 p.m. via a stretcher with a diagnosis of hypokalemia, a stable pelvic fracture and weight bearing as tolerated. A 1/10/26 nursing progress note documented at 2:20 a.m. the resident was assessed for a fall with head involvement. The resident was observed while still on the floor and her baseline physical and cognitive function was intact. There were no new limb deformities, bruising or bleeding. A small hematoma was noted at the back of the head. No spinal tenderness was noted but the resident endorsed pain. A 1/10/26 nursing progress note documented at 2:30 a.m. that a CNA opened the door to the residents room to answer a call light at 2:15 a.m. and observed the resident fall out of bed onto her head. A RN assessed the resident. A hematoma was noted to the back of the resident’s head, and her right shin had a small skin tear with bruising. The nurse practitioner (NP) was notified with a recommendation to follow up with imaging later in the morning as the resident declined to go to the hospital. A 1/10/26 nursing progress note documented 4:35 a.m. an intervention was implemented to place a fall mat at the resident’s bedside while the resident was in bed. A 1/10/26 nursing progress note documented at 11:40 p.m. the nurse assessed the resident and the resident’s pupil response was non-reactive and the resident was unable to follow commands. The resident was observed to have altered mental status, the physician was notified and an order was placed to have the resident sent to the emergency department for further evaluation.-The nursing progress notes failed to document the date the resident returned to the facility or results of the emergency department evaluation. A 1/20/26 nurses note documented at 3:14 a.m. the staff heard the resident calling out and observed the resident sitting on her bottom on a fall mat next to her bed. The resident reported she was trying to roll over and get into a better position and rolled out of bed. The resident denied hitting her head and denied pain. The resident was assessed by an RN. An immediate intervention to replace the resident's bed with a high/low bed that lowered to the floor was implemented. D. Staff interviewsCNA #2 was interviewed on 2/9/26 at 10:18 a.m. CNA #2 said when the green pedal on a resident’s bed was pushed down the bed was not locked. CNA #2 said Resident #2’s bed should be locked. -CNA #2 then used her food to push down on the red pedal under the bed to lock the bed. The DON, the NHA and regional clinical resource #2 were interviewed together on 2/9/26 at 3:05 p.m. The DON said Resident #2 could answer yes and no questions and was able to state her needs. The DON said the resident had a fall mat added to her care plan but did not know the resident self transferred and did not remember the self transfers being part of the facility’s IDT discussion for Resident #2’s falls. Regional clinical resource #2 said the facility did review Resident #2’s falls and her care plan including her fall mat intervention and talked further on 2/9/26 about Resident #2. The NHA said she did not know if the Resident #2’s bed was checked and locked at the time of the resident’s fall (on 12/31/25). Regional clinical resource #2 said the facility staff checked all the beds in the facility on 2/9/26 to ensure the beds were locked. She said the ordered a new bed from hospice for Resident #2 that included a specialty mattress and a remote control. She said the staff assisted Resident #2 in putting on non-skid socks in the morning (2/9/26 after the resident was observed without appropriate footwear per the resident’s care planned interventions). She said Resident #2 used contact guard assist in her care plan to assist and was able to transfer by herself. The DON said when the facility did fall investigations, if the staff were unable to gather the needed information from the fall reports they further discussed the resident’s falls with the staff during their daily meetings. The DON said the facility had provided education to the staff on purposeful rounding of the residents with the staff to look for improvement on getting ahead of residents needs before the residents tried to do things on their own. The DON said staff feedback was a good portion of the fall interventions and they discussed as a team if a fall intervention was not working.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 5. S923 Drug reactions and significant medication errors shall be reported within 30 minutes to the resident's practitioner. A call to the practitioner's office or answering service does not meet the facility's responsibility to provide emergency care. The resident's condition shall be monitored for 72 hours and observations documented in the health information record. S1704 A completed health information record shall be maintained on every resident from the time of admission through the time of discharge. 1) Identification and summary sheet includes: a) Resident's legal name, preferred name; b) Name, address and phone number of attending physician; c) Name of medical power of attorney, next of kin; d) Date and time of admission and discharge; e) Place admitted from and discharge to; and f) Admitting diagnoses, final diagnoses. 2) Medical data includes: a) Past medical history; b) Advanced directives; c) Documentation of an initial comprehensive physician visit within 30 days of admission and re-admission; d) Informed consents; e) Practitioner orders of all medications, treatment, diet, restorative and special procedures; f) Reports of any special examinations; g) Reports of consultations; h) Reports from all consulting persons and agencies; i) Reports of special treatments; j) Hospice, dialysis, ulcer and/or wound care; k) Dental reports; l) Treatment and progress notes written and signed by the practitioner; m) Hospital discharge summary sheet; n) Care plans; o) Interdisciplinary discharge summaries; p) Physician discharge summary; q) Transfer records; and r) When applicable, mortician receipt of body. 3) Plans and notes of the social service and resident engagement; 4) Nutritional assessments and progress notes; 5) Documentation of accidents or incidents; 6) Nursing records, dated and signed by nursing personnel.

A survey for Incident #2626348 was conducted 10/22/25 and 10/23/25. No deficiencies were cited.

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

One (1) story, Type V(111) construction. A Comparative Federal Monitoring Survey was conducted on 7/29/25, following a State Agency Annual Survey on 6/24/25, in accordance with Title 42, Code of Federal Regulations, 483.73 et seq. (Emergency Preparedness). During this Comparative Federal Monitoring Survey, the facility was found to be in compliance with Title 42, Code of Federal Regulations, 483.73 et seq. (Emergency Preparedness).

One (1) story, Type V(111) construction. A Comparative Federal Monitoring Survey was conducted on 7/29/25, following a State Agency Annual Survey on 6/24/25, in accordance with Title 42, Code of Federal Regulations, 483.90 (a) et seq. (Life Safety from Fire). During this Comparative Federal Monitoring Survey, the facility was found not to be in compliance with Title 42, Code of Federal Regulations, 483.90 (a) et seq. (Life Safety from Fire).

Based on observation and interview, the facility failed to maintain the resident room doors. The deficient practice affected 26 residents. The facility had a capacity for 103 beds with a census of 88 on the day of the survey. Observation during the building inspection tour, at 9:30 a.m., revealed the door of resident room 2 failed to latch. An interview with the Director of Maintenance confirmed this deficiency. The census of 86 was verified by the facility. The findings were acknowledged by the Administrator and Director of Maintenance during the exit interview.

Based on observation and interview, the facility failed to provide an approved automatic sprinkler system throughout. The deficient practice affected approximately 5 residents. The facility had a capacity for 103 beds with a census of 88 on the day of the survey. Observation during the building inspection tour, at 10:00 a.m., revealed closet located in the oxygen transfer room did not have sprinkler coverage. An interview, at 10:02 a.m., with the Maintenance Director revealed facility was not aware of this deficiency. The census of 88 was verified by the Administrator. The findings were acknowledged by the Administrator and the Maintenance Director during the exit interview.

Based on record review and interview, the facility failed to conduct fire drills at least quarterly on each shift. The deficient practice potentially affected all residents. The facility had a capacity for 103 beds with a census of 88 on the day of the survey. Record review of fire drills, at 11:50 a.m., revealed no documentation for the required fire drills listed below:2. shift / 2. quarter of 2025 An interview with the Maintenance Director revealed that the facility already corrected this deficiency. The census of 88 was verified by the Administrator. The findings were acknowledged by the Administrator and the Maintenance Director during the exit interview.

Based on observation and interview, the facility failed to maintain the remote annunciator panel for the generator. The deficient practice potentially affected all residents. The facility had a capacity for 103 beds with a census of 88 on the day of the survey. Observation during the building inspection tour, at 11:00 a.m., revealed remote annunciator panel for the generator did not work. An interview with the Assistant Maintenance Director revealed that facility was not aware of this requirement. The census of 88 was verified by the Administrator. The findings were acknowledged by the Administrator and the Assistant Maintenance Director during the exit interview.

Based on observation and interview, the facility failed to separate the transfilling area from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction. The deficient practice potentially affected 5 residents. The facility had a capacity for 103 beds with a census of 88 on the day of the survey. Observation during the building inspection tour, at 11:30 a.m., revealed oxygen transfilling room was not separated from the rest of the facility by a fire barrier of 1 hour fire-resistive construction due to lack of a fire damper at the ventilation line and a minimum 45 minute fire rated door. During the survey, it was observed that oxygen transfilling room door did not have a fire resisting rating label and the floor covering was vinyl tiles. An interview with the Maintenance Director revealed that facility was not aware of this deficiency. The census of 86 was verified by the Administrator. The findings were acknowledged by the Administrator and the Maintenance Director during the exit interview.

A revisit survey was completed on 7/24/25 for all previous deficiencies cited on 6/3/25. 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 June 24, 2025 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a one (1) story, Type V (111) wood frame construction with a basement. The basement is for support services only and there is no resident access. The facility was constructed in1963. The facility is licensed for 103 beds and the census on the date of the survey was 87. This facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry pipe fire sprinkler systems. The dry pipe system protects the attic spaces. The facility is classified as fully-sprinklered. The results of this survey were discussed with the Maintenance Director during the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. The deficient practice affected 2 of 7 smoke compartments. The deficient practice could affect all smoke zones,44 of 103 residents, and an indeterminable number of staff and visitors. During the inspection, observations and interviews with the maintenance director revealed that the gate swings against egress. NFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101, 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7The maintenance director discussed deficient items at the exit conference.

Based on observation and staff interviews during the record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 101. The deficient practice could affect all smoke zones,103 of 103 residents, and an indeterminable number of staff and visitors. During the inspection, the maintenance director revealed that the 90-minute annual tests were not available at the time of inspection. NFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 1/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. The maintenance director discussed deficient items at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,103 of 103 residents, and an indeterminable number of staff and visitors. During the inspection, the maintenance director revealed that the 90-minute annual tests were not available at the time of inspection. NFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 1 1/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded. NFPA 101 7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.(3)Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.(4)The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).(5)Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. The maintenance director discussed deficient items at 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,103 of 103 residents, and an indeterminable number of staff and visitors. 1. During the inspection, observations and interviews with the maintenance director revealed that door stops are needed in resident rooms. 2. During the inspection, observations and interviews with the maintenance director revealed that there are penetrations in the ceiling at the north nurse station. 3. During the inspection, observations and interviews with the maintenance director revealed that the fire rating for the activities door has been compromised, the door has been cut in half, and has a hole where the old door handle was. 4. During the inspection, observations and interviews with the maintenance director revealed that the fire door does not latch properly by room 19. 5. During the inspection, observations and interviews with the maintenance director revealed that the laundry chute does not seal properly and has a penetration. 6. During the inspection, observations and interviews with the maintenance director revealed that the new piano hinges on the fire doors are fire-rated. 7. During the inspection, observations and interviews with the maintenance director revealed that a section of the fire door has been removed at the bottom. 8. During the inspection, observations and interviews with the maintenance director revealed there is a penetration at the south nurses' station. 9. During the inspection, observations and interviews with the maintenance director revealed that there was no annual inspection fire/smoke door report. NFPA 101 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code8.7.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3Protecting the area with automatic extinguishing systems in accordance with Section 9.7Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 435.2.3 Functional Testing. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of doorbeing subject to testingNFPA 80 5.2* Inspections. 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.NFPA 80 5.2.13 Prevention of Door Blockage. 5.2.13.3 Blocking or wedging of doors in the open position shall be prohibited. 7.13.1* Hazard of Contents. 7.13.1.1 Unless prohibited by Chapters 11 through 43, the provisions of Section 7.13 shall apply, in lieu of the provisions of Sections 7.1 through 7.12, to normally unoccupied building service equipment support areas where such areas do not contain high hazard contents or operations. NFPA 101 7.2.1.5.10.2 The releasing mechanism shall open the door leaf with not more than one releasing of operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6. A.?7.2.1.5.10 Examples of devices that might be arranged to release latches include knobs, levers, and bars. This requirement is permitted to be satisfied by the use of conventional types of hardware, whereby the door is released by turning a lever, knob, or handle or by pushing against a bar, but not by unfamiliar methods of operation, such as a blow to break glass. It is also within the intent of this requirement that switches integral to traditional doorknobs, lever handles, or bars, and that interrupt the power supply to an electromagnetic lock, be permitted, provided that they are affixed to the door leaf. The operating devices should be capable of being operated with one hand and should not require tight grasping, tight pinching, or twisting of the wrist to operate. The 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, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2. The deficient practice affected 1 of 7 smoke compartments. The deficient practice could affect all smoke zones,22 of 103 residents, and an indeterminable number of staff and visitors. During the inspection, observations and interviews with the maintenance director revealed that the commercial cooking equipment on casters does not have restraint devices installed 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 maintenance director discussed deficient items at the exit conference.

Based on observation during the course of the survey it was determined the facility failed to maintain a manual fire alarm box (pull station) in accordance with NFPA 101, 9.6.2.7. The deficient practice affected 1 of 7 smoke compartments. The deficient practice could affect all smoke zones,22 of 103 residents, and an indeterminable number of staff and visitors. During the inspection, observations and interviews with the maintenance director revealed that the fire alarm pull station was blocked by storage in the basement. NFPA 101, Section 9.6.2.7 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible. The 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,103 of 103 residents, and an indeterminable number of staff and visitors. 1. During the record review, observations and interviews with the maintenance director revealed that the semi-annual fire sprinkler report was not available at the time of inspection. 2. During the record review, observations and interviews with the maintenance director revealed that the five-year fire sprinkler report was not available at the time of inspection. 3. During the inspection, observations and interviews with the maintenance director revealed that the hydraulic calculation plate was not on the fire suppression system. NFPA 101 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. NFPA 25 (2011) 4.1.9.1 Where an impairment to a water-based fire protection system occurs, the procedures outlined in Chapter 15 of this standard shall be followed, including the attachment of a tag to the impaired system. 4.1.9.2 Where a water-based fire protection system is returned to service following an impairment, the system shall be verified to be working properly by means of an appropriate inspection or test. 4.2 Corrective Action. 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. NFPA 25 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. The maintenance director discussed deficient items at the exit conference.

Based on observations and records review, it was determined that the facility did not maintain fire extinguishers in accordance with NFPA 10. The deficient practice affected 1 of 7 smoke compartments. The deficient practice could affect all smoke zones, 22 of 103 residents, and an indeterminable number of staff and visitors. During the inspection, observations and interviews with the maintenance director revealed that an exterior fire extinguisher is missing its tag. 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 Extinguishers. The maintenance director discussed deficient items at the exit conference.

Based on observation and staff interviews, it was determined that the facility failed to maintain wiring in accordance with NFPA 99 and NFPA 70.. The deficient practice affected 1 of 7 smoke compartments. The deficient practice could affect all smoke zones, 22 of 103 residents, and an indeterminable number of staff and visitors. During the inspection, observations and interviews with the maintenance director revealed that the restroom requires an outlet cover by the office. NFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. The 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 could affect all smoke zones,103 of 103 residents, and an indeterminable number of staff and visitors. During the record review, observations and interviews with the maintenance director revealed that the fire drills are missing in July and April. 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 maintenance director discussed deficient items at the exit conference.

Based on the documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). The deficient practice affected all smoke compartments. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,103 of 103 residents, and an indeterminable number of staff and visitors. During the record review, observations and interviews with the maintenance director revealed that there was no written documentation of the continuity of the grounding circuit, the polarity of the hot and neutral connections, and the retention force of the grounding blade in patient care. These assessments were not conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). The administrator and maintenance director discussed deficient items at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the backup emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. The deficient practice could affect all smoke zones,103 of 103 residents, and an indeterminable number of staff and visitors. During the record review, observations and interviews with the maintenance director revealed that the generator's transfer time was not documented. 8.4.6 Transfer switch shall be operated monthly. The administrator and maintenance director discussed deficient items at the exit conference.

Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. The deficient practice affected 1 of 7 smoke compartments. The deficient practice could affect all smoke zones, 22 of 103 residents, and an indeterminable number of staff and visitors. 1. During the record review, observations and interviews with the maintenance director revealed that the cylinders need to be labeled/separated by empty and full. 2. During the inspection, observations and interviews with the maintenance director revealed that there are concentrators stored in the oxygen room. 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. NFPA 99: .11.3.2* Storage for nonflammable gasses greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3.11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. 11.7.2 Information and Instructions. The liquid oxygen seller shall provide the user with documentation that includes, but is not limited to, the following:(1)Manufacturer ' s instructions, including labeling for storage and use of the containers(2)Requirements for storage and use of containers away from ignition sources, exits, electrical hazards, and high-temperature devices(3)Methods for container restraint to prevent falling(4)Requirements for container handling(5)Safeguards for refilling of containersThe administrator and maintenance director discussed deficient items at the exit conference.

A recertification survey with complaint #CO39200, #CO39608, #CO39676 and #CO40161 was completed on 5/28/25 to 6/3/25. Seven deficiencies were cited.

An Emergency Preparedness survey was conducted from 5/28/25 to 6/3/25. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to make prompt efforts to resolve resident grievances brought up by the resident council. Findings include:I. Facility policy and procedureThe Grievance policy, reviewed 5/13/25, was provided by the nursing home administrator (NHA) on 6/3/25 at 6:51 a.m. It read in pertinent part,"All grievances are forwarded to the grievance official and a written acknowledgment is provided to the complainant within three calendar days of receipt."The grievance official conducts a prompt investigation. Written resolution is provided within 14 calendar days. If more time is needed, interim updates are provided, with justification for delay". II. Resident group interviewFive alert and oriented residents (#65, #33, #18, #76 and #39) who regularly attended the resident council meetings were interviewed on 6/2/25 at 1:00 p.m. The residents were identified as alert and oriented through facility and assessment. The group of residents said the facility did not follow up on grievances brought up in the resident council meetings. Resident #76 said when a grievance came up in the resident council meeting the department head tried to address it during the meeting but the manager did not complete a grievance form. Resident #65 said if it was an individual grievance, the department head would follow-up with the individual resident. Resident #65 said if it was a group grievance a resolution was not consistently brought back to the next resident council meeting by the facility. III. Record reviewA review of the resident council meeting minutes, dated 3/6/25, revealed the residents brought up concerns regarding the men's section of the building needing increased heat, an individual resident needing a call light, short staffing, "lazy" night staff and requests for increased activities. -Review of the March 2025 resident council minutes did not reveal documentation indicating the facility had addressed the residents' concern. A review of the resident council meeting minutes, dated 4/3/25, revealed the residents brought up concerns regarding long call light times, cold shower water, short nursing staff, adding more vegetarian options for meals, limited snack options, increased lighting outside of the building, an individual resident's complaint of low toilets and an individual residents complaint regarding problems with wheelchair wheels. -Review of the April 2025 resident council minutes did not reveal documentation indicating the facility had addressed the residents' concerns. A review of the resident council meeting minutes, dated 5/1/25, revealed the residents brought up concerns regarding the need for improvements in taking resident's food orders, ensuring personal items, like newspapers, were not thrown away by housekeeping, requests for maintenance to install locks on drawers for individual residents, and and an individual residents complaint regarding problems with wheelchair wheels. -Review of the May 2025 resident council minutes did not reveal documentation indicating the facility had addressed the residents' concern. IV. Staff interviewsThe social services director (SSD) was interviewed on 6/2/25 at 3:15 p.m. The SSD said she facilitated the resident council meetings and the facility had a process for addressing individual resident grievances but there was not a process for following up on group grievances generated during resident council. She said the manager present at the meeting whose department would be responsible for the grievance, would talk about how they planned to resolve it in the meeting. The SSD said if the concern involved a maintenance issue, the maintenance director would initiate a work order to resolve the concern. V. Facility follow upThe NHA sent an email on 6/3/25 at 10:03 a.m. with evidence of work orders as follows;A work order, dated 3/6/25, for the individual resident who needed a call light and had complaints regarding a low toilet. A work order, dated 4/3/25, for the individual resident with wheelchair wheel complaints. A work order, dated 5/2/25, for lock installation on drawers for the residents who requested the locks and housekeeping education regarding disposing of resident items like newspapers. -No grievances or evidence of resolution was provided for any other resident council grievances.

Based on interviews and record review, the facility failed to coordinate changes to the preadmission screening and resident review (PASRR) Level II determination and evaluation report promptly with the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#38) of two residents reviewed for PASRR out of 35 sample residents. Specifically, the facility failed to notify the State Mental Health Agency when a resident received a new diagnosis (bipolar disorder) of a serious mental disorder for a PASRR Level II evaluation. Findings include:I. Facility policy and procedureThe PASRR Evaluation and Screening policy, reviewed 1/29/25, was provided by the nursing home administrator (NHA) on 6/3/25 at 6:51 a.m. It read in pertinent part, "Re-screening is required for; a new or changed psychiatric diagnoses, addition or change in psychotropic medication, or worsening behavioral or cognitive symptoms". II. Resident statusResident #38, age 70, was admitted on 3/11/21. According to the May 2025 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbances (dated 1/14/22) and bipolar disorder (dated 7/18/24). The 4/17/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS condition list indicated the resident did not have a PASRR Level II diagnosis of major mental illness. III. Resident interviewResident #38 was interviewed on 5/28/25 at 10:35 a.m. She said she was unaware she had been diagnosed with bipolar disorder. IV. Record reviewThe mood care plan, revised 1/23/25, revealed the resident used psychotropic medications related to dementia with behaviors. Interventions, dated 11/14/24, included administering medication as ordered, providing education to the resident on risks and benefits of the medication, and monitoring behaviors and interventions. The May 2025 CPO revealed the following physician orders:-Olanzapine (an antipsychotic medication) 10 milligrams (mg). Give one tablet by mouth at bedtime for dementia with behaviors, ordered on 3/27/25. A nurse practitioner visit note, dated 12/8/23, revealed a new diagnosis of unspecified bipolar disorder. The NP visited the resident at the residents request related to a urinary tract infection (UTI).-Review of Resident #38's electronic medical record (EMR) did not reveal documentation for the basis of the new diagnosis..V. Staff interviewsThe social services director (SSD) was interviewed on 6/2/25 at 3:15 p.m. The SSD said she had not been able to find supportive documentation for the physician's diagnosis of bipolar disorder on 12/8/23 or the addition of bipolar disorder to Resident #38's EMR on 7/18/24. The SSD said when she reviewed the care plans for each resident quarterly, she also reviewed the diagnosis list. She said Resident #28's care plan was reviewed on 8/4/24, 10/28/24, 1/28/25, 2/4/25 and 4/30/25, however she said she had not identified the resident's new diagnosis during those reviews or completed an updated PASRR screening. VI. Facility follow upThe NHA provided documentation pertaining to Resident #38's bipolar disorder diagnosis on 6/2/25 at 5:12 p.m. (during the survey). The documentation provided included the following: -An authorization to clarify diagnosis, dated 5/30/25 (during the survey), signed by the physician striking out bipolar disorder from Resident #38's EMR due to lack of history;A submission of a new PASRR screening, dated 5/30/25 (during the survey); and,-An automated notice of determination response to the PASRR screening, dated 5/30/25 (during the survey), revealing she did not trigger for a major mental illness or Level II condition.

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

Based on observations, record review and interviews, the facility failed to ensure one (#184) of two residents who required respiratory care received care consistent with professional standards of practice out of 35 sample residents. Specifically, the facility failed to ensure oxygen was administered as ordered by the physician for Resident #184. Findings include:I. Facility policy and procedureThe Respiratory Care and Oxygen Administration policy and procedure, revised 5/13/25, was provided by the nursing home administrator (NHA) on 6/3/25 at 5:22 p.m. It read in pertinent part, "The facility provides respiratory care, including the administration of oxygen, in accordance with medical orders and based on residents' clinical needs. Care shall be safe and evidence-based."Procedures, including respiratory care, must be ordered by a physician, nurse practitioner, or physician's assistant. Nursing staff will assess residents for signs of respiratory distress upon admission and routinely thereafter. Respiratory orders must specify oxygen flow rate, delivery method and frequency. Verify the physician's order prior to administration. Observe respiratory rate, oxygen saturation, breath sounds, and effort at least every shift."II. Resident #184A. Resident statusResident #184, age less than 65, was admitted on 4/17/24 and readmitted on 11/10/24. According to the May 2025 computerized physician orders (CPO), diagnoses included cardiac arrest (when the heart stops beating suddenly), acute respiratory failure with hypoxia, anoxic brain damage (when the brain is deprived of oxygen for a period, leading to damage or death of brain cells), cerebrovascular disease, dependence on supplementary oxygen and seizures. The 4/15/25 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS) assessment. According to the staff assessment for mental status, the resident had short-term and long-term memory deficits, severely impaired decision making and continuous disorganized thinking. Resident #184 was not cognitively oriented to staff names and faces. He was dependent on staff for all of his activities of daily living (ADLs). According to the MDS assessment, the resident had a debilitating cardiorespiratory condition and respiratory failure. The MDS assessment identified the resident required oxygen therapy, suctioning and tracheostomy care. B. Observations On 5/28/25 at 2:14 p.m. Resident #184 was lying in bed. Resident #184 had a tracheostomy inserted through the center of his throat, with oxygen running through the tracheostomy. His oxygen concentrator was turned on and set at approximately 4.8 liters per minute (LPM) of oxygen. Resident #184 was partially awake and was taking deep breaths. The resident would open his eyes momentarily, take a deep breath, and close his eyes. On 5/29/25 at approximately 9:44 a.m. Resident #184 was in bed, lying flat with his face pointed up toward the ceiling. His tracheostomy was attached to his trachea with an oxygen tube connected to the tracheostomy. His oxygen concentrator was set at 4.8 LPM of oxygen. On 6/2/25 at approximately 11:40 a.m. registered nurse (RN) #1 entered Resident #184's room to set up a formula for the resident's tube feeding. RN #1 donned (put on) a protective gown and gloves. RN #1 performed tracheostomy care, administered medications via the resident's gastrostomy tube, checked the resident's pulse oximetry and then left the resident's room after disposing of the gown and gloves.-RN #1 failed to check the liter flow of oxygen for Resident #184 or identify that the resident was receiving 4.8 LPM of oxygen instead of the continuous 4 LPM of oxygen that was specified by the resident's physician's order for oxygen (see physician's order below). C. Record reviewA review of Resident #184's May 2025 CPO revealed the following physician's order:Resident on 4 LPM of oxygen via trach (tracheostomy) every shift for shortness of breath (SOB),ordered 3/6/25. Further review of the resident's physician order history revealed Resident #184 had a physician's order for 6 LPM of oxygen via tracheostomy that was discontinued on 3/6/25. The oxygen care plan, revised 1/29/25, revealed Resident #184 received oxygen therapy related to respiratory failure with hypoxia.-The care plan did not include that Resident #184 required oxygen at 4 LPM via tracheostomy. The May 2025 oxygen saturation log, between 5/1/25 and 5/31/25, documented Resident #184's oxygen saturation levels (level of oxygen in the blood) were checked two to three times a day and ranged between 91 percent (%) and 97%.D. Staff interviewsRN #1 was interviewed on 6/2/25 at 11:46 a.m. RN #1 said Resident #184 had a physician's order for 4 LPM of oxygen via tracheostomy. RN #1 confirmed the resident was receiving 4.8 LPM of oxygen instead of 4 LPM. RN #1 said she did not know why the resident' oxygen concentrator was set to 4.8 LPM. RN #1 said she did not check the resident's oxygen settings at the start of her shift and she was not aware that Resident #184 was receiving more oxygen than the physician's order specified he should receive. She said only nurses were allowed to adjust oxygen settings on the concentrators. RN #1 said there was no titration order (order that includes a target oxygen saturation level and instructions for gradually adjusting the oxygen flow rate to maintain that oxygen saturation level target) with the resident's order and the concentrator should be left at 4 LPM. RN #1 said Resident #184 was not physically able to adjust the oxygen setting himself. Licensed practical nurse (LPN) #3 was interviewed on 6/2/25 at 2:05 p.m. LPN #3 said Resident #184 had a physician's order for 4 LPM of oxygen via tracheostomy with no titration order. LPN #3 said oxygen was a medication and required a physician's order to initiate oxygen therapy. LPN #3 said a physician's order for the use of oxygen should be followed to avoid complications associated with high levels of oxygen in the blood. The director of nursing (DON) and the NHA were interviewed together on 6/3/25 at 12:45 p.m. The DON said all nursing staff were responsible for ensuring that oxygen was administered according to the physician's orders. The DON said only nurses were permitted to set, titrate and initiate oxygen therapy. The DON said nurses should check the settings of each residents' oxygen concentrator at least once every shift. The NHA said a physician's order for oxygen should include the diagnosis explaining the reason oxygen was needed, the flow rate for the oxygen, duration of use and the delivery method for the oxygen. The NHA said nursing staff would be re-educated immediately on the need to ensure oxygen orders were followed. E. Facility follow-upOn 6/4/25 at 2:15 p.m., following the survey exit, the NHA provided the following information via email:The NHA's email revealed the facility's respiratory therapist (RT) was consulted to reassess the appropriateness of Resident #184's existing oxygen order. According to the NHA, the facility's RT concluded that, based on Resident #184's chronic tracheostomy and fluctuating respiratory status, a titrated oxygen range order was more clinically appropriate for the resident than a continuous fixed flow rate of oxygen. The information submitted by the NHA revealed Resident #184's physician's order for 4 liters LPM of oxygen was discontinued on 6/4/25 at 1:15 p.m. and the following physician's order was obtained:-Oxygen delivery via tracheostomy cannula: administer oxygen via a humidified tracheostomy. Flow rate range: 4 LPM to 10 LPM, maintain oxygen saturation between 88% and 100% every shift for altered respiratory status. If SpO2 (oxygen saturation level) falls below 88%, increase flow by 1 LPM every 5 (five) minutes up to a maximum of 10 LPM. Notify the physician if oxygen requirement exceeds 10 LPM or if signs of respiratory distress are observed.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to:-Ensure housekeeping staff followed appropriate infection control guidelines when cleaning residents' bathrooms;-Ensure housekeeping staff applied alcohol-based hand sanitizer per guidelines when cleaning residents' rooms;-Ensure staff donned appropriate personal protective equipment (PPE) when providing direct care for Resident #45, who was on enhanced barrier precautions (EBP); and,-Ensure staff donned appropriate PPE when providing wound care for Resident #16, who was on EBP.Findings include:I. Housekeeping failuresA. Professional referenceThe Centers for Disease Control and Prevention's (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 6/5/25 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/preent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part,"Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions."According to the CDC's Hand Sanitizer Guidelines and Recommendations (3/12/24), retrieved from https://www.cdc.gov/clean-hands/about/hand-sanitizer.html#:~:text=Apply%20the%20gel%20product%20to,should%20take%20around%2020%20seconds., on 6/10/25, "Cleaning hands at key times with soap and water or hand sanitizer that contains at least 60% alcohol is one of the most important steps you can take to avoid getting sick and spreading germs to those around you."Apply the gel product to the palm of one hand;Cover all surfaces of hands; and,Rub your hands and fingers together until they are dry. This should take around 20 seconds."Don't rinse or wipe off the hand sanitizer before it's dry; it may not work well against germs."B. Facility policy and procedureThe Housekeeping and Environmental Cleanliness policy, revised 11/13/24, was provided by the nursing home administrator (NHA) on 5/29/25 at 10:33 a.m. It read in pertinent part, "To ensure that the facility is maintained in a clean, sanitary, and orderly condition to promote resident safety and comfort. Resident rooms are cleaned daily and as needed, and bathrooms disinfected with approved products."All housekeeping staff are trained upon hire and annually in infection control practices, safe chemical handling and proper cleaning techniques."C. ObservationsDuring a continuous observation on 6/3/25 at 8:50 a.m., housekeeper (HK) #1 was observed cleaning room #24 and room #26. HK #1 pushed the cleaning cart to the entrance of room #24. She opened the cart and donned (put on gloves), entered the room and emptied two trash cans. She returned to the cart, removed her gloves, applied alcohol-based hand sanitizer and immediately donned a pair of gloves. She struggled to put on the gloves due to her hands being visibly wet with the alcohol-based hand sanitizer. HK #1 entered room #24 again and cleaned the high-touch areas, including the door knobs, bed controller, call light, and bedside table. She returned to her cart, removed a blue rag and disinfectant solution from the cart and entered the resident's bathroom. HK #1 sprayed a blue disinfectant solution onto the bathroom sink and cleaned the bathroom mirror. She used the blue rag to clean the mirror and the sink. HK #1 returned to the cleaning cart and placed the disinfectant solution on the cart. She removed her gloves, applied alcohol-based hand sanitizer and immediately applied clean gloves without allowing her hands to dry. HK #1 returned to room #24's bathroom with the blue disinfectant solution and a scrubbing brush. She sprayed the toilet with the disinfectant solution and allowed it to sit for approximately one minute. She used the blue rag to wipe the seat of the toilet, the rim of the toilet and around the toilet bowl. She wiped the side of the toilet again,the side of the toilet tank, the front of the toilet tank and the top of the toilet tank with the same blue rag. She sprayed the grab bar on the right side of the toilet wall with the disinfectant solution and wiped it with the same blue rag. HK #1 swept and mopped the floor in room #24 before pushing the cleaning cart to the entrance of room #26.-HK #1 did not rub her hands with the hand sanitizer until they were dry before applying gloves.-HK #1 failed to clean the bathroom from a cleaner area to a dirtier area..HK #1 used hand sanitizer, immediately donned gloves without allowing the hand sanitizer to dry and entered room #26. She emptied two trash cans and proceeded to the cleaning cart to discard the trash from the resident's room. She took off her gloves, applied hand sanitizer, and immediately donned new gloves, again without rubbing her hands until the hand sanitizer was dry. She removed the container of disinfectant solution and a blue rag from her cart and washed the inside of the sink, the mirror and the surface of the sink in the resident's bathroom. She returned the container to the cart. HK #1 removed a toilet brush, a new blue rag and the disinfectant solution spray from the cleaning cart and proceeded to room #26's bathroom. The toilet seat had splashes of urine on the surface. She sprayed the disinfectant solution onto the surface of the toilet seat and the inside of the toilet bowl and scrubbed it with the toilet brush. She placed the toilet brush into the brush holder, which she placed on the dirty floor beside the toilet bowl. HK #1 picked up the scrubbing brush holder from the floor and placed it on the cleaned surface of the bathroom sink. HK #1 then sprayed the toilet with the disinfectant solution spray bottle and used the blue rag to wipe the toilet seat, the rim of the toilet, the back of the toilet, both sides of the toilet, the top of the toilet tank, around the toilet tank and finished by wiping the toilet seat again.-HK #1 failed to clean the bathroom from cleaner to dirtier areas to avoid spreading dirt and microorganisms. -HK #1 failed to avoid contaminating clean surfaces by placing a dirty toilet brush container on the cleaned sink surface.-HK #1 did not rub her hands with hand sanitizer until they were dry before applying gloves. D. Staff interviewsHK #1 was interviewed on 6/3/25 at 9:22 a.m. HK #1 said she found it difficult to don gloves because her hands were wet with the hand sanitizer. She said it would have been easier to apply gloves if she had allowed her hands to dry before applying gloves. She said hand sanitizers were less effective if not used properly. She said she should not have placed the scrubbing brush from the toilet on the cleaned surface of the sink in the bathroom to prevent cross-contamination of microorganisms. She said the residents' toilets should have been cleaned from top to bottom. She said she forgot not to use the same cleaning rag for the toilet and the grab bar in the room #24's bathroom. The housekeeping supervisor (HKS) was interviewed on 6/3/25 at 9:30 a.m. The HKS said the toilet brush should never be placed on any clean surface after using it to clean the toilet. She said the toilet should be cleaned with a clean rag from top to bottom. She said HK #1 should not have used the same rag to clean the toilet and the grab bar in room #24's bathroom. The HKS said HK #1 should have allowed her hands to dry before applying gloves for the hand sanitizer to be effective.. She said she would immediately re-educate HK #1 and all housekeeping staff on proper cleaning procedures. II. EBP failuresA. Professional referenceAccording to The Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) (4/2/24), retrieved on 6/4/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html,"EBP are an infection control intervention, designed to reduce transmission of resistant organisms, that employ targeted gown and glove use during high contact resident care activities."Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization."Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing."B. Facility policy and procedureThe Infection Control policy, revised 11/13/24, was provided by the NHA on 5/29/25 at 10:33 a.m. It read in pertinent part, "Enhanced barrier precautions are used for residents with wounds, indwelling devices such as catheters, tracheostomies or those at high risk of multidrug-resistant organisms (MDROs) colonization, even if they are not known to be infected. "Used for residents in high-risk categories in nursing homes, especially during MDRO outbreaks or colonization events, requirements include gloves and gowns during high-contact resident care activities such as dressing, bathing, toileting and device care. Enhanced signage and personal protective equipment (PPE) in the resident care area, staff education and competency validation on all isolation practices, monitoring and auditing compliance through direct observation."All staff are trained and regularly audited to ensure adherence to these guidelines and to protectthe health and safety of all individuals in the facility."C. Resident #451. ObservationsOn 5/29/25 at 1:40 p.m. Resident #45 was lying in bed. He turned his call light on and certified nurse aide (CNA) #2 responded to the resident's call light. CNA #2 entered the resident's room and asked the resident what she could do to assist him. Resident #45 asked to be repositioned in bed. CNA #2 removed both of the resident's feet from his pressure injury boots (bunny boots) and held the resident's legs and feet to adjust them. Resident #45 had a diabetic wound on his right second toe, a diabetic foot ulcer with wounds to his left heel and wounds on his sacrum (buttocks). CNA #2 held Resident #45's feet without gloves, applied the bunny boots to the resident's feet and repositioned the resident using a wedge cushion.-CNA #2 failed to put on gloves or a gown before assisting Resident #45, who had wounds which required the use of EBP, to reposition. On 6/2/25 at 11:25 a.m., a restorative nurse aide (RNA) #6 arrived at Resident #45's bedroom to provide range of motion (ROM) exercises in the resident's bed. RNA #6 applied gloves but did not don a protective gown. He touched the resident's right hand and aligned it with his hands to provide ROM. RNA #6 removed the bunny boots from the resident's feet and held the resident's feet from below the heel area with his left hand. RNA #6 began providing ROM to Resident #45's feet. RNA #6 held the resident's feet close to the area of his diabetic wounds while providing ROM.-RNA #6 failed to put on a protective gown before providing ROM to Resident #45. On 6/2/25 at approximately 1:15 p.m. CNA #1 responded to Resident #45's call light and the resident requested to be changed. CNA #45 applied gloves, lifted the resident's bed and removed the resident's bed linens and started changing the resident. -CNA #1 failed to don a protective gown while changing Resident #45. D. Resident #161. Observations On 5/29/25 at 11:22 a.m. a sign on Resident #16's door indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. Gloves and blue gowns were observed in Resident #16's room in clear plastic bins. On 5/29/25 at 11:24 a.m. licensed practical nurse (LPN) #1 was completing wound care with a dressing change for Resident #16, who had a pressure wound on her sacral area. The wound was observed in the sacral area with clear, yellow tinged drainage. LPN #1 had gloves on. -However, LPN #1 failed to put on a gown prior to performing wound care with the resident. 2. Resident interviewResident #16 was interviewed on 5/29/25 at 11:30 a.m. Resident #16 said when the nurses were changing her wound dressing, the nurses would put on gloves but they never wore a gown. E. Staff interviewsLPN #1 was interviewed on 5/29/25 11:38 a.m. LPN #1 said Resident #16 was on EBP because the resident had an indwelling foley catheter foley and colostomy. LPN #1 said she never wore a gown for Resident #16 when she completed her wound dressing changes. LPN #1 said she was now aware of the requirement to wear a gown with wound dressing changes. LPN #1 said now that she knew the correct PPE to don, she would make sure she always wore a gown and gloves with wound care in the future. CNA #6 was interviewed on 5/29/25 at 12:35 p.m. CNA #6 said when she was providing care for any resident on EBP, she would don gloves and a gown. CNA #6 said if she was going to assist the resident with transfers, using the bathroom or helping the nurse with colostomy care, she would put on a gown and gloves to ensure the resident would not get an infection. CNA #6 said she was provided education and instruction on PPE by the facility. RN #3 was interviewed on 6/2/25 at 11:22 a.m. RN #3 said whenever she provided Resident #16 with wound care, cleaning or emptying her foley catheter or changing the resident's colostomy bag, she would wear gloves and a gown because that was the facility's protocol. RN #3 said the EBP was in place to prevent Resident #16 from getting an infection. She said all nursing staff should wear gloves and a gown with high contact care such as transfers, providing incontinence care and wound care. CNA #2 was interviewed on 6/2/25 at 1:45 p.m. CNA #2 said she did not know she had to put on a protective gown when providing care for Resident #45. CNA #2 said the only time that she applied PPE was when there was an isolation cart in front of the resident's room. She said she had received training on all isolation precautions, but she did not know to wear gloves and a protective gown before repositioning Resident #45. She said the sign posted in front of Resident #45's room should have reminded her to follow the procedure for EBP.Registered nurse (RN) #1 was interviewed on 6/2/25 at 1:55 p.m. RN #1 said there were signs posted at the entrance of each resident's room who was on EBP. She said PPE should be worn when performing personal care as indicated on the resident's care plan. The director of nursing (DON) was interviewed on 6/3/25 at 12:45 p.m. The DON said residents on EBP had signage posted at the entrance of their rooms and also indicated on their care plans. She said EBP required the use of gloves, a protective gown and in some cases a face shield, depending on the task being performed. The DON said all nursing staff were trained on isolation precautions and should know to put on the proper PPE before performing any personal care to avoid the spread of infections. The DON said she did not know why the staff failed to follow the proper infection control procedures. She said she would ensure all nursing staff were re-educated on isolation procedures, including EBP.The NHA and the DON were interviewed together on 6/3/25 at 4:02 p.m. The NHA said the facility nursing staff were provided education and training on correct EBP policy and procedure from the DON. The DON said she provided education to staff upon hire and annually thereafter, on how and when to properly use PPE when a resident was on EBP. The DON said EBP was used for high-contact interaction between staff and residents. The DON said a resident would be placed on EBP if they had an ostomy (surgical incision in the abdomen), wounds or a foley catheter. The DON said the staff should wear PPE, including a gown and gloves, when assisting residents who were on EBP with activities of daily living (ADL). The NHA said she would have the DON provide re-education to staff on proper EBP protocol.

Based on observations and interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation for one of two shower rooms and nine of 16 resident bathrooms. Specifically, the facility failed to ensure the exhaust fans in the north shower room and nine resident rooms were working properly. Findings include:I. Facility policy and procedureThe Ventilation and Environmental Condition policy, revised 11/13/24, was provided by the nursing home administrator (NHA) on 6/3/25 at 5:22 p.m. It read in pertinent part, "This facility shall maintain ventilation, lighting, and indoor environmental conditions that are safe, functional, and comfortable for residents, staff, and visitors. This policy applies to all maintenance and environmental services personnel responsible for managing heating, ventilation and air conditioning (HVAC), lighting and general facility comfort."Ventilation system requirements include operating HVAC systems in accordance with manufacturer instructions and American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) standards, ensuring that airflow does not compromise infection control and maintaining adequate natural and mechanical ventilation in all resident-use areas."II. ObservationsAn observation of the residents' environment was completed with the maintenance director (MTD) on 6/3/25 at 10:40 a.m. There were exhaust fans installed in the ceiling of each resident's bathroom and the two main shower rooms (north and south shower rooms). The exhaust fan in the north shower room was not working and it was dirty with lint hanging from the surface of the vent. The exhaust fans in the bathrooms of room #5, room #9, room #11, room #15, room #25, room #26 and room #30 did not generate air movement with the switch turned on. As a measure of checking the function of each exhaust fan, a small square of single-ply toilet paper was placed against the vent. The exhaust fans were unable to hold the toilet tissue in place, which indicated the fans were not functioning at that moment. The vents in the bathrooms of room #5, room #9, room #11 and room #15 had large holes around the vents, exposing the electrical wires. The bathroom exhaust fans of room #13 and room #35 were missing. III. Staff interviewsThe maintenance director (MTD) was interviewed on 6/3/25 at 11:40 a.m. The MTD said the exhaust fan vents in the facility were old and needed to be replaced. He said monitoring was completed once a month for all the facility's exhaust fans. He said he repaired the fans that were broken but he said he had not come across the missing exhaust fans in room #13 and room #35 during his monitoring. The MTD said he did not know how and why the exhaust fans were missing from some of the bathrooms. He said the dirty vents would be cleaned immediately and new exhaust fans would be ordered to replace the missing ones. The NHA was interviewed on 6/3/25 at 1:08 p.m. The NHA said the proper functioning of the exhaust fan vents in the facility was important to promote air quality in the building. She said the maintenance monitoring form should be updated to include more specific checks of the ventilation system. She said orders had been placed for new vents and they would be installed as soon as they arrived. The NHA said she would reeducate the MTD and the maintenance staff on the importance of the ventilation system.

A revisit survey was completed on 3/4/25 for all previous deficiencies cited on 12/31/24. The facility is in compliance with all regulations surveyed.