LAKESIDE POST ACUTE

A licensure survey was completed on 6/22/26 to 6/25/26. Four deficiencies were cited.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to its infection prevention program. Findings include:I. Cross-referenced citationsCross-reference F880: The facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. The facility failed to ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents’ rooms and high frequency touched areas (call lights, door handles and handrails), ensure housekeeping staff followed disinfectant dwell times (amount of time required to ensure germs are eliminated) when cleaning residents’ rooms, ensure housekeeping staff performed appropriate hand hygiene between glove changes and after cleaning residents’ toilets and ensure housekeeping cleaned only the toilet bowl with the toilet brush. The facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care for residents requiring device care who were on enhanced barrier precautions (EBP). The facility failed to ensure staff performed appropriate hand hygiene when moving from dirty to a clean task. Cross-reference F945: The facility failed to provide annual infection prevention and control training to staff members. A total of 36 out of 77 staff members did not receive annual training required for infection prevention and control. Infection prevention failures existed throughout the facility including cleaning of resident rooms inappropriately, failing to wear appropriate personal protective equipment (PPE) for residents on EBP, and appropriately completing hand hygiene. II. Facility policy and procedureThe Quality Assurance and Performance Improvement policy and procedure, revised February 2020, was received from the regional director of clinical services #2 on 6/23/26 at 11:24 a.m. It read in pertinent part, “This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance, establishing goals and thresholds for performance measurement, identifying and prioritizing quality deficiencies, systemically analyzing underlying causes of systemic quality deficiencies, developing and implementing corrective action and monitoring the effectiveness of corrective action.”III. Staff interviewsThe nursing home administrator (NHA) and regional director for clinical services #2 were interviewed on 6/25/26 at 12:30 p.m. The NHA said infection control was identified during QAPI as an area in need of improvement in April 2026. The NHA said there was a performance improvement plan (PIP) started, but not followed through with. The NHA said there were supposed to be weekly infection prevention audits but they were not being completed. The NHA said there was not a root cause identified for the infection prevention deficiencies. The NHA said the staff training for infection prevention was not identified in QAPI.

Based on record review and interviews, the facility failed to provide infection prevention and control program mandatory training for all staff, which included, training on the standards, policies, and procedures for the infection prevention and control program that was appropriate and effective, and as determined by staff need. Specifically the facility failed to provide annual infection control training to 36 out of 77 staff members. Findings include:I. Training record reviewA request was made for the facility’s annual infection control training records for all active staff members on 6/24/26. On 6/24/26 at approximately 10:00 a.m. the nursing home administrator (NHA) provided the records for all active staff members who had completed annual infection control training. The records revealed 36 out of 77 staff members had not completed the facility’s annual infection control training.-The facility failed to ensure all active staff members completed the annual training for infection control. Cross-reference F880: failure to use the correct disinfect, the proper cleaning technique, and proper hand hygiene during the resident room cleaning. II. Staff interviewsDietary aide #1 was interviewed on 6/25/26 at 9:52 a.m. Dietary aide #1 said he completed required training on an online training platform, which included abuse and neglect training, but could not recall whether he had completed the infection control training. Dietary aide #1 said he attended an all-staff meeting that included a demonstration on the proper use of personal protective equipment (PPE). Certified nurse aid (CNA) #6 was interviewed on 6/25/26 at 10:53 a.m. CNA #6 said she received a PPE training during an all-staff meeting. She said she had completed some training on an online platform, but she was unsure whether infection control training was among them. CNA #6 said she was unable to locate documentation verifying completion of infection control training. The human resources director was interviewed on 6/25/26 at 1:20 p.m. The human resources director said she was responsible for tracking staff training completion on the online platform. She said she pulled out a report monthly throughout the year to identify staff with incomplete training. The human resources director said she forwarded those reports to the department managers for follow up with staff. She said she reminded staff through a group messaging system to complete all assigned and required training including the infection control training. The human resources director said she was unsure identifying the failure leading staff not to complete their infection control training. She said the infection control training was a requirement for both the company and state regulations to ensure staff were competent to perform their jobs. The human resources director said, going forward, she would recommend pulling staff off the schedule until they completed all required training. The NHA and the director of nursing (DON) were interviewed together on 6/25/26 at 1:54 p.m. The NHA said the human resources director was responsible for tracking staff training completion on the online platform. He said the human resources director would report incomplete training to the NHA. The NHA said the failure to ensure completion of infection control training was a poor follow up from the management team. He said to address the issues, the human resources director should generate reports more frequently, such as weekly or daily if needed until back in compliance. The NHA said they should continue to follow up staff on a daily basis until the training got completed. The NHA said they would text, email, and call staff to remind them completing the training, if necessary taking them off the schedule until completion of the required training. The DON said she was not aware of so many staff missed the infection control training. She said she would get the assistant director of nursing to follow up with staff to ensure completion.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure kitchen equipment was clean (microwave and blenders), and; -Store food items under sanitary conditions. Findings include:I. Failure to ensure kitchen equipment was clean (microwave and blenders)A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 6/30/26. It revealed in pertinent part, “Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.” (4-601.11)B. Facility policy and procedureThe Sanitization policy, revised November 2022, was provided by the nursing home administrator (NHA) on 6/25/26 at 4:00 p.m. The policy read in pertinent part, “All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair.“All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions.“When cleaning fixed equipment (mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are:-Washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution (at the effective concentration); and,-The equipment is reassembled and any food contact surfaces that may have been contaminated during the process are re-sanitized (according to the manufacturer's instructions).”C. ObservationsThe initial kitchen tour was conducted on 6/22/26 at 8:53 a.m. and the following was observed:-The blender located next to the microwave had food debris that was yellow and sticky on the motor base of the blender. -The microwave located by the steam table had sticky food debris on the interior walls and the ceiling of the cooking cavity.-The blender located near the spice jars shelves had thick, sticky accumulation of food residue built up on the motor base of the blender. A follow-up kitchen tour was conducted on 6/23/26 at 8:51 a.m. and the following was observed:-The blender located next to the microwave remained soiled with food debris on the motor base. -The microwave located by the steam table remained soiled inside.-The blender located near the spice jars shelves remained soiled with food debris on the motor base. D. Staff interviewsDietary aide #1 was interviewed on 6/25/26 at 9:44 a.m. Dietary aide #1 said kitchen staff were responsible for cleaning any equipment they used. He said kitchen staff should clean the entire equipment after use including the blender because sometimes spills could occur. Dietary aide #1 said the cook was primarily responsible for cleaning the blender since the cook used it most frequently. He said failure to properly clean kitchen equipment could result in contamination with germs. Dietary aide #2 was interviewed on 6/25/26 at 10:14 a.m. Dietary aide #2 said there was a kitchen cleaning schedule with assigned responsibilities for kitchen staff. She said the cook was responsible for cleaning the blender after use. Dietary aide #2 said other staff could clean the kitchen equipment when requested. She said having dirty kitchen equipment was not sanitary. Cook #1 was interviewed on 6/24/25 at 8:50 a.m. Cook #1 said kitchen staff should clean the kitchen equipment after each use. He said the blender was used to prepare ingredients and the removable components were cleaned after use. Cook #1 said the microwave was cleaned twice a day or whenever it became dirty after use. He said the kitchen night crew was responsible for cleaning the kitchen equipment; however, all kitchen staff were expected to clean any equipment after use. The NHA was interviewed 6/25/26 at 1:54 p.m. The NHA said there was a cleaning kitchen schedule with assigned responsibilities for kitchen staff. He said staff were expected to adhere to it. He said he was unsure why there were two blenders in the kitchen because it created unnecessary cleaning responsibilities. The NHA said he would provide in-service training to dietary aides, cooks, and all kitchen staff on proper cleaning of kitchen equipment. II. Failure to store food items under sanitary conditionsA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 6/30/26. It revealed in pertinent part, “Food shall be protected from contamination by storing the food in a clean, dry location where it is not exposed to splash, dust, or other contamination and at least six inches above the floor.” (3-305.11)B. Facility policy and procedureThe Food Receiving and Storage policy, revised November 2022, was provided by the NHA on 6/25/26 at 4:00 p.m. The policy read in pertinent part, “Foods shall be received and stored in a manner that complies with safe food handling practices.” “Food in designated dry storage areas are kept at least six inches off the floor (unless packaged for case lot handling, for example, dollies, pallets, racks and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents.”C. ObservationsThe initial kitchen tour was conducted on 6/22/26 at 8:53 a.m. and the following was observed:-One box containing cans of tomato sauce was on the floor in the dry storage room.-Three packages of tortillas were on the floor underneath a shelf in the corner of the dry storage room. A follow-up kitchen tour was conducted on 6/23/26 at 8:51 a.m. and the following was observed:-The box containing cans of tomato sauce remained on the floor in the dry storage room.-The three packages of tortillas remained on the floor underneath a shelf in the corner of the dry storage room. D. Staff interviewsDietary aide #1 was interviewed on 6/25/26 at 9:44 a.m. Dietary aide #1 said all kitchen staff were responsible for placing food items on the shelves after deliveries including the dietary manager. He said if food items were observed on the floor and the packaging were opened, they would throw them away. Dietary aide #1 said if boxes were found on the floor, they should be removed off the floor and placed on the shelves. He said he picked up the three packages of tortillas observed on the floor and threw them away. Dietary aide #1 said storing food items on the floor was not sanitary. Cook #1 was interviewed on 6/25/26 at 10:10 a.m. Cook #1 said every kitchen staff member was responsible for ensuring food items in the dry storage room were stored off the floor. He said if he noticed an opened food item on the floor, he would throw it away. Cook #1 said he did not pay attention to the three packages of tortillas or the box containing cans of tomato sauce being on the floor in the dry storage room. The NHA was interviewed 6/25/26 at 1:54 p.m. The NHA said kitchen staff should check the dry storage room daily to ensure food items and boxes were stored off the floor. He said he would provide an in-service training to dietary aides, cooks, and all kitchen staff on proper food storage.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to:-Ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents’ rooms and high frequency touched areas (call lights, door handles and handrails);-Ensure housekeeping staff followed disinfectant dwell times (amount of time required to ensure germs are eliminated) when cleaning residents’ rooms;-Ensure housekeeping staff performed appropriate hand hygiene between glove changes and after cleaning residents’ toilets; -Ensure housekeeping cleaned only the toilet bowl with the toilet brush; -Ensure staff performed appropriate hand hygiene when moving from dirty to a clean task; and, -Ensure staff wore the appropriate personal protective equipment (PPE) when providing care for a resident requiring device care who was on Enhanced Barrier Precautions (EBP). Findings include:I. Housekeeping failuresA. Professional referenceAssadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 6/28/26 from https.//pubmed.ncbi.nlm.nih.gov. It revealed in pertinent part,"High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment."The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 6/29/26 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/pre ent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part,"High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs."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."B. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy, revised August 2013, was provided by the regional director of clinical services on 6/25/26 at 4:00 p.m. It read in pertinent part, "Manufacturers’ instructions will be followed for proper use of disinfecting (or detergent) products. Disinfecting (or detergent) solutions will be prepared as needed and replaced with fresh solution frequently. Perform hand hygiene after removing gloves."Clean horizontal surfaces (bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Do not use feather dusters. C. ObservationsOn 6/24/26 at 10:41 a.m. housekeeper (HK) #1 was observed exiting room #32. She did not perform hand hygiene after exiting the room. At 10:46 a.m. HK #1 unlocked the cleaning cart and removed a cleaning tray which contained a mold and mildew spray bottle, a scrubbing pad, a toilet brush and three rags. Without performing hand hygiene, she donned gloves and entered room #29 (a double occupancy room) and placed the three rags on the window sill. She placed the cleaning tray on the sink. She emptied the trash next to the sink and placed a new trash bag in it. She then placed the cleaning tray on the top of the trash can. HK #1 sprayed the mold and mildew cleaner into the sink and scrubbed it with the scrubbing pad. She turned on the water and used her gloved hand to rinse the sink with water. She wiped it dry with the first rag. She then used her gloved hand to splash water onto the mirror and wiped it with a paper towel. She dried the sink with a second rag and wiped down the paper towel dispenser and the soap dispenser. She used the first rag to wipe off bed A's overbed table and night stand. She used the second rag to dry them. HK #1 wet the third rag with water and wiped off bed B's overbed table and dropped some of the resident's antacids on the floor. She used her gloved hands and picked the antacids up and placed them back into the medicine cup and placed the medicine cup back onto the overbed table. HK #1 then returned to the cleaning cart to remove the broom and dust pan. She swept the room and picked up the debris and removed her gloves.-HK #1 did not use a disinfectant while cleaning the room or disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HK #1 did not change her gloves and perform hand hygiene after touching the dirty floor with her gloved hands and failed to use a clean rag on each side of the double occupant room. HK #1 removed two mops pads from the mop bucket and rang them out with her bare unwashed hands and dropped them on the floor. Without performing hand hygiene, she donned gloves, placed the mop handle on the first mop pad and mop bed B side of the room and removed the mop pad with her gloved hands. She then placed the mop handle onto the second mop pad and mopped bed A side of the room. She removed her gloves and donned clean ones. -HK #1 did not wash her hands or don gloves when removing the mop pads from the mop bucket solution, after removing the first mop pad from the handle or after removing her gloves. HK #1 removed the mold and mildew cleaner from the tray and emptied the trash. She then sprayed the mold and mildew cleaner on the toilet and the floor around the toilet. She then placed the spray bottle back into the cleaning tray. She removed the toilet brush and scrubbed the toilet bowl, the rim, under the seat, the container used to collect urine that was sitting on the toilet tank, the back of the toilet tank, the back of the toilet lid and the top of the toilet lid. She then used the toilet brush to clean the floor around the toilet. HK #1 used a clean dry rag to wipe off the toilet rim, under the seat, the seat, under the lid, the top of the lid, the tank, the grab bars, the window sill and the handle to open the window. She returned to the cleaning cart, removed two mop pads from the mop bucket and rang them out. -HK #1 did not clean the bathroom from top to bottom/clean to dirty, did not use the toilet brush only for the toilet bowl, did not use a disinfectant while cleaning the bathroom, failed to perform hand hygiene after cleaning the bathroom and failed to remove her dirty gloves before ringing out the mop pads. HK #1 dropped the three mop pads onto the floor and placed the mop handle on the first mop pad and mopped the bathroom. She used her gloved hands to remove the soiled mop pad and placed it into the cleaning tray. She used a second mop pad to mop the bathroom floor a second time and used her gloved hands to remove the mop pad and placed it in the cleaning tray. She removed her gloves and placed the cleaning tray on the cleaning cart. She removed the soiled mop pads from the tray and placed them into a plastic bag. Using her unwashed bare hands she removed a mop pad from the mop bucket and rang it out. She then mopped from the sink to the door. She used her bare hands to remove the mop pad and placed it in the trash bag. She donned gloves and cleaned the bottom of the broom. She removed her gloves and entered room #31.-HK #1 failed to perform hand hygiene after removing her gloves, after touching the soiled mop pads with her bare hands, before removing a new mop pad, after cleaning room #29 and prior to entering room #31.-Cross reference F945: failure to provide infection control training. D. Staff interviewsHK #1 was interviewed on 6/24/26 at 1:34 p.m. HK #1 said the mold and mildew cleaner had a one minute kill time. She said the mop water contained a cleaner, but she was not sure what the cleaner was. She said she should have performed hand hygiene between glove changes and every chance she had. She said she was nervous and forgot to perform hand hygiene. She said the bathroom should be cleaned last. She said she cleaned the toilet first and then the grab bars. She said the toilet brush should be used for the toilet bowl and the rim. She said she did not know what high touch surfaces were. She said she did not receive infection control training at the facility and went by her previous experience. The maintenance director was interviewed on 6/24/26 at 4:11 p.m. The maintenance director said normally the housekeeping supervisor provided the infection control training to the housekeeping staff; however, the housekeeping supervisor no longer worked at the facility. He said he provided one-to-one education with the HK's individually on hand hygiene and the proper cleaning process. He said the resident rooms should be cleaned from top to bottom and clean to dirty. He said higher areas should be cleaned first down to the floor. He said a clean rag should be used to clean each side of a double occupancy room, the sink and the bathroom. He said he was not sure if the bathroom should be cleaned first or last. He said the toilet brush should only be used to clean the toilet bowl, not the entire toilet or the floor. He said high touch surfaces should be cleaned daily. He said he provided education to HK #1 the prior day on disinfecting high touch surfaces. He said HK #1 should have performed hand hygiene after each glove change and after cleaning the toilet. He said acid bathroom and shower disinfectant should have been used for the bathroom. He said the hydrogen peroxide disinfectant, with a one minute kill time, should have been used to disinfect the room and high touch surfaces. The maintenance director said the facility was short a HK and he instructed HK #1 to just concentrate on the sink, toilet and floors the day of the observation. The director of nursing (DON) was interviewed on 6/25/26 at 9:25 a.m. The DON said hand hygiene should be performed before entering a resident room, upon exiting a resident room, between glove changes and after cleaning the bathroom. She said the toilet brush should only be used inside the toilet bowl and should not be used for cleaning anything else. She said if a rag was used to clean the toilet it should not be used to clean any other surfaces. She said the correct chemicals should be used to ensure the resident rooms were disinfected properly to prevent the spread of infection. She said a different rag should be used to clean each side of a double occupancy room, the sink and the bathroom. She said the room should be cleaned from top to bottom or clean to dirty and the high touch surfaces should be disinfected daily. The infection preventionist (IP) was interviewed on 6/25/26 at 11:46 a.m. The IP said hand hygiene should be done between everything including glove changes and before and after exiting a resident room to avoid cross contamination. She said she had only been the IP for two weeks. She said it was important to use the correct disinfectants as well as kill time or the areas would not be disinfected properly. She said high touch surfaces should be disinfected daily and the room should be cleaned top to bottom and clean to dirty to prevent cross contamination. She said the antacids that fell to the floor should have been thrown away. She said the toilet brush should only be used inside the toilet bowl. She said she would provide education to all staff regarding infection control. II. Ensure staff wore the appropriate personal protective equipment (PPE) when providing care for a resident requiring device care who was on Enhanced Barrier Precautions (EBP)A. Professional referenceAccording to the Center for Disease Control (CDC), Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/25), retrieved on 6/30/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, “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 EBP include device care and use of central lines, urinary catheters, feeding tubes and tracheostomy/ventilator use.”B. Facility policy and procedure The EBP policy and procedure, revised December 2024, was received from regional director of clinical services #2 on 6/25/26 at 4:00 p.m. It documented in pertinent part, “EBPs are utilized to prevent the spread of MDROs to residents. EBP apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device and does not have secretions or excretions that are unable to be covered or contained. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include device care or use.” C. Observations During a continuous observation on 6/23/26, from 2:02 p.m. to 2:22 p.m., the following was observed:At 2:02 p.m. registered nurse (RN) #1 was providing care to observed working with Resident #62. RN #1 gathered supplies, entered Resident #62’s room, washed her hands, donned (put on) clean gloves and hooked up a syringe to Resident #62’s gastrostomy tube (G-tube). RN #1 flushed the tube with water, administered medication and flushed the tube with water. RN #1 administered Resident #62’s tube feeding formula and flushed with water. RN #1 plugged Resident #62’s G-tube to close it.-RN #1 did not don a gown for high-contact care activities while working with Resident #62’s G-tube. III. Ensure staff performed appropriate hand hygiene when moving from dirty to a clean taskA. Facility policy and procedure The Hand Washing/Hand Hygiene policy and procedure, revised October 2023, was received from regional director ofclinical services #1 on 6/25/26 at 4:00 p.m. It documented in pertinent part, “This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated before moving from work on a soiled body site to a clean body site on the same resident. During a continuous observations on 6/24/26, from 11:58 a.m. to 12:16 p.m., the following was observed: Certified nursing aides (CNA) #1 and CNA #2 entered Resident #62’s room to provide care and get her up for lunch. CNA #1 washed her hands and donned clean gloves and a gown. CNA #1 entered Resident #62’s room and began to provide perineal care. CNA #1 cleaned Resident #62 as she had urine in her brief and a bowel movement in her brief. CNA #2 entered the room and assisted CNA #1 with rolling Resident #62 to get a clean brief under her. CNA #1 secured the clean brief and began to put on Resident #62’s pants. CNA #1 and CNA #2 rolled Resident #62 to get her pants pulled up and place a Hoyer (mechanical lift device) sling underneath her bottom. CNA #1 hooked the sling up to the lift device. CNA #1 lifted Resident #62 in the air and CNA #2 guided the wheelchair in place for Resident #62 to sit in. Once Resident #62 was securely in the wheelchair, CNA #1 and CNA #2 removed the Hoyer sling from the lift device and CNA #2 removed the sling from under Resident #62. CNA #1 and CNA #2 changed Resident #62’s shirt. CNA #1 cleaned Resident #62’s face with a clean washcloth. CNA #1 removed the gloves and gown, washed her hands and stepped out of the room. -CNA #1 did not change her gloves or complete hand hygiene after cleaning Resident #62’s perineal area after she had an incontinent episode of urine and bowel movement. B. Staff interviews CNA #1 was interviewed on 6/24/26 at 12:16 p.m. She said she was supposed to change her gloves and wash her hands after completing perineal care on a resident. She said she forgot to do this during the observation. RN #2 was interviewed on 6/24/26 at 1:25 p.m. She said residents with a G-tube should be on EBP. She said a gown and gloves should be worn during device care including administering medications and tube feeding. She said this was important because any access from outside to the inside of someone’s body increased the risk of transmitting bacteria into the body. The director of nursing (DON) was interviewed on 6/24/26 at 3:25 p.m. She said EBP were important to protect residents and staff from infections. The DON said staff should wear gloves and a gown when providing high contact care including G-tube device care. The DON said gloves should always be changed after completing a dirty task such as perineal care and hands should be washed. She said this was to prevent cross contamination from bacteria in a dirty task to the next task. The IP was interviewed on 6/25/26 at 11:45 a.m. The IP said hand hygiene was important to be completed after completing a dirty task for basic infection control measures and to prevent cross contamination. The IP said gloves and gowns should be worn when working with residents on EBP. She said residents on EBP were more susceptible to antibiotic resistant bacteria and it was for their protection. She said a gown and gloves should be worn during G-tube care including tube feeding and medication administration. C. Additional observations On 6/24/26 at 9:59 a.m. Resident #6’s coccyx wound was observed with LPN #1. There was a sign on Resident #6’s door that 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. Gowns and gloves were located in a storage bin outside of the residence room. LPN #1 donned gloves before removing Resident #6 wound dressing. -LPN #1 failed to put on a gown before providing Resident #6 with direct care. On 6/25/26 at 10:08 a.m. LPN #2 was assisting Resident #9 with rolling to his left side, and then to a sitting position on his bed. LPN #2 assisted Resident # 9 with removing his sweater. LPN #2 used his stethoscope to auscultate the resident's left upper arm to check his AV fistula (a surgically created connection between an artery and a vein, used for hemodialysis access). -LPN #2 failed to put on a gown before providing Resident #9 with direct care. D. Additional staff interviewsLPN #2 was interviewed on 6/25/26 at 10:10 a.m. LPN #2 said he was unsure if Resident #9 was on precaution. LPN #2 said he checked Resident #9’s chart and discovered the resident was on EBP. He said the resident did have a physician's order for EBP. He said he should have worn a gown when providing care and assessing the resident's AV fistula. He said he did not do that because the resident did not have signage on his door indicating he was on EBP. He said the IP was responsible for placing signage on the resident's door and obtaining PPE to be placed outside of the resident's door. The IP was interviewed on 6/25/26 at 11:46 a.m. The IP said any resident who had a wound and/or an implanted medical device would be placed on EBP. The IP said she was responsible for placing EBP signage on the resident's door, placing a storage bin containing PPE outside the resident's room, and ensuring the resident had a physician in the medical records. Said this was important because residents who meet the criteria for EBP were more susceptible to contracting bacteria and developing an infection. She said it was the facility's responsibility to ensure facility staff were following EBP recommendations with all high-contact care. She said LPN #1 and LPN #2 should have donned a gown in addition to donning gloves before providing direct care.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. Chapter 5 (15.6 E and F) RESIDENT TRANSFER, DISCHARGE OR ROOM CHANGEFacility must provide the resident and a family member or legal representative with written notice of such intent to be received at least 5 days before such move, including an explanation on their right to appeal. Chapter 5 (10.1 A) SOCIAL SERVICES Social services staff shall be involved in the pre-admission process, providing input as to appropriateness of placement from a psycho-social perspective, except in emergency admissions. Such involvement may include contact with the prospective resident or resident representative, or interdisciplinary conferences that consider psycho-social issues as well as medical/nursing criteria. Chapter 5 (19.4 E) Pharmaceutical ServicesPeriodic inspection of all pharmaceutical supplies, medications and procedures on all resident care units including inspection of prescription labels, expiration dates, storage and emergency kit procedures. Chapter 5 (9.8 A) MEDICATION ADMINISTRATIONMedications and treatments shall be given only as ordered by a practitioner. Medications shall be administered by medication certified or licensed nursing personnel as allowed within the individual’s license or certification scope of practice. Chapter 5 (7.3 B 1.2.3) PRESSURE ULCER PREVENTION AND CAREAs part of the requisite care plan, develop an individualized treatment plan that is designed to alleviate the condition; provide active treatment to improve the condition in accordance with the treatment plan; and evaluate the resident's progress and treatment at least weekly and revise the treatment plan as needed. Chapter 5 (7.11 A) GroomingThe facility shall assist the resident to obtain appropriate personal care materials and assist with personal care in a manner that preserves resident dignity and privacy. Chapter 5 (13.11) EQUIPMENTThe facility shall provide equipment of sufficient amount and adequate type for efficient and timely preparation of meals.

A recertification survey was conducted from 6/22/26 to 6/25/26. Eleven deficiencies were cited.

An Emergency Preparedness survey was conducted from 6/22/26 to 6/25/26. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for one (#18) of four residents reviewed for notifications out of 35 sample residents. Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #18 and/or the resident’s representatives. Findings include:I. Facility policy and procedureThe Change of Room or Roommate policy, undated, was provided by regional director of clinical services #2 on 6/25/26 at 4:33 p.m., The policy read in pertinent part,“It was the policy of the facility to conduct room and roommate changes in a manner that protects resident rights, dignity, choice, privacy, and safety. Room changes shall occur only when requested by the resident or when clinically, operationally, or environmentally necessary to meet resident care needs or ensure the health and safety of residents.“Residents have the right to receive advance notice of involuntary room changes and the opportunity to appeal such changes in accordance with state and federal regulations.”II. Resident #18A. Resident statusResident #18, age 77, was admitted to the facility on 4/22/25. According to the June 2026 computerized physician orders (CPO), diagnoses included cognitive function and awareness deficit, adult failure to thrive, weakness, and a vitamin D deficiency. The 4/16/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was independent with eating, oral hygiene, toileting hygiene, and chair-to-bed transfers. He required set-up or clean up assistance with showers and bathing, upper body dressing, and lower body dressing B. Resident interviewResident #18 was interviewed on 6/24/26 at 1:26 p.m. He said the staff had not come in to talk to him about the room change. He said none of the facility staff had come to explain the room change appeals process. He said he felt like he was forced to change his room because of his insurance status. He said she was not provided anything in writing regarding his room change. The resident said he was already settled into his new room. C. Record reviewThe notice of room change notification form, dated 6/8/26, revealed a verbal okay was obtained from Resident #18 to change rooms for bed management. The form documented consent was given verbally and was signed by the social services director (SSD).-However, there was no documentation in Resident #18’s electronic medical record (EMR) to indicate the facility provided the resident with written notification of the room change. D. Staff interviewThe SSD was interviewed on 6/23/26 at 3:12 p.m. The SSD said Resident #18 changed rooms because he was not getting along with his roommate at the time. She said room moves were discussed in the interdisciplinary team (IDT). She said a room change authorization form should be filled out for each resident room change or when a resident got a new roommate. She said residents were informed of the move. She said she was responsible for completing room change forms. She said she would give the resident and the roommate a five-day notice of the room change. She said she told the resident to notify her if he would like to appeal the room change. She said she did not document the appeal details in the resident's chart, or that she told the resident that he had an opportunity to appeal. She said she filled out the notice of room change one day later because she wants to get her documentation done ahead of time. -However, the room change form did not indicate a 5-day notice of appeals was given to Resident #18. The director of nursing (DON) was interviewed on 6/24/26 at 2:53 p.m. The DON said the SSD would notify a resident of the room change. She said if a resident disagreed with the room change, the resident had the opportunity to appeal. The DON said Resident #18 was told about the room change on Monday, 6/8/26. She said the resident was moved to his new room on 6/9/26. She said she updated their room change policy to notify the resident of the five-day appeal option in the event of a room change. She said the reason for giving residents a five-day appeal option was to give the resident a chance to adapt to the room change. She said she would ensure residents received the details of the five-day appeal option in writing regarding room changes.

Based on record review, and interview, the facility failed to provide choices for preference for one (#5) of two residents reviewed for self-determination out of 35 sample residents. Specifically, the facility failed to provide Resident #5 showers per her preference. Findings include:I. Resident #5A. Resident statusResident #5, age under 65, was admitted on 8/15/26. According to the June 2026 computerized physician orders (CPO), diagnoses included paraplegia and end stage renal disease. The 6/10/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. The resident required substantial to maximal assistance from staff for personal hygiene and showers. B. Resident interviewResident #5 was interviewed on 6/22/26 at 1:02 p.m. Resident #5 said she missed showers recently. She said she had dialysis on Mondays, Wednesdays and Fridays, so she preferred her showers on Tuesdays and Saturdays. She said she had talked to staff about this, but was not receiving showers per her preference. C. Record reviewReview of the resident's comprehensive care plan did not include preferences or specific days for showers. Review of the resident’s electronic medical record (EMR) revealed the resident's shower preferences were obtained, undated, and revealed the resident preferred her showers twice weekly on Monday and Thursday afternoons. Shower records for the last three months, from 3/24/26 to 6/23/26 revealed the resident received showers on 16 occasions out of a possible 35 opportunities (if offered twice weekly per her preference). D. Staff interviewsCertified nurse aide (CNA) #1 and CNA #2 were interviewed on 6/24/26 at 9:50 a.m. CNA #1 said Resident #5 had dialysis on Mondays, Wednesdays and Fridays and always refused showers on the days she went out to dialysis. CNA #1 said the EMR prompted the shower schedule. CNA #1 said Resident #5’s shower days were on Tuesdays and Saturdays and she preferred them in the evening time. Registered nurse (RN) #2 was interviewed on 6/24/26 at 1:25 p.m. She said she did not know the shower schedules and would defer to the CNA caring for Resident #5. RN #2 said she was not aware of Resident #5 refusing showers. RN #2 said if a resident refused a shower, the CNA should let the nurse know so the nurse could talk to the resident about it. RN #2 said the nurse should document a progress note in addition to filling out a shower refusals sheet that the resident signed. The director of nursing (DON) was interviewed on 6/24/26 at 3:25 p.m. She said she was not aware of Resident #5 missing any showers. The DON said Resident #5’s current shower schedule was on Tuesdays and Fridays. The DON said she was not aware of Resident #5’s preference for showers on Tuesdays and Saturdays due to dialysis on Fridays. The DON said if a resident refused a shower, it should be documented in a progress note and on a shower refusal sheet.

Based on record review and interviews, the facility failed to provide and document sufficient discharge preparation for two (#57 and #59) of two residents reviewed for a safe and orderly discharge out of 35 sample residents. Specifically, the facility failed to ensure a written discharge bed hold notice was provided to Resident #57 and Resident #59 or their representative at the time Resident #57 and Resident #59 were transferred to the hospital. Findings include:I. Facility policy and procedureThe Bed Hold Notice policy, undated, was provided by the regional director of clinical services on 6/24/26 at 9:59 a.m. It read in pertinent part, "It is the policy of the facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave."Bed hold means holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. To include the duration of the State bed hold policy, if any, during which the resident is permitted to return and resume residence in the facility."In the event of an emergency transfer of a resident, the facility will provide written notice of the facility’s bed-hold policies to the resident and/or the resident representative within 24 hours. The facility will document multiple attempts to reach the resident’s representative in cases where the facility was unable to notify the representative."II. Resident #57A. Resident statusResident #57, age 74, was admitted on 12/22/25 and discharged to the hospital on 6/12/26. According to the June 2026 computerized physician orders (CPO), diagnoses included chronic kidney disease, hypertension, repeated falls, anxiety disorder and muscle weakness. The 3/26/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. B. Record reviewA nursing progress note, dated 6/12/26 at 9:35 p.m., revealed Resident #57 had an unwitnessed fall in the bathroom with injury to his left middle finger with pain and discomfort. The resident was transferred to the emergency department for evaluation and treatment of the dislocated middle finger. -Review of Resident #57's electronic medical record (EMR) revealed no documentation to indicate Resident #57 and/or his representative were provided with a written bed hold notice at the time of the resident's transfer to the hospital on 6/12/26. III. Resident #59A. Resident statusResident #59, age 70, was admitted on 12/11/25 and discharged 3/31/26. According to the March 2026 CPO, diagnoses included chronic respiratory failure, end stage renal disease, heart failure and muscle weakness. The 3/16/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. B. Record reviewA nursing progress note, dated 3/31/26 at 4:21 p.m., revealed the resident was working with restorative therapy in the gym. Resident #59 had appeared to have seizure type activity. A call was placed to the provider and the resident was sent to the emergency room for evaluation and treatment. -Review of Resident #59's EMR revealed no documentation to indicate Resident #59 and/or her representative were provided with a written bed hold notice at the time of the resident's transfer to the hospital on 3/31/26. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 6/24/26 at 3:07 p.m. LPN #1 said when a resident was transferred to the hospital they should be provided with a bed hold notice. She said if the resident was not able to sign the notice the nurse would document the verbal acceptance of the bed hold notice. She said it was important to provide the resident with the bed hold to ensure the resident's bed was secure for their return. The unit manager was interviewed on 6/24/26 at 3:11 p.m. The unit manager said a residentshould be provided with a bed hold notice if they were transported to the hospital. He said the bed hold policy was provided to ensure the resident's bed was held for their return to the facility. The director of nursing (DON) was interviewed on 6/24/26 at 93:15 p.m. The DON said a bed hold notice should be provided to a resident when sent to the emergency department to ensure the bed would be held for them upon return. She said if the resident was not able to sign the form they would notify the responsible party and receive verbal confirmation that the bed hold notification was provided. She said she was not sure why Resident #57 and Resident #59 were not provided with a bed hold notice.

Based on record review, observations, and interviews, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services for one (#1) of three residents reviewed for ADLs out of 35 sample residents. Specifically, the facility failed to ensure Resident #1 received scheduled showers. Findings include:I. Facility policy and procedureThe Bath, Shower/Tub policy, undated, revised February 2018, was provided by the regional director of clinical services #2 on 6/25/26 at 4:33 p.m., The policy read in pertinent part,“The purposes of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin.“Be sure that the bath area is at a comfortable temperature for the resident. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. Use the emergency call signal for assistance, if needed. When transporting the resident to and from the bath area, make sure that the resident is covered and his or her privacy is maintained.“Document the date and time the shower/tub bath was performed. The name and title of the individual who assisted the resident with the shower/tub bath. All assessment data (any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. How the resident tolerated the shower/tub bath. If the resident refused the shower/tub bath, the reason(s).“Reporting: Notify the supervisor if the resident refuses the shower/tub bath. Notify the physician of any skin areas that may require treatment. Report other information in accordance with facility policy and professional standards of practice.”II. Resident #1A. Resident statusResident #1, age 70, was admitted to the facility on 5/18/22, sent to the emergency room on 5/21/26, and readmitted on 5/24/26. According to the June 2026 computerized physician orders (CPO), diagnoses included traumatic brain injury, cognitive communication deficit, difficulty walking, unsteadiness on feet, obesity, dependence on wheelchair, need for assistance with personal care, cardiovascular accident (stroke), and multiple sclerosis. The 5/31/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He needed substantial to maximal assistance with toileting hygiene, showers and bathing, upper body dressing, sitting to standing, and chair to chair/bed transfer. He was dependent on staff for lower body dressing and putting on and taking off footwear. B. Resident observations and interview Resident #1 was interviewed on 6/23/26 at 11:00 a.m. During the interview, Resident #1 was sitting in his wheelchair in his room, positioned next to his bed. There was an adult brief unfolded, lying on the resident's bed. The resident smelled of urine and stool. The resident had food stains on his shirt. Resident #1 said he received a shower yesterday (6/22/26) for the first time in two weeks. He said he would often go up to two weeks without getting a shower. D. Record reviewThe ADL care plan, initiated 5/19/22 and revised on 7/14/22, revealed the resident had an ADL self-care performance deficit related to CVA with right-sided neglect and multiple sclerosis. Pertinent interventions included scheduling bathing per resident's preferences. Requires extensive physical assistance. Encourage showers at least twice weekly, and if the resident refuses, encourage an alternative time or next shower day. The resident requires one staff maximum assistance with bathing. Offer to clean and trim nails as needed. The resident requires extensive-total assistance with toileting tasks (revised on 6/2/26). Encourage the resident to use the bell to call for assistance as needed. A review of the bathing documentation for May 2026 and June 2026 revealed a preference for showers on Monday and Thursday evenings. Review of the May 2026 bathing documentation indicatedthe resident received a shower on 5/25/26 and 5/28/26. -It indicated the resident received a shower on two of seven opportunities. Review of the June 2026 (6/1/26 to 6/15/26) bathing documentation indicated the resident received a shower on 6/9/26.-It indicated the resident received a shower on one of five opportunities. -The resident did not receive a shower or bath from 5/29/26 to 6/8/26 (10 days) and from 6/10/26 to 6/21/26 (11 days).-A review of Resident #1's electronic medical record (EMR) revealed no documentation to indicate why Resident #1 did not receive his showers as scheduled. E. Staff interviewsCertified nurse aide (CNA) #7 was interviewed on 6/23/26 at 3:10 p.m. She said if a resident refused a shower, she would have another staff member offer the resident a shower a second time. She said she would document the refusal in the resident point of care section in the EMR. She said the facility had a shower refusal binder. She said if a resident refused a shower, the staff would have the resident sign a refusal sheet and place it in the binder. She said she had not recalled the resident refusing his showers in the past. She said Resident #1 did not refuse showers. CNA #6 was interviewed on 6/24/25 at 11:20 a.m. CNA #6 said Resident #1 required assistance for going to the bathroom and taking his showers. She said Resident #1 was scheduled for showers twice a week. She said if Resident #1 refused a shower, the nursing staff were required to document the refusal in the facility shower refusal binder. She said she was unsure if the resident refused his showers. The director of nursing (DON) and regional director of clinical services #2 were interviewed together on 6/24/26 at 2:42 p.m. The DON said the staff were provided training for bathing hygiene upon hire. She said Resident #1's shower days were Mondays and Thursdays. She said if a resident refused an offer of a shower or a bath, the staff were expected to reapproach the resident and offer the shower a second time. Resident #1 should have received his showers on his scheduled preferred shower days. Regional director of clinical services #2 said she would provide an in-service immediately to the nursing staff to educate them on the facility policy regarding providing resident showers and providing residents prompt incontinence care.

Based on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries and prevent additional pressure injuries for one (#6) of two residents out of 35 sample residents. Specifically, the facility failed to ensure thorough documentation of weekly wound assessments to track the progression of a chronic pressure injury for Resident #6. Findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 6/26/26 from https://www.internatinoalguidline.com/2019 "Pressure ulcer classification is as follows:"Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk)."Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation."Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle were not exposed. Slough may be present but did not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable."Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable."Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed."Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.“Pressure injury assessment includes an evaluation of the pressure injury size and physical characteristics“Assess and document physical characteristics of the pressure injury, including: Anatomical location, category/stage, size and surface area, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining and tunneling, exudate and odor”II. Facility policy and procedureThe Pressure Injury Risk Assessment policy and procedure, revised April 2026, was provided by regional director of clinical services #2 on 6/25/26 at 4:00 p.m. It read in pertinent part,“The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries.“The purpose of a pressure injury risk assessment is to identify resident risk factors for pressure injury. Risk factors that increase a resident’s susceptibility to develop or not heal pressure injuries include, but are not limited to; prolonged mechanical load on the skin and underlying soft tissue, under nutrition, malnutrition, and hydration deficits, impaired/decreased mobility and decreased functional ability, and the presence of previously healed pressure injuries.“Document the following in the resident’s medical record. The date and time assessment is conducted. Findings of the pressure injury risk assessment and skin assessment. The date and time and type of skin care provided, if appropriate. The name and title (or initials) of the individual who conducted the assessment. Any change in the resident’s condition, if identified. How the resident tolerated the procedure or their ability to participate in the procedure. Any problems or complaints made by the resident related to the procedure. If the resident refused the treatment, the reason for refusal and the resident’s response to the explanation of the risks of refusing the procedure, the benefits of accepting, and available alternatives.”III. Resident #6A. Resident statusResident #6, age greater than 65, was admitted on 7/8/24 and readmitted on 1/13/26. According to the June 2026 computerized physician orders (CPO), diagnoses included demyelinating diseases of the central nervous system, paraplegia, chronic obstructive pulmonary disease, congestive heart failure, protein calorie malnutrition, and artificial opening of the urinary tract. The 2/4/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #6 was independent with eating and with the use of a motorized scooter. Resident #6 required partial to moderate assistance with oral hygiene, personal hygiene, toileting hygiene, rolling left to right, chair and bed to chair transfers and tub and shower transfer. Resident #6 required substantial to maximal assistance with showering and bathing himself, upper and lower body dressing. The MDS assessment revealed the resident did not have any unhealed pressure injuries. B. Resident interview Resident #6 was interviewed on 6/23/26 at 10:26 a.m. Resident #6 said he had had a wound on his coccyx for a long time. He said his wound completely healed, then reopened because he liked to sit in his motorized wheelchair. He said the nurses were treating his wound with a dressing that was changed every other day. He said the staff offered to reposition him but he was more comfortable not moving in bed and lying on his back. He said he was not able to reposition himself in bed because of his arm strength. He said he was unsure how big his wound was because the nurses never told him what it looked like. He said the wound did not hurt. C. Observation On 6/24/26 at 9:59 a.m. Resident #6’s coccyx wound was observed with licensed practical nurse (LPN) #1. A quarter-size wound was noted on the resident’s coccyx area with loss of skin and red tissue at the center of the wound that was exposed. The wound had a crater-like opening with a scant amount of reddish drainage. No exposure of bone was visualized. The resident did not demonstrate signs of any pain or discomfort during this observation. D. Record reviewResident #6’s care plan, initiated 7/8/24 and revised 2/3/26, documented Resident #6 was admitted with stage four pressure ulcers to his sacrum and the wounds were resolved on 1/15/26. The resident was at risk for further skin breakdown and/or slow and delayed healing related to paraplegia, edema, heart failure, and bowel incontinence. Interventions included administering medications as ordered, administered treatment as ordered, nutrition or hydration interventions to manage skin problems, pressure reduction cushion for chair and pressure reduction mattress for bed. -However, the care plan for Resident #6 failed to include interventions for skin assessments and documentation. A review of Resident #6’s June 2026 CPO revealed the following physician’s orders related to Resident #6’s sacral wound: Admitted to hospice for demyelinating disease of the central nervous system, ordered 10/24/25. Barrier ointment to coccyx area twice daily and PRN (as needed) with incontinence, ordered 2/26/26. Please open and complete the nursing weekly summary note every night shift on Fridays, ordered 4/24/26.-However, the nursing weekly summary failed to include wound assessments. Monitor chronic wound to the coccyx. Notify hospice of any signs and symptoms of worsening of the wound, ordered 5/28/26.-However, there was no documentation in the resident’s electronic medical record (EMR) to indicate the facility was consistently monitoring the resident’s wound. Wound care to the coccyx: cleanse with sterile water, pat dry, skin prep to the periwound only place on intact skin. Cut to fit wound bed (CollagenSilver), cover with silicone superabsorbent dressing, ordered 5/28/26 and discontinued 6/23/26. Cleanse the pressure area to the sacrum with Dakin’s solution (topical antiseptic), apply skin prep to the peri-wound area, apply calcium alginate with silver to the wound bed, and cover with a soft foam dressing. Change every other day and as needed (PRN), ordered 6/23/26. Wound measurements and skin issue evaluations to be completed weekly by nurse and PRN, ordered 6/25/26 (during the survey).-The physician’s orders for wound measurements and skin issue evaluation to be completed weekly were not initiated until after the start of the survey. The nursing change of condition note, dated 5/28/28 at 4:44 p.m., revealed the resident had a new pressure ulcer. The note documented the primary care provider feedback noted that hospice recommended to consult with wound care providers to advise on best treatment options.-However, there was no documentation in the resident’s EMR to indicate the facility consulted with a wound care provider regarding the resident’s wound. A skin issues nursing note, dated 6/25/26 at 8:57 a.m., revealed Resident #6 had a new pressure injury located at his coccyx. The note revealed the wound was acquired in-house. The note documented the following measurements for the wound:. length in centimeters (cm): 1.6, width (cm): 0.2, and depth (cm): 0.2. The wound was 20% epithelial tissue (new tissue forming over skin injury) and . 80% granulated tissue (beefy red new connective tissue in a wound). The wound had a moderate amount of exudate (fluid leaking from tissue) that was serous fluid (clear watery fluid). The wound had a faint odor after cleansing. There was no swelling or edema and normal tissue surrounded the wound. -However, the wound skin evaluation not with wound measurements was not completed until after the concern was brought to the attention of the facility during the survey. IV. Staff interviewsLPN #1 was interviewed on 6/24/26 at 10:10 a.m. LPN #1 said the main goal was to maintain Resident #6’s comfort because he was receiving hospice care services. She said the facility had a wound care nurse who was responsible for conducting wound assessments and documenting wound measurements. She said the resident’s wound was not getting better or worse and did not look to be infected. She said the drainage had not increased and the wound did not look inflamed. She said she thought the wound reopened because the resident liked to sit in his motorized wheelchair and refused repositioning when offered by facility staff. LPN #2 was interviewed on 6/24/26 at 1:10 p.m. LPN #2 said he was recently hired as the wound care nurse for the facility. He said Resident #6 had a wound on his coccyx that reopened last month (May 2026). He said the wound started because the resident was noncompliant with limiting his time in his motorized wheelchair. He said the resident had a chair cushion and a bed cushion. He said he was responsible for measuring and documenting wounds, however he did not think it needed to be done for Resident #6 because the resident was receiving hospice care services. The director of nursing (DON) and regional director of clinical services #2 were interviewed together on 6/24/26 at 1:53 p.m. The DON said she had worked as the facility’s DON since August 2025. She said the facility’s nurses would assess any newly developed wounds, document a skin assessment, and also document any change of condition in the resident's EMR. The DON said the nursing staff should notify the facility’s physician of the presence of a new pressure injury. The DON said that depending on what a wound looked like, the facility would initiate a referral for the resident to see a wound care physician. The DON said the facility’s nurses were expected to assess, measure, and document new pressure injuries and continue with wound measurement weekly to establish a baseline and monitor the progression of the wound. The DON said Resident #6 was not referred to see a wound care physician because he was receiving hospice care services. The DON said Resident #6’s stage 3 wound was present upon the resident’s admission to the facility. She said the wound was healed in January 2026. She said the wound reopened on 5/28/26. She said the facility staff completed a change of condition note in the residents EMR. She said the change of condition note did not include a detailed description of the resident's wound. She said the wound started because of the resident's comorbidities and his nutritional decline. She said the primary care physician was advised of the reopened wound. The DON said the physician advised the facility to call and notify the hospice care services provider for treatment orders. The DON said hospice provided treatment orders for Resident #6’s wound on 5/28/26. She said she was not aware that hospice recommended having the resident follow up with a wound care provider. Regional director of clinical services #2 said she would start a re-education and training for the nursing staff immediately. She said the training would include how and when to perform wound assessments. She said the training would have a focus on how to actually measure and document any new pressure injuries. The infection preventionist (IP) was interviewed on 6/24/26 at 4:54 p.m. The IP said she was not involved in wound management for facility residents or for Resident #6. She said she was unaware of when the wound started or the description of the wound. She said symptoms of an infection of a wound would include warmth, redness, fever, increased drainage and pain at the site of the wound. She said if a resident had multiple symptoms, she would be concerned of the resident possibly having an infection. The DON was interviewed again on 6/25/26 at 9:05 a.m. The DON said she did not believe Resident #6’s sacral wound was infected because the resident presented no additional signs and symptoms of infection. The DON said that when the wound was noted to have an odor on 6/21/26, the hospice care services provider was notified and new treatment orders were obtained. The DON said the hospice care services provider wanted to see if the new treatment orders were effective before moving to additional treatment options. She said Resident #6 would be followed by the wound care physician starting 6/30/26. She said the former wound care nurse did not document the wound measurements for Resident #6 because it was assumed the hospice nurses were doing the wound documentation. The DON said moving forward, the facility nurses would be responsible for wound care documentation, even if the resident was receiving hospice care services. -However, the appointment for Resident #6 to see a wound care physician was not made until the concern was brought to the facility’s attention during the survey (see record review above).

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%). Specifically, the facility’s medication error rate was 8.57%, or three errors out of 35 opportunities for error. Findings include:I. Facility policy and procedureThe Administration of Medication policy and procedure, revised April, 2019 was provided by the regional director of clinical services on 6/25/26 at 4:33 p.m., The policy read in pertinent part,“Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience.“Factors that are considered include: enhancing optimal therapeutic effect of the medication; preventing potential medication or food interactions; and honoring resident choices and preferences, consistent with his or her care plan.“Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).“The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.“During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident’s room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.“As required or indicated for a medication, the individual administering the medication records in the resident’s medical record: the date and time the medication was administered; the dosage; the route of administration; the injection site (if applicable); any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed; and, the signature and title of the person administering the drug.”II. Medication administration observations On 6/24/26 at 9:21 a.m. licensed practical nurse (LPN) #4 prepared to administer medications to Resident #41. LPN #4 checked Resident #41’s blood sugar. The blood sugar was 160 milligrams per deciliter (mg/dl). LPN #4 went back to the medication cart and retrieved Resident #41’s medications. On 6/24/26 at 9:30 a.m. LPN #4 retrieved the NovoLog insulin pen and the Lantus insulin pen. Both pens were labeled with Resident #41's name on them. LPN #4 administered 20 units of NovoLog insulin into the resident's left arm and 32 units of Lantus insulin into the resident's right arm. Review of Resident #41’s June 2026 computerized physician’s orders (CPO) revealed the following physician’s orders: Lantus (insulin glargine) given once a day, subcutaneously at 8:00 a.m.; and,NovoLog (insulin aspart) given once a day, subcutaneously at 8:00 a.m.-Both insulin doses were ordered to be given at 8:00 a.m. LPN #4 administered both insulin doses were 30 minutes late. On 6/24/26 at 10:23 a.m., registered nurse (RN) #2 prepared to administer medications to Resident #13. RN #2 dispensed the resident’s medications into a medication cup, including one 75-milligram (mg) oral tablet of Lyrica (medication used to treat nerve pain). She administered the medication to the resident. Review of Resident #13’s June 2026 CPO revealed the following physician’s order:-Lyrica oral capsule 100 mg (pregabalin). Give one capsule by mouth three times a day for neuropathic pain, ordered 6/24/26.-However, Resident #13 was to receive one tablet of Lyrica 100 mg. IV. Staff interviews LPN #4 was interviewed on 6/24/26 at 9:40 a.m. LPN #4 said the insulin doses were administered late because she was waiting for Resident #41 to return from the dining room. RN #2 was interviewed on 6/24/26 at 10:30 a.m. RN #2 said she looked at the resident’s orders in the medication administration record (MAR) while dispensing medications to make sure she followed the five rights of medication administration: right name, right time, right dosage, right route and accurate documentation. RN #2 said she did not realize it was the wrong dose when she administered it to the resident. She said she noticed the Lyrica dose had changed in the MAR, but did not check the dose on the medication card as she was dispensing it. RN #2 said she should not have given the Lyrica to the resident, and instead, should have called the pharmacy to get an order to access the lock box for the correct dose. She said she would report the medication error to the doctor and to her director of nursing (DON). The director of nursing (DON) was interviewed on 6/24/26 at 2:38 p.m. The DON said she was notified by RN #2 of the medication error for Resident #13. The DON said she called the provider to report the medication error. She said she obtained a physician's order to continue to administer the 75 mg of Lyrica until the 100 mg of Lyrica could be delivered from the pharmacy. She said Resident #31's pain level was assessed and did not increase. She said if the resident did not have the accurate dosage of pain medication, the nurses could call the pharmacy to access the facility's emergency kit and look for the medications there. She said it was important to receive pain medications promptly so residents did not have pain. The DON said LPN #4 was an agency staff member. She said agency staff and facility staff received education on policies and procedures for medication administration before working at the facility. The DON said she would provide re-education to nursing staff who were responsible for administering medications to facility residents. She said this re-education would include the importance of reviewing medication dosage and administering medications on time.

Based on observations and interviews, the facility failed to ensure all drugs and biologics used in the facility were properly stored and labeled for three of four medication carts. Specifically, the facility failed to:-Ensure prescription medications were discarded after the expiration date and after they were discontinued; and,-Ensure personal beverage containers were not stored in resident medication drawers. Findings include:I. Professional referencesThe United States Food and Drug Administration (USFDA) Don't Be Tempted to Use Expired Medicines (revised 10/31/24) was retrieved on 6/26/26 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, "Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth, and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed, there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it."The PharMerica (1/12/25) abridged list of medications with shortened expirations dates, was retrieved on 6/30/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://pharmerica.com/wp-content/uploads/2025/01/PMC-DYK-Meds-with-Shortened-Expiration-Dates_012025_FINAL.pdf. It read in pertinent part, “Once certain products are opened and in use, they must be used within a specific timeframe to avoid reduced stability, sterility and potentially reduced efficacy. Product-specific storage and expiration details can be found in the drug product’s package insert under the ‘How Supplied/Storage & Handling’ section. A drug product’s beyond use date (BUD) is the manufacturer supplied expiration date or the shortened date after opening, whichever comes first. These in-use medications should be labeled such that the date opened is noted, clearly visible and securely attached to a part of the package to not be discarded. This date is to be referenced when auditing to clear medications prior to expiration.” The Pharmcare USA’s (4/9/23) Medication Disposal Practices in Assisted Living and Long Term Care, was retrieved on 6/30/26 from https://pharmcareusa.com/education/medication-disposal-practices-in-assisted-living-ltc/. It read in pertinent part, “When medications are not disposed of correctly, they can pose serious threats to both human health and the environment. Improper disposal can lead to accidental ingestions, overdose and even death.” The Highlights of Prescribing Information for Symbicort (budesonide and formoterol fumarate dihydrate) Inhalation Aerosol, for oral inhalation use, was retrieved on 6/30/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/205382s013lbl.pdf. It read in pertinent part, “Throw away Symbicort when the counter reaches zero (‘0’) or three months after you take Symbicort out of its foil pouch, whichever comes first.”The Highlights of Prescribing Information for Fluticasone propionate, revised January 2019, was retrieved on 6/30/26 fromchrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/020121s045lbl.pdf It read in pertinent part, “Do not use your FLONASE nasal spray after the date shown as “EXP” on the label or box.”II. Facility policy and procedureThe Medication labeling and Storage policy, revised February 2023, was provided by regional director of clinical services #1 on 6/25/26 at 4:00 p.m. It read in pertinent part, “The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys.“The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.“If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.“Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses’ station or other secured location. Medications are stored separately from food and are labeled accordingly.“Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.“The medication label includes, at a minimum: medication name (generic and/or brand); prescribed dose; strength; expiration date; resident’s name; route of administration; and appropriate instructions and precautions.”III. ObservationsOn 6/23/26 at 12:30 p.m., medication cart #1 on the west unit was observed with licensed practical nurse (LPN) #3. The drawer for Resident #29 contained the following:-Symbicort (budesonide-formoterol) 80-4.5 micrograms (mcg), (a corticosteroid medication used to reduce airway inflammation). The medication was ordered for two puffs twice a day, with 85 doses remaining. The medication did not have an expiration date. On 6/23/26 at 2:58 p.m. medication cart #1 on the north unit was observed with registered nurse (RN) #1. There was a beverage container next to the resident's medication in the second-level drawer. RN #1 removed the beverage container from the medication cart and walked into the medication room. RN #1 left the medication cart unlocked and unattended. On 6/23/26 at 3:10 p.m.medication cart #2 on the north unit was observed with LPN #4. The drawer for Resident #10 contained the following:-Methocarbamol (a medication used to treat muscle pain, spasms, and stiffness) oral tablet 500 milligrams (mg) that had an expiration date of 5/31/26. The expired medication was given to the resident four times on 6/2/26, 6/5/26, 6/6/26 and 6/15/26. The drawer for Resident #5 contained the following:-Fluticasone propionate nasal suspension (a medication used to treat allergies and nasal congestion) 50 micrograms (mcg) over-the-counter medication. The medication did not have an expiration date. IV. Staff interviewsLPN #3 was interviewed on 6/23/26 at 12:33 p.m. She said she always checked the expiration date on all medication before she administered it to a resident. She said she did not notice the inhaler did not have an expiration date on the medication before she gave it to the resident. RN #1 was interviewed on 6/23/26 at 3:02 p.m. She said she was advised to store all personal beverage containers behind the nurses' station. She said she should not store her personal beverage container in the medication drawer to maintain sanitary conditions for the stored medications. LPN #4 was interviewed on 6/23/26 at 3:10 p.m. She said she worked at the facility as an agency nurse. She said she did not know who was responsible for checking the medication carts for expired medications. She said she did not remember checking the medication expiration dates during her shift. The director of nursing (DON) was interviewed on 6/24/26 at 2:23 p.m.: The DON said the facility nursing staff and agency nurses were expected to check the medication storage rooms and the medication carts regularly for expired and discontinued medications. She said the facility pharmacy consultant would come to the facility once a month to audit the medication carts and the medication rooms for expired medication. The DON said in order to ensure the medication drawers were kept clean and sanitary, nursing staff should not store personal beverage containers in the resident medication drawers. She said the facility would conduct an in-service for all facility staff trained to administer medication to check expiration dates.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure kitchen equipment was clean (microwave and blenders), and; -Store food items under sanitary conditions. Findings include:I. Failure to ensure kitchen equipment was clean (microwave and blenders)A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 6/30/26. It revealed in pertinent part, “Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.” (4-601.11)B. Facility policy and procedureThe Sanitization policy, revised November 2022, was provided by the nursing home administrator (NHA) on 6/25/26 at 4:00 p.m. The policy read in pertinent part, “All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair.“All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions.“When cleaning fixed equipment (mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are:-Washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution (at the effective concentration); and,-The equipment is reassembled and any food contact surfaces that may have been contaminated during the process are re-sanitized (according to the manufacturer's instructions).”C. ObservationsThe initial kitchen tour was conducted on 6/22/26 at 8:53 a.m. and the following was observed:-The blender located next to the microwave had food debris that was yellow and sticky on the motor base of the blender. -The microwave located by the steam table had sticky food debris on the interior walls and the ceiling of the cooking cavity.-The blender located near the spice jars shelves had thick, sticky accumulation of food residue built up on the motor base of the blender. A follow-up kitchen tour was conducted on 6/23/26 at 8:51 a.m. and the following was observed:-The blender located next to the microwave remained soiled with food debris on the motor base. -The microwave located by the steam table remained soiled inside.-The blender located near the spice jars shelves remained soiled with food debris on the motor base. D. Staff interviewsDietary aide #1 was interviewed on 6/25/26 at 9:44 a.m. Dietary aide #1 said kitchen staff were responsible for cleaning any equipment they used. He said kitchen staff should clean the entire equipment after use including the blender because sometimes spills could occur. Dietary aide #1 said the cook was primarily responsible for cleaning the blender since the cook used it most frequently. He said failure to properly clean kitchen equipment could result in contamination with germs. Dietary aide #2 was interviewed on 6/25/26 at 10:14 a.m. Dietary aide #2 said there was a kitchen cleaning schedule with assigned responsibilities for kitchen staff. She said the cook was responsible for cleaning the blender after use. Dietary aide #2 said other staff could clean the kitchen equipment when requested. She said having dirty kitchen equipment was not sanitary. Cook #1 was interviewed on 6/24/25 at 8:50 a.m. Cook #1 said kitchen staff should clean the kitchen equipment after each use. He said the blender was used to prepare ingredients and the removable components were cleaned after use. Cook #1 said the microwave was cleaned twice a day or whenever it became dirty after use. He said the kitchen night crew was responsible for cleaning the kitchen equipment; however, all kitchen staff were expected to clean any equipment after use. The NHA was interviewed 6/25/26 at 1:54 p.m. The NHA said there was a cleaning kitchen schedule with assigned responsibilities for kitchen staff. He said staff were expected to adhere to it. He said he was unsure why there were two blenders in the kitchen because it created unnecessary cleaning responsibilities. The NHA said he would provide in-service training to dietary aides, cooks, and all kitchen staff on proper cleaning of kitchen equipment. II. Failure to store food items under sanitary conditionsA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 6/30/26. It revealed in pertinent part, “Food shall be protected from contamination by storing the food in a clean, dry location where it is not exposed to splash, dust, or other contamination and at least six inches above the floor.” (3-305.11)B. Facility policy and procedureThe Food Receiving and Storage policy, revised November 2022, was provided by the NHA on 6/25/26 at 4:00 p.m. The policy read in pertinent part, “Foods shall be received and stored in a manner that complies with safe food handling practices.” “Food in designated dry storage areas are kept at least six inches off the floor (unless packaged for case lot handling, for example, dollies, pallets, racks and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents.”C. ObservationsThe initial kitchen tour was conducted on 6/22/26 at 8:53 a.m. and the following was observed:- One box containing cans of tomato sauce was on the floor in the dry storage room.- Three packages of tortillas were on the floor underneath a shelf in the corner of the dry storage room. A follow-up kitchen tour was conducted on 6/23/26 at 8:51 a.m. and the following was observed:- The box containing cans of tomato sauce remained on the floor in the dry storage room.- The three packages of tortillas remained on the floor underneath a shelf in the corner of the dry storage room. D. Staff interviewsDietary aide #1 was interviewed on 6/25/26 at 9:44 a.m. Dietary aide #1 said all kitchen staff were responsible for placing food items on the shelves after deliveries including the dietary manager. He said if food items were observed on the floor and the packaging were opened, they would throw them away. Dietary aide #1 said if boxes were found on the floor, they should be removed off the floor and placed on the shelves. He said he picked up the three packages of tortillas observed on the floor and threw them away. Dietary aide #1 said storing food items on the floor was not sanitary. Cook #1 was interviewed on 6/25/26 at 10:10 a.m. Cook #1 said every kitchen staff member was responsible for ensuring food items in the dry storage room were stored off the floor. He said if he noticed an opened food item on the floor, he would throw it away. Cook #1 said he did not pay attention to the three packages of tortillas or the box containing cans of tomato sauce being on the floor in the dry storage room. The NHA was interviewed 6/25/26 at 1:54 p.m. The NHA said kitchen staff should check the dry storage room daily to ensure food items and boxes were stored off the floor. He said he would provide an in-service training to dietary aides, cooks, and all kitchen staff on proper food storage.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to its infection prevention program. Findings include:I. Cross-referenced citationsCross-reference F880: The facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. The facility failed to ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents’ rooms and high frequency touched areas (call lights, door handles and handrails), ensure housekeeping staff followed disinfectant dwell times (amount of time required to ensure germs are eliminated) when cleaning residents’ rooms, ensure housekeeping staff performed appropriate hand hygiene between glove changes and after cleaning residents’ toilets and ensure housekeeping cleaned only the toilet bowl with the toilet brush. The facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care for residents requiring device care who were on enhanced barrier precautions (EBP). The facility failed to ensure staff performed appropriate hand hygiene when moving from dirty to a clean task. Cross-reference F945: The facility failed to provide annual infection prevention and control training to staff members. A total of 36 out of 77 staff members did not receive annual training required for infection prevention and control. Infection prevention failures existed throughout the facility including cleaning of resident rooms inappropriately, failing to wear appropriate personal protective equipment (PPE) for residents on EBP, and appropriately completing hand hygiene. II. Facility policy and procedureThe Quality Assurance and Performance Improvement policy and procedure, revised February 2020, was received from the regional director of clinical services #2 on 6/23/26 at 11:24 a.m. It read in pertinent part, “This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance, establishing goals and thresholds for performance measurement, identifying and prioritizing quality deficiencies, systemically analyzing underlying causes of systemic quality deficiencies, developing and implementing corrective action and monitoring the effectiveness of corrective action.”III. Staff interviewsThe nursing home administrator (NHA) and regional director for clinical services #2 were interviewed on 6/25/26 at 12:30 p.m. The NHA said infection control was identified during QAPI as an area in need of improvement in April 2026. The NHA said there was a performance improvement plan (PIP) started, but not followed through with. The NHA said there were supposed to be weekly infection prevention audits but they were not being completed. The NHA said there was not a root cause identified for the infection prevention deficiencies. The NHA said the staff training for infection prevention was not identified in QAPI.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of three units. Specifically, the facility failed to:-Ensure housekeeping staff followed appropriate infection control procedures when cleaning and disinfecting residents’ rooms and high frequency touched areas (call lights, door handles and handrails);-Ensure housekeeping staff followed disinfectant dwell times (amount of time required to ensure germs are eliminated) when cleaning residents’ rooms;-Ensure housekeeping staff performed appropriate hand hygiene between glove changes and after cleaning residents’ toilets; -Ensure housekeeping cleaned only the toilet bowl with the toilet brush; -Ensure staff performed appropriate hand hygiene when moving from dirty to a clean task; and, -Ensure staff wore the appropriate personal protective equipment (PPE) when providing care for a resident requiring device care who was on Enhanced Barrier Precautions (EBP). E. Additional observations On 6/24/26 at 9:59 a.m. Resident #6’s coccyx wound was observed with LPN #1. There was a sign on Resident #6’s door that 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. Gowns and gloves were located in a storage bin outside of the residence room. LPN #1 donned gloves before removing Resident #6 wound dressing. -LPN #1 failed to put on a gown before providing Resident #6 with direct care. On 6/25/26 at 10:08 a.m. LPN #2 was assisting Resident #9 with rolling to his left side, and then to a sitting position on his bed. LPN #2 assisted Resident # 9 with removing his sweater. LPN #2 used his stethoscope to auscultate the resident's left upper arm to check his AV fistula (a surgically created connection between an artery and a vein, used for hemodialysis access). -LPN #2 failed to put on a gown before providing Resident #9 with direct care. F. Additional staff interviewsLPN #2 was interviewed on 6/25/26 at 10:10 a.m. LPN #2 said he was unsure if Resident #9 was on precaution. LPN #2 said he checked Resident #9’s chart and discovered the resident was on EBP. He said the resident did have a physician's order for EBP. He said he should have worn a gown when providing care and assessing the resident's AV fistula. He said he did not do that because the resident did not have signage on his door indicating he was on EBP. He said the IP was responsible for placing signage on the resident's door and obtaining PPE to be placed outside of the resident's door. The IP was interviewed on 6/25/26 at 11:46 a.m. The IP said any resident who had a wound and/or an implanted medical device would be placed on EBP. The IP said she was responsible for placing EBP signage on the resident's door, placing a storage bin containing PPE outside the resident's room, and ensuring the resident had a physician in the medical records. Said this was important because residents who meet the criteria for EBP were more susceptible to contracting bacteria and developing an infection. She said it was the facility's responsibility to ensure facility staff were following EBP recommendations with all high-contact care. She said LPN #1 and LPN #2 should have donned a gown in addition to donning gloves before providing direct care.

Based on record review and interviews, the facility failed to provide infection prevention and control program mandatory training for all staff, which included, training on the standards, policies, and procedures for the infection prevention and control program that was appropriate and effective, and as determined by staff need. Specifically the facility failed to provide annual infection control training to 36 out of 77 staff members. Findings include:I. Training record reviewA request was made for the facility’s annual infection control training records for all active staff members on 6/24/26. On 6/24/26 at approximately 10:00 a.m. the nursing home administrator (NHA) provided the records for all active staff members who had completed annual infection control training. The records revealed 36 out of 77 staff members had not completed the facility’s annual infection control training.-The facility failed to ensure all active staff members completed the annual training for infection control. Cross-reference F880: failure to use the correct disinfect, the proper cleaning technique, and proper hand hygiene during the resident room cleaning. II. Staff interviewsDietary aide #1 was interviewed on 6/25/26 at 9:52 a.m. Dietary aide #1 said he completed required training on an online training platform, which included abuse and neglect training, but could not recall whether he had completed the infection control training. Dietary aide #1 said he attended an all-staff meeting that included a demonstration on the proper use of personal protective equipment (PPE). Certified nurse aid (CNA) #6 was interviewed on 6/25/26 at 10:53 a.m. CNA #6 said she received a PPE training during an all-staff meeting. She said she had completed some training on an online platform, but she was unsure whether infection control training was among them. CNA #6 said she was unable to locate documentation verifying completion of infection control training. The human resources director was interviewed on 6/25/26 at 1:20 p.m. The human resources director said she was responsible for tracking staff training completion on the online platform. She said she pulled out a report monthly throughout the year to identify staff with incomplete training. The human resources director said she forwarded those reports to the department managers for follow up with staff. She said she reminded staff through a group messaging system to complete all assigned and required training including the infection control training. The human resources director said she was unsure identifying the failure leading staff not to complete their infection control training. She said the infection control training was a requirement for both the company and state regulations to ensure staff were competent to perform their jobs. The human resources director said, going forward, she would recommend pulling staff off the schedule until they completed all required training. The NHA and the director of nursing (DON) were interviewed together on 6/25/26 at 1:54 p.m. The NHA said the human resources director was responsible for tracking staff training completion on the online platform. He said the human resources director would report incomplete training to the NHA. The NHA said the failure to ensure completion of infection control training was a poor follow up from the management team. He said to address the issues, the human resources director should generate reports more frequently, such as weekly or daily if needed until back in compliance. The NHA said they should continue to follow up staff on a daily basis until the training got completed. The NHA said they would text, email, and call staff to remind them completing the training, if necessary taking them off the schedule until completion of the required training. The DON said she was not aware of so many staff missed the infection control training. She said she would get the assistant director of nursing to follow up with staff to ensure completion.

A complaint survey, prompted by #CO1939328. #CO2806656, Incident #2809216 and Incident #2809269 was conducted from 3/35/26 to 3/26/26. One deficiency was cited.

Based on record review and interviews, the facility failed to fully investigate and document incidents of sexual abuse involving one (#2) of one resident reviewed out of seven sample residents. Specifically, the facility failed to: -Conduct and document a thorough investigation of an allegation of sexual abuse involving Resident #2 as the victim of sexual abuse by staff members;-Interview the resident’s roommate for what he might have heard or seen during the time of the alleged abuse incident;-Pursue the resident's ongoing allegations that staff were rough and abusive towards him during the provision of personal care; and, -Investigate why staff did not stop care when the resident made the allegation of abuse and have other staff take over care. Findings include: I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating policy, revised September 2022, was received from the nursing home administrator (NHA) on 3/26/26 at 12:30 p.m. The policy documented in pertinent part, “All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of property are reported to the local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.”II. Allegation of sexual abuse of Resident #2 by a nursing staff member on 2/18/26A. Facility investigationThe facility investigation, dated 2/24/26, documented Resident #2 told the investigator he was yelling for help so he could be changed after having a bowel movement. The nurse on duty, licensed practical nurse (LPN) #1, entered his room and shortly after, certified nurse aide (CNA) #1, entered the room and told the nurse he could assist with changing the resident. The investigation documented the resident refused the CNA #1’s offer to get him changed but CNA #1 proceeded to change him anyway. The resident alleged that CNA #1 grabbed his hands and began to wipe his backside and clean him up. The resident said while being wiped and cleaned, CNA #1 then put his fingers into his rectum. He stated that he yelled out telling him to stop but CNA #1 did not stop and continued to wipe his rectum. Resident #2 said CNA #1 finished cleaning him and left the room. The investigation report documented that Resident #2 alleged that during nighttime care interaction, while being assisted with changing, the LPN (LPN #1) on duty inserted his finger into his anus four times. Resident #2’s documented statement, dated 2/19/26, revealed the resident said he was yelling for help with incontinence care during the night shift on 2/18/26 when CNA #1 entered his room. The resident said he was not sure what time this occurred. The resident said CNA #1 started to provide care, but LPN #1 entered and told CNA #1 he would take over. -However, LPN #1 and CNA #1’s statements contradicted the resident’s statement regarding who provided the incontinence care (see staff member’s statements below). Resident #2 said he did not want LPN #1 to provide his care and he tried to swat LPN #1 away. He said it was no use because LPN #1 grabbed his hands and turned him aggressively, causing him to hit his head against the wall. LPN #1 continued to provide care. The resident said LPN #1 proceeded to change his brief and while wiping his buttocks, the nurse put his finger into his anus repeatedly four times. LPN #1 finished his care and left the room. The resident said no one checked on him for the rest of the night. The investigation report documented that the resident was distressed and agitated during the investigative interview, which “was his normal baseline.”-However, this was not Resident #2’s demeanor during the interview during the survey on 3/26/26 (see the interview below). During the interview, the resident was very clear about his allegation and was not emotional or exaggerating the initial allegation he made about the staff's behavior, which he described as abusive behavior directed towards himself. In addition, the resident very clearly repeated his initial allegation that it was the LPN not the CNA, who abused him. The investigation documented LPN #1 was off for the next couple of days after the incident, while the investigation occurred and was interviewed by phone by the facility investigator. LPN #1’s statement, dated 2/19/26, documented Resident #2 was yelling while CNA #1 was providing incontinence care from a bowel movement. He said the resident was yelling that CNA #1 was touching his anus and that was not what was happening. CNA #1’s statement, dated 2/20/26, documented Resident #2 was yelling out to be changed and he and LPN #1 entered the resident’s room. CNA #1 said he proceeded to clean Resident #2. During care, the resident said “stop putting your finger in my anus.” CNA #1 said he told the resident he was not putting his finger in his anus and continued to clean feces off the resident’s buttocks and when finished, he left the room. -The facility failed to interview the resident’s roommate to see if he saw or heard what occurred. The investigation documented that following the investigation, the facility determined the allegation was unsubstantiated based on the evidence and interviews conducted. There was no evidence or signs of trauma to the resident’s rectal area and CNA #1 and LPN #1’s interviews both corroborated their stories on what happened during the brief change. The resident also has a cognitive decline and terminal agitation, resulting in false allegations. The facility investigation documented Resident #2’s care plan was updated to include a care focus for false allegations and care in pairs to ensure the safety of the resident and accuracy of care and treatment that was provided to the resident. -The facility failed to add a care plan focus to address Resident #2’s allegation of rough care or method of incontinence care when a bowel movement occurred to ensure the resident did not feel like staff was being unnecessarily rough or abusive towards him. III. Resident #2A. Resident statusResident #2, age less than 65, was admitted on 1/28/26. According to the March 2026 computerized physician orders (CPO), diagnoses included bipolar disorder, anxiety, depression, post-traumatic stress disorder and traumatic brain injury. The 3/23/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident had aggressive behavior towards others and experienced delusions. He was dependent on staff for toileting and transfers and bed mobility. The resident used a manual wheelchair and was dependent on staff for mobility. B. Resident interview and observationResident #2 was interviewed on 3/26/26 at 1:28 p.m. Resident #2 said the care he had been receiving was terrible. He said the staff did not listen to him and were rough with care. He said he felt the staff's approach to his care was abusive. He said the nighttime nurse, LPN #1 was very rough towards him when providing his care. Resident #2 said on the night that he alleged he was abused (2/18/26), he tried to push LPN #1 away but he was weak and did not have enough strength to stop LPN #1 from rolling him over and wiping him. Resident #2 said he had limited mobility in both arms and could not reposition himself in bed without assistance from another person. Resident #2 said LPN #1 had rolled him over onto his side so aggressively his head hit the wall beside his bed. He said once he was on his side, LPN #1 began to wipe him so hard that he felt it was aggressive and abusive. He told LPN #1 to stop but he would not stop. Resident #2 said he did not want LPN #1 to provide his care but LPN #1 still provided his care, despite his request to leadership to prevent LPN #1 from taking care of him. Resident #2 said no one listened to him or believed him. Resident #2 said this was not the only time LPN #1 had been rough towards him. He said a few weeks prior, LPN #1 transferred him to bed in a rough manner, which caused him pain. He said in addition to LPN #1 providing rough care, Resident #2 said there were other staff members who failed to reposition him properly in his wheelchair, which caused him pain and bruising in his arms. Resident #2 said he had asked staff to assist him to sit up straight this morning (3/26/26) for breakfast so he could feed himself but staff did not assist him as he requested. Resident #2 said he had trouble eating when he was sitting up straight. He said this morning he was not able to eat much and he spilled a lot of food on his shirt. The resident pointed to the spilled oatmeal that was still on his shirt from his morning meal. The resident was observed during the interview with an oatmeal soiled shirt and he was slouched down and slumped over to the left in the wheelchair. His left arm was hanging over the side of the wheelchair and he had a bruise on his upper arm where the armrest was poking into his arm that was hanging over the side of the wheelchair. He said his arm was sore from hanging over the side of the wheelchair. C. Record reviewResident #2’s care plan, dated 2/6/26, revealed the resident had the potential to display behaviors that included verbal aggression towards others, delusions and hallucinations. The care plan documented the resident had a history of making false allegations. He had a history of reporting decreased interest in things with displayed tearfulness, sleep disturbance, worry, anxiety, and obsessive thoughts. The care plan documented the resident sometimes declined medications prescribed to treat related symptoms. Pertinent interventions included providing care in pairs (two staff members) at all times, documenting and recording behavioral episodes, investigating all concerns voiced, maintaining a calm, slow, understandable approach and providing the PASRR (Preadmission Screening and Resident Review) Level II recommendations, which included individual therapy due to the resident’s diagnosis of post-traumatic stress disorder (PTSD).-However, there was no related care plan focus to address the resident’s PTSD and interventions to help the resident manage PTSD symptoms. IV. Staff interviews LPN #2 was interviewed on 3/26/26 at 10:56 a.m. LPN #2 said Resident #2 was to receive care in pairs and they were to take extra time to have a conversation explaining each step of care with Resident #2 before starting and during care in order to increase comfort and trust. LPN #2 said he had not had a problem with implementing this approach with the resident. CNA #2 was interviewed on 3/26/26 at 10:59 a.m. CNA #2 said he always provided Resident #2 care with another staff person and always took extra time to make sure to be attentive and let the resident know what was occurring. He said he always made sure to tell Resident #2 thank you after care to make the resident feel respected. CNA #2 said when wiping the resident during a brief change, he was careful to provide more of dabbing motion than a wiping because that was more acceptable and comfortable for the resident. The director of nursing (DON) and the NHA were interviewed on 3/26/26 at 1:38 p.m. The NHA said the facility investigation revealed the resident had misinterpreted the staff's actions during incontinence care. The DON said the nurse witnessed the care and reported that CNA #1 had not inserted his finger into the resident’s anus. The DON said the resident had a large bowel movement and CNA #1 had to wipe the resident several times to remove all of the feces from his buttocks and anal area. The DON said CNA #1 had wiped the resident’s rectal area over and over again to properly clean him.

A survey with #CO2806657 was completed on 3/25/26 to 3/26/26. No deficiencies were cited

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The facility was advised of the requirement to ensure proper housekeeping services to keep the facility clean and odor free. maintain a clean home-like environment, particularly in the dining room, with hanging lighting fixtures and decorative wall rails. The following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 5, Section 24.1, housekeeping services. The facility was advised of the requirement to ensure personnel performed proper hand hygiene after providing resident care and between providing care with different residents. In addition, the facility was advised to make sure all antibacterial dispensers were in working order for staff use. The following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 5, Section 26.7, infection control: handwashing. The facility was advised of the requirement to ensure emergency equipment was maintained in a clean CNA sanitization condition and not to open clean and sterile supplies until individual use; specifically in reference to the suction machine and the open connected Yankauer suction wand. The following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 5, Section 26.5, infection control: sanitation of nursing and resident care equipment and 22.5 (2), emergency equipment and supplies.

A complaint survey, prompted by Incident #2656808 and Incident #2656843 was conducted on 11/5/25 to 12/5/25. No deficiencies were cited. The actual survey exit date was 11/6/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/5/25.

A survey for Incident #2573657 and Incident #2612814 was conducted on 10/14/25 to 12/5/2025. One deficiency was cited. The actual survey exit was 10/14/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/5/25.

Based on observations, record review and interviews, the facility failed to ensure one (#3) of four residents were kept free from physical abuse out of six sample residents. Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #4. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 10/9/25 at 10:05 a.m. It read in pertinent part,“Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident’s symptoms.“The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support protecting residents from abuse, neglect, exploitation or misappropriation of property by anyone; developing and implementing policies and protocols to prevent and identify abuse or mistreatment of residents neglect of residents and/or theft, exploitation or misappropriation of resident property; provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior; implementing measures to address factors that may lead to abusive situations; identifying and investigating all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and protecting residents from any further harm during investigations.”II. Incident of physical abuse between Resident #3 and Resident #4 on 6/21/25A. Facility investigationThe facility’s abuse investigation, dated 6/21/25, documented that at approximately 8:15 p.m. Resident #3 and Resident #4 were in the smoking patio area when a verbal altercation occurred. Resident #3 told Resident #4 to smell his feet and called him names. Resident #3 then moved his electric wheelchair toward Resident #4 in an aggressive manner. Resident #4 flicked a lit cigarette at Resident #3 and spit at Resident #3, grabbed Resident #3’s arm and dug his fingernails into his skin, and struck Resident #3 in the face, which caused Resident #3’s glasses to fall to the ground. Resident #3 left the patio and notified staff. Staff ensured both residents were kept apart and remained on opposite sides of the hallway for the rest of the evening. The facility initiated 15-minute checks for both residents. A registered nurse (RN) assessed Resident #3 after the incident and documented minor scratches on the resident’s arm and a small burn on his chest. Resident #3 denied pain. The RN offered wound treatment and Resident #3 declined. Resident #3 declined to discuss the incident further but appeared angry and frustrated. A physician’s assistant offered counseling and therapy and Resident #3 declined. Resident #4 was interviewed after the incident and he said that Resident #3 made inappropriate comments and moved his wheelchair toward him. Resident #4 said he reacted by striking Resident #3 in the face. The investigation documented that staff and residents were interviewed and they did not report any ongoing safety concerns. Documentation confirmed that physical contact occurred and that treatment was offered and declined. The interventions implemented after the incident for both residents included continued 15-minute checks, behavior monitoring and review of the residents’ care plans. Resident #3’s care plan directed staff to provide redirection, offer preferred activities and monitor mood and behavior. Resident #4’s care plan directed staff to maintain a calm environment, encourage expression of feelings and documented behavioral episodes with triggers. The investigation documentedthat the facility substantiated that the allegation of resident-to-resident physical abuse occurred. B. Resident #3 - victim 1. Resident statusResident #3, age less than 65, was initially admitted on 1/15/25, readmitted 4/13/25 and discharged 9/2/25. According to the September 2025 computerized physician orders (CPO), diagnoses included paraplegia, depression and anxiety. The 9/2/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial assistance with toileting, bathing, and moderate assistance with dressing. The MDS assessment did not indicate that the resident had any behaviors. 2. Resident #3 interviewResident #3 was interviewed on 10/8/25 at 5:43 p.m. Resident #3 said that on the day of the incident (6/21/25) he was in the smoking area in his wheelchair when Resident #4 made verbal and racial remarks toward him, including comments about him being crippled. He said that when he moved his wheelchair toward Resident #4, his intention was not aggressive but to respond to what was being said. He said there were no staff members present during the altercation and that his roommate ran inside to get help. Resident #3 said that before staff arrived, Resident #4 hit him twice in the face which caused his glasses to fall and break. He said Resident #4 also flicked a lit cigarette that caused a burn between his chest and stomach. He said the cigarette landed on his stomach and he did not feel it immediately because he was paraplegic and had limited sensation. He said he later noticed burn marks on his chest and stomach area. He said he declined an assessment at the time but continued to have a visible mark afterward. Resident #3 said the situation ended once staff arrived. 3. Record review The behavioral care plan, initiated 2/7/25 and revised 9/23/25, documented that Resident #3 had diagnoses of depression and anxiety and exhibited verbal aggression toward others. The care plan described a history of racist or derogatory comments, unfounded accusations and easy agitation. Resident #3 sometimes made jokes or comments that he found humorous but that could irritate others and that he could speed in his electric wheelchair when agitated. Pertinent interventions included redirecting the resident to a quiet area, encouraging the use of games on his cell phone, offering arts and crafts supplies, providing brain teaser puzzles, offering preferred music or television, offering snacks or drinks, and encouraging calm expression of feelings. Additional interventions included observing and documenting behavioral episodes, notifying the physician and responsible party of aggression or significant changes, obtaining a psychological consultation if indicated, and educating staff to provide care in pairs for safety when the resident exhibited aggressive behavior. The 6/21/25 nurse progress note revealed that Resident #3 had a verbal altercation with another resident in the smoking area and the other resident became physical with Resident #3. The 6/26/25 nurse progress note documented that a skin assessment was completed at the time of the incident on 6/21/25 and no burns or open sores were observed. The note revealed that the other resident flicked a lit cigarette at him, but no burn was noted during the assessment. The note documented that the resident was scratched by the other resident, but there was no bleeding or skin tear observed. A subsequent nurse progress note dated 6/26/25 at 6:17 p.m. revealed that Resident #3 reported an open area on his chest that appeared to be a cigarette burn. The note documented that there were no signs or symptoms of infection and that wound care orders were received. The note further documented that the open area was not present during the initial assessment on 6/21/25 and that the physician was notified. C. Resident #4 - assailant 1. Resident statusResident #4, age less than 65, was admitted on 11/22/24. According to the October CPO, diagnoses included dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 8/21/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with completing his activities of daily living (ADL). The MDS assessment did not indicate that the resident had any behaviors. 2. Resident #4’s interviewResident #4 was interviewed on 10/8/25 at 11:08 a.m. Resident #4 said his stay at the facility had been all right. He said he usually got along with the other residents and talked with them without any problems. He said he often went to the smoking area and did not have a preference whether other residents were present or not. He said he became angry and had a fight with Resident #3 in June 2025 and he did not know what was wrong with Resident #3. He said he had never had disagreements with any other residents. He said the police investigated the incident and that he now had to go to court. He said it helped him calm down when other residents did not talk to him when he felt frustrated. He said he did not want to discuss the incident further. 3. Record reviewThe behavioral care plan, initiated 12/4/24 and revised on 7/3/25, documented that Resident #4 could become angry if he perceived that he was being disrespected or teased. It documented that he could become verbally or physically abusive toward others if provoked. Pertinent interventions included observing and documenting changes in behavior, including frequency and potential triggers, encouraging the resident to verbalize feelings, redirecting to a quiet area if agitated, encouraging physical activity, offering preferred activities, music, television programs, snacks or drinks and encouraging calm expression of feelings. Additional interventions included maintaining a calm and slow approach, obtaining a psychological consultation as indicated, notifying the physician and responsible party of episodes of aggression and documenting all behavioral episodes. The 6/21/25 nurse progress note documented that Resident #4 was involved in a physical altercation with another resident (Resident #3) in the smoking area. The note indicated that a verbal disagreement occurred and escalated when Resident #4 scratched, spit, and struck the other resident in the face, knocking the resident’s glasses off. Staff separated the residents and placed both residents on frequent checks. The 6/25/25 nurse progress note documented that the frequent checks were discontinued. III. Additional resident interviewResident #6 was interviewed on 10/9/25 at 8:43 am. Resident #6 said he used a vaporizing device in the smoking area that evening on 6/21/25 and Resident #3 joked with Resident #4 to come “smell his fee.” Resident #6 said Resident #4 responded to Resident #3 to smell his own feet and Resident #4 approached and got in Resident #3’s face. Resident #6 said he left the smoking area to get help. Resident #6 said he informed RN #1 and RN #1 immediately ran into the smoking area and Resident #6 went to his room. Resident #6 said he did not see Resident #4 throwing a lit cigarette at Resident #3 or punching him, but he said Resident #3 told him that Resident #4 punched him and flicked a lit cigarette at him when Resident #6 left to get help. Resident #6 said the facility did not obtain a witness statement from him or talk to him afterward. IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 10/8/25 at 12:55 p.m. LPN #1 said he had worked at the facility for three years, first as an agency staff member and more recently as a full-time employee. He said he worked on the hall where Resident #4 resided, and that Resident #3 lived in a different area of the facility. He said there was an assigned team responsible for supervising residents who required supervision. He said the facility kept residents’ cigarettes and lighters secured. LPN #1 said staff reviewed the electronic treatment administration record (eTAR) and psychological monitoring documentation for residents who required closer observation. He said he had not seen Resident #4 display aggression or assault anyone and that he was shocked when he heard about the incident that occurred on 6/21/25 between Resident #3 and Resident #4. He said he watched for body language, nonverbal cues, agitation and anything out of the ordinary to recognize early signs that a resident was becoming agitated or aggressive so he could intervene appropriately. LPN #1 said that if one resident became physically aggressive toward another resident, he would speak to them in a calm tone, remain neutral, step between the residents if there was physical contact, separate them and call for assistance. He said he stayed with the residents until help arrived and then notified the abuse coordinator, the NHA and the director of nursing (DON). He said he had not been aware of Resident #4’s previous aggressive incidents before the 6/21/25 event and that the behavior was unexpected. He said he would review the resident’s care plan for behavioral interventions in place and that following an incident, staff typically increased monitoring until the resident returned to baseline. Certified nurse aide (CNA) #1 was interviewed on 10/8/25 at 2:07 p.m. CNA #1 said residents who were not independent had designated times for supervised smoking and that staff kept the residents’ cigarettes and lighters. She said she heard about the altercation between Resident #3 and Resident #4 from the charge nurse, who instructed staff to increase observation and monitoring of Resident #4, watch for any signs of verbal or physical aggression toward other residents and ensure that other residents were kept safe. CNA #1 said if Resident #4 became upset, the interventions were to talk to him, de-escalate the situation and notify the charge nurse if his behaviors were out of control. She said she made sure other residents were safe and kept away from Resident #4. CNA #1 said she was usually informed by the charge nurse when increased monitoring was needed for a specific resident. She said she also reviewed the Kardex (tool utilized for providing consistent care for residents) for interventions and documented her observations and interactions immediately. CNA #1 said Resident #3 occasionally made comments to staff, such as calling them lazy or using profane language when his medications were given late, but that he was redirected verbally and would apologize afterward. She said it was not typical for Resident #4 to be physically aggressive because he was very social, joked with others and often helped the activities director with setting-up activities. CNA #1 said she recognized early signs of aggression by closely monitoring changes in tone of voice, yelling, or screaming and that she would run to investigate and de-escalate the situation. She said she stayed with the residents involved to ensure safety and obtained assistance as needed. She said she reported information to the abuse coordinator and that after an incident and staff ensured resident safety. RN #1 was interviewed on 10/9/25 at 11:23 a.m. RN #1 said she could not recall who came to get her to assist the residents in the smoking area on the day of the incident between Resident #3 and Resident #4. She said Resident #3 had been talking about his showers and mentioned that his feet were smelly, then asked Resident #4 to smell his feet. She said Resident #3 also said “Can you help a brother out and smell my feet,” which offended Resident #4. RN #1 said Resident #4 began yelling at Resident #3. RN #1 said that during her assessment and observation immediately after the incident, there were no burn marks noted on Resident #3’s chest or stomach area and no burn marks observed on his shirt. She said that a day or two later, burn marks consistent with a cigarette burn appeared on Resident #3’s chest. She said the area was round, approximately 1 centimeter (cm) by 1 cm in size, irritated and raw. RN #1 said it was possible she did not see burn marks initially because the injury was fresh and had not yet fully developed. The social services director (SSD) was interviewed on 10/9/25 at 11:52 a.m. The SSD said she had not been at the facility on the day of the incident between Resident #3 and Resident #4, but she said she would normally begin the investigation when such an event occurred. She said her responsibilities included separating the residents, contacting the police if the incident involved physical abuse, notifying the ombudsman and the (interdisciplinary team (IDT) and documenting the occurrence. The SSD said that to ensure the victim was monitored for emotional trauma, staff made sure the resident was in a safe location, spoke with the resident, offered behavioral health services, provided ombudsman contact information, and offered a room change if needed. She said the facility did whatever was necessary to prevent the situation from escalating. The SSD said that once interventions were in place, the residents’ care plans were updated and staff were educated regarding behavioral interventions. She said the facility monitored whether the aggressor’s behavior improved or worsened after new interventions were implemented. She said nurses completed behavior monitoring and checked the eTAR and electronic medication administration record (eMAR) for any behaviors noted during their shifts. She said if psychotropic medications were prescribed, the facility completed psychopharmacological monitoring and gradual dose reduction (GDR) reviews. The SSD said she coordinated with nursing leadership, including the DON and the assistant director of nursing (ADON), to ensure that behavioral interventions and supervision changes were implemented and documented. She said she reviewed the records to verify that behavioral monitoring and physician orders were entered and followed. The social services assistant (SSA) was interviewed on 10/9/25 at 12:16 p.m. The SSA said she did not remember the details of the incident that occurred on 6/21/25 between Resident #3 and Resident #4 and she could not recall when she was first notified. She said she remembered obtaining statements from both residents. The SSA said she did not recall that the victim developed burn marks on his chest or stomach. The SSA said that if she identified a resident with cigarette burns or observed an altercation, she would separate the residents, redirect them and contact the police and the ombudsman. She said she would offer or provide medical attention for the victim, notify the nurse if emergency services were needed, and escort the assailant to his room or another area of the building to ensure the safety of all residents. The DON was interviewed on 10/9/25 at 1:16 p.m. The DON said she ensured that all staff understood and followed behavior management interventions in the residents’ care plans. She said the staff completed crisis prevention intervention (CPI) training annually and they provided additional education when the residents argued. She said staff were reminded to separate the residents and report the incident to management. The DON said she monitored staff compliance with behavior-related documentation and interventions by educating staff, reviewing the Kardex for interventions, confirming that nurses checked the care plans, and ensuring that behavior tracking was completed. She said she reviewed the behavior monitoring dashboard each morning and reminded staff to complete documentation if it was missing. The NHA was interviewed again on 10/9/25 at 1:00 p.m. The NHA said the facility was in the process of upgrading their cameras and that the camera in the smoking area was not functioning on 6/21/25. He said his expectation for staff during abuse incidents was to intervene, de-escalate verbal or physical behavior, notify the NHA, and for the DON to initiaterisk management, place the resident on behavior tracking, interview witnesses, implement interventions and update the care plan. He said they would also notify the ombudsman. He said if 15-minute checks were initiated, then nursing staff would follow up to ensure they monitored the residents. He said the facility ensured the accuracy of an occurrence by considering every perspective, interviewing witnesses as soon as possible, obtaining multiple points of view and requiring the SSD to investigate thoroughly. The NHA was interviewed a second time on 10/9/25 at 2:31 p.m. The NHA said the nurse progress note documented that RN #1 completed a head to toe assessment on 6/21/25 and did not observe burn marks at that time. He said the facility did not believe the chest burn came from the 6/21/25 incident although he initially had said the chest burn was caused during the incident on 6/21/25.

A survey prompted by #CO39712, #CO40029, Incident #39768 and Incident #39993 was conducted on 5/21/25 to 5/22/25. No deficiencies were cited.

A survey, prompted by Incidents #38947, #39015, #39016, #39108, #39158 and #39211, was completed on 2/10/25 to 2/12/25. One deficiency was cited.

Based on record review and interviews, the facility failed to ensure that one (#1) of four residents out of eight sample residents received adequate supervision and facility-assisted devices to prevent elopement. Specifically, the facility failed to provide Resident #1 the supervision necessary to prevent elopements. These facility failures created a situation with the likelihood of serious harm to the resident's health and safety if not immediately corrected. Resident #1 was admitted to the facility on 4/9/24 with a diagnosis of bipolar disorder (major mental illness), adult failure to thrive, cocaine dependence and alcohol dependence. A wander/elopement risk evaluation was completed upon the resident's admission on 4/9/24 and revealed Resident #1 had no previous elopement attempts and was not at risk for eloping or wandering. However, Resident #1 had an emergency court-appointed guardian who requested the resident not leave the facility without supervision due to her mental illness and substance-seeking behaviors. On 1/10/25 at approximately 10:25 a.m. Resident #1 left the facility unsupervised when the receptionist buzzed someone out the front door and failed to see Resident #1 following behind the other person leaving the facility. After actively searching for the resident and notifying the resident's guardian about the resident's elopement, Resident #1 was located by the resident's guardian at 12:45 p.m. near a homeless shelter approximately five miles from the facility and the facility's driver picked up the resident and returned her to the facility.-The facility placed Resident #1 on 15-minute checks upon her return to the facility, however, this intervention proved to be ineffective as Resident #1 eloped a second time, four hours after returning to the facility. On 1/10/25 at 5:17 p.m., despite the facility initiating and conducting 15-minute checks on Resident #1, the resident eloped from the facility a second time when a nurse buzzed the resident out the facility door after failing to check the camera to see who was being buzzed out the door. The facility again began a search for Resident #1 and notified the police and the resident's guardian. On 1/11/25 at 10:15 p.m. (almost 29 hours after the resident eloped from the facility the second time) a staff member saw Resident #1 on the side of the road in a downtown area approximately five miles from the facility and notified the nursing home administrator (NHA) and the police. When the police arrived, Resident #1 was transported to the hospital, per the guardian's request. Findings include:Observations, interviews and record review confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/10/25 to 2/12/25, resulting in the deficiency being cited as past noncompliance with a correction date of 1/14/25. I. Situation of serious harmThe facility failed to ensure facility staff were aware of which residents were able to leave the facility without supervision and which residents needed to have supervision when leaving the facility. This resulted in a staff member buzzing Resident #1 out the front door when another person left the facility on 1/10/25. The resident was located approximately five miles from the facility over two hours later. Following Resident #1's first elopement on 1/10/25 at 10:25 a.m., the facility failed to put effective interventions and systems in place to ensure Resident #1 was unable to elope again. This resulted in Resident #1 being buzzed out the front door a second time on 1/10/25 and being located approximately five miles from the facility almost 29 hours later. II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #1's elopement incidents on 1/10/25 was provided by the NHA on 2/11/25 at 1:00 p.m. The correction plan revealed the following:A. Immediate actionResident #1 had an elopement and community safety assessment completed on 1/10/25. Resident #1 was found by the police on 1/11/25 and taken to the hospital per the guardian's request until a locked unit was found for Resident #1. A sister facility with a locked unit accepted the resident. B. Identification of others affectedThe facility determined six other residents were at risk for eloping from the facility. C. Systemic changes-On 1/13/25 all residents were educated via individual letters regarding not assisting other residents to leave the facility and the process for signing in and out when leaving the facility by the NHA or designee.-On 1/13/25 all receptionists were educated to not leave the front desk unattended for breaks.-On 1/14/25 the interdisciplinary team (IDT) members reassessed all residents for elopement risk and community safety.-On 1/14/25 the IDT created an elopement binder, with a list of all residents at risk, their face sheets and photos, if allowed. The binder was placed at the front desk and the nurses' station.-On 1/14/25 staff on all shifts received education on the process for the front doors, residents at risk for eloping, notifying the nurse with concerns, location of the list of residents at risk of eloping, assisting residents to sign out and leave or redirection, elopement policy and elopement binder from the director of nursing (DON) or designee. Any staff members who were not on duty or were on leave, received education on their next scheduled work day. Agency staff were educated before the start of their shift. On 1/14/25 all residents' cell phone numbers were updated in the electronic medical records (EMR) by the IDT members. D. Preventing elopementsThe facility took the following actions to prevent elopement from reoccurring. The front desk will be staffed from 8:00 a.m. to 5:00 p.m., seven days per week and assist with helping residents sign in and out. Elopement risk assessments were to be completed on admission, with a change of condition, and quarterly by the IDT. Residents determined at risk by the IDT will have a care plan in place to prevent elopement. The DON will audit potential new admissions for elopement risk, determine if the facility can meet the resident's needs and ensure a care plan with appropriate interventions is in place if appropriate. New hires will receive education on wander, elopement and elopement binder and resident safety by the DON, the social services director (SSD) or designees. The NHA will ensure the elopement binders are kept up to date with any resident change in assessment or new admission. E. MonitoringThe DON will track/audit all resident elopement assessments monthly to ensure they are completed on admission and quarterly. A quality assurance and performance improvement (QAPI) committee performance improvement plan (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAPI committed meeting for a minimum of three months, or until the pattern of compliance is maintained."III. Facility policy and procedureThe Elopements and Wandering Residents policy, undated, was provided by the NHA on 2/12/25 at 9:00 a.m. It read in pertinent part,"The facility is equipped with door locks or alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary."IV. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 4/9/24 and discharged to the hospital on 1/11/25. According to the January 2025 computerized physician orders (CPO), diagnoses included bipolar disorder, adult failure to thrive, cocaine dependence, alcohol dependence and acquired absenceof left toes. The 10/10/24 minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #1 had no documented behaviors. Resident #1 had no impairment to her extremities and used a walker or wheelchair. B. Record reviewThe elopement evaluation, dated 4/9/24, revealed Resident #1 had a diagnosis of bipolar disorder. Resident #1 ambulated independently with or without the use of an assistive device or wheelchair. The resident did not have any hearing, vision or communication problems. Resident #1 had no previous elopements or wandering behaviors. The elopement care plan, initiated on 1/10/25 (following the residents elopements) revealed Resident #1 was at risk for wandering, eloping and exit-seeking related to agitation, difficulty redirecting, poor safety awareness and impulsivity. The resident had left the facility without notifying staff and demonstrated poor safety awareness in the community. Pertinent interventions were documented as 15-minute checks of the resident's location for safety, allowing the resident to wander in safe areas within the facility and notifying the resident's guardian and the police if Resident #1 successfully eloped. The NHA provided the timeline of Resident #1's 1/10/25 elopement incidents on 2/11/25 at 9:00 a.m. The timeline revealed the following: Resident #1 eloped from the facility on 1/10/25 at approximately 10:25 a.m. when the receptionist buzzed someone out the front door and failed to see the resident following behind the other person. At 11:00 a.m. the nursing staff were unable to locate Resident #1 in the facility's common areas or the resident's room. The staff initiated a full facility sweep. At 11:20 a.m. the NHA and the DON were notified Resident #1 had eloped. The IDT members searched known areas for the resident, which included gas stations, bus stops and downtown areas. At 12:00 p.m. Resident #1's guardian was notified the resident eloped. The facility's driver was asked to help search locations based on the guardian's recommendations. At 12:45 p.m. Resident #1's guardian located the resident near a homeless shelter approximately five miles from the facility and the facility's driver picked up the resident and returned her to the facility. At 1:15 p.m. Resident #1 returned to the facility, was assessed by nursing staff and placed on 15-minute checks. At 5:15 p.m. Resident #1 was seen in the dining room for her 15-minute check. At 5:17 p.m. Resident #1 was buzzed out by a nurse at the nurses' station who failed to check the camera to see who was being buzzed out the door. At 5:30 p.m. Resident #1 was unable to be located for her 15-minute check. At 5:37 p.m. the nurse notified the DON, the NHA, the police and the resident's guardian. At 6:10 p.m. the police and the DON arrived at the facility. The police were given the resident's face sheet and a description of the resident. On 1/11/25 at 10:15 p.m. a staff member saw Resident #1 on the side of the road in a downtown area approximately five miles from the facility and notified the NHA and the police. At 10:30 p.m. the police arrived and spoke with Resident #1 and the staff member. The guardian's number was provided and the staff member told the police the guardian wanted Resident #1 to be taken to a hospital once she was found. The facility began investigating the situation on 1/11/25 and developed a QAPI plan which included a PIP on 1/13/25. V. Staff interviewsThe NHA, the SSD and the corporate consultant (CC) were interviewed together on 2/11/25 at 11:40 a.m. The SSD said the staff were doing their normal rounds on 1/10/25 and were unable to locate Resident #1. She said the staff searched the facility and expanded the search to the community. She said Resident #1 was located and the facility's driver returned the resident to the facility. The SSD said the resident was assessed by the provider and placed on 15-minute checks. The NHA said he received a phone call on the same day, but later in the evening, that the staff were unable to locate Resident #1 when the staff were completing their 15-minute checks. He said the resident's guardian and the police were notified that Resident #1 was unable to be located on 1/10/25. The NHA said on 1/11/25 he received a phone call from a staff member who was driving home and spotted Resident #1 on the side of the road in a downtown area. He said the staff member stayed with Resident #1 until the police arrived and then asked the police to take the resident to the emergency room, per the resident guardian's request. The NHA said Resident #1 did not return to the facility after the resident's guardian requested she be taken to the hospital on 1/11/25 and was placed in a sister facility with a secured unit per the guardian's request. The NHA said Resident #1 had never left the facility prior to 1/10/25 and did not have a history of eloping. He said the first time Resident #1 left the facility was because a staff member was buzzed out and Resident #1 followed behind the staff member. He said the second time Resident #1 left the facility, the nurse failed to look at the camera to see who was trying to be buzzed out and just opened the door.

A complaint survey, prompted by #CO38219, #CO38372, #CO38551 and Incident #38268 was conducted on 12/9/24. No deficiencies were cited.

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