SKYLAKE POST ACUTE

A complaint survey, prompted by #CO2981715 was completed on 5/6/26 to 5/11/26. One deficiency was cited.

Based on record review, observations and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#4 and #16) of seven sample residents reviewed for change of condition assessments out of 14 sample residents. Resident #4 was admitted on 10/9/25 with diagnoses of dementia, severe, with other behavioral disturbance, pancytopenia (lower than normal count of all three types of blood cells), and protein-calorie malnutrition. On 12/10/25 the facility documented that Resident #4 had decreased oral and fluid intake. On 12/11/25 Resident #4 sustained an unwitnessed fall, where his mattress was found partially off the bed frame. The staff documented a decline in the resident’s function and he continued to have decreased oral and fluid intake, had increased weakness and confusion, had unsteady balance and was pale. Despite the nursing staff noticing a change in condition, the facility failed to notify the physician of the change in condition to provide further treatment to the resident. On 12/11/25 at 6:50 p.m. the resident sustained an additional unwitnessed fall. Upon assessment, the resident was noted to have pain. The resident was sent to the hospital for further assessment. While at the hospital the resident was diagnosed with a fractured hip and four subdural hematomas (bleeding between the brain and skull). Following treatment at the hospital he returned to the facility under hospice care on 12/19/25 and passed away on 12/20/25. Specifically, the facility failed to:-Monitor Resident #4 after he experienced a change of condition with multiple falls; and, -Appropriately assess and monitor Resident #16 after sustaining an unwitnessed fall. IV. Resident #16A. Resident statusResident #16, age 78, was admitted on 6/17/21. According to the May 2026 CPO, diagnoses included dementia with behavioral disturbance, generalized muscle weakness, unsteadiness on feet, difficulty in walking and repeated falls. The 3/13/26 comprehensive assessment revealed the resident had severe cognitive impairments. The resident required substantial assistance from staff for most ADLs. B. Observations and record reviewDuring a continuous observation on 5/7/26, from 11:54 a.m. to 12:38 p.m., the following was observed:At 11:54 a.m. Resident #16 was sitting up on the floor in the common area with her legs tucked to the side and supporting her weight on her arm. Multiple nursing staff members were attending to the resident, including regional director of clinical services #2 and the DON. Resident #16 had an open area on her forehead approximately two centimeters (CM) by two CM which was bleeding, blood on her hand and a small puddle of blood on the floor. At 11:56 a.m. regional director of clinical services #2 began performing a neurologic assessment on Resident #16 using a cellphone flashlight. Regional director of clinical services #2 held the cellphone flashlight toward Resident #16’s face as she turned her head away from the light. Regional director of clinical services #2 and the DON helped Resident #16 straighten her legs out in front of her and performed a brief range of motion assessment on the resident’s legs. At 12:01 p.m. regional director of clinical services #2 and the DON assisted Resident #16 to a standing position using a gait belt around the resident’s waist and walked with her to her room, where she was assisted into a chair near her bed. Regional director of clinical services #2 and the DON obtained Resident #16’s vital signs using a vitals machine and performed another neurological assessment using a cellphone flashlight. Resident #16 turned her head away repeatedly and was squinting her eyes shut while the light from the flashlight was used to attempt to assess her pupil reaction for the neurological assessment. LPN #1 removed the vital signs machine from the room and brought in wound cleanser and gauze, and the DON and regional director of clinical services #2 began cleaning the wound to Resident #16’s forehead. At 12:08 p.m. regional director of clinical services #2 and the DON closed Resident #16’s door to perform a skin check and assist the resident with getting dressed in clean clothes. At 12:17 p.m. the DON and regional director of clinical services #2 assisted Resident #16 back into the dining room where the resident sat in a dining room chair. At 12:24 p.m. RN #3 reviewed with LPN #1 how to use the facility’s neurological assessment sheet and told LPN #1 when Resident #16 would be due to assess her next set of vitals measurements. At 12:30 p.m. LPN #1 approached Resident #16 in the dining room and began collecting vital signs measurements using the vitals machine. LPN #1 used the vitals equipment to assess Resident #16’s blood pressure, heart rate and blood oxygen saturation. LPN #1 then recorded this information on the neurological assessment sheet.-However, LPN #1 did not have any flashlight or pen light available to assess Resident #16’s pupillary response. At 12:38 p.m. the neurological assessment sheet for Resident #16 was observed on LPN #1’s medication cart. The sheet contained vital signs measurements for Resident #16 which were documented to have been taken at 12:15 p.m. and 12:30 p.m. on 5/7/26. Resident #16’s pupils were documented as having been equal, round and reactive to light at the time of both the 12:15 p.m. and 12:30 p.m. assessments.-However, LPN #1 was not able to assess Resident #16’s pupillary response to light during the 12:30 p.m. assessment period (see above).-Additionally, the vital signs machine had been removed from Resident #16’s room prior to her door being closed at 12:08 p.m. C. Staff interviewsLPN #1 was interviewed on 5/7/26 at 12:38 p.m. LPN #1 said she was not sure how Resident #16 had fallen as she was assisting another resident at the time. She said she only knew the resident had fallen when she heard a thump sound behind her. LPN #1 said the unit managers and the DON had immediately begun assessing Resident #16, and said she would continue performing neurological assessments for the resident per facility policy. LPN #1 said when performing neurological assessments, she only needed to look at the resident’s pupils and see if they were reactive. LPN #1 said she did not have to use a light source when assessing the resident’s pupils, and said the unit manager and the DON had assessed Resident #16’s pupils before they assisted her up from the floor. LPN #1 said the unit managers and DON had used a cellphone flashlight to assess Resident #16 because her pen light batteries were dead. The DON and regional director of clinical services #2 were interviewed together on 5/7/26 at 1:33 p.m. The DON said neurological assessments were performed after a resident sustained a fall to monitor the resident for any change in neurological status, vital signs measurements, mentation or mental status. The DON said when performing neurological assessments, the nursing staff were looking to see if the resident was alert and oriented, had equal hand grasps on both sides, their pupils were reactive to light and equal between the left and right eye, if they had any pain, and their vital signs. The DON said pupil reactivity was assessed using a flashlight or a pen light. The DON said LPN #1 should have used a light source to assess Resident #16’s pupillary reaction.

A complaint survey, prompted by #CO2981713, #CO2981832, Incident #2983448, Incident #2983473, Incident #2999001, Incident #2999009, Incident #2999016 and Incident #2999065 was completed on 5/6/26 to 5/11/26. Two deficiencies were cited.

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Based on record review, observations and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#4 and #16) of seven sample residents reviewed for change of condition assessments out of 14 sample residents. Resident #4 was admitted on 10/9/25 with diagnoses of dementia, severe, with other behavioral disturbance, pancytopenia (lower than normal count of all three types of blood cells), and protein-calorie malnutrition. On 12/10/25 the facility documented that Resident #4 had decreased oral and fluid intake. On 12/11/25 Resident #4 sustained an unwitnessed fall, where his mattress was found partially off the bed frame. The staff documented a decline in the resident’s function and he continued to have decreased oral and fluid intake, had increased weakness and confusion, had unsteady balance and was pale. Despite the nursing staff noticing a change in condition, the facility failed to notify the physician of the change in condition to provide further treatment to the resident. On 12/11/25 at 6:50 p.m. the resident sustained an additional unwitnessed fall. Upon assessment, the resident was noted to have pain. The resident was sent to the hospital for further assessment. While at the hospital the resident was diagnosed with a fractured hip and four subdural hematomas (bleeding between the brain and skull). Following treatment at the hospital he returned to the facility under hospice care on 12/19/25 and passed away on 12/20/25. Specifically, the facility failed to:-Monitor Resident #4 after he experienced a change of condition with multiple falls; and, -Appropriately assess and monitor Resident #16 after sustaining an unwitnessed fall. Findings include:I. Immediate jeopardyA. Findings of immediate jeopardyOn 12/10/25, Resident #4 began to have decreased oral and fluid intake. On 12/11/25 at 5:00 a.m. Resident #4 had an unwitnessed fall in his room. The physician and his responsible party were notified. The resident was educated to call for assistance before transferring. At 1:06 p.m. the nurse documented he had refused breakfast and had slept most of the morning. The facility failed to adequately monitor the resident after this fall. The neurological checks (measuring level of consciousness, orientation, pupil response, strength, and vital signs) were documented as refused from 7:00 a.m. through 10:00 a.m. At 3:06 p.m. the nurse documented a drop in his blood pressure and an increase in his heart rate as well as a decrease in appetite and fluid intake and generalized weakness resulting in the need for extra assistance with activities of daily living (ADLs). He had been independent prior to fall. The provider was notified and informed the nurse that the nurse practitioner would see the resident the next day. At 6:30 p.m. the nurse documented Resident #4 did not want to eat, was sleeping more, and was unsteady when he tried to stand. At 6:50 p.m. he sustained a second unwitnessed fall from bed. He was unable to state what he was doing, was confused, and had external rotation of his right leg. He was transferred to the hospital. Following surgery and multiple blood transfusions at the hospital he returned to the facility on hospice care. He was only responsive to pain and passed away on 12/20/25. B. Facility notice of immediate jeopardy On 5/7/26 at 3:45 p.m. the nursing home administrator (NHA) and regional director of clinical services were notified that the facility's failure to identify and respond to Resident #4’s change of condition created an immediate jeopardy situation. C. Facility plan to remove immediate jeopardyOn 5/7/26 at 6:45 p.m. the facility submitted a final plan for removal of the immediate jeopardy. The plan read:On 5/7/26, Resident #16 was immediately reassessed by the director of nursing (DON) regarding the completion of a neurological assessment after a fall. A complete neurological assessment, including pupillary response to light, level of consciousness, grip strength, extremity movement, and vital signs, was completed and documented. The physician was notified immediately. The physician orders were obtained for a skin tear neurological monitoring was initiated and the care plan was updated. On 5/7/26, the involved licensed nurse received immediate one-on-one education regarding post-fall neurological assessments and documentation requirements. Beginning 5/7/26, the DON/designee completed a review of all residents with falls and concerns about changes in condition to identify any additional residents at risk for post-fall assessment, physician notification, neurological monitoring, or changes in condition that have occurred in the last seven days. The Change of Condition policy and Neurological policy were reviewed on 5/7/26 by the NHA, the DON, and medical director. Beginning on 5/7/26, the staff development coordinator/designee educated all licensed nurses currently in the facility on post-fall assessment and neurological monitoring protocols, including required vital signs, neurological assessment parameters, physician notification requirements, documentation if a resident refuses neurologic monitoring, identifying a change in condition, and documentation expectations. The plan documented any nurse who had not yet received this education would not work the floor until training was completed. Beginning on 5/7/26, the staff development coordinator/designee would educate agency-licensed nurses on the facility's policy regarding the following: The education was uploaded to the agency portal on 5/7/226. The agency platform required agency nurses to complete training before confirming the shift. Beginning on 5/8/26, and continuing daily for 30 days, then weekly for 60 days, then monthly thereafter, the DON would audit all changes of condition occurring in the facility to ensure:A complete neurological assessment was performed immediately following the fall and properly documented, including the use of a penlight for pupil assessment, grip strength, and extremity movement. Complete vital signs were obtained immediately following the fall and at required intervals per protocol. The physician was notified per protocol with documentation of time, information provided, and orders received. When residents refused any portion of the assessment, documentation included specifically what was assessed, what was refused, alternative methods attempted, the resident's level of consciousness, and the plan for reassessment. All changes in condition resulted in appropriate interventions and escalation per protocol. Care plans were updated as needed in response to falls and identified risk factors. Audit results will be compiled in a written report that notes the compliance rate, any identified deficiencies, and the corrective actions implemented. Any incidents of non-compliance will result in immediate individual staff education and re-auditing. Beginning on 5/8/26and continuing five times per week for 30 days, then weekly for 60 days, then monthly thereafter the DON/designee will audit 100% of all changes of condition.”D. Removal of the immediate jeopardy:Based on the facility’s plan above, the immediate jeopardy was removed on 5/7/26 at 7:00 p.m. However, deficient practice remained at a G level, actual harm, isolated. II. Facility policy and procedure The Change in a Resident’s Condition or Status policy, revised February 2021, was provided by regional director of clinical services #1 on 5/11/26 at 5:04 p.m. It read in pertinent part, “Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident’s medical/mental condition and/or status. “The nurse will notify the resident’s attending physician or physician on call when there has been a(an): accident or incident involving the resident; significant change in the resident’s physical, emotional, mental condition; need to transfer the resident to a hospital; and specific instruction to notify the physician of changes in the resident’s condition.“A significant change of condition is a major decline or improvement in the resident’s status that: will not normally resolve itself without intervention by staff; impacts more than one area of the resident’s health status; and ultimately is based on the judgment of the clinical staff.“Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider.“Unless otherwise instructed by the resident, a nurse will notify the resident’s representative when: the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; there is a significant change in the resident’s physical, mental, or psychosocial status; or it is necessary to transfer the resident to a hospital.“Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident’s medical/mental condition or status.“The nurse will record in the resident’s medical record information relative to changes in the resident’s medical and mental condition or status.”The Falls-Clinical Protocol policy, revised September 2012, was provided by regional director of clinical services #1 on 5/11/26 at 5:04 p.m. It read in pertinent part, “The staff, with the physician’s guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved.”Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall.”III. Resident #4A. Resident statusResident #4, age 71, was admitted on 10/9/25, readmitted on 12/19/25, and passed away on 12/20/25. According to the December 2025 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage without loss of consciousness, fracture of right femur (thigh bone), dementia, severe, with other behavioral disturbance, pancytopenia (lower than normal count of all three types of blood cells), and protein-calorie malnutrition. According to the 10/15/25 minimum data set (MDS) assessment Resident #4 had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. He was independent with ADL’s and required occasional reminders to complete oral hygiene. He had no previous falls. B. Record reviewThe fall care plan, initiated 12/11/25, indicated Resident #4 was at risk for falls related to cognitive losses and wandering. Interventions included monitoring for changes in condition that increase risk of falls. The potential for fluid deficit care plan, initiated 10/10/25, indicated Resident #4 had the potential for fluid deficit related to dementia. Interventions included monitoring, documenting, and reporting any signs or symptoms of dehydration, such as new onset confusion, dizziness on sitting or standing, increased pulse, headache, fatigue, weakness, or dizziness. The nutritional risk care plan, initiated 10/15/25, indicated Resident #4 had the potential for altered nutrition and or hydration status related to the mini nutritional assessment completed on 10/15/25 with a score of six which indicated malnourished status in the setting of dementia. Interventions included observing for signs or symptoms of malnutrition as evidenced by refusing meals, exhibiting signs or symptoms of dehydration, and reporting to the physician as needed. Review of Resident #4’s electronic medical record (EMR) revealed prior to the falls on 12/11/25 Resident #4 was able to make his needs known, he was pleasant and cooperative, had a good appetite, and ambulated independently around the facility. The nursing progress note, dated12/10/25 at 8:40 p.m., revealed Resident #4 refused dinner that evening. The staff offered some snacks and a Magic cup (frozen nutritional supplement), but he refused. The nursing progress note, dated 12/11/25 at 7:01 a.m., revealed the resident was noted on the floor next to his bed. The top of his mattress was half on the floor and half on his bed, the resident unable to tell what happened. He was assessed, cleaned, and was helped back into bed by staff. The note documented the resident’s vital signs were stable, neurological checks were started by facility protocols. The resident was instructed to call before any transfer. The note documented the physician and the family were notified. The resident's blood pressure was 102/56 millimeters of mercury (mmHg), pulse 81 beats per minute (BPM). The note documented no changes were observed in his mental status.-However, according to the neurological sheet documentation the fall occurred at 5:00 a.m. The nursing progress note, dated 12/11/25 at 1:07 p.m., revealed Resident #4 was on charting for an unwitnessed fall. The resident’s vital signs were stable. He refused to eat this morning and slept most of the morning shift. -However, review of Resident #4’s EMR and the neurological sheet documentation revealed no vital sign readings had been documented since 6:30 a.m. (See licensed practical nurse [LPN] #2’s interview below). The nursing note, dated 12/11/25 at 3:06 p.m., documented the resident had a change in food and or fluid intake. The resident’s BP was 81/57 mmHg (decreased from the documented BP at 7:01 a.m.) and his pulse was 91 BPM (increase from the documented heart rate at 7:02 a.m.). Resident #4 needed more assistance with ADLs, and had general weaknesses. The nurse received a report that the resident had a decrease in appetite and fluid intake over the last three days, which culminated in weakness and a fall this a.m. The resident appeared pale in color. The physician was made aware of the resident's condition and indicated he would have his nurse practitioner see the resident tomorrow.-Review of Resident #4’s EMR did not reveal documentation indicating the facility had notified the resident’s physician of the resident's decrease in appetite, despite the facility documenting it for three days. The nursing progress note, dated 12/11/25 at 6:30 p.m., revealed Resident #4 continued on monitoring for a decline in condition. The resident’s vital signs were: BP 102/63 mmHG, temperature 97.4 degrees Fahrenheit, pulse 90 BPM, respirations 14 breaths per minute, oxygen saturation 95% on room air. The nursing staff attempted to encourage the resident to eat and drink several times, getting him to take sips and eat a Magic cup. Staff attempted to have him eat dinner at bedside sitting up. The resident was confused attempting to stand and was unable to state why and also was unsteady with balance and was redirected back to bed. The resident was checked frequently afterwards and was sleeping.-However, the facility failed to notify the physician of the resident’s further decline in his condition. The nursing note, dated 12/11/25 at 6:50 p.m., documented the staff heard a thud coming from the resident's room. Upon entering, the resident was lying on his back on the floor away from the bed. There was external rotation of the right lower extremity. The nurse called for a registered nurse (RN) to assess the resident. The RN assessment, dated 12/11/25, documented the resident was lying on the floor on his back next to the bed. He complained of right hip pain. His right foot was externally rotated. The resident was confused and was unable to state what he was doing. Emergency medical services (EMS) were called and he was transferred to the hospital.-Review of Resident #4’s EMR did not reveal documentation indicating the facility assessed the resident’s vital signs after this fall. The fall risk observation assessment completed on 12/11/26 at 9:11 p.m. after the second fall, indicated Resident #4’s ambulation baseline was independentprior to his decline in conditions in which the resident became weaker and was in need of assistance with transfers and ambulation. The 12/11/26 hospital emergency room documentation revealed the resident’s vital signs were BP 79/45 mmHg and his pulse was 94 BPM. The note documented he had experienced generalized weakness for about one week, with poor dietary intake and output. He had right hip pain and external rotation of the right foot. The resident was pale throughout. The right lower extremity was slightly shortened. There was tenderness over the right greater trochanter (bony protrusion). The resident was also reported to be hypotensive (low BP) en route to the emergency room. One liter of intravenous (IV) fluid was ordered. The resident presented with one or more acute injuries that posed a threat to life and/or bodily function. The resident had a hemoglobin (iron-rich protein in red blood cells) of 4.5 grams per deciliter (g/dL) (normal range 13.5 to 17.5 g/dL). There were concerns that the resident’s shock may be multifactorial in the setting of hemorrhage. He had a mildly displaced right sided intertrochanteric hip fracture. There was an acute appearing subdural hematoma along the cerebral convexities (bleeding on the top and sides of the brain) bilaterally measuring 1.1 centimeter (cm) on the right and 1 cm on the left. There was a right parafalcine (between the inner layers of the brain) subdural hematoma measuring 7 millimeters (mm) in thickness. There was also a subdural hematoma in the right tentorium (area separating the cerebrum from the cerebellum) measuring 3 to 4 cm in thickness. He was admitted to the trauma intensive care unit with diagnoses of right intertrochanteric femur fracture, acute blood loss anemia (traumatic), and hemorrhagic shock, BP 79/55 mmHg. The nursing progress note, dated12/19/25 at 3:49 p.m., revealed Resident #4 returned to the facility on hospice care. The nursing progress note, dated 12/20/25 at 6:40 a.m., revealed the resident passed away. C. Staff interviewsRN #2 was interviewed on 5/7/26 at 11:00 a.m. RN #2 said when a fall occurred the resident was to be assessed by an RN prior to moving them. RN #2 said vital signs and neurological checks were started if the fall was unwitnessed or they were observed to strike their head. She said if there was a decline in a resident’s condition the provider was to be notified and if the nurse felt the resident needed labs drawn, x-rays, or needed to be sent to the hospital and the physician was reluctant to order those things, the nurse could make a nursing judgement call and notify the medical director to obtain orders. LPN #3 was interviewed on 5/7/26 at 11:15 a.m. LPN #3 said if a resident had a significant change in condition she would assess them and call the provider for orders and let the unit manager and the DON know. She said a change of condition assessment was to be completed. Certified nurse aid (CNA) #1 was interviewed on 5/7/26 at 11:30 a.m. CNA #1 said if a resident refused to eat or drink she would offer different choices and if they refused three times, she said she could not force them to eat or drink. She said if it became a repeated refusal she would then notify the nurse. CNA #2 was interviewed on 5/7/26 at 1:00 p.m. CNA #2 said if she noticed any change in a resident’s condition that was out of their normal behavior she would notify the nurse and if the nurse did not act on her concerns she would go to management and the DON.The DON was interviewed on 5/7/26 at 11:45 a.m. The DON said when a fall occurred or there was a change in a resident’s condition, nursing staff were to complete a change of condition assessment, notify the provider, and the responsible party. She said neurological checks were to be started after a fall and completed in their entirety if the resident was observed to hit their head or if the fall was unwitnessed. She said if a resident refused all or part of the assessments, the nurse was supposed to obtainand document as much of the required information on the form as possible. She said she was not notified of Resident #4’s decline in condition and vital signs. She said if she had been notified she would have had the resident sent to the hospital prior to the second fall. She said if nurses had doubts about what they were to do they should reach out to her and the issue could be escalated to the provider or the medical director for orders if necessary. LPN #2 was interviewed on 5/11/26 at 10:20 a.m. She said when she documented the progress note on 12/11/25 at 1:07 p.m. related to Resident #4 sleeping all morning and refusing to eat, that behavior was unusual for him. She said if a nurse noticed that something was off from the resident’s normal behavior the provider should be notified for orders if indicated. She said she did not notify Resident #4’s provider of the changes she noticed in his condition. She said frequent checks on Resident #4 were not timed but she would lay eyes on him if she passed his room. She said she passed on to the nurse that relieved her that day that Resident #4 was not doing well and to keep an eye on him. She said she documented that Resident #4 refused the neurological checks at 7:00 a.m., 7:30 a.m., 8:00 a.m., 9:00 a.m., and 10:00 a.m. on 12/11/25 because he pushed her away each time she tried to obtain his blood pressure. She said he stayed in bed that entire morning. She said she did not attempt any other areas of the neurological check assessment. She said if a resident refused the assessment she would normally document a progress note of the refusals and the resident's condition, but she did not do that. IV. Resident #16A. Resident statusResident #16, age 78, was admitted on 6/17/21. According to the May 2026 CPO, diagnoses included dementia with behavioral disturbance, generalized muscle weakness, unsteadiness on feet, difficulty in walking and repeated falls. The 3/13/26 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of zero out of 15. The resident required substantial assistance from staff for most ADLs. B. Observations and record reviewDuring a continuous observation on 5/7/26, from 11:54 a.m. to 12:38 p.m., the following was observed:At 11:54 a.m. Resident #16 was sitting up on the floor in the common area with her legs tucked to the side and supporting her weight on her arm. Multiple nursing staff members were attending to the resident, including regional director of clinical services #2 and the DON. Resident #16 had an open area on her forehead approximately two centimeters (CM) by two CM which was bleeding, blood on her hand and a small puddle of blood on the floor. At 11:56 a.m. regional director of clinical services #2 began performing a neurologic assessment on Resident #16 using a cellphone flashlight. Regional director of clinical services #2 held the cellphone flashlight toward Resident #16’s face as she turned her head away from the light. Regional director of clinical services #2 and the DON helped Resident #16 straighten her legs out in front of her and performed a brief range of motion assessment on the resident’s legs. At 12:01 p.m. regional director of clinical services #2 and the DON assisted Resident #16 to a standing position using a gait belt around the resident’s waist and walked with her to her room, where she was assisted into a chair near her bed. Regional director of clinical services #2 and the DON obtained Resident #16’s vital signs using a vitals machine and performed another neurological assessment using a cellphone flashlight. Resident #16 turned her head away repeatedly and was squinting her eyes shut while the light from the flashlight was used to attempt to assess her pupil reaction for the neurological assessment. LPN #1 removed the vital signs machine from the room and brought in wound cleanser and gauze, and the DON and regional director of clinical services #2 began cleaning the wound to Resident #16’s forehead. At 12:08 p.m. regional director of clinical services #2 and the DON closed Resident #16’s door to perform a skin check and assist the resident with getting dressed in clean clothes. At 12:17 p.m. the DON and regional director of clinical services #2 assisted Resident #16 back into the dining room where the resident sat in a dining room chair. At 12:24 p.m. RN #3 reviewed with LPN #1 how to use the facility’s neurological assessment sheet and told LPN #1 when Resident #16 would be due to assess her next set of vitals measurements. At 12:30 p.m. LPN #1 approached Resident #16 in the dining room and began collecting vital signs measurements using the vitals machine. LPN #1 used the vitals equipment to assess Resident #16’s blood pressure, heart rate and blood oxygen saturation. LPN #1 then recorded this information on the neurological assessment sheet.-However, LPN #1 did not have any flashlight or pen light available to assess Resident #16’s pupillary response. At 12:38 p.m. the neurological assessment sheet for Resident #16 was observed on LPN #1’s medication cart. The sheet contained vital signs measurements for Resident #16 which were documented to have been taken at 12:15 p.m. and 12:30 p.m. on 5/7/26. Resident #16’s pupils were documented as having been equal, round and reactive to light at the time of both the 12:15 p.m. and 12:30 p.m. assessments.-However, LPN #1 was not able to assess Resident #16’s pupillary response to light during the 12:30 p.m. assessment period (see above).-Additionally, the vital signs machine had been removed from Resident #16’s room prior to her door being closed at 12:08 p.m. C. Staff interviewsLPN #1 was interviewed on 5/7/26 at 12:38 p.m. LPN #1 said she was not sure how Resident #16 had fallen as she was assisting another resident at the time. She said she only knew the resident had fallen when she heard a thump sound behind her. LPN #1 said the unit managers and the DON had immediately begun assessing Resident #16, and said she would continue performing neurological assessments for the resident per facility policy. LPN #1 said when performing neurological assessments, she only needed to look at the resident’s pupils and see if they were reactive. LPN #1 said she did not have to use a light source when assessing the resident’s pupils, and said the unit manager and the DON had assessed Resident #16’s pupils before they assisted her up from the floor. LPN #1 said the unit managers and DON had used a cellphone flashlight to assess Resident #16 because her pen light batteries were dead. The DON and regional director of clinical services #2 were interviewed together on 5/7/26 at 1:33 p.m. The DON said neurological assessments were performed after a resident sustained a fall to monitor the resident for any change in neurological status, vital signs measurements, mentation or mental status. The DON said when performing neurological assessments, the nursing staff were looking to see if the resident was alert and oriented, had equal hand grasps on both sides, their pupils were reactive to light and equal between the left and right eye, if they had any pain, and their vital signs. The DON said pupil reactivity was assessed using a flashlight or a pen light. The DON said LPN #1 should have used a light source to assess Resident #16’s pupillary reaction.

A complaint survey, prompted by #CO2739753 and #CO2785717 was conducted on 3/3/26 to 3/4/26. Three deficiencies were cited.

Based on record review and interviews, the facility failed to provide choices for preference of bathing schedule for one (#1) of three residents reviewed for self-determination out of eight sample residents. Specifically, the facility failed to ensure Resident #1 received showers consistent with her preferences. Findings include:I. Resident #1A. Resident statusResident #1, age 72, was admitted on 7/14/25, readmitted on 1/16/26 and discharged to the hospital on 1/28/26. According to the January 2026 computerized physician orders (CPO), diagnoses included severe sepsis with septic shock (severe infection that causes organ failure), pneumonia, major depressive disorder, and weakness. The 1/22/26 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. She required set-up or clean-up assistance with eating and substantial to maximal assistance with oral hygiene, toileting hygiene and dressing. -The MDS assessment revealed that bathing was documented as not applicable for assistance. B. Resident’s representative interviewResident #1’s representative was interviewed on 3/3/26 at 1:26 p.m. The representative said Resident #1 told her staff were busy and were not providing her with showers. The representative said Resident #1 requested a shower the week after she was admitted to the facility (week of 1/18/26) and staff did not provide a shower to her. The representative said Resident #1 called her and said staff did not give her a shower and that was how she became aware of the concern. The representative said she had observed Resident #1 wearing the same clothing on multiple occasions, which led her to believe Resident #1 was not receiving showers. The representative said when she visited Resident #1, the resident had a personal female odor. The representative said Resident #1 appeared upset and expressed a desire to be clean. The representative said she asked the director of nursing (DON) for documentation showing completion of the showers for Resident #1, but the facility could not provide her with documentation. C. Record reviewResident #1’s activities of daily living (ADL) care plan, initiated 1/16/26, documented the resident needed partial to substantial assistance for bathing or showering.-However, the care plan failed to include the resident’s preferences or specific days for showers. A review of the certified nurse aide (CNA) bathing task documentation for Resident #1, from 1/16/26 through 1/28/26, revealed no documentation to indicate showers were provided to the resident during her stay at the facility. A review of Resident #1’s electronic medical record (EMR) revealed the resident’s shower preference assessment was not completed upon the resident’s admission to the facility. II. Staff interviewsCNA #2 was interviewed on 3/4/26 at 11:14 a.m. CNA #2 said the residents’ shower schedules were listed at the nurses’ station and indicated how often residents were to receive showers. CNA #2 said residents were scheduled to receive showers three times each week and residents could choose a preference for morning or evening showers. CNA #2 said Resident #1 was scheduled to receive showers on Monday, Wednesday and Friday. CNA #2 said the shower schedule was communicated to staff during shift change and staff reviewed the shower schedule sheet. CNA #2 said if a resident refused a shower, staff would ask the resident three times if they wanted a shower and then documented the refusal in the resident’s EMR and notified the nurse. CNA #2 said Resident #1 often prepared for therapy during the day shift and after therapy appeared exhausted and sometimes refused showers. CNA #2 said Resident #1 received therapy five times per week and sometimes refused showers due to fatigue. CNA #2 said refusals were documented and communicated to the night shift if the resident refused a shower during the morning shift. CNA #2 said if a shower was missed and staff had time the next day, they would attempt to provide the refused shower to the resident. CNA #2 said if staff were busy, the resident would not receive a shower until their next scheduled shower. Licensed practical nurse (LPN) #1 was interviewed on 3/4/26 at 11:30 a.m. LPN #1 said if a resident refused a shower, she would ask the CNA to offer the shower again and if the resident refused a third time, the nurse would document the refusal in a progress note. LPN #1 said the staff would contact the resident’s family to see if the family could encourage the resident to accept the shower. LPN #1 said during shift change, staff communicated with the oncoming shift regarding showers that were not completed. LPN #1 said if a shower was missed, staff would attempt to provide the shower the next day and Saturdays were used as a make-up day for showers that were previously refused. The director of nursing (DON) was interviewed on 3/4/26 at 2:32 p.m. The DON said residents were supposed to be offered showers two times per week unless the resident wanted more frequent showers. The DON said a preference evaluation was completed as part of the admission packet and new admissions were to be offered a shower the day after admission. The DON said staff said they offered showers to Resident #1, but they forgot to document the offers or resident refusals. The DON said the facility completed shower audits five times per week to ensure residents were offered showers and to verify refusals were documented. The DON said if a shower log showed no documented showers during a resident’s stay, the facility would investigate which staff members worked during that time and determine whether showers were offered and whether the staff completed documentation about the showers. The DON said she was not aware of any concerns or complaints from the resident or family regarding bathing while Resident #1 was at the facility. The DON said she became aware of the concern after Resident #1 had discharged from the facility.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of eight sample residents received adequate supervision to prevent risk for accident hazards. Specifically, the facility failed to ensure safe assistance was provided by staff during incontinence care for Resident #1, which resulted in the resident sustaining a fall with minor injuries when she rolled out of bed during the care. Findings include: I. Facility policy and procedureThe Falls - Clinical Protocol policy, revised March 2018, was provided by the director of nursing (DON) on 3/4/26 at 3:04 p.m. It read in pertinent part, “The physician will help identify individuals with a history of falls and risk factors for falling. Staff will ask the resident and the caregiver or family about a history of falling. The staff and physician will document in the medical record a history of one or more recent falls. “The nurse shall assess and document or report vital signs, recent injury, especially fracture or head injury, musculoskeletal function observing for change in normal range of motion and weight bearing, change in cognition or level of consciousness, neurological status and pain. “The nurse will also assess the frequency and number of falls since the last physician visit, precipitating factors and details on how the fall occurred, all current medications especially those associated with dizziness or lethargy and all active diagnoses.” II. Resident #1A. Resident statusResident #1, age 72, was admitted on 7/14/25, readmitted on 1/16/26 and discharged to the hospital on 1/28/26. According to the January 2026 computerized physician orders (CPO), diagnoses included severe sepsis with septic shock (severe infection that causes organ failure), pneumonia, major depressive disorder, and weakness. The 1/22/26 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. She required set-up or clean-up assistance with eating and substantial to maximal assistance with oral hygiene, toileting hygiene and dressing. The MDS assessment did not indicate the resident had a history of falls. B. Resident’s representative interviewResident #1’s representative was interviewed on 3/3/26 at 1:26 p.m. The representative said Resident #1 told her that during incontinence care, an unknown certified nurse aide (CNA) kept pushing her to roll over and she fell off the bed. The representative said a nurse entered the room and observed the CNA pulling Resident #1 off the floor by her right arm, even though she said she had pain in her right arm and told the CNA to stop. The representative said that Resident #1 was upset. Resident #1’s representative said Resident #1 called her approximately 30 minutes after the fall on 1/23/26 and said she sustained injuries to her right shoulder. The representative said the resident’s right shoulder had been hurting prior to the fall, but the fall made the pain worse because the CNA tried to pull her up by her right arm. The representative said every toe on the resident’s right foot had abrasions or bruising and staff placed bandages on them. Resident #1’s representative said later that night, on 1/23/26, the facility called and said Resident #1 had a fall and was fine and they wanted to notify her. The representative said the facility did not inform her that Resident #1 sustained injuries. C. Record reviewThe activities of daily living (ADL) care plan, initiated 1/16/26, revealed Resident #1 had a self-care performance deficit related to severe septic shock from pneumonia and needed staff assistance with care. -However, the bed mobility intervention did not identify the level of assistance required or the number of staff needed. Review of Resident #1's fall care plan, initiated 1/16/26 and revised 1/28/26, revealed the resident was at risk for falls related to respiratory failure, chronic obstructive pulmonary disease (COPD) and chronic pain. Pertinent interventions included one-on-one staff education, ensuring all items were in reach while the resident was in bed or her chair, anticipating and meeting the resident's needs, keeping the resident’s bed at transfer height, physical therapy evaluate and treat as ordered and two staff members to provide incontinence care. A fall risk assessment, dated 1/16/26, revealed the resident was a high fall risk. A fall investigation report, dated 1/23/26 at 8:30 p.m., revealed a CNA was providing incontinence care to Resident #1 when the resident rolled out of bed, landing on her bilateral lower extremities. No injuries were observed at the time of the fall. The resident said her pain was 4 out of 10 in her right shoulder. The nurse observed five skin tears to Resident #1's toes and a right knee abrasion. An IDT (interdisciplinary team) progress note, dated 1/27/26 at 3:37 p.m., revealed Resident #1 lifted her right leg and her weight shifted while she was being provided incontinence care. Resident #1 then rolled left and slid out of bed onto the floor, landing on her knees. Resident #1 had no new skin impairments as a result of the fall. The interventions included one-on-one staff education and two staff members were to perform incontinence care for the resident. -Review of Resident #1’s electronic medical record (EMR) revealed there were no nursing progress notes related to Resident #1's fall on 1/23/26. III. Staff interviewsCNA #2 was interviewed on 3/4/26 at 12:55 p.m. CNA #2 said staff determined how to safely turn and reposition a resident in bed based on the resident’s ability to assist with movement. CNA #2 said staff reviewed the Kardex (a comprehensive directive tool for care), care plan and hospital report information, and would ask the nurse, another CNA familiar with the resident or the resident about their ability if staff were unfamiliar with the resident or if the resident was a new admission to the facility. CNA #2 said the number of staff assisting with repositioning, bed mobility and incontinence care varied, depending on the resident’s needs. CNA #2 said staff determined whether one or two staff members were required based on the resident’s level of assistance. CNA #2 said during Resident #1’s initial admission to the facility (7/14/25), the resident required two-person assistance but later progressed to needing only one-person assistance. CNA #2 said during the resident’s second admission to the facility (1/16/26), Resident #1 required two-person assistance for bed mobility. CNA #2 said she did not know whether Resident #1 had one or two person assistance on the night of the incident (1/23/26). CNA #2 said staff were aware Resident #1 was considered a fall risk and used a wheelchair. CNA #2 said staff did not have concerns that the resident could slide off the bed while being turned during care. Registered nurse (RN) #1 was interviewed on 3/4/26 at 1:08 p.m. RN #1 said staff reviewed the care plan and Kardex to determine whether a resident required one or two-person assistance for bed mobility or repositioning. RN #1 said if the resident was newly admitted or readmitted to the facility, staff reviewed hospital records and physical therapy notes from the hospital. RN #1 said prior to the fall on 1/23/26, Resident #1 required partial to moderate assistance with turning during incontinence care and this meant the resident was able to assist with care. RN #1 said fall interventions in place prior to the fall included nonskid footwear, the call light within reach and encouragement for the resident to use the call light as needed. RN #1 said she did not find any interventions in the care plan specifically related to bed mobility and repositioning. RN #1 said staff were informed about the resident’s fall risk and required assistance through the falling staff program, which placed a star outside the resident’s door to indicate fall risk. RN #1 said staff additionally reviewed the Kardex andEMR documentation. RN #1 said after the fall occurred on 1/23/26, Resident #1’s care instructions were updated to include the resident required two-person assistance for incontinence care. RN #1 said prior to the fall, Resident #1 was considered a high fall risk. The DON was interviewed on 3/4/26 at 2:32 p.m. The DON said based on Resident #1’s medical condition, level of weakness and diagnoses, the resident required one-person assistance for turning in bed prior to the resident’s fall on 1/23/26. The DON said the level of assistance required for a resident was identified in the residents’ care plans. The DON said Resident #1 had weakness, which increased her risk for falling. The DON aid staff assessed the resident’s needs for assistance primarily based on information reported by staff working on the floor and through ongoing assessment of the resident’s condition. The DON said staff received education to use the mechanical lifts when appropriate rather than lifting residents manually. The DON said after the fall on 1/23/26, Resident #1 sustained abrasions to the right knee and toes. The DON said following the fall, the resident’s care plan was updated to require two-person assistance for during the resident’s incontinence care and repositioning. The DON said written education was provided to staff indicating Resident #1 required two-person assistance.

Based on record review and interviews, the facility failed to ensure food served accommodated residents’ allergies and intolerances for one (#1) of three residents reviewed out of eight sample residents. Specifically, the facility failed to ensure Resident #1 was not served food the resident was allergic to, despite the resident having a documented food allergy. Findings include:I. Facility policy and procedureThe Food Allergies and Intolerances policy, revised August 2017, was provided by the director of nursing (DON) on 3/4/26 at 3:04 p.m. It revealed in pertinent part, “Residents with food allergies and or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen.“Residents are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment. All reported food allergies and intolerances are documented into the resident care plan. Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat.”II. Resident #1A. Resident statusResident #1, age 72, was admitted on 7/14/25, readmitted on 1/16/26 and discharged to the hospital on 1/28/26. According to the January 2026 computerized physician orders (CPO), diagnoses included severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness. The 1/22/26 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. She required set-up or clean-up assistance with eating and substantial to maximal assistance with oral hygiene, toileting hygiene and dressing. B. Resident’s representative interviewResident #1’s representative was interviewed on 3/3/26 at 1:26 p.m. The representative said the facility had documented that Resident #1 was allergic to pineapple and the allergy was included on the resident’s meal ticket. The representative said the facility still served pineapple to Resident #1, despite documentation indicating the resident was allergic to pineapple. The representative said Resident #1 ate a few pieces of pineapple before realizing it was pineapple. The representative said staff gave Resident #1 medication to prevent any allergic reactions after the resident ate the pineapple, and no reaction was noted. The representative said Resident #1 was upset and did not understand how the pineapple was served despite the allergy being documented in the resident’s medical record and on her meal ticket the certified nurse aides (CNA) had access to when delivering the resident’s meal tray. C. Record reviewReview of Resident #1’s comprehensive care plan, initiated 1/16/26, revealed Resident #1 had allergies to pineapple and wool. The care plan report, initiated 1/16/26 and revised 1/26/26, identified Resident #1 as having an allergy to pineapple and included a nutrition intervention for staff to honor the resident’s food preferences.-The care plan did not reveal the resident's food likes and dislikes. The nursing progress note, dated 1/21/26 at 9:10 p.m., revealed the resident had pineapple on her dinner tray. The progress note documented the resident had a pineapple allergy and ate two pieces of the pineapple. The progress note documented staff notified the on-call physician orders were obtained to give the resident Benadryl (antihistamine medication). The progress note documented staff noted no adverse reactions after the incident and the resident’s vital signs were stable. The progress note, dated 1/22/26, documented a physician’s order for Benadryl (diphenhydramine HCl) 25 milligrams (mg) capsule with directions to give 25 mg by mouth every six hours as needed for allergy. Review of the facility’s Quality Assurance and Performance Improvement (QAPI) root cause analysis, dated 1/22/26, revealed Resident #1 was served pineapple on her dinner meal tray on 1/21/26, despite having a documented pineapple allergy. The review revealed the resident ingested two pieces of pineapple before staff identified the error and removed the food from the tray. Nursing management and the physician were notified and diphenhydramine (Benadryl) was ordered as needed. The resident was monitored and no allergic reaction or negative outcome was reported. Review of the QAPI root cause analysis revealed the dietary aide (DA) serving the residents’ food on 1/21/26 did not note the resident’s pineapple allergy on the meal card and pineapple was placed on the resident’s tray as a dessert. The review further revealed the CNA identified the pineapple on the tray and removed it after the resident had already ingested two pieces of the pineapple. Review of the facility’s corrective action plan revealed dietary staff were educated to verify that foods served matched the meal cards with attention to residents’ documented allergies. The document additionally revealed nursing staff were educated to verify that the food served matched the resident’s meal card. The plan documented residents’ allergies would be clearly listed on meal cards to assist staff when passing meal trays. Review of the facility’s staff education regarding meal verification and allergies revealed staff were educated to verify each resident’s meal card accurately and ensured it reflected the resident’s current diet order, texture and restrictions. The education documented staff should check meal cards daily and whenever there was a diet change for a resident. The staff education document revealed the education reviewed the process for clearly identifying residents’ food allergies on the residents’ meal cards and staff should immediately report any missing or incorrect allergy information to nursing and dietary services. The education further documented staff should confirm the meal being served matched the resident’s meal card and should not provide food items that conflicted with physician ordered diets or documented allergies. Review of the in-service sign in sheet, dated 1/27/26, revealed dietary staff attended the education regarding meal card verification and accuracy.-However, the facility failed to ensure the corrective action was sustained (see resident council notes below). Review of the resident council meeting notes, dated 1/29/26, revealed residents reported meal service concerns. One resident communicated that CNAs blamed the kitchen for meal mistakes and did not correct the issue when errors occurred. Residents also communicated that some CNAs did not ask residents for their meal choices. Review of the resident council meeting notes, dated 2/26/26, revealed a resident communicated that meal tickets were not being followed correctly by CNAs on the Evergreen unit. III. Staff interviewsThe dietary manager (DM) was interviewed on 3/4/26 at 10:21 a.m. The DM said resident allergies were identified through the meal tickets printed by either the DS or the dietitian. The DM said the meal tickets included the residents’ food allergies and the allergies were highlighted. The DM said the dDAs verified the meal tickets before the meal cart left the kitchen and the CNAs on the floor also checked the tickets. The DM said in the incident involving Resident #1’s pineapple allergy, the DA did not review the resident’s meal ticket correctly and did not pay attention to the resident’s documented food allergy because staff were trying to serve trays quickly. DA #1 was interviewed on 3/4/26 at 10:31 a.m. DA #1 said residents’ food allergies were identified by reviewing the meal tickets. DA #1 said the meal tickets listed diet textures such as soft and bite-sized diets and identified residents with allergies. DA #1 said residents’ food allergies were highlighted in yellow so staff knew what to look for when preparing trays. DA #1 said if a food item on a tray was something a resident was allergic to, staff would remove the item and provide an alternative food, such as applesauce instead of pineapple. DA #1 said if a resident’s meal tray had already been prepared with the incorrect food item, staff would discard the tray and prepare a new meal tray for the resident with the correct substitute food item. Cook (CK) #1 was interviewed on 3/4/26 at 10:36 a.m. CK #1 said residents’ food allergies were identified by reviewing the meal tickets before giving the tickets to the DA. CK #1 said kitchen staff reviewed the meal tickets thoroughly to ensure residents did not receive foods they were not allowed to have. CK #1 said if a food item on a tray was something a resident was allergic to, staff ensured the item was not served to the resident and removed the tray. CK #1 said once meal tickets were printed and the DA highlighted residents’ allergies, staff ensured residents did not receive foods that they were not allowed to have. CK #1 said the DAs checked meal trays before they left the kitchen. The registered dietitian (RD) was interviewed on 3/4/26 at 10:44 a.m. The RD said the residents’ food allergies were documented at the time of the resident’s initial admission and remained documented during subsequent admissions. The RD said the facility used a software program to track residents’ food allergies, preferences and diet orders. The RD said the software program integrated with the residents’ electronic medical records (EMR), and diet orders and allergies were communicated to the kitchen through that system and updated as needed. The RD said residents’ food allergy information was communicated to kitchen staff and nursing staff through the residents’ meal cards. The RD said the CKs prepared the entrée, passed it to the DAs and the DAs placed the dessert on the meal tray and the meal tray on the meal delivery cart. The RD said floor staff were expected to review and verify the residents’ meal cards before serving the meal trays to the residents. The RD said the incident regarding Resident #1 being served a food she was allergic to was discussed in a clinical meeting the next day following the incident (1/22/26) and education was provided to staff on 1/27/26. -However, education was not provided to staff until five days after the IDT discussed the incident and six days after the incident with Resident #1 occurred. CNA #1 was interviewed on 3/4/26 at 11:01 a.m. CNA #1 said staff identified foods a resident should not receive due to allergies or diet restrictions by reviewing the resident’s meal ticket. CNA #1 said staff checked the meal tickets to verify the correct foods were served to residents. CNA #1 said everyone in the kitchen and on the floor passing trays checked the meal tickets. CNA #1 said if a food item on the tray was something the resident may be allergic to, staff would take the tray back to the kitchen to obtain an alternative food item and reported the concern to the unit manager. Registered nurse (RN) #1 was interviewed on 3/4/26 at 11:08 a.m. RN #1 said a resident’s allergies would be documented in the admission paperwork and would then be entered into their EMR. RN #1 said the allergy information would be written on the resident’s meal tray ticket so dietary staff and nursing staff would be aware of the resident’s allergies. RN #1 said each staff member was expected to review the meal ticket on each resident’s tray to ensure residents did not receive foods they were allergic to. RN #1 said if staff identified an allergen on a resident’s tray, staff removed the meal tray and obtained a new tray from the kitchen with an alternative food item. RN #1 said if a resident ingested a food item they were allergic to, staff removed the food, obtained the resident’s vital signs and notified the physician for further orders. RN #1 said the incident would be documented in the resident’s progress notes. The DON was interviewed on 3/4/26 at 2:32 p.m. The DON said the meal ticket system populated residents’ diet orders and allergies and staff highlighted the allergy information. The DON said kitchen staff and nursing staff were expected to review the meal tickets to ensure residents did not receive foods they were allergic to. The DON said the facility was attempting to determine where the break in the system occurred related to Resident #1’s pineapple allergy incident. The DON said after the incident with Resident #1 on 1/21/26, the facility implemented audits and worked with the kitchen manager to ensure an additional staff member reviewed meal trays before they left the kitchen. The DON said nursing staff verified that the meals being delivered matched the resident’s diet orders and allergy information by comparing the meal cards with the meal trays before serving the meal to the residents. The DON said staff compliance was monitored through ongoing audits and follow-up education with staff to ensure the process was followed.-However, review of resident council meeting notes revealed residents still had concerns with CNAs not following meal tickets on 2/26/26 (see record review above).

A survey prompted by #CO2739754 was completed on 3/3/26 to 3/4/26. Two deficiencies were cited.

Based on record review and interviews, the facility failed to provide choices for preference of bathing schedule for one (#1) of three residents reviewed for self-determination out of eight sample residents. Specifically, the facility failed to ensure Resident #1 received showers consistent with her preferences. Findings include:I. Resident #1A. Resident statusResident #1, age 72, was admitted on 7/14/25, readmitted on 1/16/26 and discharged to the hospital on 1/28/26. According to the January 2026 computerized physician orders (CPO), diagnoses included severe sepsis with septic shock (severe infection that causes organ failure), pneumonia, major depressive disorder, and weakness. The 1/22/26 comprehensive assessment revealed the resident was cognitively intact. She required set-up or clean-up assistance with eating and substantial to maximal assistance with oral hygiene, toileting hygiene and dressing. -The comprehensive assessment revealed that bathing was documented as not applicable for assistance. B. Resident’s representative interviewResident #1’s representative was interviewed on 3/3/26 at 1:26 p.m. The representative said Resident #1 told her staff were busy and were not providing her with showers. The representative said Resident #1 requested a shower the week after she was admitted to the facility (week of 1/18/26) and staff did not provide a shower to her. The representative said Resident #1 called her and said staff did not give her a shower and that was how she became aware of the concern. The representative said she had observed Resident #1 wearing the same clothing on multiple occasions, which led her to believe Resident #1 was not receiving showers. The representative said when she visited Resident #1, the resident had a personal female odor. The representative said Resident #1 appeared upset and expressed a desire to be clean. The representative said she asked the director of nursing (DON) for documentation showing completion of the showers for Resident #1, but the facility could not provide her with documentation. C. Record reviewResident #1’s activities of daily living (ADL) care plan, initiated 1/16/26, documented the resident needed partial to substantial assistance for bathing or showering.-However, the care plan failed to include the resident’s preferences or specific days for showers. A review of the certified nurse aide (CNA) bathing task documentation for Resident #1, from 1/16/26 through 1/28/26, revealed no documentation to indicate showers were provided to the resident during her stay at the facility. A review of Resident #1’s electronic medical record (EMR) revealed the resident’s shower preference assessment was not completed upon the resident’s admission to the facility. II. Staff interviewsCNA #2 was interviewed on 3/4/26 at 11:14 a.m. CNA #2 said the residents’ shower schedules were listed at the nurses’ station and indicated how often residents were to receive showers. CNA #2 said residents were scheduled to receive showers three times each week and residents could choose a preference for morning or evening showers. CNA #2 said Resident #1 was scheduled to receive showers on Monday, Wednesday and Friday. CNA #2 said the shower schedule was communicated to staff during shift change and staff reviewed the shower schedule sheet. CNA #2 said if a resident refused a shower, staff would ask the resident three times if they wanted a shower and then documented the refusal in the resident’s EMR and notified the nurse. CNA #2 said Resident #1 often prepared for therapy during the day shift and after therapy appeared exhausted and sometimes refused showers. CNA #2 said Resident #1 received therapy five times per week and sometimes refused showers due to fatigue. CNA #2 said refusals were documented and communicated to the night shift if the resident refused a shower during the morning shift. CNA #2 said if a shower was missed and staff had time the next day, they would attempt to provide the refused showerto the resident. CNA #2 said if staff were busy, the resident would not receive a shower until their next scheduled shower. Licensed practical nurse (LPN) #1 was interviewed on 3/4/26 at 11:30 a.m. LPN #1 said if a resident refused a shower, she would ask the CNA to offer the shower again and if the resident refused a third time, the nurse would document the refusal in a progress note. LPN #1 said the staff would contact the resident’s family to see if the family could encourage the resident to accept the shower. LPN #1 said during shift change, staff communicated with the oncoming shift regarding showers that were not completed. LPN #1 said if a shower was missed, staff would attempt to provide the shower the next day and Saturdays were used as a make-up day for showers that were previously refused. The director of nursing (DON) was interviewed on 3/4/26 at 2:32 p.m. The DON said residents were supposed to be offered showers two times per week unless the resident wanted more frequent showers. The DON said a preference evaluation was completed as part of the admission packet and new admissions were to be offered a shower the day after admission. The DON said staff said they offered showers to Resident #1, but they forgot to document the offers or resident refusals. The DON said the facility completed shower audits five times per week to ensure residents were offered showers and to verify refusals were documented. The DON said if a shower log showed no documented showers during a resident’s stay, the facility would investigate which staff members worked during that time and determine whether showers were offered and whether the staff completed documentation about the showers. The DON said she was not aware of any concerns or complaints from the resident or family regarding bathing while Resident #1 was at the facility. The DON said she became aware of the concern after Resident #1 had discharged from the facility.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of eight sample residents received adequate supervision to prevent risk for accident hazards. Specifically, the facility failed to ensure safe assistance was provided by staff during incontinence care for Resident #1, which resulted in the resident sustaining a fall with minor injuries when she rolled out of bed during the care. Findings include: I. Facility policy and procedureThe Falls - Clinical Protocol policy, revised March 2018, was provided by the director of nursing (DON) on 3/4/26 at 3:04 p.m. It read in pertinent part, “The physician will help identify individuals with a history of falls and risk factors for falling. Staff will ask the resident and the caregiver or family about a history of falling. The staff and physician will document in the medical record a history of one or more recent falls. “The nurse shall assess and document or report vital signs, recent injury, especially fracture or head injury, musculoskeletal function observing for change in normal range of motion and weight bearing, change in cognition or level of consciousness, neurological status and pain. “The nurse will also assess the frequency and number of falls since the last physician visit, precipitating factors and details on how the fall occurred, all current medications especially those associated with dizziness or lethargy and all active diagnoses.”II. Resident #1A. Resident statusResident #1, age 72, was admitted on 7/14/25, readmitted on 1/16/26 and discharged to the hospital on 1/28/26. According to the January 2026 computerized physician orders (CPO), diagnoses included severe sepsis with septic shock (severe infection that causes organ failure), pneumonia, major depressive disorder, and weakness. The 1/22/26 comprehensive assessment revealed the resident was cognitively intact. She required set-up or clean-up assistance with eating and substantial to maximal assistance with oral hygiene, toileting hygiene and dressing. The comprehensive assessment did not indicate the resident had a history of falls. B. Resident’s representative interviewResident #1’s representative was interviewed on 3/3/26 at 1:26 p.m. The representative said Resident #1 told her that during incontinence care, an unknown certified nurse aide (CNA) kept pushing her to roll over and she fell off the bed. The representative said a nurse entered the room and observed the CNA pulling Resident #1 off the floor by her right arm, even though she said she had pain in her right arm and told the CNA to stop. The representative said that Resident #1 was upset. Resident #1’s representative said Resident #1 called her approximately 30 minutes after the fall on 1/23/26 and said she sustained injuries to her right shoulder. The representative said the resident’s right shoulder had been hurting prior to the fall, but the fall made the pain worse because the CNA tried to pull her up by her right arm. The representative said every toe on the resident’s right foot had abrasions or bruising and staff placed bandages on them. Resident #1’s representative said later that night, on 1/23/26, the facility called and said Resident #1 had a fall and was fine and they wanted to notify her. The representative said the facility did not inform her that Resident #1 sustained injuries. C. Record reviewThe activities of daily living (ADL) care plan, initiated 1/16/26, revealed Resident #1 had a self-care performance deficit related to severe septic shock from pneumonia and needed staff assistance with care. -However, the bed mobility intervention did not identify the level of assistance required or the number of staff needed. Review of Resident #1's fall care plan, initiated 1/16/26 and revised 1/28/26, revealed the resident was at risk for falls related to respiratory failure, chronic obstructive pulmonary disease (COPD) and chronic pain. Pertinent interventions included one-on-one staff education, ensuring all items were in reach while the resident was in bed or her chair, anticipating and meeting the resident's needs, keeping the resident’s bed at transfer height, physical therapy evaluate and treat as ordered and two staff members to provide incontinence care. A fall risk assessment, dated 1/16/26, revealed the resident was a high fall risk. A fall investigation report, dated 1/23/26 at 8:30 p.m., revealed a CNA was providing incontinence care to Resident #1 when the resident rolled out of bed, landing on her bilateral lower extremities. No injuries were observed at the time of the fall. The resident said her pain was 4 out of 10 in her right shoulder. The nurse observed five skin tears to Resident #1's toes and a right knee abrasion. An IDT (interdisciplinary team) progress note, dated 1/27/26 at 3:37 p.m., revealed Resident #1 lifted her right leg and her weight shifted while she was being provided incontinence care. Resident #1 then rolled left and slid out of bed onto the floor, landing on her knees. Resident #1 had no new skin impairments as a result of the fall. The interventions included one-on-one staff education and two staff members were to perform incontinence care for the resident. -Review of Resident #1’s electronic medical record (EMR) revealed there were no nursing progress notes related to Resident #1's fall on 1/23/26. III. Staff interviewsCNA #2 was interviewed on 3/4/26 at 12:55 p.m. CNA #2 said staff determined how to safely turn and reposition a resident in bed based on the resident’s ability to assist with movement. CNA #2 said staff reviewed the Kardex (a comprehensive directive tool for care), care plan and hospital report information, and would ask the nurse, another CNA familiar with the resident or the resident about their ability if staff were unfamiliar with the resident or if the resident was a new admission to the facility. CNA #2 said the number of staff assisting with repositioning, bed mobility and incontinence care varied, depending on the resident’s needs. CNA #2 said staff determined whether one or two staff members were required based on the resident’s level of assistance. CNA #2 said during Resident #1’s initial admission to the facility (7/14/25), the resident required two-person assistance but later progressed to needing only one-person assistance. CNA #2 said during the resident’s second admission to the facility (1/16/26), Resident #1 required two-person assistance for bed mobility. CNA #2 said she did not know whether Resident #1 had one or two person assistance on the night of the incident (1/23/26). CNA #2 said staff were aware Resident #1 was considered a fall risk and used a wheelchair. CNA #2 said staff did not have concerns that the resident could slide off the bed while being turned during care. Registered nurse (RN) #1 was interviewed on 3/4/26 at 1:08 p.m. RN #1 said staff reviewed the care plan and Kardex to determine whether a resident required one or two-person assistance for bed mobility or repositioning. RN #1 said if the resident was newly admitted or readmitted to the facility, staff reviewed hospital records and physical therapy notes from the hospital. RN #1 said prior to the fall on 1/23/26, Resident #1 required partial to moderate assistance with turning during incontinence care and this meant the resident was able to assist with care. RN #1 said fall interventions in place prior to the fall included nonskid footwear, the call light within reach and encouragement for the resident to use the call light as needed. RN #1 said she did not find any interventions in the care plan specifically related to bed mobility and repositioning. RN #1 said staff were informed about the resident’s fall risk and required assistance through the falling staff program, which placed a star outside the resident’s door to indicate fall risk. RN #1 said staff additionally reviewed the Kardex and EMR documentation. RN #1 said after the fall occurred on 1/23/26, Resident #1’s care instructions were updated to include the resident required two-person assistance for incontinence care. RN #1 said prior to the fall, Resident #1 was considered a high fall risk. The DON was interviewed on 3/4/26 at 2:32 p.m. The DON said based on Resident #1’s medical condition, level of weakness and diagnoses, the resident required one-person assistance for turning in bed prior to the resident’s fall on 1/23/26. The DON said the level of assistance required for a resident was identified in the residents’ care plans. The DON said Resident #1 had weakness, which increased her risk for falling. The DON aid staff assessed the resident’s needs for assistance primarily based on information reported by staff working on the floor and through ongoing assessment of the resident’s condition. The DON said staff received education to use the mechanical lifts when appropriate rather than lifting residents manually. The DON said after the fall on 1/23/26, Resident #1 sustained abrasions to the right knee and toes. The DON said following the fall, the resident’s care plan was updated to require two-person assistance for during the resident’s incontinence care and repositioning. The DON said written education was provided to staff indicating Resident #1 required two-person assistance.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 5.13.1 GENERAL DIETARY STANDARDSThe facility shall provide meals that are nutritious; attractive; well balanced; in conformity with practitioner orders and resident choice and served at the appropriate temperature in order to enhance residents' health and well being. It shall also offer nourishing snacks. Residents shall receive the care necessary to meet individual physical, psycho-social and rehabilitative needs and assistance to achieve and main their highest practicable level of independence, self-care, self-worth and well-being. Provision of care shall be documented in the health information record.

A complaint survey, prompted by, #CO2682015, Incident #2680958 and Incident #2681109 was completed on 1/5/26 to 1/6/26. No deficiencies were cited.

A complaint survey, prompted by #CO2682018 was conducted on 1/5/26 to 1/6/26. No deficiencies were cited.

A recertification survey with complaint #CO1922614, #CO2565882 and Incident #2593968 was completed from 9/22/25 to 12/01/2025. Ten deficiencies were cited. The actual survey exit date was 09/25/2025. 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 12/01/2025

An Emergency Preparedness survey was conducted from 9/22/25 to 12/01//25. No deficiencies were cited. The actual survey exit date was 09/25/2025. 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 12/01/2025.

Based on observations and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect for two of four units. Specifically, the facility failed to:-Provide Resident #155 privacy while he used the restroom, and,-Staff announced themselves prior to entering residents’ rooms. Findings include:I. Resident #155A. Resident statusResident #155, age 78, was admitted 7/24/24. According to the September 2025 computerized physician orders (CPO), diagnoses included traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the skull) without loss of consciousness, dementia with agitation, cancer of the thyroid gland, and rheumatoid arthritis. The 6/25/25 minimum data set (MDS) assessment revealed Resident #155 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS further revealed Resident #155 was independent for all of his activities of daily living (ADL). B. ObservationsOn 9/23/25 at 9:14 a.m. certified nurse aide (CNA) #3 knocked on Resident #155’s door then immediately walked into his room. Resident #155 was heard yelling, “Hey, I’m on the toilet!” CNA #3 then said, “Sorry, can I grab your tray?” CNA #3 then came out of his room without his tray and was heard saying to an unidentified CNA trainee, “He’s a very private person.”II. Failure to knock before entering resident roomsA. ObservationsOn 9/23/25 at 9:14 a.m. after CNA #3 entered Resident #155’s room, she proceeded to go from room to room on the 800 hall, knocking and immediately entering the residents’ rooms to gather room trays. She did not announce herself upon entering the rooms. On 9/24/25 at approximately 2:22 p.m. an unidentified male CNA was going from room to room down the 700 hall taking residents’ dinner orders. He was knocking then immediately entering the rooms (without announcing himself), without waiting for the residents to respond. B. Resident group interviewA group interview was conducted on 9/23/25 at 1:00 p.m. with 10 (#25, #31, #50, #2, #124, #140, #151, #152, #10 and #17) alert and oriented residents per facility and assessment. The residents said the staff knocked on their doors, but did not wait for a response. The residents said the staff knocked, then walked right in. The group called it “the knock then walk.” III. Staff interviewsCNA #2 was interviewed on 9/25/25 at 3:52 p.m. She said she knocked on the resident’s doors before entering their rooms. She said she waited 30 seconds to one minute before entering the resident’s room if she did not hear a response from the resident. She said if a resident was using the bathroom when she entered the room, the bathroom door was s usually closed or the resident would tell her before she entered the room. The director of nursing (DON) was interviewed on 9/25/25 at 3:56 p.m. She said the staff should knock before they enter a resident’s room. She said staff should be asking if they could enter before they enter the room. She said staff should wait up to fifteen seconds before entering the room if they did not get a resident’s response. She said there were certain circumstances, such as falls or other medical emergencies, where she did not want staff waiting too long before entering the resident’s room.

Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for two (#175 and #45) out of five residents reviewed for personal funds accounts out of 71 sample residents. Specifically, the facility failed to notify Resident #175 and Resident #45, who were Medicaid funded, or their legal representative when the resident’s personal funds account reached $200.00 less than the eligibility resource limit. Findings include:I. Resident accountsA. Resident #175Resident #175 had an account balance of $1,915.07.-There was no documentation the facility had notified Resident #175 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit. B. Resident #45Resident #45 had an account balance of $1,892.06.-There was no documentation the facility had notified Resident #45 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit. II. Staff interviewsThe nursing home administrator (NHA) was interviewed on 9/23/25 at 1:15 p.m. The NHA said the business office manager (BOM) was out of the office. The NHA said there was some confusion as to what the allotted limit for Medicaid funded residents was. The NHA said the facility was going to reach out to the residents’ representatives to spend down the funds.

Based on record review, observations, and interviews, the facility failed to provide supervision, assistance, services, and implement effective person centered interventions to prevent falls with injuries for one (#156) of three residents reviewed for accidents/hazards out of 71 sample residents. Specifically, the facility failed to ensure the staff were aware and implemented Resident #156's fall interventions consistently. Findings include:I. Facility policy and procedureThe Fall Risk policy, revised March 2018, was provided by the nursing home administrator (NHA) on 9/25/25 at 9:21 a.m. It read in pertinent part,"The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. In conjunction with the attending physician, staff will identify and implement relevant interventions (hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling". II. Resident #156A. Resident statusResident #156, age 89, was admitted on 6/1/25. According to the September 2025 computerized physician orders (CPO) diagnoses included dementia, diabetes and osteoporosis (a disease that weakens the bones, making them less dense and thinner). The 9/12/25 minimum data set (MDS) assessment revealed the resident had significant cognitive impairments with a brief interview of mental status (BIMS) score of one out of 15. The resident required extensive assistance with showers and transfers and used a wheelchair for mobility. The assessment revealed the resident had two falls with injury since the last review period. B. Observations On 9/22/25 at 8:45 a.m. Resident #156 was sleeping in her bed. The door was closed and the call light was on the floor. On 9/23/25 at 12:56 p.m. Resident #156 was asleep in her. The door closed. C. Record reviewThe fall care plan, revised on 6/3/25, revealed the resident was at risk for falls due to a history of falls with fractures and dementia. Interventions included to ensure the resident's call light was within reach (initiated 6/3/25), ensure the resident was wearing appropriate footwear when ambulating or mobilizing in her wheelchair (initiated 6/3/25), leaving the door open while the resident was in her room (initiated 6/30/25), assisting the resident with transfers after meals to the bed to lie down (initiated 8/8/25), ensuring the resident was in high visible areas during waking hours as tolerated (initiated 8/19/25), having the physician review the resident’s blood sugars, metformin (diabetic medication) and A1C (diabetic blood test) (initiated 8/21/25). Review of the certified nurse assistant (CNA) abbreviated care plan (tasks) did not reveal resident specific fall interventions. A nursing progress note, dated 6/2/25, revealed the resident had been admitted after an intracapsular fracture (a bone break that occurs within the joint capsule) of left femur. A physician note, dated 6/3/25, revealed the resident had significant cognitive deficits and was a high risk for falls with physical injury. 1. Fall on 6/29/25 - unwitnessed A change of condition note, dated 6/29/25, revealed the resident was found on the floor facing the wall towards the headboard in between her wheelchair and her bed. A puncture wound was noted to the right elbow, bruising to the right knee and bruising with a raised area to the back of her head near the crown. The resident was assessed by the nurse. The physician and the family were notified. An exam revealed a small laceration to her right elbow. The physician r ordered Xrays and wound care treatment. A follow up note, dated 6/30/25, revealed the Xrays showed no abnormalities. A fall interdisciplinary team (IDT) note, dated 6/30/25, revealed risk factors identified included: difficulty locking breaks when self transferring, impulsivity, primarily Russian speaking, poor safety awareness and walking without assistance. Prior interventions were to keep her bed in the low position and ensure call light was within reach. The new interventions implemented were to add brake extenders to the wheelchair and to ensure the resident's room door remained open while the resident was in the room. -However, observations revealed the resident’s door was not open while the resident was in her room (see observations above). 2. Fall on 8/4/25- unwitnessedA change of condition note, dated 8/7/25, revealed the resident had an unwitnessed fall in her room while trying to move the tray from the side table into the vanity. The resident stated she felt dizzy and fell to the ground. The nurse assessed the resident and was able to get the resident into a standing position. A physician assistant progress note, dated 8/7/25, revealed the resident was complaining of pain to the left side of her face but her physical exam was unremarkable. A health status note, dated 8/7/25, revealed at the time of the unwitnessed fall, the resident was observed laying on her back on the floor in her room. The resident was assessed by the nurse and a reddened area to her left cheek was observed. The area was tender to the touch and also had a 2 centimeter (cm) scratch. Through the translator line, the resident said she had gotten up out of her bed to do the dishes and her legs had given out, causing her to fall. A fall IDT note, dated 8/8/25, revealed risk factors identified included: difficulty locking breaks when self transferring, impulsivity, primarily Russian speaking, poor safety awareness and walking without assistance. Prior interventions were to keep her call light within reach, transfer height bed, brake extenders and to ensure the door to her room remained open while the resident was in there. The new interventions implemented were to provide supervision from staff after meals for the resident to transfer and lie down. 3. Fall on 8/18/25 - unwitnessedA nursing note, dated 8/18/25, revealed the nurse was called to assess the resident after she was found on her bathroom floor after an unwitnessed fall. The resident had no complaints of pain and was wearing non-skid socks. A fall IDT note, dated 8/18/25, revealed risk factors identified included: primarily Russian speaking, dementia and ambulating without assistance. Prior interventions were to keep her call light within reach, transfer height bed, brake extenders, ensure the door to her room remained open while the resident was in there and to provide supervision from staff after meals for the resident to transfer and lie down. The new interventions implemented were for the resident to remain in high visibility areas during waking hours as tolerated unless assisted to lie down. 4. Fall on 8/21/25 - unwitnessedA change of condition note, dated 8/21/25, revealed the resident was heard screaming in her room and was found sitting on the floor by her bed with her shoes on. A fall IDT note, dated 8/21/25, revealed risk factors identified included: history of falls and high risk medications. Prior interventions were to ensure non-skid socks, labs, de-cluttered the resident's bed, provide the resident education to call for assistance with care and adding the resident to the restorative program. The new interventions implemented were to call the medical director to review the resident's blood sugars and A1C.-Prior interventions of labs, de-cluttered the resident's bed, providing the resident education to call for assistance with care, and adding the resident to the restorative program were not included on the resident's care plan. A physician assistant note, dated 8/22/25, revealed the resident had multiple falls since the month of August 2025 without any significant injuries, recent labs had been within acceptable ranges. The note documented the falls were most likely exacerbated by generalized weakness/debility, poor safety awareness, and dementia. III. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 9/24/25 at 1:53 p.m. She said she looked at the resident's CPO for fall interventions. LPN #2 said she was unable to locate specific fall interventions for Resident #156 in the electronic medical record (EMR). She said she would use general fall interventions such as checking on her every two hours, keeping her bed in the low position, decluttering the floor in the room, ensuring the call light was in reach and answering the call light promptly. CNA #4 was interviewed on 9/24/25 at 1:59 p.m. She said she had worked at the facility for three years. She said she was not aware of where to find resident specific fall interventions. She said she would use general interventions such as watching them when they ambulated down the hallway and making sure there was nothing in their path. CNA #4 said Resident #156 was a fall risk before she was admitted to the facility. She said she was no longer a fall risk, she just had poor safety awareness. Unit manager (UM) #1 was interviewed on 9/24/25 at 2:06 p.m. He said he gave a verbal report to the staff on the unit where Resident #156 resided, twice a day. He said he would go over the falls that were discussed by the IDT and provide the staff with updates on fall interventions. UM #1 said some of the interventions he expected were to ensure the resident's door remained open and the staff were rounding every hour. He said the resident specific fall interventions were located in the residents care plan and the CNA tasks. He said when reviewing Resident #156's EMR, he said he was unable to locate her specific interventions in the tasks. Registered nurse (RN) #1 was interviewed on 9/24/25 at 2:21 p.m. He said he was new to the unit that Resident #156 was residing on. RN #1 said he checked a resident's tasks for fall interventions because he did not have access to the care plan. The director of nursing (DON) was interviewed on 9/24/25 at 3:30 p.m. She said after a resident had a fall, the IDT reviewed the fall, discussed the prior interventions and why those interventions did not work and added the specifics of the fall to the resident's care plan. The DON said the CNAs and the nurses were notified of new fall interventions when the fall prevention nurse went around and verbally told them. She said she expected the staff to also look in the resident's care plan and tasks because they were updated after every fall. She said she was not aware the staff were unclear on where to find resident fall interventions.

Based on record review and interviews, the facility failed to ensure residents who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional stands or practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#144) of three residents reviewed out of 71 sample residents. Specifically, the facility failed to ensure individualized care approaches were provided for Resident #144 to prevent re-traumatization. Findings include:I. Facility policy and procedureThe Trauma Informed Care and Culturally Competent Care policy, revised August 2022, was provided by the director of nursing (DON) on 9/25/25 at 9:29 a.m. It read in pertinent part,“Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident.”II. Resident #144A. Resident statusResident #144, age 75, was admitted on 8/1/24. According to the September 2025 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), post-traumatic stress disorder (PTSD), psychotic disorder not due to a substance or known psychological condition and anxiety. The 9/18/25 minimum data set (MDS) assessment revealed Resident #144 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #144 had no documented behaviors. B. Resident interviewResident #144 was interviewed on 9/24/25 at 9:21 a.m. She said she was scared of the nursing home administrator (NHA) because he entered her room and made himself look taller while raising his voice at Resident #144. She said she filed a grievance and the NHA responded each time, telling her she should find a new place to live since she was not happy at the facility and filed so many grievances. Resident #144 said she did not want to move facilities. C. ObservationsOn 9/24/25 at 9:50 a.m. Resident #144 needed assistance to go to an activity. The NHA said he would assist the resident to the activity. The regional clinic resource told the NHA she would assist the resident to the activity due to the resident having an issue with men. D. Record reviewResident #144’s psychosocial care plan, revised 11/15/24, revealed the resident was at risk for decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills and poor impulse control related to a history of being sexually assaulted by a male physician. Interventions included administering medications as ordered and monitoring for side effects, allowing the resident extra time to respond to questions, assisting the resident to normalize feelings so the resident knew she was not alone in her thoughts, experiences, feelings and behaviors, providing behavioral and psychological services as indicated, contacting the resident’s representative for comfort and support, encouraging the resident to express emotions, helping the resident identify triggers that prompt symptoms; monitoring for complaints of pain, observing for signs of distress, safeguarding the resident from alleged or suspected abuse perpetrator and transferring to acute care for further evaluation if indicated. Resident #144’s trauma-informed care plan, revised 3/24/25, revealed the resident was at risk for decreased psychosocial well-being due to adjustment issues, emotional distress, ineffective coping skills, and poor impulse control because she had a tornado hit her house as a child, she had a work related injury where a microwave fell on her head, a vehicle accident as a child, getting a life threatening illness and the sudden and unexpected death of her mother and uncle. Interventions included allowing the resident time to make choices regarding her care and encouraging active decision making. approaching the resident in a calm, reassuring manner, encouragingfamily visits and interactions, encouraging relaxation techniques, encouraging the resident to verbalize her feelings, encouraging activities of the resident’s choice, monitoring for signs and symptoms of decreased psychosocial well-being; offering pastoral visits as indicated, providing a psychiatry evaluation and treatment as indicated, providing psychological evaluation and treatment as indicated; reorienting and redirecting the resident as necessary; and social services visits as indicated.-The care plan did not provide interventions to address the resident’s fear of the NHA..III. Staff interviewsThe NHA was interviewed on 9/24/25 at 12:50 p.m. The NHA said he was not aware that the resident was afraid of him, but knew at times she did not like the NHA. He said any time he responded to grievances he brought a female staff with him into Resident #144’s bedroom as a witness. The NHA said he did not tell the resident she should move facilities, but asked if she wanted to move facilities because she did not seem happy with where she was. -The facility failed to identify the resident had been sexually abused by a male in power and provide appropriate interventions to address the resident’s grievances. Registered nurse (RN) #3 was interviewed on 9/24/25 at 1:07 p.m. RN #3 said Resident #144 had behaviors where she was involved in a family member’s care who also resided at the facility. RN #3 said Resident #144’s trigger was being educated on anything she did not want to hear. She said she was unaware of triggers involving men or being afraid of men. She said she only knew men were not allowed to provide her care due to her past trauma. Certified nurse aide (CNA) #5 was interviewed on 9/25/25 at 9:54 a.m. CNA #5 said Resident #144 became really anxious if things did not go her way or if she was told no. She said Resident #144 did not have issues with men but preferred females providing her care and CNA #5 said she was unsure why. CNA #5 said it was possibly documented in her care plan but said she was not sure.-The facility failed to ensure the staff caring for Resident #144 were aware of her past trauma. The DON and the regional clinical resource were interviewed together on 9/25/25 at 11:21 a.m. The DON said Resident #144 had behaviors of being accusatory of staff and one time she had expressed she wanted to kill herself, but nothing current. The DON said the resident’s triggers were hard to identify but she felt male figures were a trigger. She said the resident’s biggest fear was that the NHA would pack up her room and “kick her to the curb.” The DON said the resident was explained the process for discharging a resident. The regional clinical resource said Resident #144 always had a problem with something and there never seemed to be a resolution that made her feel satisfied. The DON said more education was going to be provided to staff so the staff knew where to find pertinent information like trauma and triggers.

Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one (#130) of three residents reviewed out of 71 sample residents. Specifically, the facility failed to:-Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions for Resident #130; and,-Document attempted non-pharmacological interventions prior to the administration of a as needed (PRN) anti anxiety medication. Findings include:I. Resident #130A. Resident statusResident #130, age greater than 65, was admitted to the facility 8/21/25. According to the September 2025 computerized physician orders (CPO), the diagnosis included cognitive communication deficit and dementia with behavioral disturbances and agitation. The 8/27/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required substantial to maximal assistance with toilet hygiene, lower body dressing and partial to moderate assistance with upper body dressing. The MDS assessment indicated the resident did not have any behaviors during the assessment look back period. B. Record reviewThe anti-anxiety care plan, dated 8/22/25, documented Resident #130 used anti anxiety medication related to adjustment issues and agitation. Pertinent interventions included administering anti anxiety medication as ordered, monitoring for side effects and effectiveness, monitor the resident for safety for increased risk of confusion, amnesia, loss of balance and cognitive impairment, monitor and record occurrence of for target behavior symptoms. The psychosocial-behavior care plan, revised on 9/16/25, documented behavioral symptoms included delusions, anxiety and yelling out. The care plan documented Resident #130 had been physically aggressive with staff. Pertinent interventions included administering medication as ordered, anticipating the residents needs and meeting promptly, encouraging the resident to verbalize feelings and maintaining a calm, slow, understandable approach. A second psychosocial-mood care plan, dated 9/16/25, documented the resident was at risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental physical social or spiritual well being related to: other displays of delusions and would threaten staff that he had a gun. Pertinent interventions included administering medications as ordered and monitoring for side effects as indicated, assessing coping strategies and respecting resident’s wishes to the extent possible, assisting with conflict resolution as needed, encouraging to voice feelings and frustrations as indicated, observing for tearfulness, increased agitation and decreased participation in care. -Review of the resident’s care plan did not reveal person-centered interventions to trial prior to the administration of the PRN lorazepam. The 9/2/25 behavioral health nurse practitioner (NP) progress note, dated 9/2/25, from the documented a new diagnoses of Alzheimer’s dementia with psychotic disturbance, Alzheimer’s disease with late onset and dementia in other diseases classified elsewhere with psychotic disturbance. A review of the September 2025 CPO revealed the following physician's orders:Lorazepam (Ativan- anti anxiety medication) oral tablet 0.5 milligrams (mg). Give one tablet by mouth every 12 hours as needed for dementia with behavioral disturbance for 14 days, ordered 9/2/25. Lorazepam oral tablet 0.5 mg. Give one tablet by mouth every eight hours as needed for dementia with agitation for 14 day, ordered 9/16/25.-Review of Resident #130’s electronic medical record (EMR) did not reveal non-pharmacological interventions that were to be trialed prior to the administration of the PRN lorazepam medication. A progress note, dated 9/4/25 at 4:03 a.m., documented Resident #130 received PRN Ativan for agitation. -There were no non-pharmacological interventions documented prior to the administration of the PRN Ativan. A progress note, dated 9/4/25 at 10:20 p.m., documented Resident #130 received PRN Ativan for being anxious, he tried to walk without assistance and looking for an exit. -There were no non-pharmacological interventions documented prior to the administration of the PRN Ativan. A progress note, dated 9/7/25 at 11:01 p.m., documented Resident #130 received PRN Ativan for yelling at the staff. Staff attempted to redirect but the resident continued to yell out.-There were no non-pharmacological interventions documented prior to the administration of the PRN Ativan. A progress note, dated 9/12/25 at 7:12 a.m., documented Resident #130 received PRN Ativan for agitation and stated he owned the place and called the staff names. -There were no non-pharmacological interventions documented prior to the administration of the PRN Ativan. A progress note, dated 9/15/25 at 4:15 p.m., documented Resident #130 received PRN Ativan for agitation. -There were no non-pharmacological interventions documented prior to the administration of the PRN Ativan. C. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 9/24/25 at 9:35 a.m. LPN #3 said when a resident exhibited behaviors the staff were to document the specific behaviors in the resident’s electronic medical record (EMR). She said when a resident was prescribed a PRN psychotropic medication, non-pharmacological interventions should be attempted prior to the administration of the medication, if the non-pharmacological interventions were not successful then the PRN medication would be administered. She said the non-pharmacological interventions that were attempted were documented in the MAR.LPN #3 said she reviewed Resident #130’s EMR and was not able to find the non-pharmacological interventions. The director of nursing (DON) and the regional clinical resource (RCR) were interviewed together on 9/25/25 at 8:18 a.m. The DON said a PRN psychotropic was given a 14 day stop date and then then resident would be reassessed to determine if a PRN medication was effective. The DON said the interdisciplinary team (IDT) and medical providers used the behavior monitoring charting and progress notes from the EMR to assess the frequency the medication was administered, what non-pharmacological interventions were used prior to the administration of the medication and the effectiveness of the non-pharmacological interventions and PRN medication. The DON said non-pharmacological interventions should be attempted and documented prior to administering a PRN medication. The DON said the non-pharmacological approaches were found in the EMR and were specific to the resident. The DON and the RCR said they were unable to find the non-pharmacological interventions specific to Resident #130 prior to administering the PRN Ativan.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in three of four medications rooms, one of five medication carts and one of one vaccine storage refrigerators. Specifically, the facility failed to:-Ensure expired vaccines were removed from refrigerators;-Ensure Tubersol (used to test for tuberculosis) vials were dated upon opening;-Ensure vaccinations were not stored in dormitory style refrigerator;-Ensure expired insulin pens were removed from the medication cart;-Ensure expired medications were removed from over the counter medications supply; and,-Ensure discarded medications were destroyed timely. Findings include:I. Professional referenceAccording to the Vaccine Storage and Handling Tool-kit, dated 3/29/24, retrieved on 9/29/25, from https://www.cdc.gov/vaccines/hcp/downloads/storage-handling-toolkit.pdf, “Do not store any vaccine in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in an icemaker/freezer compartment. These units pose a significant risk of freezing vaccines even when used for temporary storage.”According to the Tuberculin Purified Protein Derivative Tubersol package insert, retrieved on 9/29/25 from https://www.fda.gov/media/74866/download, “A vial of Tubersol which has been entered and in use for 30 days should be discarded.”According to the Lantus glargine insulin package insert, retrieved on 9/29/25 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, “When not in use store in refrigerated temperatures of 36 to 46 degrees Fahrenheit (F). When in use, it can be kept at room temperature for up to 28 days.”II. Facility policy and procedureThe Medication Labeling and Storage policy, revised February 2023, was received from the nursing home administrator (NHA) on 9/25/25 at 9:30 a.m. it revealed 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.“If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.“Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and are discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Multi-dose vials that are not opened or accessed are discarded according to the manufacturer’s expiration date.”The Discarding and Destroying Medication policy, revised June 2025, was received from the NHA on 9/25/25 at 9:30 a.m. It read in pertinent part, “Medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. Except for the following situations, medications are not returned to the pharmacy for credit or disposal, Refusal upon delivery due to order change, Refusal upon delivery due to resident’s death or expiration; and/or Pharmacy medication error in dispensing.”III. Vaccine failuresA. ObservationsOn 9/24/25 at 1:18 p.m. the vaccine refrigerator on the Garden unit was reviewed with licensed practical nurse (LPN) #1 and the infection preventionist (IP). The vaccine refrigerator contained the following:One vial of Tubersol with an open date of 6/10/25;One vial of Tubersol with open date of 6/30/25;Eight vials of the COVID-19 vaccine mRNa Spikevax 2024-2025 formula that expired 6/2/25; and, Nine vials of influenza Fluad 2024-2025 formula expired on 5/14/25. B. Staff interviewsThe IP was interviewed on 9/24/25 at 1:20 p.m. She said Tubersol was only good for 30 days once opened and it could not be effective if used past the 30 days. The IP said it was the responsibility of the night nurses to review the medication refrigerators including the vaccine refrigerators. The IP said she would dispose of the expired vaccines. IV. Medication room failuresA. Observations On 9/24/25 at 10:47 a.m. the Evergreen medication refrigerator was observed with registered nurse (RN) #2. The refrigerator contained one open vial of Tubersol with no open date.-The facility failed to label the vial with an open date. The medication refrigerator also contained three vials of Gentamicin Sulfate (antibiotic) 40 milligrams per milliliter (mg/ml). Two vials expired July 2025 and the third vial expired May 2025-The facility failed to remove expired medications from the medication refrigerators. On 9/24/25 at 11:02 a.m the Garden medication room and refrigerator was observed with licensed practical nurse (LPN) #1. The medication refrigerator had one bottle of expired magnesium citrate (laxative) that expired 9/22/25 and one open Lantus insulin pen with no open date. -The facility failed to remove expired medication from the medication refrigerator. The facility failed to have an open date on an insulin pen. The Garden medication room had a large box overflowing on the floor and a cabinet full of discontinued medications belonging to residents who no longer resided in the facility. -The facility failed to have medications sent back or discarded timely. On 9/24/25 at 11:25 a.m. the Aspen medication room was observed with LPN #2. There were two open vials of Tubersol both had no open date. -The facility failed to label vials with open dates. The Aspen medication refrigerator was a dormitory style refrigerator. The freezer compartment was observed to have excess ice built up around the freezer compartment.-The facility failed to maintain the refrigerator clean and failed to store Tubersol in the appropriate refrigerator (see professional references above). The Aspen medication room had a cabinet labeled diabetic management. The cabinet contained over the counter medications. The following over the counter medications were found in the cabinet:One bottle of Vitamin C 500 mg that expired August 2025; One bottle of Zinc 50 mg that expired March 2025; Two bottles of Fiber laxative that expired July 2025; One box with bisacodyl suppositories 10 mg that expired April 2025; One bottle of Aspirin 325 mg that expired August 2025; One bottle of Oystershell plus Vitamin D 250 mg that expired July 2025; One bottle of Vitamin D 25 micrograms (mcg) that expired July 2025; and,One bottle of Docusate sodium (stool softener) 100 mg that expired June 2025. B. Staff interviews RN #1 was interviewed on 9/24/25 at approximately 10:50 a.m. during the observation of the medication refrigerator on the Evergreen unit. She said it was important to label vials with open dates to know when they expire as they were not as effective if used past the recommended open date. RN #2 said the gentamicin vials were expired and should have been removed from the refrigerator the month they expired. RN #2 said she would take the three vials of expired gentamicin and one vial of Tuberosol to the unit manager or the director of nursing (DON). LPN #1 was interviewed on 9/24/25 at approximately 11:05 a.m. during the observation of the garden medication room. He said open dates were important to ensure medication was used before they expired or they may not be as effective if used past the recommended date. LPN #1 said he did not know how long insulin was good once opened. LPN #1 said he was going to discard the expired medications. LPN #1 said the medication room had a cabinet for discontinued medications but it was full and the staff started to add them to the box on the floor. LPN #1 said the unit manager or DON were to dispose of the discontinued medications but he did not know when this was to occur. LPN #1 said the box had been there a while. LPN #1 said the nurses working the floor, unit manager and the DON had keys to the medication rooms. LPN #2 was interviewed on 9/24/25 at approximately 11:25 a.m. during the medication room observations. LPN #2 said she was not aware how long Tubersol vials were good for once accessed. LPN #2 said she did not feel the ice built up would cause any issues with medications stored in the refrigerator. RN #1 was interviewed on 9/24/25 at 11:34 a.m. when LPN #2 asked him about how many days the Tubersol was good once opened. RN #1 said it was good for 28 days. RN #1 said he did not know who was responsible for cleaning the ice out of the refrigerator. RN #1 said the ice that builds up could cause the refrigerator to not regulate temperatures effectively. RN #1 said it was the responsibility of the nurses to review the medication rooms and carts for expired medications. UM #2 was interviewed on 9/24/25 at 1:25 p.m. He said when the DON call\eds for the discontinued medications the nurses would take them to her for her to return them to the pharmacy or be destroyed appropriately. UM #2 said he believed she called for the medication to be destroyed monthly. V. Medication cart failuresA. ObservationsOn 9/24/25 at 11:20 a.m. the 600 hall on Aspen medication cart was observed with LPN #2. The following was observed:One open insulin glargine pen with an open date of 8/16/25; and, One open Lantus insulin pen with an open date of 8/1/25.-The facility failed to identify and dispose of insulin pens after the recommended 28 days from first access (see professional reference above). B. Staff interviewsLPN #2 was interviewed on 9/24/25 at approximately 11:25 a.m during observations of a medication cart and medication room on the Aspen unit. LPN #2 said the insulin vials were good for one month after the first use. LPN #2 said if the insulin was used after one month it may not be as effective for the resident. LPN #2 said she would discard the insulin pens, check the medication refrigerator for stock if not found she would contact the pharmacy to get them ordered. VI. Additional staff interviewsThe DON was interviewed on 9/24/25 at 1:58 p.m. She said it was the responsibility of all nurses and the unit managers to complete medication room and cart checks for expired medications. The DON said she was informed by her staff of the above observations and findings of expired medications found in the medication carts and rooms. The DON said the over the counter medications should not have been stored in the medication room because the facility kept over the counter medication stored in the central supply room in the basement. The DON said discontinued medications could be sent back to the pharmacy once a month. The DON said discontinued medications stored in the medication rooms could lead to the medication leaving the room or being placed back into the medication cart, which could lead to potential medication errors. The DON said she was not aware of the amount of discontinued medications in the cabinet and the box in the Garden medication room that needed to be sent back to the pharmacy. The DON said open dates were important to ensure the medication were used or discarded by the use of dates recommended by the manufacturer. The DON said insulin was good for 28 days from first access and Tubersol was good for 30 days from initial access. The DON said it was the IPs responsibility to monitor vaccines in the facility. The DON said the facility has always stored medications and vaccines in dormitory style refrigerators with no concerns. The DON said the medication refrigerators were cleaned as needed. The DOnNsaid if ice builds up it could cause storage concerns and would need to be defrosted. The DON said the medications in the refrigerator needing to be defrosted would be temporarily moved to another medication refrigerator while they defrosted the freezer. The DON said once the medication refrigerator was defrosted and temperature maintained within range the medication could safely be returnedto the original refrigerator.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to ensure:-Beard nets were worn while preparing food in the main kitchen;-Hand hygiene was conducted during meal service and dishwashing; and,-Food was labeled and dated in the walk-in refrigerator, walk-in freezer and reach-in refrigerators. Findings include:I. Failure to ensure beard nets were worn in the kitchenA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 9/29/25. It revealed in pertinent part, "Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, linens and unwrapped single-service and single-use articles." (Chapter 2)B. Facility policy and procedureThe Preventing Foodborne Illness Employee Hygiene and Sanitary Practices policy, revised November 2022, was received from the director of nursing (DON) on 9/25/25 at 8:35 a.m. It read in pertinent part,“Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.”C. ObservationsOn 9/22/25 at 9:59 a.m. an unidentified male dietary aide (DA) with a goatee was standing by the three-compartment sink in the kitchen. He was not wearing a beard net. On 9/22/25 at 12:26 p.m. the unidentified male DA with a goatee was in the kitchen without a beard net on. On 9/24/25 at 10:06 a.m. the unidentified male DA with the goatee was in the kitchen without a beard net on washing dishes in the three-compartment sink. On 9/24/25 at 12:14 p.m. an unidentified male DA with a full beard came into the kitchen and did not put on a beard net. He went into the back area of the kitchen and began helping with food preparation after washing his hands. D. Staff interviewsThe dietary supervisor (DS) was interviewed on 9/25/25 at approximately 3:00 p.m. He said beard nets should have been worn. II. Failure to perform hand hygiene appropriately during meal service and dishwashingA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 9/29/25. It revealed in pertinent part, “ The Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20/25 read in pertinent part, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands." (2-301.15)B. Facility policy and procedureThe Preventing Foodborne Illness Employee Hygiene and Sanitary Practices policy, revised November 2022, was received from the DON on 9/25/25 at 8:35 a.m. It read in pertinent part,“Employees must wash their hands: after personal body functions ( toileting, blowing/wiping nose, coughing, sneezing); after using tobacco, eating or drinking; whenever entering or re-entering the kitchen; before coming in contact with any food surfaces; after handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks; and/or after engaging in other activities that contaminate the hands.”C. ObservationsDuring a continuous observation on 9/24/25, beginning at 11:00 a.m. and ending at 12:41 p.m., the following was observed during the meal service in the main kitchen:At 11:00 a.m. meal service began. Cook (CK) #1 was serving the main meal and DA #2 was making and plating the special orders. DA #2 washed her hands and donned a pair of gloves. At 11:07 a.m. DA #2 doffed (took off) her gloves and donned a new pair of gloves. She did not perform hand hygiene after taking her gloves off and before putting on new gloves. At 11:13 a.m. DA #2 took off her gloves after making a grilled cheese sandwich and donned a new pair of gloves without performing hand hygiene. At 11:15 a.m. CK #1 scratched her head underneath her hat, did not perform hand hygiene afterwards and continued to serve the meal. At 11:16 a.m. DA #2 cut the crust off of a peanut butter and jelly sandwich, took her gloves, placed the gloves on the cutting board with the crust from the sandwich. She then picked the used gloves and crust with her bare hands and threw all of it into the trash bin. Without performing hand hygiene, she then donned a new pair of gloves. At 11:20 a.m. without performing hand hygiene after she scratched her head, CK #1 left the serving line and returned with a new bag of paper plates. She opened the bag of plates and took out a large stack of paper plates, closed the opened bag of plates and began to serve the meal without performing hand hygiene. At 11:37 a.m. CK #2 switched spots with CK #1. At 12:20 p.m. DA #1 was washing dishes in the three-compartment sink with gloves on. He grabbed some dirty containers for the room trays so he could wash them for the meal service line. After placing some of the dirty lids and bottoms into the wash compartment, he went to the clean side and removed the clean dishes and put them away. He did not change his gloves or perform hand hygiene or remove his gloves after touching the dirty dishes and prior to touching the clean dishes. At 12:21 p.m. CK #2 touched the backside of her pants and began serving meals without performing hand hygiene. D. Staff interviewsThe DS was interviewed on 9/25/25 at approximately 3:00 p.m. He said hand hygiene should be performed after taking off gloves and when hands were soiled. III. Failure to ensure food was labeled and dated in the walk-in freezer, walk-in refrigerator and reach-in refrigerators. A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 9/29/25. It read in pertinent part,"A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request." (Chapter 3-29)B. ObservationsOn 9/22/25 at 7:10 a.m., during the kitchen tour, the following items were found in the main kitchen walk-in freezer:-An unidentified meat wrapped in tinfoil, that was not labeled or dated;-An unidentified meat that inside of a plastic bag, that was not labeled or dated;-An open bag of breakfast sausages that was not labeled or dated; and,-A large black bin filled with an assortment of different plastic bags filled with different meat patties, frozen mixed vegetables and unidentified foods that were not labeled or dated. On 9/22/25 at 7:16 a.m. the following items were found in the main kitchen walk-in refrigerator:-An opened bag of liquid eggs, without an open date; and,-An unidentified meat that was wrapped in plastic wrap that was not labeled or dated. On 9/24/25 at 10:06 a.m. in the walk-in refrigerator, there was a large container of food that resembled peeled and diced potatoes in water, which was not labeled or dated. On 9/24/25 at 11:32 a.m., during lunch service, DA #2 made a tuna salad sandwich; the tuna salad container was not labeled or dated. On 9/24/25 at 11:55 a.m., during lunch service, DA #2 reheated spaghetti with marinara sauce; the marinara sauce container was not labeled or dated. On 9/25/25 at 8:49 a.m. the following items were found in the reach-in refrigerators that was located next to the steam tables and where the facility stored sandwich supplies:-A large container of tuna salad that was not labeled or dated;-A large container of marinara sauce that was not labeled or dated; and,-An unidentified soup that was not labeled or datedC. Staff interviewThe DS was interviewed on 9/25/25 at approximately 3:00 p.m. He said everything should be labeled and dated.

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption on two of four hallways. Specifically, the facility failed to ensure safe and appropriate storage of food items in resident’s personal refrigerators. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 9/29/25 read in pertinent part, “Except during preparation, cooking, or cooling, or when time is used as thepublic health control, time/temperature control for safety food shall be maintained at 135 degrees Fahrenheit (F) or above, or at 41°F or less (3-501.16). “Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety." (3-501.17). II. Facility policy and procedureThe Foods Brought by Family/Visitors policy, dated 5/28/25, was provided by the nursing home administrator (NHA) on 9/22/25 at 11:30 a.m. It read in pertinent part, “Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The dietician, nurse supervisor, or other designee will explain safe food handling practices to family/visitors in a language and format they understand. The dietitian, nurse supervisor, or other designee will provide necessary education to the nursing staff on safe food handling practices and identify where this information is readily available for reference. Nursing staff is responsible for assisting residents to access food brought to the facility and for assisting with the consumption of the food item if the resident is not able to do so independently. The food service or nursing staff may assist with reheating or other preparation activities using safe food handling practices including safe reheating, hot/cold holding, handling of leftovers, and contamination avoidance. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration for longer than two hours are discarded.”III. Resident interviewResident #4 was interviewed on 9/22/25 at 11:54 a.m. Resident #4 said there were only two staff members that checked his refrigerator, and that one night shift nurse checked his refrigerator consistently. IV. ObservationsOn 9/22/25 at 12:00 p.m. the following observations were made in Resident #4’s personal refrigerator:-A clear four ounce container of cottage cheese with a date of 9/12/25; and,-A four ounce container of yogurt with a use by date of 9/18/25. On 9/24/25 at 2:25 p.m. the outdated food items observed on 9/22/25 (see observation above) had not been removed from the refrigerator. V. Staff interviewsThe NHA was interviewed on 9/25/25 at 4:00 p.m. The NHA said the residents’personal refrigerators should be monitored by overnight staff, specifically the nurses but the nurses could delegate the task to a certified nurse aide (CNA) to complete the temperatures.

Based on record review and interviews, the facility failed to establish a communication process that included how the communication would be documented between the facility and the provider for two (#11 and #9) of four residents reviewed for hospice care out of 71 sample residents. Specifically, the facility failed to establish a communication process according to the hospice agreement that included documentation of care and services provided by hospice filed and maintained for Resident #11 and Resident #99. Findings include:I. Facility policy and procedureThe Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 9/25/25 at 9:30 a.m. It read in pertinent part, “Our facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. Hospice providers who contract with this facility must have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency; and are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility.“In general, it is the responsibility of the facility to meet the resident’s personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident’s needs. These responsibilities include the following: Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care; notifying the hospice about the following such as a significant change in the resident’s physical, mental, social, or emotional status, clinical complications that suggest a need to alter the plan of care or a need to transfer the resident from the facility for any condition; and communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day.”II. Resident #11A. Resident statusResident #11, age greater than 65, was admitted on 8/11/25. According to the September 2025 computerized physician orders (CPO), diagnoses included acute respiratory failure, acute kidney failure, heart disease with heart failure and depression. The 8/11/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. She needed substantial assistance with hygiene and toileting and set up for eating and dressing. The assessment documented the resident received hospice care. B. Hospice agreementThe hospice agreement for Resident #11’s hospice services was provided by the director of nursing (DON) on 9/24/25 at 3:15 p.m. It read in pertinent part, “Nursing facility and hospice shall each prepare and maintain complete and detailed clinical records concerning each resident hospice patient receiving nursing facility services and hospice services under this agreement in accordance with prudent record keeping procedures and as required by applicable federal and state law and regulations and applicable federal program guidelines. Each clinical record shall completely, prompt and accurately document all services provided to, and events concerning, each residential hospice patient (including evaluations, treatments, progress notes, authorizations to admission to hospice and/or nursing facility and physician orders entered pursuant to this agreement. Nursing facility and hospice shall cause each entry made for services hereunder to be signed by the person providing the services.”C. Record reviewResident #11’s hospice care plan, initiated 8/11/25, documented she had a terminal prognosis related to a diagnosis of acute respiratory failure and received hospice care provided by a local hospice provider. Pertinent interventions, initiated 8/11/25, included working cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met, adjust the provision of activities of daily living (ADL) to compensate for the resident's changing abilities and encouraging participation to the extent the resident wished to participate. Resident #11’s skin impairment care plan, initiated 8/13/25, documented she had actual impairment to skin integrity related to wounds to her right and left lower extremities, sacrum and the need for treatment. Pertinent interventions, initiated 8/13/25, included following the facility’s protocols for the treatment of injury and to monitor and document the location, size and treatment of skin injury and reporting abnormalities, failure to heal, signs and symptoms of infection, and maceration to the physician.-However, Resident #11’s comprehensive care plan did not document what care was to be completed by the hospice provider and when. A review of Resident #54’s February 2024 CPO revealed the following physician orders: Admitted to hospice care prior to admission, ordered 8/20/2025. Resident #11’s hospice binder was retrieved from the nurses’ station and provided by licensed practical nurse (LPN) #1 on 9/24/25 at approximately 6:20 p.m. The hospice binder contained weekly visit verification forms. The binder had three hospice visits documented as routine visits on 8/8/25, 8/25/25 and 8/29/25. A review of Resident #11’s electronic medical record (EMR) revealed an 8/18/25 hospice note by an RN with routine care. -However, the 8/8/25 hospice note did not include documentation of the staff who completed the routine visit. The 8/18/25, 8/25/29 and 8/29/26 hospice notes were signed by a registered nurse (RN) but did not include any care or assessments provided. No other hospice visit notes were in the resident’s EMR.Resident #11’s hospice notes were provided by the DON on 9/25/25 at approximately 9:30 a.m. and uploaded into Resident #11’s EMR (during the survey). A review of the hospice notes revealed the following visits documented by hospice staff:A chaplain visit on 8/28/25 declined by Resident #11 due to scheduling conflicts. A certified nurse aide (CNA) completed visits on 8/28/25, 9/2/25, 9/4/25, 9/9/25, 9/16/25, 9/18/25 and 9/23/25 that included the following completed care planned interventions: Apply moisturizing lotion to skin Tuesdays and Thursdays; assist with oral care Tuesday and Thursday, and bed bath and shampoo Tuesday and Thursday. An LPN visit completed 8/15/25, 8/22/25, 9/15/25. The 9/15/25 LPN visit documentation included the following assessments and care provided: vital signs, respiratory breath sounds and wound care was completed according to the resident’s care plan. Social worker visits completed on 8/15/25, 8/28/25, 9/11/25. A registered nurse (RN) completed visits on 8/18/25, 8/25/25, 8/29/25, 9/4/25, 9/8/25, 9/10/25, and 9/19/25. The 9/4/25 RN visit note documented wound care was completed according to the care plan for the resident’s right and left leg wounds. D. Staff interviewsThe DON was interviewed on 9/25/25 at 11:00 a.m. The DON said the hospice company checked out with her after visits. The DON said the hospice company would also usually check out with the unit manager if they came in. The DON said the notes were usually provided on a week or two week basis. The DON said the notes were sent to the facility and she/the DON would upload them in the chart.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure there were monitoring measures maintained for all control measures identified that may contribute to the spread of legionella (a type of bacteria that can cause legionella disease, a severe form of pneumonia): -Ensure the facility water management plan was reviewed annually; and,-Ensure the facility water management plan was personalized and specific to the facility. Findings include:I. Facility policy and procedureThe Legionella Water Management Program policy and procedure, revised June 2021, was provided by the nursing home administrator (NHA) on 9/25/25 at 12:27 p.m. It read in pertinent part,“The purposes of a water management program are to identify areas in the water system where Legionella bacteria can grow and spread."Specific measures used to control the introduction and/or spread of legionella (temperatures and disinfectants)include; a system to monitor control limits and effectiveness of control measures."The water management program is reviewed at least once a year.” II. Water Management Plan A. Record reviewThe Water Management Plan, dated 12/20/23, was provided by the NHA on 9/24/25 at approximately 10:00 a.m. and it revealed in pertinent part,"Control measures and corrective actions include: "Ice coolers are put on a daily cleaning schedule, "HVAC (heating, ventilation and air conditioning) filters are serviced twice a year, "The juice machine juice gun is soaked daily by dietary staff in a disinfectant, taken apart weekly and cleaned, "Hot tubs should be drained, cleaned and refilled every three to four months and plumbing should be cleaned every 12 months; and, "Decorative fountains should be run daily to avoid prolonged idle periods.” On 9/25/25 at 10:18 a.m. audit logs for the daily cleaning of the ice coolers, the weekly cleaning of the juice machines, quarterly draining/cleaning of the facility hot tubs, and the twice yearly service of the facility HVAC were requested from the NHA via email on 9/25/25 at 10:18 a.m. -These documents were not provided during the surveyB. Staff interviews The maintenance director (MTD) was interviewed on 9/24/25 at 2:51 p.m. He said the facility followed the audit and cleaning schedule of the facility water management program to prevent the spread of legionella bacteria. The MTD said the program was discussed monthly in the facility quality assurance meeting. He said if the facility has moving water in the building and the water was not stagnant, then the water management plan was working. The regional clinical resource was interviewed on 9/24/25 at 3:34 p.m. She said the water management program should be reviewed and updated annually. The regional clinical resource said the facility did not have any decorative fountains and that should have been removed from the program control measures. She said it was important to keep the water plan up to day to prevent the risk of water borne illness and infections to the residents. She said the water management plan was outdated and not specific to the facility's areas of monitoring.

A recertification survey was completed on 11/18/2025. Sixteen deficiencies were cited.

The Initial Comments (ID Tag 0000) are informational only and are a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a one-story, Type V (000) wood-frame structure with a partial basement used for building services. It is fully protected by two separate automatic fire sprinkler systems. The Arbor addition, built around 1996, has its own wet pipe sprinkler system. Each sprinkler system includes an antifreeze loop to protect the drive-through canopy areas and the attic. The original facility was constructed in 1987, with additions completed in 1989 and 1996. In 2007, a 973 sq. ft. dining area was added to the Arbor Wing addition. The facility has a total of 242 beds and was surveyed on November 18, 2025, according to the National Fire Protection Association (NFPA) Life Safety Code (2012), Chapter 19, which pertains to Existing Health Care Occupancies. The deficiencies noted during the survey were discussed with the Administrator and the Director of Maintenance during the exit conference at the end of the on-site evaluation.

STANDARD not met based on observation and staff interview during the survey; it was determined that the facility failed to continuously maintain the exit discharge and access means of egress to full use in case of an emergency. Life Safety Code 101 Section 19.2.1 and 7.2.1.7. The fire-rated panic hardware on the fire doors in Aspen 600 hall is damaged, preventing the left side door from opening. 7.2.1.7 Panic Hardware and Fire Exit Hardware. 7.2.1.7.1 Where a door assembly is required to be equipped with panic or fire exit hardware, such hardware shall meet all of the following criteria: (1) It shall consist of a cross bar or a push pad, the actuating portion of which extends across not less than one-half of the width of the door leaf.(2) It shall be mounted as follows: (a) New installations shall be not less than 34 in. (865 mm), and not more than 48 in. (1220 mm), above the floor. (b) Existing installations shall be not less than 30 in. (760 mm), and not more than 48 in. (1220 mm), above the floor.(3) It shall be constructed so that a horizontal force not to exceed 15 lbf (66 N) actuates the cross bar or push pad and latches. 7.2.1.7.2 Only approved panic hardware shall be used on door assemblies that are not fire-rated door assemblies. Only approved fire exit hardware shall be used on fire-rated door assemblies. New panic hardware and new fire exit hardware shall comply with ANSI/UL 305, Standard for Safety Panic Hardware, and ANSI/BHMA A156.3, Exit Devices. If the means of egress are not properly maintained throughout the facility, this deficiency could impact all residents, staff, and visitors during a fire emergency. The exit discharge deficiency was discussed during the exit conference with the maintenance director. During a facility tour, the Maintenance Director acknowledged the condition of the door.

STANDARD not met, as evidenced by testing and staff interviews of the emergency lighting during the facility tour; it was determined that the facility needed to maintain the battery-powered emergency lights per 7.9.3 and 19.2.9.1. The emergency backup lighting at the Arbor Generator switch failed to illuminate when the test button was pressed. 7.9.2 Performance of System. 7.9.2.1* Emergency illumination shall be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 11/2 hours. A maximum-to-minimum illumination ratio of 40 to 1 shall not be exceeded. This deficiency could impact all residents and staff across all smoke compartments during a primary power outage. The maintenance director recognized the significance of maintaining the emergency lighting during the facility tour.

STANDARD needs to be met, as evidenced by the observation and staff interview during the survey. It was determined that the facility failed to maintain the marking of means of egress per Life Safety Section 7.10. There are no exit signs located in the common lobby of the Aspen 500 and 600 halls. 7.10.1.3 Exit Door Tactile Signage. Tactile signage shall be provided to meet all of the following criteria unless otherwise provided in 7.10.1.4: (1) Tactile signage shall be located at each exit door requiring an exit sign. (2) Tactile signage shall read as follows: EXIT. (3) Tactile signage shall comply with ICC/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities. If code-compliant exit signage is not provided for building egress, this deficient practice could affect all residents, staff, and visitors in the building. The Maintenance Director acknowledged the deficiency of the exit signage during the facility tour.

STANDARD not met: Through observation and discussion during the facility tour, it was determined that the facility failed to install and maintain the kitchen-hood-exhaust system as required by NFPA 96 (Chapter 7, Section 7.8.2). 1. The rooftop fan for the kitchen hood system is improperly installed. There is no mechanism to drain grease from any traps or low points in the fan or duct near the termination of the system into a collection container. This container must be noncombustible, closed, rainproof, and structurally sound for its intended use, ensuring it will not sustain combustion. 2. The fan lacks hinges or a hold-open retainer to facilitate inspection and cleaning. 3. The kitchen hood system is currently missing an essential grease-trap pan, which is needed for the effective collection of excess grease. 4. Hood system filters are coated with excessive grease build-up. 5. Cleaning records indicate annual and semi-annual cleaning in the past year, although due to the excessive amount of grease accumulated, the Authority Having Jurisdiction is requiring cleaning every quarter. 7.8.2 Rooftop Terminations. 7.8.2.1 Rooftop terminations shall be arranged with or provided with the following: (1) A minimum of 3 m (10 ft) of horizontal clearance from the outlet to the adjacent buildings, property lines, and air intakes (2) A minimum of 1.5 m (5 ft) of horizontal clearance from the outlet (fan housing) to any combustible structure (3) A vertical separation of 0.92 m (3 ft) below any exhaust outlets for air intakes within 3 m (10 ft) of the exhaust outlet (4) The ability to drain grease out of any traps or low points formed in the fan or duct near the termination of the system into a collection container that is noncombustible, closed, rainproof, and structurally sound for the service to which it is applied and that will not sustain combustion (5) A grease collection device that is applied to exhaust systems that does not inhibit the performance of any fan (6) Listed grease collection systems that meet the requirements of 7.8.2.1(4) and 7.8.2.1(5) (7) A listed grease duct complying with Section 4.4 or ductwork complying with Section 4.5 (8) A hinged upblast fan supplied with flexible weatherproof electrical cable and service hold-open retainer to permit inspection and cleaning that is listed for commercial cooking equipment with the following conditions: (a) Where the fan attaches to the ductwork, the ductwork shall be a minimum of 0.46 m (18 in.) away from any roof surface. (b) The fan shall discharge a minimum of 1.02 m (40 in.) away from any roof surface, as shown in Figure 7.8.2.1. (9) Other approved fan, provided it meets both of the following: (a) The fan meets the requirements of 7.8.2.1(3) and 8.1.3. (b) Its discharge or its extended duct discharge meets the requirements of 7.8.2.1(2). This deficient practice could affect all residents in all smoke compartments should a fire occur due to a failure to operate effectively, resulting from a non-code-compliant installation. During the facility tour, the Maintenance Director observed the state of the kitchen hood fan.

STANDARD not met, as evidenced by: Based on observation and staff interviews, it was determined that the facility needed to provide a safe location to install an Alcohol-Based Hand Rub dispenser per Life Safety Code Chapter 19, Section 19.3.2.6(8). Alcohol-based hand rub dispensers (ABHR) were located directly above an electrical light switch in the kitchen and garden Hall. Life Safety Code 101, Section 19.3.2.6 Alcohol-Based Hand-Rub Dispensers shall be protected per 8.7.3 unless all of the following conditions are met:(8) Dispensers shall not be installed in the following locations:(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source.(b) To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source. (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition sourceThis deficient practice could affect all patients and staff in the smoke compartment should an electrical fault ignite the alcohol-based dispenser. The Maintenance Director acknowledged the (ABHR) location deficiency during the facility tour.

STANDARD not met as evidenced by observation and staff interview of the fire alarm system during the tour of the facility, the facility failed to install and maintain the fire alarm system with approved components, devices, or equipment per NFPA 101 Life Safety Code (2012 Edition), section 19.3.4.3.1 and NFPA 72, section 17.7.4.1. Arbor kitchen smoke detectors are installed within 12 inches of the HVAC diffuser. NFPA 72, 29.11.3.48) Smoke alarms and smoke detectors shall not be installed within a 36 in. (910 mm) horizontal path from the supply registers of a forced air heating or cooling system and shall be installed outside of the direct airflow from those registers. The failure to adequately maintain the fire alarm system poses a significant risk to the safety of all occupants, staff, and visitors should a fire occur. During the exit conference, the deficient items were discussed with the Maintenance staff and the Administrator.

Standard not met as evidenced by the record review during the survey. It was determined that the facility failed to establish a written fire watch procedure, as required by the 2012 NFPA 101 Life Safety Code, Section 9.6.1.6. The fire watch procedure stipulates that fire alarm fire watch rounds shall be conducted every 30 minutes. Fire watch rounds must occur throughout the entire building at intervals of every 15 minutes. 2012 Life Safety Code 101 section 9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified. The building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. This deficient practice could affect all residents, staff, and visitors should the fire alarm system be out of service and a fire were to occur. During the facility's record review, the maintenance director acknowledged the need for a written Fire Watch program deficiency.

STANDARD not met: Based on record review, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standards 13 and 25. 1. During the survey, the record review revealed that the facility did not inspect and test the automatic sprinkler system in the first and second quarters as required by NFPA 25 over the past year. 2. Aspen 500 nurses station has fire sprinkler heads spaced less than 18 inches apart; one shall be removed. 3. Aspen and Evergreen Halls inspectors' test connections did not terminate in a smooth-bore, corrosion-resistant orifice giving a flow equivalent to one sprinkler of the type having the smallest orifice installed on the particular system. NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating conditions and inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.54.4* Inspection. System components shall be inspected at intervals specified in the appropriate chapters. 4.5 Testing. 4.5.1 All components and systems shall be tested to verify that they function as intended. 4.5.2 The frequency of tests shall be in accordance with this standard. 4.5.3 Fire protection system components shall be restored to full operational condition following testing, including reinstallation of plugs and caps for auxiliary drains and test valves. 4.5.4 During testing and maintenance, water supplies, including fire pumps, shall remain in service unless under constant attendance by qualified personnel or unless impairment procedures in Chapter 15 are followed. 4.5.5* Test results shall be compared with those of the original acceptance test (if available) and with the most recent test results. 5.2.1.4 The supply of spare sprinklersThis deficiency could endanger all residents in every smoke compartment if the automatic sprinkler system fails to operate effectively due to non-compliant maintenance. The Maintenance Director acknowledged that the automatic sprinkler system had deficiencies during the facility's record review.

STANDARD is not met: Through record review during the survey, it was determined that the facility failed to establish a written fire watch procedure in accordance with 2012 NFPA 101 Life Safety Code, Section 9.7.5. The facility failed to establish a written fire watch procedure in the event the fire sprinkler system was out of service for more than 10 hours in a 24-hour period. The fire watch procedure stipulates that fire watch rounds shall be conducted every 30 minutes. Fire watch rounds must occur throughout the entire building at intervals of every 15 minutes. 2012 Life Safety 101 Section 19.5.1, 9.7.5, 15.5.2 NFPA Where a required fire sprinkler system is out of service for more than 10 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. This deficient practice could affect all residents, staff, and visitors if the fire alarm or fire sprinkler system were to be out of service and a fire were to occur. The Maintenance Director acknowledged the deficiency in a written Fire Watch program during a record review of the facility.

STANDARD is not met, as evidenced by the observation and staff interview during the survey. It was determined that the facility failed to maintain corridor doors per the Life Safety Code Section 19.3.6.3. 1. Door openings in the cross-corridor of the Colorado room do not latch and close completely into the doorframes, compromising the 20-minute smoke barrier. 2. Kitchen doors opening into the corridor do not latch and close completely into the doorframes, compromising the 20-minute smoke barrier. 3. The doors in residents' rooms 404, 410, and 705 do not close and latch into the frame without excessive force. 19.3.6.3* Corridor Doors. 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 1 3/4in. (44 mm) thick, solid-bonded core wood. (2) Material that resists fire for a minimum of 20 minutes. 19.3.6.3.4 A clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted for corridor doors. 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. This deficient practice could affect all residents within three smoke compartments should the egress become untenable due to smoke and heat transfer via the non-latching corridor doors. The Director of Maintenance recognized the condition of the corridor doors during the facility tour.

STANDARD is not met based on observation. It was determined that the facility failed to provide an adequate source of outside combustion/makeup air for natural gas-fueled equipment in accordance with the National Fire Protection Association (NFPA) Life Safety Code and NFPA 54 Natural Fuel Gas Code. The laundry (clothes dryer room) was observed to have outside combustion air intakes that were obstructed by lint, dirt, and debris. Life Safety Code Section 19.5.1 requires that heating, ventilating, and air conditioning comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications. Section 9.2.2 requires that heat-producing equipment be installed in accordance with NFPA 54, National Fuel Gas Code. Gas-fueled equipment must have a continuous source of outside combustion/make-up air in accordance with NFPA 54 Section 5.3 and Section 6.4. This deficient practice could affect all residents and staff in the core smoke compartment if the natural gas-fueled heating equipment malfunctions due to improper maintenance. The Director of Maintenance acknowledged the obstructed air supply intakes during a tour of the facility.

STANDARD not met: The facility did not comply with the National Fire Protection Association 70 and the National Electrical Code, as observed during staff interviews and surveys regarding the maintenance of electrical equipment. In the Colorado room, under the sink, there is a missing cover to the electrical box, which exposes energized electrical connections. NFPA 70, National Electrical Code Article 370-25. Covers and Canopies in completed installations, each box shall have a cover, faceplate, or fixture canopy. This deficient practice could affect all residents in the smoke compartments due to increased potential hazards of electrical fire. The Maintenance Director acknowledged the electrical hazard during a tour of the facility.

STANDARD is not met based on observation. It was determined that the facility failed to maintain emergency power systems under Section 9.1.3 of the Life Safety Code, and the referenced NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 5.2.3. The generator remote annunciator panel located at the Arbor nurses' station is non-operational during testing. NFPA 99-6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular workstation (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to the load. (b) When the battery charger is malfunctioning.(2) Individual visual signals plus a common audible signal to warn of an Engine generator alarm condition shall indicate the following: (a) Low lubricating oil pressure (b) Low water temperature (below that required in 6.4.1.1.11) (c) Excessive water temperature (d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply (e) Overcrank (failed to start) (f) OverspeedThis deficient practice has the potential to affect all residents throughout the facility in the event of power loss. The emergency generator deficiency item was discussed with the Maintenance Director during the survey and the exit conference with the Administrator.

STANDARD is not met based on record review during the generator's testing; it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8. 1. No records were available at the time of the survey to verify the testing and recording of the EPSS Loads L2 and L3 after transfer. 2. The diesel annual fuel quality test was not conducted annually using applicable ASTM Standards. 2010 NFPA 110, Section 8.3.2.1 The operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature. 2010 NFPA 110, section 8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established. NFPA 110, Section 8.3.4 A permanent record of the EPSS inspections, tests, exercises, operations, and repairs shall be maintained and readily available. Level I and Level EPSSs, including all appurtenant components, shall be inspected and shall be exercised under load at least monthly. This deficient practice can potentially affect all residents throughout the facility during a power loss. The emergency generator deficiency item was discussed with the Maintenance Director during the survey and the exit conference with the Administrator.

STANDARD not met: Based on observation and staff interviews during the survey, it was determined that the facility needed to maintain the trans-filling of oxygen storage room ventilation per NFPA 99 - Health Care Facilities, 9.3.7.2, and NFPA 55 Compressed Gases and Cryogenic Fluids Code. The oxygen trans-filling storage room is not mechanically ventilated correctly to maintain a negative pressure per NFPA 99 and NFPA 55. 2012 NFPA 999.3.7.4 Trans-filling area shall be provided with ventilation in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code. 9.3.7.5.3.1Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction. 9.3.7.5.3.2Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm). 9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) off the floor and adjacent to the cylinder or containers. This deficient practice could affect all residents and staff within the smoke compartment should a fire occur in the oxygen storage room. The Director of Maintenance acknowledged the ventilation issue during a facility tour.

A licensure survey was completed on 9/22/25 to 9/25/25. One deficiency was cited.

Based on record review, observations, and interviews, the facility failed to ensure three (#164, #15 and #156) of six out of 71 sample residents met all the requirements for placement on the secure locked unit. Specially, the facility failed to ensure:-Residents #164, #15 and #156, residing on the secured locked unit, had all requirements met: a practitioner had authenticated the placement and initial evaluations of the necessity for placement; and,-Resident #15 and Resident #156’s representative had given informed written consent. Findings include: I. Facility policy and procedureThe Secure Unit Environment policy, dated 1/14/25, was provided by the nursing home administrator (NHA) on 9/25/25 at 9:28 a.m. It read in pertinent part,"Pre-Admission Assessment includes: a comprehensive evaluation: before admission, the facility must conduct a thorough assessment to determine the individual's suitability for a secured environment. This includes evaluating cognitive deficits, medical conditions, and behaviors such as wandering or compromised safety awareness."In order to place a resident into a secure environment, the facility shall ensure the following requirements are met: a practitioner has authenticated the placement and written findings and the factual basis for the placement are documented in the health information record.”II. Resident #164A. Resident statusResident #164, age greater than 65, was admitted on 8/29/25. According to the September 2025 computerized physician orders (CPO), diagnoses included unspecified dementia. The 9/3/25 facility assessment revealed the resident had severe cognitive impairments. B. Record reviewThe elopement care plan, dated 9/4/25, revealed the resident resided on a secured unit related to being an elopement risk and had a history of attempts to leave the facility unattended. Interventions, initiated 9/4/25, included to allow the resident to express her feelings and approach in a calm manner. A review of September 2025 CPO failed to reveal a physician order for secure unit placement. The informed consent for secure unit placement, dated 9/2/25, did not document the reason for placement.-Review of Resident #164’s electronic medical record (EMR) revealed there was not an initial assessment for placement or a physician’s order for the secured unit placement. III. Resident #15A. Resident statusResident #15, age 77, was admitted on 1/22/25. According to the September 2025 CPO, diagnoses included unspecified dementia. The 8/7/25 facility assessment revealed the resident had severe cognitive impairments. B. Record reviewThe discharge care plan, dated 5/6/25, revealed the resident was in a long term care facility in a secure unit.-Review of Resident #15’s EMR revealed there was not an initial assessment for placement, a physician’s order for placement or consent from the resident’s representative. IV. Resident #156A. Resident statusResident #156, age 89, was admitted on 6/1/25. According to the September 2025 CPO diagnoses included dementia. The 9/12/25 facility assessment revealed the resident had severe cognitive impairments..B. Record reviewThe elopement care plan, dated 7/7/25, revealed the resident resided on a secured unit related to being an elopement risk and had a history of attempts to leave the facility unattended. Interventions, initiated 7/7/25, included to allow the resident to express his feelings and approach in a calm manner. -Review of Resident #156’s EMR revealed there was not an initial assessment for placement, a physician's order for placement or consent from the resident’s representative. V. Staff interviewsSocial services assistant (SSA) #1 was interviewed on 9/25/25 at 11:30 a.m. SSA #1 said when a resident was admitted to the secure unit, the admissions and marketing team did an initial screening that included looking at the referrals history and wandering behaviors. She said that the interdisciplinary team (IDT) reviewed the referral and decided if the resident wasappropriate for the secure unit. SSA #1 said if a resident was an existing resident in the facility and was transferring to the secure unit, the IDT reviewed the resident in a clinical meeting and determined if the transfer was appropriate. She said the facility started using an initial assessment form earlier in the year and she would provide the initial assessments, consents, and physician authenticians for Resident #164, #15, and #156.-However, the initial assessment forms were not provided.

A revisit survey was completed on 6/11/25 for all previous deficiencies cited on 5/7/25. The facility is in compliance with all regulations surveyed.