21
Inspections
20
Deficiencies
0
Actual Harm or Above
41
Occurrences
March 2, 2026
Last Inspection
S/S D/F Potential for harm
The most recent inspection of SUNNY VISTA LIVING CENTER on record is dated March 2, 2026. Across 21 published inspections, state surveyors cited 20 deficiencies, none of which reached the actual-harm level.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
SNF/NF Dual Certification
Administrator
Downs, Stephen
Owner
SUNNY VISTA LIVING CENTER
Phone
(719) 471-8700
Payor Source
Medicare, Medicaid, Private Pay
City
COLORADO SPRINGS
ZIP
80909-4812
Inspections & Citations
21 inspections · 20 deficiencies3/2/2026Complaint Survey · ID 1F23FF-H1No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A survey for Incident #2730279 was conducted 3/2/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
12/1/2025Complaint Survey · ID 1D94CF-H1No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO2613407 was conducted on 10/14/25 to 12/1/25. No deficiencies were cited. The actual survey exit date was 10/15/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/1/25.
Plan of correction
The state did not require a plan of correction for this citation.
8/13/2025Recertification Survey · ID 1D137B-L1No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
The facility consists of a two-story limited combustible structure, Type II (111) construction, with a partial basement used for support services and is not used by residents. The basement has a 2-hour occupancy separation from the parking garage. The facility is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic wet and dry fire sprinkler systems. Sprinkler system coverage- does not include protection of the concealed attic space, which will not be used for storage. NOTE: The facility has chosen not to provide sprinkler coverage to the exterior patios with non-combustible overhangs that extend over 4-ft. from the building. Those areas are not to be allotted to be used for combustible items and/ or storage; and if at any time in the future, these unprotected areas are found to be used for combustible items, to include but not be limited to, picnic tables, furniture, chairs, tables, BBQ grills, etc. ..., the area shall be required to be equipped with fire sprinkler coverage. The survey was conducted on August 13, 2025, for compliance with the fire safety requirements of NFPA 101, Life Safety Code (lSC), 2012 edition, Chapter 19 for Existing Health Care Occupancies. It was reported that there was a census of 107 residents at the time of the survey. The facility is currently licensed for 116 beds. This surveyor found no violation during the survey. No action required
Plan of correction
The state did not require a plan of correction for this citation.
7/24/2025Complaint, Recertification Survey · ID 1D137B-H16 deficiencies▼
0000Initial CommentsSurveyor note2 building records▼
Findings · record 1 of 2
A recertification survey with Incident #2565105 was completed on 7/21/25 to 7/24/25. Six deficiencies were cited.
Findings · record 2 of 2
An Emergency Preparedness survey was conducted on 7/21/25 to 7/24/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0605Right to be Free from Chemical Restraints▼
Findings
Based on record review and interviews, the facility failed to ensure five (#63, #46, #73, #112 and #50) of nine residents were free from chemical restraints and were receiving the least restrictive approach for their needs out of 52 sample residents. Specifically, the facility failed to:-Ensure prescribed as needed (PRN) antipsychotic medication for Resident #63 had corresponding documentation of identified behaviors and use of non-pharmological interventions; -Ensure resident specific care approaches, to include medication specific target behaviors and person-centered interventions were documented and monitored for Resident #63, #46, #73, and #112’s psychotropic medications; and,-Identify specific resident behaviors, conduct behavior monitoring and ensure the least restrictive intervention was used prior to administration of psychotropic medications for Resident #50’s. Findings include: VI. Resident #50A. Resident status Resident #50, age 89 was admitted on 12/24/22. According to the July 2025 CPOs, diagnoses included Alzheimer’s disease, dementia with severe anxiety, restlessness and agitation. The 4/2/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. She required maximum assistance of two staff members with transfers, hygiene, dressing and bathing. The MDS assessment revealed the resident exhibited no behaviors and was receiving antianxiety and antipsychotic medications. B. Record reviewReview of Resident #50’s July 2025 CPO revealed the following physician's orders:Seroquel (an antipsychotic medication) 25 mg by mouth every eight hours for dementia with severe psychotic disorder, ordered 6/26/25. Lorazepam (an antianxiety medication) 0.5 mg by mouth two times a day for anxiety/agitation, ordered 6/5/24. Monitor for climbing out of bed, visual hallucinations, seeing demons, delusional if behaviors occur, every shift, ordered 8/1/23. -However, there were no physician orders to monitor for specific behaviors related to the psychotropic medications. Resident #50’s care plan for the use of antianxiety medication, initiated 12/25/22 and revised on 4/12/23, revealed interventions included to monitor for target behaviors including pacing, wandering, disrobing, inappropriate response to verbal communication and violence/aggression towards staff and others. Resident #50’s care plan for the use of antipsychotic medication, initiated 10/15/24 and revised 7/21/25 (during the time of survey) revealed interventions included monitoring for target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication and violence/aggression towards staff and others. The facility failed to ensure the comprehensive care plan included resident-specific behaviors identified and person-centered interventions for Resident #50’s use of psychotropic medications. VII. Staff interviewsCNA #2 was interviewed on 7/23/25 at 1:45 p.m. She said Resident #50 was dependent on staff for all activities of daily living (ADLs). She said Resident #50 would attempt to climb out of her wheelchair, yelled and called out for her children and she refused to eat sometimes because she said she was saving the food for her children. CNA #2 said effective interventions included talking to the resident, giving her a picture book, offering toileting assistance or playing music. She said she knew these interventions were effective because she knew the resident really well. LPN #1 was interviewed on 7/23/25 at 2:15 p.m. LPN #1 said Resident #50 exhibited behaviors when it was her indicated bathing day. She said Resident #50 would argue about having to take a shower. She said, almost daily, Resident #50 yelled out and would attempt to climb out of the wheelchair. She said they kept Resident #50 in the dining room to provide additional supervision. She said providing a baby doll and picture books helped alleviate her behaviors. LPN #1 said Resident #50 was currently on a 30 day behavior monitoring due to a change in her prescribed antipsychotic medication. She said once the 30 monitoring was completed, all behavior monitoring was documented in the EMR under nursing progress notes. The ADON and regional director of clinical operations were interviewed together on 7/24/25 at 11:00 a.m. The ADON said Resident #50’s behaviors included calling out, yelling, yelling during her showers, confusion and agitation. The regional director of clinical operations said Resident #50’s family member would come to the facility to assist in providing the resident bathing. She said she spoke to Resident #50’s family member the previous week, who said she would bring in books with songs from their childhood and suggested attempting Reiki (a healing technique to channel energy to promote relaxations, reduce stress and potentially aid in the body’s natural healing processes). She said these interventions should be documented in Resident #50’s comprehensive care plan. She said following a 30 day monitoring system for changes, the nurses should document any further behavior monitoring in the nursing progress notes of the EMR.She said the facility was not monitoring the effectiveness of the Lorazepam and Seroquel for Resident #50.
Plan of correction · submitted by the facility
Tag: 0605Description of Deficiency: Based on record review and interviews, the facility failed to ensure five (Residents #63, #46, #73, #112, and #50) of nine residents were free from chemical restraints and received the least restrictive approach for their needs out of 52 sampled residents. Specifically, the facility failed to:Ensure documentation of identified behaviors and non-pharmacological interventions prior to administering PRN antipsychotic medications for Resident #63;Document medication-specific target behaviors and person-centered interventions for Residents #63, #46, #73, and #112;Identify resident-specific behaviors, monitor those behaviors, and ensure the least restrictive intervention was used prior to psychotropic medication administration for Resident #50. Plan of Correction:Corrective Action for the Affected Residents:For Resident #63, a task was created in PCC (point click care)on 7/23/2025 to ensure staff document and monitor for specific behaviors related to his diagnosis. Non-pharmacological interventions for Resident #63 were implemented on 7/23/2025. Resident #63’s care plan was updated to include individualized, resident-centered interventions. For Residents #63, #46, #73, and #112, care plans will be updated to include:Resident-specific psychotropic medication target behaviors,Monitoring for symptoms and side effects,Documentation of non-pharmacological interventions, andBehavior monitoring. These updates will be reviewed as part of quarterly care conferences. For Resident #50, behavior identification, monitoring, and documentation of least restrictive interventions will be ensured prior to medication administration. Identification of Other Potentially Affected Residents:An audit will be conducted of residents with a diagnosis of a mental disorder or psychosocial adjustment difficulty. Training will completed with all clinical staff on the community’s psychosocial evaluation procedure. As of 7/29/2025, the communication tab in PCC includes reminders to ensure behavior documentation is completed before administering psychotropic medication. Monitoring and Sustainability Measures: Audit of residents with a diagnosis of a mental disorder or psychosocial adjustment difficulty be completed. Review of all behavior monitoring tasks for those identified in the audit, revisions made accordingly to ensure personalized interventions are appropriate. All direct care associates will receive training on the psychosocial evaluation policy along with training on recognizing and responding to new or existing behaviors. Following completion of staff training by 8/31/2025, five direct care staff will be assessed weekly for competency of our psychosocial evaluation process by Social Services or designee with immediate education to address any incompetence. Progress and outcomes will be tracked through the facility’s Quality Assurance and Performance Improvement (QAPI) program. Scope and Frequency of Monitoring:Population Monitored: Residents with a diagnosis of a mental disorder or psychosocial adjustment difficulty. Review Elements:24-hour reportBehavior/progress notesUpdated care plansStaff/provider communication and coordinationDocumentation:Audit toolsQA meeting minutesPCC progress notesCare plan update logsIntegration into QAPI:Findings and improvement strategies will be reported and reviewed during monthly QAPI meetings by nursing and social services leadership. Weekly for 4 weeks,Monthly thereafter until audit scores remain at or above 90%.Completion Date:Substantial compliance will be achieved by 9/6/2025
0684Quality of Care▼
Findings
Based on observations, record review and interviews, the facility failed to ensure one (#4) of two residents who required respiratory support received care consistent with professional standards of practice out of 52 sample residents. Specifically the facility failed to obtain a physician ordered bilevel positive airway pressure (BiPAP) machine (a type of non-invasive ventilation that helps people breathe by providing pressurized air through a mask or nasal plugs) for Resident #4 to use during sleep hours. Findings include: I. Resident #4A. Resident statusResident #4, age 71, was admitted on 5/22/25 and discharged on 7/23/25 to the community. According to the July 2025 computerized physician orders (CPO), diagnoses included acute respiratory failure, obstructive sleep apnea (breathing stops during sleep) and tachycardia (heart beats too fast). The 5/22/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He had no behaviors and did not reject care. He required assistance with toileting, dressing, bathing and transferring. He required supervision with eating and oral hygiene. The MDS assessment indicated the resident utilized a BiPAP.B. Resident representative interviewResident #4's representative was interviewed on 7/21/25 at 10:30 a.m. The representative said Resident #4 was admitted to the facility in mid-May 2025 and did not have access to his BiPAP device from the time of his admission to the facility until 7/18/25. She said that the BiPAP machine was lost during the resident’s hospitalization prior to admission, and although this information was communicated to facility staff upon admission, no replacement device was obtained until 7/18/25. The representative said the current BiPAP machine was a loaner device and he would still need his own personal machine upon his discharge to home. The representative said that the BiPAP machine replacement “fell through the cracks” with the nursing home facility and the facility did not follow up on obtaining a BiPAP machine in a timely manner. The representative said that Resident #4 did not experience any adverse effects or medical complications during the time he was without the BiPAP machine, however, she expressed concern that the lack of BiPAP therapy may have affected his memory or cognitive functioning. C. ObservationsOn 7/22/25 at 11:08 a.m. Resident #4 was speaking with social services director (SSD) #1 in the common area of the facility. During the conversation, the resident asked SSD #1 for an update on his BiPAP machine. SSD #1 responded that he was working on the resident’s BiPAP.On 7/23/25 at 10:40 a.m. Resident #4 was being discharged from the facility, leaving with his wife while facility staff carried his belongings. Resident #4 said the facility had taken care of ordering his new BiPAP machine for home and he would receive it in the mail. D. Record reviewA review of the hospital discharge paperwork which accompanied Resident #4 upon admission to the facility, dated 5/22/25, revealed that several medications were check marked by facility nursing staff. -However, the order for the resident to have a BiPAP at bedtime did not have a checkmark. Review of Resident #4’s July 2025 CPO revealed the resident had a physician's order for oxygen at 4 liters/minute via BiPAP at night only, ordered 5/22/25.-However, Resident #4 did not have access to a BiPAP machine from admission (5/22/25) until 7/18/25 (see resident representative interview above and staff interviews below). Review of Resident #4’s care plan, dated 5/23/25, identified the resident’s need for nighttime BiPAP use related to ineffective gas exchange. Interventions included oxygen therapy and monitoring for signs and symptoms of respiratory distress. -However, the facility did not ensure Resident #4 had access to a BiPAP machine for almost two months after his admission to the facility (see resident representative interview above and staff interviews below). II. Staff interviewsRegistered nurse (RN) #2 was interviewed on 7/23/25 at 9:15 a.m. RN #2 said the facility had a few ways to ensure residents had a BiPAP machine for use upon admission. RN #2 said the facility checked for a physician’s order, some residents brought their own devices, and if not, the facility worked with companies to obtain a BiPAP machine. RN #2 said once a BiPAP machine was in place, the nurses assessed the settings to ensure they were correct and functioning properly. RN #2 said the nurses also asked the resident if they were comfortable and observed them to ensure they were comfortable using the device. RN #2 said the BiPAP machine notified staff if it did not have a good seal on the resident’s face so they could adjust it. RN #2 said she did not know why Resident #4 did not receive his BiPAP machine when he was admitted to the facility. RN #2 said she typically referred those situations to social services to see if they could get a loaner BiPAP machine. RN #2 said she did not know the reason for the delay for Resident #4’s BiPAP. SSD #1 was interviewed on 7/23/25 at 10:52 a.m. SSD #1said that if a resident needed respiratory equipment, nursing handled the process of obtaining it. SSD #1 said that if the resident was discharging home, then social services placed the order and coordinated with the equipment company. SSD #1 said that for Resident #4, the respiratory company requested a sleep study and he needed to find out who would pay for it. SSD #1 said documentation from the nurse practitioner was also needed. SSD #1 said that as far as he could remember, a BiPAP machine was on the Resident #4’s table. The medical director (MD) was interviewed on 7/23/25 at 11:39 am. The MD said the BiPAP and continuous positive airway pressure (CPAP) machines were used to effectively treat sleep apnea which was associated with conditions such as depression, anxiety, diabetes, heart failure and stroke. The MD said that if a resident had a physician’s order for a BiPAP or CPAP machine, the resident should use it regularly. The assistant director of nursing (ADON) was interviewed on 7/23/25 at 12:01 p.m. The ADON said residents who required BiPAP or CPAP equipment were discussed during stand-up meetings before the resident was admitted to ensure the respiratory equipment was obtained. The ADON said she typically handled calling the oxygen company and placing an order for the device unless the resident was bringing one from their home. The ADON said Resident #4’s BiPAP machine was lost at the hospital. She said the resident’s representative contacted the hospital but the hospital could not locate it. The ADON said Resident #4 had a history of noncompliance with BiPAP use but he maintained oxygen saturation levels (level of oxygen in the blood) above 90% (percent). The ADON said Resident #4’s BiPAP machine was not ordered for nearly two months after readmission because the hospital discharge orders did not include it. She said although the BiPAP machine was documented on the care plan, it was not entered as a physician’s order when the resident was admitted to the facility. The ADON said the MDS assessment nurse identified the omission and entered a new BiPAP machine order on 6/9/25. The ADON said without the BiPAP machine, the resident could experience nighttime breathing difficulties that may worsen his arrhythmia (abnormal heart rhythm). -However, Resident #4 did not receive the ordered BiPAP until 7/18/25 (see resident representative interview above). Licensed practical nurse (LPN) #2 was interviewed on 7/24/25 at 1:20 p.m. LPN #2 said the admitting nurse was responsible for checking admission orders. LPN #2 said the physician’s orders were then given to the facility’s physician for final review. LPN #2 said she was not sure why Resident #4’s BiPAP order was missed on admission, but she said she would report any issues to management. The regional director of clinical operations was interviewed on 7/24/25 at 2:43 p.m. The regional director of clinical operations said the admitting nurse was responsible for transcribing and ensuring the accuracy of discharge orders. She said a manager usually reviewed the physician’s orders; however, this was not part of the formal process. She said the facility was currently discussing ways to improve the process.
Plan of correction · submitted by the facility
Tag: 0684Description of Deficiency:Based on observations, record review, and interviews, the facility failed to ensure one (Resident #4) of two residents who required respiratory support received care consistent with professional standards of practice out of 52 sampled residents. Specifically, the facility failed to obtain a physician-ordered bilevel positive airway pressure (BiPAP) machine for Resident #4 to use during sleep hours. Plan of Correction:Corrective Action for the Affected Resident:Resident #4 was discharged from the community on 7/23/2025. Identification of Other Potentially Affected Residents:Auditing will include all residents with a diagnosis pertaining to respiratory support needs. To prevent recurrence, training will be provided for clinical staff on how to properly review and verify physician orders for accuracy and completeness. As of 7/28/2025, a new process has been implemented to have the charge nurse or designee monitoring orders daily. Audit move-in orders daily, andReview the physician order listing report in PCC to ensure compliance with all active orders. Monitoring and Sustainability Measures:The order summary report and new move-in orders will be reviewed daily by clinical leadership. On the weekends, the charge nurse or designee will complete a review of the order summary report and notify the on-call nurse immediately if there are any issues. All findings, including identified issues and interventions taken, will be documented on a designated audit form. A new chart audit review process has been added to the move-in checklist to ensure transcription accuracy and proper equipment procurement based on physician orders. Daily reviews of physician orders are discussed in stand-up meetings (initiated 7/28/2025) to confirm timely follow-through. On the weekends, the charge nurse or designee will review physician orders and report any issues to the on-call nurse immediately. Monitoring results and trends will be discussed and tracked through monthly Quality Assurance (QA) meetings to assess the efficacy of the process and determine if further changes are needed. Scope and Frequency of Monitoring:Population Monitored: Residents with respiratory support needs. Review Elements:Physician order listing reportNew move-in order audit formsCare plan and progress note documentation in PCCDocumentation:Audit formsQA meeting minutes and reportsPCC progress notes and charting logsIntegration into QAPI:This issue and all related monitoring outcomes will be included in the facility’s QAPI process through routine reporting from the nursing and social services departments. Weekly for 4 weeks,Monthly thereafter until audit scores remain at or above 90%.Completion Date:Substantial compliance will be achieved by 9/6/2025
0742Treatment/Srvcs Mental/Psychoscial Concerns▼
Findings
Based on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing for one (#12) of six residents out of 52 sample residents. Specifically, the facility failed to:-Ensure individualized care approaches were provided and monitored with ongoing assessment for Resident #12 in order to meet the emotional and psychosocial needs of the resident;-Ensure Resident #12, who had expressed suicidal ideations with intent and a history of trauma, was monitored for signs and symptoms of suicidal ideation; and, -Ensure expressions of suicidal ideations were addressed in a timely manner in order to secure Resident #12's safety. Findings include:I. Facility policy and procedureThe Psychosocial Evaluation Procedure policy, dated December 2024, was provided by the nursing home administrator (NHA) on 7/24/25 at 11:00 a.m. It revealed in pertinent part, "If a member of the interdisciplinary team (IDT) notices the resident has element(s) of psychosocial unmet needs, such as but not limited to: self-injurious behavior or suicide ideation that IDT member initiates the psychosocial evaluation and notifies supervisor, each IDT member completes their section of the evaluation (if appropriate), the social services member completes the evaluation, and the psychosocial evaluation is used when reviewing psychotropic medications.” II. Resident #12A. Resident statusResident #12, age 88, was admitted on 9/17/24. According to the July 2025 computerized physician orders (CPO), diagnoses included post traumatic stress disorder (PTSD) and major depressive disorder. The 6/25/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident’s depression screen assessment, dated 6/25/25, revealed Resident #12 had indicated she was moderately depressed with a score of 10 out of 27. B. Resident interview and observationResident #12 was interviewed on 7/21/25 at 1:46 p.m. Resident #12 said her depression was her own fault because she was struggling to adjust to placement in the facility. She said she had previously lived in an assisted living facility and had to move to long term care and leave all her close friends. Resident #12 said she made the decision to move to her current facility to be closer to her daughter, but she said she did not see her daughter often and the two of them fought frequently. She said the fighting triggered her depression and reminded her of what she had lost (former friends and independence). Resident #12 was evasive to answering questions regarding previous threats of self harm but did share a history of suicide attempts made by her mother. She said she was aware of how traumatic it would be for her family if she killed herself, but she said she still could not help thinking about it at times. During the interview, Resident #12 denied a current plan or intent to self harm. During the interview, Resident #12's window was observed to have a bar which prevented the window from opening more than approximately four inches. C. Record reviewThe mood care plan, revised 12/24/24, revealed Resident #12 had a diagnosis of PTSD and major depressive disorder. The resident suffered from childhood trauma manifesting as isolating in bed, declining activities of enjoyment, perseverations of childhood trauma and hallucinations. Interventions, initiated 9/18/24, included monitoring for signs and symptoms of hopelessness, anxiety, sadness, insomnia, anorexia, negative statements, and tearfulness. -The care plan failed to reveal any revisions to include threats of self harm after the 12/21/24 or 7/10/25 incidents (see psychologist visit notes and progress notes below). Review of Resident #12’s July 2025 CPO revealed the following physician’s orders:Effexor (an antidepressant) 75 milligrams (mg). Give 75 mg to equal 225 mg (three capsules) in the morning for major depressive disorder, ordered 9/18/24 and decreased 6/25/25 (see physician’s order below).-Resident #12’s dosage of the antidepressant was decreased on 6/25/25, despite recommendations by the physician managing the resident's psychoactive medications to not make reductions and instead add another antidepressant (see psychologist visit notes below). Effexor 150 mg. Give 150 mg to equal 225 mg (two capsules) in the morning for PTSD, ordered 9/21/24 and discontinued 7/9/25. Effexor 37.5 mg. Give one capsule in the morning for major depressive disorder, ordered 6/25/25. Behavior monitoring for depressed mood, self-isolating in bed, perseverations on trauma, perseverations on spouse and hallucinations. Non-pharmological interventions included to offer food/fluids, offer to call a loved one, take for a walk, validate feelings and encourage an activity, ordered 9/18/24. -The July 2025 CPO did not include a physician’s order to monitor for potential signs and symptoms of suicidal ideation. Progress notes reviewed from 12/21/24 to 7/22/25 revealed the following:A nursing note, dated 12/21/24, revealed the nurse had followed up with Resident #12 regarding comments made to another nurse about suicidal thoughts. Resident #12 denied suicidal ideations and the nurse notified the physician.-The nursing note failed to indicate whether a psychosocial evaluation had been performed to ensure resident safety, as was identified as the process when a resident expressed suicidal ideation (see facility policy above). A social services note, dated 12/23/24, revealed Resident #12 had experienced highs and lows in her mood with continued difficulty with adjustment to placement as she did not feel she could relate to the other residents because she was more physically capable than them. -The note did not identify if the social services director (SSD) addressed the resident's suicidal comments from 12/21/24. A behavior note, dated 1/3/25, revealed the resident displayed anxiety, sadness, and difficulty with adjusting to placement. A behavior note, dated 1/4/25, revealed Resident #12 had asked to speak to the nurse and stated she was depressed. The nurse spent thirty minutes talking to Resident #12 about her struggle to adjust and her triggers. A behavior note, dated 2/9/25, revealed the resident had been observed to be depressed and self-isolating. Resident #12 expressed to the nurse feeling upset and distressed about not being able to return to her prior living situation. A depression screen note, dated 3/21/25, revealed Resident #12 had endorsed having little interest in things she used to like, feeling down/depressed/or hopeless, difficulty with sleeping, and decreased energy. The resident reported feeling "down just because", experiencing adjustment issues and suffering from nightmares. The screen revealed a score of four, indicating minimal depression. A nursing note, dated 4/24/25, revealed the resident reported to the nurse feelings of sadness. A nursing note, dated 4/26/25, revealed Resident #12 had been observed by the nurse to be sitting in her room in the dark with a flat affect. The resident had endorsed feeling depressed. A depression screen note, dated 6/25/25, revealed the resident had endorsed having little interest in things she used to like, feeling down/depressed/or hopeless, difficulty with sleeping, changes in appetite and decreased energy. The screen revealed a score of 10, indicating moderate depression.-The 6/25/25 depression screen note indicated Resident #12’s depression screen score had increased from a four on 3/21/25 (see above) to a 10, however, the dosage of the resident’s antidepressant medication was decreased on 6/25/25 despite the increase in the depression screen score. A nursing note, dated 7/3/25, revealed the resident had reported feeling decreased energy and extremely tired. A nursing note, dated 7/9/25, revealed Resident #12 had reported feeling tired and had been observed to be withdrawn and self-isolating. A nursing note, dated 7/10/25 at 3:24 p.m., revealed the resident had been noted to be displaying emotional outbursts to include anger throughout the day. A behavior note, dated 7/10/25 at 5:30 p.m., revealed the resident had told the nurse "I want to kill myself, I am done.” The nurse tried to reassure the resident. The resident then told the nurse she was considering overdosing on her medications but also was considering going out of her second floor window as a method to kill herself. The nurse contacted the on-call physician and requested a one time dose of Ativan (an antianxiety medication). -The progress note, on 7/10/25, failed to reveal a call was made to the director of nursing (DON), the NHA, the SSD, or Resident #12's representative. -The nursing note failed to indicate a psychosocial evaluation was performed to ensure resident safety (see facility policy above). A nursing note, dated 7/10/25 at 11:45 p.m., revealed Resident #12’s physician discontinued the Ativan and instructed the facility to move the resident to a room on the first floor due to the resident's "recurrent threats of jumping out of the window.” The physician had been informed by the facility that the move would not occur until the following day.-There was no documentation in the resident’s electronic medical record (EMR) to indicate the facility put any interventions in place to keep the resident safe until the move to the first floor could take place after the 15 minute checks ended on 7/11/15 at 5:45 a.m.-Additionally, resident interview, observations, and record review revealed Resident #12 had never moved rooms (see resident interview and observations above). A mental health provider note, dated 7/11/25 at 3:00 p.m., revealed Resident #12 had been assessed due to making suicidal statements with a viable plan. The mental health physician concluded the resident was no longer a danger to herself and could be removed from 15-minute checks by staff. -However, review of the facility’s 15 minute check logs for the resident, dated 7/10/25 to 7/11/25, revealed Resident #12 had been removed from 15-minute checks at 5:45 a.m. on 7/11/25, approximately nine hours before being cleared by the mental health physician (see 15 minute check logs below). A nursing note, dated 7/22/25, revealed Resident #12 had been observed to be tired and agitated.-Progress notes in the EMR failed to reveal that social services had followed up with an evaluation after the 12/21/24 or the 7/10/25 threat of suicide. Psychologist visit notes, reviewed from 1/6/25 to 7/7/25 revealed the following:A psychologist visit note, dated 1/6/25, revealed the staff reported to the psychologist that Resident #12 had expressed increased depression over the past few weeks and made suicidal comments. When asked by the psychologist, the resident said it had not been serious. The psychologist triggered in the note that the resident had symptoms of suicidal ideations. The psychologist completed a diagnostic depression screening and the resident had a score of seven, indicating mild depression. A chart (EMR) review made by the psychologist revealed that on 12/21/24, after an argument with her daughter, the resident told the staff that "sometimes I think that since I'm only one floor up maybe I should just jump out the window" but after considering the possibility of broken bones, she then told the staff she would rather purchase a gun to shoot herself in response to her negative feelings. -The specific EMR note referenced by the psychologist was requested during the survey, but was never provided by the facility. A psychologist visit note, dated 1/14/25, revealed Resident #12 reported to the psychologist that sometimes she "feels like giving up.” The psychologist triggered in the note the resident had trauma related symptoms. A psychologist visit note, dated 2/12/25, revealed Resident #12 had been displaying behaviors of depression, sadness, isolation, social withdrawal and agitation over the past thirty days. A psychologist visit note, dated 3/5/25, revealed Resident #12 had expressed being troubled by intrusive memories of her past trauma and hypervigilance to triggers surrounding the loss of control and the resident feeling "on edge.” The psychologist completed a diagnostic depression screening and the resident had a score of seven, indicating mild depression. A psychologist visit note, dated 3/7/25, revealed Resident #12 had displayed behaviors of anxiety, depression, sadness, isolation, social withdrawal and agitation over the past thirty days. A psychologist visit note, dated 6/25/25, revealed Resident #12 had expressed ongoing depression, with feelings of hopelessness, difficulty adjusting and loss of appetite with weight loss. The psychologist recommended adding Remeron (an antidepressant) for mood and appetite. The psychologist documented in the visit note that a reduction of the residents' psychoactive medications would be "clinically inadvisable" (likely to have unfortunate consequences).-However, the facility decreased the resident’s dosage of her antidepressant medication on 6/25/25 (see physician’s orders above). A psychologist visit note, dated 7/7/25, revealed Resident #12 expressed ongoing depression, with isolation and loss of appetite. The psychologist completed a diagnostic depression screening and the resident had a score of 10, indicating moderate depression (an increase since 3/5/25, see psychologist note above). A psychologist visit note, dated 7/16/25, revealed Resident #12 was unavailable for a visit. The note did not indicate the facility had communicated to the psychologist regarding the resident’s suicidal ideations on 7/10/25. -A review of Resident #12's EMR failed to reveal Remeron was ever started, per the psychologist’s recommendations on 6/25/25. A nurse practitioner visit note, dated 12/26/24, indicated Resident #12 had expressed her remarks of suicidal ideations were "misunderstood humor", however the resident did endorse depression and difficulty adjusting. -Despite visiting Resident #12 and discussing the incident on 12/21/24, the nurse practitioner did not follow up with the resident until five days after Resident #12's threats of suicide. A nurse practitioner visit note, dated 1/3/25, indicated Resident #12 was negative for displaying suicidal ideations during that visit. A nurse practitioner visit note, dated 7/18/25, indicated Resident #12 had been positive for depression and had a risk factor of a history of a parent attempting suicide multiple times.-Physician, psychologist, and nurse practitioner notes failed to reveal Resident #12 had been assessed for suicide lethality or safety on 12/21/24 or 7/10/25, when she made the threats of wanting to kill herself. A review of 15-minute check logs, dated 7/10/25 to 7/11/25, revealed Resident #12 had been on 15-minute checks from 4:45 p.m. on 7/10/25 until 5:45 a.m. on 7/11/25. There were no 15-minute check logs provided by the facility for 12/21/24. The social services quarterly psychosocial assessment, dated 12/23/24, revealed Resident #12 had struggled with adjustment to placement. No changes in behavior were indicated, despite recent suicidal comments (see psychologist notes above). The social services quarterly psychosocial assessment, dated 6/25/25, revealed Resident #12 had struggled with feelings of depression, experiencing a loss of appetite and a decreased interest in activities she enjoyed. Facility conducted depression and trauma screening assessments revealed the following;On 3/21/24, Resident #12 had a score of four, indicating minimal depression. On 6/25/25, the residents' depression score had increased to 10, indicating moderate depression. The trauma screening, dated 3/21/25, revealed Resident #12 suffered from sleep disturbances related to her history of trauma. The trauma screening, dated 6/25/25, revealed the resident suffered from sleep disturbances and upsetting thoughts or memories that were intrusive related to her history of trauma. -Depression and trauma screens, on 6/25/25, indicated increases in depressive symptoms and trauma responses for Resident #12, however, these increases were not addressed by the facility or reported to the physician/psychologist. -Psychotropic medication meeting minutes were requested on 7/23/25 but were not provided by the end of the survey on 7/24/25.-Contact information for the psychologist seeing Resident #12 was requested on 7/23/25 but was never provided by the facility during the survey. IV. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 7/22/25 at 12:08 p.m. LPN 33 said if a resident expressed suicidal ideations, the nurse notified the physician, kept a visual on the resident and notified nurse management and the SSD. LPN #3 said Resident #12 was being monitored for anxiety, verbal expressions of sadness and self-isolation. She said she thought Resident #12 had a history of making statements of suicidal ideations but no one had told the nurses to monitor for that specifically. LPN #3 said she had just read about the resident’s statements in the progress notes. Registered nurse (RN) #2 was interviewed on 7/22/25 at 12:20 p.m. RN #2 said if a resident expressed suicidal ideations, the nurse would stay with the resident to ensure their safety and have other staff contact nurse management, the SSD, the family, and the physician. She said nurse management would give the nurses direction on interventions, such as if the resident needed one-on-one supervision. RN #2 said Resident #12 expressed depression through behaviors of agitation, non-compliance with care and verbal expressions of anger towards staff. She said she was aware Resident #12 suffered from difficulty with placement, trauma, and major depression but she said she had not been told by nurse management that Resident #12 suffered from suicidal ideations or to monitor for suicidal ideations. Certified nurse aide (CNA) #3 was interviewed on 7/22/25 at 12:30 p.m. CNA #3 said if a resident expressed suicidal ideations or statements, the CNAs were to notify the charge nurse and the NHA. She said she had worked with Resident #12 since her admission and was not aware she had a history of suicidal ideations. CNA #5 was interviewed on 7/22/25 at 1:44 p.m. CNA #5 said if a resident was expressing suicidal ideations, she would sit and talk with the resident and notify the charge nurse. CNA #5 said she was aware that Resident #12 had PTSD and depression and that her depression manifested as increased sleeping, decreased appetite and verbal statements. She said talking about art or scripture helped Resident #12 when she was depressed. CNA #5 said she was told by other staff members that Resident #12 had made statements about wanting to kill herself and jump out of her window, but CNA #5 said she had been told by other staff that those statements had been a joke. SSD #1, the NHA, and the assistant director of nursing (ADON) were interviewed together on 7/22/25 at 2:33 p.m. The NHA said he had worked at the facility since 2021. He said resident behaviors were discussed in the morning and afternoon IDT meetings everyday and floor nurses attended those meetings. The NHA said if a resident showed new or worsening behaviors, it would be discussed in that meeting. The NHA was not aware of the specific process the facility used to respond to resident's expressions of suicidal ideations or the facility’s specific process for monitoring, he said he would have to ask the previous SSD (SSD #2), who now worked at the organization's new building across the street. The NHA said his expectation if a resident expressed suicidal ideations was that the resident would get help as soon as possible but he would have to ask SSD #2 as to the timeframe. The NHA was unable to say if he knew or did not know that Resident #12 had made statements of suicidal ideations prior to 7/10/25, he said he would have to talk to SSD #2. The ADON said she had been in her role as of February 2025 and there was no current DON in the facility. The ADON said she was aware that Resident #12 had made statements of suicidal ideations and the facility contacted the physician and the psychiatrist. The ADON said the psychiatrist came out the following day, 7/11/25, after Resident #12 threatened to jump out of her window on 7/10/25. She said the nurse and a member of nurse management provided one-on-one supervision of Resident #12 on 7/10/25 and then after a few hours, switched to 15-minute checks after the resident appeared to calm down. The ADON was unaware of how specifically the facility assessed and determined Resident #12 was no longer a danger to herself on 7/10/25 and she was unaware that Resident #12 had made statements of wanting to kill herself previously. The ADON was additionally unaware if a facility psychosocial evaluation had been completed for Resident #12 following her expressions of suicidal ideation. SSD #1 said he had worked at the facility for approximately six weeks. He said if a resident had a history of or current expressions of suicidal ideations, behavior monitoring would be implemented. SSD #1 said the process he would follow if a resident expressed suicidal ideations would be to immediately have someone provide one-on-one supervision of the resident. He said he would assess the resident for thought process, intent and risk. SSD #1 said he would create a safety plan with the resident and do a sweep of the resident's room for items the resident could use to harm themselves. SSD #1 said the resident would be removed from any method they had expressed using to kill themselves, for example if the resident said they intended to throw themselves down the stairs, staff would keep the resident away from stairs. SSD #1 said he was not aware if all the staff in the facility had been educated on how to assess an individual with suicidal ideations. He said he would attempt to get the resident assessed by the mental health physicians and if this was not possible, he would send the resident out to the hospital to be assessed, if applicable. SSD #1 said he had not completed a psychosocial assessment with Resident #12 because he was out of town on 7/10/25, but he could not say why the behavior monitoring or care plan had not been updated to include suicidal ideations after 7/10/25. SSD #2 was interviewed on 7/22/25 at 3:15 p.m. SSD #2 said if a resident expressed active statements of self harm or suicidal ideations, the facility would complete a room sweep for any dangerous items, put the resident on 15-minute checks and contact the physican. She said the facility was not equipped to provide one-on-one supervision and if that was necessary, the resident would be sent out to the hospital. SSD #2 said she was aware Resident #12 had made statements of suicidal ideations on 12/21/24 but said that there was not a serious threat determined which necessitated reaching out to the mental health physician or the telehealth physician. SSD #2 said Resident #12's psychologist was aware of the resident’s statements on 12/21/24 and met with the resident on 1/7/25. SSD #2 said she did not update the care plan or add behavior monitoring because Resident #12 had not made a statement that she specifically had a plan and the nurse had determined Resident #12 was stable and did not intend to hurt herself. She said the nurse assessed Resident #12 on 12/21/24 and determined the resident did not have a plan, however, she was unable to find nurse documentation of the 12/21/24 assessment. SSD #2 said the physician assessed Resident #12 the following day, 12/22/24, and determined the resident was safe. SSD #2 said she would reach out to the physician for that documentation. -Documentation provided by the facility was the 12/26/24 nurse practitioner visit note located in the EMR (see NP note above). The psychiatrist was interviewed on 7/22/25 at 4:20 p.m. She said when she was contacted by the facility on 7/10/25, she was advised by the facility that SSD #1 or someone else had assessed Resident #12 for ideations and safety. The psychiatrist said, based on the facility assessing the resident, numerous staff talking to the resident about the situation and the physician being called for an order of Ativan, she felt it was safe to wait until the following day to assess Resident #12 herself. She said she did not recommend the facility move Resident #12's room downstairs because this could have been perceived by the resident as another loss of control in her life. The psychiatrist said she had believed the resident had been on 15-minute checks until she assessed her the following afternoon. She said she was unaware the resident had made prior statements before 7/10/25 about wanting to kill herself and the psychiatrist was unable to say if she would have made the same recommendations if she had been aware of this history. The medical director (MD) was interviewed on 7/23/25 at 11:39 a.m. The MD said if a resident expressed suicidal ideations or expressions, he would recommend the facility begin behavior monitoring in the EMR. The MD was not aware of the facility's specific process when it came to suicidal ideations, however, he said Resident #12 should have been moved to the first floor after making the first threat of jumping out of her window.
Plan of correction · submitted by the facility
Tag: 0742Description of Deficiency:Based on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for one (Resident #12) of six residents out of 52 sampled. Specifically, the facility failed to:Ensure individualized care approaches were provided and monitored with ongoing assessment for Resident #12 to meet emotional and psychosocial needs;Monitor Resident #12, who had expressed suicidal ideations with intent and had a history of trauma, for signs and symptoms of suicidal ideation;Address expressions of suicidal ideation in a timely manner to ensure Resident #12's safety. Plan of Correction:Corrective Action for the Affected Resident:Resident #12 is currently under the care of a psychologist to support mental health needs. The resident’s care plan was updated on 7/24/2025 to reflect suicidal ideation and includes resident-specific interventions for staff. Ongoing monitoring and support are in place to ensure resident safety and well-being. Identification of Other Potentially Affected Residents:An audit of residents with a diagnosis of a mental disorder or psychosocial adjustment difficulty be completed. Review of all of the behavior monitoring tasks for those identified in the audit, revisions made accordingly to ensure personalized interventions are appropriate. All direct care associates will receive training on the psychosocial evaluation policy along with training on recognizing and responding to suicidal ideationsStaff training will be completed by 8/31/2025. Monitoring and Sustainability Measures:The 24-hour report will be reviewed during stand-up meetings (weekend reports reviewed on Monday) to identify any residents expressing or exhibiting signs of suicidal ideation or other psychosocial distress. Following completion of staff training by 8/31/2025, five direct care staff will be assessed weekly for competency by Social Services or designee with immediate education to address any incompetence. Progress and audit results will be reviewed monthly during the facility’s Quality Assurance and Performance Improvement (QAPI) committee meetings. Review tools include the 24-hour report, behavior/progress notes, and results of staff competency audits. Scope and Frequency of Monitoring:Population Monitored: Residents with a diagnosis of a mental disorder or psychosocial adjustment difficulty. Documentation:Monitoring will be documented via audit tools, QA meeting minutes, and PCC progress note reviews. Competency tracking and staff feedback will also be recorded and reviewed regularly. Integration into QAPI:The process and outcomes will be included in both nursing and social services reports as part of the facility’s ongoing QAPI efforts. Weekly for 4 weeks,Monthly thereafter until audit scores remain at or above 90%.Completion Date:Substantial compliance will be achieved by 9/6/2025
0761Label/Store Drugs and Biologicals▼
Findings
Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in two of four medication storage rooms and three of five medication carts. Specifically, the facility failed to:-Ensure medications were labeled with the date they were opened;-Ensure expired medications were removed and discarded from medication carts and storage refrigerators; and,-Ensure the temperature in a medication storage refrigerator was maintained within an acceptable temperature range. Findings include:I. Facility policy and procedureThe Medication Storage policy, dated January 2025, was received by the nursing home administrator (NHA) on 7/24/25 at 11:00 a.m. It read in pertinent part,“Medications requiring refrigeration or temperatures between 2 degrees celsius (C)/(36 degrees fahrenheit (F) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place may be refrigerated unless otherwise directed on the label as cool temperatures are those between 8 degrees C (46 degrees F) and 15 degrees C (59 degrees F). A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. “Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.”II. Failed to ensure medications were labeled with the date they were openedA. Observations and staff interviewsOn 7/23/25 at 3:23 p.m. the West 1 medication cart was observed with LPN #5. The following items were found:-An opened bottle of Lastacaft (allergy itch relief) 0.25% eye drops was labeled with a resident’s name, but was not labeled with the date opened. LPN #5 said dates should be labeled on medications so staff were aware of when they were opened and when they needed to be discarded. On 7/23/25 at 4:39 p.m. the East 2 medication cart was observed with LPN #8. The following items were found:-An opened bottle of Flonase 50 microgram (mcg) nasal spray (steroid nasal spray) was labeled with a resident’s name but was not labeled with the date opened. The pharmacy issue date listed on the bottle was 5/13/25. LPN #8 said Flonase nasal spray should be discarded 60 days after being opened. III. Failed to ensure expired medications were removed and discarded from medication carts and storage refrigeratorsA. Observations and staff interviewsOn 7/23/25 at 3:10 p.m., the West 1 medication storage room and medication refrigerator were observed with licensed practical nurse (LPN) #7. The following items were found:-A Bisacodyl 10 milligrams (mg) suppository (laxative) with an expiration date of April 2024.-Two individually packaged Bisacodyl 10 mg suppositories were labeled with a current resident’s name. The suppositories had expiration dates of 12/16/24 and 4/11/25. LPN #7 said any nurse on duty could clean out the medication refrigerator. LPN #7 said expired medications could potentially harm and cause damage to a resident. -A box of DexcomG6 (glucose monitoring) sensors was not labeled with a resident’s name and had an expiration date of 5/31/25. LPN #7 said the sensors were not kept as floor stock and should have a resident label. On 7/23/25 at 4:39 p.m. the East 2 medication cart was observed with LPN #8. The following items were found:-An opened bottle of Nighttime Relief lubricant (moisturizing) eye drops labeled with a resident’s name. The product box instructed staff to discard the medication 30 days after opening. The open date labeled on the bottle was 5/15/25. LPN #8 confirmed the eye drops should have been discarded 30 days after the open date.-An opened Advair Diskus 250 mcg – 50 mcg inhaler was inside an Advair Diskus box labeled with a resident’s name. The Advair Diskus containing the medication was labeled with the resident’s name. The open date on the inhaler was 5/6/25. LPN #8 said the Advair Diskus medication should have been discarded 30 days after opening.-Additionally, an opened Albuterol inhaler was inside the Advair Diskus box alongside the Advair Diskus medication. The albuterol inhaler had a resident’s room number written on it, which matched the room number written on the Advair Diskus box, but the inhaler was not labeled with the resident’s name. The Albuterol inhaler did not have an open date labeled on it. LPN #8 confirmed the Albuterol inhaler should not have been in the box with the Advair Diskus. She confirmed the inhaler should have had a resident's name and an open date on it. LPN #8 said she would discard both inhalers and have them reordered. LPN #8 said the night shift nurse primarily audited the medication carts, however, she said all nurses should perform audits when passing medications to look for unlabeled and expired medications.-An opened tube of Equate anti-itch cream with an expiration date of May 2024.-An opened tube of Terbinafine hydrochloride 1% (antifungal) cream with an expiration date of June 2025.-An opened bottle of Ultra sunscreen lotion sun protection factor (SPF) 30 with an expiration date of 7/1/24. IV. Failed to ensure the temperature in a medication storage refrigerator was maintained within an acceptable temperature rangeA. Observations and staff interviewsOn 7/23/25 at 3:55 p.m., the West 2 medication storage room and medication refrigerator were observed with registered nurse (RN) #4. A temperature log for the medication refrigerator was posted on the wall next to the refrigerator. The temperature reading inside of the refrigerator was observed to be 48 degrees F, which was above the appropriate temperature range of 36 degrees F to 46 degrees F. RN #4 said the temperature of the medication refrigerator should be less than 41 degrees F. RN #4 was unsure what to do for a medication refrigerator temperature reading outside of the required temperature range. He said she would have to find out. Review of the West 2 medication refrigerator temperature log revealed the following: -On 7/21/25 the medication refrigerator temperature was 55 degrees F; -On 7/22/25 the medication refrigerator temperature was 58 degrees F; and,-On 7/23/25 the medication refrigerator temperature was 58 degrees F.On 7/23/25 at 4:02 p.m., the regional director of clinical operations entered the West 2 medication storage room. She said the medication refrigerator temperature should be less than 41 degrees F. The regional director of clinical operations said staff would remove the medications currently in the refrigerator. She said she would follow up with the facility’s pharmacist to determine if any of the medications needed to be discarded and re-order any needed medications. On 7/23/25 at 4:06 p.m. the facility’s maintenance director (MTD) entered the West 2 medication storage room. The MTD used a temperature gun to check the medication refrigerator’s. The reading on the temperature gun was 51 degrees F. On 7/23/25 at 4:20 p.m. the East 2 medication storage room and medication refrigerator were observed with LPN #8. A temperature log for the medication refrigerator was posted on the wall next to the refrigerator. The temperature reading inside of the refrigerator was observed to be 48 degrees F. LPN #8 said facility management just replaced the thermometer previously in the refrigerator with a new one, so it needed to adjust to the accurate temperature. V. Additional staff interviews and observationsThe regional director of clinical operations was interviewed on 7/24/25 at 9:46 a.m. She said she spoke with the facility’s pharmacist and was told the medications in the West 2 medication storage room refrigerator were good for at least 14 days at room temperature. She said the medications were labeled with an open date of 7/21/25. On 7/24/25 at 10:08 a.m., the West 2 medication storage room was observed with RN #4. The medication storage refrigerator was not observed in the storage room. RN #4 said the refrigerator was removed and a new one was ordered. RN #4 said any new refrigerated medications received would be stored in the West 1 medication storage refrigerator until the new refrigerator arrived. On 7/24/25 at 10:17 a.m., the East 2 medication storage room refrigerator was observed with LPN #6. The refrigerator temperature was observed to be 38 degrees F.
Plan of correction · submitted by the facility
Tag: 0761Description of Deficiency:Based on observations, record review, and interviews, the facility failed to ensure proper storage of medications in two of four medication storage rooms and three of five medication carts. Specifically, the facility failed to:Ensure medications were labeled with the date they were opened;Ensure expired medications were removed and discarded from medication carts and storage refrigerators; andEnsure the temperature in a medication storage refrigerator was maintained within an acceptable temperature range. Plan of Correction:Corrective Action for the Affected Areas:As of 8/1/2025, all medication refrigerator temperature logs were updated to include check sheets with acceptable temperature ranges. An audit form was created on 8/8/2025 for night shift nurses to review medication carts for:Proper labeling of opened medications,Removal of expired medications, andRemoval of medications for discharged residents. Staff received in-service training on this new process on 8/8/2025, and implementation began on 8/13/2025. Identification of Other Potentially Affected Residents:All residents have the potential to be impacted by improper medication storage. The Staff Development Coordinator (SDC) Nurse will conduct training for all nursing staff on:Medication storage regulations,Requirements for labeling and removing expired medications, andAcceptable refrigerator temperature ranges. Staff will also be trained on completing the daily audit form and the process for reporting concerns. The Assistant Director of Nursing (ADON) or designee will perform daily audits of fridge temp logs and medication cart audits to ensure proper documentation and resolution of any issues identified. An updated refrigerator temp log has been created in accordance with our policy and the necessary clinical staff will be in-service on this form. If any issues are identified, staff will notify the on-call nurse immediately. Monitoring and Sustainability Measures:The charge nurse or designee for each unit in the community each day are responsible for completing daily medication cart audits, ensuring no expired or improperly labeled medications remain. Nurse leadership will independently verify compliance using a separate daily audit form, confirming that all identified issues are addressed promptly. Charge nurse or designee will monitor medication refrigerator temperatures daily to ensure logs are completed and temperatures remain within safe ranges and will report any issues to maintenance immediately to be addressed. Issues or trends will be reported to the Interdisciplinary Team (IDT) during daily stand-up and stand-down meetings. All results will be reviewed monthly in QA meetings to assess the process and implement necessary improvements. Scope and Frequency of Monitoring:Population Monitored: All residents. Review Elements:Medication cart audit formsRefrigerator temperature logsPCC documentation as neededDocumentation:Audit toolsQA meeting minutes and reportsNursing progress notes in PCCIntegration into QAPI:This issue will be included in monthly Quality Assurance and Performance Improvement (QAPI) reporting through nursing and social services department reviews. Weekly for 4 weeks,Monthly thereafter until audit scores remain at or above 90%.Completion Date:Substantial compliance will be achieved by 9/6/2025
0812Food Procurement,Store/Prepare/Serve-Sanitary▼
Findings
Based on observations, interviews and record review, the facility failed to store, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure kitchen equipment was stored in a clean and sanitary manner; and, -Ensure perishable foods were discarded after the date of expiration. Findings include: I. Failure to ensure stored kitchen equipment were clean and sanitary A. Professional referenceThe Colorado Department of Public Health and Environment (2021) The Colorado Retail Food Establishment Rules and Regulations, retrieved 7/30/25 revealed in pertinent part,“Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. (4-501.12)“Non food-contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.” (4-601.11). B. ObservationsThe initial kitchen tour was conducted on 7/21/25 at 8:15 a.m. The following was observed-Eight stacks of steam table pans were on a metal storage shelf and had moisture in between the pans.-Three red , two green and two white cutting boards were scored.-One white cutting board had a large circular burn resembling the bottom of a pot. On 7/23/25 at 11:20 p.m. a walk through of the walk-in refrigerator was conducted with the regional dietary resource. The following was observed:-There were two scored red and one scored white cutting board (with numerous gouges creating more than superficial indentations) ; and,-Three steam table pans that were stacked on top of each other were on a shelf were and were wet in between the pans. II. Failure to ensure perishable foods were discarded after the expiration date A. Professional reference 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)A. ObservationsThe initial kitchen tour was conducted on 7/21/25 at 8:15 a.m. The following was observed:-A pan labeled egg salad with a discard date of 7/7/25;-A pan of undated blueberries that had a white film on the exterior of the blueberries; and,-A pan of undated lettuce that had a white film on the exterior of the lettuce. III. Staff interviewsThe regional dietary resource was interviewed on 7/23/25 at 11:20 p.m. He said when cutting boards became scored, damaged or pitted the boards were replaced. He said if a cutting board was burned it was immediately replaced. The regional dietary resources said the kitchen staff utilized a cleaning schedule. He said twice a week when they received the food deliveries, the staff went through the walk-in refrigerator and discarded expired foods. He said if the kitchen staff saw any foods in the walk-in refrigerator that were spoiled, the food was to be thrown out right away. The regional dietary resource said there were drying racks for the steam table pans and the pans were to be completely dry before being stacked together. He said if the pans were stacked when wet, the moisture could cause bacteria growth. He said if the residents were served expired food it had the potential to make the residents ill if eaten by them.
Plan of correction · submitted by the facility
Tag: 0812Description of Deficiency:The facility failed to ensure stored kitchen equipment was clean and sanitary and failed to discard perishable food items after their expiration dates. Plan of Correction:Corrective Action for the Affected Areas:As of 8/15/2025, 100% of dining associates were in-serviced on:Proper drying and storage of pots and pans,Labeling and dating procedures for perishable foods. A dishwashing competency was completed for all dining staff on 8/15/2025. Daily manager rounding began on 8/10/2025 to ensure compliance with proper drying and storage protocols and to check for expired or unlabeled food items. The staff workflow was revised to emphasize sanitation, particularly regarding pot and pan drying. An old cutting board was discarded, and new cutting boards were purchased on 8/7/2025. Weekly food safety and sanitation audits began on 8/10/2025 to ensure all equipment and cutting boards meet regulatory standards. Identification of Other Potentially Affected Residents:All residents have the potential to be affected by unsanitary kitchen equipment and expired food. Dining staff were educated on how to identify and properly discard expired food items as of 8/15/2025. To mitigate risk, all dining staff have been trained and provided with updated policies regarding:Dishwashing protocols,Food storage, labeling, and expiration monitoring. Kitchen equipment and food storage practices will be reviewed and reinforced through regular audits and daily rounding. Monitoring and Sustainability Measures:Daily manager rounding occurs twice per day (AM/PM) to ensure proper drying of pots/pans and that expired or improperly labeled food is removed promptly. Food safety and sanitation audits began on 8/10/2025 and are being conducted:Weekly for 4 weeks,Monthly thereafter if audit scores remain at or above 90%.Cutting boards or other kitchen equipment will be discarded immediately if marked as noncompliant (red designation) during an audit. Audit results and identified issues are tracked to verify corrective actions were implemented effectively. Scope and Frequency of Monitoring:Population Monitored: All residents, through facility-wide dietary practices. Frequency:Daily rounding (2x/day, AM/PM)Weekly audits for 4 weeksMonthly audits thereafter if thresholds are metReview Elements:Equipment cleanliness and proper dryingFood labeling and expiration datesCutting board condition and kitchen sanitationDocumentation:Manager rounding logsSanitation audit formsQA meeting minutes and any PCC documentation (if applicable)Integration into QAPI:Food safety and sanitation compliance will be reviewed monthly in the QAPI meeting by the dietary team and administration. Any trending concerns or failed audits will be addressed through the QAPI performance improvement process. Completion Date:Substantial compliance will be achieved by 9/6/2025
0880Infection Prevention & Control▼
Findings
Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure housekeeping staff completed proper hand hygiene, cleaned high-touch surfaces and followed the appropriate guidelines for disinfectant solution when cleaning residents’ rooms; and,-Ensure appropriate infection control procedures were followed urinary catheter care for Resident #68. II. Failure to ensure appropriate infection control procedures were followed during urinary catheter care for Resident #68A. Professional referenceAccording to the CDC’s Clinical Safety: Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 7/31/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety:"When to clean your hands:-Immediately before touching a patient;-Before moving from work on a soiled body site to a clean body site on the same patient;-After touching a patient or patient's surroundings;-After contact with blood, body fluids, or contaminated surfaces; and,-Immediately after glove removal."Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings. Always clean your hands after removing gloves."When to wear gloves:-When needed for standard precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment); and,-When needed for transmission-based precautions."When to change gloves and clean hands:-If gloves become soiled with blood or body fluids after a task;-If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs; and,-If they look dirty or have blood or body fluids on them after completing a task."B. Facility policy and procedureThe Hand Hygiene policy, dated December 2024, was received by the nursing home administrator (NHA) on 7/24/25 at 11:00 a.m. It read in pertinent part,“The facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene includes both handwashing and the use of alcohol-based hand sanitizer.“The following situations require the use of hand washing of twenty (20) seconds usingsoap and water:-When hands are visibly dirty or soiled;-After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin;-After handling items potentially contaminated with blood, body fluids, orsecretions;-Before eating and after using a restroom;-Before inserting urinary catheters, peripheral vascular catheters or other invasive devicesthat do not require surgery; and,-When there is a likely exposure to C Diff (clostridium difficile) and Norovirus or GI (gastrointestinal) symptoms.“The use of gloves does not replace hand hygiene.”The Foley catheter policy, dated December 2024, was received by the NHA on 7/24/25 at 11:00 a.m. It read in pertinent part,“A urinary catheter is any tube system placed in the body to drain and collect urine from thebladder. The facility is committed to serving the present and future needs of ourresidents/guests, utilizing a wide variety of resources. Urinary catheters are used to drain thebladder and the prescriber may recommend a catheter for short-term or long-term placement dueto urinary incontinence associated with a specific diagnosis, urinary retention, surgery, or othermedical condition.“Handwashing is to be performed by the nursing personnel prior to cleansing and aftercleansing of the Foley catheter.”C. ObservationsOn 7/23/25 at 11:40 a.m. the infection preventionist (IP) #2 was providing catheter care to Resident #68. The following observations were made:IP #2 applied gown and gloves before entering Resident #68’s room. IP#2 said she performed hand hygiene at the desk before going to Resident #68’s room. Resident #68 was sitting in a chair in his room. IP #2 assisted Resident #68 with ambulating to and lying down on his bed. IP #2 went into Resident #68’s bathroom and filled a basin with warm, soapy water. IP #2 brought the basin into the room and placed it next to Resident #68 on his bed. -IP #2 did not remove her gloves or perform hand hygiene after assisting Resident #68 to lie down in bed and touching the faucet in the bathroom while filling the basin with water .IP #2 lowered Resident #68’s pants to below his belly button. Resident #68 had a urinary catheter securely inserted into his belly button (suprapubic catheter). IP #2 grabbed a washcloth and submerged it in the water basin. IP #2 used the washcloth to wipe Resident #68’s catheter site from the inside out toward his left side. IP #2 wiped the site approximately three to five times, going from inside to out. IP #2 folded the washcloth and used a new spot with each wipe. IP #2 placed the washcloth in the dirty laundry bin, removed her gloves and donned a new pair of gloves. -IP #2 did not perform hand hygiene before donning the new pair of gloves. IP #2 took a new washcloth and submerged it in the water basin. IP #2 used the washcloth to wipe Resident #68’s catheter site from the inside out, towards his right side. IP #2 wiped the site approximately three to five times from the inside to out and refolded the washcloth to wipe the site with a new spot each time. IP #2 placed the washcloth in the dirty laundry bin, removed her gloves and donned a new pair of gloves. -IP #2 did not perform hand hygiene before donning a new pair of gloves. IP #2 emptied the water basin in Resident #68’s bathroom. Wearing the same gloves, IP #2 returned to Resident #68 and pulled up his pants over his catheter site. IP #2 then assisted Resident #68 into a sitting position at his bedside. D. Staff interviewsThe assistant director of nursing (ADON) and the regional director of clinical operations were interviewed together on 7/24/25 at 11:00 a.m., in place of the infection preventionist (IP). The regional director of clinical operations said hand hygiene should be performed before and after resident care. She said it should be performed after the removal of gloves. She said this was important for reducing the transmission of infections.
Plan of correction · submitted by the facility
Tag: 0880Description of Deficiency:Based on observations, record review, and interviews, 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 housekeeping staff completed proper hand hygiene, cleaned high-touch surfaces, and followed guidelines for disinfectant solution usage when cleaning residents’ rooms;Ensure appropriate infection control procedures were followed during urinary catheter care for Resident #68. Plan of Correction:Corrective Action for the Affected Resident(s):Immediate education was provided on 7/23/2025 to the staff member who provided catheter care to Resident #68. Nursing staff began training on 7/23/2025 regarding proper catheter care, including hands-on competency assessments conducted by the Infection Prevention (IP) Supervisor. For housekeeping, all staff received training on 8/1/2025 regarding:Proper hand hygiene,Cleaning high-touch surfaces, andUse and dilution of disinfectant solutions per manufacturer guidelines. The Maintenance Director conducted initial competencies with housekeeping staff following the training. Identification of Other Potentially Affected Residents:All residents have the potential to be affected by improper infection control practices. Housekeeping staff will receive competencies post-training to ensure understanding of proper infection control procedures. The Maintenance Director or designee will conduct five random observations weekly to verify staff are:Following hand hygiene protocols,Cleaning high-touch surfaces, andUsing disinfectants correctly. For nursing staff, all nurses will go through competency observations of catheter care. This will be completed by the IP Nurse or Staff Development Coordinator (SDC) or designee. Observation results will be recorded using a standardized audit form, with any deviations documented and addressed with immediate re-education or corrective action. Monitoring and Sustainability Measures:Audit tools will be used to ensure that five random infection control observations (housekeeping and catheter care) are completed weekly. Audit forms will detail whether competencies are being followed and include documentation of any issues and interventions. Competency completion will be tracked for all nursing and housekeeping staff. Infection control trends and compliance will be reviewed at the monthly QA meeting to assess process effectiveness and implement adjustments as needed. Scope and Frequency of Monitoring: Population Monitored: All residentsReview Elements:Staff training logsCompleted competenciesWeekly audit sheetsDocumentation:Audit formsQA meeting minutes and reportsPCC updates, as applicableIntegration into QAPI:Infection control compliance, observations, and outcomes will be reported and analyzed through the facility’s ongoing QAPI process under the nursing department’s infection prevention reporting. Weekly for 4 weeks,Monthly thereafter until audit scores remain at or above 90%.Completion Date:Substantial compliance will be achieved by 9/6/2025
10/28/2024Revisit: Complaint Survey · ID 6S9S12No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A revisit survey was completed on 10/28/24 for all previous deficiencies cited on 9/4/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
9/4/2024Complaint Survey · ID 6S9S112 deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO37101 and #CO37216 was conducted on 8/20/24 to 9/4/24. Two deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0699Trauma Informed CareS/S D▼
Findings
Based on record review and interviews, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for two (#3 and #4) of three residents reviewed out of four sample residents. Specifically, the facility failed to identify Resident #3 and Resident #4's post traumatic stress disorder (PTSD) and identify triggers which may retraumatize them. Findings include:I. Facility policy and procedureThe Trauma Informed Care policy and procedure, undated, was provided by the director of nursing (DON) on 9/4/24 at 4:38 p.m. It read in pertinent part, "It is the policy of the community to ensure residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice."Each resident will be screened for a history of trauma upon move-in by the community's social service or designee."If the screening indicates that the resident has a history of trauma and/or trauma-related symptoms, an order will be obtained for the resident to be evaluated by mental health professional who is qualified and experienced in working with those exposed to trauma."Once the order is received, the referral to the mental health professional will be made."The community will account for residents' experiences, preferences, and cultural differences to eliminate or mitigate triggers that may cause re-traumatization of the resident."II. Resident #3A. Resident statusResident #3, age 78, was admitted on 3/21/21. According to the September 2024 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD), post-traumatic stress disorder (PTSD) and anxiety disorder. The 7/9/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He was dependent on staff assistance for lower body dressing, putting on/taking off footwear, chair/bed to chair transfer, toilet transfer, tub/shower transfer, showering/bathing self and toileting hygiene. B. Resident interviewResident #3 was interviewed on 9/4/24 at 11:35 a.m. Resident #3 said he served in the Navy for four years and was an aircraft carrier in Vietnam. He said he had been diagnosed with PTSD. He said he was not receiving services for PTSD.C. Record reviewThe feelings care plan, revised on 10/26/21, documented Resident #3 was at risk for feelings of sadness, emptiness, anxiety, uneasiness, depression, characterized by ineffective coping, low self-esteem, tearfulness, motor agitation and withdrawal from care/activities and loss of independence. Pertinent interventions included monitoring the resident's mental status and mood state changes when new medication was added and involving the resident in making his own schedule. The mood care plan, revised on 6/26/24, documented Resident #3 had a mood challenge related to insomnia. Interventions included monitoring and recording the resident's mood to determine if problems seem to be related to external causes, medications, treatments and or concerns over diagnosis; tracking hours of sleep and having caregivers to assist the resident/family in identifying the residents strengths, encouraging positive coping skills and reinforcing them. The behaviors care plan, revised on 12/27/21, documented Resident #3 had behavior challenges related to sexually inappropriate behaviors towards female staff. Interventions included providing the resident the opportunity for positive interaction and attention, stopping and talking with resident when passing by, having the nurses monitor the resident's behaviors for inappropriate sexual comments to female staff, offering and documenting non pharmacological interventions as needed , setting clear boundaries, educating on appropriate ways to speak to staff, offering snack or drink, redirecting to an activity, offering independent activity supplies for validation and providing encouragement to express feelings appropriately.-Review of the resident's comprehensive care plan did not reveal a care plan related to Resident #3's PTSD to include person-centered individualized interventions, personalized triggers or personalized signs and symptoms. The 1/3/24 social services quarterly assessment revealed Resident #3 had minimal depression. The resident self-reported little interest in doing things, depressed mood and feeling bad about himself. The assessment documented Resident #3 had PTSD and anxiety.-Review of Resident #3's electronic medical record (EMR) did not reveal the facility had determined what triggered Resident #3's PTSD.III. Resident #4A. Resident statusResident #4, age 79, was admitted on 1/25/24. According to the September 2024 CPO, the diagnoses included congestive and diastolic congestive heart failure, acute kidney failure and PTSD.The 7/30/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was dependent on staff assistance with toileting hygiene and showering/bathing self. He required substantial/maximal assistance with lower body dressing, putting on/taking off footwear, sitting to standing, chair/bed to chair transfer, toileting transfer and tub/shower transfer. B. Record reviewThe medications care plan, revised on 8/13/24, documented Resident #4 prescribed mirtazapine (for appetite stimulation) and duloxetine HCI ( pain medication). Interventions included administering antidepressant medications as ordered by the physician, monitoring/documenting side effects and effectiveness every shift, educating the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of antidepressant drugs being given, monitoring/documenting/reporting as needed adverse reactions to antidepressant therapy and monitoring for changes in behavior/mood/cognition. The depression care plan, revised on 8/13/24, documented Resident #4 had been diagnosed with depression however was not currently on a medication to treat it specifically. Resident #4 was prone to exhibiting the following behaviors that needed to be monitored: depressed mood, isolation, appetite changes and low energy. Interventions included assisting the resident in developing/providing resident with a program of activities that was meaningful and of interest, encouraging and providing opportunities for exercise, encouraging the resident to express his feelings and giving him time to talk, monitoring/documenting/reporting as needed any signs or symptoms of depression, including hopelessness, anxious or health-related complaints and tearfulness.-Review of Resident #4's comprehensive care plan did not reveal a care plan related to his diagnosis of PTSD post-traumatic stress disorder to include person-centered individualized interventions, personalized triggers or personalized signs and symptoms. The 2/8/24 psychosocial evaluation documented Resident #4 was very pleasant. There were no psychosocial signs or symptoms noted at that time. The 8/13/24 social services quarterly assessment documented Resident #4 reported no depression.-The assessment did not indicate the resident had a diagnosis of PTSD. -Review of Resident #4's EMR did not reveal the facility had determined what triggered Resident #3's PTSD.IV. Staff interviewThe social service director (SSD) was interviewed on 9/4/24 at 3:41 p.m. The SSD said the social services department was responsible for completing a depression screening and offering psychiatric services based on a diagnosis of trauma. She said if the resident had PTSD from Vietnam or was having nightmares that she would refer the resident for psychiatric services. She said if a resident was receiving psychiatric services she would make sure the residents' needs were being met. She said social services was responsible for making sure care plans were implemented and updated. She said care plans should be updated as needed and quarterly. She said Resident #3 had a diagnosis of PTSD and anxiety. She said Resident #3 was not prescribed any medications for his PTSD.The SSD said she did not know that Resident #4 had a diagnosis of PTSD. She said she did not know that he did not have a care plan addressing his PTSD. She said social services was responsible for implementing care plans for behaviors. The SSD said she was not a licensed social worker, so she did not feel comfortable doing a trauma assessment for residents. She said there was not another designated staff member to complete trauma assessments. She said she understood that resident's triggers needed to be identified. She said she now knew what areas she needed to work on improving. She said she would work on getting these areas fixed.
Plan of correction
The state did not require a plan of correction for this citation.
0742Treatment/Srvcs Mental/Psychoscial ConcernsS/S D▼
Findings
Based on record review and interviews, the facility failed to ensure one (#2) of three residents reviewed for psychosocial concerns out of four sample residents received the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to:-Provide Resident #2 with psychosocial support who had increasing depression since February 2024;-Update Resident #2's comprehensive care plan to identify the resident's increasing depression and recent wish to die; and,-Develop a comprehensive care plan that depicted Resident #2's accurate antidepressant medication. Findings include:I. Facility policy and procedureThe Psychosocial Evaluation policy and procedure, dated November 2022, was provided by the nursing home administrator (NHA) on 9/4/24 at 2:30 p.m. It revealed in pertinent part, "The community will evaluate and intervene in residents' psychosocial unmet needs to improve their well-being."A member of the interdisciplinary team (IDT) notices the resident has element(s) of psychosocial unmet needs, such as but not limited to: self-injurious behavior; anger, agitation and/or distress that caused aggression - hitting, shoving, biting, suicide ideation, crying, moaning, screaming, expressions of avoidable pain that is severe, fear or anxiety that may be manifested as panic, immobilization, screaming, trembling, avoidance, resistance to care, sleeplessness, fear of speaking."That IDT member initiates the psychosocial evaluation and notifies the supervisor. Each IDT member completes their section of the evaluation, if appropriate."The social services member completes the evaluation."II. Resident #2A. Resident statusResident #2, age 79, was admitted on 9/20/22. According to the September 2024 computerized physician orders (CPO), the diagnoses included major depressive disorder and aphasia (language disorder that affects a person's ability to communicate due to damage to the brain's language centers). The 8/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The assessment indicated that the resident felt down, depressed and hopeless nearly every day, felt bad about herself or that she was a failure nearly every day, had trouble concentrating two to six days (several days) during the assessment period with a total PHQ-9 (Patient Health Questionnaire for depression) severity score of seven out of 27, which indicated that the resident had mild depression. B. Resident's representative interviewThe resident's representative was interviewed on 8/20/24 at 1:00 p.m. She said Resident #2 had been having a hard time mentally. She said Resident #2 had increasing depression and the facility was not providing psychosocial support. She said social services did not refer Resident #2 to the psychologist until she insisted upon it in June 2024. C. Record reviewThe September 2024 CPOs revealed the following physician orders:-Sertraline HCI (Zoloft) (antidepressant medication) oral tablet 100 mg (milligram), give one tablet by mouth one time per day for depression, ordered on 8/7/24;-Monitor for depressed mood, crying or tearful, self-isolation, appetite changes, and/or feeling bad about herself. If the behavior occurs. Document in the behavior progress notes description of the behavior, non-pharmacological interventions, and resident response. Every shift for behavioral monitoring. Monitoring interventions that can be used are: re-positioning, offer a snack/drink, redirect to an activity, offer independent activity supplies, offer to call a loved one, assist outside, sit with resident as needed, active listening and validation, ordered on 1/17/24; and,-MediTelecare to evaluate and treat for psychiatric and psychological help, ordered on 6/12/24. The antidepressant medication care plan, initiated on 9/21/22 and revised on 3/24/23, documented that the resident used the anti-depressant medication of Lexapro.-The care plan was inaccurate as the resident was not currently prescribed Lexapro, but instead Zoloft, which was originally prescribed on 3/13/24. The 2/27/24 PHQ-9 documented Resident #2 felt tired or had little energy two to six days per week. The resident scored a two out of 27, which indicated no to minimal depression. The 3/24/24 nursing progress note documented Resident #2 said she "stayed in bed all day. I just did not feel like getting up. My appetite is off, I am not hungry and nothing tastes right."The 4/7/24 physician progress note documented Resident #2 was very tearful and stated she would like to die, but does not have a plan. The physician recommended to refer the resident to psychology services and increase the Zoloft.-However, the resident was not referred to psychological services until 6/12/24, at the insistence of the resident's responsible party. The 5/31/24 PHQ-9 documented by social services, indicated Resident #2 had little interest or pleasure in doing things, felt tired or had little energy and felt bad about herself or has let her family down with a score of three out of 27, which was a one point increase from February 2024 and indicated minimal depression.-Social services documented that the resident had a recent evaluation confirming the resident had dementia and had been taking the diagnosis hard and caused tearfulness or isolation, however record review did not reveal additional psychosocial support was provided to the resident by social services, including a psychological evaluation referral that was not completed until 6/12/24. The 7/15/24 nursing progress note documented the resident was informing her family and staff that she "is ready to die. I have lived a good life and it is time for me to go." The nurse documented that she sat with the resident and said Resident #2 would be missed if she died tonight and informed the resident staff would check on her through the night.-The resident was placed on monitoring for three days, however a review of the resident's electronic medical record (EMR) did not reveal documentation that social services had met with the resident and provided additional psychosocial support. The 8/6/24 physician progress note documented that Resident #2's anxiety and depression was severe. The resident was very tearful and perseverated on death and not wishing to be alive any longer. Resident #2 said she felt she was a burden to her family. The 8/26/24 PHQ-9 documented Resident #2 felt down, depressed or hopeless almost every day, felt bad about herself or that she was a failure or have let her family down every day and had trouble concentrating two to six days of the assessment period with a score of seven out of 27.-Resident #2 had a four point increase on the 8/26/24 PHQ-9 assessment since 5/31/24.-A review of the resident's EMR did not reveal documentation that the resident had been provided psychosocial supportive services by the social services department, other than a referral to psychology services on 6/12/24, which was prompted by the resident's family member, not the facility staff (see resident representative interview). The mood care plan, initiated on 10/9/22 and revised on 1/17/24, documented Resident #2 had a diagnosis of depression. It indicated to monitor for the following: depressed mood, crying or tearful, self-isolation, appetite changes, and/or feeling bad about herself. The interventions, which had not been revised since 10/9/22, documented arranging for a psych consult, following up as indicated encouraging the resident to express her feelings and give her time to talk, providing adequate rest periods, encouraging and reminding the resident to rest throughout the day, providing re-positioning, offering a snack/drink, redirecting the resident to an activity, offering independent activity supplies, offering to call a loved one, assist outside sit with resident as needed, providing active listening and validation and monitoring/documenting/reporting any signs and symptoms of depression.-The care plan did not address Resident #2's PHQ-9 score increased since February 2024 from two (no or minimal depression) to seven (mild depression) on 8/26/24. It did not address the resident's recent statement of being ready to die and referral to psychiatric services, nor any identified behaviors of depression or triggers for depression. III. Staff interviewsThe social services director (SSD) and the director of nursing (DON) were interviewed together on 9/4/24 at 3:40 p.m. The SSD said PHQ-9's were completed for every resident every quarter, annually and as needed by the social services department. She said the PHQ-9 score determined if a resident was offered psychological services. The SSD said upon completion of the PHQ-9, the social worker reviewed the potential need for psychological services and ensured the referral was provided. She said social services was responsible for developing the mood and behavior care plan. The SSD said the care plan should be reviewed and updated every quarter, annually and as needed with signs and symptoms of depression. She said any changes in a resident's mood or behavior should be updated on the care plan. The SSD said Resident #2 was admitted to the facility for rehabilitation, however ended up staying under long-term care. She said the resident had difficulty adjusting at first, but made a male friend who she spent a lot of time with. The SSD said Resident #2 had noted depression and had recently been referred to a counselor and psychiatrist. The SSD said she was not aware Resident #2's PHQ-9 had been increasing which indicated the resident had worsening depression. She confirmed the care plan had not been updated with Resident #2's worsening depression or recent statement of wanting to die. The SSD confirmed the facility did not have any documentation indicating the resident had received additional psychosocial support through her worsening depression, other than a referral to psychological services. The SSD confirmed the care plan documented in the resident's medical record documented that the resident was taking the antidepressant Lexapro. The SSD said Resident #2 was no longer prescribed Lexapro, but was instead prescribed Zoloft.
Plan of correction
The state did not require a plan of correction for this citation.
6/17/2024Complaint Survey · ID KZEW11No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A complaint survey, prompted by #CO36340 was conducted on 6/17/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
2/13/2024Revisit: Recertification Survey · ID O9I912No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 2/13/24 for all previous deficiencies cited on 11/30/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
2/1/2024Revisit: Recertification Survey · ID O9I922No deficiencies▼
0000INITIAL COMMENTSSurveyor note▼
Findings
A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.
Plan of correction
The state did not require a plan of correction for this citation.
12/19/2023Recertification Survey · ID O9I9211 deficiency▼
0000INITIAL COMMENTSSurveyor note▼
Findings
The Colorado Department of Public Health and Environment conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID prefix Tag # K 000) are informational and a representation of the facility's general characteristics. The facility consist of a two story limited combustible structure, Type II (111) construction, with a partial basement used for support services and is not used by residents. Basement has a 2 hour occupancy separation from the parking garage. The facility is classified as fully protected by a National Fire Protection Agency (NFPA) 13 automatic wet and dry fire sprinkler systems. Sprinkler system coverage- does not include protection of the concealed attic space, which will not be used for storage. NOTE: the facility has chosen not to provide sprinkler coverage to the exterior patios with non- combustible overhangs that extended over 4-ft. from the building. Those areas are not to be allotted to be used for combustible items and/ or storage; and if at any time in the future, these unprotected ares are found to be used for combustible items, to include but not be limited to, picnic tables, furniture, chairs, tables, BBQ grills, etc ..., the area shall be required to be equipped with fire sprinkler coverage. The survey was conducted on December 19, 2023 for compliance to fire safety requirements of NFPA 101, Life Safety Code (lSC), 2012 edition, Chapter 19 for Existing Health Care Occupancies. It was reported that there was a census of 107 residents at the time of survey. The facility is currently licensed for 116 beds.
Plan of correction
The state did not require a plan of correction for this citation.
0914Electrical Systems - Maintenance and TestingS/S F▼
Findings
Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the maintenance director at the exit conference.
Plan of correction · submitted by the facility
How the community will accomplish corrective action for those residents affected by deficient practice? Immediately upon being notified of the deficient practice, NHA and Building Ops Director ordered the correct tool needed for testing. Will complete annually per regulation beginning upon arrival of tool. How the community will identify other residents with the potential to be affected by the same deficient practice? What other residents are potentially impacted by this – How do you know? All residents have the potential to be affected by this deficient practice. As such, all resident outlets will be inspected to ensure compliance. What measures will be put into place or systemic changes will be made to ensure the deficient practice will not reoccur? What can you do to make sure this doesn’t happen again? An tool has been created and added to our maintenance inspection book to track the annual inspections. How the community plans to monitor its performance to make sure that the solutions work and are sustained: Answering the questions below – how will you know if your measures are working?Exactly How and What will be reviewed as part of the monitoring? An audit has been started to ensure that compliance is being met. The number of residents included in the monitoring: This citation specifically does have the potential to affect all residents if education and practices are not followed properly. How often (frequency) of the monitoring? Annually. Any issues noted in between will also be brought to our daily stand up or stand down meeting to be addressed. How / where are you going to document that the monitoring was completed? Polarity Retention Tool has been created to track the measurements of each resident outlet. How long will you monitor (minimum of 3 months) Completed for the year. Will continue to monitor annually. How are you going to include this in the QAPI process Progress will be monitored annually per regulation and will be discussed in our regularly held QA meeting. Any issues observed will be discussed and interventions put into place. When will the corrective action be completed? Completed 12/22/2023
Reportable Occurrences
41 records5/29/2026Neglect · ID 26020517016Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/29/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. The client’s family reported concerns with the following not working or not being provided: call light, oxygen humidifier, toenail care, medications, and response to altered mental status. During the course of the investigation, the healthcare entity assessed the client, conducted interviews, audited call logs, and reviewed records. The client was found with long toenails which were trimmed and no visible injuries or evidence of harm. The client indicated they had no concerns with the care they received from the facility. Record review showed one instance of the client’s call light not working, staff initiated frequent monitoring until the call light was fixed two hours later. Interviews revealed the client’s oxygen concentrator had a built in humidifier therefore a separate humidifier was not required. Record review showed the client received all regularly prescribed and as needed medications. Additionally, record review showed one instance of an altered mental status, staff identified the concern and acted promptly to obtain assistance. The facility assisted the client to relocate out of state with their family and audited all clients to ensure continued safety. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/24/2026 · released to the public 7/31/2026.
5/13/2026Physical Abuse · ID 26020517014Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/14/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. The client reported four unidentified women dragged them out of bed, threw him on the floor, and hit and kicked him. During the course of the investigation, the healthcare entity notified law enforcement, assessed the client, conducted interviews, and initiated increased safety monitoring. The client had no new visible injuries and no signs of trauma. The client’s descriptions of the alleged assailants varied and did not match any staff members in the facility. Record review showed the client had a history of hallucinations and was undergoing a medication adjustment at the time the event was reported. The facility completed a medication review and notified the medical provider of the event. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/13/2026 · released to the public 7/20/2026.
4/24/2026Misappropriation of Property · ID 26020517013Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/24/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. After returning from a hospital stay the client reported a missing ring. During the course of the investigation, the healthcare entity reviewed records, conducted a search and interviews. The client’s spouse reported they brought the ring from home and placed it on the client’s finger while they were at the hospital. Staff reported they had never seen the ring in the client’s room or on their finger. Record review showed the family declined to fill out an inventory record at the time of admission. The facility did not find any evidence of the ring was ever in the facility. The facility educated the client regarding avoiding bringing valuables to the facility and the benefit of completing inventory documentation. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/16/2026 · released to the public 7/23/2026.
3/18/2026Neglect · ID 26020517011Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/20/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. Reportedly, staff #1 fell asleep on their shift and did not provide care to the client. During the course of the investigation, the healthcare entity suspended staff, reviewed records, and conducted interviews. Interviews with clients indicated they received proper care according to their needs and requests. Assessments of the clients revealed no injuries or harm. Staff #1 denied the allegation and indicated that on occasion during their scheduled break they take a nap. Record review showed no lapse in care or supports provided. The facility found no information to support the allegations. Education was provided to all staff and staff #1 returned to work. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 6/11/2026 · released to the public 6/18/2026.
3/15/2026Sexual Abuse · ID 26020517008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/16/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. The client reported staff #1 attempted to touch them in an inappropriate way. During the course of the investigation, the healthcare entity notified law enforcement, suspended staff, conducted interviews, and assessed the client. An assessment did not reveal any evidence of injury or trauma. Staff #1 denied the allegation and reported they entered the room when the client pressed their call light and provided care with no concerns. Record review revealed the client suffered from previous sexual assault trauma and cognitive impairment. The facility updated the care plan to have only same sex caregivers and educated staff. The facility did not find any evidence to support the allegations. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/15/2026 · released to the public 6/22/2026.
3/14/2026Misappropriation of Property · ID 26020517009Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/16/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. The client reported they gave their debit card to a family member who then stole thousands of dollars from them. During the course of the investigation, the healthcare entity conducted interviews, notified law enforcement and adult protection services, and contacted the bank. The client reported the family member had a history of stealing from the client. The facility helped the client to secure a new bank account. Law enforcement and Adult Protective Services conducted their own investigations. The facility was unable to determine if money was stolen from the client. The client has since passed away. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 4/29/2026 · released to the public 5/6/2026.
3/11/2026Neglect · ID 26020517010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/18/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. Reportedly, staff did not answer call lights for extended periods of time causing delayed incontinence care resulting in sores near the clients lower back and private areas. During the course of the investigation, the healthcare entity conducted interviews, assessed the client, reviewed call light logs, and started increased safety monitoring. The client was found to have mild redness on their private area and back but no open wounds. Interviews and records showed consistent incontinence care which included barrier cream to prevent skin breakdown. Record review showed the client experienced frequent delusions and had recently been refusing medications. Call light record review revealed call lights were answered within a time frame that met facility expectations. The facility verified all orders related to repositioning and incontinence support and documented the client’s current status by way of photos that were uploaded to the medical records. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 6/16/2026 · released to the public 6/23/2026.
2/25/2026Neglect · ID 26020517006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/25/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. Reportedly, when staff transferred the client, their feet did not pivot, causing pain to their ankle. During the course of the investigation, the healthcare entity suspended staff, conducted interviews, and assessed the client. The client’s ankle sustained soft tissue swelling and the client received medication for pain. Both staff members indicated they entered the room to assist the client to the restroom and offered to use the mechanical lift to transfer the client. The client refused the lift so the staff members used a two person assist to transfer the client. The facility determined staff did not follow the client’s care plan which required the use of a mechanical lift. The facility educated all staff regarding following the care plan and what to do when clients refuse care. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 5/28/2026 · released to the public 6/4/2026.
1/18/2026Physical Abuse · ID 26020517004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 1/20/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, staff #1 slapped the client’s hand/arm when the client was attempting to grab a bar to reposition. During the course of the investigation, the healthcare entity notified law enforcement, suspended staff, assessed the client, and conducted interviews. The client did not sustain any visible injures. Staff denied the allegations and reported the interactions with the client had all been positive. The facility removed staff #1 from the client’s care team and provided increased monitoring to the staff member. The facility did not find any information to support the allegations. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 5/13/2026 · released to the public 5/20/2026.
1/2/2026Neglect · ID 26020517003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 1/5/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. Reportedly, staff #1 delayed calling for emergency services when the family suspected the client had a stroke. During the course of the investigation, the healthcare entity suspended staff, conducted interviews, reviewed records, and assessed the client. Hospital records indicated a suspected stroke but due to delay in being sent to the hospital the client was unable to receive stroke protocol treatment at the hospital. The family reported they notified staff #1 in the morning about the symptoms, staff #1 assessed the client and indicated they would continue to monitor but did not call emergency services. The family reported the client was sent to the hospital over four hours after their initial report to staff #1. Staff #1 indicated they did not receive a report from family until early afternoon and their assessment did not indicate an immediate need for emergency services. The facility was unable to determine if staff #1 conducted their assessment of the client appropriately. The facility educated all staff regarding timely care and client safety, staff #1 ultimately resigned. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 5/11/2026 · released to the public 5/18/2026.