LIFE CARE CENTER OF COLORADO SPRINGS

A complaint survey, prompted by #CO2961700 was conducted on 3/25/26 to 3/26/26. No deficiencies were cited.

A survey with #CO2961701 was completed on 3/25/26 to 3/26/26. No deficiencies were cited.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a). The facility is two-story, Type V (111), construction with a partial lower level.. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinklered. The facility was constructed in 1996 and is licensed for 121 beds. This re-certification survey, conducted March 24, 2024, was for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". All deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

Based on document review, observation, and staff interview, it was determined that the facility failed to arrange and maintain fire barriers in accordance with Life Safety Code NFPA 101 (12) Facility, unable to provide life safety plans for review. Life safety plans are needed to verify construction type and smoke barrier boundaries for “defend in place.”Fire Barriers within the facility need to be corrected with listed repairs | "California Patches" observed on the wall during the surveyCeiling tiles in the basement storage room need to be replaced. Regulatory Guidelines: NFPA 101 (12)4.6.12 Maintenance, Inspection, and Testing. 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 4.2 Objectives. 4.2.1 Occupant Protection. A structure shall be designed, constructed, and maintained to protect occupants who are not intimate with the initial fire development for the time needed to evacuate, relocate, or defend in place. 4.2.2 Structural Integrity. Structural integrity shall be maintained for the time needed to evacuate, relocate, or defend in place occupants who are not intimate with the initial fire development. NFPA 101: 8.2.3.1*The fire resistance of structural elements and building assemblies shall be determined in accordance with test procedures set forth in ASTM E 119, Standard Test Methods for Fire Tests of Building Construction and Materials, or ANSI/UL 263, Standard for Fire Tests of Building Construction and Materials; other approved test methods; or analytical methods approved by the authority having jurisdiction. NFPA 101: 8.3.5.1* Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly. This deficiency has the potential to affect all residents within the entire facility. Deficient items were discussed with the administrator and the facility maintenance department at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code NFPA 101 (12) 15-second signage is needed on the egress door by the conference room and the door leading downstairs by the elevatorThe egress door alarm needs to be repaired for the door leading down stairs by elevator7.2.1.6.1 Delayed-Egress Locking Systems. 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (1)The door leaves shall unlock in the direction of egress upon actuation of one of the following:(a)Approved, supervised automatic sprinkler system in accordance with Section 9.7(b)Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6(c)Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6 (2)The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism. (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions:(a)The force shall not be required to exceed 15 lbf (67 N).(b)The force shall not be required to be continuously applied for more than 3 seconds.(c)The initiation of the release process shall activate an audible signal in the vicinity of the door opening.(d)Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only.(4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:PUSH UNTIL ALARM SOUNDSDOOR CAN BE OPENED IN 15 SECONDS (5)The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9. This deficiency has the potential to affect approximately 20 residents within the entire facility. Deficient items were discussed with the maintenance team at the exit conference.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the resident corridor doors in accordance with Life Safety Code NFPA 101 (12) Rooms 302 and 223 need seals replaced | Doors do not resist the passage of smoke NFPA 10119.3.6.3* Corridor Doors. 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:1 3/4 in. (44 mm) thick, solid-bonded core wood Material that resists fire for a minimum of 20 minutesThis deficiency has the potential to affect approximately 10 residents within the entire facility. Deficient items were discussed with the maintenance team at the exit conference.

The facility had multiple items in the egress path. Items were removed during suryvey facility was reminded to ensure egress paths are maintained.

A recertification survey with complaint #CO2703224 was completed on 2/23/26 to 2/26/26. Four deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/23/26 to 2/26/26. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure one (#18) of three residents reviewed for accidents out of 44 sample residents received adequate supervision to prevent accidents. Resident #18 was admitted to the facility on 11/21/25 with diagnoses of traumatic subdural hemorrhage (bleeding near the brain) with loss of consciousness status unknown, seizures, generalized muscle weakness, cognitive communication deficit, unspecified dementia and history of falls. Resident #18 was identified as a high fall risk. On 11/26/25, Resident #18 sustained an unwitnessed fall. The facility recommended implementing care plan interventions which included a call light within reach, orienting Resident #18 to his room, assisting the resident with activities of daily living (ADL), keeping the resident’s bed in the lowest position, floor mats to side of the resident’s bed and offering Resident #18 frequent toileting. -However, observations during the survey revealed the resident’s bed was not in the lowest position and the fall mats were not at the resident's bed side. Resident #18 sustained an additional unwitnessed fall on 12/9/25, where he hit his forehead and jaw. The resident was transferred to the hospital and received glue to his forehead laceration. Upon return from the hospital, the facility recommended implementing a personal urinal to be within reach of the resident at all times. -However, observations during the survey revealed the resident did not have his personal urinal within reach. Specifically, the facility failed to ensure person-centered fall interventions were consistently implemented for Resident #18, who sustained multiple falls, including a fall with injury that required transport to the hospital for treatment of a forehead laceration. Findings include: I. Facility policy and procedureThe Fall Management policy, revised 3/11/25, was provided by the director of nursing (DON) on 2/26/26 at 2:16 p.m. It revealed in pertinent part, “The facility will assess the resident upon admission, readmission, quarterly, with change in condition, and with any fall event for any fall stocks and will identify appropriate interventions to minimize the risk of injury related to falls.“Fall refers to unintentionally coming to rest on the ground, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. “Risk refers to any external factor, facility characteristic (staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident.“Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed.. This determination is based on the individual resident’s assessed needs and identified hazards in the residents environment.”II. Resident #18A. Resident statusResident #18, age greater than 65, was admitted on 11/21/25. According to the February 2026 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage with loss of consciousness status unknown, seizures, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and a history of falling. The 1/14/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS)score of 14 out of 15. He required partial/moderate assistance with most of his activities of daily living (ADL). The MDS assessment revealed the resident had difficulty with focusing his attention. The behavior was present but fluctuated during the assessment look-back period. The MDS assessment revealed the resident had two or more falls without injury and one fall with injury since his time of admission to the facility. B. Observations On 2/24/26 at 2:54 p.m. Resident #18 was sitting in his wheelchair in his bedroom. Resident #18 was leaning forward out of his wheelchair, reaching towards the ground. Resident #18 began resting his head on the tray table in front of him. Resident #18's body began to fall forward out of the wheelchair and his legs began to buckle. Registered nurse (RN) #4 was sitting directly across the hallway at the nurses’ station from Resident #18’s room, however, she was not paying attention to Resident #18. At 2:56 p.m., upon prompting, RN #4 entered Resident #18's room and asked Resident #18 what he was doing. Resident #18 said he was trying to throw something away. Resident #18 was still bent forward out of his wheelchair. RN #4 had to physically intervene to assist Resident #18 back to an upright and safe sitting position. RN #4 provided a verbal reminder and educated the resident on the importance of using his call light when he needed help in his room. Resident #18 said he wanted to lay down. RN #4 told Resident #18 she would go find some certified nurse aides (CNA) to help assist him back into bed. RN #4 placed the resident's oxygen back on him and pushed the call light, remaining with the resident. At 2:59 p.m. CNA #11 answered Resident #18's call light. RN #4 told CNA #11 Resident #18 wanted to lay down and instructed CNA #11 to stay with the resident while she went to get a sit-to-stand lift. CNA #12 was coming down the hall and RN #4 asked her to assist them with Resident #18’s transfer from his wheelchair to his bed. On 2/26/26 at 2:06 p.m. Resident #18 was sleeping in his bed. Resident #18’s bed was not in the lowest position, his floor mats were not in place by the bed and his personal urinal was not within reach. -However, Resident #18’s care plan revealed his bed was to be in the lowest position, his personal urinal was to be within reach at all times and the floor mats were to be placed at the bed side to prevent Resident #18 from falling (see record review below). C. Record review 1. Care plan The fall care plan, revised 12/10/25, identified Resident #18 was at risk for falls related to impaired mobility, history of falls, impaired vision, seizures and psychotropic medication use (medications that affect behavior, mood, thoughts, or perception). Pertinent interventions (revised 12/10/25), included ensuring the resident’s call light was within reach, assisting the resident with ADLs as needed, providing adaptive equipment or devices as needed, completing a fall risk assessment and orienting the resident to his room. The actual fall care plan, revised 1/23/26, identified Resident #18 had multiple falls since his time of admission, with one fall resulting in an injury. Pertinent interventions (revised 1/23/26), included ensuring the resident’ bed was in the lowest position at all times (initiated 11/28/25), clipping the call light onto the resident’s clothing within his reach and vision, encouraging the resident to use the urinal for urgent episodes, ensuring the resident’s personal urinal was within reach at all times, placing floor mats to the sides of the bed, providing a lipped mattress and moving the resident to a room directly across from the nurses station-However, observations revealed person-centered fall interventions were not consistently implemented for Resident #18 (see observations above). 2. Fall on 11/22/25 - unwitnessed The 11/22/25 nursing progress note, documented at 1:45 p.m., revealed Resident #18 was found on the bathroom floor. Resident #18 was on the floor in the middle of the bathroom sitting upright. Resident #18 did not complain ofpain and no apparent injuries were assessed by the RN. Root cause analysis was related to gait imbalance and a new intervention was implemented to offer Resident #18 frequent toileting. 3. Fall on 11/24/25 - witnessed The 11/24/25 nursing progress note, documented at 1:47 p.m., revealed Resident #18 was attempting to walk with his friend. The occupational therapist (OT) assisted the resident to the floor and notified the RN. Resident #18 was wearing his personal clothing with his shoes on. Resident #18 was educated by the RN and the OT about supervised walking with authorized personnel only and safe transferring. A CNA said she had also educated the resident on this prior to the witnessed fall. No injuries were assessed.-The progress note did not indicate what the root cause of the fall was or if the resident’s fall interventions were reviewed to determine if the interventions were effective or if a new fall interventions were needed. 4. Fall on 11/26/25 - unwitnessedThe 11/26/25 nursing progress note, documented at 8:09 p.m., revealed Resident #18 was seen by the nurse at 5:00 p.m. sitting in his wheelchair watching television. The director of nursing (DON) was walking past and saw Resident #18 had his call light on. The DON walked in to the resident’s room and found Resident #18 sitting on the floor with his legs facing the sink and his wheelchair behind him. Resident #18 said he was trying to get his cell phone off the charger so he could put it away in the dresser drawer. Resident #18 was wearing non-skid socks at the time of the fall. The call light was pulled out of the wall socket and on the floor. The nurse completed the initial assessment with no obvious injuries and Resident #18 denied any pain. Resident #18 was assisted back into his wheelchair.-The progress note did not indicate what the root cause of the fall was or if the resident’s fall interventions were reviewed to determine if the interventions were effective or if a new fall interventions were needed. 5. Fall on 12/1/25 - unwitnessedThe 12/1/25 nursing progress note, documented at 1:30 a.m., revealed Resident #18 was found on the floor in his room. Resident #18 said he rolled out of bed. Resident #18 said he did not hit his head and he landed on the fall mat. No pain was noted and the nurse completed an assessment before assisting the resident from the floor. Resident #18 was repositioned and changed in bed. The wedges and fall mats were put in place on both sides of the resident. The bed was placed in the lowest position and the resident’s call light was within reach. -The progress note did not indicate what the root cause of the fall was or if the resident’s fall interventions were reviewed to determine if the interventions were effective or if a new fall interventions were needed. 6. Fall on 12/6/25 - unwitnessed The 12/6/25 nursing progress note, documented at 3:15 a.m., revealed Resident #18 was found sitting on the floor. The resident said he fell from the low bed. Resident #18 was assessed for injury and none were noted. Root cause analysis determined the cause of the resident’s fall was toileting urgency due to a possible urinary tract infection (UTI). A urine sample was collected to verify a UTI and was sent out to validate. The 12/5/25 nursing progress note, documented at 7:09 p.m., revealed a stat (immediate) urinary analysis (UA) was collected from Resident #18 via clean catch. The urine sample was in the dirty utility refrigerator awaiting laboratory (lab) pickup. The lab was notified by the charge nurse on duty. 7. Falls on 12/9/25 (two falls) - one witnessed fall and one unwitnessed fallThe 12/9/25 nursing progress note, documented at 2:17 p.m., revealed Resident #18 attempted to get out of his bed unassisted. Resident #18 was seen by the OT as he fell onto his right elbow without hitting his head. Resident #18 reported a 1 out 10 for pain to his right elbow. A head to toe assessment was performed and no injuries were noted. The nurse educated Resident #18 again, regarding the importance of calling for assistance. Resident #18 verbalized his understanding. Staff assisted the resident to the toilet before returning to bed. The 12/9/25 nursing progress note, documented at 7:24 p.m., revealed a loud thud was heard from Resident #18’s room around 6:40 p.m. by surrounding staff. The CNA notified the nurse Resident #18 was bleeding. The RN walked over and saw the resident on the floor with his back towards the wall adjacent to the door with his feet towards the bathroom door. Resident #18 was attempting to sit up. Resident #18 was wearing his personal clothing and personal shoes. Blood was observed coming from the resident’s right side of his face and top of his scalp. Resident #18 said he was attempting to empty his urinal and wanted to clean the mess up himself. No mess described by the resident was observed on the floor surrounding Resident #18. It was possible the resident mistook making a mess as he used a different urinal provided by his friend that evening and Resident #18 had impaired vision. Resident #18 did not utilize his call light for assistance. The resident was assessed by the nurse and then assisted by staff back into his wheelchair. Resident #18 was assessed for injuries after clearing away blood. The resident's right side of his forehead revealed a laceration, as well as a laceration to the right side of his jaw. Resident #18 said he had a 2 out of 10 for pain. Resident #18 was sent out to the hospital for evaluation and treatment. The resident required stitches and imaging for his head. 8. Fall 12/10/25 - unwitnessed The 12/10/25 nursing progress note, documented at 10:17 p.m., revealed Resident #18 was found in bed but called the staff to alert them that he had slid from the bed and gotten himself back into bed. Resident #18 denied hitting his head, experiencing any new pain, or new injuries. The resident was assessed by the nurse. During the resident’s neurological assessment, the nurse discovered Resident #18’s heart rate and blood pressure were changing dramatically, and Resident #18 was having increased slurred speech. The nurse practitioner (NP) was present at the facility and evaluated the resident. An physician’s order was placed to send Resident #18 to the hospital for further evaluation. Resident #18 was determined to be stable and sent back to the facility. 9. Fall 12/16/25 - unwitnessed The 12/16/25 nursing progress note, documented at 9:47 a.m., revealed Resident #18 sustained a fall while in the shower room. The nurse was alerted by a staff member and came to assess the resident. Resident #18 did not have any visible injuries and was alert and oriented. The resident said he was reaching to turn the water off and slid out of the shower chair onto the floor landing on his buttocks. Resident #18 was educated on the importance of asking for assistance and not to reach for objects out of his immediate reach. Resident #18 was also educated about this earlier in his room and the resident verbalized understanding at that time. Resident #18 was assisted back into the shower chair and taken back to his room. The CNA giving Resident #18 a shower had left the shower room, leaving the resident unattended for a few minutes during the incident. The CNA was educated on the facility’s policy for leaving residents unattended during showers. The CNA verbalized understanding. -However during an interview with the DON (see interview below), it was revealed that Resident #18 should never be left alone in the shower room as he was a high fall risk and required high supervision to ensure the resident’s safety. 10. Fall 12/31/25 - unwitnessedThe 12/31/25 nursing progress note, documented at 7:43 p.m., revealed Resident #18 was seen 10 minutes prior to his fall sitting in his wheelchair eating dinner. The resident had finished eating his dinner and wanted to get into bed. Resident #18 could not find his call light. The call light had fallen behind the left side of his wheelchair arm rest and was wrapped around the wheel. Resident #18 was wearing non-skid socks but the socks did not grip the floor to help with traction, and the resident fell to his buttocks. The bed was to the resident’s left and the wheelchair was on his right. Resident #18 denied any injury or pain. Resident #18 said he was looking for the call light to call for help. The nurse assessed Resident #18 and determined no injuries were noted at this time. The resident was assisted to bed, ensuring the call light was clipped to the resident’s shirt. Resident #18 was educated on safety awareness and calling for assistance. 11. Fall 1/19/26 - unwitnessedThe 1/19/26 nursing progress note, documented at 6:36 p.m., revealed the nurse was notified by a CNA that Resident #18 was on the floor. The nurse went into the resident’s room to assess the resident and Resident #18 was found in the bathroom with his back leaning against the wall. The resident was wearing long sleeves, a sweater, non-skid shoes, and his brief and sweatpants were around Resident #18’s knee’s. The resident said he was transferring from the toilet to the wheelchair without staff assistance and slipped when the wheelchair was not locked. A head to toe assessment was performed and no visible injuries were noted. The resident denied pain or injuries at the time of the assessment. Resident #18 was transferred back to his wheelchair. The call light was clipped to the resident. III. Staff interviews CNA #7 was interviewed on 2/26/26 at 9:08 a.m. CNA #7 said Resident #18 was very impulsive when he first arrived at the facility. CNA #7 said the resident was falling all the time; however, Resident #18 had not been falling as much lately. CNA #7 said Resident #18 had been declining recently and he was unable to stand on his own currently CNA #7 said some interventions for Resident #18 would be to keep close supervision on him. CNA #7 said if she saw Resident #18 trying to get up out of his wheelchair, she would ask the resident if he needed assistance with something. CNA #7 said up until recently, Resident #18 was good at communicating his needs. CNA #7 said if she saw Resident #18 put his feet out of the bed or if he put a leg out, that was a good indicator the resident needed to use the bathroom. CNA #7 said the resident was not on a toileting schedule, but said when she was working she toileted Resident #18 every two hours. The DON was interviewed on 2/26/26 at 2:16 p.m. The DON said accidents and hazards were defined by choking, falls with major injury, elopements, burns, leaving the facility against medical advice, and abuse and neglect. She said, depending on the incident, the procedure would be for the nurses to begin documentation by immediately completing a risk assessment. She said if the event was witnessed, then staff were to take statements from the resident and anybody else involved. The DON said making necessary notifications to the provider and family would be next as part of the investigation process. The DON said the root cause analysis of an incident was important because it helped to determine the cause of the incident and how to treat immediately to ensure the incident did not happen again. The DON said the facility put a lot of interventions in place to prevent Resident #18 from falling. The DON said Resident #18 was very impulsive due to his diagnoses. The DON said Resident #18 scored high on his BIMS assessment; however, his safety awareness was not present. The DON initially recalled the CNA was in the shower room with the resident at the time of the 12/16/25 fall. However, once she reviewed the 12/16/25 event progress note, the DON discovered that the CNA had left Resident #18 alone in the shower room. The DON confirmed the CNA was outside of the shower room for a few minutes. The DON said a resident was allowed, per the facility policy, to be left alone in the shower room only if a resident was alert and oriented. She said an alert and oriented resident did not have to be attended in the shower room, but staff was to check on the resident every five minutes. The DON said the CNA was educated on 12/16/25 by the RN. The DON said a resident with a diagnosis of high falls should not be unattended in the shower room. The DON said post-fall, the RN on duty should complete the head to toe assessment (skin, pain, fall, neuro’s if the fall was unwitnessed) before doing anything else with the resident. The DON said the nurses should document this in a progress note. The DON said the licensed practical nurses (LPN) could complete the initial assessment of the fall, but the RN had to be the one who completed the head to toe assessment. The DON said on the days Resident #18 had multiple falls, there was nothing more the facility could do, and the DON said she started calling staff to come and provide one-to-one supervision with Resident #18. The DON said that was why there was a significant decrease in his falls after 12/10/25. The DON said the resident’s family also hired a private sitter to come in and sit with Resident #18 on the days the resident’s wife could not make it or family and friends were not available. The DON said the facility attempted to offer Resident #18 a soft helmet and busy board, but his wife did not want either of those for dignity reasons. The DON said the facility arranged an appointment for the resident to see the neurological ophthalmologist. The DON said Resident #18 was complex and not appropriate for this setting. The DON said Resident #18’s entire frontal lobe had been compromised and the resident was very impulsive as a result. The DON said residents had a right to fall and the facility had an obligation to try to keep the residents as safe as possible. The DON said the facility completed a high risk audit on all the residents that were high fall risks. She said the environmental audits were completed by the DON or unit manager. The DON said on grand rounds they asked staff who they thought was going to fall next, and any concerns about residents falling. The DON said CNAs could find a resident’s fall interventions on the Kardex (comprehensive care tool. The DON said RNs would find interventions on the residents’ care plans. The DON said CNAs did walking rounds, and fall huddles were done with all the staff. The DON said she created a fall binder back in December 2025 after the high volume of falls. The DON said the binder was placed at each nurses’ station. She said the binder included a fall checklist which was a packet that each RN was to complete after a fall and give to the DON. The DON said the fall packet included a fall checklist, neurological assessment forms, resident and RN sign offs for interventions and education, and witness interview forms. The nursing home administrator (NHA) was interviewed on 2/26/26 at 6:45 p.m. The NHA said he was aware of Resident #18 being a high fall risk. The NHA said Resident #18 had a right to fall but he said he also knew the facility had a responsibility to ensure Resident #18’s safety. The NHA said he was aware of Resident #18’s impulsivity.

Based on observations and interviews the facility failed to ensure all drugs and biologics used in the facility were properly stored and labeled for one of four medications carts reviewed for storage and labeling. Specifically the facility failed to ensure over the counter (OTC) medications were discarded after the expiration date. Findings include:I. Facility policy and procedureThe House Stock Items policy, revised 9/15/24, was provided by the director of nursing (DON) on 2/25/26 at 4:05 p.m. It read in pertinent part,“The facility should post the house stock medication list in an appropriate location such as medication rooms or a medication administration binder. “The facility should ensure that house stock medications are stored in the original manufacturer's container. The medication name, strength, expiration date and lot number should be clearly visible.”II. ObservationsOn 2/24/26 at 5:01 p.m. the medication cart on the 300 east hall was observed with licensed practical nurse (LPN) #4. The following items were found:A bottle of OTC CoQ10 100 milligrams (mg) supplement had a manufacturer's expiration date of 1/24/26. A bottle of OTC Calcium 500 mg had a manufacturer’s expiration date of 1/30/26. A bottle of OTC Acetaminophen 500 mg had a manufacturer’s expiration date of 12/30/25. III. Staff interviewsRegistered nurse (RN) #4 was interviewed on 2/24/26 at 4:50 p.m. RN #4 said she had worked at the facility for approximately two years. She said she was trained to write the date of when the OTC medications were opened. She said she was trained by the facility to discard the OTC medications three months after the open date that was written on the bottle. LPN #4 was interviewed on 2/24/26 at 5:01 p.m. LPN #4 said she was unsure of whether OTC medications expired 30 days after opening or according to the manufacturer’s expiration date on the bottle. She said she did not know where to locate the OTC storage and expiration policy for the facility. She said she was unsure why nursing staff were writing the open date on the OTC medication bottles. She said if the expiration date on the manufacturer's bottle had passed then the medication should be discarded. The director of nursing (DON) was interviewed on 2/24/26 at 5:38 p.m. The DON said the nursing staff were expected to reference the manufacturer's date on the OTC medication bottles. She said all the nurses were trained by other bedside nursing staff. She said the facility did not provide any specific training on medication expiration dates of medications, whether the medications were from the pharmacy or OTC medications. The DON said all nursing staff should be properly trained and demonstrate competency for nursing medication tasks prior to performing medication administration. The DON said this was important to maintain resident safety. She said expired medications should not be administered to residents for safety reasons because expired medications could make a resident very sick.

Based on observations, record review and interviews, the facility failed to meet all requirements for the provision of hospice care for one (#41) of two residents reviewed for hospice services out of 44 sample residents. Specifically, the facility failed to ensure hospice notes were readily accessible, the comprehensive care plan was developed with delineation of care responsibilities established between the facility and hospice and the most current care plan from hospice was available for Resident #41. Findings include:I. Facility policy and procedureThe Facility and Hospice Agreement, signed 11/30/17, was provided by the nursing home administrator (NHA) on 2/23/26 at approximately 3:00 p.m. It read in pertinent part, “Each party shall prepare and maintain complete and detailed clinical records concerning each hospice patient receiving hospice services under this agreement in accordance with its usual record-keeping procedures, and as required by applicable federal and state law and regulations and applicable Medicare and Medicaid program guidelines.“Each party shall retain such records as required by applicable federal and state law. Each such record shall document that the specified services are furnished in accordance with this agreement and shall be readily accessible and systemically organized to facilitate retrieval by either party, in accordance with federal and state patient privacy laws. “Hospice will document that hospice services are furnished in accordance with this agreement.”II. Resident #41A. Resident statusResident #41, age greater than 65, was admitted on 3/6/24. According to the February 2026 computerized physician’s orders (CPO), diagnoses included hypertensive heart disease (heart disease resulting from uncontrolled high blood pressure) with heart failure, palliative care and protein-calorie malnutrition. The 12/2/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively intact with a brief interview for mental status (BIMS) score of nine out of 15. Resident #41 used a wheelchair to ambulate and needed partial assistance with bathing. The MDS assessment indicated the resident was receiving hospice services. B. Record reviewReview of Resident #41’s February 2026 CPO revealed a physician’s order for hospice services, ordered 3/22/24. A review of Resident #41’s electronic medical record (EMR) revealed the most recent plan of care from the hospice services team was active from 9/19/25 to 11/17/25.-There was no current plan of care from the hospice services team in the resident’s EMR.A review of Resident #41’s hospice care plan, initiated 3/8/24, revealed the resident was receiving hospice services. Interventions included working cooperatively with the hospice team to meet Resident #41’s needs (revised 7/19/24).-Review of Resident #41’s EMR failed to reveal clinical documentation from the hospice service team’s routine visits to the resident. III. Staff interviewsRegistered nurse (RN) #2 was interviewed on 2/25/26 at 5:05 p.m. RN #2 said neither Resident #41’s physical chart nor the EMR had the most recent copy of the hospice services team’s care plan for the certification period starting 1/17/26. RN #2 said she was not surprised the hospice notes were not updated or in chronological order in the physical chart. RN #2 said the facility’s system for ensuring hospice was providing services was for the hospice staff to check in with the facility’s nurses or physician if they had any concerns about Resident #41. RN #2 said the hospice staff did not have to sign into the facility, and there was no system in place to ensure hospice staff fulfilled their weekly visits. RN #2 said all hospice certified nurse aides (CNA) came to the facility on Tuesdays and Thursdays and usually helped their residents with bathing at that time, but there was no formal system for hospice staff to chart or report what care they had provided for the residents. Licensed practical nurse (LPN) #3 was interviewed on 2/26/26 at 2:46 p.m. LPN #3 said she had seen the CNA from the hospice services company earlier in the day (2/26/26). LPN #3 said the hospice CNA checked in with her before she left for the day. LPN #3 said she had seen the hospice RN the day before (2/25/26). LPN #3 said she knew the hospice staff would see Resident #41 because the hospice staff would usually check in with her. LPN #3 said she did not check the physical chart for hospice visit notes for the resident, because the physical chart was more for the hospice team.-However, neither Resident #41’s electronic medical record (EMR) nor her physical chart had a visit note from either the hospice CNA or RN on 2/25/26 and 2/26/26 (see record review above). The director of nursing (DON) was interviewed on 2/26/26 at 3:32 p.m. The DON said the hospice services company was not good at communicating with the facility, but the facility was ultimately responsible for ensuring the hospice services company was providing services appropriately for the residents. The DON said the facility had been searching for other hospice services companies to work with.

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 diseases and infection on three of three units. Specifically, the facility failed to: -Ensure appropriate personal protective equipment (PPE) was worn by staff while providing care for Resident #11, Resident #9 and Resident #109, who were all on enhanced barrier precautions (EBP); and,-Staff performed appropriate hand hygiene during wound care for Resident #9. V. Resident #109A. ObservationsOn 2/25/26 at 1:56 p.m. RN #4 entered Resident #109’s room to give the resident a tube feeding through the resident’s feeding tube. -RN #4 was wearing gloves and a mask but did not put on a gown, prior to completing the resident’s tube feeding. On 2/25/26 at 3:51 p.m. there was no enhanced barrier precautions sign on the outside of Resident #9’s door. -However, on 2/26/25 at 10:12 a.m. Resident #109 had an EBP sign posted on the outside of her door. The sign revealed individuals were to stop before entering the room due to EBP. Anyone entering the room was to clean their hands before entering the resident’s room and when leaving the room. Providers and staff were required to wear gloves, and a gown for high contact resident care activities such as: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing brief or assisting with toileting, device care (tube feeding, central line, urinary catheter, and tracheostomy) and wound care. B. Staff interviewsRN #4 was interviewed on 2/26/26 at 9:16 a.m. . RN #4 said Resident #109 was not on EBP and that was why she did not wear a gown during the resident’s tube feeding. RN #4 referenced her computer charting to verify and again said Resident #109 was not on EBP.. The IP was interviewed on 2/26/26 at 9:40 a.m. The IP said the determinants for EBP included if the resident had any type of indwelling medical device, or MDRO infection. The IP said she was just made aware of Resident #109’s feeding tube and was getting ready to put the orders for EBP in, but it had been a busy week. The IP said the process for establishing EBP was determined at the time of a resident's admission. The IP said the facility’s admission team would inform her of an EBP and then she added it to the resident’s chart.

A survey, prompted by #CO2703225 and #CO2792960 was completed on 2/23/26 to 2/26/26. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure one (#18) of three residents reviewed for accidents out of 44 sample residents received adequate supervision to prevent accidents. Resident #18 was admitted to the facility on 11/21/25 with diagnoses of traumatic subdural hemorrhage (bleeding near the brain) with loss of consciousness status unknown, seizures, generalized muscle weakness, cognitive communication deficit, unspecified dementia and history of falls. Resident #18 was identified as a high fall risk. On 11/26/25, Resident #18 sustained an unwitnessed fall. The facility recommended implementing care plan interventions which included a call light within reach, orienting Resident #18 to his room, assisting the resident with activities of daily living (ADL), keeping the resident’s bed in the lowest position, floor mats to side of the resident’s bed and offering Resident #18 frequent toileting. -However, observations during the survey revealed the resident’s bed was not in the lowest position and the fall mats were not at the resident's bed side. Resident #18 sustained an additional unwitnessed fall on 12/9/25, where he hit his forehead and jaw. The resident was transferred to the hospital and received glue to his forehead laceration. Upon return from the hospital, the facility recommended implementing a personal urinal to be within reach of the resident at all times. -However, observations during the survey revealed the resident did not have his personal urinal within reach. Specifically, the facility failed to ensure person-centered fall interventions were consistently implemented for Resident #18, who sustained multiple falls, including a fall with injury that required transport to the hospital for treatment of a forehead laceration. Findings include: I. Facility policy and procedureThe Fall Management policy, revised 3/11/25, was provided by the director of nursing (DON) on 2/26/26 at 2:16 p.m. It revealed in pertinent part, “The facility will assess the resident upon admission, readmission, quarterly, with change in condition, and with any fall event for any fall stocks and will identify appropriate interventions to minimize the risk of injury related to falls.“Fall refers to unintentionally coming to rest on the ground, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. “Risk refers to any external factor, facility characteristic (staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident.“Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed.. This determination is based on the individual resident’s assessed needs and identified hazards in the residents environment.”II. Resident #18A. Resident statusResident #18, age greater than 65, was admitted on 11/21/25. According to the February 2026 computerized physician orders (CPO), diagnoses included traumatic subdural hemorrhage with loss of consciousness status unknown, seizures, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and a history of falling. The 1/14/26 facility assessment revealed the resident was cognitively intact. He required partial/moderate assistance with most of his activities of daily living (ADL). The facility assessment revealed the resident had difficulty with focusing his attention. The behavior was present but fluctuated during the assessment look-back period. The facility assessment revealed the resident had two or more falls without injury and one fall with injury since his time of admission to the facility. B. Observations On 2/24/26 at 2:54 p.m. Resident #18 was sitting in his wheelchair in his bedroom. Resident #18 was leaning forward out of his wheelchair, reaching towards the ground. Resident #18 began resting his head on the tray table in front of him. Resident #18's body began to fall forward out of the wheelchair and his legs began to buckle. Registered nurse (RN) #4 was sitting directly across the hallway at the nurses’ station from Resident #18’s room, however, she was not paying attention to Resident #18. At 2:56 p.m., upon prompting, RN #4 entered Resident #18's room and asked Resident #18 what he was doing. Resident #18 said he was trying to throw something away. Resident #18 was still bent forward out of his wheelchair. RN #4 had to physically intervene to assist Resident #18 back to an upright and safe sitting position. RN #4 provided a verbal reminder and educated the resident on the importance of using his call light when he needed help in his room. Resident #18 said he wanted to lay down. RN #4 told Resident #18 she would go find some certified nurse aides (CNA) to help assist him back into bed. RN #4 placed the resident's oxygen back on him and pushed the call light, remaining with the resident. At 2:59 p.m. CNA #11 answered Resident #18's call light. RN #4 told CNA #11 Resident #18 wanted to lay down and instructed CNA #11 to stay with the resident while she went to get a sit-to-stand lift. CNA #12 was coming down the hall and RN #4 asked her to assist them with Resident #18’s transfer from his wheelchair to his bed. On 2/26/26 at 2:06 p.m. Resident #18 was sleeping in his bed. Resident #18’s bed was not in the lowest position, his floor mats were not in place by the bed and his personal urinal was not within reach. -However, Resident #18’s care plan revealed his bed was to be in the lowest position, his personal urinal was to be within reach at all times and the floor mats were to be placed at the bed side to prevent Resident #18 from falling (see record review below). C. Record review 1. Care plan The fall care plan, revised 12/10/25, identified Resident #18 was at risk for falls related to impaired mobility, history of falls, impaired vision, seizures and psychotropic medication use (medications that affect behavior, mood, thoughts, or perception). Pertinent interventions (revised 12/10/25), included ensuring the resident’s call light was within reach, assisting the resident with ADLs as needed, providing adaptive equipment or devices as needed, completing a fall risk assessment and orienting the resident to his room. The actual fall care plan, revised 1/23/26, identified Resident #18 had multiple falls since his time of admission, with one fall resulting in an injury. Pertinent interventions (revised 1/23/26), included ensuring the resident’ bed was in the lowest position at all times (initiated 11/28/25), clipping the call light onto the resident’s clothing within his reach and vision, encouraging the resident to use the urinal for urgent episodes, ensuring the resident’s personal urinal was within reach at all times, placing floor mats to the sides of the bed, providing a lipped mattress and moving the resident to a room directly across from the nurses station-However, observations revealed person-centered fall interventions were not consistently implemented for Resident #18 (see observations above). 2. Fall on 11/22/25 - unwitnessed The 11/22/25 nursing progress note, documented at 1:45 p.m., revealed Resident #18 was found on the bathroom floor. Resident #18 was on the floor in the middle of the bathroom sitting upright. Resident #18 did not complain of pain and no apparent injuries were assessed by the RN. Root cause analysis was related to gait imbalance and a new intervention was implemented to offer Resident #18 frequent toileting. 3. Fall on 11/24/25 - witnessed The 11/24/25 nursing progress note, documented at 1:47 p.m., revealed Resident #18 was attempting to walk with his friend. The occupational therapist (OT) assisted the resident to the floor and notified the RN. Resident #18 was wearing his personal clothing with his shoes on. Resident #18 was educated by the RN and the OT about supervised walking with authorized personnel only and safe transferring. A CNA said she had also educated the resident on this prior to the witnessed fall. No injuries were assessed.-The progress note did not indicate what the root cause of the fall was or if the resident’s fall interventions were reviewed to determine if the interventions were effective or if a new fall interventions were needed. 4. Fall on 11/26/25 - unwitnessedThe 11/26/25 nursing progress note, documented at 8:09 p.m., revealed Resident #18 was seen by the nurse at 5:00 p.m. sitting in his wheelchair watching television. The director of nursing (DON) was walking past and saw Resident #18 had his call light on. The DON walked in to the resident’s room and found Resident #18 sitting on the floor with his legs facing the sink and his wheelchair behind him. Resident #18 said he was trying to get his cell phone off the charger so he could put it away in the dresser drawer. Resident #18 was wearing non-skid socks at the time of the fall. The call light was pulled out of the wall socket and on the floor. The nurse completed the initial assessment with no obvious injuries and Resident #18 denied any pain. Resident #18 was assisted back into his wheelchair.-The progress note did not indicate what the root cause of the fall was or if the resident’s fall interventions were reviewed to determine if the interventions were effective or if a new fall interventions were needed. 5. Fall on 12/1/25 - unwitnessedThe 12/1/25 nursing progress note, documented at 1:30 a.m., revealed Resident #18 was found on the floor in his room. Resident #18 said he rolled out of bed. Resident #18 said he did not hit his head and he landed on the fall mat. No pain was noted and the nurse completed an assessment before assisting the resident from the floor. Resident #18 was repositioned and changed in bed. The wedges and fall mats were put in place on both sides of the resident. The bed was placed in the lowest position and the resident’s call light was within reach. -The progress note did not indicate what the root cause of the fall was or if the resident’s fall interventions were reviewed to determine if the interventions were effective or if a new fall interventions were needed. 6. Fall on 12/6/25 - unwitnessed The 12/6/25 nursing progress note, documented at 3:15 a.m., revealed Resident #18 was found sitting on the floor. The resident said he fell from the low bed. Resident #18 was assessed for injury and none were noted. Root cause analysis determined the cause of the resident’s fall was toileting urgency due to a possible urinary tract infection (UTI). A urine sample was collected to verify a UTI and was sent out to validate. The 12/5/25 nursing progress note, documented at 7:09 p.m., revealed a stat (immediate) urinary analysis (UA) was collected from Resident #18 via clean catch. The urine sample was in the dirty utility refrigerator awaiting laboratory (lab) pickup. The lab was notified by the charge nurse on duty. 7. Falls on 12/9/25 (two falls) - one witnessed fall and one unwitnessed fallThe 12/9/25 nursing progress note, documented at 2:17 p.m., revealed Resident #18 attempted to get out of his bed unassisted. Resident #18 was seen by the OT as he fell onto his right elbow without hitting his head. Resident #18 reported a 1 out 10 for pain to his right elbow. A head to toe assessment was performed and no injuries were noted. The nurse educated Resident #18 again, regarding the importance of calling for assistance. Resident #18 verbalized his understanding. Staff assisted the resident to the toilet before returning to bed. The 12/9/25 nursing progress note, documented at 7:24 p.m., revealed a loud thud was heard from Resident #18’s room around 6:40 p.m. by surrounding staff. The CNA notified the nurse Resident #18 was bleeding. The RN walked over and saw the resident on the floor with his back towards the wall adjacent to the door with his feet towards the bathroom door. Resident #18 was attempting to sit up. Resident #18 was wearing his personal clothing and personal shoes. Blood was observed coming from the resident’s right side of his face and top of his scalp. Resident #18 said he was attempting to empty his urinal and wanted to clean the mess up himself. No mess described by the resident was observed on the floor surrounding Resident #18. It was possible the resident mistook making a mess as he used a different urinal provided by his friend that evening and Resident #18 had impaired vision. Resident #18 did not utilize his call light for assistance. The resident was assessed by the nurse and then assisted by staff back into his wheelchair. Resident #18 was assessed for injuries after clearing away blood. The resident's right side of his forehead revealed a laceration, as well as a laceration to the right side of his jaw. Resident #18 said he had a 2 out of 10 for pain. Resident #18 was sent out to the hospital for evaluation and treatment. The resident required stitches and imaging for his head. 8. Fall 12/10/25 - unwitnessed The 12/10/25 nursing progress note, documented at 10:17 p.m., revealed Resident #18 was found in bed but called the staff to alert them that he had slid from the bed and gotten himself back into bed. Resident #18 denied hitting his head, experiencing any new pain, or new injuries. The resident was assessed by the nurse. During the resident’s neurological assessment, the nurse discovered Resident #18’s heart rate and blood pressure were changing dramatically, and Resident #18 was having increased slurred speech. The nurse practitioner (NP) was present at the facility and evaluated the resident. An physician’s order was placed to send Resident #18 to the hospital for further evaluation. Resident #18 was determined to be stable and sent back to the facility. 9. Fall 12/16/25 - unwitnessed The 12/16/25 nursing progress note, documented at 9:47 a.m., revealed Resident #18 sustained a fall while in the shower room. The nurse was alerted by a staff member and came to assess the resident. Resident #18 did not have any visible injuries and was alert and oriented. The resident said he was reaching to turn the water off and slid out of the shower chair onto the floor landing on his buttocks. Resident #18 was educated on the importance of asking for assistance and not to reach for objects out of his immediate reach. Resident #18 was also educated about this earlier in his room and the resident verbalized understanding at that time. Resident #18 was assisted back into the shower chair and taken back to his room. The CNA giving Resident #18 a shower had left the shower room, leaving the resident unattended for a few minutes during the incident. The CNA was educated on the facility’s policy for leaving residents unattended during showers. The CNA verbalized understanding. -However during an interview with the DON (see interview below), it was revealed that Resident #18 should never be left alone in the shower room as he was a high fall risk and required high supervision to ensure the resident’s safety. 10. Fall 12/31/25 - unwitnessedThe 12/31/25 nursing progress note, documented at 7:43 p.m., revealed Resident #18 was seen 10 minutes prior to his fall sitting in his wheelchair eating dinner. The resident had finished eating his dinner and wanted to get into bed. Resident #18 could not find his call light. The call light had fallen behind the left side of his wheelchair arm rest and was wrapped around the wheel. Resident #18 was wearing non-skid socks but the socks did not grip the floor to help with traction, and the resident fell to his buttocks. The bed was to the resident’s left and the wheelchair was on his right. Resident #18 denied any injury or pain. Resident #18 said he was looking for the call light to call for help. The nurse assessed Resident #18 and determined no injuries were noted at this time. The resident was assisted to bed, ensuring the call light was clipped to the resident’s shirt. Resident #18 was educated on safety awareness and calling for assistance. 11. Fall 1/19/26 - unwitnessedThe 1/19/26 nursing progress note, documented at 6:36 p.m., revealed the nurse was notified by a CNA that Resident #18 was on the floor. The nurse went into the resident’s room to assess the resident and Resident #18 was found in the bathroom with his back leaning against the wall. The resident was wearing long sleeves, a sweater, non-skid shoes, and his brief and sweatpants were around Resident #18’s knee’s. The resident said he was transferring from the toilet to the wheelchair without staff assistance and slipped when the wheelchair was not locked. A head to toe assessment was performed and no visible injuries were noted. The resident denied pain or injuries at the time of the assessment. Resident #18 was transferred back to his wheelchair. The call light was clipped to the resident. III. Staff interviews CNA #7 was interviewed on 2/26/26 at 9:08 a.m. CNA #7 said Resident #18 was very impulsive when he first arrived at the facility. CNA #7 said the resident was falling all the time; however, Resident #18 had not been falling as much lately. CNA #7 said Resident #18 had been declining recently and he was unable to stand on his own currently CNA #7 said some interventions for Resident #18 would be to keep close supervision on him. CNA #7 said if she saw Resident #18 trying to get up out of his wheelchair, she would ask the resident if he needed assistance with something. CNA #7 said up until recently, Resident #18 was good at communicating his needs. CNA #7 said if she saw Resident #18 put his feet out of the bed or if he put a leg out, that was a good indicator the resident needed to use the bathroom. CNA #7 said the resident was not on a toileting schedule, but said when she was working she toileted Resident #18 every two hours. The DON was interviewed on 2/26/26 at 2:16 p.m. The DON said accidents and hazards were defined by choking, falls with major injury, elopements, burns, leaving the facility against medical advice, and abuse and neglect. She said, depending on the incident, the procedure would be for the nurses to begin documentation by immediately completing a risk assessment. She said if the event was witnessed, then staff were to take statements from the resident and anybody else involved. The DON said making necessary notifications to the provider and family would be next as part of the investigation process. The DON said the root cause analysis of an incident was important because it helped to determine the cause of the incident and how to treat immediately to ensure the incident did not happen again. The DON said the facility put a lot of interventions in place to prevent Resident #18 from falling. The DON said Resident #18 was very impulsive due to his diagnoses. The DON said Resident #18 scored high on his BIMS assessment; however, his safety awareness was not present. The DON initially recalled the CNA was in the shower room with the resident at the time of the 12/16/25 fall. However, once she reviewed the 12/16/25 event progress note, the DON discovered that the CNA had left Resident #18 alone in the shower room. The DON confirmed the CNA was outside of the shower room for a few minutes. The DON said a resident was allowed, per the facility policy, to be left alone in the shower room only if a resident was alert and oriented. She said an alert and oriented resident did not have to be attended in the shower room, but staff was to check on the resident every five minutes. The DON said the CNA was educated on 12/16/25 by the RN. The DON said a resident with a diagnosis of high falls should not be unattended in the shower room. The DON said post-fall, the RN on duty should complete the head to toe assessment (skin, pain, fall, neuro’s if the fall was unwitnessed) before doing anything else with the resident. The DON said the nurses should document this in a progress note. The DON said the licensed practical nurses (LPN) could complete the initial assessment of the fall, but the RN had to be the one who completed the head to toe assessment. The DON said on the days Resident #18 had multiple falls, there was nothing more the facility could do, and the DON said she started calling staff to come and provide one-to-one supervision with Resident #18. The DON said that was why there was a significant decrease in his falls after 12/10/25. The DON said the resident’s family also hired a private sitter to come in and sit with Resident #18 on the days the resident’s wife could not make it or family and friends were not available. The DON said the facility attempted to offer Resident #18 a soft helmet and busy board, but his wife did not want either of those for dignity reasons. The DON said the facility arranged an appointment for the resident to see the neurological ophthalmologist. The DON said Resident #18 was complex and not appropriate for this setting. The DON said Resident #18’s entire frontal lobe had been compromised and the resident was very impulsive as a result. The DON said residents had a right to fall and the facility had an obligation to try to keep the residents as safe as possible. The DON said the facility completed a high risk audit on all the residents that were high fall risks. She said the environmental audits were completed by the DON or unit manager. The DON said on grand rounds they asked staff who they thought was going to fall next, and any concerns about residents falling. The DON said CNAs could find a resident’s fall interventions on the Kardex (comprehensive care tool. The DON said RNs would find interventions on the residents’ care plans. The DON said CNAs did walking rounds, and fall huddles were done with all the staff. The DON said she created a fall binder back in December 2025 after the high volume of falls. The DON said the binder was placed at each nurses’ station. She said the binder included a fall checklist which was a packet that each RN was to complete after a fall and give to the DON. The DON said the fall packet included a fall checklist, neurological assessment forms, resident and RN sign offs for interventions and education, and witness interview forms. The nursing home administrator (NHA) was interviewed on 2/26/26 at 6:45 p.m. The NHA said he was aware of Resident #18 being a high fall risk. The NHA said Resident #18 had a right to fall but he said he also knew the facility had a responsibility to ensure Resident #18’s safety. The NHA said he was aware of Resident #18’s impulsivity.

A survey for Incident #2654669 was conducted on 11/3/25 through 12/9/25. One deficiency was cited. The actual survey exit date was 11/4/25. 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 12/9/25.

Based on record review and interviews, the facility failed to ensure residents received adequate supervision and were kept free from elopement for one (#1) of three residents at risk for elopement out of three sample residents. Specifically, the facility failed to provide Resident #1 with the supervision necessary to prevent elopement. Resident #1, who had moderate cognitive impairments and had diagnoses of aphasia and encephalopathy, had a history of wandering and required an escort to his appointment off of the facility’s property. On 9/9/25 at approximately 1:00 p.m. Resident #1 was scheduled for pickup by an outside medical transportation company. The resident was taken to his appointment by the transportation driver and escorted into the building. Per the clinic’s notes, the resident was seen from 2:17 p.m. to 2:32 p.m., at which time the resident was discharged from the clinic and he subsequently walked away from the clinic. On 9/9/25 at 4:00 p.m. the outside transportation company returned to the clinic to transport Resident #1 back to the facility, but the driver could not find the resident. The transportation company contacted the facility and alerted them they were unable to locate the resident. Facility staff began searching the area for the resident. On 9/9/25 at approximately 6:40 p.m. (four hours after the last known sighting of Resident #1 and 2.5 hours after the resident was identified as missing) the director of nursing (DON) found Resident #1 walking on a sidewalk approximately 3.4 miles away from the clinic where he had attended his appointment. Serious harm to Resident #1 was likely to have occurred during Resident #1's elopement on 9/9/25. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/3/25 through 11/4/25, resulting in the deficiency being cited as past noncompliance with a correction date of 9/12/25. I. Situation of serious harmOn 9/9/25 at approximately 1:00 p.m. Resident #1 was scheduled for pickup by an outside medical transportation company. The resident was taken to his appointment by the transportation driver and escorted into the building. Per the clinic’s notes, the resident was seen from 2:17 p.m. to 2:32 p.m., at which time the resident was discharged from the clinic and subsequently walked away from the clinic. On 9/9/25 at 4:00 p.m., the outside transportation company returned to the clinic to transport Resident #1 back to the facility, but the driver could not find the resident. The transportation company contacted the facility and alerted them they were unable to locate the resident. Facility staff began searching the area for the resident. On 9/9/25 at approximately 6:40 p.m. (four hours after the last known sighting of the resident and 2.5 hours after the resident was identified as missing) the director of nursing (DON) found Resident #1 walking on a sidewalk approximately 3.4 miles away from the clinic where he had attended his appointment. II. Facility plan of correctionThe corrective action plan the facility implemented in response to Resident #1's elopement incident on 9/9/25 was provided by the nursing home administrator (NHA) on 11/3/25 at 1:11 p.m. The plan documented the following:A. Immediate action Resident #1 was returned to the facility by the DON on 9/9/25 at approximately 7:00 p.m. Resident #1 was assessed by the nursing staff and was not found to have any injuries. Nursing staff working with the resident that evening were educated by the NHA to closely monitor Resident #1 for his wandering behaviors. B. Identification of other residentsOn 9/9/25 an audit was initiated to identify all residents residing in the facility who were at risk for elopement. Identified residents’ care plans were reviewed. Photographs of residents at risk for elopement were updated and their information was placed in the elopement binders at the reception desk. Audits were completed by 9/12/25. Residents with upcoming appointments were reviewed by the interdisciplinary team (IDT) and arrangements were made to have a staff member accompany each resident and ensure their appropriate assistive devices were sent with them to their appointments. C. Systemic changesOn 9/10/25 the elopement binder was updated and accurate based on residents' elopement assessments. On 9/9/25 education on the elopement policy, the elopement binder and the updated procedures for residents’ appointments outside the facility was initiated for all staff and added to the orientation education. The education was completed by the DON and the NHA. Education for core staff responsible for patient care was completed on 9/12/25, and all facility staff were educated by 9/19/25. The process and procedures for residents’ appointments outside the facility was updated by 9/12/25. The procedures were updated to ensure a staff member or designee accompanied all residents to their appointments, and established a chain of communication with the transportation coordinator, the NHA and the DON. Outside transportation companies were educated on the changes in the facility’s processes for appointment transportation. The transportation drivers needed to check in with a facility nurse, who needed to ensure the transportation provider had the appropriate documentation and assistive equipment available for the resident before they were taken to their appointment. The transportation provider would also check in with the nurse after the resident’s appointment and provide them with any documentation from the appointment. Resident appointments and escort needs were discussed daily during grand rounds and reviewed. All new admissions would be assessed for risk of elopement on admission, quarterly, and as needed with any change in condition. D. MonitoringThe DON or designee would audit the transportation requests for physician appointment forms to ensure they were completed and staff members were assigned to accompany each resident. This would be done five times per week for four weeks, at which point the frequency would be reevaluated. The DON or designee would ensure resident appointments and the staff members assigned to supervise those appointments were discussed in the facility’s grand rounds. This would be done daily for four weeks, at which point the frequency would be reevaluated. The DON or designee would report the results of the audits and outcomes of their grand rounds discussions to the quality assurance and performance improvement (QAPI) committee for review by the QAPI team monthly, along with any recommendations for process changes or frequency of ongoing monitoring. III. Facility policy and procedureThe Unsafe Wandering and Elopement Prevention policy and procedure, revised 8/26/25, was provided by the NHA on 11/3/25 at 1:11 p.m. It read in pertinent part, “The facility will ensure that residents are assessed to determine risk for elopement in accordance with current standards of practice and implement interventions as appropriate to mitigate the risks identified.“As residents’ conditions may vary throughout the day, week, month or other time period, the identification of unsafe wandering and elopement indicators is an ongoing interdisciplinary assessment process.”IV. Resident #1A. Resident statusResident #1, age less than 65, was admitted on 8/7/25, hospitalized on 8/12/25, readmitted on 8/18/25 and discharged home with home health services on 9/20/25. According to the September 2025 computerized physician orders (CPO), diagnoses included encephalopathy (a disturbance in brain function), aphasia, dysphagia, hemiplegia and hemiparesis (weakness and paralysis on one side of the body), signs and symptoms involving cognitive functions following a stroke, alcohol dependence and epilepsy. The 9/20/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments per the staff assessment for mental status. The assessment documented the resident was independent for most activities of daily living (ADL). The assessment indicated the resident had not exhibited any wandering behavior during the assessment look-back period. B. Resident #1's representative's interviewResident #1’s representative was interviewed on 11/3/25 at 11:35 a.m. The resident’s representative said Resident #1 had an appointment with his neurologist on 9/9/25, so the facility had coordinated transportation for him. The resident’s representative said no one supervised Resident #1 during his appointment, and when the appointment was over, the neurologist’s office sent the resident back outside. The resident’s representative said Resident #1 wandered away from the neurologist’s office and was missing for several hours. The resident’s representative said Resident #1 was a vulnerable person, as he had aphasia and dementia. She said Resident #1 did not have a history of wandering prior to admitting to the facility, and seemed like he wanted to get out of the facility and go home. The resident’s representative said the facility had told her they usually had a staff member to supervise and sit with residents during their appointments. She said she had spoken with a member of the social services staff, who said Resident #1 would need supervision during his appointment and that she would be sure to let the transportation staff know about Resident #1’s need for supervision. The resident’s representative said Resident #1’s appointment finished early and the resident was assisted back to the lobby afterward, and staff supervision would have been paramount for the resident during the period between when his appointment concluded and when the transportation services returned to pick him up. C. Record reviewThe elopement care plan, initiated 9/9/25, revealed Resident #1 was at risk for elopement. Resident #1 was disoriented and had impaired safety awareness. Resident #1 wandered aimlessly and significantly intruded on the privacy or activities of others. Pertinent interventions included adding Resident #1 to the facility’s elopement book, documenting wandering behaviors and diversional interventions, encouraging the resident to participate in activities and the use of visual barriers including stop signs, ribbons and tape.-However, the care plan was not initiated until after Resident #1’s elopement incident on 9/9/25. An elopement risk evaluation, dated 8/7/25, revealed Resident #1 was not at risk for elopement. The assessment documented Resident #1 did not have cognitive impairments and did not have a history of substance use disorder.-However, Resident #1’s diagnoses included cognitive impairments and alcohol dependence (see above). A progress note, dated 8/8/25 at 9:27 p.m., revealed Resident #1 had acute onset dysphagia, wandering and confusion. An elopement risk evaluation, dated 8/18/25, revealed Resident #1 was not at risk for elopement. The assessment documented Resident #1 was able to ambulate independently, was recently admitted, and had cognitive impairments. The assessment documented Resident #1 did not have a history of substance use disorder.-However, Resident #1’s diagnoses included cognitive impairments and alcohol dependence (see above). A progress note, dated 8/20/25 at 8:02 p.m., revealed Resident #1 was noted to be wandering around to other residents’ rooms and was reoriented several times by staff. Resident #1 was pleasant with reorientation. A progress note, dated 8/21/25 at 9:00 p.m., revealed Resident #1 was reoriented to his room by a member of the nursing staff. Resident #1 was noted to be wandering around to other residents’ rooms and was reoriented several times. A progress note, dated 8/31/25 at 11:48 p.m., revealed Resident #1 wandered onto a different hall in the facility and was found by staff sitting in a wheelchair. An unidentified certified nurse aide (CNA) assisted Resident #1 back into his room. Resident #1 had a history of cognitive deficits and epilepsy. A progress note, dated 9/8/25 at 11:15 p.m., revealed Resident #1 was wandering down the hallway and tended to go into other residents’ rooms. Resident #1 needed redirection from staff back to his room. Resident #1 accepted redirection from the staff and was pleasant.-Despite numerous progress notes indicating Resident #1 was wandering into other residents’ rooms and needed frequent reorientation, the facility failed to identify the resident as a potential elopement risk. A progress note, dated 9/9/25 at 9:34 p.m., revealed Resident #1 was evaluated on his return to the facility. Resident #1’s skin evaluation did not reveal any new injuries. Staff were educated about Resident #1’s tendency to wander, and were vigilant in monitoring the resident and offering redirection as needed. Staff were educated regarding appointment safety for cognitively impaired residents by the NHA. An elopement risk evaluation, dated 9/9/25 (after the resident’s elopement), revealed Resident #1 was at risk for elopement. The assessment documented Resident #1 wandered aimlessly, ambulated independently, had cognitive impairments, had a history of substance use disorder and a history of actual elopement. The facility investigation, dated 9/9/25, was provided by the NHA on 11/3/25 at 1:11 p.m. and revealed the following:A timeline of events, undated, revealed that at approximately 1:00 p.m. Resident #1 was scheduled to be picked up by an outside transportation company for an appointment. The transportation driver arrived at the facility, assisted Resident #1 to his appointment and escorted him into the building. Resident #1 was seen by the neurologist and discharged at approximately 2:15 p.m., at which point the resident walked away from the hospital.-However, the neurology clinic said the resident was seen at the clinic from 2:17 p.m. until 2:32 p.m. (see interview below). At approximately 4:00 p.m. the transportation driver contacted the facility to notify the facility’s receptionist they were unable to locate Resident #1 at the neurology clinic. The receptionist notified the facility’s transportation coordinator and the NHA. The transportation coordinator left the facility and began to look for Resident #1 in the area surrounding the neurology clinic. At 5:02 p.m. the transportation coordinator contacted the facility and notified the facility staff they were not able to locate Resident #1. The DON and the social services director (SSD) left the facility to aide in the search for Resident #1. Facility staff also contacted the police department regarding Resident #1’s status as a missing person at that time, and notified Resident #1’s representative. At approximately 6:40 p.m. Resident #1 was found by the DON walking along a sidewalk 3.4 miles away from the neurology clinic. The DON was able to redirect Resident #1 into her vehicle and transport the resident back to the facility. At 7:00 p.m. Resident #1 returned to the facility, ate dinner and was assessed for any injuries by the nursing staff. Resident #1 did not have any new injuries and did not complain of any pain. An interview with Resident #1’s neurology clinic revealed the resident was seen from 2:17 p.m. to 2:32 p.m. The neurology staff said they did not help their patients to ensure they had transportation after their appointments. An interview with the outside transportation company revealed Resident #1 was picked up by the transportation driver at 1:35 p.m. and dropped off at the neurology clinic at 2:02 p.m. The transportation driver was scheduled to arrive back at the neurology clinic at 4:00 p.m. to assist the resident back to the facility. The transportation company said Resident #1 was in the lobby when the driver arrived at the facility. Resident #1’s transportation paperwork said he needed an escort to his appointment and that the resident’s representative would be escorting him to his appointment. The transportation company said the driver spoke with two unidentified staff members at the facility who both said Resident #1 was okay to go tothe appointment by himself, and if Resident #1’s representative was not at the clinic, the facility would send a staff member to meet the resident at his appointment. The transportation company said their process typically involved the driver ensuring a resident's escort was available and ready prior to the appointment. V. Staff interviewsCNA #1 was interviewed on 11/3/25 at 12:40 p.m. CNA #1 said she monitored any residents displaying wandering behaviors, notified the nurse and documented the residents’ behaviors. CNA #1 said Resident #1 was very confused, had dementia and had been wandering around the hallways of the facility prior to his elopement event on 9/9/25. CNA #1 said all of the nursing staff knew to monitor the resident as a result of those behaviors. CNA #1 said Resident #1 had an incident in which he was going to an appointment and someone was supposed to attend the appointment with him. CNA #1 said the transportation driver took Resident #1 to the appointment but did not stay with the resident. CNA #1 said the facility staff were wondering where Resident #1 was later that evening and found out the transportation driver could not find him. Transportation coordinator #1 was interviewed on 11/3/25 at 1:15 p.m. Transportation coordinator #1 said the facility had two transportation coordinators. He said the transportation coordinators usually received notification that a resident needed an appointment, and they would set up the resident’s appointment time and date. Transportation coordinator #1 said the assistant director of nursing (ADON) helped to coordinate escorts for residents’ appointments and reviewed which residents needed escorts to their appointments. Transportation coordinator #1 said the nurses filled out an appointment form, which documented the residents’ physical abilities, whether or not they needed an escort, and the transportation coordinators then reviewed the form and clarified any additional information with the ADON.Transportation coordinator #1 said another transportation coordinator had contacted the outside transportation services for Resident #1’s appointment, so he did not see his transportation paperwork and was not sure what was arranged. Transportation coordinator #1 said he assumed Resident #1’s paperwork documented he needed an escort, but he was not sure who told the transportation driver to leave before an escort was identified. Transportation coordinator #1 said the transportation company arrived to pick Resident #1 up from his appointment at the neurologist at 4:00 p.m. and alerted the facility that they could not find the resident at 4:10 p.m. Transportation coordinator #1 said the facility staff checked the hospital’s security footage and searched the area for the resident. Transportation coordinator #1 said since the incident on 9/9/25, there were more staff members involved in the transportation arrangement process. Transportation coordinator #1 said the facility provided staff escorts during all residents’ appointments. Transportation coordinator #1 said the outside transportation company reviewed and signed off that they understood the changes to the facility’s transportation arrangement process. Registered nurse (RN) #2 was interviewed on 11/3/25 at 2:35 p.m. RN #2 said residents were evaluated for elopement risk on admission and quarterly. RN #2 said if a resident exhibited any new wandering or exit seeking behaviors, it would prompt the nurse to perform a new elopement risk evaluation. RN #2 said if a resident was considered at risk for elopement, the nursing staff would be prompted to create an elopement care plan and pertinent interventions. RN #2 said wandering behaviors were documented in the resident’s progress notes or the skilled nursing assessments in the resident’s electronic medical record (EMR). RN #2 said the facility did not previously use resident escorts whenever a resident had an appointment outside the facility, but family members could join the residents if they wanted to. RN #2 said the facility started sending escorts with residents to outside appointments after Resident #1’s elopement incident on 9/9/25. RN #2 said Resident #1 was confused and exhibited wandering behaviors. RN #2 said Resident #1 was not able to ambulate independently when he first admitted to the facility and primarily stayed in bed due to his altered mental status, but as the resident began feeling better he had started wandering more. RN #2 said Resident #1 wandered around the facility hallways and went into other residents’ rooms, so the staff had to redirect him multiple times per day. RN #2 said he thought Resident #1’s family member was supposed to go with him to his appointment on 9/9/25 but he was not sure. The social services assistant (SSA) was interviewed on 11/3/25 at 4:18 p.m. The SSA said she had received a call from Resident #1’s representative on 9/8/25. She said the resident’s representative had asked her to assist in scheduling the resident's neurologist appointment to an earlier date. The SSA said the appointment had been initially scheduled on 9/23/25. The SSA said she called the clinic and left a message and was waiting for a response; however, the resident’s representative called back and told the SSA that she had been able to reschedule the resident's appointment for the following day herself. The SSA said the resident’s representative also informed her that she would not be able to attend the new scheduled date due to her work obligations. She said the resident's representative asked that the facility provide a staff member to accompany the resident to his appointment since she was not going to be able to go with him. The SSA said she replied that she would inform the transportation department; however, since it was a late notice from the representative, it was likely that the facility would not be able to get an escort to accompany the resident. The SSA said the resident’s representative said that it was okay for the resident to attend the appointment without an escort. The SSA said she informed transportation coordinator #2 and the case manager of the resident's new appointment date and the request for an escort since the resident’s representative was not going to be available. The case manager was interviewed on 11/4/25 at 10:25 a.m. The case manager said she was responsible for overseeing insurance processing and occasionally managing transportation documentation, which involved setting appointments for residents admitted for skilled nursing care (speech, occupational, and physical therapy). The case manager said she overheard the SSA inform transportation coordinator #2, that Resident #1’s representative had rescheduled the resident’s appointment to an earlier date of 9/9/25. The case manager said she heard from the SSA that the resident’s representative would not be able to attend the appointment, and requested that the facility send an escort to accompany the resident. The case manager said she did not act on this information because it was late in the day and she felt that transportation coordinator #2 was capable of managing the situation by setting up the appointment with an escort. The DON and the NHA were interviewed together on 11/3/25 at 3:08 p.m. The DON said the transportation coordinators typically arranged residents’ appointments, and the nurses filled out the transportation sheet. The DON said residents with noted elopement risk needed an escort to outside appointments. The DON said if the staff were not sure if a resident needed an escort to their appointment, they could bring the issue to her so they could talk through the situation and determine if an escort was necessary. The DON said elopement risk evaluations were performed on admission and quarterly. The DON said the determination of whether or not a resident was at risk for elopement was the nurse’s discretion. The DON said the social services staff audited the elopement evaluations and emailed a list of residents who were at risk of elopement to the DON. The DON said the facility nurses were trained in-house on how to fill out the elopement assessments. The NHA said Resident #1 liked to walk around the facility’s halls and had aphasia, so he was not able to vocalize things. The NHA said Resident #1 knew he had an appointment the day of 9/9/25, so he sat on a bench by the front door of the facility. The NHA said the outside transportation driver entered the facility and asked the receptionist for Resident #1, and the receptionist identified the resident. The NHA said RN #2 provided the driver with Resident #1’s transportation documents. The NHA said Resident #1 walked out of the building with the driver and was taken to his appointment at the neurology clinic. The DON said later on that day (9/9/25) the transportation driver could not find Resident #1, so they called the facility’s transportation team. The DON said she contacted the neurology clinic, who said Resident #1’s appointment had ended early and they did not know the resident’s whereabouts. The DON said Resident #1 did not have any injuries after he returned to the facility on 9/9/25. The NHA said Resident #1 was assessed by the nursing staff when he returned to the facility and did not have any changes in cognition or disposition. The NHA said Resident #1’s representative was scheduled to be his escort to his appointment that day, as she had previously expressed interest in accompanying Resident #1 to his appointment.-However, according to interviews with the SSA and the case manager, Resident #1’s representative informed the facility she would not be able to attend the resident’s appointment and she requested the facility provide an escort to the appointment for the resident (see interviews above). The DON said Resident #1’s representative knew she would not be able to attend the resident’s appointment because she was working that day and had called the neurology clinic to let them know Resident #1 would need help calling the transportation services for pick up after his appointment. The DON said Resident #1 had cognitive impairments and a history of wandering. The DON said before Resident #1 was able to ambulate independently, he would self-propel in his wheelchair around the facility. The DON said Resident #1 had been added to the elopement book prior to his elopement incident on 9/9/25 due to his aphasia diagnosis, but he did not have an elopement care plan. The DON said the resident was more sedate when he first admitted to the facility, so the first two elopement risk assessments were accurate. The DON said she did not believe there was anything in the facility’s policy which indicated the nursing staff should have completed a new elopement evaluation when Resident #1’s wandering behaviors were noted to begin, but she said it was a missed opportunity. The DON said the MDS coordinator or the social services staff would typically implement care plans for wandering and elopement. The DON said if the nursing staff identified a resident was at risk for elopement, they could also trigger pertinent interventions in the resident’s care plan. The DON said Resident #1 should have had a care plan developed for his wandering prior to his elopement on 9/9/25. The DON said Resident #1 had a comprehensive nursing assessment completed on 9/3/25, at which point he was already exhibiting wandering behaviors, so those behaviors should have been included in his comprehensive care plan. The NHA said Resident #1 would walk around the facility’s main floor but did not have exit-seeking behaviors. The NHA said after the incident on 9/9/25, every staff member who worked on the floor of the facility was educated on what was necessary for a resident to leave the facility, the elopement policy, and the updated procedure for resident escorts. The NHA said every morning since 9/9/25, the facility staff ensured each resident with an outside appointment that day had an escort to go with them. The NHA said if a resident was being escorted to an appointment by a family member, the family member had to go to the facility first so the facility staff could verify they were able to escort the resident. Transportation coordinator #2 was interviewed on 11/04/25 at 10:22 a.m. Transportation coordinator #2 said she tried to make sure resident escorts to outside appointments were scheduled at least a week in advance prior to their appointment date. She said she checked the resident outside appointment list daily to make sure everything was in order. Transportation coordinator #2 said she would sometimes receive late cancellations from the assigned resident escort and she would do her best to find a replacement. Transportation coordinator #2 said if she could not find a replacement escort for the resident, she would volunteer as the escort herself. Transportation coordinator #2 said she had not been aware Resident #1’s representative was unable to attend his outside appointment on 9/9/25. Transportation coordinator #2 said she had not been notified by facility staff nor the resident’s representative of the need for a replacement escort. Transportation coordinator #2 said on the day of Resident #1’s elopement, the neurologist’s office ended the appointment early because Resident #1 did not have an escort with him.

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

A revisit survey was completed on 6/4/24 for all previous deficiencies cited on 4/16/24. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is two story, Type V (111), construction with a partial lower level.. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1996 and is license for 121 beds. This re-certification survey conducted May 15, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". All deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Delayed egress door in-op kitchen egress hallway | Mag-lock disengages with with fire alarm kitchen egressNFPA 101 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met:(1)The door leaves shall unlock in the direction of egress upon actuation of one of the following:(a)Approved, supervised automatic sprinkler system in accordance with Section 9.7(b)Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6(c)Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6(2)The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism.(3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions:(a)The force shall not be required to exceed 15 lbf (67 N).(b)The force shall not be required to be continuously applied for more than 3 seconds.(c)The initiation of the release process shall activate an audible signal in the vicinity of the door opening.(d)Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only.(4)* A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:PUSH UNTIL ALARM SOUNDSDOOR CAN BE OPENED IN 15 SECONDS(5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9. 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.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Annual Fire Alarm Report shows that elevator detectors were missed on the Aug inspection | These were tested in Feb no inspection report is available to show that they were inspected in the last 12 months NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes. Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors within the building should a delay occur in locating a fire throughout the facility. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Leak on dry system needs to be repaired | facility working on repair | 2. Need to review 3 year full trip test | This will need to also be repeated after repair of system 3. Loaded (dirty) sprinkler head dryer room NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected and tested periodically. Section 19.7.6, 4.6.1213.4.4.2 Testing. (Dry Systems)13.4.4.2.1* The priming water level shall be tested quarterly. 13.4.4.2.2* Each dry pipe valve shall be trip tested annually during warm weather. 13.4.4.2.2.1 Dry pipe valves protecting freezers shall be trip tested in a manner that does not introduce moisture into the piping in the freezers. 13.4.4.2.2.2* Every 3 years and whenever the system is altered, the dry pipe valve shall be trip tested with the control valve fully open and the quick-opening device, if provided, in service. 13.4.4.2.2.3* During those years when full flow testing in accordance with 13.4.4.2.2.2 is not required, each dry pipe valve shall be trip tested with the control valve partially open. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference.

Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In accordance with NFPA 10. 1. Elevator extinguisher downstairs needs to be moved to below 5ftNFPA 10 6.1.3.8 Installation Height. 6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. 5.5.5* Class K Cooking Media Fires. Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. 5.5.5.1 Class K fire extinguishers manufactured after January 1, 2002, shall not be equipped with extended wand–type discharge devices. 5.5.5.2 Fire extinguishers installed specifically for the protection of cooking appliances that use combustible cooking media (animal or vegetable oils and fats) without a Class K rating shall be removed from service. 5.5.5.3* A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment of the facility. Deficient items were discussed with the administrator and maintenance director at the exit conference

Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61. Fire Drills closer than an hour 2 and 3rd quarter 3rd shift NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 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 administrator and maintenance director at the exit conference.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1. Fuel report incomplete | need to re-sampled8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdiction 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. 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.

A recertification survey was conducted from 4/10/24 to 4/16/24. Two deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/10/24 to 4/16/24. No deficiencies were cited.

Based on observations, interviews, and record review, the facility failed to ensure one (#15) of two residents reviewed for communication out of 28 sample residents was provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to provide Resident #15, who had difficulties with speech due to a stroke, with an appropriate communication tool to ensure the resident was able to effectively communicate her needs to staff. Findings include:I. Resident #15A. Resident status Resident #15, under age 65, was admitted on 8/30/22. According to the April 2024 computerized physician orders (CPO), the diagnoses included cerebral infarction (stroke). The 3/8/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a (BIMS) score of 14 out of 15. She needed substantial assistance from one staff member for transferring and needed supervision or hands on assistance of one staff member for eating and personal hygiene. The MDS assessment indicated Resident #15 was usually understood with difficulty communicating some words or finishing thoughts but was able if prompted or given time and was able to understand others with clear comprehension. B. Observations and interviewOn 4/15/24 at 9:31 a.m. Resident #15 was sitting in her room pointing at her chest and using her index finger to draw a line from her throat to her chest area. Certified nurses aide (CNA) #2 asked Resident #15 if she needed something to drink or eat, Resident #15 shook her head to indicate no. CNA #2 asked Resident #15 if she needed something for her throat and the resident shook her head to indicate no and continued using her index finger to draw a line from her throat to her chest. CNA #2 asked the resident if her chest was bothering her. Resident #15 attempted to verbally communicate but was unable to pronounce words clearly. CNA #2 said she was unable to understand what Resident #15 was trying to say and left to find assistance from another staff member. CNA #2 did not return, unit care coordinator (UCC) #1 returned instead, approached Resident #15 and asked if the resident was trying to something about her throat to CNA #2. Resident #15 shook her head indicating no and looked at the ground. UCC #1 asked the resident if she wanted juice and Resident #15 shrugged her shoulders and shook her head to indicate yes. C. Record reviewThe communication care plan, revised on 10/23/24, revealed Resident #15 had a communication problem related to cerebral infarction and unclear speech. It indicated the resident would be able to make basic needs known on a daily basis through the review date. Pertinent interventions included using alternative communication tools as needed.-The care plan did not indicate what communication tool to utilize when communicating with Resident #15. D. Staff interviewsCNA #2 was interviewed on 4/15/24 at 9:35 a.m. CNA #2 said staff needed to take their time with Resident #15 when trying to understand what she was trying to communicate or find another staff member who was better at communicating with the resident. CNA #2 said Resident #15 expressed frustration in the past when she could not be understood. CNA #2 said she was not aware of any communication devices being used by staff to assist in communicating with Resident #15. CNA #1 was interviewed on 4/15/24 at 9:31 a.m. He said he was aware of Resident #15 having a communication board but had never used it with her. He said another staff member informed him of Resident #15 having a communication board and he would not have known of it otherwise. CNA#1 was unable to locate a communication board in Resident #15's room. Registered nurse (RN) #1 was interviewed on 4/15/24 at 9:40 a.m. She said Resident #15 had a communication board available to staff in her room but the resident may have thrown it away. RN #1 said she did not know why Resident #15 threw her communication board away. RN #1 said there was a communication board at the nurses station that was kept in the narcotic count book. RN #1 said she did not know how direct care staff would know to look in the narcotic count book for a communication board for Resident #15. UCC #1 was interviewed on 4/15/24 at 10:00 a.m. UCC #1 said using alternative communication tools for Resident #15 was indicated to CNAs in the Kardex (tool utilized by staff to provide person centered care). UCC #1 said the Kardex did not specify what the alternative communication tools were. UCC #1 said the care plan would be updated to specify the communication board as an alternative tool. -However, despite UCC #1 indicating the communication care plan would be updated, it was not updated prior to the end of survey on 4/16/24. The speech therapist (ST) was interviewed on 4/16/24 at 11:00 a.m. The ST said prior to 4/16/24 Resident #15 had never been on her caseload. She said she was going to assess the resident for swallowing issues. The ST said Resident #15 had not been assessed by therapy for the use of a communication board and she was unsure when the resident started using it or who recommended it to be used. Social services assistant (SSA) #1 was interviewed on 4/16/24 at 12:43 p.m. She said she was unaware Resident #15 had a communication board prior to 4/15/24. II. Facility follow upThe education material that was provided to the CNAs and nurses was provided on 4/14/24 at 2:30 p.m. by the director of nursing (DON). It read in pertinent: "Be aware of having difficulty communicating with Resident #15 there is a communication board taped to the inside of her closet. In addition, one is always available on the nurses cart."

Based on observations, record review and interviews the facility failed to ensure one (#55) of one resident received treatment and care in accordance with professional standards of practice out of 28 sample residents. Specifically, the facility failed to ensure Resident #55 was assisted with applying her compression stockings to treat her bilateral lower leg edema. Findings include: I. Facility policy and procedureThe Anti Embolism (compression) Stocking Application policy, revised 9/8/23, was received by the director of nursing (DON) on 4/16/24 at 10:43 a.m. It read in pertinent part,"The facility will provide anti embolism stocking application in accordance with professional standards of practice."The services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet the professional standards of quality."The facility will utilize Lippincott (nursing) procedures for anti embolism stocking application." The Anti Embolism stocking application checklist, undated, was provided by the DON on 4/16/24 at 10:43 a.m. It read in pertinent part,"To apply knee-length anti embolism stockings according to standard of care;-Insert your hand into the stocking from the top, grasp the heel pocket from the inside, and turn the stocking inside out;-Position the stocking over the patient's foot and heel; -Grasp a few inches of the stocking and begin pulling it up around the patient's ankle and calf;-Continue pulling the stocking up the patient's leg using short pulls, alternating from the front to the back, until the bottom of the stocking's band falls one to two inches below the knee;-Smooth out wrinkles in the stocking;-Make sure the patient's toes are visible through the toe inspection area; and,-Document the procedure."II. Resident #55A. Resident statusResident #55, over the age of 65, was admitted on 3/5/21. According to the April 2024 computerized physician orders (CPO), diagnoses included pain in fingers, low back pain, pain in the shoulder and congestive heart disease. The 3/10/24 minimum data set (MDS) assessment revealed Resident #55 was cognitively intact with a brief interview for mental status (BIMS) score of 15 of 15. Resident #55 was independent with putting on her shoes and socks and dressing her upper and lower body. -However, the resident needed assistance in applying her compression stockings. B. Resident interview and observationsOn 4/11/24 at 10:30 a.m., Resident #55 said staff did not help her put on her compression stockings. She said the stockings helped control the swelling in her feet. She said she was unable to pull them up on her own. Resident #55's feet were observed to be swollen. She was wearing slippers that went over the top of her foot and had open heels to accommodate the swelling in the resident's feet. On 4/15/24 at 9:15 a.m., Resident #55 had slippers on her feet and her feet were swollen. Resident #55 was in the hallway outside her room and asked certified nurse aide (CNA) #1 to assist her. She said staff would not help her put on the compression stockings. CNA #1 said he did not know the resident. He said he did not feel comfortable applying the compression stockings because her feet were so swollen. CNA #1 spoke with licensed practical nurse (LPN) #1. LPN #1 said staff was supposed to put her compression stockings on every morning. CNA #1 said he needed larger stockings because the stockings for Resident #55 were too small to fit over her legs due to the increased swelling. The unit care coordinator (UCC) #1 walked up to where CNA #1 and LPN #1 were talking in the hall. UCC #1 said Resident #55 was supposed to put the stockings on herself. Resident #55 said she was unable to pull the stockings up on her own because it was too difficult for her to do. Resident #55 said she previously told staff but no one helped her apply the compression stockings. On 4/16/24 at 9:15 a.m., Resident #55 was in her room and was observed without her compression stockings on. Resident #55 said staff had not offered to assist her in putting her compression stockings on. She said staff did not help her with the stockings on 4/13/24 or 4/14/24. III. Record reviewReview of Resident #55's medical records revealed a physician's order, dated 4/9/24, which read in pertinent part, "Please give resident compression stockings to wear during the day while awake." The edema care plan, initiated on 3/9/21 revealed the resident had edema related to her diagnosis of congestive heart failure. -A review of the comprehensive care plan did not reveal an updated intervention to include the 4/9/24 physician's order for compression stockings. IV. Nursing interviewThe DON was interviewed on 4/16/24 at 9:45 a.m. The DON said Resident #55 had a history of refusing to wear compression stockings. The DON was unable to find documentation in April 2024 that Resident #55 refused to wear the compression stockings. The DON said the physician's order for compression stockings was entered incorrectly and did not prompt the staff to assist the resident with the compression stockings. The DON said because the physician's order was not correctly entered, it did not prompt the staff to document when they assisted the resident in putting on the compression stockings. She said when UCC #1 confirmed the physician's order on 4/9/24 she should have clarified the order to ensure it was entered correctly. The DON was interviewed again on 4/16/24 at 10:40 a.m. The DON said staff had just helped Resident #55 apply the compression stockings. The DON said she clarified the physician's order for the resident to have compression stockings applied and removed daily. The DON said she updated Resident #55's care plan to include the application of the compression stockings and to apply the compression stockings and monitor Resident #55's edema.