VALLEY REHABILITATION AND HEALTHCARE CENTER, THE

A complaint survey, prompted by #CO2639268 and Incident #2639401 and Incident #2661504 was completed on 11/4/25 to 12/10/25. One deficiency was cited. The actual survey exit date was 11/5/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the facility was provided with the CMS-2567, 12/10/25.

Based on interviews, record review and observations, the facility failed to ensure residents were free from accidents or hazards for one (#1) of three residents reviewed out of seven sample residents. Specifically, the facility failed to ensure Resident #1 was provided transportation, by use of the facility vehicle, without injury. Resident #1, was admitted on was admitted on 8/1/19, with diagnoses of dementia, mild, with other behavioral disturbances, age-related osteoporosis without current pathological fracture, muscle weakness, difficulty walking, abnormalities of the gait and mobility, need for assistance with personal care and adult failure to thrive. On 9/15/25 the resident was being transported to an appointment outside of the facility. Activities assistant (AS) #1 had to abruptly stop, which caused Resident #1’s seatbelt to become unfastened and Resident #1 fell out of her wheelchair. Resident #1 sustained a fracture of her left femur which required surgery. Findings include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to an accident with a facility vehicle during transport that resulted in Resident #1 being injured and hospitalized prior to the onsite investigation on 11/4/25 to 11/5/25. The deficiency was cited as past non-compliance with a correction date of 9/24/25. I. Incident on 9/15/25The 9/15/25 reported facility investigation for equipment malfunction read in part:“The transport driver/activity aide was taking the resident to an appointment. During this transport, the transport driver needed to make a hard, sudden stop to prevent an accident. The resident, who had a seat belt on, then fell out of the wheelchair. “Based on investigation by the corporate official and the maintenance director, the seatbelt appeared to be locked and secure. Under force, the seatbelt came loose. “The transport driver was placed on driving suspension until the investigation was complete. The vehicle was placed out of commission until repaired and passed a safety inspection. All other transport vehicles not related to this incident was also inspected for potential safety issues. No issues were found with the other vehicles.”According to the investigation, the resident was taken to the emergency room for evaluation. The 9/15/25 police incident report was provided by the nursing home administrator (NHA) on 11/4/25 at approximately 3:50 p.m. The incident report identified a police officer received a call on 9/15/25 regarding a traffic incident that resulted in an injury to a passenger. According to the report, the reporting party stated that she worked for the facility and was transporting a resident when a car in front of her hit the brakes, stopping abruptly, causing her to hit her brakes abruptly. The passenger in the back of the vehicle, who was seated in a wheelchair, was ejected from the chair, causing an injury to her knee. The reporting party stated the resident was flown out due to the injuries. A 9/24/25 written statement from the plant operations director was provided by the NHA 11/4/25 at approximately 3:50 p.m. The statement read, “When the initial investigation was communicated to the NHA and the plant operations director from the maintenance director, it was thought that the end of the seatbelt that was used (during the 9/15/25 incident) was the Toyota manufactured end, placed into the external seatbelt end, from the Q-straight belt. Upon further investigation and reenactment from the driver, it was determined that the end of the van seatbelt that was supposed to attach to the Q-straight, was used to latch the resident in. The driver was interviewed and she thought the seatbelt was fully secure. During the investigation it was also determined that the Toyota manufactured ends were not compatible with the external seatbelt from Q-straight. The non-compatible ends of the Toyota seat belts were disabled from use and new seat belts were ordered. The van was placed out-of-order until the new seatbelts arrived.” The 9/24/25 amendment of the facility’s final report was provided by the NHA on 11/4/25 at approximately 3:50 p.m. The amendment read, “Upon further investigation, the facility found the transport driver latched non-compatible ends of the seat belt together to cause the malfunction. Non-compatible ends are no longer accessible to prevent a reoccurrence. Daily safety inspections of the vehicle will be formed by the transport driver or designee for proper seat belt latching.” II. Facility plan of correctionThe plan of correction was provided by the NHA on 11/4/25 at 11:57 a.m. A. Immediate action to correct the deficient practice The plan of correction documented the transport drivers were all re-education to ensure competency on safe transportation. The drivers were not allowed to drive until they successfully passed the competency review. The driver competency audit began on 9/15/25 related to the 9/15/25 incident. The corporate plant operations director reviewed the vehicle for proper safety restraints in place to transport residents on 9/24/25. Through the investigation it was found that the driver involved in the 9/15/25 incident latched non-compatible ends of the seat belt together to cause the malfunction. The non-compatible ends were removed from the vehicle to prevent a reoccurrence of the incident. The van involved in the incident was placed out of commission on 9/24/25. The transport driver training checklists for seven staff members trained to transport residents were provided by the NHA on 11/4/25 at 12:20 p.m. The trainings identified the staff members, including AS #1 were trained on how to complete a facility vehicles inspection; adjust the mirrors; inspect the wheelchair, the use of the ramps, use of the hydraulic lift, how to operate the hydraulic lift with two people, properly securing a passenger with a seatbelt; acknowledgment of emergency procedures; and, how to drive an oversized vehicle. The training identified the education was conducted beginning on 9/15/25. A photo packet for training was provided by the NHA on 11/4/25 at approximately 3:50 p.m. The photos identified the correct way to secure a wheelchair on the mini van. B. Systematic changesThe plan of correction identified the implementation of systematic changes to prevent a reoccurrence. The facility implemented daily safety inspections of the vehicle by the transport driver or designee to ensure proper seat belt latching. The daily inspections would be documented on a quality assurance and plan of improvement (QAPI) checklist form. According to the plan of correction, the transport drivers would be evaluated every six months for proper safety procedures for resident transports. Vehicle safety inspection reports and checklists were provided by the NHA on 11/4/25 at 12:20 p.m. The checklists identified the vehicle and securements were inspected daily between 9/24/25 and 11/4/25 when in use. The 9/24/25 inspection report noted there was a missing end of a seatbelt restraint on the mini van and the vehicle would be out of use until the new belt arrived. C. MonitoringThe plan of correction documented the monitoring action following the incident. The maintenance director would bring the prior weeks’ vehicle inspections to the NHA every Monday. The inspections would be then reviewed by the NHA with the IDT during the QAPI meetings to ensure that sufficient practice had been corrected. The QAPI review would continue over the following six months. III. Facility policy and procedureThe Transporting of Resident (Facility Van), undated, was provided by the NH) on 11/5/25. The policy read in pertinent part, “It is the policy of the facility to provide residents safe, non-emergency transportation to doctor’s appointments and activity outings, and any other trips the facility deems necessary.“The van will be well maintained and equipped with safety features. Each resident will be secured in a seatbelt or in a wheelchair secured with wheelchair tie downs.“Staff authorized to drive the van would have necessary training and licensure to operate the vehicle as well as knowledge on safety features.”IV. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 8/1/19 and discharged on 9/15/25. According to the August 2025 computerized physician orders (CPO), diagnoses included dementia, mild, with other behavioral disturbances, age-related osteoporosis without current pathological fracture, muscle weakness, difficulty walking, abnormalities of the gait and mobility, need for assistance with personal care and adult failure to thrive. The 9/15/25 minimum data set (MDS) assessment documented Resident #1 had moderately impaired cognition with memory problems with a staff assessment for mental status. Resident #1 required substantial to maximal assistance with mobility and used a wheelchair. The MDS assessment revealed Resident #1 was dependent on staff for vehicle transfers. The MDS assessment identified she had a history of falls since her admission to the facility. The MDS assessment identified Resident #1 was discharged to hospital. B. Resident #1’s representative interviewResident #1’s representative was interviewed on 11/5/25 at 3:13 p.m. The representative said Resident #1 had a medical appointment on 9/15/25. She said she called the facility when the resident did not arrive for the appointment as scheduled. She said the facility told her Resident #1 had left the facility with the transport driver and would arrive shortly. The representative said the facility called her back and told her there had been an incident and Resident #1 was taken to the hospital. The representative said she went to the hospital and spoke to the transport driver/activity assistant (AS) #1. She said AS #1 told her someone stopped in front of her when she was driving and she had hit the brakes on the vehicle, causing Resident #1 to fall out of her wheelchair and onto the floor. The representative said AS #1 told her she felt that she did everything right but the seat belt came loose. Resident #1’s representative said Resident #1 was expressing a lot of pain at the hospital on 9/15/25 and could not move her leg. The representative said she was shown an Xray of the resident’s injury. She said Resident #1 had a femur fracture down to her knee and had to be flown to another hospital for surgery. C. Observation and staff interviewsThe securement of a resident’s wheelchair in the facility vehicle, was observed on 11/5/25 at approximately 1:30 p.m. with the maintenance assistant and certified nurse aide (CNA) #1. CNA #1 identified herself as the primary transport driver. CNA #1 and the maintenance assistant secured the wheelchair by locking the brakes, used the appropriate and matching securements to tighten the wheelchair to the floor of the van and fasten the seat belt to cross over the wheelchair, making sure each component was secure and could not be self released with force. CNA #1 said they needed to check all the belts when securing a wheelchair to make sure the wheelchair and/or the resident would not come loose. E. Record reviewThe fall care plan, revised 8/13/24, identified Resident #1 was at risk for falls. According to the care plan, the goal for the resident was to minimize risks for falls and minimize injuries related to falls. The 9/15/25 fall occurrence note documented AS #1 notified the facility that there was an incident on the way to Resident #1’s podiatry appointment. According to the note, AS #1 said she had to slam on her breaks as the vehicles in front of her came to an abrupt stop. The resident had her seatbelt on and the wheelchair was locked in place but the resident fell out of the chair. The note documented the incident occurred on 9/15/25 at 11:35 a.m. The 9/15/25 hospital emergency department note identified Resident #1 was brought to the emergency department after her transport van slammed on the brakes and the resident came out of her wheelchair and landed on the floor of the van, landing on the left side of her body. According to the note, the resident was transferred to a second hospital for surgical repair. The 9/15/25 hospital notes identified the resident sustained skin tears, left lower thigh pain, swelling and a left distal femur fracture with intercondylar extension after a fall from her wheelchair. According to the hospital notes, the resident underwent surgery as a result of the fracture. The 9/16/25 interdisciplinary team (IDT) note documented Resident #1 was in the facility vehicle, secured by the seat belt to the vehicle, when the driver came to an abrupt stop. The sudden stop caused the resident to fall out of the wheelchair and land on the floor of the vehicle. The note indicated Resident #1 was immediately transported to hospital after the incident. The note revealed maintenance evaluated the seat belt and determined the seat belt was faulty and the vehicle would be placed out of commission while the seat belt was repaired. V. Staff interviewsThe NHA and the corporate plant operations director were interviewed together on 11/4/25 at 3:10 p.m. The NHA said AS #1 was interviewed after the 9/15/25 incident. AS #1 said a motorcycle pulled out into traffic causing her to have to stop suddenly. The plant operations director said AS #1 was driving the facility’s mini van when she was cut off in traffic. The NHA said Resident #1 was no longer an employee at the facility as a personal choice, which was not related to the 9/15/25 incident. The plant operations director said he reviewed the vehicle involved in the incident to try to determine why the seatbelt did not hold Resident #1 in her wheelchair when the AS #1 made a sudden stop. He said he had AS #1 demonstrated to him how she secured the resident on 9/15/25. The plant operations director said when AS #1 attempted to secure the resident in the vehicle on 9/15/25, she thought she had done everything correctly but during the replay demonstration, after the incident, she he realized she used the wrong seat belts components to secure Resident #1. He said the lack of proper securement was an employee error. He said the vehicle had different brands of belts/straps that were not compatible with each other if attempted to use together and would not create a secure hold. The plant operations director said he has since disabled and/or removed all the incompatible straps in the mini van and replaced them with all matching and compatible belts/straps to prevent the recurrence of the error. The plant operations director said he inspected the other facility vehicles to make sure they all had compatible belts made from the same manufacturer. The plant operations director said all daily inspections of the vehicles, before they transport a resident, now require the driver to test the seatbelts with force to ensure the belts stay latched when in use. The NHA said the vehicles were inspected monthly prior to 9/15/25. She said the drivers were now inspecting and recording daily inspections on the vehicles before they transport residents as part of the plan of correction. The maintenance assistant was interviewed on 11/5/25 at 4:06 p.m. The maintenance assistant said he has had ongoing training with the facility vehicle. He said he sometimes assisted with resident transports but was not usually the driver. The maintenance assistant said he learned a lot since the 9/15/25 incident and was aware of what could go wrong. He said a big part of what he learned was to go slow, make sure everything was done correctly and ask questions if he saw something wrong. He said every morning the vehicles were inspected to make sure they were fit to drive and all securement components matched and latched correctly. He said CNA #1 and the plant operations director oversaw the process. He said he felt comfortable with securing a resident and driving the mini van if needed. The NHA and the plant operations director were interviewed together on 11/5/25 at 4:35 p.m. The NHA said the facility would continue with the plan of correction to prevent resident injuries during transport. The plant operations director said the facility would continue to look at ongoing training opportunities for transport drivers.

A complaint survey, prompted by #CO2598628, Incident #2582514 and Incident #2582543 was completed on 9/8/25 to 9/11/25. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure a copy of medical records were provided timely for one (#1) of two residents out of seven sample residents. Specifically, the facility failed to ensure medical records were provided timely upon request to Resident #1’s representative. Findings include:I. Facility policy and procedure The Release of Information policy, revised November 2009, was provided by the clinical regional director on 9/10/25 at 3:21 p.m. The policy read in pertinent part, “The resident may initiate a request to release such information contained in his or her records and charts to anyone he or she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative. “A resident may obtain photocopies of his or her records by providing the facility with at least a 48 hour advance notice of such request.” II. Resident representative interviewResident #1’s representative was interviewed on 9/10/25 at 2:09 p.m. The representative said she requested Resident #1’s medical records from the facility but had never received them after multiple requests. She said she signed the authorization for release form on 7/11/25 and provided the form to the nursing home administrator (NHA). She said she later received a call from the social service director (SSD) that Resident #1’s medical records were ready, but the file was very large and she needed to know how the representative wanted it to be sent to her. The resident’s representative said she called the facility and spoke to the business office manager (BOM). She said she asked for Resident #1’s last two months of physician’s orders and labs to be emailed to her. The resident’s representative said she called the facility again on 8/5/25 and told the SSD that she still had not received the records and wanted them emailed to her. III. Record reviewThe authorization for release of protected health information (PHI) form for Resident #1 was provided by the medical records director on 9/10/25 at 1:20 p.m. The PHI authorization release form for Resident #1 identified that a request for the resident’s medical records was signed on 7/11/25. The form did not identify when the representative received the medical records or when the medical records were sent to the representative. -Review of Resident #1’s electronic medical record (EMR) identified that the spelling of the resident representative’s name in her email address was spelled incorrectly on the contact list. IV. Staff interviewsThe medical records director was interviewed on 9/10/25 at 12:20 p.m. The medical records director said when a resident or their representative requested medical records, they needed to submit an authorization for release form for the medical records. The medical records director said the facility had 30 days to gather the medical records and send them to the requester. She said Resident #1’s medical records were requested by his representative on 7/11/25. The medical records director said she had the resident’s medical records ready on 7/17/25. The medical records director said she did not know in what format the representative wanted the files to be sent to her so the SSD followed up with Resident #1’s representative. The SSD was interviewed on 9/10/25 at 2:51 p.m. The SSD said she emailed the requested medical records to Resident #1’s representative on 7/21/25. She said she used the email address on the resident’s EMR contact list.-However, the resident representative’s name was misspelled in the email address listed on the resident’s EMR contact list (see record review above). The NHA and the BOM were interviewed together on 9/10/25 at 3:05 p.m. The NHA compared the email address she had for Resident #1’s representative with the email address on the resident’s EMR contact list and said the representative’s email address was documented incorrectly on the contact list. She said it was facility’s error and she would make sure Resident #1’s received all requested medical records to the appropriate email address. The BOM said she would update Resident #1’s EMR contact list with the representative’s correct email address. The NHA said she would make sure that any new resident/resident representative contact information would be provided to the facility in writing and then added to the resident’s EMR. The NHA was interviewed again on 9/10/25 at 3:25 p.m. The NHA said the facility tried to send medical record requests within 48 hours, excluding holidays and weekends, but believed the facility had 30 days to send the medical records. The NHA reviewed the medical record policy and said the facility should have provided the medical records to Resident #1’s representative within 48 hours. She said to help with the timeliness of medical records requests, she would educate the medical records director on the appropriate timeline. She said the facility would conduct an audit of all of the residents’ EMR contacts to ensure the facility had accurate records for the contact information for residents’ representatives. The medical records director was interviewed again on 9/11/25 at 10:34 p.m. The medical records director said the NHA informed her that the facility’s policy stated the facility should provide medical record requests to the resident’s representative within 48 hours after the receipt of the PHI authorization release form. The medical records director said a medical record assistant was recently hired. She said the additional staff member would ensure someone from medical records was at the facility five days a week and provide timeliness of record requests. V. Facility follow upThe NHA was interviewed a third time on 9/10/25 at 3:09 p.m. She said she sent Resident #1’s representative the requested medical records to the correct email address on 9/10/25. Review of the email sent by the NHA identified that the email was sent to the resident’s representative on 9/10/25 at 3:07 p.m.

Based on record review and interviews, the facility failed to ensure care plans were revised and appropriate for three (#1 and #3) of four residents reviewed for comprehensive care plans out of seven sample residents. Specifically, the facility failed to:-Ensure Resident #1’s fall care plan was revised to include new interventions if needed to assist in the prevention of falls for 11 out the resident’s 13 falls between 1/17/25 and 6/27/25; and,-Ensure Resident #3’s care plan was revised to include new interventions if needed after the resident fell on 7/27/25. Findings include:I. Facility policy and procedure The Falls-Clinical Protocol policy, revised March 2018, was provided by the nursing home administrator (NHA) on 9/10/25 at 8:01 p.m. via email. According to the fall policy, the staff and the physician would identify pertinent interventions to try to prevent falls and to address the risks of clinical significant consequences of the falls. The policy identified the staff would try various relevant interventions based on the assessment of the nature of the fall until the falls were reduced, stopped or a reason for the fall continuation. The policy documented the staff would continue to monitor and document the individual’s response to the interventions intended to reduce the falls or the consequence of falls. The Care Plans, Comprehensive Person-Centered policy, revised March 2022, was provided by the NHA on 9/11/25 at 3:21 p.m. The policy read in pertinent part, “A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident.“The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident.“The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.“When possible, interventions address the underlying sources of the problem areas, not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident’s condition changes. “The IDT reviews and updates the care plan when there has been a significant change in the resident’s condition; when the desired outcome is not met; when the resident has been re-admitted facility from a hospital stay; and, at least quarterly in conjunction with required quarterly minimum data set (MDS) assessments.”II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 7/24/23 and discharged to the hospital on 6/27/25. According to the June 2025 computerized physician orders (CPO), diagnoses included adult failure to thrive, unspecified dementia, severe with mood disturbance, generalized muscle weakness, difficulty in walking, unsteadiness on feet, other abnormalities of gait and mobility, need for assistance with personal care, repeated falls, and reduced mobility. The 6/15/25 MDS assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The MDS assessment documented Resident #1 used a wheelchair for mobility, required substantial staff assistance to sit to stand and partial to moderate staff assistance to transfer to and from a bed/chair/wheelchair. The MDS assessment revealed the resident had had two or more falls that included injury since his admission. According to the MDS assessment, the resident had a history of wandering but his wandering did not put him at risk to be in a dangerous place. B. Resident representative interviewResident #1’s representative was interviewed on 9/10/25 at 2:08 p.m. The representative said that Resident #1 had multiple falls at the facility and was sent to the hospital after his last fall on 6/27/25. C. Record reviewThe fall care plan, initiated 7/26/23, revised 7/3/25 (after the resident transferred to hospital on 6/27/25 and discharged from the facility) identified Resident #1 was at risk for falls related to cognition, dementia, poor safety awareness and weakness. The intervention, initiated 3/21/25, directed staff to place bed cane to my bed to assist with self positioning and independence. The intervention, initiated 3/27/25, directed staff to place grip tape on the bathroom floor. The Kardex report (a tool utilized to provide staff with instructions for resident care) documented the resident had had falls with injury. -The Kardex did not include interventions to help prevent additional falls. A nursing falls documentation form, dated 1/17/25, documented that Resident #1 experienced an unwitnessed fall at 4:15 p.m. The form documented Resident #1 fell out of his wheelchair on his way to the dining room on 1/17/25. The resident sustained small abrasions/scratches to both of his knees. The 1/7/25 wound evaluation note documented Resident #1 had scattered abrasions on his knees and above his right eyebrow. A nursing falls documentation form, dated 1/17/25, documented that Resident #1 experienced an unwitnessed fall at 7:00 p.m. The form documented Resident #1 wandered into another resident’s room, became confused and fell to the floor. According to the form, the resident stated he was looking for his room when he fell. The resident sustained an abrasion to his left palm.-The facility failed to update or revise the fall plan of care with new interventions as needed after Resident #1 experienced the resident’s two unwitnessed falls on 1/17/25 (see care plan above). A nursing falls documentation form, dated 2/12/25, documented that Resident #1 experienced an unwitnessed fall at 4:38 p.m. The form documented Resident #1 was heard yelling from his room. He was discovered on the floor after attempting to self-transfer from his wheelchair to his bed without injury. -The facility failed to update or revise the fall plan of care with new interventions as needed after Resident #1 experienced the unwitnessed fall on 2/12/25 (see care plan above). A nursing falls documentation form, dated 2/17/25, documented that Resident #1 experienced an unwitnessed fall at 11:15 a.m. The form documented Resident #1 was discovered sitting on the floor besides his wheel chair on 2/17/25. The resident sustained a small skin tear on his resident's right elbow.-The facility failed to update or revise the fall plan of care with new interventions as needed after Resident #1 experienced the unwitnessed fall on 2/17/25 (see care plan above). A nursing falls documentation form, dated 3/15/25, documented that Resident #1 experienced an unwitnessed fall at 11:30 a.m. The form documented Resident #1 was discovered on the floor in the dining room with his dining table chair in front of him and his wheelchair behind him. The resident did not sustain an injury related to the fall. According to the form, the nurse educated the resident to notify staff when he wanted to be transferred.-The facility failed to update or revise the fall plan of care with new interventions as needed after Resident #1 experienced an witnessed fall on 3/15/25 (see care plan above). A nursing falls documentation form, dated 3/21/25, documented that Resident #1 experienced an unwitnessed fall. The form documented Resident #1 fell when he attempted to transfer himself to a chair near the nurses’ station without injury. The 3/21/25 fall occurrence note documented the fall occurred on 3/21/25 at 5:30 p.m. The facility updated the resident’s care plan with a new intervention (see care plan above). A nursing falls documentation form, dated 3/25/25, documented that Resident #1 experienced a staff assisted fall at 7:25 p.m. The form documented Resident #1 fell during a staff assisted transfer from the toilet to his wheelchair. The resident sustained an abrasion on his right forearm measuring 2 centimeters (cm) by 1.5 cm. The facility updated the resident’s care plan with a new intervention on 3/27/25 (see care plan above). A nursing falls documentation form, dated 4/16/25, documented that Resident #1 experienced an unwitnessed fall at 6:00 p.m. The form documented staff was looking for Resident #1 who was discovered outside on the ground after wandering outside to the patio. The resident sustained a bruise to his right knee. According to the form, the resident wanted to wander most of the time and would attempt to stand by himself resulting in a loss in balance.-The facility failed to update or revise the fall plan of care with new interventions as needed after Resident #1 experienced an unwitnessed fall on 4/16/25 (see care plan above). A nursing falls documentation form, dated 4/22/25, documented that Resident #1 experienced a witnessed fall at 3:15 p.m. The form documented Resident #1 was attempting to stand up from the edge of a recliner. A certified nurse aide (CNA) assisted the resident to the floor. The resident sustained a scratch/abrasion to his back.-The facility failed to update or revise the fall plan of care with new interventions as needed after Resident #1 experienced the witnessed fall on 4/22/25 (see care plan above). A nursing falls documentation form, dated 4/22/25, documented that Resident #1 experienced a second fall, unwitnessed, on 4/22/25 at 6:00 p.m. The form revealed Resident #1 was discovered on the floor in another resident’s room after the staff was looking for him during the start of the shift. The form identified he sustained a skin tear on his right wrist measuring 5 cm by 1.5 cm.-The facility failed to update or revise the fall plan of care with new interventions as needed after Resident #1 experienced an unwitnessed fall (his second fall on that date) on 4/22/25 (see care plan above). A nursing falls documentation form, dated 5/6/25, documented that Resident #1 experienced an unwitnessed fall at 8:30 a.m. The form documented Resident #1 was discovered on the floor of the hallway, gripping the chair railing with his left arm while his wheelchair was positioned behind him. He did not sustain an injury as a result of the fall. -The facility failed to update or revise the fall plan of care with new interventions as needed after Resident #1 experienced an unwitnessed fall on 5/6/25 (see care plan above). A nursing falls documentation form, dated 5/30/25, documented that Resident #1 experienced an unwitnessed fall at 12:40 p.m. The form documented Resident #1’s fall was recorded on the facility’s security camera. According to the form, the resident was in the dining room when he stood up from his wheelchair and moved the dining chair closer to him. He attempted to sit down but missed the dining chair and fell backwards against the table without injury. -The facility failed to update or revise the fall plan of care with new interventions as needed after Resident #1 experienced the unwitnessed fall on 5/30/25 (see care plan above). A 5/31/25 fall occurrence note documented that Resident #1 experienced a witnessed fall at 11:00 p.m. The note documented Resident #1 fell when staff was attempting to transfer the resident from his wheelchair to the toilet when he became weak and fell on his coccyx with his back against the wall. He did not sustain injuries as a result of his fall.-The facility failed to update or revise the fall plan of care with new interventions as needed after Resident #1 experienced a staff assisted fall on 5/31/25 (see care plan above). A nursing falls documentation form, dated 6/27/25, documented that Resident #1 experienced an unwitnessed fall at 5:30 p.m. The form revealed he was discovered on the floor at the end of the bed, in another resident’s room, after attempting to transfer himself to the bed. The form documented there was blood observed in the bathroom and on the door of the bathroom. He had a small open area to the back of his head and skin tears to both of his elbows. The form identified Resident #1 was transferred tothe hospital for evaluation and treatment. III. Resident #3A. Resident statusResident #3, age greater than 65, was admitted on 8/1/19 and readmitted on 8/24/23. According to the September 2025 CPO, diagnoses included a history of falling, adult failure to thrive, generalized muscle weakness, difficulty with walking, unsteadiness on feet, other abnormalities of the gait and mobility, need for assistance with personal care, unspecified dementia mild with other behavioral disturbance and displaced fracture of upper end of left humerus, subsequent encounter for fracture with routine healing. The 6/19/25 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of three out of 15. The MDS assessment indicated Resident #3 had inattention and disoriented thinking. The MDS assessment identified she used a wheelchair for mobility and required substantial staff assistance transfer from surface to surface. According to the MDS assessment, the resident had a history of falls. B. Record reviewThe fall care plan, initiated 2/15/23, identified Resident #3 was at risk for falls related to bladder and/or bowel incontinence, decreased strength and endurance and need for assistance with her activities of daily living (ADL). Interventions, dated 2/15/23, directed staff to place her bed against the wall in the lowest position, keep her food/fluids/call light and other needed items within reach and educate the resident how to use her call light and reminders of use. The intervention dated 11/12/24 documented Resident #3’s room was moved closer to the nurses’ station. The intervention, dated 3/8/25, directed staff to provide the resident with non-skid footwear. The intervention, dated 3/21/25, identified Resident #3 had a bed cane (assistive device) to help her with independence and self positioning. The interventions, dated 6/18/25, directed staff to make sure her oxygen tank had oxygen in the tank and that the oxygen tank was turned on and offer her ice water. -The facility failed to update or revise the fall plan of care with new interventions as needed after Resident #1 experienced an unwitnessed fall on 7/27/25 (see progress note below). The 7/27/25 fall occurrence note documented Resident #3 was found on the floor on 7/27/25 at 8:45 a.m. in front of her wheelchair, in the doorway of her room. The 7/27/25 health status note documented there were no injuries related to the 7/27/25 fall. The 7/28/25 IDT meeting note documented Resident #3 was working with therapies on safety awareness, education for the need to ask for assistance and visual cues to call for assistance. IV. Staff interviewsThe NHA and the director of nursing (DON) were interviewed together on 9/10/25 at 5:36 p.m. The NHA said after a resident fell, the fall was discussed in the next morning meeting and in the at-risk meeting. The NHA said the facility conducted a fall investigation, to include checking if the room was safe, looking for any potential fall hazards and making any needed changes. The DON said the IDT reviewed the resident’s past fall history and looked for any trends and patterns. She said the only pattern that was identified for Resident #1 was that he usually fell because he was self transferring himself. The NHA and the DON reviewed Resident #1’s falls and fall care plan and said many of the resident’s fall recommendations were not added to the care plan or the Kardex. The NHA said the care plan was a staff directive and the Kardex was a communication guide for the CNAs. CNA #1 was interviewed on 9/11/25 at 9:11 a.m. CNA #1 said she would find out from other staff members what a resident’s fall interventions were. CNA #2 was interviewed on 9/11/25 at 9:14 a.m. She said she would ask the nurse what the residents’ fall precautions were. Licensed practical nurse (LPN) #1 was interviewed on 9/11/25 at 9:25 p.m. LPN #1 said she was newer to the facility and would read the residents’ care plans to let her CNAs know what the residents’ fall interventions were. The NHA was interviewed a second time, along with the clinical regional director on 9/11/25 at 9:53 a.m. The clinical regional director said there were no care planned interventions added to the care plan after Resident #3 fell on 7/27/25. The NHA said there was a sign in the resident’s room reminding her to ask for assistance, but the intervention should have been to the care plan. The social services director (SSD) was interviewed on 9/11/25 at 10:19 p.m. The SSD said she was a CNA and would frequently pick up shifts as a CNA. She said she would look at a resident’s care plan to know what the resident’s fall interventions were. The clinical regional director was interviewed a second time on 9/11/25 at 10:25 p.m. The clinical regional director said CNAs had access to a resident’s Kardex. She said the Kardex would include a resident’s fall interventions but the interventions would be generated from the fall care plan. The minimum data set (MDS) coordinator was interviewed on 9/11/25 at 9:40 a.m. The MDS coordinator said she was new to her position but was currently taking on the role of updating residents’ care plans. She said when she initially created care plans, she would figure out what the residents’ needs and preferences were. She said the care plan was updated quarterly, upon changes of condition or any time the resident’s needs would change. She said she was continuing to try to learn the facility’s care plan process and trying to personalize each resident’s care plan. She said care plans should be updated to continue to meet the resident’s needs. The MDS coordinator said she had started a facility-wide care plan audit to make sure that residents’ care plans were updated and included all appropriate interventions. She said she had not had the opportunity to complete the audit and make the needed changes/interventions. She said the IDT reviewed the residents’ falls during the morning meeting and her goal was to then add new fall prevention interventions to the care plans right away if the interventions could be immediately implemented. The MDS coordinator said it was important to make sure interventions were on the care plan so the personal-centered interventions could be transferred to the Kardex. She said the care plan was a form of communication so staff knew the personalized steps to take care of each resident. The NHA and the DON were interviewed again together on 9/11/25 at 11:25 a.m. The NHA said moving forward, she would make sure the IDT would stay in the at-risk meeting until all the newly identified fall interventions were updated on the care plans. The DON said if some of the interventions required permission from the residents’ representatives, they would update the care plan with the interventions as soon as the facility obtained the needed permission. The NHA said the facility had started a Kardex training today (9/11/25) to ensure all the CNAs were familiar with how to access the residents’ Kardex and identify the fall prevention interventions for residents at risk for falling.

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

A revisit survey was completed on 7/24/24 for all previous deficiencies cited on 6/27/24. The facility is in compliance with all regulations surveyed.

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, 33,951 square foot, Type II (111) construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinkled. The facility was constructed in 1992 and is licensed for 110 beds. This re-certification survey conducted on July 24, 2024, was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey. The Administrator reported the daily census to be 61. NOTE: Existing life safety features that meet the requirements for new construction at the time of licensure or certification shall be maintained and not be diminished.

Through observation during the survey, it was determined that the facility failed to maintain doors in accordance with NFPA 101. This was evidenced by:1) The courtyard needs to remove obstructions on the egress pathway to a public wayNFPA 101 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 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 facility maintenance director during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:1) The courtyard needs exit signage to the public way2) Need to assess exit signage to dining hall per original design; doors do not swing in the path of travel as it is currently markedNFPA 101 19.2.10.1 & 7.10: Marking of Means of EgressThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. Deficient items were discussed with the facility maintenance director during the exit conference.

Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 25. This was evidenced by:1) Fire Suppression Semi-Annual: 12.21.24 Not done per NFPA 25 standards, need to exercise valves and flow switches2) Fire Suppression Annual: 6.28.24 Cooper Fire report needs to reflect the year of heads. NFPA 101, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, Chapter 5 Sprinkler SystemsTable 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. NFPA 25, Chapter 13 Common Components and ValvesTable 13.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. NFPA 25 4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. 4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. This deficiency could affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 80. This was evidenced by:1) medical record storage not latching2) The dining hall office door closure needs to be adjusted3) A wing janitor closet needs a new door closure 4) Need closure reinstalled on the director of the nursing room5) Need closure reinstalled in the activity roomNFPA 101, 8.3.3.1Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code. NFPA 80, 5.2 Inspections. 5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.5.2.15.3 Where a fire door, frame, or any part of its appurtenances is damaged to the extent that it could impair the door ' s proper emergency function, the following actions shall be performed:(1)The fire door, frame, door assembly, or any part of its appurtenances shall be repaired with labeled parts or parts obtained from the original manufacturer.(2)The door shall be tested to ensure emergency operation and closing upon completion of the repairs. These deficiencies can potentially affect occupants, including residents, staff, and visitors throughout the facility. The deficient item was discussed with the maintenance team at the exit conference.

Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): Not ProvidedNFPA 996.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. 6.3.4.1.3 Receptacles not listed as hospital-grade at patient bed locations and in locations where deep sedation or general anesthesia is administered shall be tested at intervals not exceeding 12 months. NFPA 996.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) trans-filling exhaust not within 12" of the floor NFPA 99 9.3.7.4 Transfilling area shall be provided with ventilation in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code. NFPA 55 6.15.7.26.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. The deficient item was discussed with the maintenance team at the exit conference.

A recertification survey with complaint #CO36239 was completed on 6/24/24 to 6/27/24. Three deficiencies were cited.

An Emergency Preparedness survey was conducted from 6/24/24 to 6/27/24. No deficiencies were cited.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled on three of five units. Specifically, the facility failed to ensure residents' topical medications were stored and locked in appropriate medication carts or medication storage rooms that were accessed only by authorized licensed personnel. Findings include:I. Facility policy and procedureThe Medication Labeling and Storage policy and procedure, reviewed February 2023, was provided by the nursing home administrator (NHA) on 6/26/24 at 2:20 p.m. It read in pertinent part,"Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise available to others."Medications are stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer or other holding area to prevent the possibility of mixing medications of several residents."II. ObservationsOn 6/24/24 at 9:15 a.m. the E hallway shower room contained a cart with Triamcinolone cream 0.1% labeled for Resident #26 and an over the counter (OTC) antifungal powder spray, which was not labeled with a specific resident's name, sitting on it. On 6/24/24 at 11:02 a.m. a bottle of Nystatin (an antifungal) 100,000 units per one gram topical powder and an OTC antifungal powder spray, both labeled for Resident #164, were observed on the chest of drawers in Resident #164's room. On 6/25/24 at 10:25 a.m. a bottle of Nystatin 100,000 units per one gram topical powder and an OTC antifungal powder spray, both labeled for Resident #164, were observed on the chest of drawers in Resident #164's room. On 6/26/24 at 11:00 a.m. the E hallway shower room contained a cart with an OTC antifungal powder spray, which was not labeled with a specific resident's name, sitting on it. On 6/26/25 at 11:03 a.m. the D hallway shower room contained a cart with an OTC antifungal powder spray, which was not labeled with a specific resident's name, sitting on it. On 6/26/25 at 11:06 a.m. the A hallway shower room contained a cart with an OTC antifungal powder spray, which was not labeled with a specific resident's name, sitting on it. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 6/26/24 at 11:00 a.m. RN #1 said all medications, which included OTC medications, should be stored in a medication cart or in the medication storage room. She said medications should not be stored unsecured in shower rooms or in residents' rooms. RN #1 said unlicensed personnel could not administer medications. She said it was a hazard if other residents obtained unsecured medications and self administered them. The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 6/26/24 at 11:30 a.m. The IP said medications needed to be secured in a medication cart or a medication storage room so unlicensed personnel could not administer them. The IP said medications should be properly secured to ensure other residents could not access the medications and self administer them.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to:-Ensure kitchen staff handled ready-to-eat foods in an appropriate sanitary manner to prevent cross contamination; and,-Ensure safe holding temperatures for food items were maintained. Findings include:I. Inappropriate handling of ready-to-eat foodsA. Professional referenceThe Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 7/1/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment."B. Facility policyThe Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, revised 11/2022, was provided by the nursing home administrator (NHA) on 6/26/24 at 2:20 p.m. It read in pertinent part, "Gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed and gloves are replaced between handling soiled and clean dishes."Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper, and spatulas as tools to prevent foodborne illness."C. ObservationsOn 6/25/24 the lunch meal service was observed during a continuous observation, beginning at 10:00 a.m. and ending at 1:10 p.m. At 10:24 a.m. cook (CK) #1 began preparing hamburger buns for lunch service. CK #1 donned a pair of gloves and opened the plastic packaging for the buns. CK #1 pulled a sheet of hamburger buns out of the packaging and separated them using the same pair of gloves before placing them into a steam table bin. CK #1 opened the plastic packaging of the next set of hamburger buns and started separating the buns using the same pair of gloves. From 11:30 a.m. to 11:42 a.m., CK #1 used the same pair of gloves to grab hamburger buns out of the steam table bin and separate the top and bottom buns and put them onto plates. CK #1 held the top of the sandwich while cutting it in half for several residents' meals before grabbing the sandwich slices and putting them onto plates. -CK #1 was handling tray cards and serving utensils between each resident's hamburger bun without changing gloves or washing hands. At 11:42 a.m. CK #1 began using tongs to take hamburger buns out of the bin and separate them.-At several points during the lunch service, CK #2 touched several hamburger buns while wearing gloves to stabilize the buns while scooping chicken onto them. -CK #2 was observed touching the bottom of the plates and serving utensils with the same pair of gloves. D. Staff interviewThe dietary director (DD) was interviewed on 6/26/24 at 9:31 a.m. The DD said ready-to-eat foods should be handled with tongs and kitchen staff should not cross-contaminate food by touching handles before touching ready-to-eat foods. The DD said she had re-educated the kitchen staff on the subject many times. The DD said gloves should only be worn when touching raw food or during meal preparation and kitchen staff needed to wash their hands in between glove changes. II. Maintain safe holding temperatures for food itemsA. Professional referenceThe Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 7/1/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Time/temperature control for safe food cold holding shall be maintained at 5 (five) degrees Celsius (C) (41 degrees Fahrenheit) or less.""Time/temperature control for safety food that is cooked to a temperature and for a time specified under §§ 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57 degrees C (135 degrees Fahrenheit) or above."According to the product guidelines for MedPass Fortified Nutritional Shake, retrieved on 7/1/24 from https://www.hormelhealthlabs.com/resources/for-healthcare-professionals/product-protocols/med-pass-fortified-nutritional-shake-medication-pass-program/, "MedPass products can safely remain on a medication cart as long as it is kept at refrigerated temperature range 34 to 40 degrees Fahrenheit (F)."Cover, label and refrigerate opened containers of MedPass products and discard after four days as long as the product has been kept at the proper refrigerated temperature range."B. Facility policyThe How to Monitor and Record in Temperature and PPM (parts per million) Logbooks document, undated, was provided by the DD on 6/26/24 at 1:43 p.m. It read in pertinent part, "To record a hot or cold hold temperature, insert a thermometer in food or dish on the service line and record it in the log. This should be done at least 30 to 45 minutes after to ensure that steam tables or ice baths are holding food at appropriate ranges. "If hot hold temperature is out of range (below 135 degrees F) notify the dietary director and/or maintenance director directly. If cold hold temperature is out of range, food product was not placed in an adequate ice bath, more ice should be added, or the container should be submerged deeper in the ice bath. Adjust as needed."C. ObservationsOn 6/25/24 at 12:48 p.m. final temperatures were taken of food items that were served to residents during lunch service. A batch of french fries measured 125 degrees fahrenheit (F). At 12:53 p.m. CK #1 served french fries to a resident from this batch without reheating it.-The temperature of this hot food item was below the safe temperature parameter for hot foods of 135 degrees F or above. On 6/25/24 temperatures of food items kept at the nurses' medication carts were obtained. Each medication cart had a small plastic bin with no lid and side walls approximately four inches high. At 1:03 p.m., on the D and E hall medication carts, the MedPass nutritional supplement measured 58 degrees F. The bin holding the MedPass supplement was filled with fresh ice that reached approximately halfway up the MedPass carton.-The temperature of this nutritional supplement was above the safe temperature parameter for cold foods of 41 degrees F or less. At 1:07 p.m. on the I hall medication cart, the MedPass nutritional supplement measured 62 degrees F. The bin holding the MedPass supplement did not contain any ice.-The temperature of the nutritional supplement was above the safe temperature parameter for cold foods of 41 degrees F or less. D. Record reviewThe kitchen temperature log book was reviewed on 6/25/24 at 1:10 p.m. -The temperatures from lunch service on 6/24/24 through lunch service on 6/25/24 had not been recorded. E. Staff interviewsCK #1 was interviewed on 6/25/24 at 12:48 p.m. CK #1 said 30 to 39 degrees F were safe holding temperatures for cold items and 160 to 170 degrees F for hot items. CK #1 said he would reheat hot foods that had fallen below the safe holding temperature prior to serving them to residents. CK #1 said he had not yet filled out the temperature logs from lunch nor breakfast that day (6/25/24).-However, CK #1 was observed serving a resident french fries that had fallen below 135 degrees F without reheating them following the interview above. The dietary director (DD) was interviewed on 6/26/24 at 9:31 a.m. The DD said she had to consistently remind the kitchen staff about time and temperature control and it was an ongoing issue. The DD said she had held weekly meetings with the kitchen staff to try to correct the issue. The DD was interviewed a second time on 6/26/24 at 12:57 p.m. The DD said safe holding temperatures for hot foods were from 150 to 165 degrees F and 40 degrees F or below for cold foods. The DD said it was not okay to serve hot foods that had fallen below safe holding temperatures and the food would need to be reheated prior to serving. The DD said she did not know the kitchen was to be involved with supplement storage on medication carts. The Dd said she did not know what temperature the nutritional supplements needed to be stored at. The DD said she assumed the supplements needed to be cold. III. Additional InformationThe kitchen staff disciplinary and educational records were provided by the DD on 6/27/24 at 10:01 a.m. The records revealed the following:On 4/10/24 CK #2 received education on food temperatures, cleanliness, safety, and maintaining temperature logs each shift. On 4/15/24 CK #1 received education on handwashing, food temperatures, and sanitation. On 5/20/24 CK #1 received education on safety, cleanliness, and maintaining temperature logs. On 5/20/24 all kitchen staff were educated on safety, cleanliness, cross-contamination, food temperatures, and handwashing.-However, despite the education above being provided to dietary staff on several occasions, observations during the survey revealed staff were not adhering to appropriate food handling and safe food temperature guidelines (see observations above).

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on four of five units. Specifically, the facility failed to:-Ensure residents' rooms were cleaned in a sanitary manner; -Ensure residents' personal care items were labeled and stored in a sanitary manner; and,-Ensure a urinary catheter was maintained in a sanitary manner. Findings include:I. Housekeeping failuresA. Professional referenceThe Centers for Disease Control and Prevention (CDC), Environment Cleaning Procedures (5/4/23), was retrieved on 7/1/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, "Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms."Clean patient areas (patient zones) before patient toilets."B. Manufacturer's recommendationsAccording to the Lysol Power and Fresh Multi-Surface Cleaner guidelines, undated, retrieved on 7/1/24 from https://www.lysol.com/products/multi-purpose-cleaners/lysol-power-and-fresh-multi-surface-cleaner,"To sanitize leave for one minute before wiping, to disinfect leave for six minutes before wiping."C. Facility policy and procedureThe Cleaning Residents Rooms policy and procedure, undated, was provided by the nursing home administrator (NHA) on 6/27/24 at 10:09 a.m. It read in pertinent part,"Protective gloves must be worn and changed with a sanitization between each change of the gloves throughout the entire cleaning process."Clean from clean to dirty meaning the bathroom will always be last and clean from top to bottom."Always follow chemical specific instructions and dwell times for each individual chemical."D. ObservationsOn 6/27/24 at 9:30 a.m. housekeeper (HSK) #1 was observed cleaning room #I-06..HSK #1 put on gloves. She obtained the toilet brush from the housekeeping cart and scrubbed the inside of the toilet bowl with Comet cleaner. She proceeded to scrub under the toilet seat with the toilet brush and placed the toilet brush handle between the toilet seat and toilet bowl with the toilet brush hanging into the toilet bowl.-HSK #1 failed to ensure that she did not proceed to a cleaner area after cleaning the inside of the toilet bowl. -HSK #1 failed to ensure the handle of the toilet brush was kept sanitary by not propping the handle of the toilet brush on top of the toilet bowl underneath the toilet seat lid. HSK #1 wiped the outside of the sink with a rag that was soaking in Lysol Power Fresh Multi-Surface disinfectant solution. She wiped the towel dispenser on the bathroom wall, along the bathroom railing and the top of the toilet tank. She used the same rag and wiped the top of the toilet lid, the top of the toilet bowl, down the sides of the toilet bowl and back to the top of the bowl.-HSK #1 failed to ensure the surfaces remained visibly wet for the six minute disinfectant time specified by the manufacturer's guidelines (see guidelines above). -HSK #1 failed to clean from higher surface areas before proceeding to lower surface areas. -HSK #1 failed to change her gloves, perform hand hygiene and use a new rag before moving to a higher or cleaner area. HSK #1 placed her used rag into the used rag container. She removed and replaced her gloves.-HSK #1 failed to perform hand hygiene after her gloves were removed before putting on a new pair of gloves. HSK #1 obtained a new rag from the disinfectant solution and wiped the light switch, top of the chest of drawers, door handles, top of the table, closet handles, window sill and remote control.-HSK #1 failed to ensure surfaces remained visibly wet for the six minute disinfectant time specified by the manufacturer's guidelines (see guidelines above). .-HSK #1 failed to clean the resident's room before cleaning the bathroom. On 6/27/24 at 9:45 a.m. HSK #1 was observed cleaning room#I-05. HSK #1 donned new gloves and obtained a new rag from the disinfectant solution. She wiped the door handles, light switches, bathroom door handles, bedside table window sill and top of chairs. She disposed of the rag in the used rag container and donned new gloves.-HSK #1 failed to ensure surfaces remained visibly wet for the six minute disinfectant time specified by the manufacturer's guidelines (see guidelines above). . -HSK #1 failed to perform hand hygiene before donning gloves to clean the room. HSK #1 obtained an uncovered toilet scrub brush lying on top of used rags. She used Comet cleaner on the inside of the toilet bowl and scrubbed the inside of the toilet bowl, top of the bowl and inside of the bowl. She proceeded to scrub under the toilet seat with the toilet brush and placed the toilet brush handle between the toilet seat and toilet bowl with the toilet brush hanging into the toilet bowl.-HSK #1 failed to ensure that she did not proceed to a cleaner area after cleaning the inside of the toilet bowl. -HSK #1 failed to ensure the handle of the toilet brush was kept sanitary by not propping the handle of the toilet brush on top of the toilet bowl underneath the toilet seat lid. HSK #1 placed the toilet brush on the used rags. She obtained a new rag from the disinfectant solution on the housekeeping cart. She wiped the bathroom handrails, soap dispenser, towel dispenser, top of the toilet tank, the raised commode seat, top of the toilet seat lid, the toilet tank, the top of the toilet seat lid, the top of the toilet bowl and down the side of the toilet bowl.-HSK #1 failed to ensure hand hygiene was performed and new gloves were donned before touching clean rags in the disinfectant solution. -HSK #1 failed to ensure surfaces remained visibly wet for the six minute disinfectant time specified by the manufacturer's guidelines (see guidelines above). -HSK #1 failed to clean from higher surface areas before proceeding to lower surface areas. -HSK #1 failed to change her gloves, perform hand hygiene and use a new rag before moving from a dirty area to a clean area. E. Staff interviewsHSK #1 was interviewed on 6/27/25 at 10:00 a.m. HSK #1 said she should start with the residents' room first before she cleaned the bathroom. She said when she cleaned the bathroom she would first sanitize with the rag soaked in the disinfectant solution. She said she did not know what disinfectant was used and she said she was not sure how long the solution should stay wet on the surfaces. HSK #1 said when she cleaned the toilet, she cleaned with the toilet brush first and would prop the handle of the toilet brush under the toilet seat lid to let the toilet brush drain into the toilet bowl. She said she would use the toilet brush to scrub the toilet seat lid if it was dirty with fecal material. She said after a dirty area was cleaned, a new rag was used after hand hygiene was performed and new gloves were donned. She said after the bathroom was cleaned, hand hygiene was performed and new gloves were donned before touching clean items on the housekeeping cart.-However, HSK #1 failed to perform hand hygiene or change her gloves appropriately while cleaning the residents' rooms (see observations above) HSK #1 said, after she used the toilet brush, she placed it on the bottom of the housekeeping cart next to the used rags. She said she was not aware of any procedure to clean or disinfect toilet brushes after they were used. The housekeeping manager (HLM) was interviewed on 6/27/24 at 10:30 a.m. The HLM said Lysol Multi Surface Cleaner was used for resident rooms and had a ten minute disinfectant time according to the label instructions. She said resident rooms should be cleaned from clean to dirty and clean areas should not be cleaned after dirty areas unless a new rag was used, hand hygiene was performed and new gloves were donned. She said resident rooms should be cleaned first before cleaning resident bathrooms. The HLM said high areas shouldbe cleaned first before lower areas. She said, after bathrooms were cleaned, gloves should be removed and hand hygiene performed before touching clean supplies on the housekeeping cart. She said the toilet brush handle should not be propped under the toilet lid to drain because the handle should be kept as sanitary as possible. She said she was not sure of the process of disinfecting toilet brushes but they should be kept in a bag on the bottom of the cart so it did not touch anything else on the cart. She said the toilet brush should be disinfected once a day. The plant and facility operations director (PFOD) was interviewed on 6/27/24 at 10:40 a.m. The PFOD said he contacted the chemical vendor to find a cleaning solution that did not require such a long disinfectant time. He said this was to ensure that areas were cleaned in a sanitary manner and housekeepers were able to keep surface areas wet for the required disinfectant time. II. Personal items failuresA. ObservationsOn 6/24/25 at 9:15 a.m. the E hallway shower room had a cart with a Eucerin cream, lotions, shampoo, conditioners and deodorant sitting on it.-None of the personal items on the cart were labeled with a specific resident's name. On 6/26/24 at 11:00 a.m. the E hallway shower room cart had a Eucerin cream, lotions, shampoos, conditioners and personal deodorant sitting on it.-None of the personal items on the cart were labeled with a specific resident's name. On 6/26/24 at 11:05 a.m. the D hallway shower room cart had a Eucerin cream sitting on it.-The Eucerin cream was not labeled with a specific resident's name. On 6/26/24 at 11:08 a.m. the A hallway shower room cart had personal deodorant, lotions and shampoo sitting on it.-None of the personal items on the cart were labeled with a specific resident's name. B. Staff interviewsRegistered nurse (RN) #1 was interviewed on 6/26/24 at 11:00 a.m. RN #1 said all residents' personal care items should be labeled and stored so that the items were not used on multiple residents. She said if personal items were used on multiple residents it was not a sanitary practice. She said any unlabeled used personal items in the shower room should be discarded. Certified nurse aide (CNA) #1 was interviewed on 6/26/24 at 12:00 p.m. CNA #1 said she would use only personal care items that were labeled for specific residents. She said unlabeled personal care items in the shower room should not be used and stored in the shower room. The infection preventionist (IP) was interviewed on 6/26/24 at 2:35 p.m. The IP said CNAs should label and place personal care items in an individual emesis basin if a resident shared a room with another resident. She said unlabeled personal items should not be stored in the shower rooms as this could cause personal items to be used on multiple residents. The IP said any unlabeled personal care items in the shower rooms should be discarded. III. Urinary catheter failureA. ObservationsOn 6/24/24 at 11:03 a.m. Resident #164's urinary catheter drainage bag was observed hanging on the edge of the trash can. On 6/25/24 at 10:24 a.m. Resident #164's urinary catheter drainage bag was observed on the floor. On 6/26/25 at 10:54 a.m. Resident #164's urinary catheter drainage bag was observed on the floor. B. Staff interviewsRN #1 was interviewed on 6/26/25 at 10:55 a.m. RN #1 said urinary catheter drainage bags should be kept off the floor to keep them from being contaminated by microorganisms on the floor. She said the hook on Resident #164's urinary catheter drainage bag was broken and that was why the bag was on the floor. She said the resident's urinary catheter drainage bag should be changed out with a new bag. The director of nursing (DON) was interviewed on 6/27/24 at 10:00 a.m. The DON said urinary catheter drainage bags should be kept off the floor because of the potential for contamination from microorganisms from the floor. She said urinary catheter drainage bags that were kept on the floor should be changed out with a new bag.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 03/06/2023 and 03/12/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.