PINE RIDGE REHABILITATION AND HEALTHCARE CENTER

This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a)This survey was conducted on March 9, 2026, for compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies;" NFPA 99, Health Care Facilities Code (2012); and all referenced standards. The facility will meet these requirements when the following deficiencies are corrected. The facility is a type V (000) single-story structure with a full crawl space building, constructed November 26, 1997, with a connected eight room addition type V(111) constructed, August 11, 2005. The facility incorporates a distinct, two-hour, fire-rated separation from the rehabilitation area. The facility contains an automatic fire suppression system classified as fully sprinklered. The facility is licensed for 60 beds with a census on the day of survey of 45.

Based on observation and staff interview, the facility’s fire sprinkler was not compliant with NFPA 101 and NFPA 25. This deficiency was identified with staff during the survey walk-through. Findings include: 1. Multiple fire sprinkler heads are corroded within the dishwashing area of the kitchen. Regulatory Reference: 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. NFPA 25 (5)5.2.1 Sprinklers. 5.2.1.1Sprinklers shall be inspected from the floor level annually. 5.2.1.1.1Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:(1) Leakage(2) Corrosion(3) Physical damage(4) Loss of fluid in the glass bulb heat responsive element(5) Loading(6) Painting unless painted by the sprinkler manufacturerThis deficient practice has the potential to affect staff and approximate 15-20 residents within the kitchen and dining room area. Deficient items were discussed with the Administrator and Maintenance Team at the exit conference.

Based on observation and staff interview, the facility failed to maintain the building services electrical wiring was not compliant with NFPA 101 and NFPA 70. Findings include:1. Wall plate covering an electrical outlet and wiring is broken in the Administrator’s Office 2. The protective sheathing for the plug-end has separated where the cord meets the plug-end exposing the electrical wiring. This is due to furniture being pushed against the plug end causing damage to the protective sheathing. Regulatory Reference: NFPA 101 (12)19.5 Building Services. 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 9.1 Utilities. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70, National Electric Code (11) Article 400 Flexible Cords and Cables - Part I. General 400.1 Scope. This article covers general requirements, applications, and construction specifications for flexible cords and flexible cables. 400.3 Suitability. Flexible cords and cables and their associated fittings shall be suitable for the conditions of use and location. Article 406 Receptacles, Cord Connectors, and Attachment Plugs (Caps)406.1 Scope. This article covers the rating, type, and installation of receptacles, cord connectors, and attachment plugs (cord caps). 406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. The deficient practice has the potential to affect the room occupants, who might include residents, staff, and visitors. Deficient items were discussed with the Administrator and Maintenance Director at the exit conference.

A survey with #CO2694166 was completed on 2/9/26 to 2/12/26. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#5) of six residents reviewed for accident hazards out of 14 sample residents. Resident #5 was admitted on 6/19/23 with a diagnosis of dementia. Resident #5 was at risk for falls related to impaired mobility and cognition. Resident #5, who had a history of falls with major injury, sustained an unwitnessed fall on 8/14/25. The facility re-educated the resident on the use of the call light. However, the resident had impaired cognition and did not always remember to use the call light. On 8/22/25 the resident sustained another unwitnessed fall. The resident sustained a laceration to her hand and a fracture of the metacarpal base to her left hand The resident was sent to the hospital and received sutures to the laceration. Upon return, the facility failed to implement person-centered fall interventions and the resident sustained four more additional falls on 10/24/25, 1/12/26, 2/2/26 and 2/5/26. Specifically, the facility failed to implement effective person-centered fall interventions to prevent recurrent falls for Resident #5. Findings include:I. Facility policy and procedureThe Falls-Clinical Protocol policy, revised March 2018, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:51 p.m. It read in pertinent part,“For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem. If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. After a fall, the physician should review the resident’s gait, balance, and current medications that may be associated with dizziness or falling. Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. “Treatment/Management: Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Examples of such interventions may include calcium and vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing, or changing problematic medications (for example, those that could make the resident dizzy or cause blood pressure to drop significantly on standing). If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance).“The staff and physician will monitor and document the individual’s response to interventions in-tended to reduce falling or the consequences of falling. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented.“If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has been resolved by addressing the underlying cause. If the individualcontinues to fall, the staff and physician will reevaluate the situation and reconsider possible reasons for the resident’s falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. II. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on 6/19/23. According to the February 2026 computerized physician's orders (CPO), diagnoses included chronic kidney disease, generalized muscle weakness, dementia with behavioral disturbance, generalized anxiety, transient ischemic attack (TIA) cerebral infarction without residual deficits (stroke), abnormal gait and mobility, history of falling and history of COVID-19. The 11/30/25 comprehensive assessment revealed Resident #5 had severe cognitive impairment. Resident #5 required substantial/maximal assistance with bathing. Resident #5 required supervision or touching assistance with all transfers, toileting, oral and personal hygiene, upper and lower body dressing as well as footwear. Resident #5 had limited range of motion to both lower extremities, used a wheelchair for mobility and required moderate assistance to move over 50 feet. The assessment indicated the resident had a fall without injury. -However, Resident #5 sustained a fall with injury on 8/22/25. B. Observation and interviewResident #5 was interviewed on 2/9/26 at 2:07 p.m. Resident #5 commented multiple times during the interview that her shirt and her pants felt wet. Resident #5 said she was not sure how often staff checked on her or what staff helped her with. The room had a faint odor of urine. Resident #5 had her touch pad call light within reach. There was not a visual reminder in the resident’s room to use her call light. C. Record review 1. Care plan Resident #5’s fall care plan, revised 2/9/26, documented the resident was at risk for falls related to decreased mobility and unsteady gait. Pertinent interventions included attempting to provide all needed items for hygiene and toileting while Resident #5 was in the bathroom to try to help prevent her from reaching for things and potentially falling; placing needed items directly next to Resident #5 within reaching distance, re-arranging furniture items in the room, placing non-skid tape in front of bed, toilet and recliner, fall mat, reaching device, and placing a sign in the resident’s room to remind her to use her call light for assistance. 2. Fall on 8/14/25 - unwitnessed The progress note, dated 8/14/25 at 9:17 p.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 reported to staff she was trying to get out of bed and fell. The note documented Resident #5 sustained two small skin tears to the left knee. The progress note, dated 8/15/25 at 9:14 a.m., revealed an interdisciplinary team (IDT) meeting reviewing Resident #5’s fall. The progress note documented the nursing recommendation was to re-educate Resident #5 on the importance of using her call light for assistance with ambulation. The progress note documented no other recommendations from other departments at this time. The progress note, dated 8/21/25 at 9:58 a.m., revealed an IDT meeting reviewing effectiveness of the current fall interventions. The progress note documented staff re-educated Resident #5 on the importance of using the call light when needing to ambulate. The progress note documented no other recommendations from other departments at this time. 3. Fall on 8/22/25 - unwitnessed The progress note, dated 8/22/25 at 4:30 a.m., revealed Resident #5 had an unwitnessed fall. The progress note documented two unidentified certified nurse aides (CNA) reported Resident #5 was found sitting on the floor in front of her bed, bleeding from her left hand. The progress note revealed the registered nurse (RN) assessed Resident #5 and found a laceration across the resident’s left palm. The laceration measured two inches long, 0.5 centimeters (cm) wide and 0.5 cm deep. The progress note documented first aid was applied to the wound and Resident #5 was transported to the local area emergency room for further evaluation. The progress note, dated 8/22/25 at 9:37 a.m., revealed an IDT meeting reviewing the fall occurring on 8/22/25. The progress note documented the nursing recommendation was to rearrange the furniture in Resident #5’s room for ease of transfers. The progress note documented the additional intervention of a wedge pillow between the bed and bedside table to protect the resident from sharp edges. The progress note documented no other recommendations from other departments at this time. -Additionally, the facility did not reassess moving the furniture around after the family requested for the furniture to be moved back (see interviews below). The progress note, dated 8/22/25 at 10:45 a.m., revealed Resident #5 returned to the facility from the local area emergency room. The progress note documented Resident #5 required sutures to her left palm laceration and Resident #5 sustained a metacarpal base fracture to her left hand as a result of the fall. The progress note, dated 8/22/25 at 11:55 a.m., revealed Resident #5’s representative was contacted about the intervention of rearranging the furniture in the resident’s room. The progress note documented Resident #5’s representative was in agreement with the changes. 4. Fall on 10/24/25 - unwitnessed The progress note, dated 10/24/25 at 4:43 a.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 was found on the floor in front of her bed by an unidentified CNA. The progress note documented Resident #5 said she was trying to get up without assistance and fell. The progress note documented no injuries as a result of the fall. The progress note, dated 10/24/25 at 11:51 a.m., revealed an IDT meeting reviewing recent fall and fall interventions. The progress note documented the resident declined therapy services when offered at this time. The progress note documented the nursing recommendation was to continue with all current interventions, to frequently remind Resident #5 to call for assistance and to increase monitoring. 5. Fall on 1/12/26 - unwitnessed The progress note, dated 1/12/26 at 12:50 p.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 was found sitting on the floor in front of her recliner in her room. The progress note documented Resident #5 sustained a small skin tear to her right shin. The progress note documented Resident #5 said to staff she was trying to go somewhere but could not recall where. The progress note, dated 1/13/26 at 4:31 p.m., revealed an IDT meeting reviewing recent falls and fall interventions. The progress note documented the nursing recommendation to change the call light to a touch pad call light for visual reminder to use the call light. The progress note documented no other recommendations from other departments at this time. 6. Fall on 2/2/26 - unwitnessed The progress note, dated 2/2/26 at 5:45 a.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 was found on the fall mattress next to her bed. The progress note documented Resident #5 appeared as though she attempted to do a flip and was unable to finish. The progress note documented the resident denied pain and appeared without injuries. 7. Fall on 2/5/26 - unwitnessed The progress note, dated 2/5/26 at 5:42 p.m., revealed Resident #5 had an unwitnessed fall. The progress note documented an unidentified staff member witnessed Resident #5 slide out of her recliner onto the floor. The progress note documented Resident #5 denied pain and appeared without injuries. The progress note, dated 2/6/26 at 9:00 a.m., revealed an IDT meeting reviewing falls and fall interventions. The progress note documented the nursing recommendation was to re-educate Resident #5 about using her reaching device and to educate staff to ensure reaching device and frequently used items were inreach. The progress note documented no other recommendations from other departments at this time. IV. Staff interviewsCNA #7 was interviewed on 2/11/26 at 10:13 a.m. CNA #7 said they checked on Resident #5 frequently because she did not use her call light consistently. CNA #7 said they did not remember seeing Resident #5 falling or attempting to ambulate without assistance, but they were aware she had fallen frequently. CNA #7 said they used the fall mat next to her bed because the family wanted Resident #5 to use her own bed instead of a low bed provided by the facility. CNA #7 said Resident #5 required assistance with all transfers and could not ambulate more than a few steps without assistance. CNA #7 said Resident #5 was inconsistent when reporting her needs or if she was incontinent. The director of therapy services was interviewed on 2/12/26 at 11:21 a.m. The director of therapy services said she remembered she previously provided therapy to Resident #5 from 10/24/24 through 11/29/24 when the resident experienced a fall with a wrist fracture. The director of therapy services said she was not sure why therapy services stopped at the time. The director of therapy services said they thought they offered therapy again after another fall but Resident #5 refused. The director of nursing (DON) and the NHA were interviewed together on 2/12/26 at 1:41 p.m. The NHA said the facility started a Quality Assurance and Performance Improvement (QAPI) plan due to the facility having 21 falls in August of 2025. The NHA said the goal of the plan was to reduce the number of falls to 10 falls or less per month, and the facility met their goal by November 2025. The NHA said interventions from the QAPI plan included a post fall IDT huddle within 24 hours post fall and a weekly IDT review of all falls. The NHA said residents who had more than five falls had a root cause analysis completed. The NHA said she completed a root cause analysis for Resident #5 after her fall on 2/5/26. The NHA said the root cause analysis revealed Resident #5 frequently overestimated her abilities and attempted to ambulate without assistance due to her dementia. The NHA said the rearranging of Resident #5’s furniture was also not an effective intervention because the family wanted to move the furniture back shortly after. The NHA said the family also refused to use a low bed or hospital bed as interventions. The NHA said the root cause analysis showed her the previous interventions of reminding and educating Resident #5 would not have been effective due to her impaired cognition.

A recertification survey with complaint #CO2694165, #CO2704495, #CO2735143 and Incident #2736424 was conducted on 2/9/26 to 2/12/26. Eight deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/9/26 to 2/12/26. No deficiencies were cited.

Based on observations, record review and interviews, the facility failed to ensure two (#10 and #31) of eight residents out of 32 sample residents were free from abuse. Specifically, the facility failed to protect Resident #10 and Resident #31 from physical abuse toward each other. Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) 2/9/26 at 1:33 p.m. It read in pertinent part,“The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:“Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: facility staff; other residents; consultants; volunteers; staff from other agencies; family members; legal representatives; friends; visitors; and/or any other individual.“Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements. Protect residents from any further harm during investigations. Establish and implement a QAPI (Quality Assurance and Performance Improvement) review and analysis of reports, allegations or findings of abuse, neglect, mistreatment or misappropriation of property.”II. Incident of resident-to-resident physical abuse between Resident #10 and Resident #31A. Facility investigationThe facility investigation was provided by the NHA on 2/11/26 at 11:27 a.m. The investigation documented that on 11/6/25 at 3:00 p.m. Resident #31 approached Resident #10 and placed her hands on Resident #10’s walker. Resident #10 screamed and hit Resident #31 three times on the arm then Resident #31 hit Resident #10 once in the arm. The investigation documented the residents were separated from each other by certified nurse aide (CNA) #6. The facility investigation included a written statement by CNA #6, dated 11/6/25. The statement revealed CNA #6 witnessed Resident #31 approach Resident #10, then Resident #10 screamed and CNA #6 witnessed Resident #10 hit Resident #31 in the arm three times. The statement revealed CNA #6 then witnessed Resident #31 hit Resident #10 once in the arm. The statement revealed CNA #6 said Resident #10 thought Resident #31 was trying to steal her walker. The facility investigation included an interview with Resident #10, conducted by the NHA, dated 11/6/25. The interview revealed Resident #10 said she thought Resident #31 was trying to steal her walker, so she hit her. The facility investigation revealed Resident #31 was interviewed on 11/6/25 and had no recollection of the event. The facility investigation revealed each resident was placed on 15-minute rounds for the next 72 hours. The facility investigation included 15-minute rounds logs of Resident #10 and Resident #31 with no changes in behavior from baseline. The facility investigation revealed five additional residents were interviewed and five additional staff members were interviewed. The facility investigation revealed no other residents reported witnessing any situations in which a resident was physically harmed by a staff member or another resident, and no other residents reported feeling unsafe in the facility. The facility investigation revealed no other staff members reported witnessing or having been told any situations in which a resident was physically harmed by a staff member or another resident. The facility investigation revealed the incident was witnessed and substantiated the resident-to-resident physical abuse. The facility investigation documented Resident #10 was the assailant. The facility investigation revealed new interventions to prevent resident-to-resident physical abuse were added to Resident #10’s care plan. Staff were to encourage Resident #10 to watch television (TV) in the living room and encourage Resident #10 to call for assistance when personal space was invaded.-However, despite Resident #10 and Resident #31 hitting each other, the facility investigation documented Resident #10 as the only assailant and Resident #31 as the only victim. The facility investigation revealed no changes were made to Resident #31’s care plan. B. Resident #10 (assailant and victim) 1. Resident statusResident #10, age greater than 65, was admitted on 7/10/24. According to the February 2026 computerized physician orders (CPO), diagnoses included hypertension, hyperlipidemia, presence of a left artificial hip, generalized muscle weakness, abnormal gait and mobility, dementia with mood disturbance, cognitive communication deficit, hypothyroidism, protein-calorie malnutrition. The 1/1/26 minimum data set (MDS) assessment revealed Resident #10 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #10 required supervision or touching assistance with toileting, bathing, oral and personal hygiene, upper and lower body dressing as well as footwear. 2. Record reviewResident #10’s care plan, updated 11/11/25, revealed Resident #10 was at risk for resident-to-resident altercations related to individuals invading Resident #10’s personal space. Interventions included educating staff regarding Resident #10’s need for personal space, redirecting Resident #10 if she became aggressive toward others, offering Resident #10 her own place to sit in the common areas, offering her a quiet space when agitated when Resident #10’s personal space was invaded and offering independent activities, such as drawing, writing, and watching westerns on TV. Interventions added to Resident’s #10’s care plan on 11/11/25 (after the resident-to-resident altercation) included encouraging Resident #10 to watch TV in the common area to protect her personal space and encouraging Resident #10 to call staff for assistance when others invaded her personal space. The progress note, dated 9/2/25 at 10:06 p.m., revealed Resident #10 was observed slapping another resident (Resident #31) on the arm. Resident #10 reported she did not want the other resident to sit next to her. The progress not documented the residents were separated and placed on frequent monitoring. The skin assessment, dated 11/6/25 at 3:21 p.m., documented Resident #10 had no new skin issues. The progress note, dated 11/6/25 at 3:49 p.m., documented Resident #10 was at psychosocial baseline and was in the common area watching TV.-Review of Resident #10’s progress notes revealed no documentation of the resident-to-resident physical abuse between Resident #10 and Resident #31 on 11/6/25. C. Resident #31 (assailant and victim) 1. Resident statusResident #31, age greater than 65, was admitted on 2/12/22. According to the February 2026 CPO, diagnoses included Alzheimer's disease, diabetes, essential tremor, anxiety, depression, insomnia, hypothyroidism, hyperlipidemia and a history of falls. The 11/13/25 MDS assessment revealed Resident #31 had severe cognitive impairment with impaired short term and long term memory. The MDS assessment revealed staff assessments of Resident #31 indicated the resident had impaired cognitive skills for decision making, inattention and disorganized thinking. The MDS assessment documented Resident #31 experienced hallucinations and delusions. The MDS assessment documented Resident #31 had frequent physical behavioral symptoms directed toward others. The assessment indicated the resident did not wander. Resident #31 required supervision when eating, moderate assistance with upper body dressing, substantial assistance with lower body dressing, footwear, toileting, personal hygiene and oral hygiene. Resident #31 was dependent on staff for bathing. 2. ObservationsOn 2/9/26 at 8:43 a.m. Resident #31 was observed wandering at the end of the 200 hall. Resident #31 was pulling on cords attached to window blinds at the end of the hall. Resident #31 could not recall her name or what town she was in. Resident #31 pulled on the cords for less than five minutes before wandering back to the common area. On 2/10/26 at 11:44 a.m. Resident #31 was observed wandering into room #114. Resident #31 left the room shortly after as the room was empty. 3. Record reviewResident #31’s care plan, updated 11/15/25, revealed a wandering care plan. Interventions included redirecting Resident #31 out of other residents’ rooms, encouraging Resident #31 to participate in activities and implementation of a wander guard with ongoing assessments for appropriate use. -However, review of Resident #31’s care plan revealed no documentation indicating Resident #31’s risk for resident-to-resident altercations due to her wandering. The long-term care evaluation note, dated 10/25/25 at 2:44 p.m., documented Resident #31 was observed with chronic behaviors of wandering during the day, intermittent sleep with wandering at night and refusal of medications. The skin assessment, dated 11/6/25 at 3:31 p.m., documented Resident #31 had no new skin issues. The progress note, dated 11/6/25 at 3:50 p.m., documented Resident #31 was at psychosocial baseline. The progress note documented Resident #31 was wandering hallways visiting other staff members and at times sitting and reading paper.-Review of Resident #31’s progress notes revealed no documentation of the resident-to-resident physical abuse between Resident #10 and Resident #31 on 11/6/25. III. Staff interviewsCNA #8 was interviewed on 2/11/26 at 10:13 a.m. CNA #8 said all nursing staff did their best to keep track of Resident #31 since she wandered around the facility and had been found wandering in other residents' rooms. CNA #8 said normally Resident #31 was easy to redirect to another space, but some residents did not like anyone unexpectedly entering their room or getting too close to their personal space. CNA #8 said Resident #10 was one of the residents that she knew did not like people touching her or her things. CNA #8 said they provided Resident #10 her own chair in the common area, not only to respect her space, but because the chair was also located in line of sight with staff in the nurses’ station. The director of nursing (DON) and the NHA were interviewed together on 2/12/26 at 1:41 p.m. The NHA said Resident #10 was indicated as the only assailant and Resident #31 was indicated as the only victim because during the investigation, they thought Resident #31 only hit Resident #10 as a reaction to being hit by Resident #10. The NHA said she was not sure why the progress notes on the day of the resident-to-resident physical abuse between Resident #10 and Resident #31 did not describe the events, but the facility started the investigation immediately and maybe the nurse who completed the documentation thought the statements gathered during the investigation were adequate documentation of the event. The NHA said the facility had not previously considered that Resident #31 was at risk for future resident-to-resident altercations due to her wandering. The NHA said the facility planned to update the care plan for Resident #31 and educate staff. The DON and the NHA were interviewed together again on 2/12/26 at 5:13 p.m. The NHA said the facility had updated the care plan for Resident #31 and provided written education to all staff.

Based on record review and interviews, the facility failed to report an alleged violation to the state survey and certification agency in accordance with state law for one (#49) of eight residents reviewed for an injury of unknown source out of 32 sample residents. Specifically, the facility failed to report Resident #49’s death which resulted from an injury of unknown source, to the state oversight office, when the resident was found on the floor, unresponsive, with her head and neck lying on a trash can, with a coroner’s finding of preliminary cause of death to be positional asphyxiation (suffocation). Findings include:I. Facility policy and procedure The Abuse Investigation and Reporting Policy, revised July 2017, was provided by the nursing home administrator (NHA) on 2/12/26 at 12:37 p.m. It read in pertinent part, “All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator or his/her designee to the following: the state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsmen, the resident’s representative (sponsor) or record, adult protective services (where state law provides jurisdiction in long-term care), law enforcement officials, the resident’s attending physician and the facility medical director.” II. Facility investigationThe facility’s investigation for Resident #49’s accident/death was provided by the NHA on 2/10/26 at 3:20 p.m. The investigation included an undated handwritten statement by the NHA that she was notified on 1/18/26 at 5:30 a.m. that Resident #49 had been found on the floor in her room unresponsive and was deceased. The statement documented the coroner had been at the facility after Resident #49’s death and returned to the facility to interview staff. -The investigation was not reported to the State Agency as required. III. Resident #49A. Resident statusResident #49, age 76, was admitted on 12/29/23 and expired on 1/18/26. According to the January 2026 computerized physician orders (CPO), diagnoses included chronic respiratory failure, high blood pressure, kidney disease and neurogenic bladder (nerve damage from injury or disease). The 11/21/25 minimum data set (MDS) assessment identified Resident #49 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed the resident required set-up assistance with eating, moderate assistance with personal hygiene, toileting, dressing and transferring and substantial assistance with showering. B. Staff interviewsThe coroner was interviewed on 2/11/26 at 8:00 a.m. The coroner said the deputy coroner contacted him on 1/18/26 and said Resident #49’s death was suspicious. The coroner said the mystery was why the resident decided to get up without assistance. The coroner said he was waiting for additional information, but the preliminary cause of Resident #49’s death was positional asphyxiation. The coroner said he did not think the facility failed to prevent an accident, and her death would probably be determined to be an accident. The coroner said his initial concern was that there was a suspicious death and the facility had not notified the coroner after her death. The director of nursing (DON) and the NHA were interviewed together on 2/12/26 at 9:47 a.m. The NHA said she was notified of Resident #49’s death and was initially told Resident #49 was found lying face down in her room and was unresponsive. The NHA said on 1/18/26 at 9:15 a.m. she received a call from the social services director (SSD). She said the SSD told her the coroner had been asking questions and would come back to the facility to interview staff. The NHA said the coroner returned to the facility on 1/20/26 and asked for LPN #2 to clarify her progress note to match what she had told him, specifically that Resident #49 was found lying with her head on the trash can. The NHA said she knew on the day of the incident that the coroner was looking into the accident. The NHA said she did not think she needed to complete a facility investigation or report an occurrence because the coroner was investigating Resident #49’s cause of death. The NHA said the facility did not report the incident as an occurrence and did not notify the police or adult protective services. The NHA said the coroner told her on 1/19/26 or 1/20/26 that he did not think anything malicious had occurred, however the NHA also said Resident #49’s preliminary cause of death was asphyxiation. The NHA said a full facility investigation would include witness statements and interviews with staff, and also a timeline of events. She said at least five residents should be interviewed during investigations. The NHA said the facility could have done a better investigation. The NHA was interviewed again on 2/12/26 at 2:25 p.m. The NHA said based on the information that she had about Resident #49’s injury of unknown source and unexpected death, the facility should have reported her death as an occurrence and investigated thoroughly. -Cross reference F610, the facility failed to thoroughly investigate an alleged violation.

Based on record review and interviews, the facility failed to fully investigate and document an investigation for one (#49) of eight residents reviewed out of 32 sample residents. Specifically, the facility failed to conduct and document a thorough investigation of Resident #49’s death which resulted from an injury of unknown source, when the resident was found on the floor, unresponsive, with her head and neck lying on a trash can, with a coroner’s finding of preliminary cause of death to be asphyxiation (suffocation). Findings include:I. Facility policy and procedureThe Abuse Investigation and Reporting Policy, revised July 2017, was provided by the nursing home administrator (NHA) on 2/12/26 at 12:37 p.m. It read in pertinent part,“If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual.“The administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation.“The administrator will keep the resident and his/her representative informed of the progress of the investigation.“The individual conducting the investigation will, at a minimum review the completed documentation forms, review the resident’s medical record to determine events leading up to the incident, interview the person(s) reporting the incident, interview any witnesses to the incident, interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, interview resident’s roommate, family members and visitors, review all events leading up to the alleged incident.“Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it.“Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the administrator.”II. Facility investigationThe facility’s investigation for Resident #49’s accident/death investigation was provided by the NHA on 2/10/26 at 3:20 p.m. The investigation included an undated handwritten statement by the NHA that she was notified on 1/18/26 at 5:30 a.m. that Resident #49 had been found on the floor in her room unresponsive and was deceased. The statement documented the coroner had been at the facility after Resident #49’s death and returned to the facility to interview staff. The investigation included an undated handwritten statement from certified nurse aide (CNA) #2. It documented she was contacted by another CNA to go to Resident #49’s room after she was found unresponsive. It documented she assisted with moving Resident #49 to the bed and assisted with providing the resident's bath after her death. The investigation included a handwritten statement from licensed practical nurse (LPN) #2 on 1/21/26. It documented Resident #49 was found lying on the floor in front of her recliner with her head and neck laying in the trash can. The investigation included a statement documented on 2/7/26 (three weeks after the incident) by LPN #3. The investigation included three additional undated handwritten statements by CNA #1, CNA #3 and CNA #4.-All of the CNAs documented they had not seen the resident that night during their entire shift until 1/8/26 at 5:30 a.m., when the resident was found unresponsive. The investigation included record of call light audit for the night of 1/17/26 that revealed Resident #49 had not used her call light. The investigation included the resident’s medication administration record.-The investigation did not include documentation of any staff or resident interviews. -The investigation did not include any communications with authorities or reporting to state agency. Cross-reference F609, reporting of alleged violations to the state oversight office. -The investigation did not include any evaluation of the incident, clarification of conflictual witness statements (see facility investigation above and interviews below) or investigative conclusions. III. Resident #49A. Resident statusResident #49, age 76, was admitted on 12/29/23 and expired on 1/18/26. According to the January 2026 computerized physician orders (CPO), diagnoses included chronic respiratory failure, high blood pressure, kidney disease and neurogenic bladder (nerve damage from injury or disease). The 11/21/25 minimum data set (MDS) assessment identified Resident #49 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed the resident required set-up assistance with eating, moderate assistance with personal hygiene, toileting, dressing and transferring and substantial assistance with showering. B. Record reviewA nursing progress note on 1/18/26 at 5:30 a.m. documented LPN #2 entered Resident #49’s room to empty her catheter and found the resident lying on the floor in front of her recliner on her stomach. It documented Resident #49 was unresponsive. The note documented the nurse began cardiopulmonary resuscitation (CPR) on the resident until it was determined her code status was do not resuscitate (DNR), upon which CPR was stopped. The note documented CNAs transferred the resident to her bed. An additional nursing progress note entered as a late entry was dated 1/18/26 at 5:30 a.m. documented Resident #49 was found on the floor in front of her recliner with her head and neck lying on the trash can. A First Report-Coroner’s Case document, dated 1/18/26, was provided by the coroner on 2/11/26 at 8:00 a.m. The report documented an interview with LPN #2 revealed she was the last person to see Resident #49 on 1/17/26 at 8:45 p.m. and when she returned to the room on 1/18/26 at 5:30 a.m., LPN #2 found Resident #49 on the floor lying face down in front of her seat lift recliner with her head resting on a small trash can against a wall. It documented LPN #2 initiated CPR until Resident #49’s DNR status was determined. It documented the resident was moved by nursing staff to her bed, prior to the coroner evaluation. The report documented an interview with the medical director revealed he was notified Resident #49 was found on the floor, however the medical director was not told the resident’s head was found in the trash can. The report documented interviews with nursing staff revealed the resident had always used her call light for staff to move the recliner position, yet the recliner was found in an elevated position. The report documented since the deceased had not been under hospice care and due to the circumstances it was advised to initiate a coroner investigation. C. Staff and additional interviewsLPN #2 was interviewed on 2/9/26 at 4:37 p.m. LPN #2 said she provided Resident #49’s breathing treatment, and then left the room on 1/17/26 at approximately 9:30 p.m. LPN #2 said that Resident #49 did not like to be woken during the night. LPN #2 said that Resident #49 had everything in reach, including her call light. She said the next time she saw Resident #49 was at 5:30 a.m., when she went in the resident’s room and found Resident #49 on the floor in front of her recliner with her head turned to the side and resting on a trash can. LPN #2 said when she turned Resident #49 over, there was a mark on the side of her neck where it had been laying on the trash can. The coroner was interviewed on 2/11/26 at 8:00 a.m. The coroner said the facility had provided conflicting information regarding Resident #49’s death to the deputy coroner. The coroner said the facility staff had said that Resident #49 never operated her wheelchair independently and always called for assistance. The coroner said the facility had not notified the coroner of any deaths over the past year. He said after Resident #49’s death he asked the facility to notify the coroner’s office of all deaths until further notice, whether it was expected or not. The coroner said a resident representative told him that the facility called the representative to notify him of Resident #49’s death and the facility said it appeared Resident #49 had a heart attack and was found on the floor. The coroner said he instructed the facility to leave a resident how they were found until the coroner came to the facility to investigate. The coroner said the statement from the nurse did not initially state that Resident #49 was found with her head lying on the trash can. The coroner said the deputy coroner contacted him on 1/18/26 and said Resident #49’s death was suspicious. He said the resident had bruising on her arm and face. The coroner said the mystery was why the resident decided to get up without assistance. The coroner said he was waiting for additional information, but the preliminary cause of Resident #49’s death was positional asphyxiation. The coroner said he did not think the facility failed to prevent an accident, and it would probably be determined to be an accident. The coroner said his initial concern was a suspicious death and the lack of notification to the coroner after her death. The director of nursing (DON) and the NHA were interviewed together on 2/12/26 at 9:47 a.m. The NHA said she was notified of Resident #49’s death and was initially told Resident #49 was found lying face down in her room and was unresponsive. The NHA said on 1/18/26 at 9:15 a.m. she received a call from the social services director (SSD). She said the SSD told her the coroner had been asking questions and would come back to the facility to interview staff. The NHA said the coroner returned to the facility on 1/20/26 and asked for LPN #2 to clarify her progress note to match what she had told him, that Resident #49 was found lying with her head on the trash can. The NHA said she knew on the day of the incident that the coroner was looking into the accident. The DON said she started to ask nursing staff to write statements about the incident on or about 2/1/26, two weeks after the incident. The DON said she interviewed staff involved about Resident #49’s death, but she was not sure when she interviewed the staff and she did not document any of the interviews. The DON said she should have documented the interviews. The NHA said she did not think she needed to do an investigation because the coroner was investigating Resident #49’s cause of death. The DON said she interviewed LPN #2, LPN #3 and CNA #1, but did not document these interviews. The DON said there were other CNAs working that night, however she did not interview them. The DON said she should have interviewed anyone who went into Resident #49’s room. The NHA said the facility did not report the incident as an occurrence and did not notify the police or adult protective services. The NHA said the coroner told her on 1/19/26 or 1/20/26 that he did not think anything malicious had occurred, however Resident #49’s preliminary cause of death was asphyxiation. The NHA said a full facility investigation would include witness statements and interviews with staff, and also a timeline of events. She said at least five residents should be interviewed during investigations. The NHA said the facility could have done a better investigation. The NHA was interviewed again on 2/12/26 at 2:25 p.m. The NHA said based on the information that she had about Resident #49’s injury of unknown source and unexpected death, the facility should have reported her death as an occurrence and investigated thoroughly. -Cross reference F609, Reporting of alleged violations.

Based on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#5) of six residents reviewed for accident hazards out of 32 sample residents. Resident #5 was admitted on 6/19/23 with a diagnosis of dementia. Resident #5 was at risk for falls related to impaired mobility and cognition. Resident #5, who had a history of falls with major injury, sustained an unwitnessed fall on 8/14/25. The facility re-educated the resident on the use of the call light. However, the resident had impaired cognition and did not always remember to use the call light. On 8/22/25 the resident sustained another unwitnessed fall. The resident sustained a laceration to her hand and a fracture of the metacarpal base to her left hand The resident was sent to the hospital and received sutures to the laceration. Upon return, the facility failed to implement person-centered fall interventions and the resident sustained four more additional falls on 10/24/25, 1/12/26, 2/2/26 and 2/5/26. Specifically, the facility failed to implement effective person-centered fall interventions to prevent recurrent falls for Resident #5. Findings include:I. Facility policy and procedureThe Falls-Clinical Protocol policy, revised March 2018, was provided by the nursing home administrator (NHA) on 2/12/26 at 4:51 p.m. It read in pertinent part,“For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. Often, multiple factors contribute to a falling problem. If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. After a fall, the physician should review the resident’s gait, balance, and current medications that may be associated with dizziness or falling. Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. “Treatment/Management: Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Examples of such interventions may include calcium and vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing, or changing problematic medications (for example, those that could make the resident dizzy or cause blood pressure to drop significantly on standing). If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance).“The staff and physician will monitor and document the individual’s response to interventions in-tended to reduce falling or the consequences of falling. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented.“If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has been resolved by addressing the underlying cause. If the individual continues to fall, the staff and physician will reevaluate the situation and reconsider possible reasons for the resident’s falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. II. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on 6/19/23. According to the February 2026 computerized physician's orders (CPO), diagnoses included chronic kidney disease, generalized muscle weakness, dementia with behavioral disturbance, generalized anxiety, transient ischemic attack (TIA) cerebral infarction without residual deficits (stroke), abnormal gait and mobility, history of falling and history of COVID-19. The 11/30/25 minimum data set (MDS) assessment revealed Resident #5 had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #5 required substantial/maximal assistance with bathing. Resident #5 required supervision or touching assistance with all transfers, toileting, oral and personal hygiene, upper and lower body dressing as well as footwear. Resident #5 had limited range of motion to both lower extremities, used a wheelchair for mobility and required moderate assistance to move over 50 feet. The assessment indicated the resident had a fall without injury. -However, Resident #5 sustained a fall with injury on 8/22/25. B. Observation and interviewResident #5 was interviewed on 2/9/26 at 2:07 p.m. Resident #5 commented multiple times during the interview that her shirt and her pants felt wet. Resident #5 said she was not sure how often staff checked on her or what staff helped her with. The room had a faint odor of urine. Resident #5 had her touch pad call light within reach. There was not a visual reminder in the resident’s room to use her call light. C. Record review 1. Care plan Resident #5’s fall care plan, revised 2/9/26, documented the resident was at risk for falls related to decreased mobility and unsteady gait. Pertinent interventions included attempting to provide all needed items for hygiene and toileting while Resident #5 was in the bathroom to try to help prevent her from reaching for things and potentially falling; placing needed items directly next to Resident #5 within reaching distance, re-arranging furniture items in the room, placing non-skid tape in front of bed, toilet and recliner, fall mat, reaching device, and placing a sign in the resident’s room to remind her to use her call light for assistance. 2. Fall on 8/14/25 - unwitnessed The progress note, dated 8/14/25 at 9:17 p.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 reported to staff she was trying to get out of bed and fell. The note documented Resident #5 sustained two small skin tears to the left knee. The progress note, dated 8/15/25 at 9:14 a.m., revealed an interdisciplinary team (IDT) meeting reviewing Resident #5’s fall. The progress note documented the nursing recommendation was to re-educate Resident #5 on the importance of using her call light for assistance with ambulation. The progress note documented no other recommendations from other departments at this time. The progress note, dated 8/21/25 at 9:58 a.m., revealed an IDT meeting reviewing effectiveness of the current fall interventions. The progress note documented staff re-educated Resident #5 on the importance of using the call light when needing to ambulate. The progress note documented no other recommendations from other departments at this time. 3. Fall on 8/22/25 - unwitnessed The progress note, dated 8/22/25 at 4:30 a.m., revealed Resident #5 had an unwitnessed fall. The progress note documented two unidentified certified nurse aides (CNA) reported Resident #5 was found sitting on the floor in front of her bed, bleeding from her left hand. The progress note revealed the registered nurse (RN) assessed Resident #5 and found a laceration across the resident’s left palm. The laceration measured two inches long, 0.5 centimeters (cm) wide and 0.5 cm deep. The progress note documented first aid was applied to the wound and Resident #5 was transported to the local area emergency room for further evaluation. The progress note, dated 8/22/25 at 9:37 a.m., revealed an IDT meeting reviewing the fall occurring on 8/22/25. The progress note documented the nursing recommendation was to rearrange the furniture in Resident #5’s room for ease of transfers. The progress note documented the additional intervention of a wedge pillow between the bed and bedside table to protect the resident from sharp edges. The progress note documented no other recommendations from other departments at this time. -Additionally, the facility did not reassess moving the furniture around after the family requested for the furniture to be moved back (see interviews below). The progress note, dated 8/22/25 at 10:45 a.m., revealed Resident #5 returned to the facility from the local area emergency room. The progress note documented Resident #5 required sutures to her left palm laceration and Resident #5 sustained a metacarpal base fracture to her left hand as a result of the fall. The progress note, dated 8/22/25 at 11:55 a.m., revealed Resident #5’s representative was contacted about the intervention of rearranging the furniture in the resident’s room. The progress note documented Resident #5’s representative was in agreement with the changes. 4. Fall on 10/24/25 - unwitnessed The progress note, dated 10/24/25 at 4:43 a.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 was found on the floor in front of her bed by an unidentified CNA. The progress note documented Resident #5 said she was trying to get up without assistance and fell. The progress note documented no injuries as a result of the fall. The progress note, dated 10/24/25 at 11:51 a.m., revealed an IDT meeting reviewing recent fall and fall interventions. The progress note documented the resident declined therapy services when offered at this time. The progress note documented the nursing recommendation was to continue with all current interventions, to frequently remind Resident #5 to call for assistance and to increase monitoring. 5. Fall on 1/12/26 - unwitnessed The progress note, dated 1/12/26 at 12:50 p.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 was found sitting on the floor in front of her recliner in her room. The progress note documented Resident #5 sustained a small skin tear to her right shin. The progress note documented Resident #5 said to staff she was trying to go somewhere but could not recall where. The progress note, dated 1/13/26 at 4:31 p.m., revealed an IDT meeting reviewing recent falls and fall interventions. The progress note documented the nursing recommendation to change the call light to a touch pad call light for visual reminder to use the call light. The progress note documented no other recommendations from other departments at this time. 6. Fall on 2/2/26 - unwitnessed The progress note, dated 2/2/26 at 5:45 a.m., revealed Resident #5 had an unwitnessed fall. The progress note documented Resident #5 was found on the fall mattress next to her bed. The progress note documented Resident #5 appeared as though she attempted to do a flip and was unable to finish. The progress note documented the resident denied pain and appeared without injuries. 7. Fall on 2/5/26 - unwitnessed The progress note, dated 2/5/26 at 5:42 p.m., revealed Resident #5 had an unwitnessed fall. The progress note documented an unidentified staff member witnessed Resident #5 slide out of her recliner onto the floor. The progress note documented Resident #5 denied pain and appeared without injuries. The progress note, dated 2/6/26 at 9:00 a.m., revealed an IDT meeting reviewing falls and fall interventions. The progress note documented the nursing recommendation was to re-educate Resident #5 about using her reaching device and to educate staff to ensure reaching device and frequently used items were in reach. The progress note documented no other recommendations from other departments at this time. IV. Staff interviewsCNA #7 was interviewed on 2/11/26 at 10:13 a.m. CNA #7 said they checked on Resident #5 frequently because she did not use her call light consistently. CNA #7 said they did not remember seeing Resident #5 falling or attempting to ambulate without assistance, but they were aware she had fallen frequently. CNA #7 said they used the fall mat next to her bed because the family wanted Resident #5 to use her own bed instead of a low bed provided by the facility. CNA #7 said Resident #5 required assistance with all transfers and could not ambulate more than a few steps without assistance. CNA #7 said Resident #5 was inconsistent when reporting her needs or if she was incontinent. The director of therapy services was interviewed on 2/12/26 at 11:21 a.m. The director of therapy services said she remembered she previously provided therapy to Resident #5 from 10/24/24 through 11/29/24 when the resident experienced a fall with a wrist fracture. The director of therapy services said she was not sure why therapy services stopped at the time. The director of therapy services said they thought they offered therapy again after another fall but Resident #5 refused. The director of nursing (DON) and the NHA were interviewed together on 2/12/26 at 1:41 p.m. The NHA said the facility started a Quality Assurance and Performance Improvement (QAPI) plan due to the facility having 21 falls in August of 2025. The NHA said the goal of the plan was to reduce the number of falls to 10 falls or less per month, and the facility met their goal by November 2025. The NHA said interventions from the QAPI plan included a post fall IDT huddle within 24 hours post fall and a weekly IDT review of all falls. The NHA said residents who had more than five falls had a root cause analysis completed. The NHA said she completed a root cause analysis for Resident #5 after her fall on 2/5/26. The NHA said the root cause analysis revealed Resident #5 frequently overestimated her abilities and attempted to ambulate without assistance due to her dementia. The NHA said the rearranging of Resident #5’s furniture was also not an effective intervention because the family wanted to move the furniture back shortly after. The NHA said the family also refused to use a low bed or hospital bed as interventions. The NHA said the root cause analysis showed her the previous interventions of reminding and educating Resident #5 would not have been effective due to her impaired cognition.

Based on observations, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being one (#15) of six residents reviewed for unnecessary medications out of 32 sample residents. Specifically, the facility failed to discontinue or reevaluate a physician’s order for Resident #16’s as needed (PRN) lorazepam (an antianxiety medication) after 14 days. Findings include:I. Facility policy and procedureThe Psychotropic Medication Use policy, revised February 2025, was provided by the nursing home administrator (NHA) on 2/12/26 at 5:01 p.m. It revealed in pertinent part,“Psychotropic medications are not prescribed or administered on a PRN basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. Psychotropic medications may be used on a PRN basis in certain situations, for example: while the dose is being adjusted; to address acute or intermittent symptoms; or in an emergency. “PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order. For psychotropic medications that are antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication.”II. Resident #15A. Resident statusResident #15, age greater than 65, was admitted on 11/24/25. According to the February 2026 computerized physician orders (CPO), diagnoses included mesothelioma, history of malignant neoplasm of the prostate, malignant neoplasm of the bronchus or lung, agranulocytosis secondary to cancer chemotherapy, generalized muscle weakness, repeated falls, cerebral infarction without residual deficits, insomnia, depression, anxiety, hyperlipidemia and chronic hypoxic respiratory failure. The 12/2/25 minimum data set (MDS) assessment revealed Resident #15 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #15 was dependent on staff for toileting, bathing, lower body dressing, footwear and personal hygiene. Resident #15 required set up assistance to eat. Resident #15 required substantial/maximum assistance with toileting, upper body dressing, lower body dressing, footwear, personal hygiene and oral hygiene. B. Record reviewReview of Resident #15's November 2025 CPO revealed the following physician's order:Ativan (lorazepam) Oral Tablet 0.5 milligrams (mg), give 1 tablet by mouth every 4 hours as needed for Anxiety, ordered on 11/25/25 and discontinued on 1/03/26. -This order was continued for a total 39 days, which was 25 days longer than the 14 day limit for as needed anti-anxiety medication usage. Review of Resident #15’s November 2025 and December 2025 medication administration record (MAR) revealed one PRN dose was administered on 12/17/25.-A review of Resident #15’s electronic medical record (EMR) revealed no documentation to indicate the physician had reevaluated the resident’s PRN Ativan in order to justify the use of the medication beyond the 14-day limit for PRN medications. Review of Resident #15's January 2026 CPO revealed the following physician's order:Ativan (lorazepam) oral tablet 0.5 mg, give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days, ordered on 12/31/25. The order then specified to automatically restart four more additional times without clinical justification from the physician. Review of Resident #15’s January 2026 and February 2026 MAR revealed no PRN doses were administered during the timeframe. Review of the most recent quarterly psychotropic medication review meeting, dated 11/24/25, the day prior to the start of the November 2025 PRN lorazepam order did not reveal documentation regarding the lorazepamIII. Staff interviewsThe director of nursing (DON) and the NHA were interviewed together on 2/12/26 at 1:41 p.m. The DON said she remembered placing the first PRN Lorazepam order for Resident #15 in November 2025 and the second set of Lorazepam orders in January 2026. The DON said she was aware PRN Lorazepam should be reviewed or discontinued after 14 days. The DON said she had just started in her role when she placed the PRN Lorazepam order in November 2025, and she did not know why the order did not include a proper end date. She said normally she spoke with the provider when the order was about to be discontinued and the provider would provide a verbal recommendation to continue to order or discontinue. The DON said she could not recall if she spoke with the provider about Resident #15’s PRN Lorazepam orders. The DON said the PRN lorazepam orders for every two weeks, starting in January 2026, were all placed at the same time. The DON said the PRN Lorazepam orders were based on the recommendations from the hospice nurse. The DON said the facility keeps a supply of Lorazepam in their stat safe, and if the resident were to experience a change in condition indicating the use of PRN Lorazepam, the facility could contact the on-call provider or hospice agency at any time to obtain a new order. The DON said PRN lorazepam orders should be reviewed for continued use every 14 days because Lorazepam was a strong medication and the order should be discontinued if the resident did not need it.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of two medication storage carts. Specifically, the facility failed to:-Date residents’ insulin pens and inhaler with the date they were opened; -Label a nasal spray with the resident’s name;-Ensure a medication was not at the resident’s bedside without an order; and,-Discard medications that have expired. Findings include:I. Professional referencesAccording to the manufacturer, Sanofi-Aventis, How to Use Your Lantus SoloStar Pen, August 2022, retrieved on 2/16/26 from https://www.lantus.com/dam/jcr:817aed9c-a677-4cd6-a6b3-d93d8ba629a/lantus-solostar-pen-guide.pdf “After 28 days, throw your opened Lantus pen away-even if it still has insulin in it.”According to the manufacturer, GlaxoSmithKline, Patient Information Advair Diskus (fluticasone propionate and salmeterol inhalation powder), June 2023, retrieved on 2/16/26 from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Inforamtion/Advair_Diskus/pdf/ADVAIR-DISKUS-PI-PIL-IFU.PDF#nameddest=PIL “Safely throw away Advair Diskus in the trash one month after you open the foil pouch or when the counter reads zero, whichever comes first.”II. Facility policy and procedureThe Medication Labeling and Storage policy, revised February 2023, was provided by the nursing home administrator (NHA) on 2/11/26 at 3:46 p.m. It read in pertinent part, “The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.“If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.“The medication label includes at a minimum: medication name, prescribed dose, strength, expiration date, when applicable, resident’s name, route of administration and appropriate instructions and precautions.“Only the dispensing pharmacy may label or alter the label on a medication container or package.”III. Observations and interviewsOn 2/9/26 at 12:15 p.m., a used eight ounce bottle of Equate stomach relief was observed on Resident #4’s bedside table. Resident #4 said she took the medication when she needed to for stomach aches. Resident #4 said she took the medication on the morning of 2/9/26. Resident #4 said she did not know if nursing staff knew she had taken the medication. On 2/11/26 at 11:44 a.m., the #1 medication administration cart was observed with licensed practical nurse (LPN) #1. The following medications were found:- A used Lantus SoloStar 100 units per milliliter (ml) injectable insulin pen for Resident #7 which was not labeled with the date it was opened.- A used Lantus SoloStar 100 units per ml injectable insulin pen for Resident #19 which was not labeled with the date it was opened. LPN #1 said there should be a date opened on both insulin pens as they were only good for 28 days after opening and the insulin pens should be discarded. LPN #1 said the insulin could be less effective if used beyond expiration.-An unlabeled bottle of Nasacort nasal spray. LPN #1 said the bottle should be labeled with the resident’s name.-A used fluticasone propionate and salmeterol (Advair Diskus) inhaler 250 microgram (mcg)/50 mcg for Resident #19 which was not labeled with the date it was opened. LPN #1 said the inhaler should be labeled with the date it was opened.-An unopened floor stock bottle of famotidine 20 milligrams (mg) with an expiration date of January 2026. LPN #1 said the famotidine medication should have been discarded in January 2026.-A used bottle of Neilmed earwax softener drops (carbamide peroxide 6.5%) for Resident #16 with an expiration date of September 2025. LPN #1 said the earwax drops should have been discarded when they expired. IV. Staff interviewsThe director of nursing (DON) was interviewed on 2/11/26 at 12:55 p.m. The DON said the insulin and inhaler should have been labeled withthe date opened as they could be less effective if used too long. The DON said the expired medications should have been discarded upon expiration. The DON said the nasal spray should have been labeled with the resident’s name. She said all of these medications had been discarded. The DON was interviewed again on 2/11/26 at 3:30 p.m. The DON said the Equate stomach relief medication was found in Resident #4’s room on 2/11/26 by nursing staff. The DON said the medication had been removed from Resident #4’s room and it should be stored in the medication storage cart. The DON was interviewed again on 2/12/26 at 2:41 p.m. The DON said she discovered there had not been a physician’s order for the stomach relief medication which had been at Resident #4’s bedside. The DON said Resident #4 should not be permitted to store any medications at her bedside as she was unable to manage the medication administration.

Based on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for two out of four units. Specifically, the facility failed to:- Use appropriate infection control practices related to hand hygiene.- Follow infection prevention practices during the wound care of Resident #2 Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention’s (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, retrieved on 2/18/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, It read in pertinent part,“CDC provides the following recommendations for hand hygiene in healthcare settings.“Know when to clean your hands: immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; after contact with blood, body fluids, or contaminated surfaces; immediately after glove removal.“When to use an alcohol-based hand sanitizer (ABHS): Unless hands are visibly soiled, ABHS is preferred over soap and water in most clinical situations because: it is more effective at killing germs on hands than soap; easier to use when providing care, especially when moving from soiled to clean activities on the same patient or when moving between care of patients in shared rooms; results in improved skin condition with less irritation and dryness than soap and water; improves hand hygiene adherence.“When to wash with soap and water: when hands are visibly soiled; before eating; after using the restroom; during the care of patients with suspected or confirmed infection during outbreaks of C. difficile and norovirus.”II. Facility policy and procedureThe Handwashing/Hand hygiene policy, revised October 2023, was provided by the nursing home administrator (NHA) on 2/11/26 at 2:46 p.m. It revealed in pertinent part,“Hand hygiene is indicated: immediately before touching a resident; before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal. “Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations “Wash hands with soap and water: when hands are visibly soiled; and after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. “Single-use disposable gloves should be used; before aseptic procedures; when anticipating contact with blood or body fluids; and when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. “The use of gloves does not replace hand washing/hand hygiene.” III. ObservationsOn 2/10/26 at 8:52 a.m. housekeeper (HK) #1 was observed cleaning room #302. Prior to the start of the room cleaning, houseHK #1 performed hand hygiene using ABHS and donned gloves. During the observation, HK #1 failed to remove their gloves and perform hand hygiene after cleaning the resident’s bathroom including the toilet. HK #1 then grabbed clean hand towels from the covered linen bag on her housekeeping cart without removing the soiled gloves. HK #1 finished cleaning the room by mopping the residents bedroom floor and bathroom floor without removing the soiled gloves or completing hand hygiene. On 2/11/26 at 11:22 a.m. housekeeper #2 was observed cleaning room #501. Prior to the start of the room cleaning, HK #2 performed hand hygiene using ABHS and donned gloves. During the observation, HK #2 failed to remove their gloves and perform hand hygiene after taking out the trash. HK #2 then used a new washcloth to clean the surfaces in the bathroom, obtained new clean hand towels from the covered linen bag, cleaned the toilet, mopped the bedroom and bathroom floor without removing the soiled gloves or performing hand hygiene. On 02/10/26 at 1:13 p.m. registered nurse (RN) #3 completed wound care for Resident #2. RN #3 completed hand hygiene and donned appropriate enhanced barrier precautions prior to the wound care. However, after removing the soiled dressing from Resident #2’s heel, RN #3 changed gloves but failed to complete hand hygiene or use an ABH) before donning new gloves. RN #3 applied medihoney to the wound bed as ordered, however RN #3 used her gloved finger instead of a sterile application tip. IV. Staff interviewsRN #3 was interviewed on 02/10/2026 at 1:32 p.m. RN #3 said she was not sure why the previous dressing was not dated or labeled. RN #3 said she did not complete hand hygiene or use an ABHS after removing her soiled gloves and prior to donning new gloves because she was not aware she needed to, and thought changing gloves was sufficient. RN #3 said she typically applied topical treatments to wound beds using her gloved finger and did not think to bring a sterile tip applicator. RN #3 said the sterile tip applicators were not in the bin of wound care supplies, but she knew the facility stored them somewhere. RN #3 said she planned to find the sterile tip applicators and add them to the wound care supplies for future use. HK #2 was interviewed on 2/11/26 at 11:31 a.m. HK #2 said she normally changed her gloves during the linen change, after removing the dirty linen and prior to placing the clean linen. Housekeeper #2 said she did not change gloves while cleaning the room because the resident was in bed and did not want her linens changed. HK #2 said she thought she did not need to change gloves because she cleaned the room by completing the dirtiest tasks last. The housekeeping supervisor was interviewed on 2/11/25 at 2:28 p.m. The housekeeping supervisor said housekeepers should perform hand hygiene and don gloves prior to cleaning, after cleaning was completed, and whenever they were handling a soiled item while cleaning. However, they did not necessarily need to change gloves or perform hand hygiene during the clean because each housekeeper was trained to clean from the cleanest areas to the dirtiest. The housekeeping supervisor said the last areas the housekeepers should clean were the bathroom counters and then the toilet as the last item. The housekeeping supervisor said she was not aware the housekeepers were not cleaning the toilet last as instructed, and she was not aware the housekeepers were handling clean linens while wearing soiled gloves. The housekeeping supervisor said the risk of improper hand hygiene techniques while cleaning was the chance for cross contamination. The housekeeping supervisor said each department supervisor was responsible for training their staff on proper hand hygiene. The director of nursing (DON) and the NHA were interviewed together 02/11/26 at 12:55 p.m. The DON said she completed annual hand hygiene education and competency evaluations for the nursing staff in the facility. The DON said the risk of handling clean items with soiled gloves was the possible cross contamination of bacteria or fecal matter. The DON said each department had specific areas reviewed in their annual competency evaluation, but all employees completed annual training and competency evaluations regarding hand hygiene. She said she was not certain what additional training the non nursing departments received since each department was responsible for training their staff. The DON said it was an expectation for nurses to complete hand hygiene or use an ABHS and don clean gloves after removing the soiled dressing. The DON #2 said RN #2 should not have used a glove finger when applying the topical treatment to the wound bed because you cannot guarantee the glove was not contaminated, but RN #2 might have been confused because some previous orders have specifically said not to use a sterile tip applicator. The infection preventionist (IP) on 02/11/26 at 2:47 p.m. The IP said training and competency evaluation regarding hand hygiene was completed with all staff on hire and annually. The IP said each department supervisor was responsible for additional training on hand hygiene and could give corrective education any time they observed poor hand hygiene. The IP said each supervisor could decide to audit staff hand hygiene at any time, but the facility did not currently complete audits of hand hygiene for any departments on a regular interval. The IP said housekeeping staff should be performing hand hygiene and changing gloves any time they handle a dirty item. The IP said touching clean items using dirty gloves could cause cross contamination onto the clean items or cleaning supplies. The IP said dietary staff should also complete hand hygiene frequently and with each tray pass because they may inadvertently touch resident items while assisting with meal set up, and traveling from room to room without hand hygiene could cause the spread of pathogens. The IP said it was an expected professional standard for nurses to complete hand hygiene or use an ABHS and don clean gloves after the removal of a soiled dressing. The IP said this was because gloves cannot be guaranteed to be sterile. The IP said this was also the reason staff should not use a gloved finger to apply topical treatments to a wound bed. The IP said they should use a sterile tip applicator, but may also use another sterile dressing or item. The IP said not using wound cleanser as indicated in the wound care order could increase the risk of the wound becoming infected. V. Failed to ensure nursing staff used hand hygiene appropriately during medication administrationA. Observations and staff interviewsOn 2/11/26 at 10:48 a.m. registered nurse (RN) #1 and RN #2 (who was mentoring RN #1) entered Resident #18’s room to administer medications. Both RN #1 and RN #2 did not perform hand hygiene prior to preparing medications, prior to entering the resident room to administer medications or upon leaving the resident’s room. On 2/11/26 at 11:05 a.m. RN #1 and RN #2 entered Resident #25’s room to administer medications. Both RN #1 and RN #2 did not perform hand hygiene prior to preparing medications, prior to entering the resident room to administer medications or upon leaving the resident’s room. On 2/11/26 at 11:24 a.m. RN #1 prepared an ophthalmic (eye) ointment medication to administer to Resident #10. He did not use hand hygiene prior to preparing the medication. RN #1 was interviewed on 2/11/26 at 11:25 a.m. RN #1 said he should have used hand hygiene prior to and after administering medications to Resident #18 and Resident #25. B. Staff interviewsRN #2 was interviewed on 2/11/26 at 11:26 a.m. RN #2 said he forgot to use hand hygiene in both residents’ rooms. RN #2 said both RN #1 and RN #2 should have used hand hygiene prior to entering and upon leaving the residents’ rooms to prevent the spread of infection. The IP was interviewed on 2/11/26 at 3:00 p.m. The IP said nursing staff should use hand hygiene prior to and after administering medications to prevent the spread of infection to other residents.

Based on observations, record review and interviews, the facility failed to ensure COVID-19 vaccinations were administered for five (#10,#24, #30, #35 and #5) of five residents out of 32 sample residents. Specifically, the facility failed to offer COVID-19 vaccine to Residents #10, #24, #30, #35 and #5, who requested one when they were offered. Findings include:I. Facility policy and procedureThe Coronavirus Disease (COVID-19) - Vaccination of Residents policy, revised August 2025, was provided by the nursing home administrator (NHA) on 2/12/26 at 5:01 p.m. It revealed in pertinent part,“The COVID-19 vaccine may be offered and provided directly by the LTC facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity.“COVID-19 vaccine education, documentation, and reporting are overseen by the infection preventionist and coordinated by their designee. Vaccines are administered in accordance with CDC, ACIP, FDA, and manufacturer guidelines. Facility data on resident vaccine status is reported to the NHSN by the infection preventionist.“The resident’s medical record includes documentation that indicates, at a minimum, the following: The resident or resident representative was provided education regarding the benefits and potential risks associated with COVID–19 vaccine; each dose of COVID-19 vaccine administered to the resident (or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal; signed consent; date of administration; any adverse effects associated with administration; and type, manufacturer, lot number, and administration site of each dose of COVID–19 vaccine that was administered to the resident.”II. Resident #35A. Resident statusResident #35, age less than 65, was admitted on 11/15/18. According to the February 2026 computerized physician orders (CPO), diagnoses included diabetes, Guillain-Barré syndrome (a neurological condition where the immune system attacks peripheral nerves), respiratory failure, quadriplegia (partial or total loss of function in all four limbs and the torso), depression and anxiety. The 1/1/26 minimum data set (MDS) assessment revealed Resident #35 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #35 was dependent on staff for toileting, bathing, lower body dressing, footwear and personal hygiene. Resident #35 required maximum assistance with upper body dressing and partial assistance with oral hygiene. The MDS assessment revealed Resident #35’s COVID-19 vaccination was not up to date. B. Resident interviewResident #35 was interviewed on 2/12/26 at 1:12 p.m. Resident #35 said she remembered she was asked if she wanted the COVID-19 vaccine in October of 2025, but she never received one. Resident #35 said she was not sure why she never received the COVID-19 vaccine for this year, and she did not remember a staff member providing any update when she did not receive one. Resident #35 said she still wanted a COVID-19 vaccination for this year if the facility acquired them. C. Record reviewReview of Resident #35’s electronic medical record (EMR) did not reveal the resident was administered the COVID-19 vaccine or education regarding the COVID-19 vaccine. III. Resident #30A. Resident statusResident #30, age greater than 65, was admitted on 11/1/23. According to the February 2026 CPO, diagnoses included anemia, hypertension, paroxysmal atrial fibrillation, dysphagia and generalized muscle weakness. The 11/6/25 MDS assessment revealed Resident #30 was cognitively intact with a BIMS score of 15 out of 15. Resident #30 required supervision or touching assistance with toileting, bathing, oral and personal hygiene, upper and lower body dressing as well as footwear. The MDS assessment documented Resident #30 was up to date on his COVID-19 vaccination.-However, review of Resident #30’sEMR revealed no documentation of education, administration, or refusal of the updated 2025 COVID-19 vaccination. B. Resident interviewResident #30 was interviewed on 2/12/26 at 1:17 p.m. Resident #30 said he lived at the facility with his spouse. Resident #30 said they were both offered this season’s COVID-19 vaccine sometime last fall, but he could not remember the exact date. Resident #30 said to his knowledge neither of them ever received an updated COVID-19 vaccination. He said he was not sure if they would still want the vaccine now since it was already late in the cold and flu season and he would like the facility to offer or review the information with him again. C. Record reviewReview of Resident #30’s EMR revealed no documentation that the COVID-19 vaccine was administered, education or corresponding declination form. IV. Resident #10A. Resident statusResident #10, age greater than 65, was admitted on 7/10/24. According to the February 2026 CPO, diagnoses included hypertension, hyperlipidemia, presence of a left artificial hip, generalized muscle weakness, abnormal gait and mobility, dementia with mood disturbance, cognitive communication deficit, hypothyroidism, protein-calorie malnutrition. The 1/1/26 MDS assessment revealed Resident #10 had moderate cognitive impairment with a BIMS score of 12 out of 15. Resident #10 required supervision or touching assistance with toileting, bathing, oral and personal hygiene, upper and lower body dressing as well as footwear. The MDS assessment documented Resident #10 was not up to date on her COVID-19 vaccination. B. Record reviewReview of Resident #30’s EMR revealed no documentation of COVID-19 vaccine administration, education or corresponding declination form. V. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on 6/19/23. According to the February 2026 CPO, diagnoses included chronic kidney disease, generalized muscle weakness, dementia with behavioral disturbance, generalized anxiety, transient ischemic attack (TIA) cerebral infarction without residual deficits (stroke), abnormal gait and mobility, history of falling and history of COVID-19. The 11/30/25 MDS assessment revealed Resident #5 had severe cognitive impairment with a BIMS score of five out of 15. Resident #5 required substantial/maximal assistance with bathing. Resident #5 required supervision or touching assistance with toileting, oral and personal hygiene, upper and lower body dressing as well as footwear. The MDS assessment documented Resident #5 was up to date on her COVID-19 vaccination. B. Record reviewReview of Resident #5’s EMR revealed no documentation of COVID-19 vaccine administration, education or corresponding declination form. V. Resident #24A. Resident statusResident #24, age greater than 65, was admitted on 6/24/24. According to the February 2026 CPO, diagnoses included generalized muscle weakness, dementia with anxiety, hearing loss, depression, abnormal gait and mobility, pulmonary embolism and hypertension. The 1/8/26 MDS assessment revealed Resident #24 had severe cognitive impairment with impaired short term and long term memory. The MDS assessment documented Resident #24 had severely impaired cognitive decision making skills with disorganized speech. T. Resident #24 required supervision or touching assistance with eating. Resident #24 required moderate assistance with toileting, oral and personal hygiene, upper and lower body dressing as well as footwear. Resident #24 required substantial/maximal assistance with bathing. The MDS assessment documented Resident #5 was up to date on her COVID-19 vaccination. B. Record reviewReview of Resident #24’s EMR revealed no documentation of COVID-19 vaccine administration, education or corresponding declination form. VI. Facility tracking documentAn internal tracking document, last updated 9/29/25, was provided by the director of nursing (DON) on 2/11/26 at 6:12 p.m. It revealed in pertinent part,Residents #5’s representative was offered the COVID-19 vaccine but declined. Residents #10, #24, #30 and #35 and an additional 19 residents or resident representatives each answered “yes” when offered the updated 2025 COVID-19 vaccination. VII. Staff interviewsThe infection preventionist (IP) was interviewed on 2/12/26 at 11:12 a.m. The IP said to her knowledge, the facility had not administered the updated 2025 COVID-19 vaccination to any residents due to billing questions raised by the previous DON. The IP said the previous DON typically tracked and managed immunizations for all residents in the facility. The IP said the previous DON was working at the time of the vaccine screenings and she remembered the previous DON said she was not sure who was going to cover the cost of the vaccines, saying some families would not want to pay out of pocket for them. The IP said the previous DON left the facility shortly after and the IP said she was not sure if the current interim DON was aware if part of her duties were to manage and track resident vaccinations. The IP said all residents should have documentation of vaccine education and administration or refusal each year, even if a resident refused the COVID-19 vaccine a previous year. The DON and the NHA were interviewed together on 2/12/26 at 1:41 p.m. The DON said she was only aware no residents in the facility received the updated 2025 COVID-19 vaccine until the survey. The DON said she was aware one of her responsibilities was to offer, track and order vaccines for the residents, but she was not aware the previous DON did not finish this task before she left last fall. The DON said they completed an annual audit of all immunizations for residents, but this system failed since they were not aware of the missed vaccine administrations. The DON said she was aware all residents needed to be offered the annual COVID-19 vaccine each year, but she was not aware each resident had to have documentation of education and either vaccine administration or declination in their EMR. The DON said she was not sure how many residents requested the updated 2025 COVID-19 vaccination and did not receive one, but she would assume each resident who answered “yes” on the provided tracking document would want the vaccine and none of those residents received one. The NHA said they planned to rescreen every resident in the facility, starting with all of the residents who responded “yes” on the provided tracking document. The DON said it was important to administer the updated 2025 COVID-19 vaccine to all residents who requested it because the population of residents in the facility were more vulnerable to serious respiratory illness compared to the average person.

A complaint survey, prompted by #CO1918866 #CO1918868 was conducted 8/5/25. No deficiencies were cited.

A complaint survey, prompted by #CO36019 was conducted on 7/1/24 and 7/2/24. No deficiencies were cited.

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

A revisit to the 1/10/2024 survey was completed on 4/10/2024. The facility was in compliance with the regulations surveyed.

The Colorado Department of Public Health and Environment conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). Life safety features, which met the requirements for new construction at the time of licensure or certification, shall be maintained and not diminished. The initial comments (ID Prefix Tag K-0000) are informational only, and are a representation of the facility's general characteristics. The facility is a type V (000) single-story structure with a full crawl space building, constructed November 26, 1997, with a connected eight room addition type V(111) constructed, August 11, 2005. The facility incorporates a distinct, two-hour, fire-rated separation from the rehabilitation area. The facility contains an automatic fire suppression system classified as fully sprinklered. The facility is licensed for 60 beds with a census on the day of survey of 44. The facility was surveyed, on January 31st 2024, for compliance to fire safety requirements using the National Fire Protection Association (NFPA) 101-Life Safety Code, 2012 Edition; under Chapter 19, Existing Health Care Occupancies; the NFPA 99- Health Care Facilities code, and all referenced standards. The facility will meet these requirements when the following deficiencies are corrected. The deficiencies were discussed with the Maintenance Supervisor during the walk through inspection of the building and the survey concluded with a discussion of the deficiencies with the Administrator and Maintenance Supervisor during the exit conference.

Based on observation, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 7.2.1.6.1.1(4) or 7.2.1.5.10.2.1. Delayed egress hardware, the door did not have proper signage posted 2. One motion locks need to be installed on doors for CNA room, Physical Therapy, BOM office, beauty room. 7.2.1.6.1.1(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 15/30 SECONDS7.2.1.5.10.2 The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient item(s) were discussed with the maintenance team at the exit conference.

Based on observation, it was determined that the facility failed to arrange and maintain the vertical openings in accordance with Life Safety Code Section 19.3.11. vertical opening to crawl space from portable AC unit exhaust duct work in Med room and activities room. 19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. Deficient item(s) were discussed with the maintenance team at the exit conference.

A recertification survey was conducted from 1/7/24 to 1/10/24. Four deficiencies were cited.

An Emergency Preparedness survey was conducted from 1/7/24 to 1/10/24. No deficiencies were cited.

Based on observation, record review and interviews the facility failed to ensure four (#11, #12, #21 and #46) out of 18 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure blood pressure medication was ordered with administration parameters for Residents #11, #12, #21 and #46. Findings include:I. Professional reference According to Khashayar, F., Arif, J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 1/19/24. "Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur."The patient's heart rate and blood pressure require monitoring while using beta-blockers."According to McKeever, R.G., Hamilton, R.J. (2022). Calcium Channel Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK482473/ retrieved on 1/19/24. "Calcium channel antagonists, also known as calcium channel blockers (CCBs), have been widely used for many indications. This cardiovascular drug class is one of the leading causes of drug-related fatalities."Patients require close monitoring. The improvement of their symptoms of angina or maintenance of their blood pressure is an indication of efficacy (effectiveness for the desired result). Hypotension (low blood pressure) may be profound and life-threatening. Many factors may affect the severity of overdose, including the calcium-channel antagonist dose, the formulation, ingestion with other cardioactive medications such as beta-blockers, the patient's age, and comorbidities. These medications may also be life-threatening with as little as one tablet in small pediatric patients."Kiziior, R. J., Hodgson, K. J. (2023). Lisinopril. Saunders Nursing Drug Handbook. Elsevier. P. 704."Obtain blood pressure, apical pulse immediately before each dose in addition to regular monitoring (be alert to fluctuations)."According to Herman, L.L, Weber, P, Bashir K (2023) Hydrochlorothiazide. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK430766/ retrieved on 1/9/24. "Hydrochlorothiazide is a medication to treat hypertension and peripheral edema. Blood pressure should be closely monitored to ensure patients on hydrochlorothiazide treatment achieve and maintain their target blood pressure, minimizing the risk of adverse effects associated with high or low blood pressure."II. Resident #11A review of the December 2023 computerized physician orders (CPO) revealed:-Metoprolol Tartrate Oral Tablet 25 milligrams (mg). Give 0.5 tablet by mouth twice daily, started 11/29/23. A review of the December 2023 medication administration record (MAR) revealed:-Metoprolol was administered on 12/4/23, 12/11/23 and 12/15/23 when the resident's blood pressure was low with normal blood pressure being 120/80. A review of the December 2023 blood pressure summary showed Resident #11 had a blood pressure of 85/44 on 12/4/23, a blood pressure of 85/54 on 12/11/23 and a blood pressure of 70/38 on 12/15/23. II. Resident #12 A review of the December 2023 CPO revealed:-Lisinopril Oral Tablet 20mg. Give one tablet by mouth one time a day related to essential primary hypertension, started 11/2/23. A review of the December 2023 MAR revealed:-Lisinopril was given on 11/24/23, 11/30/23 and12/26/23. A review of the November 2023 and December 2023 blood pressure summary showed Resident #12 had a blood pressure of 84/56 on 11/24/23, a blood pressure of 89/57 on 11/30/23 and a blood pressure of 78/53 on 12/26/23. III. Resident #21 A review of the December 2023 CPO revealed:-Hydrchlorithiazide (HCTZ) Oral Tablet 12.5 mg. Give one tablet by mouth three times daily related to essential primary hypertension. A review of the October 2023 medication administration record (MAR) revealed the HCTZ medication was administered consistently according to the order. A review of the October 2023 medication regimen review from the pharmacist revealed the resident had a diastolic blood pressure of less than 60, six times during the previous 30 days and the medication was administered. The pharmacist recommended either eliminating the medication or adding hold parameters in order to lessen the potential fall risk associated with hypotension (low blood pressure), drug to drug interactions and side effects. IV. Resident #46 A review of the November 2023 CPO revealed:-Amlodipine Besylate Oral Tablet five mg. Give one tablet by mouth one time a day related to essential primary hypertension, date started 11/2/23 and was discontinued on 11/13/23. A review of the November 2023 MAR revealed amlodipine was given on 11/5/23. -A review of the November 2023 blood pressure summary showed Resident #46 had a blood pressure of 87/56 on 11/5/23. V. InterviewsRegistered nurse (RN) #1 was interviewed on 1/8/24 at 10:57 a.m. She said there were no standing orders for acceptable blood pressure ranges for residents on blood pressure medications. She said she used her own judgment when determining if the medication should be administered. She said the certified nurse aides with medication authority (CNA/MA) only took the resident's blood pressure when necessary as ordered by the physician. She said in most cases, the blood pressure was only ordered to be checked once daily. CNA/MA #1 was interviewed on 1/8/24 at 11:01 a.m. He said he checked residents' blood pressure if he was requested to and reported the results to the nurse on duty. The director of nursing (DON) was interviewed on 1/9/24 at 1:32 p.m. She said she was aware there were not currently any orders that directed staff on when it was appropriate to hold blood pressure medications. She said the CNA/MAs and nursing staff were to use good judgment and withhold medications when appropriate.

Based on record review and interviews, the facility failed to ensure two (#44 and #16) of seven residents reviewed for unnecessary medications out of 18 sample residents were free from unnecessary medications. Specifically, the facility failed to:-Ensure Resident # 44 was assessed by the interdisciplinary team (IDT) prior to implementation of a psychotropic medication treatment and appropriate non-pharmacological interventions were initiated;-Ensure Resident #16's psychoactive medication, an antidepressant, was not increased without evidence and documentation of change of behaviors or attempts of non-pharmacological interventions, and,-Resident # 16's hours of sleep were documented for hypnotic medication use. Findings include: I. Facility policy The Psychotropic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 1/10/24 at 8:02 a.m. and read in parts:"Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record."Consideration of the use of any psychotropic medications is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes."Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible."When determining whether to initiate, modify, or discontinue medication therapy, the IDT (interdisciplinary team) conducts an evaluation of the resident." II. Resident # 44 A. Resident status Resident #44, age 83, was admitted on 7/17/23. According to the January 2023 computerized physician order (CPO) diagnoses included dementia, history of urinary tract infections and type 2 diabetes mellitus. The 1/2/24 minimum data set (MDS) assessment revealed resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of two out of 15. Section E revealed presence of hallucinations and delusions, physical and verbal behavioral symptoms directed towards others occurred in one to three days. Rejection of care and wandering occurred in one to three days. B. Resident observations Resident #44 was observed on 1/8/24 throughout the day. She was wearing a dark coat and was carrying a purse. She was walking up and down the hallways throughout the facility and occasionally rested in the television room next to the nurses' station. She was invited to participate in the afternoon activities, however she did not stay. On 1/10/24 at approximately 9:30 a.m. the resident was observed walking on the 300 hall. She was dressed in a dark coat and was carrying a purse. She appeared upset and agitated. She said she did not know where she was and would like to go home. C. Record review Physician orders: -Seroquel oral tablet 25 mg (Quetiapine Fumarate) (antipsychotic medication), give one tablet by mouth three times a day related to unspecified dementia, mild, without behavioral disturbance. Start date 1/4/24-Melatonin oral tablet 10 mg (Melatonin) (supplement used for insomnia), give one tablet by mouth at bedtime for insomnia. Start date12/28/23 Care plan: The comprehensive care plan review revealed the following:-(Resident) takes psychotropic medications r/t (related to) dementia with behaviors. Interventions included: Administer medications as indicated by physician orders. Consult with pharmacist/physician for gradual dose reduction if appropriate. Monitor for and report to physician adverse effects of antipsychotic medication use (drowsiness, dizziness, restlessness, weight gain, dry mouth, constipation, nausea/vomiting, blurred vision, low blood pressure, uncontrolled movements/tics/tremors, seizures, increased risk for falls). Review with resident/family/responsible person the risks vs. benefits of psychotropic medication use. Care plan was initiated on 1/7/24-(Resident) has impaired cognitive function r/t (related to) diagnosis of dementia (dated 9/12/23). Interventions included: Encourage resident to participate in daily decision making with daily activities. Keep resident's routine as consistent as possible to avoid anxiety and frustration. Notify nurse, physician of any significant change in (Resident's) baseline cognitive status. Reassure (Resident) of safety. Redirect as needed. -The resident's care plan did not include non-pharmacological interventions for the psychotropic medication Seroquel. -The resident's care plan did not include the use of Melatonin for insomnia. Interdisciplinary notes: On 11/11/23 a nurse documented: "Resident was found standing outside the door of her room crying stating 'no one likes me, no one wants me' . RN (registered nurse) provided therapeutic listening and reassurance, given cup of tea and encouraged to socialize. Then she wandered around the unit, and required encouragement to return to her room to change into pajamas. Resident's roommate voiced complaints that resident was talking loudly to self in her room. When RN arrived, resident was sleeping sitting upright in bed. RN closed room window as (resident) seems bothered by the cold. Will pass on to dayshift that new room assignment may not be best fit."On 11/15/23 a nurse documented: "This resident has been up wondering the hallways t/o the noc (throughout the night). Resident will sleep for two hours and then get back up. When approached by this RN, resident states 'I just can't sleep'."On 11/17/23 a nurse documented: "Resident appears to be having more issues during the night. At the beginning of the shift resident was wondering the halls but not really communicating what she was looking for, commenting she was waiting on the baby, or looking for a coat she had misplaced. Resident was then standing in the hall in front of her room being very weepy making comments that she only wanted to be nice to people. Reassured resident that all was well and encouraged her to go to bed. Later in the evening she was assisted to bed by staff and has been asleep since that time."On 12/26/23 a nurse documented: "Resident redirected to stay in room several times per hour due to isolation precautions. Encouraged to wear mask when out of the room. Resident forgetful and becomes anxious, confused, and agitated. Redirected and reiterated that resident is safe and shown location of room through day. Call light within reach and resident encouraged to use as needed."On 1/1/24 a nurse documented: "Resident continues to be very upset, agitated towards staff. Also continues to go into other rooms frequently upsetting other residents. Very difficult to redirect. Will not stay in her room, getting very little sleep."On 1/3/24 a nurse documented: "Resident attempted to hit CNA (certified nurse aide) while being redirected out of another resident's room. Resident walking up and down the hallway shouting 'cheaters' Resident not easily redirectable at this time. Encouraged adequate space while ensuring safety."On 1/4/24 a nurse documented: "Resident was arguing with another resident this evening and the altercation almost became physical. Nursing staff intervened prior to this occurring. Resident not easily redirectable. Resident was noted to be very agitated, yelling, wandering, and aggressive with other residents and staff at the beginning of this shift. Resident was walking up and down the hallway in the eve on January 3rd, 2024, and was calling staff 'liars'. Nursing staff encouraged space while ensuring safety of all residents and staff. Resident was assisted to change into pajamas and into bed at 2130 (9:30 p.m.). Resident still lying in bed resting. Call light and personal items are within reach."On 1/6/24 a nurse documented: "Resident noted with verbal outbursts and verbal aggression toward staff. Pacing and upset about 'missing the bus to Texas', positive reinforcement and redirection provided but resident responds angrily and walks away. Resident allowed space and frequent visual checks continue. Staff will continue to provide a safe and hazard free environment." D. Staff interviews The medical director (MD) was interviewed on 1/8/24 at 10:35 a.m. He said the antipsychotic medication Seroquel was prescribed for dementia with behaviors. He said the nursing staff told him the resident was verbally and physically aggressive towards staff and occasionally with other residents. He said he did not consider a lower dose for the resident. He said the medication had six hours half-life and the nursing staff observed significant positive changes in resident's behaviors. The director of nursing (DON), the social service director (SSD) and the activities director (AD) were interviewed on 1/9/24 at 5:00 p.m. The DON said it was the facility policy the interdisciplinary team (IDT) should review and assess a resident's behaviors prior to asking physician for a drug, especially an antipsychotic medication. She said the nurses were frequently reminded not call the physician and ask for a psychotropic medication. The SSD said there were no non-pharmacological interventions implemented for resident increased behaviors and there was no care plan for it. She said the resident was moved to different rooms three times in the past two months and that could have triggered increased of confusion and behaviors. The AD said Resident #44 was always invited to the group activities however she would not stay long. RN #1 was interviewed on 1/9/24 at 5:30 p.m. She said Resident #44's behaviors increased during her isolation due to COVID-19 diagnosis. She would not stay in her isolation room and would not wear a facemask. She began being aggressive towards staff. RN#1 said after the COVID-19 isolation was over, the resident returned to her previous room and became more confused. She said the resident was wandering to other residents' rooms and was not easily redirectable. She said she notified the MD of Resident #44's behaviors and he prescribed the antipsychotic medication. III. Resident #16A. Resident status Resident # 16, age 94, was admitted on 11/22/23. According to the January 2024 computerized physician order (CPO) diagnoses included pneumonia, chronic obstructive pulmonary disease (COPD), insomnia, major depressive disorder and anxiety. The 12/5/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. She had no identified behaviors or rejections of care. The mood interview PHQ-9 (the nine questions of patient health questionnaire objectifies degree of depression severity) score was two out of 27 which indicated no depression. She was administered high risk medications included an antidepressant, hypnotic and anticoagulant. B. Resident interview Resident #16 was interviewed on 1/10/24 at 9:55 a.m. She said she was not aware her antidepressant was increased a week ago. She said she usually went to bed and fell asleep around 10:30 p.m. woke up one time to go to the bathroom and slept the rest of the night. C. Record review Physician orders: -Citalopram Hydrobromide, oral tablet 10 mg (Citalopram Hydrobromide) (antidepressant known as selective serotonin reuptake inhibitors). Give one tablet by mouth one time a day related to major depressive disorder. Start date 12/5/23. End date 1/2/24.-Citalopram Hydrobromide, oral tablet 20 mg (Citalopram Hydrobromide). Give one tablet by mouth one time a day related to major depressive disorder and anxiety disorder. Start date 1/3/24. -Temazepam oral capsule 15 mg (Temazepam) (Benzodiazepine used to treat severe insomnia). Give 15 mg by mouth at bedtime for insomnia. Start date11/22/23. Care plan The comprehensive care plan reviewrevealed the following:-There was no care plan for the antidepressant medication in resident's record.-There was no care plan for the hypnotic medication in resident's record-There was no care plan for non-pharmacological interventions for the above medications. Review of the resident's electronic record revealed there were no behavior notes identifying any behaviors. The January 2024 CPO identified the medication Citalopram Hydrobromide for depression and anxiety was increased on 1/3/24 from 10 mg to 20 mg every day (qd). -The facility failed to have evidence of increased behaviors and attempts at non-pharmacological interventions prior to the increase of Citalopram Hydrobromide from 10 mg to 20 mg. Interdisciplinary notes On 12/5/23 a nurse documented: "Citalopram 10mg started for increased anxiety. No unusual behaviors noted with no adverse reactions."On 1/2/24 a nurse documented: "MD in house to see resident. Resident verbalizing increase in anxiety. New orders obtained to change Citalopram to 20mg PO QD. Orders noted and carried out. Resident made aware." D. Staff interviews The DON and MDS coordinator (MDSC) were interviewed on 1/10/24 at 8:35 a.m. The MDSC said the resident's care plan was not finished timely. She said the resident's care plan did not address the insomnia and antidepressant medications. She said there were no non-pharmacological approaches for the above medications in the resident's care plan. The DON was interviewed on 1/10/24 at 9:40 a.m. She said the resident was admitted on Tomazepam from the hospital. She said there were no hours of sleep documented. She said she was not aware the resident's antidepressant was increased and IDT did not review change in behaviors or increase in depression.

Based on observations and interviews the facility failed to ensure one of one medication refrigerators stored narcotic medications in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, revised February 2023, was provided by the director of nursing (DON) on 1/9/24 at 1:00 p.m. It read in pertinent part, "Controlled substances (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected."II. ObservationsOn 1/8/24 at 10:33 a.m. the medication refrigerator was observed with registered nurse (RN) #1. There were two controlled medication locked boxes in the refrigerator not permanently affixed to the refrigerator and they contained liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat anxiety) and liquid morphine (pain medication). III. Staff interviewsRN #1 was interviewed on 1/8/24 at 10:36 a.m. She said she was not aware that the controlled medication box in the refrigerator should be permanently affixed to the refrigerator. She said she now knew that anyone with access to the refrigerator could just take the boxes of controlled medications out of the refrigerator. The director of nursing (DON) was interviewed on 1/9/24 at 1:14 p.m. The DON said she was not aware of the requirement that the controlled medication boxes should be permanently affixed to the refrigerators.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to: -Ensure reheated food reached the appropriate temperature; and, -Ensure beard nets were worn in the kitchen. Findings include: I. Reheated food A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. "Reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating." (Retrieved 1/10/24) B. ObservationsCook #1 was asked on 1/7/24 at 11:52 a.m. to reheat soup that was brought by the family. The cook placed the soup in the microwave for less than two minutes. He did not rotate or stir the soup, did not take the temperature of the soup and did not allow the soup to stand covered for two minutes. Dietary aide (DA) #2 was asked on 1/9/24 at 11:12 a.m. to reheat a cinnamon roll that was in a paper bag. DA #2 placed the cinnamon roll in the original packaging in the microwave for less than two minutes. She did not take the temperature of the cinnamon roll. She did not rotate the cinnamon roll, did not take the temperature of the cinnamon roll and did not allow the cinnamon roll to stand covered for two minutes. C. Staff interviewsThe corporate dietary manager was interviewed on 1/9/24 at 3:20 p.m. She said cooks should be the only ones who reheat food. She preferred outside food to be sealed and in its original packaging. She said that any food that is reheated should be tested with a thermometer to ensure the food reached 165 degrees Fahrenheit. D. Facility follow-upThe corporate dietary manager provided documentation on 1/10/24 at 9:47 a.m. training was provided to kitchen staff that food should be reheated to reach 165 degrees Fahrenheit. II. Hair restraints A. Professional referenceThe Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf."Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn effectively keep their hair from contacting exposed food." (Retrieved 1/22/24) B. Observations Cook #1 and an unidentified dietary aide were observed on 1/9/24 at 11:01 a.m. Both staff were continuously observed during the lunch meal on 1/9/24 from 11:01 a.m. until 11:48 a.m. Both staff had a beard that was less than one inch. They both did not have a beard net worn to prevent their hair from contacting exposed food. C. Staff interviews The corporate dietary manager provided documentation on 1/10/24 at 9:47 a.m. She said any dietary staff that entered the kitchen should have worn hair coverings that covered body hair including beards. She said she would talk to the kitchen staff who have beards to wear hair coverings. D. Facility follow-upThe corporate dietary manager provided documentation on 1/10/24 at 9:47 a.m. She provided documentation training was provided to all kitchen staff to wear hair coverings including beard nets.

A complaint survey, prompted by #CO34042 was conducted on 11/14/23-11/16/23. No deficiencies were cited.